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).

A Cross-Sectional Decision-Making Approach to Inform Neuropsychological Battery Development in Professional Hockey

OBJECTIVE

Neuropsychologists commonly use a large battery of tests to inform clinical decisions. Decision analysis can be used to determine which individual tests play a role in the decision-making process. The objective of this project was to conduct quantitative and qualitative decision analysis of decisions by team neuropsychologists with professional hockey players being evaluated as part of the National Hockey League (NHL)/NHL Players Association Concussion Protocol.

METHOD

We extracted neuropsychological data from an NHL clinical program database. Team neuropsychologists evaluated concussed players using a hybrid neuropsychological test battery. The neuropsychologists then determined whether players were experiencing concussion-related cognitive difficulties. Logistic regression was used to examine which tests accounted for unique variance in the decision-making process. We also conducted a survey of NHL neuropsychologists, asking them to rate the usefulness of each test in the battery.

RESULTS

Five of the fifteen measures accounted for unique variance in team neuropsychologists' decisions, including the ImPACT Verbal Memory Composite, Visual Motor Composite, Reaction Time Composite, Symptom Score, and Brief Visuospatial Memory Test-Revised Delayed Recall. Notable discrepancies were uncovered between quantitative indications of usefulness and self-reported qualitative perceptions of test usefulness when making decisions. Qualitatively, clinicians reported that the Hopkins Verbal Learning Test-Revised, Symbol Digit Modalities Test, ImPACT Reaction Time, and Color Trails 2 were the most useful tests when making decisions.

CONCLUSIONS

Along with validation studies, decision analysis can be used as part of a comprehensive evaluation process to inform the development of best-practice batteries for use among athletes with sports concussion.

A much needed metric: Defining reliable and statistically meaningful change of the oral version Symbol Digit Modalities Test (SDMT)

BACKGROUND

The Symbol Digit Modalities Test (SDMT) has been recommended for use in clinical trials and outcome studies to monitor cognitive change. However, defining what is a meaningful change has been elusive for several years.

OBJECTIVE

The present investigation aimed to develop methods for assessing individual-level statistically significant change on the SDMT - reliable change indices (RCIs) and standardized regression-based (SRB) equations.

METHODS

A total of 219 healthy individuals completed the oral version SDMT at baseline, 6-month and 1-year follow-up.

RESULTS

The SDMT demonstrated high reliability across all time points (r's = 0.83 to 0.86). Reliable change scores of 7, 8, and 10 points for the 6-month intervals represented statistically meaningful change at the 0.70, 0.80, and 0.90 confidence intervals, respectively. Over 1-year, a difference of 8, 10, and 12 was statistically meaningful at the 0.70, 0.80, and 0.90 confidence intervals, respectively. SRB equations are also provided taking into account additional factors found to be predictive of SDMT scores over time.

CONCLUSION

Clinicians frequently denote a decline of 4 points on the SDMT as meaningful. Results in this large normative sample show that higher cut-points are needed to demonstrate statistically significant decline at the individual level. RCIs are provided for 6 month and one year assessment, which is typical in clinical practice and trials. SRB equations are also provided for use when applicable and may provide a more precise assessment of meaningful change.

A quick assessment of reliable change in fatigue: Reliable change indices of the modified fatigue impact scale - 5 item (MFIS-5)

BACKGROUND

Reliably monitoring changes in fatigue is an ongoing concern.

OBJECTIVE

Evaluate reliable change using the Modified Fatigue Impact Scale 5-item version (MFIS-5) in people with MS (PwMS).

METHODS

The MFIS-5 was administered at three time points in 157 PwMS. Test-retest reliability and reliable change scores were calculated at the 0.70, 0.80, 0.90, and 0.95 confidence intervals.

RESULTS

Difference scores of 3, 4, 5, and 6 represent statistically meaningful change at the 0.70, 0.80, 0.90, and 0.95 confidence intervals, respectively.

CONCLUSION

Cut points derived from this study and prior work can help reliably assess changes in fatigue over time.

Disability measurement in Multiple Sclerosis patients 55 years and older: What is the Expanded Disability Status Scale really telling clinicians?

BACKGROUND

The Expanded Disability Status Scale (EDSS) measures disease progression in Multiple Sclerosis (MS). EDSS changes are assumed to be due to worsening MS-related disability. Strict interpretation of this premise may include some normal findings as abnormal, inflating the disability score. Further, determining the cause of neurologic symptoms can be difficult in an older population with comorbid illness and polypharmacy.

OBJECTIVE

To examine the association between EDSS, age, comorbidities and polypharmacy.

METHODS

106 people, 55 years and older, with and without MS were administered the EDSS and a validated comorbidity questionnaire. Polypharmacy was also assessed.

RESULTS

Median EDSS scores were 6.0 in people with MS and 3.0 in people without MS. No participant in our cohort had an EDSS of 0. Higher EDSS scores were associated with older age and more polypharmacy. Pyramidal and cerebellar functional systems accounted for the largest percentage of unique variance between groups.

CONCLUSION

Older individuals with and without MS demonstrated significant disability on the EDSS. These findings indicate that EDSS scores may be partially due to factors other than MS. Our understanding of disease course and disability may benefit from the development of normative EDSS scores to correct for these factors.

A new look at an old test: Normative data of the symbol digit modalities test -Oral version

BACKGROUND

The Symbol Digit Modalities Tests (SDMT) is the most sensitive measure to multiple sclerosis (MS)-related cognitive dysfunction. However, existing normative data has been under scrutiny. Specifically, they are outdated, do not take into account gender, and are poorly stratified by education. More importantly, there exists no oral only version norms, which is typical administration among individuals with MS.

OBJECTIVE

The present investigation aimed to develop updated normative data of the oral version SDMT in which age, gender, and education were taken into consideration.

METHODS

A total of 675 healthy individuals, stratified by age, gender, and education completed the oral version SDMT.

RESULTS

Significant effects were found for age, gender, and education, consistent with previous contentions. Specifically, performance on the SDMT tends to decline with age, with the most noticeable decline beginning in the third decade of life and continuing into the sixth decade. Women, in general perform better than men, with an average of 5.1 more points. Finally, education effects were apparent among those aged 25-54.

CONCLUSION

Based on these findings, updated normative data are provided. Utilization of these updated norms will result in a much needed and more accurate assessment of processing speed for individuals with MS.

Testing the Hybrid Battery Approach to Evaluating Sports-Related Concussion in the National Hockey League: A Factor Analytic Study

Purpose

Traditional “paper and pencil” neuropsychological tests and computerized test batteries have been employed in the assessment of sports-related concussion (SRC). Each type of test has inherent strengths and weaknesses. The NHL has constructed a “hybrid” battery of tests that uses both traditional and computerized measures in the evaluation of its players suspected of SRC. The purpose of this paper is to use factor analytic techniques to examine the relationships among the measures that comprise this battery.

Methods

Post-injury neuropsychological test data using the hybrid battery were obtained from 343 NHL players following their first concussion while playing in the league. ImPACT was used as the computer test battery. The traditional battery included: Hopkins Verbal Learning Test, Brief Visuospatial Memory Test, Color Trails, PSU Cancellation, Symbol Digits Modalities Test (including incidental memory), and Verbal Fluency.

Results

Five factors were extracted explaining 64.55% of the variance. The factor labels and the measures principally loading on each factor were as follows: Factor 1, Verbal Learning and Memory (HVLT Total and Delayed Recall); Factor 2, Processing Speed (Color Trails A/B, PSU Cancellation, and SDMT-Total); Factor 3, Visual Memory (BVMT- Total and Delayed); Factor 4, Cued Memory (ImPACT-Visual and Verbal Memory Composites); and Factor 5, Reaction Time (ImPACT Reaction Time and Visual Motor Speed composites).

Conclusion

These data underscore the unique contributions of traditional and ImPACT neuropsychological measures to the evaluation SRC in a sample of professional hockey players. It appears that both approaches measure different aspects of cognitive functioning. The next logical step is to use these data in evaluating the diagnostic utility of these measures as part of a combined battery.

The Utility of the King-Devick Test in Evaluating Professional Ice Hockey Players with Suspected Concussion

Purpose

The King-Devick (KD) is a measure of rapid number naming used in the evaluation of sports-related concussion (SRC). Recent data from the Canadian Football League and Rugby Union suggest that the KD should not be used as a stand-alone measure of SRC. The purpose of this study was to examine the diagnostic utility of the KD in professional ice hockey players.

Methods

NHL players who were suspected of having a concussion were evaluated with the KD and either the SCAT3 or the SCAT5. Players who were evaluated and not diagnosed with concussion served as Active controls. A small group of non-Active control players was also tested twice and was included in the present study for comparison.

Results

1605 players were evaluated with the KD at baseline. Of these, 53 were diagnosed with concussion, 76 were Active controls, and 11 were non-Active controls. Concussed players revealed a decline in performance from baseline to acute evaluation, t(52)=3.05, p<.01, d=.42 while Active controls significantly improved, t(75)=2.05, p<.05, d=.24. No significant change between baseline and acute testing was observed for non-Active controls. Using a cut score of any decline in performance from baseline to suspected injury evaluation yielded Sensitivity=64%, Specificity=61%, Positive Predictive Value=53% and Negative Predictive Value=71%.

Conclusion

Our data are consistent with previous studies suggesting that while the KD is useful in differentiating concussed and not concussed athletes acutely, the relatively low predictive values indicate that a decline in KD performance should not be used as a standalone measure to diagnose concussion.

Computer-Based Executive Function Training for Combat Veterans With PTSD: A Pilot Clinical Trial Assessing Feasibility and Predictors of Dropout

Background: While evidence-based PTSD treatments are often efficacious, 20-50% of individuals continue to experience significant symptoms following treatment. Further, these treatments do not directly target associated neuropsychological deficits. Here, we describe the methods and feasibility for computer-based executive function training (EFT), a potential alternative or adjunctive PTSD treatment. Methods: Male combat veterans with full or partial PTSD (n = 20) and combat-exposed controls (used for normative comparison; n = 20) completed clinical, neuropsychological and functional neuroimaging assessments. Those with PTSD were assigned to EFT (n = 13) or placebo training (word games; n = 7) at home for 6 weeks, followed by repeat assessment. Baseline predictors of treatment completion were explored using logistic regressions. Individual feedback and changes in clinical symptoms, neuropsychological function, and neural activation patterns are described. Results: Dropout rates for EFT and placebo training were 38.5 and 57.1%, respectively. Baseline clinical severity and brain activation (i.e., prefrontal-insula-amygdala networks) during an emotional anticipation task were predictive of treatment completion. Decreases in clinical symptoms were observed following treatment in both groups. EFT participants improved on training tasks but not on traditional neuropsychological assessments. All training completers indicated liking EFT, and indicated they would engage in EFT (alone or as adjunctive treatment) if offered. Conclusion: Results provide an initial framework to explore the feasibility of placebo-controlled, computerized, home-based executive function training (EFT) on psychological and neuropsychological function and brain activation in combat veterans with PTSD. Clinical severity and neural reactivity to emotional stimuli may indicate which veterans will complete home-based computerized interventions. While EFT may serve as a potential alternative or adjunctive PTSD treatment, further research is warranted to address compliance and determine whether EFT may benefit functioning above and beyond placebo interventions.

Implementation of the European health interview survey (EHIS) into the German health update (GEDA)

Background

This methodological paper describes the integration of the ‘European Health Interview Survey wave 2’ (EHIS 2) into the ‘German Health Update’ 2014/2015 (GEDA 2014/2015-EHIS).

Methods

GEDA 2014/2015-EHIS is a cross-sectional health survey. A two-stage stratified cluster sampling approach was used to recruit persons aged 15 years and older with permanent residence in Germany. Two different modes of data collection were used, self-administered web questionnaire and self-administered paper questionnaire. The survey instrument implemented the EHIS 2 modules on health status, health care use, health determinants and social background variables and additional national questions. Data processing was conducted according to the quality and validation rules specified by Eurostat.

Results

In total, 24,824 questionnaires were completed. The response rate was 27.6%. The two-stage cluster sample method seems to have been successful in achieving a sample with high representativeness. The final micro data file was inspected, approved and certified by Eurostat. Access to micro data of the EHIS 2 can be provided by Eurostat via research contract and to the GEDA 2014/2015-EHIS public use file by the Research Data Centre of the Robert Koch Institute. First EHIS 2 results are available at the Eurostat website.

Conclusions

Integrating a multinational health survey into an existing national health monitoring system was a challenge in Germany. The national survey methodology for conducting the survey had to be further developed in order to meet the overarching goal of harmonizing the health information from national statistical offices and public health research institutes across the European Union. The harmonized EHIS 2 data source will profoundly impact international public health research in the near future. The next EHIS wave 3 will be conducted around 2019.

PTSD and cognitive symptoms relate to inhibition-related prefrontal activation and functional connectivity

BACKGROUND

Posttraumatic stress disorder (PTSD) is associated with reduced executive functioning and verbal memory performance, as well as abnormal task-specific activity in prefrontal cortex (PFC) and anterior cingulate cortices (ACC). The current study examined how PTSD symptoms and neuropsychological performance in combat veterans relates to (1) medial PFC and ACC activity during cognitive inhibition, and (2) task-independent PFC functional connectivity.

METHODS

Thirty-nine male combat veterans with varying levels of PTSD symptoms completed the multisource interference task during functional magnetic resonance imaging. Robust regression analyses were used to assess relationships between percent signal change (PSC: incongruent-congruent) and both PTSD severity and neuropsychological performance. Analyses were conducted voxel-wise and for PSC extracted from medial PFC and ACC regions of interest. Resting-state scans were available for veterans with PTSD. Regions identified via task-based analyses were used as seeds for resting-state connectivity analyses.

RESULTS

Worse PTSD severity and neuropsychological performance related to less medial PFC and rostral ACC activity during interference processing, driven partly by increased activation to congruent trials. Worse PTSD severity related to reduced functional connectivity between these regions and bilateral, lateral PFC (Brodmann area 10). Worse neuropsychological performance related to reduced functional connectivity between these regions and the inferior frontal gyrus.

CONCLUSIONS

PTSD and associated neuropsychological deficits may result from difficulties regulating medial PFC regions associated with "default mode," or self-referential processing. Further clarification of functional coupling deficits between default mode and executive control networks in PTSD may enhance understanding of neuropsychological and emotional symptoms and provide novel treatment targets.

Persistent nonmalignant pain management using nonsteroidal anti-inflammatory drugs in older patients and use of inappropriate adjuvant medications

Objective

Due to the high risk of life-threatening side effects, nonsteroidal anti-inflammatory drugs (NSAIDs) are not favored for treating persistent nonmalignant pain in the elderly. We report national prescription trends with determinants of NSAIDs prescription for persistent nonmalignant pain among older patients (age 65 and over) in the US outpatient setting.

Methods

A cross-sectional analysis was performed using National Ambulatory Medical Care Survey data. Prescriptions for NSAIDs, opioids, and adjuvant agents were identified using five-digit National Ambulatory Medical Care Survey drug codes.

Results

About 89% of the 206,879,848 weighted visits in the US from 2000 to 2007 recorded NSAIDs prescriptions in patients (mean age =75.4 years). Most NSAIDs users had Medicare (75%), and about 25% were prescribed with adjuvant medications considered inappropriate for their age. Compared to men, women were 1.79 times more likely to be prescribed NSAIDs.

Conclusion

The high percentage of NSAIDs prescription in older patients is alarming. We recommend investigating the appropriateness of the high prevalence of NSAIDs use among older patients reported in our study.

Preventive effects of diltiazem on cyclosporin A-induced vascular smooth muscle dysfunction

Cyclosporin A may cause vascular smooth muscle dysfunction due to calcium overload as a consequence of chronically augmented calcium influx. In the present study, the responsiveness to vasocontrictors was investigated in rats after chronic treatment for 6 weeks with placebo, cyclosporin A (30 mg/kg per day), diltiazem (60 mg/kg per day), or cyclosporin A plus diltiazem. Twenty-four hours after the last oral treatment the animals were sacrificed and rings of the thoracic aorta were suspended in organ chambers under isometric conditions in the absence of cyclosporin A or diltiazem. Chronic treatment with cyclosporin A significantly augmented contractions to angiotensin II (10(-9)-10(-5) M). This effect was prevented by cotreatment with diltiazem. Diltiazem did not affect the cyclosporin A-induced reduction in the response to potassium chloride (10-80 mM). The contractions to phenylephrine (10(-9)-10(-6) M) and endothelin-1 (10(-9)-10(-7) M) were not significantly different in the four groups. The preventive effect of diltiazem against the cyclosporin A-induced hypersensitivity to angiotensin II supports the hypothesis of increased calcium influx during cyclosporin A therapy. The results may provide an additional rationale for the use of calcium antagonists in the treatment of the vascular side effects of cyclosporin A.

Calcium entry blockade may prevent cyclosporin A-induced hypersensitivity to angiotensin II and endothelial dysfunction in the rat aorta

Vascular smooth muscle dysfunction after chronic treatment with cyclosporin A was in part explained by chronically augmented calcium influx leading to calcium overload. The potential protective effect of calcium antagonism with diltiazem as regards endothelial and vascular smooth muscle reactivity was investigated during chronic treatment with cyclosporin A. Male Wistar rats were orally treated for 6 weeks with either cyclosporin A (30 mg.kg-1 x day-1 in 1 ml, n = 8), with the vehicle alone (n = 10), with diltiazem (60 mg.kg-1 x day-1, n = 10) or with a combination of cyclosporin A and diltiazem (30 mg.kg-1 x day-1 and 60 mg.kg-1 x day-1, n = 8), respectively. Rings of the isolated thoracic aorta were mounted in organ chambers to measure isometric force. Chronic treatment with diltiazem alone did not affect the responsiveness to any of the drugs tested, but the augmentation of contractions to angiotensin II (10(-9) to 10(-6) M) after treatment with cyclosporin, was prevented by co-treatment with diltiazem. Co-treatment with diltiazem, however, did not affect the response to potassium chloride (20-80 mM), endothelin-1 (10(-9) to 10(-7) M) or phenylephrine (10(-9) to 10(-6) M). Endothelium-dependent relaxations to calcitonin gene-related peptide (CGRP, 10(-10) to 10(-7) M) and acetylcholine (10(-8) to 10(-5) M) were reduced in cyclosporin A treated rats. Co-treatment with diltiazem normalized the response to CGRP. The response to acetylcholine was not significantly affected.(ABSTRACT TRUNCATED AT 250 WORDS)

Endothelial and vascular smooth muscle function after chronic treatment with cyclosporin A

We wished to characterize the altered reactivity of vascular smooth muscle and endothelial cells in rat aorta during chronic treatment with cyclosporin. Male adult rats were treated orally for 6 weeks with either cyclosporin A (30 mg/kg/day in 1 ml olive oil, n = 9) or with vehicle alone (n = 10). Rings of isolated thoracic aorta were mounted in organ chambers to measure the change in isometric force in response to smooth muscle-contracting drugs and endothelium-dependent and independent vasodilators. Contractions to potassium chloride (20-80 mM) were markedly reduced in cyclosporin-treated rats. Contractions to phenylephrine (10(-10)-10(-6) M) were reduced at high concentrations (> or = 10(-7) M); those to endothelin-1 (10(-10)-10(-7) M) were not significantly altered. In contrast, contractions to angiotensin II (AII 10(-9)-10(-6) M) were significantly augmented. Endothelium-dependent relaxations to acetylcholine (ACh 10(-8)-10(-5) M) or ADP (10(-7)-10(-5) M) were reduced in cyclosporin-treated rats; endothelium-independent relaxations to SIN-1 (10(-7)-10(-5) M) and atrial natriuretic peptide (ANP 10(-10)-10(-7) M) remained unaffected. Thus, chronic treatment with cyclosporin affects both endothelium-dependent vasodilation and vascular smooth muscle contraction in rat aorta depending on the stimulus applied. The enhanced response to AII and the reduced release of endothelium-derived relaxing factor (EDRF) may contribute to augmented vascular tone and further damage to the arterial wall.