Cognitive-behavioral therapy for depression in Parkinson's disease: a pilot study

Cognitive rehabilitation in Parkinson's disease: evidence from neuroimaging

Cognitive impairment in Parkinson’s disease (PD) has received little attention to date and as such, there are currently very few treatment options available. The aim of the present study was to determine whether cognitive training might alleviate these cognitive symptoms and if so, whether such changes might be correlated with altered brain patterns. The performance of 10 PD patients and 10 paired healthy controls was assessed in a modified version of the Stroop task performed in association with functional magnetic resonance imaging, and half of the PD patients were given 6 months of cognitive daily training based on Sudoku exercises. Results showed that the training program improved the cognitive performance in the Stroop test of the trained Parkinson’s patients during MRI, specifically in terms of reaction time, and of correct and missing answers. Moreover, training provoked reduced cortical activation patterns with respect to untrained patients that were comparable to the patterns of activation observed in controls. Based on these findings, we propose that cognitive training can contribute significantly to save brain resources in PD patients, maybe by readdressing the imbalance caused by the alterations to inhibitory circuitry. Furthermore, these data strongly support the development and use of standardized cognitive training programs in PD patients.

Telephone-based cognitive-behavioral therapy for depression in Parkinson disease

BACKGROUND

Although face-to-face cognitive-behavioral therapy (CBT) was found to be beneficial for the treatment of depression in Parkinson disease (dPD) in a recent randomized-controlled trial, access to care was identified as a critical issue that needs to be addressed in order to improve the management of this nonmotor complication in PD. The purpose of this study was to examine the feasibility and effect of telephone-based CBT for dPD.

METHODS

Twenty-one depressed people with PD participated in a National Institutes of Health-sponsored uncontrolled pilot trial of telephone-based CBT in an academic medical center from October 2009 to February 2011. The Hamilton Depression Rating Scale was the primary outcome. Treatment was provided to people with PD for 10 weeks, modified for delivery over the phone, and supplemented with 4 separate phone-based caregiver educational sessions. Assessments were completed at baseline and 5 (midpoint), 10 (end-of-treatment), and 14 weeks (follow-up) post-enrollment.

RESULTS

Twenty (95%) people with PD completed the study treatment. Phone-based CBT was associated with significant improvements in depression, anxiety, negative thoughts, and coping. Mean Hamilton Depression Rating Scale change from baseline to week 10 was 7.91 points (P < .001, Cohen d = 1.21).

CONCLUSIONS

Telephone-based CBT may be a feasible and helpful approach for treating dPD and warrants further exploration in randomized-controlled trials. Results were comparable to those observed in the few in-person cognitive-behavioral treatment studies for dPD conducted to date.

Apathy and depression: separate factors in Parkinson's disease

The objective of this study was to test the hypothesis that apathy and depression are dissociable in Parkinson disease (PD) by conducting a confirmatory factor analysis (CFA) of items from two commonly used mood scales. A total of 161 non-demented PD patients (age = 64.1; ± 8.4 years) were administered the Apathy Scale and the Beck Depression Inventory-II. Items were hypothesized to load onto four factors: (1) an apathy factor representing loss of motivation, (2) dysphoric mood factor representing sadness and negativity, (3) loss of interest/pleasure factor representing the features common to both apathy and depression, and (4) a somatic factor representing bodily complaints. Results indicated a good fit for the overall CFA model, χ² (128, N = 146) = 194.9; p<.01. RMSEA was .060 (p = .16). The four-factor model was significantly better than all alternative nested models at p < .001, including an overarching single factor model, representing "depression." Results support the concept that apathy and depression are discrete constructs. We suggest a "factor based" scoring of the Apathy Scale and Beck Depression Inventory-II that disentangles symptoms related to apathy, depression, overlapping symptoms, and somatic complaints. Such scoring may be important in providing useful information regarding differential treatment options.

Cognitive-behavioral therapy for depression in Parkinson's disease: a randomized, controlled trial

OBJECTIVE

Despite the negative effects of depression in Parkinson's disease, there is currently no evidence-based standard of care. The purpose of this study was to examine the efficacy of individually administered cognitive-behavioral therapy (CBT), relative to clinical monitoring (with no new treatment), for depression in this medical population.

METHOD

Eighty depressed (based on DSM-IV criteria) patients with Parkinson's disease participated in a randomized, controlled trial of CBT relative to clinical monitoring (1:1 ratio) in an academic medical center from April 2007 to July 2010. All patients continued to maintain stable medication regimens under the care of their personal physicians. The 17-item Hamilton Depression Rating Scale (HAM-D) total score was the primary outcome. CBT was modified to meet the unique needs of the Parkinson's disease population and provided for 10 weeks. Assessments were completed by blind raters at baseline and 5 (midpoint), 10 (end of treatment), and 14 weeks (follow-up evaluation) postrandomization.

RESULTS

The CBT group reported greater reductions in depression (change in HAM-D score) than the clinical monitoring group. At week 10, the mean HAM-D score change was 7.35 for CBT relative to 0.05 for clinical monitoring. CBT was also superior to clinical monitoring on several secondary outcomes (i.e., Beck Depression Inventory scores, anxiety, quality of life, coping, Parkinson's disease symptom ratings). There were more treatment responders in the CBT group than the clinical monitoring group (56% versus 8%, respectively).

CONCLUSIONS

CBT may be a viable approach for the treatment of depression in Parkinson's disease. Further research is needed to replicate and extend these findings.

Coping in Parkinson's disease: an examination of the coping inventory for stressful situations

BACKGROUND

Parkinson's disease (PD) brings with it a range of stresses and challenges with which a patient must cope. The type of coping strategies employed can impact upon well-being, although findings from coping studies in PD remain inconsistent. The variety of coping scales used without validation in PD has been cited as a possible cause of this inconsistency. The present study sought to examine the validity of the coping inventory for stressful situations (CISS) in a sample of patients with PD.

METHODS

Five hundred and twenty-five patients with PD were recruited as part of a longitudinal investigation of mood states in PD. Four hundred and seventy-one participants completed the CISS. Confirmatory factor analysis was used to explore the structural validity of the scale. Internal reliability, test-retest reliability, convergent validity and discriminant validity were assessed using Cronbach's alpha, intraclass correlations and Pearson's correlations.

RESULTS

Both three and four factor solutions were examined. The four factor model was found to provide a better fit of the data than the three factor model. The internal reliability, discriminant validity, convergent validity, and test-retest reliability of the CISS scales were shown to be good. Use of emotion-focused coping was associated with greater depression and anxiety whilst, task-oriented coping was associated with better psychological well-being.

CONCLUSION

The results provide support for the validity and reliability of the CISS as a measure of coping in patients with PD. Further research into the relationship between coping and well-being is warranted. The identification of helpful and unhelpful coping strategies may guide the development of evidence-based therapies to improve well-being in patients with PD.

Targeting reasoning biases in delusions: a pilot study of the Maudsley Review Training Programme for individuals with persistent, high conviction delusions

Delusions are often resistant to change, persisting despite successful antipsychotic treatment or Cognitive Behavioural Therapy. This study aimed to target reasoning processes, particularly the 'Jumping to Conclusions' (JTC) bias and belief flexibility, which are thought to play a part in maintaining delusional conviction. 13 participants with a diagnosis of psychosis and high levels of conviction in their delusions completed a one-off computerised training package, lasting approximately 1.5 h. Outcomes were assessed at baseline, pre-intervention (two weeks later), post-intervention (immediately after completing the training) and at 1 month follow-up. The package was well received by participants. There were improvements in JTC, belief flexibility and delusional conviction between pre- and post-intervention measures. Controlled studies powered to detect changes in key outcomes are warranted in order to evaluate the efficacy of the programme.

Palliative care in Parkinson's disease: role of cognitive behavior therapy

BACKGROUND

Parkinson's disease (PD) is a chronic, progressive, neurodegenerative disorder that leads to the classic features of akinesia (encompassing hypokinesia and bradykinesia), tremor, rigidity and postural instability. Other non-motor complications include depression, fatigue, pain, and sleep disturbances. For the management of these complications, non-pharmacological techniques, such as Cognitive-behavioral therapy (CBT) can be used. This can focus on overt behavior and underlying cognitions and train the patient in coping strategies to obtain better symptom control.

OBJECTIVES

To review studies on CBT as palliative care in PD patients.

MATERIALS AND METHODS

A survey was conducted for all available English-language studies by means of a MEDLINE search. Keywords in the searches included Parkinson's disease, palliative care, and cognitive behavior therapy. All articles that reported the cognitive behavior therapy and palliative care in a group of PD patients regardless of the method used by the researchers were identified and analyzed.

RESULT AND CONCLUSION

CBT has a strong evidence base for its use and has proven to be an effective treatment in management of people with chronic pain, fatigue syndrome, depression and sleep disturbances, with efficacy that lasts beyond the duration of treatment. Although PD patients suffer from these complications, there are only a few studies on administration of CBT on them. Considering its effectiveness, CBT can be used as an option for palliative care for PD patients, directed toward improving the patient's functional status, clinical disability and quality of life. Further studies are required in this area.

The role of cognitive-behavioural therapy for patients with depression in Parkinson's disease

Depression is a common complication of Parkinson's disease (PD) with considerable impact on patients' quality of life. However, at present the most appropriate treatment approach is unclear. There are limited data on antidepressant medications in PD-associated depression (dPD) and those available suggest limited efficacy and tolerability of these drugs. Cognitive behavioural therapy (CBT) has been shown to be an effective treatment of depressive disorders. Treatment of dPD with CBT may pose particular challenges, including possible different pathophysiology, physical and mental comorbidities, and barriers to treatment through disability, which do not allow simple transfer of these results to patients with dPD. However, a number of case reports, case series, and small pilot studies suggest that this is a promising treatment for patients with PD. We here summarise the published evidence on this treatment in dPD.

The role of dopamine agonists in the treatment of depression in patients with Parkinson's disease: a systematic review

Depressive disorders as well as depressive symptoms are common in Parkinson's disease (PD) and an important factor affecting quality of life. Treatment of depressive symptoms not only improves mood but is also associated with improvement of motor symptoms, disability and cognitive symptoms. Currently, dopamine agonists are being suggested as an alternative to antidepressants for the treatment of depression in PD. The aim of this article is to systematically review the efficacy of dopamine agonists in the treatment of depression in PD. Since 1983, 19 studies have reported on the effects of dopamine agonists on depressive disorder, depressive symptoms or mood in PD. To date, no double-blind, placebo-controlled, randomized controlled trial of the treatment of major depressive disorder in PD with a dopamine agonist has been conducted. Studies of the effects of treatment with dopamine agonists on depressive symptoms in PD, or on mood in non-depressed PD patients, have yielded inconclusive results. Most studies are not designed to test effects on mood and are limited by methodological flaws. It can be concluded that, although the preliminary evidence of the effects on mood and depression in PD is interesting and in need of further study, there is as yet insufficient evidence to recommend dopamine agonists in the treatment of either depressive disorder or depressive symptoms in patients with PD. Treatment of depressive disorder and clinically relevant depressive symptoms should be based on pharmacological or non-pharmacological interventions with known efficacy in this population, such as citalopram, nortriptyline, desipramine or cognitive behavioural therapy. This strategy has the additional advantage of enabling the clinician to treat depressive symptoms independently of motor symptoms, thus avoiding potential complications of dopaminergic therapy.

Parkinson's disease: the quintessential neuropsychiatric disorder

Although diagnosed by characteristic motor features, Parkinson's disease may be preceded, and is frequently accompanied by, a wide range of cognitive and neuropsychiatric features. In addition to the most commonly studied disorders of dementia, depression, and psychosis, other relatively common and clinically significant psychiatric complications include impulse control disorders, anxiety symptoms, disorders of sleep and wakefulness, and apathy. These problems may be underrecognized and are frequently undertreated. The emergent focus on nonmotor aspects of Parkinson's disease over the past quarter of a century is highlighted by a nonlinear increase in the number of articles published devoted to this topic. Although the development of newer antidepressants, atypical antipsychotics, and cholinesterase inhibitors in recent years has had a positive benefit on the management of these troublesome and distressing symptoms, responses are frequently suboptimal, and this remains an area of major unmet therapeutic need.

Does age make a difference in caregiver strain? Comparison of young versus older caregivers in early-stage Parkinson's disease

Family care research has identified negative outcomes of providing care to a spouse with Parkinson's disease (PD), such as declining physical and mental health. Research has also identified protective variables that decrease negative outcomes such as high mutuality and rewards of meaning. It is important for clinicians to identify "at risk" family caregivers and provide earlier interventions. Despite the importance of age and developmental stage there is a paucity of research comparing young versus older spouse caregivers. This study compared the difference in negative aspects of strain and modulators of strain in young and older PD spouse caregivers. A series of hierarchical multiple regressions were used to examine the contribution of age on both positive and negative aspects of the care situation for 65 (37 young, 28 old) PD spouse caregivers. Negative variables included 3 dimensions of strain; strain from lack of personal resources, strain from worry, and global strain. Positive or protective variables included mutuality, preparedness, and rewards of meaning. Even in early stage disease before significant care is required, young spouses (40-55) were found to be at greater risk for negative consequences of the care situation reporting significantly more strain from lack of personal resources, and lower levels of mutuality and rewards of meaning than older (greater than 70) spouses. As expected, young spouses were more likely to be working, caring for children in the home, and in better physical health than older spouses. Clinicians are well-situated to identify the unique needs of young spouses and intervene early in the caregiving trajectory. These findings provide ideas for targeted interventions. Future larger studies that compare young and older spouses should include later stage disease to more fully understand the developmental differences raised by the present findings.

New developments in depression, anxiety, compulsiveness, and hallucinations in Parkinson's disease

Increasing research efforts are focused on nonmotor aspects of Parkinson's disease (PD). Depression, anxiety, compulsivity (dopamine dysregulation symptoms), and hallucinations/psychosis are among these disorders, and all complicate the management of PD with negative influences on quality of life. There is a strong overlap between depression and apathy and likewise, depression and anxiety can coexist and require careful pharmacologic management. Dopamine dysregulation syndrome is linked to medication use and most clearly associated with dopamine agonists. In contrast, although hallucinations and psychosis do not occur unless patients with PD are treated with dopaminergic drugs, medication doses do not directly relate to this problem. Functional neuroimaging provides an excellent resource for investigating these behaviors as well as their anatomical and neurochemical bases. New treatments are being developed, but there have been very few large-scale randomized clinical trials to test the relative roles of new or available agents for abating these problematic behaviors.

Non-motor symptoms: identification and management

Non-motor symptoms are an important part of Parkinson's disease (PD) symptoms complex. They cause a significant burden on the quality of life of patients and their carers and remain a major cause of hospitalisation. Treatment of non-motor symptoms can be challenging as these symptoms are often unresponsive to conventional dopaminergic therapy. However, awareness that these symptoms are related to PD is vital as research into treatment and causation will be the cornerstone for delivering a comprehensive modern treatment for PD.

CBT for the treatment of depression in Parkinson's disease: a promising nonpharmacological approach

Depression is very common in Parkinson's disease (PD) and linked with a faster progression of physical symptoms, greater cognitive decline and poorer quality of life. Nonpharmacological approaches, such as cognitive-behavioral therapy (CBT), for the treatment of depression in PD (dPD) have received little experimental attention despite strong demonstrated efficacy in other geriatric and medical populations. Depressed PD patients often differ from the depressed non-PD elderly in that they present with increased rates of both executive dysfunction and comorbid psychiatric diagnoses, may differ in their depressive symptom presentation and typically have caregivers who are highly involved in their treatment. Therefore, it is not possible to conclude that empirically validated treatments in the depressed aged will generalize to those with PD. In order to be most effective for PD patients, CBT should be tailored to their unique needs. Additional controlled research is needed to further explore the efficacy of CBT for dPD.