The Science, Art and Practice of Behavioural Medicine in MS: Amy B Sullivan PsyD ABPP

Report by Denisse Bongol, MS Clinical Nurse Specialist, National Hospital for Neurology and Neurosurgery

Aims of the session

Amy Sullivan shared a series of learning objectives from the session, which were to:

• Examine the cost of chronic diseases and mental health issues in the general population,
• Improve ability to assess and understand the path of the person with MS,
• Describe the multidisciplinary nature of MS providers and treatment,
• Discuss strategies to manage depression, anxiety and stress,
• List the top three behavioural medicine treatment needs,
• Recognise the mind–body connection,
• Incorporate improved skills in stress management and resilience.

The cost of chronic diseases and mental health issues

Dr. Sullivan promotes the use of behavioural medicine (BM) with a preventative biopsychosocial model and incorporating wellness in improving people’s overall quality of life (QoL) and, ultimately, reducing the prevalence and cost of chronic illnesses including mental health disorders.

She presented the following key findings to expound on this:

• Research suggests that 50% of adults have at least one chronic disease with an estimated annual cost of $2.5 trillion in the USA.
• Among 1000 patients reviewed in primary care in Brooke Army Medical Center, Texas, 14 common symptoms including chest pain, fatigue and dizziness were observed and only 16% of patients had an organic aetiology for the symptoms (Kroenke, 1989).
• Dr. Sullivan highlighted that the majority of the visits in primary care were related to behavioural health (BH) needs but were not identified as mental health disorders.
• As many as 75% of patients with depression seek care for physical symptoms (Unutzer, 2006). Dr. Sullivan remarked that patients who would benefit from behavioural health (BH) services to relieve somatic symptoms rarely think that BM is what they need and the healthcare costs were also observed to be twice as high for those diagnosed with depression compared to those without.
• The benefit of psychotherapy in cost saving was shown in a study among patients in a Kaiser Permanente study where it showed a 77.9% decrease in the average length of hospital stay, a 66.7% decrease in frequency of hospitalizations, a 48.6% decrease in number of physician office visits, a 45.3% decrease in emergency room (ER) visits and a 31.2% decrease in telephone contacts (Lechnyr, 1993).

Chronic disease: the patient experience

Dr. Sullivan explained that people with MS are often perceived to have much positivity and resilience while, in reality, they may be experiencing invisible, often debilitating, symptoms. They also undergo different dynamic challenges throughout the course of their disease and we need to recognise and address these challenges to improve their overall QoL.

In view of this, Dr. Sullivan discussed the following key points:

Invisible symptoms are prevalent among MS patients, including fatigue (90%), cognitive symptoms (60%), pain (89–90%), sexual dysfunction (70–72%) and mood symptoms (50%).

• Mental health disorders are more prevalent in people with MS compared to the general population. In people with MS, around 50% are diagnosed with depression, 36% with anxiety disorders, 22% with adjustment disorders, 13% with bipolar disorders and 3% with psychotic disorders.
• Treating depression may be associated with decreased QoL, poor adherence to treatment, apathy in treatment decisions and relationship stress.
• MS patients may experience several emotions, including grief, depression, anxiety, anger and denial in certain difficult circumstances that might involve disclosing symptoms, treatment decisions and planning for the future.
• Dr. Sullivan shared her observations of the negative emotional health impacts of COVID-19 among MS patients brought about by isolation and loneliness, an influx of information and uncertainties over the future. In particular, they underwent a decrease in overall wellbeing and psychological health, depression, anxiety and stress.

The multidisciplinary nature of MS providers and treatments

Dr. Sullivan provided insight into the practice of behavioural medicine in the Mellen Center for MS where they use the following:

• A multidisciplinary approach in accessing behavioural medicine through various referral sources; as an example, their MS patients receive BH services even at initial diagnosis through shared medical appointments (SMA).
• Electronic self-assessment tools (e.g. PHQ9 for depression) that are stored into a secure, wireless system, which also allows them to track patients’ response to treatment over time and identify factors that could be affecting their progress.
• An electronic health record (HER) (e.g. EPIC) that has integrated best practice alerts, which alert healthcare professionals to high PHQ9 scores and allow them to select the appropriate course of action, such as referral to BH services or pharmacological treatment.
• An efficient assessment tool using open-ended questions, including any stress factors that could potentially impact their daily life dynamics.

Strategies to manage the behavioural trio: depression, anxiety and stress

Dr. Sullivan highlighted that depression differs from normal grieving and noted that irritability is more frequently observed than tearfulness. She also discussed the following:

• Some 50% of people with chronic illness are likely to experience depression throughout the course of their disease, with a 7.5-times higher suicide rate compared to the general population.
• Depression in the MS population may be seen at the onset of the disease or throughout the disease course, and this can be in the aftermath of neuropathologic changes, medication side effects, exacerbations or even life changes.
• Factors, including younger age, earlier disease course, progressive disease subtype and greater disability, could contribute to suicide or suicidal ideation.

She presented the following treatment strategies for depression, particularly those of use in her practice:

• Cognitive behavioural therapy (CBT), which focuses on understanding the relationship between thoughts, emotions and behaviours and their interaction on mood. Its primary goal is to reconstruct thoughts, which then reconstructs mood. CBT involves relaxation, stress management, breathing, visualisation and mindfulness-based interventions.
• The Kubler-Ross’ grief–acceptance–adaptation model, which is their adaptation to the five stages of grieving model. In this model, they focus on ‘adaptation’ as their MS patients’ primary goal, where they will learn to adapt to the changes in their function or environment.
• Group therapies that are also tailored specifically for certain groups of individuals, such as the young professionals group, caregivers group, neurocognitive group and men’s MS group.
• Pharmacotherapy, including selective serotonin reuptake inhibitors (SSRIs), as the first-line treatment for anxiety and depression, and serotonin and norepinephrine reuptake inhibitors (SNRIs) for additional anxiety or pain.

Anxiety and adjustment disorder

Adjustment disorder is the development of anxious or depressed symptoms in response to a medical condition or symptom, which can occur within 3 months from diagnosis. It was also highlighted that this can occur at any point a person’s function changes among the MS population over the course of their disease (i.e. relapses, progressive disability). The treatment involves normalising, empathising, education, stress management techniques, medication and time.

Anxiety is a common symptom in adjustment disorder, but can also develop into a separate, more chronic anxiety disorder. This can be characterised by hypervigilance about changes in environment or one’s body, restlessness, physiological symptoms and fatigue.

Stress management

Dr. Sullivan highlighted that for a situation to be stressful, it must present as a threat to something a person values highly and where one believes that they don’t have any control over the situation. She emphasised how stress can negatively impact one’s mood, cognition, immune system and overall physical health. She presented a report from a randomised clinical trial by Mohr et al. (2012) that studied the correlation between stress management and the prevention of new brain lesions in MS patients [4]. The study looked at 121 MS patients who were randomly assigned for treatment with sixteen 51-minute individual therapy sessions over 24 weeks, followed by a post-treatment follow-up at 6 months. The authors used MRI gadolinium (GAD)-enhancing lesions and T2 brain lesions as outcome measures. To summarise, the findings included the following:

• The results showed that 76.8% of the participants in the treatment group had fewer GAD-enhancing lesions compared to 54.7% of the control group.
• There was also a reduction in new T2 lesions in the treatment group, where 70% remained free of new lesions compared to 43% in the control group.
• Finally, these benefits (reduction in new lesions) were no longer seen during the 6-month post-treatment follow-up.

Dr. Sullivan also shared the practice at the Mellen Center, where they developed a 4-session stress management protocol over the course of 4–6 months. They incorporate CBT, diaphragmatic and circular breathing skills. She also recommended the following stress management strategies:

• Maintaining wellness through healthy diet, regular exercise, adequate sleep and spirituality
• Taking a break from social media and staying informed through a trusted source, which is applicable in the current circumstances with the pandemic
• Getting enough sleep and rest through limiting stimulants, alcohol and nicotine before bed, keeping one’s normal wake–sleep cycle and finding a wind-down routine
• Staying connected with other people

Developing resistance

Dr. Sullivan emphasised the importance of improving one’s resilience and, to achieve this, one should allow time to understand the situation as much as possible, learn new coping strategies and behaviours, and allow oneself to have shifts in priorities.

More information

References noted were:

• Kroenke K, Mangelsdorff AD. Common symptoms in ambulatory care: incidence, evaluation, therapy, and outcome. Am J Med 1989; 86(3):262–266.
• Unutzer J, Schoenbaum M, Druss BG, KeatonWJ. Transforming mental health care at the interface with general medicine: Report for the Presidents. Commission Psychiatr Serv 2006; 57(1):37–47. doi.org/10.1176/appi.ps.57.1.37
• Lechnyr R. The cost savings of mental health services. EAP Digest 1993; 14(1):22.
• Mohr DC, Lovera J, Brown T et al. A randomized trial of stress management for the prevention of new brain lesions in MS. Neurology 2012; 79(5):412–419.

More from Amy Sullivan: watch her full CMSC presentation on interdisciplinary care in MS via NeurologyLive.

This activity has been sponsored by Roche Products Limited. Roche Products Limited has had no control over the educational content of this activity.