Clinic Speak: CBT for depression

Are you depressed? If you are CBT may help. #ClinicSpeak #MSBlog #MSResearch

"Depression, the silent killer. Up to 50% of MSers will experience major depression in their lifetime; this is much higher than the general population or for people with other chronic disabling diseases, for example rheumatoid arthritis. Depression usually coexists with a cluster of other negative symptom, which includes anxiety, fatigue, poor sleep and pain. These symptoms can all be linked to the negative consequences of having MS, i.e. breakdowns in interpersonal relationships, social isolation, unemployment, cognitive impairment and frank dementia, poor adherence to medication, increased risk of suicide, a reduction in the quality of life and a reduction in life expectancy. Why do MSers get depressed? There are many reasons for this and it is not simply a reactive depression to getting bad news about having a chronic disease. I suspect that it is linked to some of the mechanisms that underlie MS pathogenesis, i.e. ongoing inflammation and end organ damage (progressive damage to the brain). This is why it is so important to view the treatment of depression in MS holistically."

"The paper below describes a meta-analysis of CBT (cognitive behavioural therapy) for the treatment of MS-related depression and shows that CBT works. This is my experience as well. CBT is as least as effective as anti-depressant medication and can augment the pharmacological management of depression. The problem in the NHS is quick and easy access to CBT therapists. Therapists are usually only accessible via psychiatric services and if general practitioners can refer directly to therapists the waiting time to see a therapist can be months. In addition, the quality of CBT can be variable. To address these issues of poor access and poor quality online computer-based and telephone CBT programmes have been launched and studied. Is eMedicine the way forward?"

"What is CBT? CBT is a psychotherapeutic approach that addresses dysfunctional emotions, maladaptive behaviors and cognitive processes and contents through a number of goal-oriented, explicit systematic procedures. CBT teaches you how to identify negative thoughts that impact on your feelings and behaviours and teaches you how to cope with them. CBT is "problem focused" (undertaken for specific problems) and "action oriented" (the therapist tries to assist you in selecting specific strategies to help address those problems). CBT teaches you to cope with depression, for example it reduces your perceived burden of disease and improves your sense of wellbeing."

"What is important to know that left untreated, MS-related depression does not appear to remit spontaneously, however it is responsive to treatment using both medication and psychotherapeutic interventions. How do you know if you are depressed? You can complete a simple screening questionnaire; a commonly used one is the Beck Depression Inventory below. If you are depressed you should bring this to the attention of your neurologist or GP so that they can help you with its treatment. Please note I say help; this implies that part of the treatment of depression is self-managed, which is what CBT is; a self-management tool."

"It is also important that co-morbidities that exacerbate depression are also addressed. It is no point in treating depression without also trying to reduce the impact of other symptoms that can make depression worse. This include poor sleep, fatigue, pain, anxiety, etc. Another strategy is prevention; depression is clearly linked to progression of disease and it is therefore important to have your MS disease activity suppressed with DMTs; treat-2-target of NEDA. It is clear that the highly-effective DMTs are much better at improving Quality of Life and reducing depression, particularly when used early."

Epub: Hind et al. Cognitive behavioural therapy for the treatment of depression in people with multiple sclerosis: a systematic review and meta-analysis. BMC Psychiatry. 2014 Jan 9;14(1):5.

BACKGROUND: Depression is a common symptom in MSers. We systematically reviewed published controlled trials on the effectiveness of cognitive behavioural therapy (CBT) for the treatment of depression in people with multiple sclerosis.

METHODS: Publications were identified using MEDLINE, PsycINFO and the Cochrane Central Register of Controlled Trials to June/July 2013. We combined thesaurus and free-text terms which were synonyms of the concepts MS, depression and cognitive behavioural therapy. We included published controlled trials which compared individual, group CBT, conducted face-to-face or remotely, to no CBT. Two reviewers extracted data to calculate standardized mean differences (SMD) for self-reported symptoms of depression and weighted mean differences (WMD) for the Multiple Sclerosis Impact Scale (MSIS-29), with 95% Confidence Intervals (CIs). We investigated statistical heterogeneity using I2.

RESULTS: Seven eligible studies (n = 433) were identified, which evaluated the effect on depression of CBT delivered individually (3 studies), in a group (3 studies) and by computer (1 study). The summary effect (SMD -0.61, 95% CI -0.96 to -0.26, p=0.0006) was reduced (SMD -0.46, 95% CI -0.75 to -0.17, p=0.002) when an outlying study was removed in a sensitivity analysis to examine statistical heterogeneity. Three studies (n=213) observed a direction of effect using the MSIS-29 which was not statistically significant (WMD -4.36, 95% CI -9.33 to 0.62, p=0.09). There was no between-subgroup heterogeneity (I2=0).

CONCLUSIONS: CBT can be an effective treatment for depression in MS. Further research should explore optimal durations and modalities of treatment for patients with different characteristics.

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