This transcript has been edited for clarity.
Hello. My name is Dr Fred Foley, and I'm the director of neuropsychology and psychosocial research at Holy Name Medical Center's Multiple Sclerosis (MS) Center in Teaneck, New Jersey, and a professor emeritus in psychology at Yeshiva University in the Bronx, New York.
I'm here to speak with you today about improving quality of life in MS, primarily from a psychological perspective. People frequently ask me, "Well, what is quality of life? How do you measure it?" To begin, I think we should start with a definition of quality of life.
It really is a multidimensional construct containing perceptions. Quality of life is really a perception. It's the perception of how you're doing physically. It's the perception of how much your physical problems interfere in your role functioning, that is, the roles that we assume as adults, such as getting educated, working, and raising a family. It also typically measures your vitality or energy level, your perception of that, as well as if you're in chronic pain and your estimate of how much pain you're in.
Finally, quality-of-life measures also look at how you're doing emotionally. How is your emotional health? How does your emotional health interfere or not in your expected role functioning? These are the typical dimensions associated with it.
In MS, quality of life has been found to be affected by many factors. About 80% of persons with MS experience fatigue. This isn't the kind of fatigue that you or I may feel at the end of a long, hard day. This is an illness fatigue, more akin to the kind of fatigue you would feel if you had the flu or another viral infection. As you might imagine, this can be quite disabling, and it frequently is in MS.
There have been some recent studies that have attempted different types of interventions to see whether MS-related fatigue could be improved. Unfortunately, medicines that have been tried haven't been that effective. There's a large amount of mixed evidence for trying stimulants and other types of medications to alleviate fatigue.
However, a large meta-analysis has found that exercise helps with decreasing fatigue and improving estimates of quality of life. Also, there's a specific type of psychotherapy called cognitive-behavioral therapy, which is relatively short-term and is highly structured. Addressing fatigue using cognitive-behavioral therapy has also been found to be effective.
There are other things that can significantly affect quality of life in MS. About 50% of persons with MS will experience clinical depression during the course of their lives. This is higher than in the general population. Of course, people in the general population can get depressed, but it happens more frequently in persons with MS.
Studies of depression view it as something that is a symptom of the illness. It's just one more symptom that people with MS can develop. That's the bad news, that depression occurs frequently in MS. The good news is that clinical depression can be treated successfully in MS. When people are depressed, they lose interest in the things they're usually interested in. They feel sad most of the time, they feel senses of helplessness and hopelessness, and their quality-of-life ratings really plummet during a depression.
Treatments that have been found to be effective include that highly structured psychotherapy I mentioned that was applied to fatigue and cognitive-behavioral therapy. That works by getting people to change their thinking, getting people to change that feeling of helplessness and hopelessness, and engaging them in something called behavioral activation.
This involves getting them to move more; getting them to participate in activities of daily living and in life more, even if they don't feel like doing it; and getting them to try to force themselves to engage. If they can do that, that has been found to decrease clinical depression scores. Also, a class of medicines called selective serotonin reuptake inhibitors has been found to be effective in treating depression in MS.
Another problem is that people with MS can develop is anxiety. The majority of persons with MS experience significant clinical anxiety at times. Anxiety is an important symptom to address because anxiety can not only make you uncomfortable and decrease your quality-of-life ratings but also interfere in your thinking and your cognition. I'm going to be talking a little bit more about that in a minute.
Because of their impact on quality of life and on cognition, it's important to assess or screen for clinical depression and clinical anxiety. There are very brief screeners that can be used that have been validated and are in the public domain for depression especially and also for anxiety. Having your patients fill them out while they're in the waiting room will give you important information about their state of mind and their related quality of life. As with depression, anxiety has also been successfully treated in persons with MS with medicines and with cognitive-behavioral therapy.
There are other aspects of MS and living with MS that can impact quality of life. There are many adjustments that frequently have to be made. For example, if you can't work anymore or can't fulfill some of those roles in life that you expect yourself to fulfill, that can alter your mood, which could decrease your quality of life. Brief counseling can sometimes help people adjust to the changes and the living with the uncertainty that comes with MS.
Cognition can also be impacted in MS. Specifically, speed of processing, that is, how quickly you can process information, gets slowed down in MS. That's the most common cognitive problem in MS. Cognitive problems happen in more than 50% of persons with MS at some time during the course of their illness.
Cognitive problems in MS are not like cognitive problems in Alzheimer's disease. They don't tend to be as severe. They tend to be more focal in nature. Verbal and visual memory; processing speed; and executive function, which includes your attention, concentration, and rapid problem-solving, seems to be potentially impaired in persons with MS.
I mentioned anxiety before. One of my previous PhD students published a study demonstrating that anxiety interacts with cognitive changes. It's kind of like pouring gasoline on a fire. We have patients come in all the time who think they have cognitive impairments. After we do a neuropsychological test battery on them, we find out that frequently, they're just very anxious or depressed. If we treat the anxiety or depression, then they start thinking more clearly and their cognition improves.
It's important to understand that these psychological conditions can affect other aspects of thinking. If you treat them successfully, you will see improvements in a person's perception of their quality of life.
Another problem that occurs in MS that is quite common is sexual dysfunction. Sexual dysfunction happens to the majority of persons with MS. A large study found that this condition, when present, negatively affects people's perceptions regarding the mental health aspects of their quality of life.
People are frequently diagnosed in their twenties and early thirties with MS. This is a time in the life cycle when sexual function is important to people and is ranked highly in people's estimates of their quality of life.
It's important to do a brief assessment for this when your patient comes into the clinic. Just ask the simple question, "How is your sex life doing?" If you do that, you'll probably be surprised to find many of your patients will let you know that there is a problem.
Fortunately, there are treatments that are available. Just educating patients and providing them with materials and brochures have been found to be helpful. Also, brief counseling that incorporates education about sexual function and important information about local resources to get treatment have been found to be effective in treating the symptom and, by proxy, people's estimates of their quality of life.
Thank you very much for your time today.
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Cite this: Improving Quality of Life in MS: Psychological Strategies - Medscape - Mar 29, 2024.
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