The Parkinson’s Foundation (parkinson.org) hosted an hour-long webinar in late November 2017 about non-medication treatment of depression in Parkinson’s Disease (PD). Actually, very little of the material presented was specific to PD but rather applies to anyone coping with depression. Our mood (degree of positive and negative thoughts) affects our quality of life, anxiety level, and motor function.
Find a link to the archived webinar recording here as well as a link to the slides: (you must register to view the recording)
parkinson.org/Living-with-Parkinsons/Resources-and-Support/PD-ExpertBriefings-Webinars/Archives
The excellent speaker was Roseanne Dobkin, PhD, a clinical psychologist at Robert Wood Johnson Medical School. She offered good advice for:
* changing negative thought patterns toward more realistic thinking
* setting incremental goals to overcome apathy and depression
* addressing another person’s negative or pessimistic comments
As always, Denise’s detailed notes are below. They are well worth reading.
Robin
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Notes by Denise Dagan, Brain Support Network volunteer
Parkinson’s Foundation Expert Briefing
Depression and PD: Treatment Options
Speaker: Roseanne D. Dobkin, Ph.D.
November 21, 2017
Solutions to Parkinson’s complaints are not something you can just call in. You need to take action to improve the situation for both motor and non-motor symptoms. Knowing the solutions and not implementing them will not help you.
Cognitive-Behavioral Therapy (CBT)
– Evidence-based psychotherapy
– Targets thoughts and behaviors
– Skills-based
– Very suitable for enhancing effective coping and treating depression in PD
CBT: Key Points of Emphasis
Multiple interacting causal factors of depression.
– Biological (brain chemistry, nutrition/diet, exercise/fitness)
– Cognitive
– Behavioral
Intervening on any one of these factors will improve depression, but improving on all of them will have the most beneficial effect.
Examples of 1:1 Interventions
* Increasing meaningful and social activities. Not just busy work, but something you really want to do, especially goal-oriented.
– Old: think what you used to love to do
– New: consider activities you didn’t participate in before PD
– Modified: accept you will need to do things differently than you used to, but you can still participate/contribute.
* Exercise every day
* Social goal – every day
* Self-soothing every day – what is relaxing and comforting to you? Hot tub, nature stroll, fire pit and wine.
– Taking action toward your goals doesn’t have to be huge daily. Start with baby steps and add more effort and time toward each goal up to your time and energy limits.
* Problem solving for physical limitations:
– Pacing of activities so you don’t overdo it
– Appropriate daily goals/less rigid demands
– Plan around “off time”
– Walk 10 minutes 3 x daily, instead of 30 minutes at a time
– Follow through with referrals for PT, OT and Speech
Roseanne told a story of a former fire fighter with PD whom she worked with to find ways in which he could still stay involved with his fire company. He began by joining them for a few social get-togethers, then began volunteering for charity works the fire company was involved in until he began spearheading some charity drives.
* Anxiety management and relaxation – Google these topics or find books at your local library
– Breathing exercises
– Progressive muscle relaxation
– Guided visualization (taking your mind to a place of calm actually brings down blood pressure & anxiety)
– Worry control
* Sleep hygiene
– Using bed for sleep only
– Relaxing before bedtime (limit blue light screen time in the hour, or longer, before sleep)
– Keeping regular sleep hours
– Limiting excess time in bed, daytime naps, caffeine, or alcohol in the evening
– If you aren’t falling asleep, get out of bed until you do feel sleepy so you don’t associate the bed with NOT sleeping, which can lead to insomnia.
* Thought monitoring and restructuring – Rethink the big picture. Use these techniques to rethink how you are feeling and responding to various situations. Stop the negative thought process, rewind what you thought, felt and did and project what you might do differently next time.
– Catch the negative thought
– Press pause
– Rewind
– Replay
* Multiple methods/techniques – to catch yourself and reframe your thinking from negative/unrealistic toward positive/realistic.
Thought Chart Examples: Keep track of the situation, your emotional response, and your thoughts.
Situation: Doing volunteer work
Emotion: Hopeless
Thoughts: I’m not capable of contributing. My life is meaningless.
Situation: Find out you are not invited to something
Emotion: Depressed
Thoughts: My PD makes friends uncomfortable.
Situation: Thinking about going to a party
Emotion: Anxious and scared
Thoughts: It will be horrible if people see my tremor
Are your thoughts balanced? Not rosy and positive, but realistic. Everything is not gloom and doom, either. There is usually a bit of both + and – in every situation. What would a jury of your peers decide? Is your perspective the only way to think about the situation? Are your thoughts fact based, in perspective rather than skewed?
Examine the “Evidence” for your thinking, in this case: I’m helpless. Was this person really helpless? No.
– Situation: Freezing in the bathroom.
– Automatic Thought: I’m helpless
– Evidence For: I was alone in the bathroom in the middle of the night and unable to move.
– Evidence Against: This happens quite a bit, so I planned in advance. I had my cell phone in my pocket. I called my wife on the house phone and she helped me back to bed.
– Rationale Response: Even though I was physically unable to move my feet, I was able to help myself out of the situation (thus I am not helpless).
Behavioral Experiment – because we often anticipate the worst before we have actually tried, so do a behavioral experiment, like this one:
– Negative Thought or Prediction:
“It will be impossible to have dinner in a restaurant because of my tremor.”
– Experiment:
I will to to the Olive Garden with my spouse on Saturday at 6pm.
– Outcome:
I was able to eat dinner at the Olive Garden. I ordered food that did not need to be cut and requested a straw and lid for my coke. I enjoyed getting out of the house. There were no leftovers to bring home.
You have control over your thinking and actions in response to your PD symptoms and circumstances: If you are thinking, “I am not accomplishing anything anymore.” Revise your thinking to, “I am still accomplishing many things for my family and community, even though I am no longer working in my business.”
If you are thinking, “I am rapidly deteriorating.” Revise your thinking to, “The neurologist said I was the same as 6 months ago and did not change my medications.”
If you are thinking, “Nobody at the party will talk to us.” Revise your thinking to, “At least some people will talk to us. It is highly unlikely that we will be completely ignored.”
CBT Outcome Data in PD studies:
* Dr. Dobkin’s first randomized control trial of CBT for people diagnosed with PD
– 80 people with PD (PWP) and caregivers were enrolled in the trial
– Intervention: CBT + clinical monitoring (neurologist) + standard care
– Control: Clinical monitoring (neurologist) + standard care
* 10 sessions of one-on-one CBT for the PD patient
* 4 supplemental caregiver educational sessions
* After the 10-week treatment period, there was a follow up 1-month later, which found those with CBT had significantly lessened feelings of depression for both the person with PD and their caregiver. Continuing this type of therapy over the phone can continue the effects of the initial treatment.
* Secondary outcomes improved, as well !
– Anxiety lessened
– Coping skills improved
– Quality of life improved
– Motor function improved (motor function follows mood: poor mood, poor motor function & vice versa)
– Negative thoughts lessened
Conclusions:
* Your mood is one critical aspect of living with PD that you can control.
* Don’t suffer in silence!
* Effective non-pharmacological treatments are available that can be used alone or in conjunction with standard pharmaceutical treatments.
QUESTION AND ANSWER
Q. Are medications helpful for depression in PD.
A. Absolutely, if someone’s depression is milder Dr. Dobkin recommends starting with CBT therapy. When symptoms are moderate to severe she recommends medication in combination with CBT therapy.
Q. How to people come to a psychiatrist, like Dr. Dobkin?
A. 30% of the time the patient is self-referred, they ask around to get a recommendation. 30% of the time they are referred to psychiatry from their neurologist. 30% of the time they are referred to psychiatry by a friend/family member or primary care physician.
Q. If you have apathy, how do you get motivated to get treatment?
A. Depression is feeling sad or low, and apathy is more of a lack of feeling. There is overlap because one symptom depression is lack of motivation. If you are feeling unmotivated, set yourself a very small, specific goal based on what is important to you or someone in your family. If you are not exercising, get a goal to walk for just a few minutes. Success in reaching your goal may motivate you to set your goal to walk a few minutes longer next week.
Q. If someone is biologically inclined toward depression aren’t they doomed to experience depression?
A. The biology component of the factors which contribute to depression is only one factor. It doesn’t matter how much biology is contributing to depression because the cognitive and behavior factors are also at play. Intervening in either or both the cognitive and behavior factors toward the positive make a significant positive impact on reducing feelings of depression.
Q. Is there any research data on the use of narrative therapy in PD?
A. Not that Dr. Dobkin knows of, but there is a place for all sorts of evidence-based non-pharmacological treatments that have been successful in other disorders and it will probably have some degree of success in Parkinson’s, as well.
Q. Is the Hamilton Depression Scale more for use by a clinician or by patients and their families?
A. It would be difficult to self administer, but there are dozens of tools that would be more user friendly for self evaluation. Most scales are best used in conversation with a health care professional. There are some good self help books that use cognitive behavior therapy as their basis for helping the reader. These books have some quizzes and self evaluations along with the self guided CBT based advice.
Q. Over the holidays what advice would you give families for helping someone who’s blue?
A. Let your distressed loved one know you are willing to listen if they want to talk. Try to engage them in planned family activities. People who are depressed tend to both think and speak in depressed language. Talk back to negative statements in positive ways to help them balance their thinking toward a more realistic perspective.