Disease management for depression in an MS clinic

Self-management, self-esteem and their associations with psychological well-being in people with multiple sclerosis

BACKGROUND

Optimal self-management seem to be protective factor of health-related quality of life and psychological well-being in many chronic conditions. However, the results in people with multiple sclerosis (MS) are still inconclusive. Thus, the aim of this study is to assess the associations between self-management, self-esteem and psychological well-being in people with MS when controlled for sociodemographic and clinical variables.

METHODS

A total of 165 people with MS filled in The Multiple Sclerosis Self-Management Scale, Rosenberg Self-Esteem scale, and General Health Questionnaire-28, to assess main variables under study. Functional status was measured by Kurtzke disability Status Scale.

RESULTS

We found significant associations between self-esteem and somatic symptoms, anxiety/insomnia, social dysfunction and severe depression. Explained variance of the models ranged from 16% to 38% for somatic symptoms and severe depression, respectively. Self-management significantly contributed to the explained variance in all models sans GHQ social dysfunction. Self-esteem was significant contributor to overall variance in all models.

DISCUSSION

According to our results, self-management and self-esteem were found to be associated with multiple domains of psychological well-being. These findings may be used in neurological practice, to help people with MS who report psychological distress in one or more domains.

Improving the quality of depression and pain care in multiple sclerosis using collaborative care: The MS-care trial protocol

BACKGROUND AND OBJECTIVES

Evidence-based pharmacological and behavioral interventions are often underutilized or inaccessible to persons with multiple sclerosis (MS) who have chronic pain and/or depression. Collaborative care is an evidence-based patient-centered, integrated, system-level approach to improving the quality and outcomes of depression care. We describe the development of and randomized controlled trial testing a novel intervention, MS Care, which uses a collaborative care model to improve the care of depression and chronic pain in a MS specialty care setting.

METHODS

We describe a 16-week randomized controlled trial comparing the MS Care collaborative care intervention to usual care in an outpatient MS specialty center. Eligible participants with chronic pain of at least moderate intensity (≥3/10) and/or major depressive disorder are randomly assigned to MS Care or usual care. MS Care utilizes a care manager to implement and coordinate guideline-based medical and behavioral treatments with the patient, clinic providers, and pain/depression treatment experts. We will compare outcomes at post-treatment and 6-month follow up.

PROJECTED PATIENT OUTCOMES

We hypothesize that participants randomly assigned to MS Care will demonstrate significantly greater control of both pain and depression at post-treatment (primary endpoint) relative to those assigned to usual care. Secondary analyses will examine quality of care, patient satisfaction, adherence to MS care, and quality of life. Study findings will aid patients, clinicians, healthcare system leaders, and policy makers in making decisions about effective care for pain and depression in MS healthcare systems. (PCORI- IH-1304-6379; clinicaltrials.gov: NCT02137044). This trial is registered at ClinicalTrials.gov, protocol NCT02137044.

Depression in epilepsy, migraine, and multiple sclerosis: Epidemiology and how to screen for it

Purpose of review

To provide an overview of the epidemiology of depression in chronic neurologic conditions that can affect individuals throughout the lifespan (epilepsy, migraine, multiple sclerosis [MS]) and examine depression screening tools for adults with these conditions.

Recent findings

Depression is common in neurologic conditions and can be associated with lower quality of life, higher health resource utilization, and poor adherence to treatment. It affects around 20%-30% of those with epilepsy, migraine, and MS, and evidence for a bidirectional association exists for each of these conditions. Depression screening tools generally perform well in neurologic conditions, but are not without limitations.

Summary

Depression is a major contributor to poor outcomes in epilepsy, migraine, and MS. Although psychiatric resources are scarce globally, this is no reason to ignore depression in neurologic conditions. Depression screening tools are available in neurology and should be considered in clinical practice.

World Health Organization disability assessment schedule 2.0: An international systematic review

PURPOSE

This systematic review examines research and practical applications of the World Health Organization Disability Assessment Schedule (WHODAS 2.0) as a basis for establishing specific criteria for evaluating relevant international scientific literature. The aims were to establish the extent of international dissemination and use of WHODAS 2.0 and analyze psychometric research on its various translations and adaptations. In particular, we wanted to highlight which psychometric features have been investigated, focusing on the factor structure, reliability, and validity of this instrument.

METHOD

Following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) methodology, we conducted a search for publications focused on "whodas" using the ProQuest, PubMed, and Google Scholar electronic databases.

RESULTS

We identified 810 studies from 94 countries published between 1999 and 2015. WHODAS 2.0 has been translated into 47 languages and dialects and used in 27 areas of research (40% in psychiatry).

CONCLUSIONS

The growing number of studies indicates increasing interest in the WHODAS 2.0 for assessing individual functioning and disability in different settings and individual health conditions. The WHODAS 2.0 shows strong correlations with several other measures of activity limitations; probably due to the fact that it shares the same disability latent variable with them. Implications for Rehabilitation WHODAS 2.0 seems to be a valid, reliable self-report instrument for the assessment of disability. The increasing interest in use of the WHODAS 2.0 extends to rehabilitation and life sciences rather than being limited to psychiatry. WHODAS 2.0 is suitable for assessing health status and disability in a variety of settings and populations. A critical issue for rehabilitation is that a single "minimal clinically important .difference" score for the WHODAS 2.0 has not yet been established.

Enrolling and keeping participants in multiple sclerosis self-management interventions: a systematic review and meta-analysis

OBJECTIVES

The objectives were to provide an estimate of expected enrolment and attrition rates based on published studies of existing self-management interventions for people with multiple sclerosis, and to identify contributing factors and impact on outcomes.

REVIEW METHODS

A systematic literature search was conducted using Ovid MEDLINE, PsychINFO, EMBASE, AMED, CINAHL, OT Seeker, PubMed, and the Cochrane Database of Systematic Reviews databases. Controlled trials with or without randomization using either a between-group or within-person design were included if they met specified criteria. A random-effect meta-regression analysis was conducted to estimate the overall enrolment and attrition proportions, effect of person- and study-related factors, and impact on outcomes.

RESULTS

A total of 48 studies, comprising 4446 persons were identified. The estimated enrolment rate was 50.3% (95% confidence interval (CI): 49.6 to 51.1) and the estimated attrition rates in the intervention and control groups were 16.8% (95% CI: 16.2 to 17.3) and 14.4% (95% CI: 13.8 to 14.9), respectively. The main reported reason for refusing to participate was lack of interest (70.6%), while the reported reasons for dropping out were mainly owing to medical issues (26.1%) and disliking the intervention (17.9%). Trial, programme, and patient-related variables were found to influence the enrolment and/or attrition rates. Studies that had a 10% higher attrition rate had an effect size that was larger by 0.19 (95% CI: 0.17 to 0.24).

CONCLUSION

Greater understanding of the factors associated with enrolment and attrition rates would help in planning and developing a more appealing self-management intervention that patients can easily accept and incorporate into their everyday lives.

Exploration of Undertreatment and Patterns of Treatment of Depression in Multiple Sclerosis

BACKGROUND

Depression is a common comorbid condition with multiple sclerosis (MS). Historically, however, it has been undertreated. Little is known about the characteristics of those who receive, or do not receive, treatment for depression in the MS population. This study evaluated depression treatment in patients with MS, associated patient characteristics, and probable determinants of antidepressant drug use in those with and without depression.

METHODS

A total of 152 patients with MS completed questionnaires and the Structured Clinical Interview for DSM-IV-TR (SCID) to determine depression status. Tabular analyses and a binary regression model were used to identify patient characteristics associated with antidepressant drug use.

RESULTS

Of participants with major depression according to the SCID, 65% were taking antidepressant medications. With adjustment for successful treatment (antidepressant drug use by those not currently depressed and currently depressed), the prevalence of treated depression increased to 85.7%. Of those receiving treatment for depression, 19% were receiving nonpharmacologic treatment alone, 38% were taking antidepressant drugs only, and 44% were receiving both pharmacologic and nonpharmacologic treatments. Demographic and clinical variables were not statistically significantly associated with antidepressant drug use in those with depression.

CONCLUSIONS

A large proportion of participants with depression in MS are now receiving treatment, a change from previous reports. The adequacy of treatment has become a bigger question because many of the treated patients continued to have depressive symptoms. Further research is needed to identify ways to achieve better outcomes for depression.

Models for treating depression in specialty medical settings: a narrative review

OBJECTIVE

This review answered two questions: (a) what types of specialty medical settings are implementing models for treating depression, and (b) do models for treating depression in specialty medical settings effectively treat depression symptoms?

METHOD

We searched Medline/Pubmed to identify articles, published between January 1990 and May 2013, reporting on models for treating depression in specialty medical settings. Included studies had to have adult participants with comorbid medical conditions recruited from outpatient, nonstandard primary care settings. Studies also had to report specific, validated depression measures.

RESULTS

Search methods identified nine studies (six randomized controlled trials, one nonrandomized controlled trial and two uncontrolled trials), all representing integrated care for depression, in three specialty settings (oncology, infectious disease, neurology). Most studies (N=7) reported greater reductions in depression among patients receiving integrated care compared to usual care, particularly in oncology clinics.

CONCLUSIONS

Integrated care for depression in specialty medical settings can improve depression outcomes. Additional research is needed to understand the effectiveness of incorporating behavioral and/or psychological treatments into existing methods. When developing or selecting a model for treating depression in specialty medical settings, clinicians and researchers will benefit from choosing specific components and measures most relevant to their target populations.

Co-occurring depression and pain in multiple sclerosis

Depression and pain are highly prevalent among individuals with multiple sclerosis, and they often co-occur. The purpose of this article is to summarize the literature and theory related to the comorbidity of pain and depression and describe how their presence can impact individuals with multiple sclerosis. Additionally, the article discusses how existing treatments of pain and depression could be adapted to address shared mechanisms and overcome barriers to treatment utilization.

Internet-based self-help treatment for depression in multiple sclerosis: study protocol of a randomized controlled trial

BACKGROUND

Depression in MS patients is frequent but often not treated adequately. An important underlying factor may be physical limitations that preclude face-to-face contact. Internet-based treatment showed to be effective for depressive symptoms in general and could thus be a promising tool for treatment in MS.

METHODS/DESIGN

Here, we present a study protocol to investigate the effectiveness of a 5 week Internet-based self-help problem solving treatment (PST) for depressive symptoms in MS patients in a randomized controlled trial. We aim to include 166 MS patients with moderate to severe depressive symptoms who will be randomly assigned to an Internet-based intervention (with or without supportive text-messages) or waiting list control group. The primary outcome is the change in depressive symptoms defined by a change in the sum score on the Beck Depression Inventory (BDI-II). Secondary outcomes will include measures of anxiety, fatigue, cognitive functioning, physical and psychological impact of MS, quality of life, problem solving skills, social support, mastery, satisfaction and compliance rate. Assessments will take place at baseline (T0), within a week after the intervention (T1), at four months (T2) and at ten months follow-up (T3: only the intervention group). The control group will be measured at the same moments in time. Analysis will be based on the intention-to-treat principle.

DISCUSSION

If shown to be effective, Internet-based PST will offer new possibilities to reach and treat MS patients with depressive symptoms and to improve the quality of care.

TRIAL REGISTRATION

The Dutch Cochrane Center, NTR2772.

A scoping review of self-management interventions for adults with multiple sclerosis

The purpose of this scoping review is to identify self-management tasks and skills that are being taught in existing interventions for persons with multiple sclerosis and to describe intervention strategies used to facilitate the learning of self-management tasks and skills. Multiple strategies were used to search for studies published or in press between 1980 and 2008 that evaluated self-management interventions. The main exclusion criteria were case studies, inadequate description of the intervention, and traditional clinical patient education interventions. Two independent coders categorized the interventions by using Lorig and Holman's self-management framework and Abraham and Michie's taxonomy of behavior change techniques. Twenty-seven interventions were identified from 34 articles. Common intervention topics included fatigue management (n = 12), coping, depression, and stress management (n = 10), and medication management (n = 6). Also, no 2 interventions used the same delivery format to implement the same combination of intervention strategies. Furthermore, markedly different intervention strategies were used to improve the same outcomes. These results highlight a need to systematically test intervention strategies one at a time, or in a clear specified combination, as well as compare existing interventions to determine which are most effective in supporting persons with multiple sclerosis to learn and incorporate self-management tasks and skills.

Challenges in screening for depression in multiple sclerosis

BACKGROUND

Screening has frequently been proposed as a strategy for detection of depression in multiple sclerosis (MS). In a recent study, we found a minimal impact of screening, even when this was coupled with rapidly responsive and evidence-based depression care.

METHODS

In order to explore the challenges involved in screening we analyzed prospective data from the Canadian Impact of MS (CIMS) database, which provides annual ratings on a self-report depression rating scale, the Center for Epidemiologic Studies Depression Rating Scale (CES-D).

RESULTS

Approximately 30% of respondents screened positive at each visit. CES-D ratings correlated fairly strongly from year to year, Pearson's r ranged from 0.65 to 0.73. Approximately 10% of those below the CES-D cut-point at each assessment exceeded the cut-point when rated 1 year later, but only about half of these cases had large (≥10 points) increases in their scores.

CONCLUSIONS

Screening interventions are generally oriented towards early detection, whereas the longitudinal pattern of depressive symptoms in MS appears to be characterized more prominently by a persistent burden of depressive symptoms in a substantial proportion of the population. Resources invested in screening efforts can probably be more effectively deployed in other areas, such as improved long-term clinical management.

Clinical and economic impact of a specialty care management program among patients with multiple sclerosis: a cohort study

Background: To evaluate the clinical and economic impact of a specialty care management program among patients with multiple sclerosis.

Methods: This retrospective cohort analysis included patients aged ≥18 years with ≥2 claims of multiple sclerosis diagnosis and ≥1 multiple sclerosis medications from 1 January 2004 to 30 April 2008. The outcome metrics included medication adherence and persistence, multiple sclerosis-related hospitalization, and multiple sclerosis-related cost. Multivariate analyses were performed to adjust for demographics and clinical characteristics.

Results: Among the 3993 patients identified, 78.3% participated in the program and 21.7% did not. Over 12 months, medication adherence and persistence improved among participants but deteriorated among non-participants (medication possession ratio change: +0.08 vs −0.03, p < 0.001; persistence change: +29.2 days vs −9.2 days, p < 0.001). Multiple sclerosis-related hospitalization decreased from 9.6% to 7.1% for participants, whereas it increased from 10.1% to 12.0% for the non-participant group (p < 0.001). Multiple sclerosis-related medical spending (non-pharmacy) decreased among participants, but it increased among non-participants (mean: −US$264 vs + US$1536, p < 0.001). Total multiple sclerosis-related cost for both groups increased over time (+US$4471 vs +US$4087, p < 0.001).

Conclusions: This program was associated with improved medication adherence and persistence, reduced multiple sclerosis-related hospitalization, and decreased multiple sclerosis-related medical costs. Unfortunately, the cost savings in the medical component did not offset the increased pharmacy expenditures during the 12-month follow-up period.