Teaching happiness to dementia caregivers reduces their depression, anxiety

Caring for family members with dementia -- which is on the rise in the U.S. -- causes significant emotional and physical stress that increases caregivers’ risk of depression, anxiety and death. 

A new method of coping with that stress by teaching people how to focus on positive emotions reduced their anxiety and depression after six weeks, reports a new national Northwestern Medicine study. It also resulted in better self-reported physical health and positive attitudes toward caregiving. 

“The caregivers who learned the skills had less depression, better self-reported physical health, more feelings of happiness and other positive emotions than the control group,” said lead study author Judith Moskowitz, professor of medical social sciences at Northwestern University Feinberg School of Medicine. She also is director of research at the Osher Center for Integrative Medicine at Feinberg. 

The positive-emotion intervention does not require a licensed therapist and can be widely implemented, making it accessible and affordable for busy caregivers. 

The paper was published May 2 in Health Psychology.  

“Nationally we are having a huge increase in informal caregivers,” Moskowitz said. “People are living longer with dementias like Alzheimer’s disease, and their long-term care is falling to family members and friends. This intervention is one way we can help reduce the stress and burden and enable them to provide better care.” 

Most current approaches to helping caregivers focus on education about dementia or problem solving around challenging behaviors but haven’t specifically addressed reducing the emotional burden of providing care. 

The intervention designed by Moskowitz and colleagues included eight skills that evidence shows increase positive emotions. They include noticing and capitalizing on positive events, gratitude, mindfulness, positive reappraisal, personal strengths, attainable goals and acts of kindness. (More details below.)  

Moskowitz wasn’t sure how many caregivers would be able to complete the program because “they are such a stressed, burdened group. But they were engaged and committed, which speaks to how much they need programs like this,” she said.

Currently there are 5.5 million people in the United States diagnosed with Alzheimer’s disease, which could increase to 16 million by 2050. The average life expectancy post diagnosis is eight to 10 years, although some people live as long as 20 years.

In the trial, 170 dementia caregivers were randomly assigned to either the intervention group in which they learned positive emotion skills such as recognizing a daily positive event and keeping a gratitude journal, or to a control group in which they filled out a daily questionnaire about their emotions. The positive emotion skill sessions, called LEAF (Life Enhancing Activities for Family caregivers), were presented by a facilitator via web conference, reaching caregivers across the U.S. The web delivery is especially important for caregivers who live in rural areas without local caregiver support services, Moskowitz said. 

In addition to Northwestern, the study was conducted out of the University of California San Francisco (UCSF). Dr. Glenna Dowling of the UCSF School of Nursing was the co-principal investigator on the study. 

In six weekly sessions, caregivers reviewed positive emotion skills and then had daily homework to practice the skills, including audio recordings. If the topic was acts of kindness, for example, their homework was to go out and practice an act of kindness.

All participants filled out a questionnaire about their depression, anxiety, physical health and caregiver burden at the start and completion of the study. 

LEAF participants had a 7 percent greater drop in depression and a 9 percent greater drop in anxiety compared to the control group. Participants in the intervention group decreased from showing moderate symptoms of depression relative to the population norm, to falling within the normal range of depressive symptoms by the post-intervention assessment. In contrast, participants in the control condition showed a smaller decrease in depression scores and remained within the mild to moderate range.  

One participant wrote, “The LEAF study and the techniques I learned by participating in it have brought about a serenity and calmness to my life and to that of my husband. We have both benefitted from my changed attitude.” 

Another commented, “Doing this study helped me look at my life, not as a big neon sign that says, ‘DEMENTIA’ in front of me, but little bitty things like, ‘We’re having a meal with L’s sister, and we’ll have a great visit.' I’m seeing the trees are green, the wind is blowing. Yeah, dementia is out there, but I’ve kind of unplugged the neon sign and scaled down the size of the letters."

Skills taught to participants in the study:  

1. Recognizing a positive event each day
2. Savoring that positive event and logging it in a journal or telling someone about it
3. Starting a daily gratitude journal
4. Listing a personal strength each day and noting how you used this strength recently
5. Setting an attainable goal each day and noting your progress
6. Reporting a relatively minor stressor each day, then listing ways in which the event can be positively reappraised or reframed
7. Understanding small acts of kindness can have a big impact on positive emotion and practicing a small act of kindness each day
8. Practicing mindfulness through paying attention to daily experiences and with a daily 10-minute breathing exercise, concentrating on the breath

Moskowitz will launch a new study funded by the National Institute of Aging where she will compare the facilitated version of the intervention (the one shown to be effective in this study) to a self-guided online version of the intervention (without a facilitator).  If the self-guided version is as effective as the facilitated one, the LEAF program can be implemented widely at relatively low cost to help the growing number of dementia caregivers in the U.S., she said.

Elaine Cheung was a Northwestern coauthor.

The article is titled “Randomized controlled trial of a facilitated online positive emotion regulation intervention for dementia caregivers.”

This work was supported by grant R01NR014435 from the National Institute of Nursing Research of the National Institutes of Health.