1. Alexa Stuifbergen, PhD, RN, FAAN Heather Becker, PhD, Frank Perez, PhD
Impact of a Cognitive Rehabilitation Intervention on Depressive Symptoms
Alexa Stuifbergen, PhD, RN, FAAN
Heather Becker, PhD,
Frank Perez, PhD

3. Acknowledgement
This work was supported by the National Institutes of Health, National Institute of Nursing Research, 1R01NR The content is solely the responsibility of the authors and does not necessarily represent the official views of the NINR or the NIH. The authors have no conflicts of interest to report.

4. Learning Objectives The learner will be able to:
Describe the impact of a cognitive rehabilitation intervention on depressive symptoms

5. Collaborators Heather Becker, PhD Frank Perez, PhD Vicki Kullberg, MA
Janet Morrison, PhD, RN
Ashley Henneghan, PhD, RN
Ana Todd, PhD, RN
Adama Brown, PhD
Wenhui Zhang
Taylor Molton

6. Background
The effects of MS on cognition have gained increasing recognition as on of the major disabling symptoms of the disease
Cognitive symptoms often co-occur with depressive symptoms and may increase the impact of cognitive changes on quality of life.

7. Early Descriptive Findings
Most participants in the longitudinal study had significant concerns about their memory.
65% thought something was wrong with their memory
61% thought their memory was going downhill, and
62% were embarrassed about their memory

8. Cognitive Concerns
Participants reported frequent memory mistakes and very limited use of internal strategies or external aids to memory.
Depressive symptoms, functional limitations, memory contentment scores, and gender accounted for 61% of the variance in scores on the Quality of Life Index
Phillips L & Stuifbergen A. (2006). The influence of metamemory on quality of life in multiple sclerosis. Journal of Neuroscience Nursing, 38(6),

9. Purpose
To determine if participants in a multi-site randomized controlled trial of a cognitive rehabilitation intervention would experience improvements in depressive symptoms and sustain those improvements over a 6-month follow-up

10. MAPSS-MS Intervention
Memory, Attention and Problem Solving Skills for Persons with MS
Purpose is to help the individual acquire the highest level of cognitive functioning and functional independence through
teaching the use of compensatory skills
retraining skills (home-based computer training), and
environmental/lifestyle support for cognitive functioning including wellness strategies that may impact cognition and depressive symptoms

11. MAPSS-MS Intervention
Classes (2 hours per week for 8 weeks) addressing:
Compensatory strategies for memory, attention and problem solving skills
Lifestyle factors that affect cognitive performance (physical activity, stress management, depression, sleep/rest)
Computer practice 45 minutes three times per week using prescribed games

12. Design Multi-site randomized controlled trial
Recruitment in Houston, San Antonio and Dallas/Fort Worth metropolitan areas
Recruited 183 participants over 4 years
Randomized to treatment or usual care plus comparison
Study participation lasted 8 months – testing at baseline, immediate post-intervention and 3 and 6 months post-intervention

13. Primary Outcomes
Neuropsychological performance tests and self-reports of cognitive function
Use of compensatory strategies
Stuifbergen A, Becker H, Perez F, Morrison J, Brown A, Kullberg V, Zhang W (2018). Computer-Assisted cognitive rehabilitation in persons with multiple sclerosis: Results of a multi-site randomized controlled trial with six month follow-up. Disability and Health.

14. Sample (N=183) Randomly assigned – 93 intervention; 90 control
Age – mean of 49.6 yrs. (SD 8.00); Range 26 – 60
EDSS Scores mean of 5.2 (SD 1.56)
Length of time since diagnosis – mean of 13.0 years
Majority was
Female (87%)
White (75%)
Married (64%)
Not employed full-time (71%)
College-Educated (60%)

15. Self-report and performance measures of cognitive functioning and depressive symptoms at 4 time points
10-item Center for Epidemiologic Studies Depression Scale (CES-D) measured depressive symptoms in the last week

16. Data Analysis
Changes in depressive symptom outcomes analyzed using a repeated measures ANOVA design to determine time and time by group effects on outcomes
Due to large variability among persons with MS, Analysis of Covariance (ANCOVA) was used to determine the differences between the intervention group and comparison groups at Time 2, 3, and 4 , after controlling for baseline scores

17. Findings

18. Correlations with CES-D score at Baseline (N=183)
Not significantly correlated with age, gender, years of education or race/ethnicity
Small, significant correlations with marital status (r= -0.23) and EDSS total (r=0.23)
Significantly correlated with use of memory strategies (r=0.26), and perceived cognitive abilities (r=-0.44)
No significant correlations between depressive symptoms and performance on neuropsychological tests – CVLT, BVMT, PSAT, SDMT, COWAT and EPT

19. CES-D Scores over time Baseline Post-Intervention
3 months post intervention
6 months post intervention
Intervention
11.4 (6.2)
9.7 (5.6)
9.9 (6.2)
10.1 (6.2)
Comparison
11.4 (5.8)
11.4 (5.6)
11.5 (6.6)
10.5 (5.9)
F group by time effect – 2.914; p<.05

20. ANCOVA Results
Immediately following the intervention, the intervention group scored significantly lower on the CES-D (F=7.63, p=.006)
3- months post-intervention, the intervention scored significantly lower on the CES-D (F=5.04, p<.05)
Differences between groups were not seen at 6 month time point

21. Limitations Convenience sample
Generally well-educated and moderately impaired group
Limited to English speakers
Treatment contamination difficult to control in more pragmatic community-based studies

22. Statistically significant group by time effect on the CES-D may reflect the co-occurrence of positive improvements in cognition or the positive effects of the group intervention in helping participants reframe the challenges they face, particularly in the area of cognitive abilities
Strongest differences were immediate post-intervention suggesting the assertion that on-going interpersonal support can be particularly important

23. Questions??