Behavioral Interventions in Multiple Sclerosis

A Biopsychosocial Perspective

C Heesen; S Köpke; J Kasper; J Poettgen; A Tallner; DC Mohr; SM Gold


Expert Rev Neurother. 2012;12(9):1089-1100. 

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Expert Commentary

Taken together, BI represent an underdeveloped area of treatment in MS when putting the disease in a biopsychosocial framework (Figure 2). Carefully performed trials have shown that these interventions can improve neuropsychiatric symptoms such as fatigue and depression, as well as enhancing coping and ameliorating cognitive dysfunction. Two recent studies[59,67] provide the first evidence that BI might also impact disease activity. A large amount of resources has been put into neuroprotective drug development, yet without convincing clinical effect. In comparison, few rigorous studies of BI have been conducted. In addition, preciously little is known about the strategies needed to successfully induce behavior change and, most importantly, how to sustain it.

Figure 2.

Biopsychosocial networks in multiple sclerosis. Displayed are the major functional systems integrating mind and body interactions. Strength of arrows indicates the extent of evidence for interactions. Integration of mind into the system is still a major area in need of research. Psychoneuroimmunology is the discipline dealing with an integration of these factors also in social and environmental contexts.

The evidence provided to date clearly supports the potential of BI as symptomatic treatments and perhaps also as disease-modifying therapies in MS. However, more work needs to be done. First and foremost, a strong theoretical and mechanistic formulation is needed. CBT is founded in cognitive neurosciences, but self-management and patient empowerment are not. While CBT is applied as the underlying concept in many interventions, rigorous standards regarding what constitutes an intervention as CBT are missing. Therefore, more classification work is needed. Additionally, interventions need to be standardized as much as possible and manuals should be made available to enhance replication and implementation, which is a neglected area. Although receiving considerable attention in the care of psychiatric symptoms, mindfulness has not thoroughly been investigated on a mechanistic level. Cognitive behavior-oriented intervention studies have often been very broad in their aims but small in sample size, short in duration and unspecific in outcomes. Many address psychological domains but behavior change or healthcare utilization has rarely been addressed. Furthermore, most studies have compared a new intervention against care as usual. Therefore, comparative studies are urgently needed to clarify the effect of different interventions. An important unanswered issue is the differential effect of face-to-face (single or group) compared with telephone or online interventions. Work in this area will provide important information regarding the active components of each approach; for example, the relevance of social support or peer counseling. Finally, we need to study different maintenance strategies such as booster sessions and internet counseling to enable and sustain behavior change.

Based on the evidence available, we conclude that among the established BI, EBPI is the most promising approach to enhance self-management and decision autonomy. Increasing evidence suggests that exercise could be a putative neuroprotective therapy in MS, but this remains to be shown in rigorously designed RCTs. CBT as well as mindfulness and exercise appear to be effective symptomatic treatments to control fatigue and depression, and may have beneficial effects on cognitive function. To take this area of research to the next level, clinical studies from Phase I to IV trials, modeled after drug development studies and employing generally accepted outcome measures, are urgently needed. This may finally lead to reimbursement of interventions by insurances or national health services.