Cognitive-Behavioral Therapy Improves Fatigue in MS Patients

Pauline Anderson

May 31, 2014

DALLAS ― Fatigue, often linked to insomnia, is one of the most common complaints of patients with multiple sclerosis (MS), so anything that controls this debilitating condition would be a welcome relief.

Cognitive-behavioral therapy (CBT), a psychotherapeutic treatment that helps patients understand the thoughts and feelings that influence their behaviors, appears to be a viable option. A small, new study showed that it increases sleep time and reduces fatigue and depression in MS patients suffering insomnia.

It is hard to tease out whether the intervention first has an effect on the fatigue or on the depression and then perhaps has a kind of snowball effect, said lead author Megan Clancy, PhD, Mellen Center for Multiple Sclerosis Treatment and Research, Cleveland Clinic, in Ohio.

"We don't know if it's the chicken or the egg," Dr. Clancy said, that is, whether the problem with insomnia started with depression or with fatigue, and then made the other problem worse. In any case, CBT appears to work on both.

Dr. Clancy discussed the data at a poster presentation here at the 6th Cooperative Meeting of the Consortium of Multiple Sclerosis Centers (CMSC) and the Americas Committee for Treatment and Research in Multiple Sclerosis (ACTRIMS).

Chicken or Egg

According to a recent survey of about 7700 MS patients, more than half (56%) reported sleep disturbances, including insomnia, which can have negative effects on physical and mental health. These sleep problems often overlap with depression, Dr. Clancy noted. Patients with MS are at 26% to 51% increased risk for depression compared with the general population, she said.

The new study was a retrospective analysis of 11 MS patients who participated in individual or group CBT at the Sleep Disorders Center at the Cleveland Clinic Foundation between January 2008 and December 2013. The 1 male and 10 female participants ranged in age from 36 to 69 years; 8 were white, and 3 were African American.

Researchers assessed depression, fatigue, and insomnia before and after the treatment intervention using the Patient Health Questionnaire (PHQ-9), the Fatigue Severity Scale (FSS), and the Insomnia Severity Index (ISH), respectively. The tests all use self-reported measures.

The CBT, which took place over an average of 4 to 6 sessions, targeted specific behaviors and thoughts related to sleep. Components included the following: stimulus control (going to bed only when sleepy, limiting activities in bed to sleep and sex, getting out of bed at the same time every morning, and arising if not asleep within 20 minutes); sleep hygiene (for example, limiting use of caffeine and other simulants before retiring and having no technology within reach while in bed); relaxation training; and cognitive therapy.

The study showed that patients reported improvements across all domains. A majority (73%) reported an increase in total sleep time ― an overall increase of 1.25 hours.

About 60% of the patients reported a reduction in fatigue (mean change, 1.9), but all patients continued to have a clinical level of fatigue.

"We used a scale for fatigue that just rated a patient as having clinical fatigue or not having clinical fatigue," explained Dr. Clancy. "Everybody reduced their level of fatigue, but they were still clinically fatigued, which is not surprising given that it's MS."

Half of the patients reported improvement in depression measure (mean change, 1.2), and they reported an overall decrease in depression severity. About 86% of the group reported improvement in insomnia, and 43% reported an overall reduction in severity of insomnia.

Root Cause

Asked to comment, Robert Lisak, MD, professor and chair, Department of Neurology, Wayne State University School of Medicine, Detroit, Michigan, and new president of the CMSC, said that CBT can be helpful for fatigue in MS patients, but it depends on the root cause of the fatigue.

For example, it will not do much for fatigue caused by "getting up 3 times during the night to go to the bathroom to urinate" because of a bladder problem, but it may be useful if the fatigue is linked to depression, said Dr. Lisak. "You can try to fish out the cause, but it's my experience that it's almost never just 1 factor."

Obesity, which increases risk for obstructive sleep apnea, may contribute to insomnia and fatigue in MS patients, noted Dr. Lisak.

In addition to CBT, doctors may turn to pharmacologic approaches to treat fatigue, including amantadine (Symadine, Solvay Pharmaceuticals, Inc), a drug originally used to prevent flu. Another approach, usually done in collaboration with physiotherapists or occupational therapists, is "economy of effort," said Dr. Lisak. This involves encouraging patients to plan ahead with respect to daily activities ― for example, going upstairs only once to fetch things instead of going up and down 4 times.

Dr. Clancey and Dr. Lisak have reported no relevant financial relationships.

6th Cooperative Meeting of the Consortium of Multiple Sclerosis Centers (CMSC) and the Americas Committee for Treatment and Research in Multiple Sclerosis (ACTRIMS). Abstract CG26. Presented May 29, 2014.

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