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Multiple sclerosis (MS) poses a host of cognitive and psychosocial challenges that may contribute to functioning and quality of life (QOL). Although each patient’s experience with MS is different, some challenges are more common than are others, including cognitive changes, depression, and maintaining positive health behaviors. William’s case study illustrates some of these challenges as well as the resources and strategies of the psychologists at the MS
Centers of Excellence (MSCoE) to help patients with MS adapt and thrive.
Cognition
Difficulties with cognitive functioning are common in patients with MS. About half of patients with MS will develop cognitive impairments in one or more areas during their lifetime.1 Although cognitive difficulties tend to worsen over the course of the disease, they can appear at any point in the illness, differ greatly from patient to patient, and are only modestly correlated with physical symptoms.1 Impairments are most common in the areas of information processing speed and memory, as well as in complex attention and mental flexibility. These impairments can impact activities of daily living, sustained employment, driving, and social relationships.
Early in the disease, William, who admitted to difficulties with cognition and the impact of cognitive impairment on his life, benefited from neuropsychological testing. Typically, an MSCoE will use a battery of tests tailored to patients with MS. For patients, the results of these tests can be used to clarify areas of relative strength and weakness and inform team decisions related to treatment and future life activities, such as whether the patient will need accommodations at work. Test results may also be used to guide how the MS treatment team interacts with the patient.
An initial clinic screening from neurology indicated William had below average cognitive processing speed, and he agreed to neurocognitive testing. The psycholopsychologist asked William about his functioning at home. William noted poor attention and memory made it difficult to advocate for himself. He recounted an episode of taking his car to be repaired and only later realizing that he had been charged twice for the same part. He also disclosed that he had gotten lost while driving through familiar places. On several occasions while cooking, he had become distracted and started another task only to find he had burned his food.
Cognitive rehabilitation has shown considerable promise in helping patients work through difficulties with memory, attention, and problem solving by developing compensatory strategies.2 Skill training is available in individual and group formats. There is also promising but very preliminary evidence that some psychosocial interventions might improve memory performance for patients with MS.3
William’s neuropsychological testing confirmed impairments in information processing speed, attention, and memory, and William was diagnosed with cognitive disorder not otherwise specified. His cognitive impairment correlated with his magnetic resonance imaging (MRI) findings, which included lesions on the corpus callosum and in multiple subcortical areas.
During a feedback session, William was encouraged to use compensatory strategies, including memory aids, visual cueing, and self-pacing. He was given a referral to speech and language pathology to develop and practice these strategies. The psychologist also reminded William’s health care team to speak slowly and repeat important information to him, write down important instructions, and cue him when asking questions in the clinic. William was provided with a kitchen timer and instructed to set it whenever he began cooking, so that even if he got distracted, the alarm would remind him to return to his cooking. William was asked whether he would like to participate in the MSCoE cognitive compensatory training program.4 The program, offered through a research protocol, involved a series of classes that taught strategies to manage cognitive symptoms and improve patients’ ability to function independently. William agreed to participate and reported feeling hopeful that his situation could improve.
Depression
Multiple sclerosis brings many variable and unpredictable challenges and can be a source of distress. Often these challenges occur with the onset of new disease milestones, such as the diagnosis or an increased disability. Given the physical, cognitive, and social stresses, it is not surprising that depression is extremely common, appearing in about half of patients with MS over their lifetime.5 During the course of ordinary MS care, the majority of patients with depression can be identified by a brief screening and referred for additional assessment and treatment.
Fortunately, there are many available treatment options. Antidepressant medications have shown some efficacy.6 Cognitive behavioral therapy (CBT), a counseling strategy that helps individuals become more active, connects them with rewarding activities, and challenges maladaptive thought patterns, has been shown to be effective in individual and group counseling settings via in-person or telephone-based delivery.7,8 Anxiety is also common experience among patients with MS and is treated with many of the same types of psychotherapy intervention.9
Focusing on the psychological and social needs of patients with MS has obvious implications for holistic care and QOL, but in some instances, MS may also contribute to safety concerns. Nearly one-third of veterans with MS admit to suicidal ideation, and the ultimate risk of suicide is about twice that of similar individuals without MS.10,11 For this reason, screening for risk of self-harm should be routinely incorporated into MS care.
A quick look at William’s Computerized Patient Record System (CPRS) record revealed that he had called the VA suicide prevention hotline. During the conversation he had noted that although he originally thought he would be able to deal with MS on his own, he realized he couldn’t. When the psychologist asked William about life at home, he disclosed that some days he never left his bed except to go to the bathroom. He stated he had given up on dating, and asked “who would want me?” He reported little appetite or interest in sex.
William was anxious about the problems he faced from day to day and grieving about the future that he no longer believed was possible. His distress was generally related to the MS diagnosis, and he spent a significant amount of time minimizing his disability, avoiding his family for this reason.
The psychologist diagnosed William with adjustment disorder with mixed anxiety and depressed mood and initiated individual CBT. The psychologist suggested that William attend the MS social work support group and the MS education group to get to know other veterans with MS and learn about managing symptoms. William agreed to attend the groups and admitted it would be good to have a reason to leave the house.
Health Behavior
Recognizing that MS is a chronic illness that requires coordinated efforts, the MS team helped William manage his disease and maintain his health. The psychological and social components of this process were considerable. For most newly diagnosed patients with MS, diseasemodifying therapies (DMTs) are important tools to decrease relapses and short-term disability. Although the benefits of these medications are well known, many patients are nonadherent. Contributing to poor adherence are adverse effects, cognitive challenges, anxiety, depression, and lack of belief in their efficacy.12,13 Brief
counseling, problem solving, and clinical monitoring have all been shown to reduce missed doses and improve DMT use.13 Both the MS Assessment Tool and the pharmacy database within CPRS are helpful for tracking patient adherence over time.
Other health behaviors may contribute not only to overall health, but also to the disease course. Patients who smoke have accelerated progression of their MS disease process and greater mortality than that of nonsmokers.14 Likewise, patients who engage in regular physical activity experience not only greater strength and endurance, but also less fatigue, depression, and better QOL.15 As part of his chronic illness care, the MS team provided William with information about the potential impact of health behaviors on MS progression.
William’s emotional and cognitive symptoms of MS presented important challenges to the management of his MS care. Initially, he ignored his diagnosis, delayed care, and refused to take a DMT. Once he agreed to taking a DMT, he often forgot to take it. He frequently missed medical appointments, because he did not remember them. Depression, fatigue, and stress decreased his motivation to follow through with recommendations from his health care providers.
Given William’s multiple psychosocial needs and transportation challenges, VA psychologists initiated telehealth visits with William in addition to clinic visits to provide many services, including psychotherapy and health behavior counseling. This continued support, along with the coordination of the rest of his health care team has been vital to maintaining William’s adherence to his treatment plan and QOL.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
1. Rao SM, Leo GJ, Bernardin L, Unverzagt F. Cognitive dysfunction in multiple sclerosis. I. Frequency, patterns, and prediction. Neurology. 1991;41(5):685-691.
2. Cicerone KD, Langenbahn DM, Braden C, et al. Evidence-based cognitive rehabilitation: Updated review of the literature from 2003 through 2008. Arch Phys Med Rehabil. 2011;92(4):519-530.
3. Chiaravalloti ND, Moore NB, Nikelshpur OM, DeLuca J. An RCT to treat learning impairment in multiple sclerosis: The MEMREHAB trial. Neurology. 2013;81(24):2066-2072.
4. Huckans M, Pavawalla S, Demadura T, et al. A pilot study examining effects of group-based Cognitive Strategy Training treatment on self-reported cognitive problems, psychiatric symptoms, functioning, and compensatory strategy use in OIF/OEF combat veterans with persistent mild cognitive disorder and history of traumatic brain injury. J Rehabil Res Dev. 2010;47(1):43-60.
5. Sadovnick AD, Remick RA, Allen J, et al. Depression and multiple sclerosis. Neurology. 1996;46(3):628-632.
6. Wallin MT, Wilken JA, Turner AP, Williams RM, Kane R. Depression and multiple
sclerosis: Review of a lethal combination. J Rehabil Res Dev. 2006;43(1):45-62.
7. Mohr DC, Boudewyn AC, Goodkin DE, Bostrom A, Epstein L. Comparative outcomes for individual cognitive-behavior therapy, supportive-expressive group psychotherapy, and sertraline for the treatment of depression in multiple sclerosis. J Consult Clin Psychol. 2001;69(6):942-949.
8. Mohr DC, Hart SL, Julian L, et al. Telephone-administered psychotherapy for depression. Arch Gen Psychiatry. 2005;62(9):1007-1014.
9. Korostil M, Feinstein A. Anxiety disorders and their clinical correlates in multiple sclerosis patients. Mult Scler. 2007;13(1):67-72.
10. Turner AP, Williams RM, Bowen JD, Kivlahan DR, Haselkorn JK. Suicidal ideation in multiple sclerosis. Arch Phys Med Rehabil. 2006;87(8):1073-1078.
11. Stenager EN, Stenager E. Suicide and patients with neurologic diseases. Methodologic problems. Arch Neurol. 1992;49(12):1296-1303.
12. Bruce JM, Hancock LM, Arnett P, Lynch S. Treatment adherence in multiple sclerosis:
Association with emotional status, personality, and cognition. J Behav Med. 2010;33(3):219-227.
13. Turner AP, Kivlahan DR, Sloan AP, Haselkorn JK. Predicting ongoing adherence to disease modifying therapies in multiple sclerosis: Utility of the health beliefs model. Mult Scler. 2007;13(9):1146-1152.
14. Overs S, Hughes CM, Haselkorn JK, Turner AP. Modifiable comorbidities and disability in multiple sclerosis. Curr Neurol Neurosci Rep. 2012;12(5):610-617.
15. Motl RW, Pilutti LA. The benefits of exercise training in multiple sclerosis. Nat Rev Neurol. 2012;8(9):487-497.
Multiple sclerosis (MS) poses a host of cognitive and psychosocial challenges that may contribute to functioning and quality of life (QOL). Although each patient’s experience with MS is different, some challenges are more common than are others, including cognitive changes, depression, and maintaining positive health behaviors. William’s case study illustrates some of these challenges as well as the resources and strategies of the psychologists at the MS
Centers of Excellence (MSCoE) to help patients with MS adapt and thrive.
Cognition
Difficulties with cognitive functioning are common in patients with MS. About half of patients with MS will develop cognitive impairments in one or more areas during their lifetime.1 Although cognitive difficulties tend to worsen over the course of the disease, they can appear at any point in the illness, differ greatly from patient to patient, and are only modestly correlated with physical symptoms.1 Impairments are most common in the areas of information processing speed and memory, as well as in complex attention and mental flexibility. These impairments can impact activities of daily living, sustained employment, driving, and social relationships.
Early in the disease, William, who admitted to difficulties with cognition and the impact of cognitive impairment on his life, benefited from neuropsychological testing. Typically, an MSCoE will use a battery of tests tailored to patients with MS. For patients, the results of these tests can be used to clarify areas of relative strength and weakness and inform team decisions related to treatment and future life activities, such as whether the patient will need accommodations at work. Test results may also be used to guide how the MS treatment team interacts with the patient.
An initial clinic screening from neurology indicated William had below average cognitive processing speed, and he agreed to neurocognitive testing. The psycholopsychologist asked William about his functioning at home. William noted poor attention and memory made it difficult to advocate for himself. He recounted an episode of taking his car to be repaired and only later realizing that he had been charged twice for the same part. He also disclosed that he had gotten lost while driving through familiar places. On several occasions while cooking, he had become distracted and started another task only to find he had burned his food.
Cognitive rehabilitation has shown considerable promise in helping patients work through difficulties with memory, attention, and problem solving by developing compensatory strategies.2 Skill training is available in individual and group formats. There is also promising but very preliminary evidence that some psychosocial interventions might improve memory performance for patients with MS.3
William’s neuropsychological testing confirmed impairments in information processing speed, attention, and memory, and William was diagnosed with cognitive disorder not otherwise specified. His cognitive impairment correlated with his magnetic resonance imaging (MRI) findings, which included lesions on the corpus callosum and in multiple subcortical areas.
During a feedback session, William was encouraged to use compensatory strategies, including memory aids, visual cueing, and self-pacing. He was given a referral to speech and language pathology to develop and practice these strategies. The psychologist also reminded William’s health care team to speak slowly and repeat important information to him, write down important instructions, and cue him when asking questions in the clinic. William was provided with a kitchen timer and instructed to set it whenever he began cooking, so that even if he got distracted, the alarm would remind him to return to his cooking. William was asked whether he would like to participate in the MSCoE cognitive compensatory training program.4 The program, offered through a research protocol, involved a series of classes that taught strategies to manage cognitive symptoms and improve patients’ ability to function independently. William agreed to participate and reported feeling hopeful that his situation could improve.
Depression
Multiple sclerosis brings many variable and unpredictable challenges and can be a source of distress. Often these challenges occur with the onset of new disease milestones, such as the diagnosis or an increased disability. Given the physical, cognitive, and social stresses, it is not surprising that depression is extremely common, appearing in about half of patients with MS over their lifetime.5 During the course of ordinary MS care, the majority of patients with depression can be identified by a brief screening and referred for additional assessment and treatment.
Fortunately, there are many available treatment options. Antidepressant medications have shown some efficacy.6 Cognitive behavioral therapy (CBT), a counseling strategy that helps individuals become more active, connects them with rewarding activities, and challenges maladaptive thought patterns, has been shown to be effective in individual and group counseling settings via in-person or telephone-based delivery.7,8 Anxiety is also common experience among patients with MS and is treated with many of the same types of psychotherapy intervention.9
Focusing on the psychological and social needs of patients with MS has obvious implications for holistic care and QOL, but in some instances, MS may also contribute to safety concerns. Nearly one-third of veterans with MS admit to suicidal ideation, and the ultimate risk of suicide is about twice that of similar individuals without MS.10,11 For this reason, screening for risk of self-harm should be routinely incorporated into MS care.
A quick look at William’s Computerized Patient Record System (CPRS) record revealed that he had called the VA suicide prevention hotline. During the conversation he had noted that although he originally thought he would be able to deal with MS on his own, he realized he couldn’t. When the psychologist asked William about life at home, he disclosed that some days he never left his bed except to go to the bathroom. He stated he had given up on dating, and asked “who would want me?” He reported little appetite or interest in sex.
William was anxious about the problems he faced from day to day and grieving about the future that he no longer believed was possible. His distress was generally related to the MS diagnosis, and he spent a significant amount of time minimizing his disability, avoiding his family for this reason.
The psychologist diagnosed William with adjustment disorder with mixed anxiety and depressed mood and initiated individual CBT. The psychologist suggested that William attend the MS social work support group and the MS education group to get to know other veterans with MS and learn about managing symptoms. William agreed to attend the groups and admitted it would be good to have a reason to leave the house.
Health Behavior
Recognizing that MS is a chronic illness that requires coordinated efforts, the MS team helped William manage his disease and maintain his health. The psychological and social components of this process were considerable. For most newly diagnosed patients with MS, diseasemodifying therapies (DMTs) are important tools to decrease relapses and short-term disability. Although the benefits of these medications are well known, many patients are nonadherent. Contributing to poor adherence are adverse effects, cognitive challenges, anxiety, depression, and lack of belief in their efficacy.12,13 Brief
counseling, problem solving, and clinical monitoring have all been shown to reduce missed doses and improve DMT use.13 Both the MS Assessment Tool and the pharmacy database within CPRS are helpful for tracking patient adherence over time.
Other health behaviors may contribute not only to overall health, but also to the disease course. Patients who smoke have accelerated progression of their MS disease process and greater mortality than that of nonsmokers.14 Likewise, patients who engage in regular physical activity experience not only greater strength and endurance, but also less fatigue, depression, and better QOL.15 As part of his chronic illness care, the MS team provided William with information about the potential impact of health behaviors on MS progression.
William’s emotional and cognitive symptoms of MS presented important challenges to the management of his MS care. Initially, he ignored his diagnosis, delayed care, and refused to take a DMT. Once he agreed to taking a DMT, he often forgot to take it. He frequently missed medical appointments, because he did not remember them. Depression, fatigue, and stress decreased his motivation to follow through with recommendations from his health care providers.
Given William’s multiple psychosocial needs and transportation challenges, VA psychologists initiated telehealth visits with William in addition to clinic visits to provide many services, including psychotherapy and health behavior counseling. This continued support, along with the coordination of the rest of his health care team has been vital to maintaining William’s adherence to his treatment plan and QOL.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
Multiple sclerosis (MS) poses a host of cognitive and psychosocial challenges that may contribute to functioning and quality of life (QOL). Although each patient’s experience with MS is different, some challenges are more common than are others, including cognitive changes, depression, and maintaining positive health behaviors. William’s case study illustrates some of these challenges as well as the resources and strategies of the psychologists at the MS
Centers of Excellence (MSCoE) to help patients with MS adapt and thrive.
Cognition
Difficulties with cognitive functioning are common in patients with MS. About half of patients with MS will develop cognitive impairments in one or more areas during their lifetime.1 Although cognitive difficulties tend to worsen over the course of the disease, they can appear at any point in the illness, differ greatly from patient to patient, and are only modestly correlated with physical symptoms.1 Impairments are most common in the areas of information processing speed and memory, as well as in complex attention and mental flexibility. These impairments can impact activities of daily living, sustained employment, driving, and social relationships.
Early in the disease, William, who admitted to difficulties with cognition and the impact of cognitive impairment on his life, benefited from neuropsychological testing. Typically, an MSCoE will use a battery of tests tailored to patients with MS. For patients, the results of these tests can be used to clarify areas of relative strength and weakness and inform team decisions related to treatment and future life activities, such as whether the patient will need accommodations at work. Test results may also be used to guide how the MS treatment team interacts with the patient.
An initial clinic screening from neurology indicated William had below average cognitive processing speed, and he agreed to neurocognitive testing. The psycholopsychologist asked William about his functioning at home. William noted poor attention and memory made it difficult to advocate for himself. He recounted an episode of taking his car to be repaired and only later realizing that he had been charged twice for the same part. He also disclosed that he had gotten lost while driving through familiar places. On several occasions while cooking, he had become distracted and started another task only to find he had burned his food.
Cognitive rehabilitation has shown considerable promise in helping patients work through difficulties with memory, attention, and problem solving by developing compensatory strategies.2 Skill training is available in individual and group formats. There is also promising but very preliminary evidence that some psychosocial interventions might improve memory performance for patients with MS.3
William’s neuropsychological testing confirmed impairments in information processing speed, attention, and memory, and William was diagnosed with cognitive disorder not otherwise specified. His cognitive impairment correlated with his magnetic resonance imaging (MRI) findings, which included lesions on the corpus callosum and in multiple subcortical areas.
During a feedback session, William was encouraged to use compensatory strategies, including memory aids, visual cueing, and self-pacing. He was given a referral to speech and language pathology to develop and practice these strategies. The psychologist also reminded William’s health care team to speak slowly and repeat important information to him, write down important instructions, and cue him when asking questions in the clinic. William was provided with a kitchen timer and instructed to set it whenever he began cooking, so that even if he got distracted, the alarm would remind him to return to his cooking. William was asked whether he would like to participate in the MSCoE cognitive compensatory training program.4 The program, offered through a research protocol, involved a series of classes that taught strategies to manage cognitive symptoms and improve patients’ ability to function independently. William agreed to participate and reported feeling hopeful that his situation could improve.
Depression
Multiple sclerosis brings many variable and unpredictable challenges and can be a source of distress. Often these challenges occur with the onset of new disease milestones, such as the diagnosis or an increased disability. Given the physical, cognitive, and social stresses, it is not surprising that depression is extremely common, appearing in about half of patients with MS over their lifetime.5 During the course of ordinary MS care, the majority of patients with depression can be identified by a brief screening and referred for additional assessment and treatment.
Fortunately, there are many available treatment options. Antidepressant medications have shown some efficacy.6 Cognitive behavioral therapy (CBT), a counseling strategy that helps individuals become more active, connects them with rewarding activities, and challenges maladaptive thought patterns, has been shown to be effective in individual and group counseling settings via in-person or telephone-based delivery.7,8 Anxiety is also common experience among patients with MS and is treated with many of the same types of psychotherapy intervention.9
Focusing on the psychological and social needs of patients with MS has obvious implications for holistic care and QOL, but in some instances, MS may also contribute to safety concerns. Nearly one-third of veterans with MS admit to suicidal ideation, and the ultimate risk of suicide is about twice that of similar individuals without MS.10,11 For this reason, screening for risk of self-harm should be routinely incorporated into MS care.
A quick look at William’s Computerized Patient Record System (CPRS) record revealed that he had called the VA suicide prevention hotline. During the conversation he had noted that although he originally thought he would be able to deal with MS on his own, he realized he couldn’t. When the psychologist asked William about life at home, he disclosed that some days he never left his bed except to go to the bathroom. He stated he had given up on dating, and asked “who would want me?” He reported little appetite or interest in sex.
William was anxious about the problems he faced from day to day and grieving about the future that he no longer believed was possible. His distress was generally related to the MS diagnosis, and he spent a significant amount of time minimizing his disability, avoiding his family for this reason.
The psychologist diagnosed William with adjustment disorder with mixed anxiety and depressed mood and initiated individual CBT. The psychologist suggested that William attend the MS social work support group and the MS education group to get to know other veterans with MS and learn about managing symptoms. William agreed to attend the groups and admitted it would be good to have a reason to leave the house.
Health Behavior
Recognizing that MS is a chronic illness that requires coordinated efforts, the MS team helped William manage his disease and maintain his health. The psychological and social components of this process were considerable. For most newly diagnosed patients with MS, diseasemodifying therapies (DMTs) are important tools to decrease relapses and short-term disability. Although the benefits of these medications are well known, many patients are nonadherent. Contributing to poor adherence are adverse effects, cognitive challenges, anxiety, depression, and lack of belief in their efficacy.12,13 Brief
counseling, problem solving, and clinical monitoring have all been shown to reduce missed doses and improve DMT use.13 Both the MS Assessment Tool and the pharmacy database within CPRS are helpful for tracking patient adherence over time.
Other health behaviors may contribute not only to overall health, but also to the disease course. Patients who smoke have accelerated progression of their MS disease process and greater mortality than that of nonsmokers.14 Likewise, patients who engage in regular physical activity experience not only greater strength and endurance, but also less fatigue, depression, and better QOL.15 As part of his chronic illness care, the MS team provided William with information about the potential impact of health behaviors on MS progression.
William’s emotional and cognitive symptoms of MS presented important challenges to the management of his MS care. Initially, he ignored his diagnosis, delayed care, and refused to take a DMT. Once he agreed to taking a DMT, he often forgot to take it. He frequently missed medical appointments, because he did not remember them. Depression, fatigue, and stress decreased his motivation to follow through with recommendations from his health care providers.
Given William’s multiple psychosocial needs and transportation challenges, VA psychologists initiated telehealth visits with William in addition to clinic visits to provide many services, including psychotherapy and health behavior counseling. This continued support, along with the coordination of the rest of his health care team has been vital to maintaining William’s adherence to his treatment plan and QOL.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review the complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.
1. Rao SM, Leo GJ, Bernardin L, Unverzagt F. Cognitive dysfunction in multiple sclerosis. I. Frequency, patterns, and prediction. Neurology. 1991;41(5):685-691.
2. Cicerone KD, Langenbahn DM, Braden C, et al. Evidence-based cognitive rehabilitation: Updated review of the literature from 2003 through 2008. Arch Phys Med Rehabil. 2011;92(4):519-530.
3. Chiaravalloti ND, Moore NB, Nikelshpur OM, DeLuca J. An RCT to treat learning impairment in multiple sclerosis: The MEMREHAB trial. Neurology. 2013;81(24):2066-2072.
4. Huckans M, Pavawalla S, Demadura T, et al. A pilot study examining effects of group-based Cognitive Strategy Training treatment on self-reported cognitive problems, psychiatric symptoms, functioning, and compensatory strategy use in OIF/OEF combat veterans with persistent mild cognitive disorder and history of traumatic brain injury. J Rehabil Res Dev. 2010;47(1):43-60.
5. Sadovnick AD, Remick RA, Allen J, et al. Depression and multiple sclerosis. Neurology. 1996;46(3):628-632.
6. Wallin MT, Wilken JA, Turner AP, Williams RM, Kane R. Depression and multiple
sclerosis: Review of a lethal combination. J Rehabil Res Dev. 2006;43(1):45-62.
7. Mohr DC, Boudewyn AC, Goodkin DE, Bostrom A, Epstein L. Comparative outcomes for individual cognitive-behavior therapy, supportive-expressive group psychotherapy, and sertraline for the treatment of depression in multiple sclerosis. J Consult Clin Psychol. 2001;69(6):942-949.
8. Mohr DC, Hart SL, Julian L, et al. Telephone-administered psychotherapy for depression. Arch Gen Psychiatry. 2005;62(9):1007-1014.
9. Korostil M, Feinstein A. Anxiety disorders and their clinical correlates in multiple sclerosis patients. Mult Scler. 2007;13(1):67-72.
10. Turner AP, Williams RM, Bowen JD, Kivlahan DR, Haselkorn JK. Suicidal ideation in multiple sclerosis. Arch Phys Med Rehabil. 2006;87(8):1073-1078.
11. Stenager EN, Stenager E. Suicide and patients with neurologic diseases. Methodologic problems. Arch Neurol. 1992;49(12):1296-1303.
12. Bruce JM, Hancock LM, Arnett P, Lynch S. Treatment adherence in multiple sclerosis:
Association with emotional status, personality, and cognition. J Behav Med. 2010;33(3):219-227.
13. Turner AP, Kivlahan DR, Sloan AP, Haselkorn JK. Predicting ongoing adherence to disease modifying therapies in multiple sclerosis: Utility of the health beliefs model. Mult Scler. 2007;13(9):1146-1152.
14. Overs S, Hughes CM, Haselkorn JK, Turner AP. Modifiable comorbidities and disability in multiple sclerosis. Curr Neurol Neurosci Rep. 2012;12(5):610-617.
15. Motl RW, Pilutti LA. The benefits of exercise training in multiple sclerosis. Nat Rev Neurol. 2012;8(9):487-497.
1. Rao SM, Leo GJ, Bernardin L, Unverzagt F. Cognitive dysfunction in multiple sclerosis. I. Frequency, patterns, and prediction. Neurology. 1991;41(5):685-691.
2. Cicerone KD, Langenbahn DM, Braden C, et al. Evidence-based cognitive rehabilitation: Updated review of the literature from 2003 through 2008. Arch Phys Med Rehabil. 2011;92(4):519-530.
3. Chiaravalloti ND, Moore NB, Nikelshpur OM, DeLuca J. An RCT to treat learning impairment in multiple sclerosis: The MEMREHAB trial. Neurology. 2013;81(24):2066-2072.
4. Huckans M, Pavawalla S, Demadura T, et al. A pilot study examining effects of group-based Cognitive Strategy Training treatment on self-reported cognitive problems, psychiatric symptoms, functioning, and compensatory strategy use in OIF/OEF combat veterans with persistent mild cognitive disorder and history of traumatic brain injury. J Rehabil Res Dev. 2010;47(1):43-60.
5. Sadovnick AD, Remick RA, Allen J, et al. Depression and multiple sclerosis. Neurology. 1996;46(3):628-632.
6. Wallin MT, Wilken JA, Turner AP, Williams RM, Kane R. Depression and multiple
sclerosis: Review of a lethal combination. J Rehabil Res Dev. 2006;43(1):45-62.
7. Mohr DC, Boudewyn AC, Goodkin DE, Bostrom A, Epstein L. Comparative outcomes for individual cognitive-behavior therapy, supportive-expressive group psychotherapy, and sertraline for the treatment of depression in multiple sclerosis. J Consult Clin Psychol. 2001;69(6):942-949.
8. Mohr DC, Hart SL, Julian L, et al. Telephone-administered psychotherapy for depression. Arch Gen Psychiatry. 2005;62(9):1007-1014.
9. Korostil M, Feinstein A. Anxiety disorders and their clinical correlates in multiple sclerosis patients. Mult Scler. 2007;13(1):67-72.
10. Turner AP, Williams RM, Bowen JD, Kivlahan DR, Haselkorn JK. Suicidal ideation in multiple sclerosis. Arch Phys Med Rehabil. 2006;87(8):1073-1078.
11. Stenager EN, Stenager E. Suicide and patients with neurologic diseases. Methodologic problems. Arch Neurol. 1992;49(12):1296-1303.
12. Bruce JM, Hancock LM, Arnett P, Lynch S. Treatment adherence in multiple sclerosis:
Association with emotional status, personality, and cognition. J Behav Med. 2010;33(3):219-227.
13. Turner AP, Kivlahan DR, Sloan AP, Haselkorn JK. Predicting ongoing adherence to disease modifying therapies in multiple sclerosis: Utility of the health beliefs model. Mult Scler. 2007;13(9):1146-1152.
14. Overs S, Hughes CM, Haselkorn JK, Turner AP. Modifiable comorbidities and disability in multiple sclerosis. Curr Neurol Neurosci Rep. 2012;12(5):610-617.
15. Motl RW, Pilutti LA. The benefits of exercise training in multiple sclerosis. Nat Rev Neurol. 2012;8(9):487-497.