Mindfulness-Based Interventions for the Improvement of Well-Being in People With Multiple Sclerosis: A Systematic Review and Meta-Analysis

Managing multiple sclerosis in individuals aged 55 and above: a comprehensive review

Multiple Sclerosis (MS) management in individuals aged 55 and above presents unique challenges due to the complex interaction between aging, comorbidities, immunosenescence, and MS pathophysiology. This comprehensive review explores the evolving landscape of MS in older adults, including the increased incidence and prevalence of MS in this age group, the shift in disease phenotypes from relapsing-remitting to progressive forms, and the presence of multimorbidity and polypharmacy. We aim to provide an updated review of the available evidence of disease-modifying treatments (DMTs) in older patients, including the efficacy and safety of existing therapies, emerging treatments such as Bruton tyrosine kinase (BTKs) inhibitors and those targeting remyelination and neuroprotection, and the critical decisions surrounding the initiation, de-escalation, and discontinuation of DMTs. Non-pharmacologic approaches, including physical therapy, neuromodulation therapies, cognitive rehabilitation, and psychotherapy, are also examined for their role in holistic care. The importance of MS Care Units and advance care planning are explored as a cornerstone in providing patient-centric care, ensuring alignment with patient preferences in the disease trajectory. Finally, the review emphasizes the need for personalized management and continuous monitoring of MS patients, alongside advocating for inclusive study designs in clinical research to improve the management of this growing patient demographic.

Predictive Model of Anxiety and Depression Perception in Multiple Sclerosis Patients: Possible Implications for Clinical Treatment

Multiple Sclerosis (MS) is a neurodegenerative disease characterized by motor and non-motor symptoms, including emotional distress, anxiety, and depression. These emotional symptoms currently have a pharmacological treatment with limited effectiveness; therefore, it is necessary to delve into their relationship with other psychological, functional, or prefrontal alterations. Additionally, exploring non-pharmacological therapeutic alternatives that have shown benefits in addressing emotional distress in MS patients is essential.

AIM

To establish a predictive model for the presence of anxiety and depression in MS patients, based on variables such as psychological well-being, functional activity, and prefrontal symptoms. Additionally, this study aimed to propose non-pharmacological therapeutic alternatives based on this model.

MATERIALS AND METHODS

A descriptive, observational, and cross-sectional study was conducted with a sample of 64 diagnosed MS patients who underwent functional and cognitive assessments using the following questionnaires and scales: Functional Activities Questionnaire (FAQ), Acceptance and Action Questionnaire (AAQ-II), Experiences Questionnaire (EQ), Self-Compassion Scale Short Form (SCS-SF), Beck Depression Inventory II (BDI-II), State-Trait Anxiety Inventory (STAI), and Prefrontal Symptoms Inventory (PSI).

RESULTS

The model showed an excellent fit to the data and indicated that psychological well-being was the most significant predictor of the criteria (β = -0.83), followed by functional activity (β = -0.18) and prefrontal symptoms (β = 0.15). The latter two are negatively related to psychological well-being (β = -0.16 and β = -0.75, respectively).

CONCLUSIONS

Low psychological well-being is the variable that most significantly predicts the presence of anxiety and depression in MS patients, followed by functional activity and prefrontal alterations. Interventions based on mindfulness and acceptance are recommended, along with nutritional interventions such as antioxidant-enriched ketogenic diets and moderate group physical exercise.

Placebo and Nocebo Effects as Bayesian-Brain Phenomena: The Overlooked Role of Likelihood and Attention

The Bayesian-brain framework applied to placebo responses and other mind-body interactions suggests that the effects on the body result from the interaction between priors, such as expectations and learning, and likelihood, such as somatosensorial information. Significant research in this area focuses on the role of the priors, but the relevance of the likelihood has been surprisingly overlooked. One way of manipulating the relevance of the likelihood is by paying attention to sensorial information. We suggest that attention can influence both precision and position (i.e., the relative distance from the priors) of the likelihood by focusing on specific components of the somatosensorial information. Two forms of attention seem particularly relevant in this framework: mindful attention and selective attention. Attention has the potential to be considered a "major player" in placebo/nocebo research, together with expectations and learning. In terms of application, relying on attentional strategies as "amplifiers" or "silencers" of sensorial information could lead to an active involvement of individuals in shaping their care process and health. In this contribution, we discuss the theoretical implications of these intuitions with the aim to provide a comprehensive framework that includes Bayesian brain, placebo/nocebo effects, and the role of attention in mind-body interactions.

A systematic review and meta-analysis exploring the efficacy of mindfulness-based interventions on quality of life in people with multiple sclerosis

BACKGROUND

Quality of life (QoL) is commonly impaired among people with multiple sclerosis (PwMS). The aim of this study was to evaluate via meta-analysis the efficacy of Mindfulness-based interventions (MBIs) for improving QoL in PwMS.

METHODS

Eligible randomized controlled trials (RCTs) were identified via searching six major electronic databases (MEDLINE, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, AMED, and PsycINFO) in April 2022. The primary outcome was QoL. Study quality was determined using the Cochrane Collaboration risk of bias tool. Meta-analysis using a random effects model was undertaken. Effect sizes are reported as Standardized Mean Difference (SMD). Prospero ID: 139835.

RESULTS

From a total of 1312 individual studies, 14 RCTs were eligible for inclusion in the meta-analysis, total participant n = 937. Most studies included PwMS who remained ambulatory. Cognitively impaired PwMS were largely excluded. Comorbidities were inconsistently reported. Most MBIs were delivered face-to face in group format, but five were online. Eight studies (n = 8) measured MS-specific QoL. In meta-analysis, overall effect size (SMD) for any QoL measure (n = 14) was 0.40 (0.18-0.61), p = 0.0003, I² = 52%. SMD for MS-specific QoL measures (n = 8) was 0.39 (0.21-0.57), p < 0.0001, I² = 0%. MBI effect was largest on subscale measures of mental QoL (n = 8), SMD 0.70 (0.33-1.06), p = 0.0002, I² = 63%. Adverse events were infrequently reported.

CONCLUSIONS

MBIs effectively improve QoL in PwMS. The greatest benefits are on mental health-related QoL. However, more research is needed to characterize optimal formatting, mechanisms of action, and effects in PwMS with more diverse social, educational, and clinical backgrounds.

Feasibility, Acceptability, and Efficacy of Mindfulness Training in People With Upper Motor Neuron Disorders: A Systematic Review

OBJECTIVES

This systematic review aims to gain a comprehensive understanding of the feasibility, acceptability, and efficacy of mindfulness-based interventions (MBIs) on depression, anxiety, fatigue, and health-related quality of life among individuals with upper motor neuron disorders (UMNDs).

DATA SOURCES

PubMed, PsycINFO, Excerpta Medica Database, and Cumulative Index to Nursing and Allied Health Literature were searched for relevant studies published between January 2001 and June 2021.

STUDY SELECTION

Clinical trials published in English evaluating MBIs in adults with the 4 most common UMNDs (multiple sclerosis, brain injury including stroke, spinal cord injury, amyotrophic lateral sclerosis) were included.

DATA EXTRACTION

Two reviewers independently performed the risk of bias assessment using standardized tools and extracted desired data electronically.

DATA SYNTHESIS

A total of 44 studies were included: 26 randomized controlled trials, 10 nonrandomized controlled trials, and 8 pre-post intervention studies. The average ± SD duration of MBIs was 8±2 weeks. On average, 85%±14% of participants completed the MBI, and the retention rate at follow-up was 80%±16%. Only 14% of the studies delivered MBIs virtually, and feasibility metrics were similar to in-person studies. Among studies reporting acceptability data, most participants reported satisfaction with the MBI. Randomized controlled trials that evaluated the effects of MBI on depression, anxiety, fatigue, and quality of life revealed greater relative improvement in these outcomes among MBI participants compared with controls, with differences greater when compared with passive control than active control participants. None of the studies included in this review studied dose response.

CONCLUSIONS

Based on current data, MBIs are feasible and offer a promising approach to address the biopsychosocial needs of individuals with UMNDs. MBIs are associated with a high acceptance rate among participants, with notable improvements in depression, anxiety, fatigue, and quality of life post intervention. Future studies are needed to evaluate alternate models of delivery of MBIs and the dose-response relationship.

The Effectiveness of Cognitive-Behavioral, Mindfulness and Acceptance and Commitment Therapies to Improving the Psychological Symptoms of Patients with Multiple Sclerosis in Iran (Systematic Review and Meta-analysis)

Context: Multiple sclerosis (MS) is a neurological disease in which the myelin lining the central nervous system is damaged and often occurs between the ages of 20 and 40. In addition to loss of motor, sensory, and cognitive function, patients with MS also experience related symptoms such as depression, anxiety, stress, fatigue, and pain. Objectives: The aim of this study was to systematically and meta-analyze the effectiveness of cognitive-behavioral, mindfulness and acceptance and commitment (CMAC) therapies to improving the psychological symptoms of patients with multiple sclerosis in Iran. Methods: The study was conducted using preferred reporting items for systematic reviews and meta-analysis. This study examined articles published from the beginning until November 20, 2021 in Persian and English on cognitive and behavioral interventions performed in Iran, in order to influence psychological symptoms for people with multiple sclerosis. Articles relevant to research were screened in external (Google Scholar, PubMed, Scopus, Science Direct, Web of Science) and internal databases (Sid, Magiran, Ganj, Irandoc, Civilica). The quality of the included RCTs was assessed using the Cochrane guideline risk of bias tool. The results were expressed in terms of mean difference (MD) and the corresponding 95% confidence interval. Data analyses were performed by RevMan5.4. Results: In the first stage of the search, 792 articles were obtained. After reviewing the titles of the articles, 701 articles were discarded due to irrelevance and duplication and 91 articles remained. Finally, 21 studies were selected by reviewing the abstracts and considering the inclusion criteria. Compared with the control group, the standardized mean difference (SMD) estimate depression was 1.60 (2.27, 0.93), for anxiety 0.49 (0.80, 0.19), for stress 0.97 (1.70, 0.23) and for fatigue 0.19 (2.75, 1.25) had a positive effect; But no significant effect on pain reduction equal to 0.49 (2.21, 1.23) was not found. Conclusions: The meta-analysis in the posttest showed that the effects of CMAC were considerable on reducing depression, anxiety, stress, and fatigue, but the effects were not notable for pain mitigation. Future high quality studies with follow-up evaluations are needed to support the effects of CMAC on reducing symptoms in people with multiple sclerosis and to evaluate the interventional features that enhance and maintain the effects.

Anticipatory threat responses mediate the relationship between mindfulness and anxiety: A cross-sectional study

Increasing research has shown that mindfulness-based interventions can effectively alleviate anxiety; however, the underlying neural mechanism has not yet been elucidated. Recent studies suggest that abnormal and excessive anticipatory responses to unpredictable threats play an important role in anxiety symptoms. Mindfulness refers to the non-judgmental awareness of the present moment's real experience, which is antithetical to the future-oriented thinking processes involved in anxiety-oriented cognition and its corresponding emotion regulation tactics. Thus, mitigating anticipatory threat responses may be a potential mechanism by which mindfulness alleviates anxiety. This study aimed to detect the possible mediating effects of anticipatory threat responses on the relationship between mindfulness and anxiety. A total of 35 trait-anxious (TA) individuals and 36 low-anxious (LA) individuals were recruited to participate in the predictable and unpredictable threat test. Self-reported intolerance of uncertainty (IU) and electroencephalographic responses to uncertainty were recorded. TA individuals reported more IU and less mindfulness, and exhibited significantly higher late positive potential (LPP) and longer reaction time (RT) than LA individuals in the unpredictable negative threat condition. In addition, there were significant mediating effects of the LPP amplitude and RT in the uncertain threats on the relationship between mindfulness and anxiety. The data from this study verified that mitigating anticipatory threat responses (including self-reported IU, behavioral RT, and LPP amplitude) might be the potential mechanism by which mindfulness alleviates anxiety. These findings may have practical implications for the development and optimization of mindfulness treatments for anxiety.

A randomized controlled trial of a web-based mindfulness programme for people with MS with and without a history of recurrent depression

BACKGROUND

Evidence shows small positive effects associated with psychological treatments for people with multiple sclerosis (PwMS). In a recent meta-analysis, the treatment with the largest effect size was a mindfulness-based intervention (MBI).

OBJECTIVES

We aimed to determine whether an Internet-delivered MBI was beneficial for PwMS. Furthermore, we aimed to investigate history of recurrent depression as a moderator of treatment outcome.

METHODS

Participants (N = 132) were assessed based on whether they had a history of recurrent depression, then stratified and randomized to MBI or waitlist. Outcomes were assessed at baseline, post-intervention, and 3 and 6 months.

RESULTS

The MBI group reported significantly improved depressive symptoms (primary outcome) compared with the waitlist (p = 0.046, Cohen's d = 0.39). Those with a history of recurrent depression benefitted significantly more than those without (p = 0.034, d = 0.66). There were benefits for health-related quality of life (HRQoL) in the MBI, irrespective of depression history (p = 0.009, d = 0.5). Pain interference was less overall in the MBI group (p < 0.001, d = 0.2), but change over time did not differ from waitlist. There were no treatment effects for anxiety, pain severity or fatigue.

CONCLUSION

The Internet-delivered MBI significantly improved depressive symptoms and HRQoL in PwMS. For depression, the benefits were greater for those with a history of recurrent depression.

TRIAL REGISTRATION

ACTRN12618001260213, available at: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=375598.

Mindfulness training during brief periods of hospitalization in multiple sclerosis (MS): beneficial alterations in fatigue and the mediating role of depression

OBJECTIVES

Persons with MS (PwMS) are frequently affected by fatigue and depression. Mindfulness-based interventions may reduce these symptoms in PwMS and consequently their application has been extended to various settings. Only few efforts have been made to explore effects of short-term mindfulness training during brief periods of hospitalization. In the current study, the feasibility and potential effects of short-term mindfulness training on depression, fatigue, rumination and cognition were explored in PwMS in an acute-care hospital setting. Based on previous work, it was further examined whether the relation between trait mindfulness and fatigue prior to and following the intervention was mediated by depression and whether a mediation effect was also observable throughout the intervention.

METHODS

A short-term mindfulness training protocol was developed, tailored to the requirements of the acute-care setting. Subsequently, 30 PwMS were recruited sequentially and received mindfulness training during the routine clinical process (median duration in hospital: eight days, number of sessions: four). Participants completed relevant self-report measures (depression, fatigue, rumination) and a neuropsychological assessment before and after training.

RESULTS

Participants reported significantly increased trait mindfulness and decreased depression and fatigue following the intervention. Respective change scores were highly correlated so that increased trait mindfulness was associated with decreased symptoms. In the rumination domain, patients reported a tendency for an increased adaptive ability to engage in distractive behavior during arising negative mood. Other measures of trait rumination and cognition remained relatively stable. Results of the mediation analyses indicated that depression mediated the negative relationship between trait mindfulness and fatigue symptoms at pre and post assessments. With regards to the change scores, an association between mindfulness and cognitive fatigue ceased to be significant when depression was controlled, albeit in this case, the mediation effect did not reach significance.

CONCLUSION

Results of the current study indicate that short-term mindfulness training during brief periods of hospitalization may be beneficial for PwMS. They further complement previous work by identifying depression as a potential mediator of the antagonistic relationship between mindfulness and fatigue. Based on the current exploratory study, future trials are warranted to address this mechanism of mindfulness training in more detail.

Outdoor Adventure Programs for Persons with Multiple Sclerosis: A Review and Agenda for Future Research

Persons with multiple sclerosis (MS) often experience myriad symptoms that affect functioning and quality of life (QOL). Although there are a growing number of nonpharmacologic interventions designed to improve symptom severity and interference and maximize QOL, these particular treatments are limited by barriers to accessibility and, at times, a poor patient-intervention fit. Thus, it is important to consider alternative or supplemental nonpharmacologic treatments for people with MS. Outdoor adventure programs-group-based outdoor adventures aimed at enhancing QOL and fostering personal growth-could be one such alternative or supplemental approach. This topical review provides an overview of outdoor adventure programs; explores the current literature on these types of programs for the general population and medical populations; examines how outdoor adventure programs could enhance mood, functioning, and QOL for individuals with MS; and suggests future directions for research on outdoor adventure programs tailored to persons with MS.

A mindfulness group intervention in newly diagnosed persons with multiple sclerosis: A pilot study

BACKGROUND

Relapsing MS (RMS) is a lifelong disease without a cure, usually diagnosed between 20-40 years of age. Being newly diagnosed with RMS is a highly stressful event due to the unpredictable disease course after diagnosis. Thus, it is imperative that persons with MS have the skills and support to cope with the negative physical and emotional effects of the disease. The objective of this study was to assess whether a mindfulness-based intervention (MBI) would improve coping skills and thus lessen the negative consequences of stress due to being newly diagnosed with RMS.

METHODS

This was a single-blind (assessor), randomized, prospective study of a 10-week MBI vs. usual standard of care in persons newly diagnosed (within 1 year) with RMS, recruited from one tertiary care MS clinic in London (ON), Canada. The MBI was administered in group format with a trained MBI facilitator. Primary outcomes included the Brief COPE measure and the Hospital Anxiety and Depression Scale (HADS) subscales. Secondary outcomes included measures of perceived stress, cognitive function, fatigue, and quality of life. Exploratory (tertiary) outcomes included serum markers of inflammation and stress. Subjects were assessed at baseline, post intervention (or equivalent) and 6 months later. A repeated measures multivariate analysis of covariance (MANCOVA) was used, with baseline scores employed as covariates and the test scores, to compare longitudinal changes, immediately after the MBI sessions and 6 months later.

RESULTS

Twenty-five subjects were recruited (16 MBI, 9 controls) for two (Fall and Spring) MBI interventions over 1.5 years. All controls completed the study, while 4 MBI participants did not, leaving 21 subjects in the analysis. Most were women (17, 81%), with a mean age of 37.1 ± 9.4 years. Two thirds had already started a DMT at the time of consent; the median EDSS was 2.0 (0.0-4.0). The groups were well matched on baseline characteristics, with the exception of months since diagnosis (MBI 6.4 ± 6.5 vs. control 3.6 ± 2.8, p=0.023). All controls completed the study, while 4 MBI participants did not. The MBI group improved significantly on the COPE measure when compared to the control group (p=0.024) pre and post intervention; the MBI group also improved significantly on the HADS depression subscale (p=0.007). There was no significant difference over time on the HADS anxiety subscale (p=0.179). The effect size on COPE was 0.56 and 0.40 on HADS-D. On the secondary outcomes, there was a significant improvement on the Perceived Stress Scale (p=0.015). The exploratory outcomes were not significantly different. None of the outcomes were significant at the six-month follow-up.

CONCLUSION

This pilot study demonstrates that an MBI may improve coping, depression and perceived stress in newly diagnosed (within one year) persons with RMS in the short term. Future research to confirm these results, as well as further investigate measures to extend the benefit beyond the immediate intervention.

Mindfulness- and Acceptance-Based Interventions for Symptom Reduction in Individuals With Multiple Sclerosis: A Systematic Review and Meta-Analysis

OBJECTIVE

To examine the effects of mindfulness- and acceptance-based interventions (MABIs) on reducing symptoms in individuals with multiple sclerosis (MS).

DATA SOURCES

A comprehensive search was conducted within the PubMed, CINAHL, PsycINFO, and SCOPUS databases for articles published from inception to July 3, 2020.

STUDY SELECTION

Randomized controlled trials (RCTs) were included if MABIs were provided to individuals with MS exclusively, with reported pre-and posttest results in symptoms of depression, anxiety, stress, fatigue, or pain.

DATA EXTRACTION

Characteristics of the included RCTs and data for meta-analysis were extracted. The quality of the included RCTs was assessed using the Cochrane Collaboration risk of bias tool.

DATA SYNTHESIS

A random effects model with the inverse variance method was used with effect size reported as standardized mean difference. Heterogeneity was assessed using the I² statistic.

RESULTS

Twenty-three RCTs met the eligibility criteria. Meta-analyses found large effects of MABIs on reducing depressive symptoms, anxiety, stress, and pain, as well as a moderate effect of MABIs on reducing fatigue at the immediate posttest. Large effects of MABIs on reducing depressive symptoms, anxiety, and stress at follow-up were also found, whereas a moderate effect on reducing fatigue was found at follow-up. There was no significant effect of MABIs on reducing pain at follow-up.

CONCLUSIONS

Fewer studies were included in meta-analyses for pain at the immediate posttest and follow-up and stress and fatigue at follow-up. The overall risk of bias was unclear. Future high-quality studies with follow-up evaluations are needed to support effects of MABIs on reducing symptoms in individuals with MS and examine intervention features that increase and maintain effects.

Effects of mindfulness-and acceptance-based interventions on quality of life, coping, cognition, and mindfulness of people with multiple sclerosis: a systematic review and meta-analysis

This systematic review and meta-analysis of randomized controlled trials (RCTs) examined effects of mindfulness- and acceptance-based interventions (MABIs) on quality of life (QoL), coping, cognition, and mindfulness among people with multiple sclerosis (MS). Four electronic databases were searched to 3 July 2020. Data was combined in a random-effects meta-analysis model. Eighteen RCTs met the eligibility criteria. Meta-analyses at the immediate posttest found: moderate effects of MABIs on QoL, coping, and attention; and a large effect on memory. A large effect of MABIs on QoL was found at follow-up. There was no significant effect of MABIs on mindfulness. Relatively fewer studies in outcomes other than QoL were found, and the overall risk of bias across the included 18 RCTs was unclear. Future high-quality studies with follow-up evaluations are needed to support effects of MABIs on QoL, coping, cognition, and mindfulness in people with MS and examine intervention features that increase and maintain effects.