Do symptoms of depression,anxiety or stress impair the effectiveness of cognitive behavioural therapy for insomnia? A chart-review of 455 patients with chronic insomnia

BackgroundCo-occurring insomnia and symptoms of depression, anxiety, and stress pose difficult diagnostic and treatment decisions for clinicians. Cognitive Behavioural Therapy for Insomnia (CBTi) is the recommended first-line insomnia treatment, however symptoms of depression, anxiety and stress may reduce the effectiveness of CBTi. We examined the effect of low, moderate, and severe symptoms of depression, anxiety, and stress on insomnia improvements during CBTi.MethodsWe undertook a chart-review of 455 patients (67% Female, Age M = 51.7, SD = 15.6) attending an outpatient CBTi program. Sleep diaries and questionnaire measures of insomnia, depression, anxiety, and stress symptoms were completed at pre-treatment, post-treatment and three-month follow up. We examined 1) the effect of low, moderate, and severe symptoms of depression, anxiety, and stress before treatment on changes in sleep diary and questionnaire measures of insomnia during CBTi, and 2) changes in symptoms of depression, anxiety, and stress during CBTi.ResultsSleep diary and questionnaire measures of insomnia severity showed moderate-to-large improvements during CBTi (d = 0.5–2.7, all p ≤ 0.001), and were not moderated by levels of depression, anxiety or stress before treatment (all interactions p > 0.05). Symptoms of depression, anxiety, and stress improved by three-month follow-up (M improvement = 41–43%; CI = 28–54, Cohen's d = 0.4–0.7).ConclusionsSymptoms of depression, anxiety, and stress do not impair the effectiveness of CBTi. Instead, CBTi was associated with moderate-to-large improvement of depression, anxiety, and stress symptoms in patients with insomnia disorder. Clinicians should refer patients with insomnia for CBTi even in the presence of comorbid symptoms of depression, anxiety, and stress.     

Combining drug and music therapy in patients with moderate Alzheimer’s disease: a randomized study

Alzheimer’s disease (AD) can impair language, but active music therapy (AMT) and memantine (M) can improve communication. This study aimed to clarify whether adding AMT to M may improve language in comparison with drugs alone in patients with moderate AD on stable therapy with acetylcholinesterase inhibitors (AchEI). Forty-five AD patients treated with stable dose of AchEI were randomized to receive AMT plus M 20 mg/day or M 20 mg/day for 24 weeks. The Severe Impairment Battery-Language (SIB-l), SIB, Mini Mental State Examination, Neuropsychiatric Inventory (NPI), Lubben Social Network Scale, Activities of Daily Living, and Instrumental Activities of Daily Living scores at baseline and 12 and 24 weeks assessed language (primary variable) and overall cognitive, psycho-behavior, social, and functional aspects (secondary variables). The SIB-l showed a stabilization of the baseline condition in both groups, in the absence of between-group differences. The NPI depression and appetite scores significantly improved in the M-AMT group. Moreover, significantly less patients in the M-AMT group than those in the M group showed worsening of the NPI total score. Daily activities, social relationships, and overall cognitive performance did not deteriorate. In patients with moderate AD, AMT added to pharmacotherapy has no further benefits for language in comparison with pharmacotherapy alone. However, this integrated treatment can improve the psycho-behavioral profile.     

REM sleep behavior disorder and motor dysfunction in Parkinson's disease – A longitudinal study

ObjectivesLongitudinal assessment of a Parkinson's disease (PD) cohort, to investigate the evolution or REM sleep behavior symptoms (RBD) over time and to test the relation between RBD at onset and motor dysfunction progression.MethodsAn early stage PD cohort (n = 61) was assessed at two time points, separated by a two years interval. Diagnostic criteria for RBD were: violent behavior during sleep and body movements or vocalization indicative of dream enacting and at least six affirmative answers in the REM sleep behavior disorder screening questionnaire. Motor function assessment was performed with the Unified Parkinson's Disease Scale part II and III (total and partial scores for tremor, bradykinesia, rigidity, gait/postural instability and dysarthria).Results25 Patients had RBD at baseline, vs. 35 at follow-up. Three RBD changed to non-RBD at follow-up, while 10 non-RBD patients developed RBD at follow-up (annual incidence of 12.5%). RBD and non-RBD patients did not differ significantly at baseline or follow-up. The presence of RBD at baseline was significantly related to an increase in UPDRS total and bradykinesia scores over time.DiscussionRBD symptoms can vary over time and have a tendency to increase during the early stages of disease. The presence of RBD symptoms could be a risk factor for motor function deterioration and particularly for bradykinesia worsening.     

Gender and onset age-related features of non-motor symptoms of patients with Parkinson's disease – A study from Southwest China

BackgroundNon-motor symptom (NMS) differences between male Parkinson's disease (PD) and female PD, and between early-onset PD (EOPD) and late-onset PD (LOPD) in Chinese populations remain largely unknown.MethodsA total of 522 PD patients from Southwest China were included. Patients were assessed using the Non-Motor Symptom Scale (NMSS) and Unified PD Rating Scale (UPDRS).ResultsMore NMS and significantly higher NMSS score were found in LOPD patients than in EOPD patients (9.3 ± 5.9 vs. 7.7 ± 5.6, P = 0.005; 37.4 ± 32.2 vs. 30.5 ± 28.9, P = 0.018), while no such differences were found between male and female patients. The NMS of gastrointestinal and urinary domains were more common in LOPD patients than in EOPD patients, whereas sexual dysfunction was more common in EOPD than in LOPD. The sleep/fatigue domain, the mood/apathy domain and “pain” symptoms were more prevalent and severe in female patients than in male patients while urinary symptoms were more common and severe in male patients. Significant positive correlations were observed between disease duration, Hoehn & Yahr stage, UPDRS Ⅲ, and NMSS score in the total sample, subgroups of both male and female patients as well as both EOPD and LOPD patients.ConclusionsNMS are common in the Chinese PD population. LOPD patients are likely to present with more and severe NMS than EOPD patients. Males are subjected to urinary symptoms and females are subjected to mood/apathy, sleep and pain symptoms.     

Self-referral to group cognitive behavioural therapy: Is it effective for treating chronic insomnia?

ObjectivesTo evaluate the effectiveness of a short (3 session) programme of group cognitive behavioural therapy (CBT) on insomnia, sleepiness and symptoms of anxiety and depression.MethodsProspective observational study of group CBT with follow-up at 3 months. Participants were self-referred patients with chronic insomnia. Outcome measures were the insomnia severity scale (ISI), the Epworth sleepiness scale (ESS), depression (Pichot scale), and the number of anxiety symptoms.ResultsParticipation in CBT was offered to 489 patients of whom 474 completed the programme and 154 were followed up at 3 months. Significant improvements in insomnia were seen: ISI score (17.74–14.27, P < 0.0001) after CBT and at follow-up (13.78, P < 0.0001). At the end of CBT, 76% (59/78) with initial severe insomnia and 52% (132/255) with moderate insomnia were improved, maintained at 3 months in 71% (15/21) with severe insomnia and 56% (50/90) with moderate insomnia. Depression and anxiety symptoms were significantly improved: mean depression symptoms (4.15–3.35, P < 0.0001) and anxiety symptoms (4.52–3.95, P < 0.0001), maintained at 3 months with mean depression symptoms (3.17, P < 0.0001) and mean anxiety symptoms (3.62, P < 0.0001). Sleepiness increased between baseline and the end of the group (6.67–7.24, P = 0.015) followed by a reduction at 3 months (7.19–6.34 at 3 months, P = 0.001). Initial ISI score but neither sex nor age were predictive of outcome.ConclusionsA short programme of CBT can improve sleep, depression and anxiety symptoms in self-referred patients suffering from chronic insomnia with good adherence and maximum benefit in patients with severe insomnia.     

A controlled study of the effect of cognitive–behavioural group therapy for pathological gamblers

As the number of pathological gamblers has increased recently, the need for effective treatment has become more evident. The aim of this study was to evaluate the effectiveness of a short-term cognitive–behavioural group therapy programme for pathological gamblers. Fourteen subjects (three females and 11 males), who met the criteria for pathological gambling in accordance with the Diagnostic and Statistical Manual of Mental Disorders IV, were randomly assigned to a Treatment Group (n=7) or a waiting list Control Group (n=7). An experimental design with three repeated measures was used (pre-treatment, post-treatment/post-waiting list and follow-up). The dependent variables were DSM-IV Criteria for Pathological Gambling, Money Spent on Gambling During the Last Week and Gamblers Inventory of Negative Consequences. The Treatment Group improved on the DSM-IV Criteria for Pathological Gambling, but did not show a significant improvement on Money Spent on Gambling During the Last week from pre-treatment to post-treatment. Combining both groups at 3-months follow-up, there was a significant improvement on all three variables from pre-treatment to follow-up. The results of this controlled study indicate that a short-term cognitive–behavioural group treatment for pathological gamblers had an effect.     

Restless legs syndrome in Korean patients with drug-naïve Parkinson's disease: A nation-wide study

BackgroundRestless legs syndrome is a common neurologic disorder, and there is increasing evidence for a dopaminergic link between Parkinson's disease and restless legs syndrome. However, most previous studies did not take into account the effects of dopaminergic medication. We conducted a nation-wide, cross-sectional study to determine the prevalence and clinical characteristics of restless legs syndrome in Korean drug-naïve Parkinson's disease patients.MethodsOne hundred and fifty-one drug-naïve patients with Parkinson's disease were enrolled from 18 centers in South Korea over the course of one year. Clinical profiles of parkinsonism, restless legs syndrome, psychiatric symptoms, and laboratory data were collected. The findings of subjects with and without restless legs syndrome were compared.ResultsThe prevalence of restless legs syndrome in drug-naïve patients with Parkinson's disease was 16.5%. Subjects with restless legs syndrome had a higher mean Hoehn and Yahr stage and more severe limb parkinsonism, especially tremor. There was, however, no difference in iron metabolism between patients with and without restless legs syndrome. Analysis demonstrated that Beck's depression inventory score was associated with the severity of restless legs syndrome.ConclusionOur study demonstrated an increased prevalence of restless leg syndrome in drug-naïve patients with Parkinson's disease than in the general population. Based on the association between parkinsonism and restless legs syndrome, and the unique characteristics of restless legs syndrome in patients with Parkinson's disease, we suggest that the pathophysiology of restless legs syndrome in Parkinson's disease differs from that in patients without Parkinson's disease.     

Magnetic resonance imaging: A biomarker for cognitive impairment in Parkinson's disease?

Dementia is a frequent and disabling complication of Parkinson's disease (PD). Clinicians and researchers lack a biomarker capable of tracking the structural and functional changes that underlie the evolution of cognitive dysfunction in PD. Magnetic resonance imaging (MRI) has been adopted as a biomarker in natural history and interventional studies of Alzheimer's disease (AD) and amnestic mild cognitive impairment (MCI), but its utility as a biomarker for PD and Parkinson's disease dementia (PDD) is unclear. In this review, the authors summarize the studies that have used MRI to investigate cognitive decline in PD, outline limitations of those studies, and suggest directions for future research. PD dementia is associated with extensive cortical atrophy, which may be quantified with structural MRI. More promisingly, patterns of atrophy may be present in those who have PD with MCI (PD‐MCI). Subcortical white matter tract degeneration is detectable early in the disease with diffusion tensor imaging and may precede changes observed on conventional structural MRI. Although less well studied, other MR techniques, such as functional MRI, MR perfusion imaging with arterial spin labeling, and MR spectroscopy, have demonstrated differences in activation and metabolism between PD and PDD. In this review, the ability to compare studies was limited by the heterogeneity of study populations, cognitive testing methods, and imaging protocols. Future work should adopt agreed scan protocols, should be adequately powered, and should use carefully phenotyped patients to fully maximize the contribution of MRI as a biomarker for PDD. © 2013 Movement Disorder Society     

Apathy in drug-naïve patients with Parkinson's disease

ObjectiveThe aim of this study is to explore the prevalence and clinical correlates of apathy in early-stage Parkinson's disease (PD) from a cohort of Chinese patients.MethodsA cross-sectional analysis of 133 treatment-naive PD patients was conducted. Each subject was categorized as PD with or without apathy using the Lille Apathy Rating Scale (LARS).ResultsOf 133 patients, 30 PD patients (22.56%) reported apathy, of whom 23 (17.29%) did not have concomitant depression. The stepwise binary logistic regression model indicated that the lower Frontal assessment battery (FAB) score (OR = 0.623, 95% CI = 0.466–0.834, P = 0.001), the higher sleep/fatigue score from the Non-Motor Symptoms Scale (NMSS) (OR = 1.171, 95% CI = 1.071–1.279, P = 0.001), the higher Hamilton Depression Rating Scale including 24 items (HAMD-24) score (OR = 1.112, 95% CI = 1.005–1.230, P = 0.039) and the higher Unified Parkinson's Disease Rating Scale (UPDRS) part III score (OR = 1.119, 95% CI = 1.045–1.198, P = 0.001) were associated with apathy. No significant associations were found between apathy and other parameters such as age, sex distribution, disease duration, anxiety, Fatigue Severity Scale (FSS) score, Montreal Cognitive Assessment (MOCA) score and remaining domain scores for NMSS.ConclusionsApathy is not rare (22.56%) in Chinese treatment-naïve PD patients. Apathy in PD is not only related to the severity of motor symptoms of the disease but also to some non-motor symptoms, such as executive dysfunction, depression and sleep disturbances.     

What determines resilience in patients with Parkinson's disease?

ObjectiveTo investigate the relationship of resilience to disease severity, disability, quality of life (QoL) and non-motor symptoms in Parkinson's disease (PD). A secondary objective was to investigate whether resilience is distinct from other personality domains in PD.BackgroundResilience is the ability to reestablish emotional equilibrium in the face of adversity. It may play a pivotal role in disability and quality of life and has not been studied in PD.Methods83 PD patients (Age 66.3 ± 10.6, Total Unified Parkinson's Disease Rating Scale (T-UPDRS) 36.9 ± 17.8) completed the Resilience Scale 15 (RS-15). Scales measuring disability, mental and physical health-related QoL, non-motor symptoms (depression, anxiety, somatization, apathy, fatigue), and personality domains were completed. Pearson's correlations were analyzed between these scales and the RS-15.ResultsGreater resilience correlated with less disability (r = ?.30, p = .01), and better physical and mental QoL (r = .31, p < .01; r = .29, p = .01), but not with PD severity (T-UPDRS, r = ?.17, p > .05). Among non-motor symptoms and personality domains, resilience strongly correlated with less apathy (r = ?.66), less depression (r = ?.49), and more optimism (r = .54, all p < .001). Moderate correlations were seen between more resilience, reduced fatigue (r = ?.40) and anxiety (r = ?.34; both p < .001).ConclusionsResilience correlated with less disability and better QoL but not with PD severity. Resilience was also highly associated with both non-motor symptoms (less apathy, depression, fatigue) and a personality domain (more optimism). The role of resilience in helping patients adapt to living with symptoms of chronic disease may explain its lack of correlation with PD severity.     

Is dopamine agonist therapy associated with developing pathological gambling in Parkinson's disease patients?

In recent years, improving the quality of life and the level of functioning in Parkinson's disease patients has become the main challenge of all therapeutic protocols for this chronic disease. Hence, identifying comorbid psychiatric conditions is the ambition of many studies in the field. To date, a few research studies have investigated the development of problem gambling as a potential side effect of dopamine agonist medications. However, there are still controversies among experts in the field. Thus far, published reports have been able to neither demonstrate the extent of risk for gambling-related problems nor study the correlation of dosage with this potential adverse effect among Parkinson's disease patients treated with dopaminergic medications. In fact, prospective epidemiologic studies are needed to technically estimate the incidence rate and the relative risk of pathological gambling among patients with Parkinson's disease and to determine the correlation between dosage of these medications and the development of pathological gambling.     

Technology Matters: SPARX – computerised cognitive behavioural therapy for adolescent depression in a game format

Adolescent depression is common, and its prevalence is thought to be increasing in many high income nations. Addressing adolescent depression has proven challenging using traditional face-to-face psychotherapies, with major barriers including workforce shortages internationally and reluctance to seek help among some adolescents. There is substantial evidence to support the use of digital tools to treat mental health problems, with the National Institute for Health and Care Excellence (NICE) now recommending such tools as a first-line treatment. In this article, we outline the evidence base for SPARX, a digital tool named specifically in NICE guideline NG134, and discuss its use in clinical settings. We also consider implementation issues and future research directions.     

Is heart rate variability related to gait impairment in patients with Parkinson's disease? A pilot study

Background and purposeImpairments in gait and autonomic function are common in patients with Parkinson's disease (PD). These are likely independent symptoms, based on different etiologic mechanisms. However, a few recent reports have observed an association between motor function, in particular gait impairment, and autonomic function in PD. In those studies, the Unified Parkinson's Disease Rating Scale (UPDRS) was used to evaluate gait and motor function. The present study was performed to further examine this putative relationship using quantitative measures of autonomic function and gait in order to shed light on the underlying pathophysiology of these symptoms.MethodsNine healthy young, 15 healthy elderly and 18 PD patients were studied. Heart rate variability (HRV) measures were collected during rest. Gait speed, swing time and swing time variability were measured during a 1-min walk at comfortable speed. The motor portion of the UPDRS was also evaluated in all subjects.ResultsHRV values were highest in the young adults, intermediate in the healthy elderly controls, and lowest in the PD patients. Gait measures tended to deteriorate with age and were significantly worse in the PD patients, compared to the elderly controls. HRV was not correlated with any measure of gait performance (p > 0.129) nor with the UPDRS-motor score (p > 0.147).Discussion and conclusionsThe present findings support the idea that gait and autonomic function impairments co-exist in PD, but their etiology is based on distinct pathophysiological pathways, with minimal overlap.     

Can memory and executive functions in patients with obsessive–compulsive disorder predict outcome of cognitive behavioural therapy?

Background: Most studies find that patients with obsessive–compulsive disorder (OCD) have impaired memory and executive functions. Cognitive behavioural therapy (CBT) is the recommended psychotherapeutic treatment of patients with OCD. We hypothesized that impairments in memory and executive functions would predict poor outcome of CBT. Aim: To investigate whether memory and executive functions in patients with OCD could predict outcome of CBT. Methods: We assessed 39 patients with OCD before CBT with neuropsychological tests of memory and executive functions, the Hamilton Depression Rating Scale, and the Global Assessment of Functioning Scale. Furthermore, we assessed severity of OCD symptoms before and after CBT using the Yale–Brown Obsessive Compulsive Scale. Results: There were no statistically significant differences between recovered (41%) and non-recovered patients (59%) on any neuropsychological test variables or on any baseline demographic variables. Furthermore, change in OCD symptoms was not predicted by neuropsychological test performances or baseline severity of OCD symptoms. The only statistically significant finding was that non-recovered patients had lower social functioning before CBT than recovered patients (p = 0.018, d = 0.797). Conclusions: Memory and executive functions in patients with OCD could not predict outcome of CBT, but level of social functioning may be a predictor of CBT outcome. Some of the main clinical implications are that we cannot use memory and executive functions, or baseline severity of OCD symptoms to determine which patients should be offered CBT.     

Orthostatic hypotension in Parkinson's disease: association with cognitive decline?

BACKGROUND: Orthostatic hypotension is common in Lewy body disorders and may be related to disease progression and the spread of Lewy body pathology. We therefore hypothesize that PD patients with orthostatic hypotension (OH) have a different cognitive profile compared to PD patients without OH. METHODS: This cross-sectional study included 175 PD patients. Blood pressure (BP) was measured with a validated digital blood pressure monitor and patients with a systolic BP drop of > or =20 mmHg or a systolic pressure of <90 mm Hg after standing were considered to have OH. Cognition was assessed using MMSE extended by a selection of computerized cognitive tests focusing on reaction time, sustained attention, working memory and episodic verbal and visual memory. RESULTS: Eighty-seven (49.7%) of the PD patients had OH. These patients were significantly more impaired in sustained attention and visual episodic memory compared to PD patients without OH. CONCLUSION: We conclude that there are differences in the neuropsychological performance of patients with PD and OH, supporting the hypothesis that OH might be a marker for disease progression and cognitive decline in PD.     

The bidirectional longitudinal relationship between insomnia,depression and anxiety in patients with early-stage,medication-naïve Parkinson's disease

IntroductionWhile anxiety, depression and insomnia frequently (co-)occur in Parkinson's disease (PD) patients, little is known about their temporal relationship. In this study, we tested two hypotheses: i) insomnia predicts an increase in symptoms of depression or anxiety and ii) anxiety or depression at baseline predicts insomnia in PD patients six months later.MethodsWe used longitudinal data from a prospective cohort study of early-stage, medication-naïve PD patients. Primary outcome measures were: anxiety symptoms, measured with the State-Trait Anxiety Inventory (STAI); depressive symptoms, measured with the 15-item Geriatric Depression Scale (GDS-15); and insomnia, defined as a score ≥ 2 on item 1.7 of the Movement Disorder Society – Unified Parkinson's Disease Rating Scale. We performed linear and logistic regression analyses, correcting for baseline value of the respective outcome variable.ResultsBaseline insomnia was not associated with GDS-15 or STAI total score at follow-up. In a post hoc analysis, we found that insomnia predicted a higher STAI State score (B(SE) = 2.50 (1.07), p < 0.05), while the association with the STAI Trait score was not significant. Baseline STAI scores (B(SE) = 0.02 (0.01), p = 0.001) and GDS-15 score (B(SE) = 0.15 (0.05), p < 0.001) were significantly associated with insomnia at follow-up.ConclusionSymptoms of anxiety and depression may constitute a risk factor for insomnia in PD. The relationship between insomnia and anxiety is bidirectional, which suggests that both anxiety and sleep disorders can start a negative spiral in PD patients, where one enhances the other. Independent clinical attention for these symptoms in PD patients is therefore warranted.     

Are patients with Parkinson's disease suicidal?

Using the National Center of Health Statistics' mortality statistics databases for 1991 through 1996 (12,430,473 deaths), we isolated 144,364 individuals 40 years of age or older with a primary diagnosis of Parkinson's disease (PD). Of these, 122 died by suicide. The rate of suicide in the general population was about 10 times higher than in patients with PD (0.8% compared with only 0.08%, respectively). These different rates of suicide cannot be attributed to differences in age, gender, race, education, or marital status. Compared with patients with suicidal PD, patients with PD who died from other causes manifested significantly lower rates of affective disorders. The referent population exhibited a higher rate of malignancy and a lower rate of depression. The findings suggest that marital status, mood disorder, and somatic comorbidity provide only a limited understanding of completed suicide.