Change and processes of change within interventions to promote adjustment to multiple sclerosis: Learning from patient experiences

Experiences of people with multiple sclerosis and clinicians in using cognitive behavioural therapies for hidden symptoms: a systematic review and meta-aggregation

PURPOSE

Cognitive behavioural therapies (CBTs) are a standard of care for treatment of many 'hidden symptoms' in people with MS (PwMS), such as stress, depression, and fatigue. However, these interventions can vary widely in formatting and may not be tailored for PwMS. To optimize CBTs for MS, understanding the experiences of PwMS and clinicians is essential. This systematic review and meta-aggregation synthesizes existing qualitative data on stakeholder perspectives of CBTs for PwMS.

METHODS

Systematic searches across five major electronic databases were conducted. Studies reporting qualitative data were identified. Two reviewers performed screening, quality assessment, data extraction, and certainty of evidence assessments. Meta-aggregation was performed as per the Joanna Briggs Institute approach, entailing qualitative data extraction, developing categories, and synthesizing overall findings.

RESULTS

Twenty-eight studies were included in this review, comprising data from 653 PwMS and 47 clinicians. In the meta-aggregation, 122 qualitative results were extracted and grouped into nine categories. Categories were then combined into six synthesized findings: (1) setting the context-life with MS, (2) reasons for participating in CBTs, (3) acceptability of and experiences with participating in CBTs, (4) perceived benefits of CBTs, (5) perceived challenges with CBTs, and (6) suggestions to improve CBTs for PwMS.

CONCLUSIONS

A range of benefits including psychological, social, and lifestyle improvements were reported, but varied based on the design of the CBT intervention. Future CBT interventions should be tailored to participant needs, delivered in group settings, offer online options, and be delivered by a trained facilitator familiar with MS. Further exploration of the ideal CBT design for PwMS, as well as engagement with caregivers and clinicians treating MS, is warranted.

Experiences of psychological interventions in neurodegenerative diseases: a systematic review and thematic synthesis

Background: Psychological interventions for managing emotional distress in neurodegenerative diseases are needed, but progressive worsening of symptoms and increasing disability might pose difficulties with engagement. We aimed to synthesise the experiences of engaging with and using psychological interventions in neurodegenerative diseases and identify relevant barriers and facilitators. Methods: Systematic searches were conducted in six electronic databases and results were screened. We included qualitative and mixed methods studies reporting patient or caregivers' views or experiences of psychological interventions. Qualitative data were extracted and thematically synthesised. Results: 34 papers were included, covering a range of diseases and interventions. Engagement was facilitated by flexible intervention formats and tailoring to the specific needs of people with neurodegenerative diseases. Interventions were sometimes inaccessible or burdensome because of physical and cognitive symptoms, and the time and effort required for the intervention. Participants' levels of acceptance and readiness often differed and influenced engagement with the intervention. Across different interventions, participants experienced wide-ranging benefits including changes in insight, perspective, self-efficacy, emotions and relationships. Conclusion: Although people with neurodegenerative diseases and caregivers experience benefits from psychological interventions, burden-reducing adaptations and sensitive tailoring to the specific disease context is required to improve acceptability and engagement.

Experiences of receiving a diagnosis of multiple sclerosis: a meta-synthesis of qualitative studies

PURPOSE

This meta-synthesis aimed to synthesise qualitative evidence on experiences of people with Multiple Sclerosis (MS) in receiving a diagnosis, to derive a conceptual understanding of adjustment to MS diagnosis.

METHODS

Five electronic databases were systematically searched to identify qualitative studies that explored views and experiences around MS diagnosis. Papers were quality-appraised using a standardised checklist. Data synthesis was guided by principles of meta-ethnography, a well-established interpretive method for synthesising qualitative evidence.

RESULTS

Thirty-seven papers were selected (with 874 people with MS). Synthesis demonstrated that around the point of MS diagnosis people experienced considerable emotional upheaval (e.g., shock, denial, anger, fear) and difficulties (e.g., lengthy diagnosis process) that limited their ability to make sense of their diagnosis, leading to adjustment difficulties. However, support resources (e.g., support from clinicians) and adaptive coping strategies (e.g., acceptance) facilitated the adjustment process. Additionally, several unmet emotional and informational support needs (e.g., need for personalised information and tailored emotional support) were identified that, if addressed, could improve adjustment to diagnosis.

CONCLUSIONS

Our synthesis highlights the need for providing person-centred support and advice at the time of diagnosis and presents a conceptual map of adjustment for designing interventions to improve adjustment following MS diagnosis.Implications for RehabilitationThe period surrounding Multiple Sclerosis diagnosis can be stressful and psychologically demanding.Challenges and disruptions at diagnosis can threaten sense of self, resulting in negative emotions.Adaptive coping skills and support resources could contribute to better adjustment following diagnosis.Support interventions should be tailored to the needs of newly diagnosed people.

How and for whom does supportive adjustment to multiple sclerosis cognitive-behavioural therapy work? A mediated moderation analysis

The supportive adjustment for multiple sclerosis (saMS) randomised controlled trial showed cognitive behavioural therapy (CBT) reduced distress at 12-months compared to supportive listening (SL). Larger changes in distress and functional impairment following CBT occurred in participants with clinical distress at baseline. This secondary analysis investigates whether CBT treatment effects occur through pre-defined CBT mechanisms of change in the total cohort and clinically distressed subgroup. 94 participants were randomised to saMS CBT or SL. Primary outcomes were distress and functional impairment (12 months). Mediators included cognitive-behavioural variables at post-treatment (15 weeks). Structural equation mediation and mediated-moderation models adjusting for baseline confounders assessed mediation overall and by distress level. Significant mediation was found but only for those with clinical distress at baseline. Illness acceptance (-0.20, 95% confidence interval -0.01 to -0.46) and reduced embarrassment avoidance behaviours (-0.22, -0.02 to -0.58) mediated CBT's effect on distress. Changes in beliefs about processing emotions (-0.19, -0.001 to -0.46) mediated CBT's effect on functional impairment. saMS CBT had effects on distress and functional impairment via some of the hypothesised mechanisms drawn from a theoretical model of adjustment for MS but only among participants with clinical distress at baseline. Increasing acceptance and emotional expression and decreasing embarrassment avoidance improves MS adjustment.

The nature of anger in people with multiple sclerosis: a qualitative study

Objective: People with multiple sclerosis (pwMS) who experience higher levels of anger also report poorer quality of life (QoL). This qualitative study explored the subjective experience of anger amongst pwMS, and how anger influenced their lives.Methods: A series of semi-structured, face-to-face interviews were conducted with 20 pwMS. Interviews were recorded, transcribed and then Interpretative Phenomenological Analysis was used to analyse the emerging themes.Results: The most common experience of anger was frustration that MS-related symptoms restricted participation in everyday activities. Also, some experiences of anger-with-self were focused on frustration at the inability to overcome symptom-related activity limitations. Participants reported frustration with others' insensitivity to the effects of the disease process, as well as usual daily irritations with family and colleagues. Some of the participants reported the use of coping strategies to deal with anger episodes.Conclusion: Many pwMS experience frustration at the restrictions that the disease places on them, self-directed anger, and irritation with others' attitude towards them. Much research in MS focuses on physical symptoms, but current results indicate that there is a need to better understand the emotional challenges faces by pwMS, and to provide more support for those who are experiencing frustration.

The Self-Efficacy in Multiple Sclerosis (SEMS) Scale

Abstract. This research developed a new scale to evaluate Self-Efficacy in Multiple Sclerosis (SEMS). The aim of this study was to investigate dimensionality, item functioning, measurement invariance, and concurrent validity of the SEMS scale. Data were collected from 203 multiple sclerosis (MS) patients (mean age, 39.5 years; 66% women; 95% having a relapsing remitting form of MS). Fifteen items of the SEMS scale were submitted to patients along with measures of psychological well-being, sense of coherence, depression, and coping strategies. Data underwent Rasch analysis and correlation analysis. Rasch analysis indicates the SEMS as a multidimensional construct characterized by two correlated dimensions: goal setting and symptom management, with satisfactory reliability coefficients. Overall, the 15 items reported acceptable fit statistics; the scale demonstrated measurement invariance (with respect to gender and disease duration) and good concurrent validity (positive correlations with psychological well-being, sense of coherence, and coping strategies and negative correlations with depression). Preliminary evidence suggests that SEMS is a psychometrically sound measure to evaluate perceived self-efficacy of MS patients with moderate disability, and it would be a valuable instrument for both research and clinical applications.

The Experience of Persons With Multiple Sclerosis Using MS INFoRm: An Interactive Fatigue Management Resource

We aimed to understand participants' experiences with a self-guided fatigue management resource, Multiple Sclerosis: An Interactive Fatigue Management Resource ( MS INFoRm), and the extent to which they found its contents relevant and useful to their daily lives. We recruited 35 persons with MS experiencing mild to moderate fatigue, provided them with MS INFoRm, and then conducted semistructured interviews 3 weeks and 3 months after they received the resource. Interpretive description guided the analysis process. Findings indicate that participants' experience of using MS INFoRm could be understood as a process of change, influenced by their initial reactions to the resource. They reported experiencing a shift in knowledge, expectations, and behaviors with respect to fatigue self-management. These shifts led to multiple positive outcomes, including increased levels of self-confidence and improved quality of life. These findings suggest that MS INFoRm may have a place in the continuum of fatigue management interventions for people with MS.

A qualitative study exploring the experience of people with IBD and elevated symptoms of anxiety and low mood and the type of psychological help they would like

BACKGROUND

People with inflammatory bowel disease (IBD) are at increased risk of developing anxiety and low mood. We sought to explore the experience of people with IBD and moderate-severe symptoms of anxiety/low mood to identify psychological processes which could be targeted in psychological interventions, as well as the kind of psychological support preferred.

METHODS

Twenty-five participants with IBD and moderate-severe symptoms of anxiety/low mood were recruited for interview. Template analysis was utilised to analyse interview data. We explored the situations, cognitions and behaviour linked to symptoms of anxiety and low mood by people with IBD, as well as the kind of psychological help preferred.

RESULTS

Two themes were identified within participants accounts of symptoms of anxiety; 'under performance' and 'preventing an accident'. Two further themes were identified for symptoms of low mood; 'lack of understanding' and 'stigma'. Expertise and understanding was the main theme identified for the type of psychological help desired.

CONCLUSION

The analysis highlights situations, cognitions and behaviour linked to anxiety and low mood by people with IBD and the type of psychological support desired. Our findings link to the knowledge and competencies set for psychological therapist working with long-term conditions.

Exploring change in a group-based psychological intervention for multiple sclerosis patients

PURPOSE

The study is focused on a group-based cognitive behavioral intervention aimed at promoting the quality of life and psychological well-being of multiple sclerosis patients. The study investigates how the group intervention promoted change among participants and fostered their adjustment to the illness.

MATERIALS AND METHODS

The intervention involved six groups of patients (a total of 41 patients) and included four consecutive sessions and a 6-month follow-up. To explore change, verbatim transcripts of the intervention sessions were analyzed using a mixed-methods content analysis with qualitative data combined with descriptive statistics. The categories of resistance and openness to change were used to describe the process of change.

RESULTS

Resistance and openness to change coexisted during the intervention. Only in the first session did resistance prevail over openness to change; thereafter, openness to change gradually increased and stabilized over time, and openness to change was then always stronger than resistance.

CONCLUSIONS

The study builds on previous research on the effectiveness of group-based psychological interventions for multiple sclerosis patients and gives methodological and clinical suggestions to health care professionals working with multiple sclerosis patients. Implications for rehabilitation The study suggests that a group-based cognitive behavioral intervention for multiple sclerosis patients focused on the promotion of identity redefinition, a sense of coherence and self-efficacy in dealing with multiple sclerosis fosters the process of change and may be effective in promoting patients' adjustment to their illness. Health care professionals leading group-based psychological interventions for multiple sclerosis patients should be aware that resistance and openness to change coexist in the process of change. The study suggests that the duration of the intervention is a crucial factor: a minimum of three sessions appears to be necessary for group participants to develop greater openness to change and follow-up sessions should be implemented to maintain positive changes among participants. The use of qualitative instruments to evaluate group interventions captures the complexity of processes and gives useful indications to health professionals to improve rehabilitation programs.

Exploring patients' attitudes to different intervention approaches for supporting psychosocial needs

BACKGROUND

Many patients with end-stage kidney disease (ESKD) have significant psychosocial needs as a consequence of their illness and treatment. Unmet needs can impact negatively on their health and well-being. Patients want improved psychosocial support particularly in relation to coping and adjustment. Little is known about the relevance and applicability to patients of intervention approaches to support their psychosocial needs.

OBJECTIVES

To explore patients' attitudes to different intervention approaches that could be developed to help them cope with the psychosocial stressors of ESKD, and to assess the potential acceptability of these approaches.

METHODS AND MATERIALS

Qualitative interviews and mini-focus groups were undertaken with 15 patients who have ESKD. Different intervention approaches were shown to participants through use of audio-visual films. Constant comparative data analysis was employed to derive a framework of categories and themes, guided by stress and coping theory.

RESULTS

Psychosocial support was viewed by patients as an essential constituent of quality care. While some intervention approaches were more or less popular than others, responses were overall variable and individualistic, seemingly influenced by participants' personal coping strategies. Any perceived connection with depression could make an intervention approach less attractive; physical exercise was particularly acceptable because there was no explicit association with someone not coping.

CONCLUSIONS

There is value in clinicians making available a choice of appropriately timed and tailored interventions to meet patients' different psychosocial support needs at key points of distress across the ESKD pathway. Congruence between intervention features and patient coping style could stimulate interest and take-up.

How Do People with Multiple Sclerosis Experience Prognostic Uncertainty and Prognosis Communication? A Qualitative Study

Background

Disease progression in multiple sclerosis (MS) is highly variable and predicting prognosis is notoriously challenging. Patients’ prognosis beliefs, responses to prognostic uncertainty and experiences of prognosis-related communication with healthcare professionals (HCPs) have received little study. These issues have implications for patients’ psychological adjustment and are important in the context of the recent development of personalised prognosis forecasting tools. This study explored patient perspectives on the experience of prognostic uncertainty, the formation of expectations about personal prognosis and the nature of received and desired prognosis communication.

Methods

15 MS patients participated in in-depth semi-structured interviews which were analysed using inductive thematic analysis.

Results

Six themes captured key aspects of the data: Experiencing unsatisfactory communication with HCPs, Appreciating and accepting prognostic uncertainty, Trying to stay present-focused, Forming and editing personal prognosis beliefs, Ambivalence towards forecasting the future, and Prognosis information delivery. MS patients report having minimal communication with HCPs about prognosis. Over time MS patients appear to develop expectations about their disease trajectories, but do so with minimal HCP input. Provision of prognosis information by HCPs seems to run counter to patients’ attempts to remain present-focused. Patients are often ambivalent about prognosis forecasting and consider it emotionally dangerous and of circumscribed usefulness.

Conclusions

HCPs must carefully consider whether, when and how to share prognosis information with patients; specific training may be beneficial. Future research should confirm findings about limited HCP-patient communication, distinguish predictors of patients’ attitudes towards prognostication and identify circumstances under which prognostic forecasting benefits patients.

Understanding User Reactions and Interactions With an Internet-Based Intervention for Tinnitus Self-Management: Mixed-Methods Process Evaluation Protocol

Background

Tinnitus is a common medical symptom that can affect an individual’s emotional and functional quality of life. Psychological therapies are acknowledged as beneficial to people with tinnitus; however, such therapies are not always readily accessible. With their global reach, automated Internet-based interventions have the potential to reduce the disparity in access to psychological support that people with tinnitus currently experience. However, the evidence on the acceptability and efficacy of these interventions is lacking. Process evaluations that develop an in-depth understanding of how users experience these interventions provide an essential first step when evaluating complex psychological interventions.

Objective

To describe the protocol for a study that will explore past, current, and new users’ reactions to and interactions with the Tinnitus E-Programme, an Internet-based intervention for the self-management of tinnitus.

Methods

Two parallel mixed-methods studies will be carried out with 2 different populations. Study 1 will use an online survey to gather past and current users’ views of the program. Study 2 will recruit new program users to take part in an interview and complete a relaxation log to explore how well they were able to implement the skills they learned during the program in their everyday lives. The findings from both studies will be triangulated to develop an in-depth understanding of the program’s mechanisms of impact and identify any implementation or contextual factors that strengthen or impede its delivery and functioning.

Results

Study 1 is open for recruitment with a projected completion in June 2016 and Study 2 was completed November 2015. At the time of submission, 36 participants have been recruited to Study 1 and 12 participants have taken part in Study 2.

Conclusions

Findings will inform the optimization of the Tinnitus E-Programme and guide future evaluation work to assess the program’s effectiveness as a therapy for people with tinnitus.

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.