The efficacy of cognitive behavioural therapy for depression and anxiety in multiple sclerosis: A systematic review and meta-analysis

BACKGROUND

Adults with multiple sclerosis (MS) frequently experience symptoms of depression and anxiety, which pose significant challenges. However, psychological support for these symptoms remains a major unmet healthcare need.

OBJECTIVES

To inform the evidence base for the psychological management of adults with MS, this study examined the efficacy of cognitive behavioural therapy (CBT) interventions for improving symptoms of depression and anxiety. CBT interventions teach skills for improving the relationships between an individual's thoughts, feelings, and/or behaviours. The study also examined the role of intervention and study characteristics as moderators of treatment effects.

METHODS

Medline, Embase, PsycINFO, and Cochrane Central Register of Controlled Trials were searched up to August 2024 for randomised control trials.

RESULTS

A meta-analysis of 15 clinical trials (1508 participants) was conducted, which found a medium significant treatment effect size for depression symptoms (g = 0.59, 95 % Confidence Interval [CI] [0.38, 0.80]) and a small significant treatment effect size for anxiety symptoms (g = 0.38 95 % CI [0.19, 0.57]). Moderator analyses revealed treatment effects for anxiety, but not depression, were significantly larger for studies conducted in non-Western countries compared to Western countries, and for those with smaller sample sizes.

CONCLUSIONS

CBT-based interventions appear efficacious for the management of depression and anxiety symptoms in adults with MS. However, future clinical trials with larger samples and more rigorous methodology are warranted. Further examination of intervention characteristics, including ways in which CBT is tailored and how this relates to outcomes, may help to refine interventions for people with MS.

Cognitive behavioral therapies for depression and anxiety in people with chronic disease: A systematic review and meta-analysis

OBJECTIVE

Anxiety and depression in chronic disease are common and burdensome co-morbidities. There has been growing interest in cognitive and behavioral therapies (CBTs) for anxiety and depression in chronic disease, however their efficacy has not been well-established. This study examined the efficacy of CBTs for depression and/or anxiety symptoms within chronic disease and explored the moderating role of clinical and methodological characteristics.

METHODS

Following prospective registration, electronic databases were searched up to 2023 for randomized controlled trials (RCTs) examining CBTs for depression and/or anxiety in any adult chronic disease population.

RESULTS

We included 56 RCTs. The overall effect of CBTs was g = 0.61 (95% CI, 0.49, 0.72) for depression and g = 0.56 (95% CI, 0.42, 0.70) for anxiety. A range of methodological features significantly moderated the effect sizes obtained, including type of control group and the outcome measure used. Risk of Bias ratings indicated some concerns regarding RCT conduct and reporting.

CONCLUSIONS

CBTs lead to moderate improvements in both depression and anxiety symptoms among people with chronic disease. However, the efficacy of CBT should be interpreted considering certain study and sample characteristics. It is recommended that future studies make improvements to study methodology and reporting.

The emotional disorders associated with multiple sclerosis

Multiple sclerosis (MS) is associated with a high prevalence of emotional and mood disorders. Emotional disorders may worsen during illness progression and affect the quality of life of patients and their families. MS is often associated with depression, with an increased risk of suicide, poor adherence to treatment, decreased functional status, and quality of life. The diagnosis and treatment of emotional and mood disorders in these patients is often challenging since several symptoms of these disorders overlap with those of MS. Other prevalent emotional disorders in MS include bipolar disorder, anxiety disorders, emotional blunting (apathy), and pseudobulbar affect. Early recognition and treatment of these comorbidities could contribute to the reduction of disability and even to decreased mortality. The aim of this chapter is to provide an up-to-date review of mood and emotional disorders that are often associated with MS, focusing on their epidemiology, clinical features, pathogenesis, assessment, and treatment. The interplay between the psychosocial impact of the chronic disability and the demyelinating structural lesions of the brain in precipitating emotional and mood disorders is discussed, as well as its implications for diagnosis and treatment.

The effectiveness of emotional wellness programs on mental health outcomes for adults with multiple sclerosis: a systematic review and meta-analysis

BACKGROUND

People with multiple sclerosis (MS) have a greater prevalence of depression and anxiety than the general population. Emotional wellness programs (any psychological or psychosocial interventions that focus on awareness, acceptance, managing, or challenging thoughts and feelings) could be important for people with MS. However, there have been no reviews on the effectiveness of emotional wellness programs for people with MS. The objective of this review was to determine the effectiveness of emotional wellness programs on mental health outcomes for adults with MS.

INCLUSION CRITERIA

Randomised controlled trials (RCTs) and quasi-experimental trials evaluating emotional wellness programs for adults with any form of MS were included. Mental health outcomes included were depression, anxiety, quality of life, and stress. The comparator groups were waitlist controls, usual care, or another intervention.

METHODS

This review was registered with PROSPERO (registration number CRD42019131082) and conducted in accordance with PRISMA guidelines. CINAHL, Cochrane, MEDLINE, PsycInfo, Web of Science, ProQuest Dissertations and Theses, Cochrane register of Controlled Trials, and Google Scholar were searched for English- language publications. Titles and abstracts were initially screened, followed by a screen of full text articles. Studies were critically appraised for methodological quality using the JBI standardised critical appraisal checklists. Data were extracted on intervention details, study outcome measures, behaviour change techniques, and results. Random effects meta-analyses were performed for outcomes assessed in at least five studies, with results reported as the standardised mean difference (SMD).

RESULTS

This review comprised 25 RCTs and four quasi-experimental studies (n participants=2323); 21 were included in meta-analyses. Meta-analyses produced statistically significant results favouring the interventions (SMD (95% CI) for depression -0.55 (-0.87, -0.24); anxiety -0.42 (-0.70, -0.14); quality of life 0.28 (0.14, 0.43); and stress -1.00 (-1.58, -0.43)). The most commonly used behaviour change techniques were behaviour practice/rehearsal, social comparison, and social support.

CONCLUSIONS

This review provides evidence to support the effectiveness of emotional wellness programs for improving mental health outcomes in adults with MS. However, these findings should be interpreted with caution given the high degree of heterogeneity between the studies, and potential for biases in analysis due to missing data and/or incomplete reporting.

An economic evaluation attached to a single-centre, parallel group, unmasked, randomized controlled trial of a 3-day intensive social cognitive treatment (can do treatment) in patients with relapsing remitting multiple sclerosis and low disability

Aims: This trial-based economic evaluation (EE) assesses from a societal perspective the cost-effectiveness of an intensive 3-day cognitive theory-based intervention (CDT), compared to care-as-usual, in patients with relapsing remitting multiple sclerosis (RRMS) and low disability (Expanded Disability Status Scale [EDDS] score < 4.0). Materials and methods: The trial of the EE was registered in the Dutch Trial Register: Trial NL5158 (NTR5298). The incremental cost-effectiveness ratio (ICER) was expressed in cost on the Control sub-scale of the Multiple Sclerosis Self-Efficacy Scale (MSSES) and the incremental cost-utility ratio (ICUR) in the cost per Quality Adjusted Life Years (QALY) using the EQ-5D-5L. Bootstrap, sensitivity, and sub-group analyses were performed to determine the robustness of the findings. Results: The two groups of 79 patients were similar in baseline characteristics. The base case ICER is situated in the northeast quadrant (€72 (40.74/€2,948)) due to a higher MSSES Control score and higher societal costs in the CDT group. The ICUR is situated in the northwest (inferior) quadrant due to losses in QALY and higher societal costs for the CDT group (-0.02/€2,948). Overall, bootstrap, sensitivity, and sub-group analyses confirm the base case findings. However, when the SF-6D is used as a study outcome, there is a high probability that the ICUR is situated in the northeast quadrant. Limitations: The relative short follow-up time (6 months) and the unexpected increase in MSSES Control in the control group. Conclusions: When using the EQ-5D-5L to calculate a QALY, CDT is not a cost-effective alternative in comparison to care as usual. However, when using self-efficacy or SF-6D as outcomes, there is a probability that CDT is cost-effective. Based on the current results, CDT for patients with RRMS clearly show its potential. However, an extended follow-up for the economic evaluation is warranted before a final decision on implementation can be made.

The effects of cognitive behavioral and mindfulness-based therapies on psychological distress in patients with multiple sclerosis, Parkinson's disease and Huntington's disease: Two meta-analyses

OBJECTIVE

Psychological distress has a high impact on quality of life in patients with multiple sclerosis (MS), Parkinson's disease (PD), and Huntington's disease (HD). Studies have shown that cognitive behavioral therapy (CBT) and mindfulness-based therapies (MBTs) are successful in reducing psychological distress in patients with anxiety, depressive, and chronic somatic disorders. We aimed to investigate the effectiveness of these therapies in MS, PD, and HD patients.

METHODS

We performed a comprehensive literature search in PubMed, PsycINFO, Embase and the Cochrane Central Register of Controlled Trials up to March 2018. Randomized controlled trials (RCTs) investigating a CBT or MBT and reporting psychological outcome measures were included. Two separate meta-analyses were performed; one on studies comparing psychological therapy with a treatment as usual or waitlist condition and one on studies with active treatment control conditions.

RESULTS

The first meta-analysis (N = 12 studies, 8 in MS and 4 in PD populations) showed a significant effect size of g = 0.51 in reducing psychological distress. The second meta-analysis (N = 7 studies, in MS populations) showed a mean effect size of g = 0.36. No RCTs were found in HD populations. The overall quality of the included studies was low and considerable heterogeneity was found. No evidence was found for publication bias.

CONCLUSION

CBT and MBTs have a small to moderate effect on reducing psychological distress in patients with PD and MS. However, more research with better methodological quality and larger study samples is warranted, especially in HD patient populations.

Information provision for people with multiple sclerosis

BACKGROUND

People with multiple sclerosis (MS) are confronted with a number of important uncertainties concerning many aspects of the disease. These include diagnosis, prognosis, disease course, disease-modifying therapies, symptomatic therapies, and non-pharmacological interventions, among others. While people with MS demand adequate information to be able to actively participate in medical decision making and to self manage their disease, it has been shown that patients' disease-related knowledge is poor, therefore guidelines recommend clear and concise high-quality information at all stages of the disease. Several studies have outlined communication and information deficits in the care of people with MS. However, only a few information and decision support programmes have been published.

OBJECTIVES

The primary objectives of this updated review was to evaluate the effectiveness of information provision interventions for people with MS that aim to promote informed choice and improve patient-relevant outcomes, Further objectives were to evaluate the components and the developmental processes of the complex interventions used, to highlight the quantity and the certainty of the research evidence available, and to set an agenda for future research.

SEARCH METHODS

For this update, we searched the Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group Specialised Register, which contains trials from CENTRAL (the Cochrane Library 2017, Issue 11), MEDLINE, Embase, CINAHL, LILACS, PEDro, and clinical trials registries (29 November 2017) as well as other sources. We also searched reference lists of identified articles and contacted trialists.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster-randomised controlled trials, and quasi-randomised trials comparing information provision for people with MS or suspected MS (intervention groups) with usual care or other types of information provision (control groups) were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the retrieved articles for relevance and methodological quality and extracted data. Critical appraisal of studies addressed the risk of selection bias, performance bias, attrition bias, and detection bias. We contacted authors of relevant studies for additional information.

MAIN RESULTS

We identified one new RCT (73 participants), which when added to the 10 previously included RCTs resulted in a total of 11 RCTs that met the inclusion criteria and were analysed (1387 participants overall; mean age, range: 31 to 51; percentage women, range: 63% to 100%; percentage relapsing-remitting MS course, range: 45% to 100%). The interventions addressed a variety of topics using different approaches for information provision in different settings. Topics included disease-modifying therapy, relapse management, self care strategies, fatigue management, family planning, and general health promotion. The active intervention components included decision aids, decision coaching, educational programmes, self care programmes, and personal interviews with physicians. All studies used one or more components, but the number and extent differed markedly between studies. The studies had a variable risk of bias. We did not perform meta-analyses due to marked clinical heterogeneity. All five studies assessing MS-related knowledge (505 participants; moderate-certainty evidence) detected significant differences between groups as a result of the interventions, indicating that information provision may successfully increase participants' knowledge. There were mixed results on decision making (five studies, 793 participants; low-certainty evidence) and quality of life (six studies, 671 participants; low-certainty evidence). No adverse events were detected in the seven studies reporting this outcome.

AUTHORS' CONCLUSIONS

Information provision for people with MS seems to increase disease-related knowledge, with less clear results on decision making and quality of life. The included studies in this review reported no negative side effects of providing disease-related information to people with MS. Interpretation of study results remains challenging due to the marked heterogeneity of interventions and outcome measures.

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.

A qualitative study of cognitive behavioural therapy in multiple sclerosis: experiences of psychotherapists

Purpose: To investigate how psychotherapists experience using individual, face-to-face cognitive behavioural therapy (CBT) aimed at alleviating depressive symptoms in persons with multiple sclerosis (MS).

Method: Semi-structured interviews with three psychotherapists were conducted after CBT with 12 participants with MS, and analysed using qualitative content analysis.

Results: Two main themes emerged: Trusting their expertise as psychotherapists whilst lacking MS-specific knowledge, and The process of exploring the participants’ readiness for CBT with modifications of content and delivery. The psychotherapists perceived it difficult to know whether a symptom was attributable to depression or to MS, and for some participants the CBT needed to be adapted to a more concrete content.

Conclusions: Psychotherapists may need more MS-specific knowledge and an insight into the individual’s functioning. The content of CBT in terms of concrete home assignments and behavioural activation needs to be individualised.

Evaluation of an adjustment group forpeople with multiple sclerosis and lowmood: a randomized controlled trial

Background: Mood problems affect many people with multiple sclerosis (MS). The aim was to evaluate the effectiveness of a group treatment based on cognitive behavioural principles.

Methods: People with MS were screened on the General Health Questionnaire 12 (GHQ-12) and Hospital Anxiety and Depression Scale (HAD). Those identified with low mood were invited to take part in a randomized trial comparing the effect of attending an adjustment group with a waiting list control. Patients allocated to the adjustment group received six 2 h group treatment sessions. Outcomes were assessed 4 and 8 months after randomization, blind to group allocation.

Results: Of the 311 patients identified, 221 (71%) met the criteria for low mood and 151 (68%) agreed to take part. Hierarchical regression analyses were conducted to compare the two groups, correcting for baseline mood and disability. At 4 months, group allocation alone was a significant predictor of the primary outcome measure, the GHQ-12. At 8 months, group allocation alone was no longer a significant predictor for GHQ-12 scores, but it was when baseline GHQ-12 and Guy’s Neurological Disability Scale scores were controlled for. Comparison of the area under the curve revealed significant differences between the groups for GHQ-12 ( p = 0.003), HAD Anxiety ( p = 0.013), HAD Depression ( p = 0.004), Beck Depression Inventory ( p = 0.001), MS Self-efficacy ( p = 0.037) and MS Impact Scale Psychological ( p = 0.012).

Conclusion: Patients receiving treatment were less distressed and had less depression and anxiety. There was some evidence of improved self-efficacy and a reduction of the impact of MS on people’s lives.

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.

Comparing individual and group intervention for psychological adjustment in people with multiple sclerosis: a feasibility randomised controlled trial

Objective:

To modify a published group intervention for adjustment to multiple sclerosis (MS) to suit an individual format, and to assess the feasibility of a randomised controlled trial (RCT) to compare individual and group intervention for people with multiple sclerosis and low mood.

Design:

Feasibility randomised controlled trial.

Setting:

Participants were recruited through healthcare professionals at a hospital-based multiple sclerosis service and the MS Society.

Subjects:

People with multiple sclerosis.

Interventions:

Adjustment to multiple sclerosis in individual or group delivery format.

Main measures:

Participants completed mood and quality of life assessments at baseline and at four-month follow-up. Measures of feasibility included: recruitment rate, acceptability of randomisation and the intervention (content and format), and whether the intervention could be adapted for individual delivery. Participants were screened for inclusion using the General Health Questionnaire-12 and Hospital Anxiety and Depression Scale, and were randomly allocated to receive either individual or group intervention, with the same content.

Results:

Twenty-one participants were recruited (mean age 48.5 years, SD 10.5) and were randomly allocated to individual ( n=11) or group ( n=10) intervention. Of those offered individual treatment, nine (82%) completed all six sessions. Of those allocated to group intervention, two (20%) attended all six sessions and three (30%) attended five sessions. There were no statistically significant differences between the groups on the outcome measures of mood and quality of life.

Conclusions:

The intervention could be provided on an individual basis and the trial design was feasible. There were lower attendance rates at group sessions compared to individual sessions.

Individual Face-to-Face Cognitive Behavioural Therapy in Multiple Sclerosis: A Qualitative Study

OBJECTIVE

To investigate how people with multiple sclerosis (MS) experience their participation in individual, face-to-face cognitive behavioural therapy (CBT) aimed at alleviating depressive symptoms.

METHOD

Semistructured interviews with 12 participants were conducted after CBT and analyzed using qualitative content analysis.

RESULTS

Two main themes emerged: CBT as a demanding process and confronting everyday life after CBT with self-knowledge and well-being. The participants had gained strategies for handling feelings of depression and anxiety. The therapist was considered important for guiding them through the demanding therapy.

CONCLUSION

It is important to inform the participants of what CBT entails so that they are mentally prepared for the demanding process and can make the necessary adjustments in their daily life. Knowledge of MS among the therapists as well as collaboration with the multidisciplinary MS care may facilitate participation in CBT.

The effectiveness of behaviour change interventions to increase physical activity participation in people with multiple sclerosis: a systematic review and meta-analysis

Objective:

A systematic review and meta-analysis was conducted to illustrate whether people with multiple sclerosis engage in more physical activity following behaviour change interventions.

Data resources:

MEDLINE, CINAHL, PubMed, Web of Sciences, Cochrane Library, SCOPUS, EMBASE and PEDro were searched from their inception till 30 April 2015.

Trial selection:

Randomized and clinical controlled trials that used behaviour change interventions to increase physical activity in people with multiple sclerosis were selected, regardless of type or duration of multiple sclerosis or disability severity.

Data extraction:

Data extraction was conducted by two independent reviewers and the Cochrane Collaboration’s recommended method was used to assess the risk of bias of each included study.

Results:

A total of 19 out of 573 studies were included. Focusing on trials without risk of bias, meta-analysis showed that behaviour change interventions can significantly increase physical activity participation (z = 2.20, p = 0.03, standardised main difference 0.65, 95% confidence interval 0.07 to 1.22, 3 trials, I2 = 68%) (eight to 12 weeks’ duration). Behaviour change interventions did not significantly impact on the physical components of quality of life or fatigue.

Conclusion:

Behaviour change interventions provided for relatively short duration (eight to 12 weeks) may increase the amount of physical activity people with multiple sclerosis engage in, but appear to have no effect on the physical components of quality of life and fatigue. Further high quality investigations of the efficacy of behaviour change interventions to increase physical activity participation that focus on dose, long-term impact and method of delivery are warranted for people with multiple sclerosis.

Cognitive behavioural interventions for depression in chronic neurological conditions: a systematic review

OBJECTIVE

Chronic neurological conditions (CNCs) affect over one million people in the UK alone. Individuals with CNCs endure an increased prevalence of comorbid depression and anxiety. Poor mental health exacerbates the cost of the treatment and management of CNCs. CBT is recommended for the treatment of depression. However the application of CBT to individuals with CNCs may be limited by disease characteristics (e.g. mobility issues restricting therapy attendance and reducing engagement with behavioural activation, as well as difficulties challenging the veracity of disease-related negative thoughts that may reflect accurate appraisals). The objective of this review is to assess the clinical effectiveness of cognitive and behavioural interventions for depressive symptoms in individuals with non-acquired, medically explained CNCs.

DATA SOURCES

Searches of The Cochrane Controlled Trials Register, PubMed, and PsychINFO were conducted.

RESULTS

All studies suggested that CBT is an effective treatment for depression comorbid to CNCs, however when CBT was compared to an active therapy control condition, between group differences were unstable.

CONCLUSION

CBT has promise for the treatment for depression in such conditions; however treatment protocols and outcome measures should be adapted for this population. Future trials should control for non-specific effects of therapy and, as much as possible, introduce blinding into methodologies.

What are the support needs of men with multiple sclerosis, and are they being met?

BACKGROUND

Multiple sclerosis (MS) is a chronic, degenerative condition of the central nervous system that can lead to high levels of disability and a range of psychological and social problems. Although considerable research has been conducted on the experience of living with MS and the disease's psychosocial consequences, much of this has focused on women, with the male perspective seldom considered. It is possible, therefore, that men differ from women in how they experience MS and the type of support or interventions that meet their needs.

METHODS

A literature review was undertaken to identify the specific support needs of men with MS, describe current support available to men with MS, and evaluate the extent to which these needs are met by current service provision.

RESULTS

The literature reviewed suggests that the needs of men with MS are different from those of women in terms of psychological factors such as well-being and mental health and support.

CONCLUSIONS

If interventions are to be evidence based, health-care professionals need to take into account the needs, desires, and capabilities of men with MS in the development of services. Further qualitative and quantitative research is required to address the gaps in the evidence base of support needs for men with MS.

Predictors of anxiety in multiple sclerosis

PURPOSE/OBJECTIVES

The aims of this study were to (1) identify the predictors of symptoms of anxiety, and (2) evaluate the differential association of somatic and nonsomatic symptoms of depression on anxiety over time in persons with multiple sclerosis (MS).

METHOD/DESIGN

Participants were 513 persons with MS who previously enrolled in a study exploring the experience of living with MS and completed a 4-month follow-up survey. The main outcome measure used was the Hospital Anxiety and Depression Scale-Anxiety. Demographic, disease-associated variables (time since onset of MS, Expanded Disability Status Scale Mobility, pain, and fatigue), and Time 1 psychological variables were entered into a hierarchical regression model to examine predictors at baseline for anxiety symptoms at Time 2.

RESULTS

A large portion of the sample was White (92%), female (82%), and had relapsing-remitting MS (57%). After adjusting for demographic and disease related variables, anxiety (β <.001), employment (β = .07), and nonsomatic depressive symptoms (β = .10) at baseline significantly predicted anxiety at Time 2, ps < .05. Interactions revealed significant effects for time since onset of MS and somatic symptoms as well as time since onset and nonsomatic symptoms, ps < .05. Nonsomatic symptoms were more linked to anxiety early in the disease and somatic symptoms were more prominently linked to anxiety later in the disease.

CONCLUSIONS

Findings suggest that nonsomatic symptoms of depression and employment predict anxiety in MS. The relationship between different aspects of depression and anxiety may change over the course of the disease.

Symptom changes in multiple sclerosis following psychological interventions: a systematic review

Background

Multiple Sclerosis is a disease of the central nervous system involving a variety of debilitating physical, sensory, cognitive and emotional symptoms. This literature review evaluated the impact of psychological interventions on the physiological symptoms associated with the illness.

Methods

A systematic literature search was conducted using Medline, PsycINFO, Scopus, and the Cochrane Library databases, as well as reference lists. Relevant studies were selected and assessed according to a preset protocol.

Results

The search produced 220 articles, with 22 meeting inclusion criteria for the review. A total of 5,705 subjects with Multiple Sclerosis were analyzed. Results from the included studies indicate a general improvement in both psychological and physiological outcomes following psychological treatment. The most highly influenced physical symptoms include fatigue, sleep disturbances, pain, and physical vitality.

Conclusions

Findings from the review suggest a positive relationship between psychological interventions and physiological Multiple Sclerosis symptoms. Implications for future research are discussed.

Treatment of mood disorders in multiple sclerosis

OPINION STATEMENT

Multiple sclerosis (MS) is a chronic demyelinating disease of the central nervous system with a significant comorbidity with depressive disorders. Prevalence rates for major depressive disorder (MDD) range from 36 % to 54 % and the rate is around 22 % for adjustment disorders. Selective serotonin reuptake inhibitors (SSRIs) are considered well-tolerated first-line treatment. Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) are generally reserved for second-line use after SSRIs, because of sedating or anticholinergic side effects. SNRIs, with the exception of duloxetine, and combinations of newer antidepressants have failed to treat depression due to their side effects profile and frequent interaction with other drugs. Among SSRIs, sertraline is usually the first option, starting at 25 mg/day and increasing to 50 mg/day; and waiting a few weeks to assess drug effects before increasing the dose. The maximum is generally 200 mg/day in a single dose. Paroxetine is the second choice, starting at 10 mg/day for the first 5 days, and then at 20 mg/day thereafter. The maximum dose is about 50 mg/day in a single dose. Fluvoxamine is used at 100-200 mg/day, starting with 25 mg/day, and increasing 25 mg/day every 5 days until 200 mg/day is reached. We should take into account increasing blood level amounts of MS treatments (corticosteroids and cyclophosphamide) with fluvoxamine. With duloxetine, doses will be at 60-120 mg/day. The initial dose for depression is 40 mg/day in two doses; it can increase to 60 mg/day in one to two doses if necessary. The maximum dose is generally 120 mg/day. Duloxetine may increase liver problems through interaction with these MS treatments: teriflunomide, interferon beta-1a, and interferon beta-1b. Considering psychotherapy, only cognitive behavior therapy and mindfulness-based interventions have shown efficacy in improving depression disorders in MS. A comprehensive treatment for depression should include pharmacotherapy and psychotherapy.

Information provision for people with multiple sclerosis

BACKGROUND

People with multiple sclerosis (MS) are confronted with a number of important uncertainties concerning many aspects of the disease. Among others, these include diagnosis, prognosis, disease course, disease-modifying therapies, symptomatic therapies and non-pharmacological interventions. It has been shown that people with MS demand adequate information to be able to actively participate in medical decision making and to self-manage their disease. On the other hand, it has been found that patients' disease-related knowledge is poor. Therefore, guidelines have recommended clear and concise high-quality information at all stages of the disease. Several studies have outlined communication and information deficits in the care of people with MS and, accordingly, a number of information and decision support programmes have been published.

OBJECTIVES

To evaluate the effectiveness of information provision interventions for people with MS that aim to promote informed choice and improve patient-relevant outcomes.

SEARCH METHODS

We searched the Cochrane Multiple Sclerosis and Rare Diseases of the Central Nervous System Group Specialised Register which contains trials from CENTRAL (The Cochrane Library 2013, Issue 6), MEDLINE, EMBASE, CINAHL, LILACS, PEDro and clinical trials registries (12 June 2013) as well as other sources. In addition, we searched PsycINFO, trial registries, and reference lists of identified articles. We also contacted trialists.

SELECTION CRITERIA

Randomised controlled trials, cluster randomised controlled trials and quasi-randomised trials comparing information provision for people with MS or suspected MS (intervention groups) with usual care or other types of information provision (control groups) were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the retrieved articles for relevance and methodological quality, and extracted data. Critical appraisal of studies addressed the risk of selection bias, performance bias, attrition bias and detection bias. We contacted authors of relevant studies for additional information.

MAIN RESULTS

Ten randomised controlled trials involving a total of 1314 participants met the inclusion criteria and were analysed. The interventions addressed a variety of topics using different approaches for information provision in different settings. Topics included disease-modifying therapy, relapse management, self-care strategies, fatigue management, family planning and general health promotion. The interventions contained decision aids, educational programmes, self-care interventions and personal interviews with physicians. All interventions were complex interventions using more than one active component, but the number and extent of the intervention components differed markedly between studies. The studies had a variable risk of bias. We did not perform meta-analyses due to marked clinical heterogeneity. All four studies assessing MS-related knowledge (524 participants; moderate-quality evidence) detected significant differences between groups as a result of the interventions indicating that information provision may successfully increase participants' knowledge. There were mixed results from four studies reporting effects on decision making (836 participants; low-quality evidence) and from five studies assessing quality of life (605 participants; low-quality evidence). There were no adverse events in the six studies reporting on adverse events.

AUTHORS' CONCLUSIONS

Information provision for people with MS seems to increase disease-related knowledge, with less clear results on decision making and quality of life. There seem to be no negative side effects from informing patients about their disease. Interpretation of study results remains challenging due to the marked heterogeneity of the interventions and outcome measures.

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.

Systematic Review of Occupational Therapy–Related Interventions for People With Multiple Sclerosis: Part 2. Impairment

This article is the second part of a systematic review of studies on occupational therapy–related intervention for people with multiple sclerosis (MS). The objective of this systematic review was to critically appraise and synthesize the applicable findings to address the following focused question: What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice for people with multiple sclerosis? Part 1 (Yu & Mathiowetz, 2014) reviewed evidence for the effectiveness of activity- and participation-based interventions for people with MS. In contrast to the top-down approach, enabling occupational performance can be achieved through remediating impaired personal abilities. Therefore, Part 2 focuses on occupational therapy interventions targeting impairment. Studies included in this review focused on improving client factors and performance skills in people with MS, including cognition, emotional regulation, and motor and praxis skills.

Using existing data to identify candidate items for a health state classification system in multiple sclerosis

PURPOSE

In multiple sclerosis (MS), the use of preference-based measures is limited to generic measures such as Health Utilities Index Mark 2 and 3, the EQ-5D and the SF-6D. However, the challenge of using such generic preference-based measures in people with MS is that they may not capture all domains of health relevant to the disease. Therefore, the main aim of this paper is to describe the development of a health state classification system for MS patients. The specific objectives are: (1) to identify items best reflecting the domains of quality of life important to people with MS and (2) to provide evidence for the discriminative capacity of the response options by cross-walking onto a visual analog scale of health rating.

METHODS

The data come from an epidemiologically sampled population of people with MS diagnosed post-1994. The dataset consisted of 206 items relating to impairments, activity limitations, participation restrictions, health perception and quality of life. Important domains were identified from the responses to the Patient Generated Index, an individualized measure of quality of life. The extent to which the items formed a uni-dimensional, linear construct was estimated using Rasch analysis, and the best item was selected using the threshold map.

RESULTS

The sample was young (mean age 43) and predominantly female (n = 140/189; 74%). The P-PBMSI classification system consisted of five items, with three response levels per item, producing a total of 243 possible health states. Regression coefficient values consistently decreased between response levels and the linear test for trend were statistically significant for all items. The linear test for trend indicated that for each item the response options provided the same discriminative ability within the magnitude of their capacity. A scoring algorithm was estimated using a simple additive formula. The classification system demonstrated convergent validity against other measures of similar constructs and known-groups validity between different clinical subgroups.

CONCLUSION

This study produced a health state classifier system based on items impacted upon by MS, and demonstrated the potential to discriminate the health impact of the disease.

The effects of a group-based cognitive behavioral therapy on people with multiple sclerosis: a randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of a cognitive behavioral group-based intervention aimed at reducing depression and fostering quality of life and psychological well-being of multiple sclerosis patients through the promotion of identity redefinition, sense of coherence, and self-efficacy.

DESIGN

A randomized controlled trial.

SETTING

Non-medical setting, external to the Multiple Sclerosis Clinic Centre.

SUBJECTS

Eighty-two patients: 64% women; mean age 40.5, SD = 9.4; 95% with relapsing-remitting multiple sclerosis; Expanded Disability Status Scale (EDSS) between 1 and 5.5 were included in the study.

INTERVENTIONS

Patients were randomly assigned to an intervention group (five cognitive behavioral group-based sessions, n = 41) or to a control group (three informative sessions, n = 41).

MAIN MEASURES

Depression (CES-D), Quality of life (MSQOL revised), Psychological well-being (PANAS), Identity Motives Scale, Sense of Coherence (SOC), and Self Efficacy in Multiple Sclerosis.

RESULTS

Quality of life increased in the intervention group compared with the control at 6-months follow-up (mean change 0.72 vs. -1.76, p < 0.05). Well-being in the intervention group increased for males and slightly decreased for females at 6-months follow-up (mean change 6.58 vs. -0.82, p < 0.05). Contrasts revealed an increase in self-efficacy in the intervention group at posttreatment compared with the control (mean change 2.95 vs. -0.11, p < 0.05). Depression tended to lower, while identity and coherence increased in the intervention group compared with the control, though the differences were not significant.

CONCLUSIONS

Preliminary evidence suggests that intervention promotes patients' quality of life and has an effect on psychological well-being and self-efficacy.

Cost-effectiveness of an adjustment group for people with multiple sclerosis and low mood: a randomized trial

OBJECTIVE

To evaluate the cost effectiveness of a psychological adjustment group shown to be clinically effective in comparison with usual care for people with multiple sclerosis.

DESIGN

Randomized controlled trial with comparison of costs and calculation of incremental cost effectiveness ratio.

SETTING

Community.

PARTICIPANTS

People with multiple sclerosis were screened on the General Health Questionnaire 12 and Hospital Anxiety and Depression Scale, and those with low mood were recruited.

INTERVENTIONS

Participants randomly allocated to the adjustment group received six group treatment sessions. The control group received usual care, which did not include psychological interventions.

MAIN MEASURES

Outcomes were assessed four and eight months after randomization, blind to group allocation. The costs were assessed from a service use questionnaire and information provided on medication. Quality of life was assessed using the EQ-5D.

RESULTS

Of the 311 patients identified, 221 (71%) met the criteria for having low mood. Of these, 72 were randomly allocated to receive treatment and 79 to usual care. Over eight months follow-up there was a decrease in the combined average costs of £378 per intervention respondent and an increase in the costs of £297 per patient in the control group, which was a significant difference (p=0.03). The incremental cost-effectiveness ratio indicated that the cost per point reduction on the Beck depression inventory-II was £118.

CONCLUSION

In the short term, the adjustment group programme was cost effective when compared with usual care, for people with multiple sclerosis presenting with low mood. The longer-term costs need to be assessed.

Do generic utility measures capture what is important to the quality of life of people with multiple sclerosis?

PURPOSE

The three most widely used utility measures are the Health Utilities Index Mark 2 and 3 (HUI2 and HUI3), the EuroQol-5D (EQ-5D) and the Short-Form-6D (SF-6D). In line with guidelines for economic evaluation from agencies such as the National Institute for Health and Clinical Excellence (NICE) and the Canadian Agency for Drugs and Technologies in Health (CADTH), these measures are currently being used to evaluate the cost-effectiveness of different interventions in MS. However, the challenge of using such measures in people with a specific health condition, such as MS, is that they may not capture all of the domains that are impacted upon by the condition. If important domains are missing from the generic measures, the value derived will be higher than the real impact creating invalid comparisons across interventions and populations. Therefore, the objective of this study is to estimate the extent to which generic utility measures capture important domains that are affected by MS.

METHODS

The available study population consisted of men and women who had been registered after 1994 in three participating MS clinics in Greater Montreal, Quebec, Canada. Subjects were first interviewed on an individualized measure of quality of life (QOL) called the Patient Generated Index (PGI). The domains identified with the PGI were then classified and grouped together using the World Health Organization's International Classification of Functioning, Disability and Health (ICF), and mapped onto the HUI2, HUI3, EQ-5D and SF-6D.

RESULTS

A total of 185 persons with MS were interviewed on the PGI. The sample was relatively young (mean age 43) and predominantly female. Both men and women had mild disability with a median Expanded Disability Status Scale (EDSS) score of 2. The top 10 domains that patients identified to be the most affected by their MS were, work (62%), fatigue (48%), sports (39%), social life (28%), relationships (23%), walking/mobility (22%), cognition (21%), balance (14%), housework (12%) and mood (11%). The SF-6D included the most number of domains (6 domains) important to people with MS, followed by the EQ-5D (4 domains) and the HUI2 (4 domains) and then the HUI3 (3 domains). The mean and standard deviation (SD) for the PGI, EQ-5D and the SF-6D were 0.50 (SD 0.25), 0.69 (0.18) and 0.69 (0.13), respectively. The magnitude of difference between the PGI and the generic utility measures was large and statistically significant.

CONCLUSION

Although the generic utility measures included certain items that were important to people with MS, there were several that were missing. An important consequence of this mismatch was that values of QOL derived from the PGI were importantly and significantly lower than those estimated using any of the generic utility measures. This could have a substantial impact in evaluating the effect of interventions for people with MS.

Effectiveness of psychologically focused group interventions for multiple sclerosis: A review of the experimental literature

Psychologically focused group interventions for multiple sclerosis were reviewed. Studies reviewed (14) were quantitative, experimental and involved a comparison group (control or other intervention). Compared with controls, psychologically focused group interventions achieved considerable improvements in depression and moderate improvements in self-efficacy and quality of life but little change in anxiety. Psychologically focused group interventions compared well with other interventions, although evidence was limited. Psychologically focused group intervention was less effective short term for depression than individual cognitive behavioural therapy or medication but comparable long term. Intervention heterogeneity made comparisons difficult. Specificity of effect is unclear. Limited evidence suggests psychologically focused group intervention is effective in improving certain outcomes.

Factors affecting anxiety in multiple sclerosis

PURPOSE

Anxiety is common in people with multiple sclerosis (MS). Little is known about the factors related to anxiety. The aim was to identify factors associated with the presence of anxiety.

METHODS

This was a cohort study. Participants were sent questionnaires to measure factors potentially related to anxiety. The factors included disability, depression, self-efficacy, locus of control, general stress, psychological distress and factors specific to MS. Participants with significant levels of anxiety, as measured by the Hospital Anxiety and Depression Scale (HADS), were compared to those who were not anxious.

RESULTS

Of the 157 participants who took part, 89 (57%) were clinically anxious. Participants who were anxious had a lower level of self-efficacy (p < 0.001), higher level of disability (p < 0.001), higher level of depression (p < 0.001) and higher level of stress (p < 0.001). The regression analysis showed that experiencing depression (χ(2) = 5.05, OR = 1.32, p < 0.05) was the only factor that significantly predicted whether someone was anxious or not, accounting for 46% of the variance.

CONCLUSION

There was a high prevalence of anxiety in people with MS. Depression, low levels of self-efficacy, disability and stress increased the likelihood of experiencing anxiety.

The effects of clinical interventions on health-related quality of life in multiple sclerosis: a meta-analysis

The objective is to estimate the extent to which existing health care interventions designed specifically to target health-related quality of life (HRQL) in persons with multiple sclerosis (MS) achieve this aim. The structured literature search was conducted using multiple electronic databases including Ovid MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature and the Cochrane Central Register of Controlled Trial, for the years 1960 to 2011. The methodological quality of selected randomized controlled trials (RCTs) was assessed using the Cochrane Collaboration's recommended domain-based method. Effect size (ES) was used to measure the effect of each intervention on HRQL. The studies were combined using a random-effects model to account for inter-study variation. Heterogeneity was tested for using the I-test and publication bias was assessed using funnel plots and the Egger weighted regression statistic. Thirty-nine RCTs met the criteria, all with acceptable methodological quality. Six major types of interventions were identified through the search. The smallest effect was observed for self-management and complementary and alternative medicine (ES=0.2), followed by medication (ES=0.3) then cognitive training and exercise (ES=0.4), and psychological interventions to improve mood (ES=0.7). The magnitude of positive effect on HRQL varied between the different types of interventions. The extent to which interventions are able to improve HRQL depends on delivering a potent intervention to those persons who have the potential to benefit.

Attendance at a psychological support group for people with multiple sclerosis and low mood

PURPOSE

A cognitive behavioural group promoting psychological adjustment for people with multiple sclerosis (MS) was found to reduce psychological distress. Not all those offered treatment attended the group sessions. The aims were to examine the rates of attendance and to evaluate feedback from participants.

METHOD

Participants with MS and low mood were recruited to a randomized trial comparing attendance at a psychological support group with a usual care control group. The attendance at each session was determined and those who attended were compared with those who failed to attend using a Mann-Whitney U-test or chi-squared. A sample of participants completed a telephone feedback questionnaire to determine their views of the group.

RESULTS

The 44 participants who attended four or more sessions were not significantly different from the 28 who attended fewer than four sessions on demographic variables, disability, self-efficacy or quality of life, but significantly fewer men attended than women (p = 0.03). Participants' feedback from the group was mainly positive, and no factors were identified associated with non-attendance.

CONCLUSIONS

Men were less likely to attend group treatment sessions than women, but no other variables were associated with non-attendance. Attendance rates influence the effectiveness of interventions and reasons for non-attendance need to be determined.

Anxiety and depression in multiple sclerosis patients around diagnosis

OBJECTIVES

To prospectively identify anxiety and depressive symptoms, and their predictors, during the multiple sclerosis (MS) peridiagnostic period.

METHODS

The Hospital Anxiety and Depression Scale (HADS) was administered during diagnostic workup (baseline), and one and six months after diagnosis disclosure, to SIMS-Trial participants (ISRCTN81072971).

RESULTS

Of 197 screened patients, 120 (61%) were diagnosed with MS. At baseline, median HADS anxiety (HADS-A) score was 7.0 (interquartile range [IQR] 5.0-9.5), ≥8 (anxiety cut-off) in 43% (95% confidence interval [CI] 34%-52%). Median HADS depression (HADS-D) was 3.0 (IQR 1.0-5.0), ≥8 (depression cut-off) in 11% (95% CI 5%-16%). Independent predictors of anxiety were female sex (odds ratio [OR] 2.8, 95% CI 1.1-7.2) and HADS-D score (OR 20.8, 95% CI 2.5-175.5). The only predictor of depressive symptoms was HADS-A score (OR 20.0, 95% CI 2.8-260.9). Anxiety symptoms had decreased slightly but significantly (p<0.001) at six months. Depressive symptoms remained low.

CONCLUSIONS

Anxiety was prominent in the period surrounding MS diagnosis disclosure, particularly in women. A slight but significant reduction occurred six months after diagnosis disclosure. Depressive symptoms were less common and stable over time. In addition to sex, depressive symptoms were the only variable independently associated with anxiety.