Mental Health Comorbidity in MS: Depression, Anxiety, and Bipolar Disorder.

Among individuals with multiple sclerosis (MS), mental health comorbidities play a significant role in contributing to secondary disability and detracting from quality of life. This review examines current evidence surrounding three mental health issues of particular relevance to MS: depression, anxiety, and bipolar disorder. We review what is known of the prevalence, correlates, screening mechanisms, and current treatment of each issue and provide recommendations for future areas of research.

Injection anxiety remains a long-term barrier to medication adherence in multiple sclerosis.

OBJECTIVE: To evaluate the contribution injection anxiety to disease modifying therapy (DMT) adherence among individuals with multiple sclerosis (MS). Injection anxiety has been associated with medication discontinuation early in the course of treatment, but little is known about the relationship between injection anxiety and sustained DMT adherence over time. METHOD: Eighty-nine outpatients receiving care at a Veterans Administration MS clinic completed a telephone survey at baseline and monthly telephone follow-up for 6 months. RESULTS: Participants were established DMT users (M = 3.43 years, SD = 3.29), with relatively high adherence overall (over 80% achieved 80% adherence or greater). Using logistic regression and controlling for demographics, MS disability, type of DMT, and time on DMT, the authors found that baseline injection anxiety predicted lower levels of adherence at 4 months and 6 months, with a similar trend at 2 months. CONCLUSION: Sustained adherence to DMT remains a challenge for a subset of individuals with MS well beyond the initial period of acclimation. Injection anxiety is an important and promising target of psychological intervention during all periods of medication use.

Physical activity and depression in MS: The mediating role of behavioral activation.

BACKGROUND: Depression is a common comorbid condition among individuals with multiple sclerosis (MS) and is associated with greater overall disease burden and lower quality of life. Numerous clinical trials have supported physical activity interventions versus education, usual care, and attention control conditions for improving depressive symptoms in individuals with MS. However, little is known about the psychological mechanisms that may underlie physical activity-related improvements in depression. Behavioral activation posits that depression may stem from a reduction or loss of personally meaningful and rewarding activity. The process of behavioral activation involves re-engaging with these experiences. Behavioral activation might represent one mechanism by which physical activity interventions improve depression. OBJECTIVE: To examine behavioral activation as a mechanism mediating the effects of physical activity intervention on depressive symptom improvement in individuals with MS. METHODS: Mediational path analysis using data from a randomized controlled trial (N = 64) comparing telephone-based physical activity counseling (TC) to education (EC). RESULTS: Participation in TC resulted in greater improvements in behavioral activation from months 0-3. Improvements in behavioral activation were associated with fewer baseline-adjusted depressive symptoms at month 6. The corresponding indirect (mediational) pathway was significant. CONCLUSION: Behavioral activation may represent one mechanism by which physical activity improves depression in MS. Future physical activity trials should capitalize on this relationship and place additional emphasis on identifying and engaging in personally meaningful life activity. Future trials of therapies focused on behavioral activation might benefit from encouraging physical activity goals. TRIAL REGISTRATION: Trial Registration clinicaltrials.gov Identifier: NCT01198977.

Improving fatigue and depression in individuals with multiple sclerosis using telephone-administered physical activity counseling.

OBJECTIVE: To evaluate the impact of a physical activity intervention consisting of telephone counseling with home-based monitoring to improve fatigue and depression in individuals with multiple sclerosis (MS). METHOD: Single-blind randomized controlled trial. Sixty-four individuals with MS received either telephone counseling (N = 31), or self-directed physical activity education (N = 33). The education condition (EC) consisted of advice to increase physical activity and a DVD with examples of in-home exercises for multiple physical ability levels. The telephone counseling condition (TC) included EC as well as mailed graphic feedback, 6 telephone counseling sessions using principles of motivational interviewing, and telehealth home monitoring to track progress on physical activity goals. Booster sessions were provided when participants indicated they did not meet their goals. Assessment was conducted at baseline, 3-month, and 6-month follow-up. RESULTS: TC participants reported significantly reduced fatigue (d = -.70), reduced depression (d = -.72) and increased physical activity (d = .92) relative to EC participants. Of individuals receiving TC, 33.3% experienced clinically significant improvement in fatigue (vs. 18.2% in EC) and 53.3% experienced clinically significant improvement in depression (vs. 9.1% in EC). Improvements in physical activity mediated improvements in fatigue with a similar trend for depression. TC was highly feasible (participants completed 99.5% of schedule telephone sessions) and well tolerated (100% rated it highly successful). CONCLUSION: Telephone-based counseling with home monitoring is a promising modality to improve physical activity and treat fatigue and depression.

Telephone counseling and home telehealth monitoring to improve medication adherence: results of a pilot trial among individuals with multiple sclerosis.

OBJECTIVE: To evaluate the impact upon medication adherence of brief telephone-based counseling using principles of motivational interviewing and telehealth home monitoring. DESIGN: Randomized controlled pilot trial of 19 veterans with multiple sclerosis (MS) currently prescribed disease modifying therapy (DMT) who endorsed missing doses. Follow-up was conducted at 1, 3, and 6 months. RESULTS: Participants in the intervention condition reported better adherence relative to controls at 6-month follow-up [M (SD) = 1.3 (2.1) vs. 8.2 (12.3) past month missed doses]. All participants in the intervention condition completed all 3 telephone counseling sessions and 90% or greater rated the program as highly successful. CONCLUSION: Brief telephone counseling represents a promising mechanism for improving medication adherence. The primary components, motivational interviewing and home telehealth monitoring, provided complementary mechanisms for initiating and sustaining behavior change over time. The intervention was well tolerated and provided an opportunity to extend access and reduce barriers to care by bringing it into the homes of participants.

Access to multiple sclerosis specialty care.

BACKGROUND: Health care providers recommend an annual visit to a multiple sclerosis specialty care provider. OBJECTIVE: To examine potential barriers to the implementation of this recommendation in the Veterans Health Administration. DESIGN: Observational cohort study. SETTING: Veterans Health Administration. PARTICIPANTS: Participants were drawn from the Veterans Affairs Multiple Sclerosis National Data Repository and were included if they had an outpatient visit in 2007 and were alive in 2008 (N = 14,723). MAIN OUTCOME MEASUREMENTS: Specialty care visit, receipt of medical services. RESULTS: A total of 9643 (65.5%) participants had a specialty care visit in 2007. Veterans who were service connected, had greater medical comorbidity, and who lived in urban settings were more likely to have received a specialty care visit. Veterans who were older and had to travel greater distances to a center were less likely to have a specialty care visit. CONCLUSIONS: Access to care in rural areas and areas at a greater distance from a major medical center represent notable barriers to rehabilitation and other multiple sclerosis-related care.