ADHERENCE TO PSYCHOLOGICAL
INTERVENTIONS IN MS
PROFESSOR RONA MOSS-MORRIS
ISSUES TO CONSIDER IN CLINICAL
TRIALS AND PRACTICE
1. Person affection by MS (paMS)
presenting for initial session
2. paMS attendance at sessions
3. paMS completion of homework or
practice tasks.
4. Therapist adherence to therapy
protocol (treatment fidelity)
1. PRESENTING FOR THE INITIAL SESSION
• Stigma of psychology/mental health
• Integrated care versus separate physical and mental
health services.
• Importance of referral
• ‘Psychology as last port of call’
• ‘Nothing else I can do….’
• After first session – maintaining paMS in sessions
• engagement
• relevance of treatment model for MS
• collaborative approach
2. ATTENDANCE AT
SESSIONS.
CBT FOR MS ADJUSTMENT
1. Introduction to adjusting to MS
2. Adapting to living with MS
3. Setting goals and problem solving
4. Managing symptoms
5. How to tackle negative and unhelpful thoughts
6. Improving the quality of your sleep
7. Managing stress
8. Managing social relationships
9. Preparing for the future
8 not eligible
10 changed their minds
CONSENTED
N=122
BASELINE
ASSESSMENT
n=94
RANDOMISATION
RANDOMISATION
8 SESSIONS CBT
n=48
15 WEEKS FOLLOW UP
n=47
IN-DEPTH INTERVIEW
n=15
8 SESSIONS
SUPP. LISTENING
n=46
15 WEEKS FOLLOW UP
n=42
6 MONTH FOLLOW UP
n=46
6 MONTH FOLLOW UP
n=39
12 MONTH FOLLOW UP
n=45
12 MONTH FOLLOW UP
n=45
IN-DEPTH INTERVIEW
n=15
PRIMARY OUTCOME MEASURES
General Health Questionnaire (GHQ-12, Goldberg,
1992)
• improvements in both groups but changes in CBT
significantly greater than in SL at end of treatment and
12 months follow-up
Work and Social Adjustment Scale (WSAS, Mundt
et al., 2002)
• greater improvement in CBT group but differences not
significant.
ADHERENCE TO SESSIONS COMPLETED
• 85% of trial participants completed all 8 sessions
• CBT – 7 participants (14.6%) dropped out before
completing all eight sessions
• SL – 7 participants (15.2%)
• Reasons
• too busy
• finding therapy unhelpful or not useful
• feeling they had already gained benefit.
8
10
12
14
16
CHANGE IN GHQ MODERATED BY SESSIONS
COMPLETED
baseline
post-therapy
time
<8 sessions CBT
12M
8 sessions CBT
16
14
12
10
8
mid-therapy
post-therapy
<8 sessions in Arm A
8 sessions in Arm A
time
6M
<8 sessions in Arm B
8 sessions in Arm B
12M
5
10
15
20
CHANGE IN WSAS MODERATED BY SESSIONS COMPLETED
baseline
post-therapy
tt
<8 sessions CBT
12M
8 sessions CBT
3. HOMEWORK
HOMEWORK IN
COGNITIVE BEHAVIOURAL THERAPY
Homework tasks are a core and crucial feature of
CBT
• planned therapeutic activities undertaken by clients
between sessions
• Based on content from the cognitive behavioural model
but individualised to client formulation
• designed collaboratively
(Kazantzis et al., 2005)
PURPOSE OF HOMEWORK TASKS
• Self assess thoughts, moods, physiology and
behaviours
• Allow clients to experience behavioural and
cognitive change in vivo
• Experiment with new behaviours
• Practice and maintain new skills or techniques
(Judith Beck, 1995)
META-ANALYSIS OF EFFECTS OF
HOMEWORK TASKS ON TRIAL OUTCOME
• 27 psychotherapy studies of mental health
conditions.
• Effects size on treatment outcome
• inclusion of homework tasks (.36)
• compliance with those tasks (.22)
(Kazantzis, Deane, & Ronan, 2000)
• Is it about quality (i.e. doing the homework
correctly) or quantity
HOMEWORK RATINGS
• Completed each session by therapists
• 1 – 10 scale of how well patients
completed homework
• Significantly predicted improvements in
WSAS at 12 months, but not GHQ
15 – 20% OF THE POPULATION SUFFER
FROM IBS
Symptoms
• abdominal pain or
discomfort
• altered stool frequency
• altered stool form
• altered stool passage
• abdominal bloating
GLOBAL RATINGS OF RELIEF: INTENTIONTO-TREAT (N=64)
100
90
80
percentage
70
60
treatment
control
50
40
30
20
10
0
improved
not improved
Change in IBS-SSS across Groups
8 months
5 months
Control
Treatment
2 months
0
50
100
150
ADHERENCE TO AMOUNT OF
HOMEWORK
• Only 1 out of 30 self management patients did not
complete therapy
• 24 out of the 30 (80%) participants in the selfmanagement group returned their homework
sheets.
• Quantity score – number of sheets completed
• The mean score for the quantity completed was
6.94 (S.D.=2.66) out of a total of 10 sheets.
QUALITY SCORE
• Generated an ideal formulation for each of the
homework tasks following Schmidt and WoolawayBickel (2000)
e.g. an ideal answer for goals around bowel
symptom management.
• the goal was specific to time, place, frequency
• the participant set realistic goals for each area
• the participant completed self-monitoring of goals
• Rating done by two independent raters (kappa .64)
CONCLUSIONS
• Adherence of paMS does affect outcome in CBT
based treatments.
• For therapist delivered CBT – number of sessions
completed is important
• Homework appears important for improvements at longer
term follow up, particularly for impact of MS on life roles
• For self-management based on CBT – completing
homework (quantity and quality) is associated with better
outcome in IBS.