Internet-delivered cognitive behavioural therapy programme to reduce depressive symptoms in patients with multiple sclerosis: a multicentre, randomised, controlled, phase 3 trial

BACKGROUND

Depression is three to four times more prevalent in patients with neurological and inflammatory disorders than in the general population. For example, in patients with multiple sclerosis, the 12-month prevalence of major depressive disorder is around 25% and it is associated with a lower quality of life, faster disease progression, and higher morbidity and mortality. Despite its clinical relevance, there are few treatment options for depression associated with multiple sclerosis and confirmatory trials are scarce. We aimed to evaluate the safety and efficacy of a multiple sclerosis-specific, internet-based cognitive behavioural therapy (iCBT) programme for the treatment of depressive symptoms associated with the disease.

METHODS

This parallel-group, randomised, controlled, phase 3 trial of an iCBT programme to reduce depressive symptoms in patients with multiple sclerosis was carried out at five academic centres with large outpatient care units in Germany and the USA. Patients with a neurologist-confirmed diagnosis of multiple sclerosis and depressive symptoms were randomly assigned (1:1:1; automated assignment, concealed allocation, no stratification, no blocking) to receive treatment as usual plus one of two versions of the iCBT programme Amiria (stand-alone or therapist-guided) or to a control condition, in which participants received treatment as usual and were offered access to the iCBT programme after 6 months. Masking of participants to group assignment between active treatment and control was not possible, although raters were masked to group assignment. The predefined primary endpoint, which was analysed in the intention-to-treat population, was severity of depressive symptoms as measured by the Beck Depression Inventory-II (BDI-II) at week 12 after randomisation. This trial is registered at ClinicalTrials.gov, NCT02740361, and is complete.

FINDINGS

Between May 3, 2017, and Nov 4, 2020, we screened 485 patients for eligibility. 279 participants were enrolled, of whom 101 were allocated to receive stand-alone iCBT, 85 to receive guided iCBT, and 93 to the control condition. The dropout rate at week 12 was 18% (50 participants). Both versions of the iCBT programme significantly reduced depressive symptoms compared with the control group (BDI-II between-group mean differences: control vs stand-alone iCBT 6·32 points [95% CI 3·37-9·27], p<0·0001, effect size d=0·97 [95% CI 0·64-1·30]; control vs guided iCBT 5·80 points [2·71-8·88], p<0·0001, effect size d=0·96 [0·62-1·30]). Clinically relevant worsening of depressive symptoms was observed in three participants in the control group, one in the stand-alone iCBT group, and none in the guided iCBT group. No occurrences of suicidality were observed during the trial and there were no deaths.

INTERPRETATION

This trial provides evidence for the safety and efficacy of a multiple sclerosis-specific iCBT tool to reduce depressive symptoms in patients with the disease. This remote-access, scalable intervention increases the therapeutic options in this patient group and could help to overcome treatment barriers.

FUNDING

National Multiple Sclerosis Society (USA).

Spectrum, rate and unmet needs of sociomedical interventions in outpatient psychotherapy

OBJECTIVE

Psychological disorders often take a long-term course, resulting in impairment in daily life and work. Treatment must therefore target not only symptoms of illness but also capacity limitations and context restrictions, as outlined in the International Classification of Functioning, Disability and Health (ICF). This includes sociomedical and interdisciplinary interventions like coordination with other specialists, contact to employers and employment agencies, social support agencies, debt counselling, self-help and leisure groups. There are no data on the spectrum, rate and unmet needs of sociomedical interventions in outpatient psychotherapy.

METHOD

Following a semistructured interview schedule, 131 psychotherapists in private practice were asked to report on unselected patients. The interviewer assessed to what degree 38 predefined sociomedical interventions were applied so far or should be considered in the future.

RESULT

Reports for 322 patients were gathered. All sociomedical interventions were applied, depending on the sick leave status and course of illness. Cognitive behaviour therapists used more sociomedical interventions than psychodynamic therapists.

CONCLUSION

The data show that sociomedical interventions are a frequent part of psychotherapy. They are used preferably in patients with participation restrictions. Psychotherapeutic concepts and education should include sociomedical aspects.