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The Impact of Mindfulness-based Stress Reduction (MBSR) on Depression, Anxiety and Stress in People with Parkinson


The Impact of Mindfulness-based Stress Reduction (MBSR) on Depression, Anxiety and Stress in People with Parkinson s Disease Kelly Birtwell – PowerPoint PPT presentation

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Title: The Impact of Mindfulness-based Stress Reduction (MBSR) on Depression, Anxiety and Stress in People with Parkinson

The Impact of Mindfulness-based Stress Reduction
(MBSR) on Depression, Anxiety and Stress in
People with Parkinsons Disease
  • Kelly Birtwell
  • Linda Dubrow-Marshall

  • To evaluate the impact of an 8-week
    Mindfulness-Based Stress Reduction course (MBSR)
    on people with Parkinsons 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

Parkinsons 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

Parkinsons 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

  • 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 beginners
    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

  • 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)

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
  • 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
  • Sephton et al (2011) MBSR for people with PD,
    slower breathing and reduced evening cortisol
  • 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 Parkinsons who attended a
    mindfulness course

Method Patient public involvement
  • Patients with Parkinsons 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

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

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

PDQ39 Secondary Outcome Measure
  • Parkinsons 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

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

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

Participants recruitment
  • Participants referred from an Acute Hospital
  • Inclusion criteria
  • Diagnosis of idiopathic Parkinsons disease
    (Parkinsons 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

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

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).

  • 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

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

Mean (SD) Range
Age at disease onset 59.13 (7.39) 51.2 - 70.5
Age at diagnosis 60.33 (5.92) 55 - 70
Disease duration 8.82 (5.47) 2.16 - 18.35
Hoehn Yahr staging (symptom progression) 2.33 (0.68) 1.5 - 3.0
  • Mean scores for depression, anxiety and stress
  • Statistically significant improvements

DASS-21 severity categories
Depression Anxiety Stress
Normal 0-9 0-7 0-14
Mild 10-13 8-9 15-18
Moderate 14-20 10-14 19-25
Severe 21-27 15-19 26-33
Extremely Severe 28 20 37
  • Score range 0 - 42

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

  • 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
  • Cognitive impairment and communication worsened
    at wk8 then stayed the same or worsened again at
  • The mean summary index score worsened at wk8 then
    returned to baseline at wk16

  • 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

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

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

What would you tell other people with Parkinsons
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.

  • Mindfulness-based interventions could benefit
    people with Parkinsons
  • The intervention is acceptable to patients
  • Interpretation of the results is limited small
    sample size and lack of control group

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