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Kelly Birtwell kelly.birtwell@mhsc.nhs.uk Linda Dubrow-Marshall l.dubrow-marshall@salford.ac.uk

The Impact of Mindfulness-based Stress Reduction (MBSR) on Depression, Anxiety and Stress in People with Parkinson’s Disease. Kelly Birtwell kelly.birtwell@mhsc.nhs.uk Linda Dubrow-Marshall l.dubrow-marshall@salford.ac.uk. Aim.

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Kelly Birtwell kelly.birtwell@mhsc.nhs.uk Linda Dubrow-Marshall l.dubrow-marshall@salford.ac.uk

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  1. The Impact of Mindfulness-based Stress Reduction (MBSR) on Depression, Anxiety and Stress in People with Parkinson’s Disease Kelly Birtwell kelly.birtwell@mhsc.nhs.uk Linda Dubrow-Marshall l.dubrow-marshall@salford.ac.uk

  2. Aim • To evaluate the impact of an 8-week Mindfulness-Based Stress Reduction course (MBSR) on people with Parkinson’s disease (PD) experiencing depression, anxiety and stress, or difficulty coping with PD • Completed as part of MSc Applied Psychology (Therapies) degree, University of Salford • Other authors: Dr J Raw, T Duerden & A. Dunn

  3. Parkinson’s disease • Affects 120,000 people in the UK • Mainly older adults, age 50+ • People under 40 can be affected, 10,000 diagnosed ‘young onset’ per year • Exact cause unknown • No cure, symptoms controlled by medication. Treatment is complex • Motor symptoms: resting tremor, bradykinesia, rigidity, postural instability

  4. Parkinson’s non-motor symptoms • 40-45% of patients experience depression, up to 40% experience anxiety • Anxiety and depression can predate motor symptoms by several years • Apathy, mild cognitive impairment (MCI), sleep problems, autonomic disturbance, pain • NMS have major impact on quality of life • Improved management of NMS is needed • New treatments needed, and further research into psychosocial interventions for anxiety and depression in PD

  5. Mindfulness • “Paying attention in a particular way: on purpose, in the present moment and non-judgementally” (Jon Kabat-Zinn, 2004) • Building blocks: intention, attention, attitude (Shapiro et al, 2006) • 7 attitudes: non-judging, patience, a beginner’s mind, trust, non-striving, acceptance and letting go (Kabat-Zinn, 2004) • Formal or informal practice • One-to-one or group mindfulness courses • MBCT (NICE guidelines), MBSR

  6. MBCT & MBSR • MBSR: group based, 8 week programme • Includes stories, poetry, metaphors • Yoga / mindful movement • Physiological and psychological bases of stress • For physical and mental health problems • More suitable for general population • Described but not manualised (responsive) • MBCT: integration of MBSR and CBT • NICE guidelines recommend MBCT for people currently well, with a history of 3 or more episodes of depression • Manualised (developed through RCT)

  7. Mindfulness - applications • MBSR for pain (Kabat-Zinn et al, 1985), GAD (Kabat-Zinn et al, 1992), psoriasis (Kabat-Zinn et al, 1998) • MBSR increases grey matter density (Holzel et al 2011) • Fitzpatrick et al (2010): MBCT acceptable and of benefit to people with PD • Dreeben et al (2011): MBSR for people with PD, reduced anxiety and depression, psychological adjustment • Sephton et al (2011): MBSR for people with PD, slower breathing and reduced evening cortisol levels • Bucks et al (2011): coping processes and quality of life in PD, recommended mindfulness • Pickut et al (2013): increases in grey matter density of people with Parkinson’s who attended a mindfulness course

  8. Method:Patient & public involvement Patients with Parkinson’s were involved throughout the life of the study: • Discussion of the initial idea • Choosing outcome measures • Adaptations to the MBSR course • Review and feedback of the study documents

  9. Design and outcome measures • Mixed methods design • Data collected at baseline, wk8, and wk16 • Age and Parkinson’s history recorded • Primary outcome measure: DASS-21 • Secondary outcome measures: • PDQ39 (well-being and stigma) • MAAS • Qualitative follow-up questionnaires

  10. DASS-21 – Primary Outcome Measure • Depression Anxiety & Stress Scales (DASS-21) Lovibond & Lovibond 1995 • Short form of the DASS – 21 questions • Reliable and valid in elderly population • Used in previous mindfulness studies • Higher scores indicate higher levels of distress / worsening of symptoms

  11. PDQ39 – Secondary Outcome Measure • Parkinson’s Disease Questionnaire 39 (Jenkinson et al 1995) • Disease specific rating scale for PD • 39 questions over 8 dimensions: • mobility, activities of daily living (ADLs), emotional well-being, stigma, social support, cognition, communication, bodily discomfort • Higher scores indicate worsening of symptoms • Widely used and fully validated • Developed with patients to cover areas of life that are important to them

  12. MAAS – Secondary Outcome Measure • Mindful Attention Awareness Scale (Brown & Ryan, 2003) • 15 item questionnaire • Provides overall rating of mindful awareness • Higher scores indicate increased mindful awareness • Suitable for meditation naïve participants • Validated scale

  13. Qualitative follow-up questionnaires • Designed specifically for this study • Questions about taking part in the MBSR course, and in the study • What was helpful or unhelpful • What would they change • Has their experience of living with PD changed since attending the course • What would they tell others considering attending an MBSR course

  14. Participants & recruitment • Participants referred from an Acute Hospital Trust • Inclusion criteria • Diagnosis of idiopathic Parkinson’s disease (Parkinson’s UK Brain Bank criteria) • Identified as experiencing depression, anxiety, stress, or difficulty coping with PD • Exclusion criteria • Lacking capacity to consent • Just begun a major life change

  15. MBSR course • Developed by Jon Kabat-Zinn • 8 week, group course • 1 session per week, up to 3 hours duration • One full day ‘silent retreat’ towards the end of the course • Daily home practice, up to 45 minutes • CDs and worksheets provided • Delivered by experienced mindfulness teachers

  16. MBSR course adaptations • Order of practices and curriculum – body as source of distress • Option of sitting for body scan • Duration of practices shortened • Full day ‘retreat’ not included • Other studies made adaptations (e.g. Sephton et al, 2011).

  17. Findings Recruitment and reasons for withdrawal • 13 participants were recruited • 9 attended wk1, 6 completed full course • Withdrawal before the MBSR course began: • Scheduling conflict = 2 • Unexpected health issues = 2 • Withdrawal after the first MBSR session: • Scheduling conflict = 1 • Unexpected health issues = 1 • Did not wish to continue = 1

  18. Demographics and PD history • 6 Participants: male = 5, female = 1 • Mean age = 67.96 (5.64 SD, range: 60.8 - 72.9) • PD history:

  19. DASS-21 • Mean scores for depression, anxiety and stress decreased • Statistically significant improvements

  20. DASS-21 – severity categories • Score range: 0 - 42

  21. PDQ39 • At wk8 and wk16 levels of change varied across the dimensions

  22. PDQ39 • Results were not statistically significant • Continuous improvements seen in 3 dimensions: mobility, stigma, social support • ADLs and well-being showed increase in problems at wk8 then return to baseline levels at wk16 • Problems with bodily discomfort increased at wk8 then decreased at wk16, but not to baseline levels • Cognitive impairment and communication worsened at wk8 then stayed the same or worsened again at wk16 • The mean summary index score worsened at wk8 then returned to baseline at wk16

  23. MAAS • Little change in self-reported mindfulness • Mean scores: 3.83 – 3.77 – 3.90 • Slight decrease at wk8 • Slight increase at wk16 compared to baseline • Results not statistically significant • Score range: 1-6, higher score = increased mindful awareness

  24. Qualitative follow-up questionnaires • Overall participants found the course worthwhile and felt some benefit • ‘Has your experience of living with Parkinson’s changed at all since attending the MBSR course?’

  25. Qualitative follow-up questionnaires • Some confusion reported: • Some mindfulness concepts • Aims of the practices • Terminology used • Needed fuller explanations earlier in course • Mindfulness of breath practiced most often

  26. What would you tell other people with Parkinson’s considering attending an MBSR course? • “I would tell them not to be put off too soon, as its relevance takes some time to become obvious.” • “Go with an open mind, enjoy the course.” • “To go ahead and try it.” • “Yes get involved because it's made me think about things and realise I'm not on my own.” • “Do it.” • “Prepare to be stimulated in an unusual way.”

  27. Conclusion • Mindfulness-based interventions could benefit people with Parkinson’s • The intervention is acceptable to patients • Interpretation of the results is limited – small sample size and lack of control group

  28. Future research • Larger sample sizes required • Carers could also participate in the mindfulness course • Further adaptations could be considered to meet the needs of people with PD • People with Parkinson’s should be involved in all stages of future studies, including study design

  29. Questions • kelly.birtwell@mhsc.nhs.uk • l.dubrow-marshall@salford.ac.uk

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