Review of intervention studies on depression in persons with multiple sclerosis

Third wave cognitive behavioural therapies for people with multiple sclerosis: a scoping review

PURPOSE

Multiple sclerosis (MS) is a chronic condition linked to a wide range of psychological difficulties. While traditional cognitive behavioural therapy has been studied extensively with people with MS, much less is known about more recent "third wave" approaches.

METHODS

A scoping review was carried out by performing a systematic search across MEDLINE Complete, PsycINFO, CINAHL, Academic Search Ultimate, and Cochrane Library up to January 2022.

RESULTS

From an initial return of 8306 citations, 35 studies were included, 20 of which were randomised controlled trials (RCTs). These showed that four third wave approaches have been investigated with people with MS to date: acceptance and commitment therapy (ACT), dialectical behaviour therapy (DBT), mindfulness-based stress reduction (MBSR), and mindfulness-based cognitive therapy (MBCT). MBSR and MBCT may be helpful to address a range of psychological difficulties up to three months post-intervention. However, MS-specific adaptations may be required, and more evidence is needed on longer-term effectiveness. Limited evidence is also available for DBT and ACT, but additional research is warranted before any recommendation can be made.

CONCLUSIONS

As third wave approaches keep being refined, further more rigorous investigations are needed to implement them to the benefit of people with MS. Implications for RehabilitationMultiple sclerosis is linked to a wide range of psychological difficulties in adults.Little is currently known on third wave psychotherapies for people with MS.Mindfulness-based stress reduction and mindfulness-based cognitive therapy may be helpful to address a wide range of difficulties in MS.Specific adaptations may be needed to deliver suitable therapies to people with MS.Additional research is warranted to build on preliminary findings for DBT and ACT.

Neurological Benefits, Clinical Challenges, and Neuropathologic Promise of Medical Marijuana: A Systematic Review of Cannabinoid Effects in Multiple Sclerosis and Experimental Models of Demyelination

Despite current therapeutic strategies for immunomodulation and relief of symptoms in multiple sclerosis (MS), remyelination falls short due to dynamic neuropathologic deterioration and relapses, leading to accrual of disability and associated patient dissatisfaction. The potential of cannabinoids includes add-on immunosuppressive, analgesic, neuroprotective, and remyelinative effects. This study evaluates the efficacy of medical marijuana in MS and its experimental animal models. A systematic review was conducted by a literature search through PubMed, ProQuest, and EBSCO electronic databases for studies reported since 2007 on the use of cannabidiol (CBD) and delta-9-tetrahydrocannabinol (THC) in MS and in experimental autoimmune encephalomyelitis (EAE), Theiler’s murine encephalomyelitis virus-induced demyelinating disease (TMEV-IDD), and toxin-induced demyelination models. Study selection and data extraction were performed by 3 reviewers, and 28 studies were selected for inclusion. The certainty of evidence was appraised using the Cochrane GRADE approach. In clinical studies, there was low- and moderate-quality evidence that treatment with ~1:1 CBD/THC mixtures as a nabiximols (Sativex®) oromucosal spray reduced numerical rating scale (NRS) scores for spasticity, pain, and sleep disturbance, diminished bladder overactivity, and decreased proinflammatory cytokine and transcription factor expression levels. Preclinical studies demonstrated decreases in disease severity, hindlimb stiffness, motor function, neuroinflammation, and demyelination. Other experimental systems showed the capacity of cannabinoids to promote remyelination in vitro and by electron microscopy. Modest short-term benefits were realized in MS responders to adjunctive therapy with CBD/THC mixtures. Future studies are recommended to investigate the cellular and molecular mechanisms of cannabinoid effects on MS lesions and to evaluate whether medical marijuana can accelerate remyelination and retard the accrual of disability over the long term.

Content Validity of an Integrated Yoga Module for Practice During Remission in Relapsing-Remitting Multiple Sclerosis Patients

Background:

Some investigations point to the beneficial effects of yoga in alleviating the motor and cognitive dysfunctions in multiple sclerosis (MS) patients by using varying combinations of physical, breathing, and meditative practices of yoga. There is a need for a validated yoga module with a holistic approach that can be used as a standardized protocol by researchers and therapists.

Purpose:

To develop and validate an integrated yoga module for practice in relapsing–remitting MS patients to improve their quality of life.

Methods:

We did a thorough review of the literature for the development of the yoga module. We formed an expert group with 24 experts and a neurologist and used two rounds of interactive Delphi method to combine their opinion to obtain content validity of the module through online structured questionnaire prepared for the purpose on a Google Form. We incorporated all suggestions obtained by the experts. The final module (60 min per session, twice a day, five days per week) included warm-up exercises, customized asanas, relaxation techniques, and OM meditation. Advice on yogic diet and discussion using yogic concepts for stress management also form a part of the holistic approach to yoga lifestyle modification.

Results:

Analysis divulged that 30 out of 39 practices exhibited a content validity ratio value greater than or equal to 0.42.

Conclusion:

The study has shown good content validity of the integrated yoga module. Future clinical studies are being planned to rule the feasibility and reliability of this module.

Depression in Multiple Sclerosis: Epidemiology, Aetiology, Diagnosis and Treatment

Depressive disorders are common in patients with multiple sclerosis, influencing their quality of life and adherence to treatments, as well as becoming more frequent with the progression of the disease and in the secondary progressive form of multiple sclerosis. Patients with multiple sclerosis often experience a typical cluster of symptoms in association with depression, such as fatigue, pain and cognitive impairment. However, the pathogenesis of multiple sclerosis-related depression remains partially unclear, even though genetic, immune-inflammatory and psychosocial factors might be seen to play a role, in addition to the brain structural alterations documented by magnetic resonance imaging studies. The high incidence and burden of depression in people affected with multiple sclerosis are matters of crucial importance. Despite such importance, the efficacy of pharmacologic treatments has been poorly studied and, for the most part, the access to non-pharmacological treatments is partially dependent on the local health system availability. It has been determined that interferon-beta and glatiramer acetate do not cause depressive symptoms; however, no definitive data in this regard are avaible for the newer disease-modifyng medications. In this review, we discuss the diagnosis, prevalence, pathogenesis, clinical aspects, magnetic resonance imaging findings and treatments available in patients experiencing multiple sclerosis-related depression.

Therapeutic Yoga: Symptom Management for Multiple Sclerosis

Multiple sclerosis (MS) is the most common autoimmune inflammatory demyelinating disease of the central nervous system, affecting over 2.3 million people worldwide. According to the National Institute of Neurological Disorders and Stroke, the age of disease onset is typically between 20 and 40 years, with a higher incidence in women. Individuals with MS experience a wide range of symptoms, including declining physical, emotional, and psychological symptoms (e.g., fatigue, imbalance, spasticity, chronic pain, cognitive impairment, bladder and bowel dysfunction, visual and speech impairments, depression, sensory disturbance, and mobility impairment). To date, both the cause of and cure for MS remain unknown. In recent years, more individuals with MS have been pursuing alternative methods of treatment to manage symptoms of the disease, including mind-body therapies such as yoga, meditation, breathing, and relaxation techniques. It has been suggested that the practice of yoga may be a safe and effective way of managing symptoms of MS. Therefore, the purpose of this paper is to summarize the most relevant literature on exercise and mind-body modalities to treat MS symptoms and, more specifically, the benefits and potential role of yoga as an alternative treatment of symptom management for individuals with MS. The article also discusses future directions for research.

Managing psychological stress in the multiple sclerosis medical visit: Patient perspectives and unmet needs

Psychological stress can negatively impact multiple sclerosis. To further understand how stress is addressed in the multiple sclerosis medical visit, 34 people with multiple sclerosis participated in focus groups. Transcripts were analyzed by inductive thematic analysis. The majority of participants did not discuss stress with their provider, citing barriers to communication such as lack of time, poor coordination between specialties, physician reliance on pharmaceutical prescription, and patient lack of self-advocacy. Participants recommended several ways to better manage psychological well-being in the clinical setting. These findings provide a foundation for future studies aimed at minimizing the detrimental effect of stress in multiple sclerosis.

Relationship between disease-modifying therapy and depression in multiple sclerosis

Many prescribers of disease-modifying therapies (DMTs) for multiple sclerosis (MS) believe that interferon beta (IFNβ) is more likely than glatiramer acetate (GA) to increase depression during the course of MS treatment. Therefore, newly diagnosed patients with a history of depression are often placed on GA therapy from the onset of MS treatment. The aim of this study was to examine the relationship between DMT type and depression among patients with relapsing-remitting MS (RRMS). Patients with RRMS who were examined from 2000 to 2007 and who remained on a single course of therapy (either an IFNβ or GA) were included in a retrospective review of medical records. Patients were asked to complete the Beck Depression Inventory (BDI) at treatment initiation and every 6 months thereafter for up to 4 years. Only patients who had completed a BDI within 6 weeks of starting their DMT were included in the analysis. No significant differences in mean change in BDI score were observed from baseline to 48 months between the IFNβ and GA subgroups. Additionally, no significant differences in mean BDI score change were observed between antidepressant-treated and non-antidepressant-treated patients within the IFNβ or GA subgroup. Neither IFNβ nor GA therapy appears to exacerbate depressive symptoms in patients with RRMS who remain on their initial therapy.

Cognitive behavioural therapy for the treatment of depression in people with multiple sclerosis: a systematic review and meta-analysis

BACKGROUND

Depression is a common symptom in people with multiple sclerosis. We systematically reviewed published controlled trials on the effectiveness of cognitive behavioural therapy (CBT) for the treatment of depression in people with multiple sclerosis.

METHODS

Publications were identified using MEDLINE, PsycINFO and the Cochrane Central Register of Controlled Trials to June/July 2013. We combined thesaurus and free-text terms which were synonyms of the concepts multiple sclerosis, depression and cognitive behavioural therapy. We included published controlled trials which compared individual, group CBT, conducted face-to-face or remotely, to no CBT. Two reviewers extracted data to calculate standardized mean differences (SMD) for self-reported symptoms of depression and weighted mean differences (WMD) for the Multiple Sclerosis Impact Scale (MSIS-29), with 95% Confidence Intervals (CIs). We investigated statistical heterogeneity using I².

RESULTS

Seven eligible studies (n = 433) were identified, which evaluated the effect on depression of CBT delivered individually (3 studies), in a group (3 studies) and by computer (1 study). The summary effect (SMD -0.61, 95% CI -0.96 to -0.26, p=0.0006) was reduced (SMD -0.46, 95% CI -0.75 to -0.17, p=0.002) when an outlying study was removed in a sensitivity analysis to examine statistical heterogeneity. Three studies (n=213) observed a direction of effect using the MSIS-29 which was not statistically significant (WMD -4.36, 95% CI -9.33 to 0.62, p=0.09). There was no between-subgroup heterogeneity (I²=0).

CONCLUSIONS

CBT can be an effective treatment for depression in MS. Further research should explore optimal durations and modalities of treatment for patients with different characteristics.

Internet-based self-help treatment for depression in multiple sclerosis: study protocol of a randomized controlled trial

BACKGROUND

Depression in MS patients is frequent but often not treated adequately. An important underlying factor may be physical limitations that preclude face-to-face contact. Internet-based treatment showed to be effective for depressive symptoms in general and could thus be a promising tool for treatment in MS.

METHODS/DESIGN

Here, we present a study protocol to investigate the effectiveness of a 5 week Internet-based self-help problem solving treatment (PST) for depressive symptoms in MS patients in a randomized controlled trial. We aim to include 166 MS patients with moderate to severe depressive symptoms who will be randomly assigned to an Internet-based intervention (with or without supportive text-messages) or waiting list control group. The primary outcome is the change in depressive symptoms defined by a change in the sum score on the Beck Depression Inventory (BDI-II). Secondary outcomes will include measures of anxiety, fatigue, cognitive functioning, physical and psychological impact of MS, quality of life, problem solving skills, social support, mastery, satisfaction and compliance rate. Assessments will take place at baseline (T0), within a week after the intervention (T1), at four months (T2) and at ten months follow-up (T3: only the intervention group). The control group will be measured at the same moments in time. Analysis will be based on the intention-to-treat principle.

DISCUSSION

If shown to be effective, Internet-based PST will offer new possibilities to reach and treat MS patients with depressive symptoms and to improve the quality of care.

TRIAL REGISTRATION

The Dutch Cochrane Center, NTR2772.

Feasibility and outcome of a web-based self-help intervention for depressive symptoms in patients with multiple sclerosis: a pilot study

BACKGROUND

Depressive symptoms are highly prevalent among patients with multiple sclerosis (MS). Web-based problem solving therapy (PST) is easily accessible and showed to be effective in depressed patients.

OBJECTIVES

The aims of this pilot study were to examine feasibility and outcome (reduction of depressive symptoms) of an applied web-based PST intervention in MS patients.

METHODS

Forty-four MS patients with mild to severe depressive symptoms followed a web-based PST intervention. Feasibility was measured by compliance rate and satisfaction scales. The Beck Depression Inventory (BDI-II) was used to measure depressive symptoms before and after the intervention.

RESULTS

The compliance rate was 52%, and 85% of the patients rated the quality of the intervention as good or excellent. After the intervention, depressive symptoms had significantly decreased (BDI-II change: mean=-3.9, p=0.01, d=0.51 in intention-to-treat analysis; BDI-II change: mean=-9.0, p<0.001, d=1.50 in completers analysis).

CONCLUSIONS

This study suggests that applied web-based PST is feasible and reduces depressive symptoms in MS patients. Especially MS patients who experience disease-related or other barriers to participate in face-to-face counselling could benefit. However, ways to increase compliance should be considered. A randomized controlled trial is recommended to more extensively investigate effectiveness of this intervention in treating depressive symptoms in MS patients.

Symptomatic therapy in multiple sclerosis: a review for a multimodal approach in clinical practice

As more investigations into factors affecting the quality of life of patients with multiple sclerosis (MS) are undertaken, it is becoming increasingly apparent that certain comorbidities and associated symptoms commonly found in these patients differ in incidence, pathophysiology and other factors compared with the general population. Many of these MS-related symptoms are frequently ignored in assessments of disease status and are often not considered to be associated with the disease. Research into how such comorbidities and symptoms can be diagnosed and treated within the MS population is lacking. This information gap adds further complexity to disease management and represents an unmet need in MS, particularly as early recognition and treatment of these conditions can improve patient outcomes. In this manuscript, we sought to review the literature on the comorbidities and symptoms of MS and to summarize the evidence for treatments that have been or may be used to alleviate them.

Change in quality of life in patients with relapsing-remitting multiple sclerosis over 2 years in relation to other clinical parameters: results from a trial of intramuscular interferon {beta}-1a

BACKGROUND

A randomized, placebo-controlled, multicenter study of weekly intramuscular injections of interferon beta-1a (IFNβ-1a) in relapsing-remitting multiple sclerosis included the Sickness Impact Profile (SIP), a validated measure of patient-reported quality of life (QoL).

OBJECTIVE

To demonstrate the impact of moderate to severe SIP disability at baseline and change in QoL as measured by SIP over 2 years in relation to other study parameters.

METHODS

In 158 patients, SIP scores were determined at baseline and 2 years. Scores were correlated with disease progression and treatment.

RESULTS

Patients who experienced disability progression, as defined by Expanded Disability Status Scale (EDSS) and annualized relapse rate, during the study demonstrated significant worsening in Physical SIP scores compared with patients who did not progress (p=0.031). In patients with low SIP scores, indicating moderate or severe disability at baseline, treatment with IFNβ-1a significantly improved Physical SIP subscores.

CONCLUSIONS

Patients with disability progression defined using EDSS, the physician-derived primary outcome measure, had Physical SIP scores indicating worsening disability, validating the physician-derived primary outcome measure using patient self-report. Treatment with IFNβ-1a had beneficial effects on QoL in patients with worse SIP scores at baseline.