Injectable medication for the treatment of multiple sclerosis: the influence of self-efficacy expectations and injection anxiety on adherence and ability to self-inject.

The management of many chronic illnesses involves medications that must be injected on a frequent basis. With fewer support resources available, patients are increasingly being obliged to manage injectable medications themselves. Interferon beta-1a (IFNbeta-1a), recommended for the treatment of multiple sclerosis (MS), must be injected intramuscularly on a weekly basis. Patients are generally advised and taught to self-inject, if possible. This longitudinal study examined cognitive and affective contributions to the ability to self-inject and adherence to IFNbeta-1a over 6 months following initiation of medication. Participants were 101 patients with a relapsing form of MS. Injection self-efficacy expectations, injection anxiety, adherence expectations, method of injection administration, and 6-month adherence to IFNbeta-1a were fitted to a path analytic model. Pretreatment injection self-efficacy expectations were significantly related to 6-month adherence. This relation was mediated by the patient's ability to self-inject. Patients 'experienced level of injection anxiety was related to adherence but not to method of injection.

Comparative outcomes for individual cognitive-behavior therapy, supportive-expressive group psychotherapy, and sertraline for the treatment of depression in multiple sclerosis.

This study compared the efficacy of 3 16-week treatments for depression in 63 patients with multiple sclerosis (MS) and major depressive disorder (MDD): individual cognitive-behavioral therapy (CBT), supportive-expressive group therapy (SEG). and the antidepressant sertraline. Significant reductions were seen from pre- to posttreatment in all measures of depression. Intent-to-treat and completers analyses using the Beck Depression Inventory (BDI; A. T. Beck, C. H. Ward. M. Medelson. J. Mock, & J. Erbaugh, 1961) and MDD diagnosis found that CBT and sertraline were more effective than SEG at reducing depression. These results were largely supported by the BDI-18, which eliminates BDI items confounded with MS. However, the Hamilton Rating Scale for Depression (M. Hamilton, 1960) did not show consistent differences between treatments. Reasons for this inconsistency are discussed. These findings suggest that CBT or sertraline is more likely to be effective in treating MDD in MS compared with supportive group treatments.

Psychological stress and the subsequent appearance of new brain MRI lesions in MS.

OBJECTIVE: To examine the relationship between stressful life events and psychological distress, and the subsequent development of gadolinium-enhancing (Gd+) brain lesions. BACKGROUND: It has long been speculated that stressful life events and psychological distress are associated with disease exacerbation in MS. This is the first prospective longitudinal study of the relationship between stressful life events, psychological distress, and disease activity as measured by Gd+ brain MRI. METHODS: Thirty-six patients (mean age, 44.4 years; 22 women, 14 men) with relapsing forms of MS were assessed once every 4 weeks for 28 to 100 weeks. Assessments included Gd+ MRI, the Social Readjustment Rating Scale (SRRS), the Hassles Scale, and the Profile of Mood States. The SRRS was altered in the following manner: 1) three items that confounded with MS were eliminated, 2) endorsed items were rated for intensity, and 3) the scale was divided into three subscales: major negative events, conflict and disruption in routine, and positive life events. Data were analyzed using mixed-effects logistic regression to account for intrasubject correlations. Stress and distress measures were used to predict concurrent and future MRI activity. RESULTS: For the total sample of patients, increased conflict and disruption in routine was followed by increased odds of developing new Gd+ brain lesions 8 weeks later (odds ratio, 1.64; p = 0.00083). There was no strong evidence of a relationship between psychological stress or distress and clinical exacerbation. CONCLUSIONS: These data provide support for the notion that conflict and disruption in routine are related to subsequent disease activity in MS. However, this relationship is not sufficiently robust to predict clinical exacerbations reliably in individual patients.

Contextualizing the effects of childhood sexual abuse on adult self- and social functioning: an attachment theory perspective.

OBJECTIVE: This retrospective survey study explored the hypothesis that multiple maltreatment and loss experiences in early childhood would interfere with the formation of secure attachments, creating (1) an increased vulnerability to childhood sexual abuse (CSA), and (2) adult problems in self- and social functioning. METHOD: Data were collected from 687 undergraduates on an urban, commuter campus. They were analyzed by means of between group (individuals with and without CSA histories) and within group (individuals with CSA histories) path analytic models. RESULTS: The number of maltreatment and loss experiences encountered in early childhood predicted greater CSA frequency in childhood and increased maltreatment in adulthood in the form of more frequent reports of sexual, physical, and emotional abuse. Childhood maltreatment and loss experiences also predicted poor adult self-functioning in the form of higher levels of depression and lower levels of self-esteem. Self-blame in response to CSA and maltreatment in adult relationships also predicted poorer adult self- and social functioning for individuals with CSA histories. CONCLUSIONS: Findings support both direct and mediational effects of childhood maltreatment and loss experiences on adult self- and social functioning and are consistent with predictions derived from attachment theory.

Course of depression during the initiation of interferon beta-1a treatment for multiple sclerosis.

OBJECTIVE: To examine the hypothesis that increases in depression after initiation of treatment with interferon beta-1a for multiple sclerosis can be explained as representing a return to pretreatment levels of depression. DESIGN: Level of depression in patients with multiple sclerosis was assessed at 3 time points: 2 weeks before initiation of interferon beta-la treatment, at initiation of treatment, and at 2-month follow-up. SETTING: A health maintenance organization. PATIENTS: Fifty-six patients with confirmed relapsing forms of multiple sclerosis. MAIN OUTCOME MEASURE: The depression-dejection scale of the Profile of Mood States. RESULTS: Patients who scored high on the depression measure 2 weeks before the initiation of interferon beta-1a treatment showed significant reduction in depression at the initiation of treatment. However, depression returned nearly to initial levels within 2 months. CONCLUSIONS: These findings suggest that increases in depression after initiation of interferon beta-1a treatment are related to level of depression 2 weeks before initiation of treatment. Physicians should assess history of depression for all patients in whom interferon beta-1a treatment is initiated. Patients with a recent history of depression are at risk for increased depression within 2 months after starting interferon beta-1a treatment, even though they may not be depressed at the time of treatment initiation.

The psychosocial impact of multiple sclerosis: exploring the patient's perspective.

This study examined subjective patient experiences of the psychosocial consequences of multiple sclerosis (MS). Fifty patients were interviewed regarding the effects MS had on their lives and interpersonal relationships. These statements were collated and administered with a 5-point Likert scale to 94 MS patients. The responses were subjected to factor analysis. Three areas of subjective patient experience of the psychosocial consequences of MS emerged: demoralization, benefit-finding, and deteriorated relationships. Of particular interest was benefit-finding, which included a deepening of relationships, enhanced appreciation of life, and an increase in spiritual interests. Although benefit-finding was related to adaptive coping strategies such as positive reappraisal and seeking social support, it was unrelated to depression and was related to higher levels of anxiety and anger. These findings indicate that benefit-finding is a substantial and poorly understood part of the illness experience for MS patients.

Treatment adherence and patient retention in the first year of a Phase-III clinical trial for the treatment of multiple sclerosis.

The purpose of this study was to examine the relationship between patient management strategies employed by study personnel, and patient retention and adherence to treatment in the first year of a Phase III clinical trial of interferon beta-1b for treatment of secondary progressive multiple sclerosis (MS). Study staff from each of 35 sites were interviewed regarding patient management practices. Sites which were rated as more empathetic, as instilling a sense of purpose in the patient, and promoting less formal relationships with patients had high rates of adherence to treatment. In addressing specific patient concerns, attention to patients' emotional status and patients' expectations of trial participation were related to better adherence.

Side effect profile and adherence to in the treatment of multiple sclerosis with interferon beta-1a.

This study examines the course of patient-reported side effects during the first 4 months of treatment for multiple sclerosis (MS) with interferon beta-1a (IFN beta-1a), and the relationship of those side effects to discontinuation of medication. Flu-like symptoms, muscle aches and chills decreased over the first 2 months of treatment but did not change over the second 2 months. Loss of feeling or numbness, tingling and depression increased over 4 months, however these side effects were generally mild. Loss of feeling or numbness and tingling at 2 month follow-up were significantly related to discontinuation of IFN beta-1a by 4 month follow-up.

Assessing resilience in adults with histories of childhood sexual abuse.

Adults with histories of childhood sexual abuse were categorized as being either resilient or nonresilient on the basis of current levels of depression and self-esteem. Characteristics of both the individual and the early family environment distinguished resilient from nonresilient abuse survivors, as did the physically coercive nature of the abuse experience.

Psychological, interpersonal, and behavioral correlates of chronic self-destructiveness: an exploratory study.

In this study, we selected individuals high and low on a measure of chronic self-destructiveness--the tendency to perform behaviors that later reduce positive consequences and increase the probability of experiencing negative ones--and attempted to differentiate high and low scorers based on a set of hypothesized antecedent and concurrent psychological, interpersonal, and behavioral correlates. Men and women were equally represented in high- and low-scoring groups. High scorers reported experiencing more interpersonal exploitation, greater depression, lower self-esteem, more externalizing attitudes, and less control in relationships than low scorers. High-scoring individuals also engaged in more frequent acts of acute self-destructiveness, including attempted suicide. A significant age covariate effect emerged: high-scoring men and women were younger than low-scoring individuals. These findings underscore the importance of studying chronic self-destructiveness within a developmental framework and suggest that issues of safety and self-care may be particularly germane to educational and clinical interventions aimed at young adults.

Childhood sexual abuse as a precursor to depression and self-destructive behavior in adulthood.

Childhood sexual abuse (CSA) as a predictor of depression and self-destructive behaviors in adulthood was examined relative to other traumatic stressors in childhood and adulthood with special attention to sex differences. In a college sample of 173 men and 265 women, 16% of male (n = 28) and 24% of female respondents (n = 63) reported having been sexually abused as children. CSA, ranging from unwanted kissing and fondling to unwanted sexual intercourse, predicted depression, chronic self-destructiveness, self-harm ideation, acts of self-harm, suicide ideation, and suicide attempts, for both men and women. The more frequent and severe the sexual abuse and the longer its duration, the more depression and self-destructiveness reported in adulthood. Other stressors predicted these effects less consistently but their occurrence in combination with CSA contributed to the negativity of long-term outcomes. Study results affirm previous findings of a relationship between CSA and depression and self-destructiveness in adult females and extend them to males.