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Psychosocial interventions in people with multiple sclerosis: a review

Kathryn Malcomson, Lynn Dunwoody and Andrea Lowe-Strong.
University of Ulster, Newtownabbey, Northern Ireland

Way Ahead 2008;12(1):8-9

Introduction

Multiple sclerosis (MS) is a chronic progressive disease of the central nervous system. In MS, like many other chronic illnesses, alleviating the physical symptoms resultant of the physiological process itself, does not equate to treating the individual as a whole1. MS is much more than a medical disease it is also an emotional and socially intrusive illness2. Individuals are confronted with numerous threats and challenges; these include the need to deal with uncertainty, unpredictability, and the ensuing changes in family, employment and social life3. In addition, there are the demands of managing symptoms on a daily basis, preparing for progressive functional losses and the acceptance of there being no cure3. Psychosocial interventions aim to help individuals manage these psychological and social consequences4 by addressing the intrusion of the disease upon emotional wellbeing/quality of life (QoL)5, in an attempt to improve one's ability to cope with MS on a day to day basis6.

sad woman looking at her reflection

The National Institute of Health and Clinical Excellence (NICE)7 recognise that psychosocial management should be routine in the care of people with MS. However, the exact content of such interventions remains elusive7. This lack of direction has created uncertainty for health professionals who seek to help individuals manage the psychosocial consequences of MS8. Therefore, evaluation research investigating psychosocial interventions, in particular those that aim to improve QoL and/or wellbeing in people with MS, was warranted.


Aim

To present a systematic review of the literature that identified all randomised controlled trials (RCTs), quasi-experimental, cohort, case control and case series studies that have investigated the effectiveness of psychosocial interventions in people with MS; to assess their methodological quality, and to identify the effectiveness of these interventions on the primary outcome of emotional wellbeing/QoL.


Methodology

Search strategy
Searches were carried out using computerised databases with predefined search terms. This was supplemented by manual searches of reference lists of all retrieved articles. Relevant journals were also hand searched.

Selection criteria
Papers written in English and published before January 2006 were eligible for inclusion. All RCTs, quasi-experimental, cohort, case control and case series designs addressing the effectiveness of psychosocial interventions in people with MS were considered. Abstracts and conference proceedings were excluded, as full methodological details were not provided. Papers were also excluded if they were not published in English, if they delivered interventions to a population other than MS, if the intervention was not considered psychosocial in nature, or if the paper was non-experimental in design, ie personal narratives, clinical observations or qualitative studies.

Primary outcome
Papers were included if the primary outcome purported to measure emotional wellbeing and/or QoL. Where authors failed to identify the primary outcome a decision was made by the authors, based on the title and aims/hypothesis of the study, as to which outcome most closely equated to the primary outcome.

Data collection and analysis
Methodological quality was independently assessed by two reviewers using the Downs and Black quality-scoring checklist9. The qualitative and quantitative characteristics of studies were extracted using a data extraction sheet.


Results

Following the computerised search strategy, 4,931 initial hits were obtained. An additional 41 papers were obtained through hand searching relevant journals and retrieving cited references making an overall total of 4,972. Once the inclusion criteria had been applied, 4,939 papers were excluded from the review. Interventions were categorised as follows:

  • cognitive behavioural therapy (CBT) for depression;
  • group psychotherapy;
  • wellness and support;
  • exercise and movement;
  • relaxation;
  • stress management; and
  • other.

All of the included studies (n=33) had methodological weaknesses, with the majority (n=26) failing to meet even 56% of the quality criteria (ie scoring less than 18 out of a possible 32). Quality of reporting was often unsatisfactory with inadequate details of any adverse events (n=29) and omission of exact p-values (n=19). Over 75% of the studies (n=25) achieved a score of zero for external validity, highlighting authors' failure to describe the representativeness of participants, facilities and/or staff. There were shortcomings relating to measurement bias, eg failure to describe blinding procedures (n=27). In the majority of studies (n=25) the number of participants required to detect a clinically important effect was insufficient. This notwithstanding, there were three studies10-12 of adequate quality to provide some evidence regarding the value of encouraging proactivity (eg completion of homework assignments), education, discussion forums, multidisciplinary/peer support and exercise.


Limitations

The quality checklist employed in this review is considered valid and reliable13, yet Downs and Black9 suggest that more testing is required before its regular use is encouraged. The authors of this review recognise that questions on the checklist may not be entirely appropriate for all designs, for example case series, resulting in such designs receiving a lower score. In addition, weighting of items within the five subscales may have underestimated or overestimated the quality of some studies. However, this checklist was used because it is considered appropriate for both randomised and non-randomised studies9.


Conclusion

Psychosocial interventions purport to offer individuals with MS hope by helping to alleviate or manage psychological and social challenges14. There is some evidence to suggest the possible benefit of exercise, proactivity on the part of the participant, and support, both multidisciplinary and peer, in improving the psychological wellbeing/QoL in individuals with MS. However, in order to assess the effectiveness of such interventions further research is required in the form of well-designed RCTs. Only then can specific recommendations be made as to what may be beneficial in the psychosocial care of individuals with MS, which may ultimately contribute to the development of clinical guidelines for this population.


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