Depressive symptoms are prevalent among patients with Multiple Sclerosis (MS). However, depression in MS patients is often not recognized and adequate treatment tends to be lacking. Besides that, MS patients can experience difficulties in assessing psychotherapy treatment due to disease related barriers as fatigue, physical disabilities and transportation difficulties. Recently, web-based cognitive behaviour therapy (CBT) self-help treatment has been demonstrated as an effective intervention for reducing depressive symptoms in patients with a depressive disorder. We expect it to be a promising approach to the treatment of co-morbid depression in MS patients, because it is easy accessible and can overcome disease-related barriers to participate in face-to-face counselling.
Our recent pilot study has shown promising results (WC2008-033) in treating depressive symptoms in MS patients with a web-based CBT intervention. It encourages us to proceed with the intervention and to examine the effectiveness of this web-based self-help course for the treatment of depressive symptoms in MS in a randomized clinical trial. To the best of our knowledge, this will be the first randomized controlled study to evaluate effectiveness of a web-based CBT self-help treatment for depressive symptoms in MS. We expect that the online intervention will be more effective for the treatment of depressive symptomatology in MS patients than care as usual. Moreover, we expect positive effects from the online intervention on anxiety, fatigue, disability level and quality of life because of the suggested association of depression with these parameters.
Depression in multiple sclerosis
Depressive symptoms are highly prevalent in patients with multiple sclerosis (MS). Lifetime risk for depression in the MS population has been estimated at around 50%, compared with 10-15% in the general population (1;2). Depression is related to poorer quality of life, disrupts social support and family systems, and has been associated with fatigue, a cutback in working hours and cognitive impairment in MS patients (1). The risk of suicide is 2.3 times elevated in the MS population (3), with the most important risk factor for suicide being a depressive episode (4). Furthermore, depression can result in decreased adherence to MS treatment, which may affect health status adversely (5). It remains unclear whether depressive symptoms in patients with MS are primarily reactive in nature as a response to the unpredictable and uncertain course of the disease, or whether neurobiological factors play a part (1;6).
Treatment of depression in MS
Despite the unclear etiology of depression in MS, a couple of clinical trials on cognitive behaviour therapy (CBT) have shown that psychotherapy is an effective treatment for depression in patients with MS (1;7-9). Especially when the treatment focuses on developing skills to cope with the unpredictable and uncertain course of the disease and its consequences (8;10). Apparently, depression in MS patients has been related to poor problem-solving skills, while learning various coping strategies has been found to reduce symptoms of depression in MS patients (9). High levels of problem-focused coping and/or low levels of emotion-focused coping may make patients resistant to depression (11).
Depression: under diagnosed & undertreated
In the general practice it turns out that more than half of depressed MS patients go undiagnosed (12, 13). Possible reasons could be (i) the perception of patients that emotional problems are an indissoluble component of the disease process, therefore leaving this problem unmentioned in the consulting room of the physician and/or (ii) the limited focus on mental problems by treating physicians and general practitioners (11). Besides, (iii) if depressive symptoms are recognized by the physician adequate treatment tends to be lacking (1). Patients experience difficulties in accessing psychotherapy treatment. This is due to disease-related factors such as fatigue, physical impairments and transportation difficulties that make it difficult to attend scheduled therapy sessions. These complicating factors seem to have a major impact on face-to-face treatment in MS patients with co-morbid depression (14).Therefore we sense an urgent need to provide treatment for depression in a format which is easy accessible and can minimize potential barriers for psychological treatment in this patient group.
Use of web-based CBT self help treatment
In order to avoid the aforementioned barriers to face-to-face therapy and counselling, alternatives with a greater self-help orientation can be offered. During the past several years there has been a significant increase in the use of telecommunication to provide self-help oriented psychotherapy for a wide range of psychiatric conditions. Recent evidence shows that CBT treatment provided over the telephone or using the Internet is an effective method of treatment for depression in general (15;16). In depressed MS patients, Mohr and colleagues found a significantly larger decrease of depressive symptoms in those receiving a telephone-administered CBT compared to those receiving supportive emotion-focused therapy (17) or no mental healthcare at all (18). This cost effective form of treatment results in a reduction of treatment times and commuting times. Furthermore it has the advantage of making it possible to reach a large number of people who have functional impairments due to physical health problems.
Use of web-based CBT self help treatment
In order to avoid the aforementioned barriers to face-to-face therapy and counselling, alternatives with a greater self-help orientation can be offered. During the past several years there has been a significant increase in the use of telecommunication to provide self-help oriented psychotherapy for a wide range of psychiatric conditions. Recent evidence shows that CBT treatment provided over the telephone or using the Internet is an effective method of treatment for depression in general (15;16). In depressed MS patients, Mohr and colleagues found a significantly larger decrease of depressive symptoms in those receiving a telephone-administered CBT compared to those receiving supportive emotion-focused therapy (17) or no mental healthcare at all (18). This cost effective form of treatment results in a reduction of treatment times and commuting times. Furthermore it has the advantage of making it possible to reach a large number of people who have functional impairments due to physical health problems.
Preliminary pilot findings of web-based treatment for MS patients with depressive symptoms
In view of the findings described above, the obvious next step is to use the Internet as a medium in providing accessible treatment for MS patients. In January 2009 we started a pilot study (WC2008-033) to examine the feasibility and effectiveness of a web-based CBT self-help treatment for MS patients with depressive symptoms. The intervention at issue is called ‘Minder Zorgen’ (Worry Less; www.minderzorgen.nu) and links up with an existing online therapy that is currently being offered as part of various depression trials (Everything under Control; www.allesondercontrole.nu). The intervention is based on what is known as problem-solving therapy, comprising a cognitive behavioural therapy self-help intervention. Dutch and international studies alike have found the intervention to be effective in the treatment of depression (19;20).We made a number of modifications to make the intervention applicable for people with MS, concerning (i) additional information about MS and its psychosocial consequences, and (ii) text and examples applying to MS patients.
This pilot study provides evidence that an adjusted version of web-based PST is a feasible treatment for depressive symptoms in patients with MS. More than half of the patients completed the intervention and the majority reported to be satisfied with this web-based intervention. Furthermore, our preliminary findings indicate that the intervention can reduce depressive symptoms in MS patients, especially in those who report more depressive symptoms at baseline and complete the intervention. Apparently, this subgroup of patients could benefit most from this kind of treatment.
Randomised controlled trial The findings from our pilot study, strongly encourage us to proceed with this intervention, and to examine the effectiveness of this web-based self-help course for the treatment of depressive symptoms in MS in a randomized clinical trial. To the best of our knowledge, this will be the first randomized controlled study to evaluate effectiveness of a web-based self-help treatment for depressive symptoms in MS. We expect that the online intervention, based on the principles of problem solving therapy, will be more effective for the treatment of depressive symptomatology in MS patients than care as usual. Moreover, we expect positive effects from the online intervention on anxiety, fatigue, cognition, social support, disability level, mastery and quality of life because of the suggested association of depression with these parameters. With an easy accessible web-based self-help intervention we will improve the level of care and reach and treat a group of patients with MS and co-morbid depressive symptoms who experience disease-related barriers to participate in face-to-face counselling.
The present study has been developed in collaboration with the Netherlands Study of Depression and Anxiety (NESDA; www.nesda.nl). NESDA is an ongoing cohort study designed to investigate the course and consequences of depressive and anxiety disorders. A detailed description of the NESDA study design and sampling procedures can be found elsewhere (21). Our effectiveness study creates a unique opportunity to compare the presentation and characteristics of depressive and anxiety symptoms, social support, mastery and perceived need of care in MS patients with a co-morbid depression versus patients with a current depressive disorder without co-morbid chronic medical illness, and depressed patients with other co-morbid chronic medical illness. This allows us to gain more insight into the specific nature of present depression among MS patients in terms of symptom profile, history, severity etc. To ensure the comparison between these patient groups, patients in our trial will receive some standard baseline measurements corresponding to the baseline assessment of NESDA.
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