Clinical Psychology Interventions Case Study by V.M. Westerberg

Clinical Psychology Interventions 1 V.M. Westerberg

Brief Home-Based Cognitive-Behavioural Therapy for Parkinson’s Disease-Related Depression: A Case-Study

V.M. WesterbergMassey University School of Psychology

Palmerston North, New Zealand

Abstract

An innovative, brief, home-based Cognitive-Behavioural Therapy (CBT) for Parkinson’s Disease-related depression (dPD) was evaluated. The participant was a 67-year-old male with dPD who was attending the STAR (Services for Treatment, Assessment and Rehabilitation) Centre at Palmerston North Hospital for motor function improvement. Psychological outcomes were assessed using well validated mood and quality of life measures. The participant showed considerable symptom improvement mostly related to a decrease in his cognitions regarding failure and shame. Mood amelioration was related to a perceived life-quality improvement. Some increase in his activity level was noted during therapy and follow up. Plausible reasons for the findings are discussed together with their significance for theory, research, and clinical applications.

Keywords: Cognitive-Behavioural Therapy, Parkinson’s Disease, Depression.

Introduction

No other psychotherapeutic intervention has received more clinical and research attention than CBT. Its origins date back to the 1940s when a pressing need emerged to develop an effective short-term psychotherapy for the many returning WWII veterans who were failing to adjust to everyday life. CBT evolved over the following decades as a multi-theoretical intervention that drew from behavioural, cognitive, social learning, information processing and, more recently, Asian–philosophy theories. Given its multiple sources, a single, uniform type of CBT intervention could hardly be expected. Evaluation of the efficacy of CBT has enabled variations in its delivery as reported in countless journal articles. One such variation is the form and length of treatment, which are at the very origins of CBT


(DeYoung, Flanders, & Peterson, 2008; Cole & Vaughan, 2005; Merrick, 2013).

Standard CBT treatments typically span 15–20 sessions (Merrick, 2013). Brief CBT consists of fewer than 10 sessions (Cole & Vaughan, 2005; Saxena et al., 2009) and a 2-session model was originally developed to prevent suicide among military personnel in combat (Rudd, 2012). Among the advantages of briefness are use in emergencies (suicidal or homicidal ideation) and an increased cost-effectiveness (accessibility to more patients). The rapid symptom improvement benefits therapy credibility and patient motivation. On the other hand, a brief approach requires a well circumscribed problem and a motivated patient. That is why brief CBT is not recommended for patients with Axis I and II disorder comorbidities but is for patients with a psychological disorder brought about by a medical condition, because the latter individuals often have acute rather than chronic psychological issues and are more likely to have adequate coping strategies (Cole & Vaughan, 2005; Rosso, Crespi, Martini, & Maina, 2009; Saxena et al., 2009).

Home-based therapy is often the only option when a patient cannot keep clinic appointments due to illness, disability, personal crisis, distance to clinic, or for lack of resources, transportation, time, or dependent relative care. Home-based therapy can be used as primary approach, intermittently, or to supplement in-clinic sessions (Rybarczyk, Lopez, Schelble, & Stepanski, 2005; GoodTherapy, 2013). Clinician-patient communication can be done by phone, e-mail, or video-conference (Foroushani, Schneider, & Assareh, 2011; Veazey, Cook, Stanley, Lai, & Kunik, 2009; Diefenbach, Tolin, Gilliam, & Meunier, 2008). The latter option will be more of a mainstream approach in some 15-20 years’ time when virtually all the elderly population will be computer-literate (Glueckauf et al., 2012; Cosio, Jin, Siddique, & Mohr, 2011; Purves, Bennett, & Wellman, 2009).

Because of the extensive evidence-based success of standard CBT with psychopathological disorders, it has been tried with a growing number of medical conditions including chronic pain and neurological disorders like multiple sclerosis and dementia (Blom, Bosmans, Cuijpers, Zarit, & Pot, 2013; Askey-Jones,


David, Silber, Shaw & Chalder, 2013; Dennison & Moss-Morris, 2010). Moreover, neurologists have began recommending CBT for dPD, but very few studies have been published evaluating the effectiveness of standard – let alone brief and/or home-based – CBT (Armento et al., 2012; Charidimou, Seamons, Selai, & Schrag, 2011).

Parkinson’s disease (PD) is more a sporadic than an inherited neurodegenerative condition characterised by slow, progressive death of dopaminergic neurons in the basal ganglia of the midbrain resulting in motor symptoms (tremor, rigidity, imbalance, bradykinesia) and non-motor symptoms (depression, anxiety, insomnia, psychosis, dementia). Medication, like SinemetR, can only slow down PD progression. About 1% of people over 60 (mean age of diagnosis) have PD. PD hinders life quality more than life expectancy (Braunwald et al., 2008).

Depression is a biopsychosocial mood disorder characterised by feelings of sadness, hopelessness, worthlessness, guilt, anhedonia, psychomotor retardation, and social withdrawal. The biology of depression points towards genetic causes leading to anatomical (prefrontal cortex, amygdala, hippocampus) and functional (serotonin, dopamine, and noradrenalin receptors) abnormalities (Braunwald et al., 2008). Widely accepted psychological explanations of depression include behavioural and cognitive theories. The behavioural approach claims that depressive behaviour is learnt and can be unlearnt through positive reinforcement and the teaching of new skills. The cognitive model states that a triad of negative perceptions of self, the world and the future, combined with negative schemas and cognitive biases produces a vicious circle resulting in depression. Finally, social-learning theories assert that depressive behaviour is modelled and that therapy requires role models with healthier behaviours (Sadock & Sadock, 2007; Merrick, 2013; Prochaska & Norcross, 2013).

The high prevalence of depression in patients with PD has also been related to a combination of biopsychosocial factors (Sadock & Sadock, 2007). PD and depression share biological abnormalities in brain anatomy leading to impairment in motor function, cognition and information processing, and to functional abnormalities in dopamine and serotonin levels (Braunwald et al., 2008). The psychopathology of depression in PD has been


attributed to a worsening in quality of life due to relentless disability. Finally, PD and depression are socially undesirable conditions that frequently cause shame and isolation (Nijhof, 1995).

About 70% of individuals with dPD are either not medicated for their depression or treatment becomes progressively ineffective (Braunwald et al., 2008). One reason for undertreatment is underdiagnosis because most dPD patients do not fulfill the criteria for major depressive disorder (APA, 2013). An accurate diagnosis is important because dPD differs from isolated depression in etiology and patient characteristics. Patients with dPD tend to be older, physically disabled, and with some degree of cognitive impairment. How CBT should be modified for dPD patients requires further research (Kaiser, Bodey, & Bodey, 2000) and justifies the current study. From a pioneer study by Dreisig, Beckmann, Wermuth, Skovlund and Bech (1999) to a more recent research by Dobkin et al., (2011), CBT has been shown to lead to improvement on some psychological aspects in cases of dPD. Brief CBT has been successfully tried in patients with symptoms similar to PD, suggesting that CBT influences cognition regardless of the underlying pathology – organic or psychological (Westbrook, Kennerley, & Kirk, 2012).

Method

Procedure

Following referral from the participant’s neurologist, the clinician phoned the participant to arrange a home visit to explain the process, goals, and format of the study, the assessment, and the intervention. This was followed by a 1-hour semi-structured clinical interview which informed the case description and by the test battery which informed the intervention. The participant was told how to complete the 10-day-baseline measurements and the pre-, post- and follow up outcome measures. He was given a Daily Activity Planner (DAP) and a copy of Beck’s (2000) “Coping with depression when you have Parkinson’s disease” to guide the self-administered intervention (Cole & Vaughan, 2005). A written report was sent


to the participant a month after the last follow-up check.

Participant

Mr P is a 67-year-old Caucasian male who was recruited at the Rehabilitation Services in the STAR Centre at Palmerston North Hospital to which he was referred by his neurologist following an ICD-10-AM diagnosis: “F06.30: Mood disorder due to known physiological condition” (WHO, 2013), which was this study’s inclusion criteria together with an age ≥60. The exclusion criteria were co-morbid Axis I and Axis II diagnoses and current or past alcohol or substance abuse. Mr P is a farm equipment mechanic with a healthy lifestyle who had to retire a year after his PD diagnosis at age 62. His mood worsened considerably when his PD symptoms led to the revocation of his driver’s license. Mr P is divorced and lives alone with his 9-year-old dog, Max, in rural Waipawa, not far from his younger brother. His only daughter lives abroad with her husband and 3 children. Mr P is much liked by his ex-workmates, neighbours, and parishioners. He enjoys going to church and taking Max for a walk. His fear of further disability leading him to involuntary commitment is his motivational drive, which led him to attend the STAR Centre and join the current study.

Assessment

Appropriate assessment is a pre-requisite for all psychological interventions (Groth-Marnat, 2009; Clarke, 2012). Ethical issues like withdrawal, informed consent, and confidentiality were addressed in the first session. The assessment protocol started with a semi-structured clinical interview which included a mini-mental status examination (MMSE), followed by direct observation in different contexts (STAR clinic, home), and psychometric tests. The wealth of information gathered during the clinical interview included: Personal and family history, motor skills (dexterity, orientation, balance), sensory perception, language use and level, memory, general cognition, attention span, relationships and behavioural abnormalities, basic functions alterations (grooming, sleeping, and feeding habits), signs of psychopathology, suicidal and homicidal ideation, attributional style, coping style, core beliefs, values, and cultural background (Groth-Marnat, 2009; Kline, 2000;


Westerberg, 2012).

The clinical interview led to the identification of the 5 P’s of psychopathology (Merrick, 2013): Presenting problems, predisposing, precipitating, perpetuating, and protective factors for dPD (see Figure 1). With the patient’s consent, further health information was requested from his GP.

Figure 1. The 5P’s of dPD in this case study.

Assessment of outcome measures was optimised to the shortest, simplest, and most information-yielding battery given the limitations and severity of the participant’s condition. Appendix A shows a detailed description of the instruments.

Geriatric Depression Scale (GDS-15) (Sheikh & Yesavage, 1986). This reliable and sensitive tool requires “yes/no” responses to 15 short questions. The depression cut-off score is ≥5. It was chosen because it measures symptoms of depression in elderly individuals with concurring clinical pathology (Pomeroy, Clark, & Philp, 2001).

Hoehn and Yahr scale (1967). This commonly used, practical scale grades PD motor symptoms progression from 1 (minimal disability) to 5 (wheelchair bound).

Beck Depression Inventory–II (BDI-II) (Beck, Steer, & Brown, 1996). This psychometric tool was selected for being a practical,


robust, highly validated instrument for depression in elderly individuals with coexisting biomedical problems, like PD (Laidlaw, 2001).

Brief Coping Orientation for Problem Experiences Inventory (B-COPE) (Carver, 1997). This self-reported, flexible, age and situation-specific questionnaire measures coping strategies, problem-solving skills, feelings venting style, social support, and religious beliefs. Scores range from 28(worst)-112(best). Identifying patient’s coping styles may proof invaluable for therapeutic and prognostic outcomes.

Parkinson’s Disease Quality of Life Questionnaire (PQLQ) (De Boer, Wijker, Speelman, & De Haies, 1996). The PQLQ is a comprehensive tool that measures organic, psychological, and social aspects of PD in order to assess how the individual perceives his life quality.

Intervention

The intervention chosen was a modification of Cole and Vaughn’s (2005) based on Beck’s CBT protocol (2000) and is shown in Table 1. It consisted of an A-B design with an improved theoretical base , assessment and interventional approach, and an extended follow-up. Ten days prior to the intervention, the participant had to self-evaluate and record his baseline levels of daily activities and mood. This was followed by the intervention guided by Beck’s (2000) booklet consisting of 1-hour a week sessions (one per heading/chapter) for 7 consecutive weeks. The clinician phoned the participant every Monday morning to check on his weekly progress. Once a month after completion and for a total of 10 months, the participant was asked to repeat baseline measures to assess for recurrences or maintenance of improvement. Baseline, treatment, and follow-up, mood levels were evaluated using a face-colour visual analogue scale ranging from 0 “not depressed” to 10 “very depressed” (see Appendix B). The participant was also told to record the type and number of activities he engaged in on a Daily Activity Planner (DAP) modified from Bourne (2000)(see Appendix C). Detailed session description can be found in Appendix D.

Progress and difficulties were addressed during the 10-minute


weekly phone conversations and summarised and evaluated in session 7 and during follow-up. Therapy and supervision were delivered by the author who has a clinical neuropsychology background.

Results

A baseline measure of 58/112 on the B-COPE was unexpectedly low, but not the post-intervention and follow up scores, based on the information gathered during the clinical interview. Pre-intervention assessment revealed a score of 12/15 (moderate to severe depression) on the GDS-15. The patient’s GP confirmed that Mr P had been diagnosed with moderate dPD, did not have symptoms of dementia, and was taking SinemetR, an antiparkinsonian medication with known antidepressant effects. Mr P kept taking his medication during the intervention. The Hoehn and Yahr scale (1967) score of 3/5 categorised his motor disability as moderate to severe. A BDI-II result of 34/40 indicated a severe degree of pre-interventional dPD. The initial PQLQ scores showed that the patient was not satisfied with his current quality of life.

Cognitive symptoms of dPD, like failure and guilt, were identified in session 1 and addressed in sessions 4 and 5 and during follow


up. The mood enhancing activities were particularly welcome as the participant was motivated to improve and avoid being regarded as disabled. When his symptoms of PD worsened so did his depression, which sometimes made it challenging for him to comply with his behavioural work.

Despite the participant’s attempts to keep himself busy, he feared that his imbalance would cause him to fall and worsen his disability. This fear was addressed during cognitive restructuring together with other concerns related to the course of dPD. Overall, his engagement in the recommended activities led to a substantial mood and quality of life improvement during and after therapy. His post-intervention and follow-up GDS scores showed a depressive mood decrease, although BDI and self mood assessment evidenced a few remaining low mood symptoms.

Table 2 shows the participant’s scores on the outcome measures before (pre-) and after (post-) intervention, and the 10-month follow-up averages. The pre-interventional GDS-15 score evidenced a moderate to severe level of depression, and his BDI-II score of ≥16 indicated moderate dPD. All the post-treatment measures consistently show that mood level is inversely proportional to activity level. The data for this participant suggest that mood amelioration was a factor of an improvement in perceived quality of life (Cole & Vaughan, 2005; Leentjens et al., 2000).

To establish whether improvement was clinically significant, Jacobson and Truax (1991) Reliable Change Index (RCI) was used to calculate the difference in the GDS and the BDI-II pre- and post-therapy scores. With a test-retest reliability (TRR) of 0.85, findings for the total GDS scores indicate significant clinical amelioration (Yesavage et al., 1983), and with a TRR of 0.93 (Beck, Steer, & Brown, 1996) data for the BDI-II show a consistent improvement for this patient who had a moderate-severe pre-interventional depression. The participant’s scores for the BDI factors with a TRR of 0.85 (Cole & Vaughan, 2005) indicated a greater and significant improvement in the cognitive domain, with lower feelings of post-interventional unhappiness, despair, shame, and failure.

Table 2. Participant’s parametres and psychometric data


SinemetR is an antiparkinsonian drug with antidepressant effects. *The higher the PQLQ total score, the better the perceived quality of life.

Table 3. Reliable Change Indices (RCI) for outcome measures.

The participant’s self-recorded levels of activity engagement and


associated mood are shown in Figure 2. It should be noted that an improving trend can be difficult to interpret because test responses and results can be affected by physical pain or disability (Cole & Vaughan, 2005). The increase in activity and mood levels was initiated early during therapy and was sustained throughout follow-up.

Figure 2. Self-recorded activity and mood levels at the different stages of the intervention.

Discussion

The results obtained show that brief, home-based CBT led to significant symptom amelioration in this case of moderate-severe dPD. The improvement rate reported for the current case is in keeping with results from similar, larger N, standard CBT research studies (Cole & Vaughan, 2005; Feeney, Egan, & Gasson; 2005; Charidimou et al., 2011).

Particular attention should be drawn to the meaning of the discrepancies between the GDS-15 and the BDI for dPD diagnosis and prognosis. The specificity of the GDS-15 is similar to other short depression inventories (Weintraub, Oehlberg, Katz, & Stern, 2006). On the other hand, the somatic items in the BDI have been said to have the potential to confound interpretation (Williams & Richardson, 1993). In order to prevent false positives in dPD, a high cut-off point of 15 was determined meaning that cases of mild dPD may be overrated by the GDS and underrated by the BDI (Cole & Vaughan, 2005). The high specificity-low sensitivity dilemma is known to scientists, and in the case of dPD research (Burn, 2002; Dobkin et al., 2011)


it emphasises the need to develop instruments that can detect differences between organic and psychological symptoms of the disease.

Having said that, the association between an improved quality of life leading to a decrease in depressive mood was evidenced in this study. The behavioural component of CBT resulted in some improvement in the patient’s activity frequency, which was not as high as expected, possibly because the patient was rightly wary of his risk of falling or freezing and having no one to help him. This behaviour represents a rational evaluation of the patient’s physical disability due to PD and differs from the abulia in purely psychological depression (Sadock & Sadock, 2007). On the other hand, despite the patient’s motor limitations, the cognitive component of CBT resulted in a significant mood improvement as shown by the follow up BDI scores (Cole & Vaughan, 2005). This suggests that maybe cognitive therapy alone might have been just as good an approach for this patient.

LimitationsOne clear limitation was the impossibility to ensure whether the selected patient was representative of those with dPD, which hampers generalisation of results. Secondly, the briefness of baseline and treatment were chosen for being less taxing for the participant and maybe standard-length CBT would have been even more successful. Thirdly, the lack of a control group for a randomized control trial (RCT) and there being only one clinician to administer the intervention, make it difficult to tell whether the results should be attributed to the clinician, to the design and delivery (briefness, home-based), or to the CBT intervention itself (Cole & Vaughan, 2005). However, in view of the negligible amount of literature regarding brief, home-based CBT for dPD, the potential for symptom improvement demonstrated in this study warrants further research.


Conclusions

The available evidence from the literature and the current study, even with the limitations described, speak in favour of the effectiveness of brief, home-based CBT in individuals with dPD. Additional information from RCTs is still required to evidence the efficacy of this therapeutic approach in the management of patients with dPD. Questions to answer in future research are whether the intervention will improve the cognitive, the behavioural, the motor and/or the non-motor symptoms, what degree of PD and depression severity will benefit the most, and how the intervention should be modified for dPD. If shown effective in large RCTs, brief, home-based CBT could be used combined or as an alternative to medication in cases of tolerance in dPD.


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APPENDICES

APPENDIX APSYCHOMETRIC BATTERY

GERIATRIC DEPRESSION SCALE (GDS-15)


Source: http://www.stanford.edu/~yesavage/GDS.htmlThis scale is in the public domain.

Choose the best answer for how you have felt over the past week:


BECK’S DEPRESSION INVENTORY (BDI- II) (Beck, Steer, & Brown, 1996)

Source: www.thecommunityhouse.orgThis scale is in the public domain.


BRIEF COPE (B-COPE)(Carver, 1997)

Source: http://www.psy.miami.edu/faculty/ccarver/sclCOPEF.htmlThis scale is in the public domain


PARKINSON’S DISEASE QUALITY OF LIFE QUESTIONNAIRE (PQLQ)

Source: http://www.mapi-trust.org/questionnaires/accept/22This questionnaire was obtained with permission of the licensor

(Mapi Research Trust).


APPENDIX B

FACE-COLOUR DEPRESSION VISUAL ANALOGUE SCALEModified from www.wongbakerfaces.org

Instructions: Tick the box that best describes your mood today.

NOT DEPRESSED VERY DEPRESSED

MOOD LEVEL

0 1 2 3 4 5 6 7 8 9 10

DAY 1

DAY 2

DAY 3

DAY 4

DAY 5

DAY 6

DAY 7

DAY 8

DAY 9

DAY 10


APPENDIX CDAILY ACTIVITY PLANNER

[Modified from: Bourne, E. J. (2000). The Anxiety & Phobia Work Book (3rd Ed.) Oakland, CA: New Harbinger Publications]


APPENDIX D

BRIEF, HOME-BASED CBT SESSION DESCRIPTION

SESSION 1 comprised ethics protocols, clinical interview (included a MMSE), psychometric battery administration, explanation of therapy procedure and goals, and identifying depressive symptoms using the self-reported mood scale provided.

SESSIONS 2 and 3 dealt with the behavioural aspects and goals of therapy and addressed how his behaviour can perpetuate his dPD with statements like “I don’t go out anymore for fear of falling” and “I don’t call anyone because I have nothing to tell other than complain about my disabilities”. Therapist and participant agreed on two goals to address the question “How do I change my behaviour?”

Goal 1: Increase physical activity, control, and confidence. After breakfast, Mr P went out for a short 10-minute walk with his dog, nearby, and always carrying an umbrella-looking walking stick and his mobile phone. The length of the walks increased by 5 minutes every week, up to 30 minutes. Mr P would smile and say hi when walking past a neighbour or acquaintance, and maybe make some brief small talk (weather, news). Mr P recorded how much housework, shopping and other errands or activities he had done in his DAP.

Goal 2: Engaging in social contacts. Mr P was encouraged to engage in activities he enjoyed before his dPD diagnosis: Go play cards on Thursday afternoon and to go to the noon mass on Sundays. He also agreed to make 2 phone calls a week: one to a relative and one to a friend focusing mainly on the other person. When speaking about himself, he discussed his motivation and progress with therapy, focusing on what he can and not on what he cannot do.


SESSIONS 4 and 5: Cognitive restructuring or how to change depressive thinking like “I am no longer good for anything” or “I have nothing to look forward to”. The aim was to change his negative automatic thoughts which were triggered by the diagnosis of PD and perpetuated by depression after his forced, early retirement and the withdrawal of his driver’s license. Mr P had to record and challenge each negative thought with a positive one and record the resulting emotion and behavior in his DAP. For example “I am no longer good for anything. This makes me feel sad and guilty”, was challenged with: “The fact is that I have been living on my own for 12 years and I have managed my care, my home, and my finances pretty well. This makes me feel proud of myself and I intend to go on being self-reliant”. “I have nothing to look forward to makes me feel hopeless” was challenged with: “The fact is that I have a daughter and 3 grandchildren. They are my legacy and are more important than anything material I could have. This makes me feel happy and reassured, and it makes me want to keep in contact with them”.

SESSION 6 – Problem solving: The therapist informed Mr P about how dPD affects problem solving skills. During this session, the patient drew a list of all the problems he was experiencing. Then Mr P had to identify the single most important current problem and write down at least 3 solutions that he would discuss with the therapist over the phone to identify the best and most realistic solution/s. The benefits of the combination of his medical treatment for dPD and psychotherapy were emphasised in this session.

SESSION 7: The therapist summarised and evaluated the patient’s achievements and how progress had been his own doing. Therapy termination issues and relapse prevention were addressed in this session and the patient was encouraged to keep practising his newly learned skills and to call his therapist if he noticed that his symptoms were recurring or worsening. The participant looked forward to proceeding with the monthly follow up programme over the next 10 months. The therapist reassured the patient saying that dPD relapses are not uncommon and do not necessarily mean that the treatment had failed, just like getting over a cold does not mean you will not get a cold again, it just needs to be treated, the sooner the better.

Clinical Psychology Interventions Case Study by V.M. Westerberg

Healthcare

Transcript of Clinical Psychology Interventions Case Study by V.M. Westerberg