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A Cognitive-Behavioral Treatment Package for Depression in Parkinson’s Disease

Received January 29, 2005; revised April 29, 2005; accepted June 3, 2005. From the Depts. of Psychiatry and Neurology, UMDNJ–Robert Wood Johnson Medical School, Piscataway, NJ. Send correspondence and reprint requests to Dr. Dobkin, Dept. of Psychiatry, UMDNJ–Robert Wood Johnson Medical School, 675 Hoes Lane, Rm. D-317, Piscataway NJ 08855. e-mail: dobkinro{at}umdnj.edu

Key Words: Depression • Cognitive-Behavioral Treatment • Parkinson’s Disease

INTRODUCTION

TOP INTRODUCTION Case Series Discussion REFERENCES

 
Parkinson’s disease (PD), a progressive illness that is associated with significant functional disability, is the second most common neurodegenerative disorder in the United States.¹ Depression is the most frequently cited non-motor complaint in PD, with about 40% of PD patients meeting DSM–IV criteria for either major depressive disorder (20%) or dysthymia (20%).² Depression is particularly important in PD patients because it has been linked with an increased progression of physical symptoms, cognitive decline, poor quality of life, and decrements in self-care.^3,4

Despite the impact of depression, there is a paucity of well-designed research that can guide treatment of this complication in PD. Although there are some placebo-controlled trials that have supported the use of antidepressants for PD patients, the confidence in their conclusions has been hampered by methodological shortcomings in their study designs.⁵ Furthermore, tolerability concerns regarding the worsening of motor functioning (associated with the use of selective serotonin reuptake inhibitors [SSRIs]) and increased cognitive impairment (associated with the use of tricyclic antidepressants [TCAs]) may limit the effectiveness of these options.^6,7

Nonpharmacological approaches to the treatment of depression in PD, including cognitive-behavior therapy (CBT), have received little attention, despite having a well-established evidence-base for the treatment of depression in other populations.⁸ Depressed PD patients may differ from their non-PD counterparts in that they present with increased rates of both executive dysfunction⁹ and comorbid psychopathology,¹⁰ and typically have family members who are highly involved in their care.¹¹ Therefore, unique modifications may need to be made in order to tailor nonpharmacologic treatments to this population. The following case series describes the modification and application of a 12- to 14-session cognitive-behavioral intervention (based on A.T. Beck^12,13) and its augmentation with three-to-four separate caregiver psychoeducational sessions, evenly dispersed throughout the course of treatment, for depression in PD.

Case Series

TOP INTRODUCTION Case Series Discussion REFERENCES

 
Patient overview The three patients described below were diagnosed with PD on the basis of a neurologist’s exam and standard PD research criteria; they met DSM–IV criteria for recurrent major depressive disorder (with duration of the current episode ranging from 6 months to 1 year), and did not present with dementia or psychosis. In addition to dysphoric mood, sleep difficulties, anxiety, anhedonia, and concerns about their disease progression and appearance were identified as their most troublesome symptoms. Patients agreed to keep their psychotropic and PD medication stable while in the study.

Patient 1 This patient was a 52-year-old, married, white man with a 5-year history of PD (Hoehn and Yahr¹⁴ Stage II.5). He was unemployed and had been receiving full disability for depression for the past 10 years. Feeling no sense of meaning or purpose to life, he rarely left his house. Current medications included carbidopa-L-dopa for PD and escitalopram, mirtazapine, and clonazepam for depression and anxiety. He had a history of poor response to antidepressant medication. Comorbid DSM–IV diagnoses included generalized anxiety disorder and history of panic disorder with agoraphobia. His wife of 30 years was his primary caregiver.

Patient 2 This patient was a married, 60-year-old white woman who had had PD for the past 9 years (Hoehn and Yahr¹⁴ Stage III). She had been unable to work at her long-term job as a waitress during the previous year because of the progressive nature of her PD (e.g., freezing, balance difficulties, tremor). She was extremely motivated to participate in community and social events but felt "beaten down" by chronic medical and familial stresses. She had a history of poor tolerance to antidepressants and was not currently taking psychotropic medication. Current PD medications included carbidopa-L-dopa and ropinirole hydrochloride. Her husband had a lifetime history of alcohol dependence; her 30-year-old daughter was her primary caregiver.

Patient 3 This was a 76-year-old married, white man diagnosed with PD in the past year (Hoehn and Yahr¹⁴ Stage II). He had a history of poor tolerance to antidepressants but was taking clonazepam for anxiety and carbidopa-L-dopa for the PD. He believed that the PD diagnosis rendered him a useless person with a purposeless life, and he was extremely concerned about burdening his family if the disease were to progress. He reported fleeting suicidal thoughts.

Psychological Assessment
The following measures were administered at baseline (Time 1), midpoint of the treatment (Time 2), endpoint (Time 3), and 1-month follow-up (Time 4): the Hamilton Rating Scale for Depression (Ham-D)¹⁵ and Beck Depression Inventory (BDI),¹² measures of depression; the Inference Questionnaire (IQ),¹⁶ a measure of negative cognitions; the State–Trait Anxiety Inventory (STAI),¹⁷ a measure of anxiety; and the Adaptive Inferential Feedback Questionnaire (AIFQ),¹⁸ a measure of social support that assesses the extent to which caregivers refuted the patients’ negative cognitions. The Ham-D was designated as the primary outcome measure. A summary of scores is presented in Table 1.

View this table: [in this window] [in a new window]

TABLE 1. Patient Characteristics and Outcomes

Psychosocial Intervention
The treatment involved training in stress management, behavioral modification, sleep hygiene, relaxation techniques, and cognitive restructuring. Treatment began by identifying life stressors that appeared to be contributing to depressed mood. Afterwards, both long- and short-term plans to minimize stress and maximize quality of life were formulated. Toward this end, goals regarding daily exercise were collaboratively established to enhance both mood and motor function while helping to decrease stress, fatigue, and rumination. We established a focus on meaningful activities early in treatment in order to help patients maintain and/or achieve a sense of purpose and fulfillment in their lives, despite the progressive nature of PD. Patients were also encouraged to adjust their expectations of themselves, expanding the repertoire of activities that they found to be enjoyable and "do-able," in order to maximize the amount of positive reinforcement derived from the environment. Pleasant activities were also hypothesized to decrease the patients’ focus on their physical condition. Because all patients had sleep difficulties, we introduced sleep hygiene techniques, such as avoiding daytime naps and establishing bedtime and wake-up routines. Overall, behavioral strategies were intended to help patients maximize control in their lives.

Given the high prevalence of anxiety and somatic complaints in the PD population,¹⁹ relaxation techniques, such as diaphragmatic breathing, abbreviated progressive muscle relaxation, and guided visualization, were incorporated into the study treatment, with emphasis dictated by patient preference. We emphasized the incorporation of these relaxation strategies into daily routines as well as the application of these techniques in the face of stress, with the intention of lowering patients’ overall level of arousal. Moreover, Patients #2 and #3 (described above) were able to use relaxation strategies to control the exacerbation of tremor and dyskinesia during times of stress.

Throughout the course of treatment, patients were also asked to monitor the thoughts and feelings that they had in response to stressful situations on the Automatic Thought Logs, as described by A.T. Beck.^12,13 Patterns of thoughts, feelings, and behaviors were highlighted in order to identify areas for intervention. For example, common negative thoughts endorsed by these three patients included "I’m helpless ... useless ... just a burden." As a complement to the behavioral strategies described above, the patients’ negative thoughts were evaluated. A major focus was on the confrontation of thoughts leading to excessive disability and dependency. Moreover, we emphasized that depression is distinct from PD; thus, PD patients are not inevitably depressed, and they may experience noticeable improvement in mood despite the continued presence of their medical condition.

In order to tailor the intervention to the specific needs of the PD population, the following adaptations to Beck’s treatment for depression¹² were made: fewer topics were addressed in each session, and treatment material was simplified, presented in a variety of modalities, and frequently summarized (e.g., with handouts or worksheets). Also, therapy material was repeated in both written and oral form throughout the session. Patients were encouraged to listen to the audiotape of each previous treatment session before the upcoming session, to facilitate practice and mastery.

Caregiver sessions, occurring separately from the patients’ treatment sessions, served as a supplement to the patients’ individual therapy. These sessions focused on psychoeducation, as well as strategies for responding to the patients’ negative and pessimistic thoughts in a constructive manner. The caregiver was educated about the course and prognosis of PD and depression. We suggested ways for the caregiver to reinforce the patients in their application of the newly-acquired coping skills learned during the treatment program, as well as strategies for minimizing the patients’ sense of helplessness (e.g., not offering assistance in areas where it is not needed). The repetition of the treatment material by the caregiver was hypothesized to help compensate for the patients’ deficits in executive functioning. The caregiver was also trained to recognize patients’ negative thoughts such as "I’m so stupid for making that mistake yesterday" and to offer nondepressogenic alternatives, such as, "Everyone makes mistakes sometimes." Essentially, the feedback that the caregiver was taught to provide to the depressed patient at home mirrored and reinforced the cognitive interventions provided to the patient in the office.^18,20 In addition to reducing the patients’ feelings of depression and hopelessness, these techniques were intended to help reduce the caregivers’ feelings of frustration by providing them with specific techniques that could be applied on a regular basis in response to the patients’ worries and concerns.

Outcome
All three patients and their caregivers found the treatment package desirable, practical, and helpful. All patients experienced a meaningful reduction in depressive symptoms over the course of treatment on both clinical outcome measures (the Ham-D and BDI, as shown in Table 1). These gains were observable by the midpoint of treatment and maintained at 1-month follow-up. Patients also demonstrated a notable decrease in negative and suicidal thoughts and an increased perception of a specific type of social support (e.g., AIFQ; caregivers actively challenging their negative cognitions). Only minimal changes in anxiety were observed in response to the study treatment.

Discussion

TOP INTRODUCTION Case Series Discussion REFERENCES

 
This case series examined the feasibility and effectiveness of a cognitive-behavioral treatment package for depression in PD patients. Results suggest that psychosocial interventions, when modified appropriately, may be feasible and effective options for the treatment of depression in PD. All three patients demonstrated clinically significant improvements in depression from baseline to endpoint, as evidenced by an approximately 50% reduction in symptoms as assessed by the Ham-D and BDI. Moreover, the Ham-D and BDI endpoint scores of Patients #2 and #3 reflected only minimal-to-mild depression symptoms.^21–23 Negative cognitions, a main target of change and major pathway for altering depressed mood within the CBT framework, also decreased over the course of treatment (IQ and BDI). This change may be attributable to the cognitive restructuring conducted during the patients’ individual therapy sessions, the caregivers’ disputing the patients’ depressogenic beliefs at home, improved mood resulting from the other components of treatment (e.g., behavioral activation, relaxation), and/or the synergistic effects of these various techniques. Since negative cognitions decreased in conjunction with depressed mood, patient gains in these areas are more likely the result of the active components of the study treatment, as opposed to concerted effort between therapist and caregiver, or other nonspecific factors.

We noted only minimal improvements in anxiety. Although the intervention did incorporate relaxation strategies and address somatic concerns, it was largely geared toward a reduction in anhedonia, an increase in meaningful activities, and the challenging of depressogenic cognitions—strategies very specific to the treatment of depression, as opposed to anxiety. It is possible that larger improvements in anxiety would have occurred if the treatment had placed a greater emphasis on the alleviation of somatic tension and arousal, as well as the modification of anxiogenic thoughts. The finding may also be an artifact of the small sample size. A larger, controlled study is needed to further isolate and explore the mechanisms of change specific to this intervention.

Our utilization of the caregiver as an integral part of treatment was innovative and has not been previously described. To date, evidence-based treatments for mood disorders in elderly patients do not have standardized approaches for working directly with members of patients’ social networks, with the primary intent of alleviating the patients’ depression. A major component of the caregiver sessions focused on techniques for recognizing and responding to the patients’ negative thoughts in a targeted manner. Both the caregivers’ reports during their training sessions, as well as the patients’ responses on the AIFQ, indicated that the caregivers demonstrated a notable increase in these skills over the course of treatment. The patients’ improved mood over the course of treatment may have also led them to view their communications with their caregivers in a more favorable light (with patients possibly demonstrating less negative filtering).

Future studies should include a more formalized assessment of caregiver burden, as well as the caregivers’ perception of the patients’ depression. Real-time assessment (e.g., with the use of electronic media) of the communications between patient and caregiver may also allow for the more precise measurement of social support in the home environment. Because the caregivers’ disputing of patients’ depressogenic thoughts decreased somewhat during the follow-up period (as assessed by the AIFQ), additional caregiver booster sessions may prove helpful.

Since the treatment outcomes presented in this series are limited to three patients, further research is needed to assess the applicability and generalizability of these findings. Once fully developed, this augmented intervention may prove particularly helpful for PD patients with mild-to-moderate major depression who prefer a nonpharmacological treatment as a first-line approach or those who have experienced poor efficacy or tolerability of antidepressant medication. This intervention may also be salubrious for moderate-to-severe, as well as treatment-refractory cases of depression, which often benefit from a multimodal treatment approach.^24–26 By providing caregivers with a specific set of skills that can be applied on a daily basis, the treatment package also has the potential to ameliorate the deleterious impact of caregiver burden on PD patients’ psychosocial adjustment.

REFERENCES

TOP INTRODUCTION Case Series Discussion REFERENCES

 

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