1. von Gaudecker, Jane R.

Article Content

In this issue of JNN, Tietjen and colleagues1 report the findings of a secondary data analyses to investigate the effect of an internet-based intervention in depression management among people with multiple sclerosis. This is an excellent example of intervention studies used to improve health outcomes among people living with multiple sclerosis (MS).


Study Purpose

The purposes of this secondary data analyses were to evaluate participant engagement and effects of an internet-based self-directed program on depressive symptoms among people with MS and to inform future treatment options for those with MS and coexisting depressive symptoms.



Depression is a major concern among people with MS with a 50% lifetime prevalence. The consequences significantly affect the quality of life of people with MS. A vast majority of people with MS who screened positive for depression do not receive any treatment or are inadequately treated (treatment gap).


Disease modifying therapies (DMT) help slow the progression of MS and are key components in MS care. Studies report that people with depression are half as likely to adhere to their DMT protocol. Therefore, treating depression is important to improve overall health outcomes among people with MS. Cognitive behavioral therapy (CBT), a common form of psychotherapy, is an evidence-based form of treatment for depression. The goal of CBT is to reduce depressive symptoms by challenging maladaptive cognitions to affect positive change in how a person responds to behavioral problems or emotional distress.



The parent study, conducted in the U.S., was a randomized control trial examining feasibility and efficacy of "Think Clearly About Depression," an 8-week online program. Adults (N = 47) with chronic illness diagnosis, who were screened positive for depressive symptoms completed the study. For this analysis, participants were divided into two dichotomous groups: with an MS diagnosis (n = 11); without MS diagnosis (n = 36).



"Think Clearly About Depression" is a publicly available online program based on cognitive behavioral therapy concepts. The goal of this program is to teach mildly or moderately depressed individuals about the role of thinking in the development and maintenance of depression. The recognition and self-management of depressive symptoms are encouraged through educational videos, interactive activities, and homework exercises.


Measures Used

Demographic data were collected at baseline. Further, all participants completed the following scales at baseline and weeks 4 and 8: Personal Health Questionnaire Depression Scale (PHQ-8); Health Distress Scale; Self-Rated Health Scale; Chronic Disease Self-Efficacy Scales.



Difference between participants with and without MS diagnosis in treatment and control groups were analyzed using univariate and bivariate analysis ([chi]2statistics and independent samples t test). "Number needed to treat" (NNT) analysis was performed to determine how many people with MS would be needed to achieve a clinically significant finding.



Ninety one percent of participants with an MS diagnosis received therapy or pharmacological treatment for depressive symptoms at some point in time. At the time of the study, 36% of them were on an antidepressant. Compared to participants without MS, the average depressive symptom burdens were severe for those with an MS diagnosis. Among participants with an MS diagnosis, 60% in the treatment group had clinically significant improvement, and no improvement for those in control group. The self-efficacy for exercising regularly, social/recreational activities, and controlling/managing depression improved the most for participants with MS in the treatment group at the end of 8-weeks. Greater self-efficacy was reported among non-MS participants in managing shortness of breath and getting information about disease. The NNT analysis indicated that half of those with MS who participate can expect clinically significant improvement.



A few of the access to care barriers identified were geography, physical disability, transportation, and availability of psychiatric and neurology providers who can screen for depression and help with self-care. This online program based on CBT concepts may be a good intervention for people living with MS and depressive symptoms.




1. Tietjen K., Wilson M., Amiri S., Dietz J. (2017). Online depressive symptom self-management: Comparing program outcomes for adults with multiple sclerosis versus other chronic diseases. J Neurosci Nurs, 50(1):13-19. [Context Link]