Cognitive-behavioral therapy may help address pain and depression in patients with MS

By Jeff Craven

People with multiple sclerosis (MS) who received cognitive-behavioral therapy (CBT) in addition to standard of care had better, but not significantly different, pain and depressive symptom outcomes over a period of time, compared with people who received an educational intervention, according to recent research in the International Journal of MS Care.

The results represent one of the first randomized, controlled trials exploring CBT in patients with MS. While patient pain and depression scores did not significantly improve in the CBT group, compared with the educational group, both groups reported high treatment satisfaction and said that the interventions met their behavioral goals.

Pain is a “highly prevalent” problem among patients with MS, said corresponding author Robert D. Kerns, PhD, professor of psychiatry, neurology, and psychology at Yale University, New Haven, Conn., and one of three directors of the Yale-based Pain Management Collaboratory Coordinating Center. MS-related pain can present as specific to the disease or as a secondary condition, such as developing low back pain from sitting in a wheelchair. Identifying pain related to MS or any disease can be complicated, he said, and once identified and structured around a plan of care, efficacy of pain-relief options like over-the-counter or prescriptions medications are limited.

“The bottom line is that, across virtually all painful conditions, particularly chronic painful conditions, the efficacy or effectiveness of any particular medication, even if there is an indication of that medication for a specific pain condition, is at best moderate, meaning about 30% of people respond to any particular medication or class of medication,” Dr. Kerns said in an interview. “This is likely true for pain among people with MS.”

Dr. Robert D. Kerns

Can CBT impact MS-related pain?

After seeing the beneficial effects of CBT for chronic pain in the general population, Dr. Kerns and colleagues set out to assess whether the intervention could improve pain outcomes in patients with MS, randomly assigning 20 patients with moderate MS-related pain to receive 12 weekly sessions of either CBT or MS-related education in addition to standard care with follow-up at 15 weeks. Overall, the participants were mostly white (75%), male (60%) patients with relapsing remitting MS (70%). The cohort had a mean age of 52.6 years and a disease duration of 13.25 years. Nearly all participants reported pain in their legs or feet (95%) or their lower back (80%). Pain was reported in a mean of 4.25 different locations.

Analyses were approached as intention to treat. Differences between the two treatment groups’ demographic and disease-related characteristics were assessed using T tests for continuous data and chi-square tests for categorical data. Changes on the outcome measures were evaluated using a 2 (CBT/standard care and education/standard care) × 2 (before and after treatment) factorial design. Treatment credibility, treatment satisfaction, and behavioral goal accomplishment between the two conditions were compared using T tests.

The investigators examined participants’ pain severity, pain interference, depressive symptoms, and treatment satisfaction at 15 weeks, compared with baseline. At baseline, there was no difference in composite pain scores between groups (t18, –0.30; P = .767), but a significantly lower severity of pain in the CBT group (t18, –3.42; P = .003). Participants in the CBT group also had lower depressive symptom severity scores at baseline, compared with the educational group (t18, –2.04; P = .056).

Time carried a significant effect for pain severity (F1,18, 4.61; P = .046) and for pain interference (F1,18, 4.63; P = .045) but there was not a statistically significant effect for time × treatment interaction for either pain severity (F1,18, 0.61; P = .444) or pain interference (F1,18, 0.06; P = .813) at 15 weeks. In the CBT group, there was a significantly different mean behavioral goal accomplishment rating (1.27; 95% confidence interval, 0.87-1.66) from zero, compared with the educational group (0.65; 95% CI, –0.35 to 1.65), but there were no significant differences between the CBT and educational groups (t9,37, 1.36; P = .207).

Regarding depressive symptom change, the CBT group had a lower but not statistically significant difference in symptom severity, compared with the educational group (t18, –2.04; P = .056). Time also carried a significant effect for depression symptom severity, but the time × treatment effect was not statistically significant (F1,18, 1.24; P = .280). Participants in the CBT group rated their treatment credibility and expectations for improving higher than the educational group (t15, 1.52; P = .150), but there was no significant difference between groups (t16, –0.04; P = .967), with high total satisfaction in both CBT and educational groups.

The investigators attributed the underpowered nature of the study to the low number of patients who were ultimately enrolled, and said that a low engagement rate, inability of a neurologist to confirm an MS diagnosis, and failure to meet the study’s pain thresholds contributed.

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Prioritizing CBT: A tough buy-in for patients and providers

“Even though in our study we found benefit of CBT for people with MS-related pain, I think like in other conditions, but maybe particularly important in the management of MS and MS-related pain, it may take additional research to help us better understand how to promote interest in and engagement and participation in these kinds of approaches,” Dr. Kerns said. “It may be that, when push comes to shove, their interest and willingness to invest time and effort to learn the kinds of skills and approach that’s applied in CBT may really not be the priority for some people.”

Training health care providers in CBT and educational approaches is one way to raise awareness of the potential benefits of nonpharmacologic interventions to pain management, but many providers are unable to commit the time to learn how these approaches work and how to discuss them with patients, Dr. Kerns said. “Even if physicians and patients are all on board, those are big issues.”

Dr. Kerns noted that he and his group are working to build and disseminate CBT and educational tools that patients with any disease state affected by pain can use, even if their access to care is limited. “It doesn’t take the place of the first step: Discussing pain with their health care providers – whether it’s a primary care provider, a neurologist, or an MS specialist – showing their interest and an awareness of these kinds of approaches and working with that person to try to develop the best plan, first looking in their communities but then not giving up if there really isn’t something or somebody available in there,” he said.

This study was funded in part by the Department of Veterans Affairs; Rehabilitation Research and Development Service; Health Services Research and Development Service; Center of Innovation; and the Pain Research, Informatics, Multimorbidities, and Education Center. The authors reported no relevant conflicts of interest.