Results of a randomized trial reported in The Lancet Digital Health suggest a role for internet-based cognitive behavioral therapy, but many of the study volunteers were left with symptoms that would classify them as having major depressive disorder.
Depression and multiple sclerosis often go hand-in-hand. Depression is the most common comorbidity of multiple sclerosis, and half of those with multiple sclerosis experience depression sometime during their lifetime. Some evidence suggests that depression is associated with hastening of disability in people with multiple sclerosis and, in some cases, may be an early manifestation of the disease.
Against this backdrop, results from a randomized trial testing internet-based cognitive behavioral therapy (CBT) for depression in people with multiple sclerosis is likely to be welcomed as good news, especially because of the scarcity of therapists who can deliver CBT and some question the effectiveness of antidepressants.
First author Stefan M. Gold, Ph.D., of the Medizinische Klinik mS Psychosomatik, Charité– Universitätsmedizin Berlin in Berlin, Germany, and his colleagues enrolled 279 people with multiple sclerosis with self-reported depression in the trial. They were randomized into one of three groups: standalone internet-based CBT, CBT that included some email support from a clinical psychologist or a control group. The patients were recruited at five academic medical centers, two in Germany and three in the U.S., with large outpatient multiple sclerosis care units.
The primary outcome was a score on the Beck Depression Inventory-II, a standard 21-item questionnaire that is used to measure depression, especially in research contexts. Gold and his colleagues measured depression at 12 weeks after randomization and then, in an extension trial, six and 12 months after randomization.
The outcomes showed a significant reduction in depressive symptoms as measured by the Beck Depression Inventory at the 12 weeks and six months in the patients randomize to CBT but not difference between those treated with standalone CBT and those treated with CBT with some guided help from a clinical psychologist. The researchers also saw improvement in assessments in the study participants’ quality of life in those in the two CBT groups, although there was no improvement in the measurement of fatigue.
“This trial provides evidence for safety and efficacy of this multiple sclerosis-specific online tool as a standalone or guided application to reduce depressive symptoms in multiple sclerosis over a 12-week period,” Gold and his colleagues concluded. “This remote-access, scalable intervention increases the therapeutic options in this patient group and could help to overcome treatment barriers.”
Like all studies, this one has limitations and reasons to hedge on a full embrace of the results. For one thing, the dropout rate from the study was high; at week 12, 18% (50 of 279) of those enrolled had left the study. Gold and his colleagues also fell short of their planned enrollment of 375, a shortfall that they chalked up to stalled enrollment during the height of the COVID-19 epidemic.
Another reason for some pause: The CBT intervention did not result in a significant proportion of people meeting the diagnostic criteria of major depressive disorder. “Although the reduction in depressive symptoms in the two intervention groups was statistically significant, symptoms remained above the clinical threshold for depression, demonstrating that complete freedom from depression is difficult to achieve,” noted an accompanying editorial that suggested that future work should zero in on optimizing internet-based CBT.