IJMSC Author Spotlight: Tamanna Islam, MSc, and Lisa Walker, PhD

Authors Tamanna Islam, MSc, and Lisa Walker, PhD, published Implementation of Cognition, Fatigue, and Mental Health Screening at a Canadian Multiple Sclerosis Center: A Quality Improvement Initiative in the International Journal of Multiple Sclerosis Care (IJMSC) in August 2025.

Lisa Walker, PhD

[photo courtesy of the author]

Lisa Walker obtained her PhD in psychology at the University of Windsor. She has worked as a clinical neuropsychologist at the Ottawa Hospital for over 25 years. Walker is also a clinician investigator with the Ottawa Hospital Research Institute where she leads the Cognitive Health in Multiple Sclerosis lab. She is also a founding members of MSCanRehab, an interdisciplinary group of MS researchers and rehabilitation professionals from across Canada.

Tamanna Islam, MSc

[photo courtesy of Lisa Walker]

Tamanna Islam is a PhD candidate in experimental psychology at the University of Ottawa. Her research focuses on cognitive fatigability in individuals with multiple sclerosis. She has successfully defended her doctoral thesis proposal.

Authors Walker and Islam recently sat down with IJMSC to talk about their paper, their career paths, and their continuing research.

International Journal of Multiple Sclerosis Care (IJMSC): Please introduce yourselves and tell us about how you got involved in multiple sclerosis (MS) research.

Tamanna Islam, MSc (TI): I am a doctoral candidate in the Experimental Psychology Program at the University of Ottawa, working under the supervision of Dr Lisa Walker. I have always been drawn to rehabilitation research, particularly the opportunity to address mental health concerns in the context of physical disability. When I was looking for mentors who could guide me in developing and implementing behavioral interventions, I came across Dr Walker’s work in MS, and I was intrigued immediately, and this is how I became involved in the field of MS.

Lisa Walker, PhD (LW): My story is a bit of a fluke. Back in graduate school, I was working with a mentor, Byron Rourke, [PhD], and his interest was in nonverbal learning disabilities, which is, of course, far from the field of MS. Part of his theory about how nonverbal learning disabilities worked was that it had to do with white matter pathology. He was a pediatric neuropsychologist, and I wanted to work with adults. What was the adult white matter disease? At that time, it was, of course, multiple sclerosis. Since then, we certainly have learned a lot more about MS and that it’s much more than a white matter disease, but that was how I fell into it, and then I stayed in it because of the patients. They’re wonderful to work with. They’re amazingly inspiring people, and that’s what keeps me motivated to continue.

IJMSC: I always love to hear people's stories, how they found their line of work, so thank you. Tell us the story of this paper. Where did the idea come from?

LW: We know that there’s a very high prevalence of mental health [issues], cognitive [impairment], and fatigue in people with MS, so that was the starting point in our clinic here at the Ottawa Hospital. We realized that we were probably not addressing those issues well enough. Frankly, we’re still not…but we’re working on it. Our group then did a paper that was about the gaps between research [data] and what we’re actually doing in clinic, and we realized that we were not picking up the degree of difficulties in mental health and cognitive issues in particular. We knew we had to do better. And that’s when we started looking at what we can do to improve this situation, and…one of the very simple things we can do is to put in screenings at our clinic.

IJMSC: And how did you get involved, Ms Islam?

TI: Dr Walker asked me to contribute to this project, [which] started before I joined her lab. She approached me [to see] if I could help her with the analysis and writing.

IJMSC: Was anything about this research surprising?

LW: The main surprising thing was how long it took to implement. It was a relatively simple thing, or so we thought. But of course, there are roadblocks, and one of those was how we were going to implement this in a way that works for the clinic and how we were going to integrate it with our electronic health record. That involves IT [information technology], and they, of course, have their own priorities…so it was finding the right IT person with the time to help us. Then the pandemic happened, and that threw a wrench into everything. So it became a multiyear process, which I did not expect when we started.

"Our clinic serves over 4000 patients. We have a very large catchment area, and so the physicians are already quite burdened by the tasks…to serve this great number of people. [They did not have the] ability to implement something that takes a lot of time, so we needed to find a way to do something…that was time efficient, and that’s why [we thought of] incorporating it into the electronic health record." ~LW

IJMSC: When I read the paper, 2 terms that I keyed into were "low burden" and "invisible symptoms." Can you talk about those concepts in relation to the paper?

LW: Our clinic serves over 4000 patients. We have a very large catchment area, and so the physicians are already quite burdened by the tasks…to serve this great number of people. [They did not have the] ability to implement something that takes a lot of time, so we needed to find a way to do something that didn’t overburden them…that was time efficient, and that’s why [we thought of] incorporating it into the electronic health record. All of our patients [have an] electronic health record [with] MyChart, where they can access their own information. One of the beautiful things about MyChart is it sends reminders about upcoming appointments, and when it sends those reminders by email, it can link to questionnaires and other information that can [be] filled out before [an appointment]. It doesn’t require a staff person…. That’s the low-burden aspect of it. In terms of invisible symptoms, these are things that a great majority of people with MS experience but that are not objectively observable to other people. They don’t have a big Band-Aid on their head when they have cognitive difficulties, but [the] experience is no less impactful. In fact, we know that cognitive difficulties and mental health challenges have a greater impact on quality of life than physical disability does in MS. We needed a way to address these things, because these are the [symptoms] that are important to patients.

IJMSC: Could you both choose something that you would like clinicians to take away from the paper?

TI: Based on my experience, I have noticed that newly diagnosed people often do not realize these invisible symptoms can be related to their MS, and as a result, they do not mention [them] to their clinician. Having this formal screening in place will help both physician and patient to better address these symptoms. And I would suggest that clinicians go over the scores and see [whether] there is a consistent pattern in cognitive issues, mental health issues, or fatigue concerns and if they need extra support to address these issues.

LW: I would add that relatively simple changes can make a big difference, particularly with regard to mental health. These changes can be lifesaving because if someone is experiencing suicidal ideation related to their depression symptoms, we can now highlight that in a timely manner and connect them with the resources they need….

"I have noticed that newly diagnosed people often do not realize these invisible symptoms can be related to their MS, and as a result, they do not mention [them] to their clinician. Having this formal screening in place will help both physician and patient to better address these symptoms." ~TI

IJMSC: Do the data show that patients are up-front on the form?

LW: That’s an excellent question. Psychologists are used to assessing what we call performance validity or symptom validity when we do larger psychology evaluations, [but] it’s a little bit harder to do at the level of a screening test because you really don’t know somebody’s motivation as they’re filling it out. I suppose we just have to trust [that] our patients are going to report how they feel; otherwise, they won’t be able to access the care that they need. I think people are motivated to represent themselves truthfully because they are the ones asking for support. In our clinic, we don’t have a lot of the time, but at least we have a way, a mechanism now, to connect people with adequate support.

IJMSC: My next question is about clinical practice and how this paper could imact it. Could you answer in 2 parts? One, have you seen an impact in your clinic already? And, two, your hopes for the future: How do you see findings like yours impacting clinical practice as a whole?

LW: In our clinic, we know from the data analysis that we definitely increased the number of people who are being screened for mental health issues, for cognitive impairment, and for fatigue. We also know that we have increased the amount of people who are receiving resource information, so there’s a very direct impact in our clinic.

What I hope from the paper is that it will let other clinics know that there are things that are low burden…that can be relatively easily implemented…that will allow them to not only identify the issues but, as Tamanna mentioned, monitor people over time. I think we’re moving toward using this information to help guide treatment decisions. It’s not there yet, but I think that we’re moving in that direction.

IJMSC: That goes right into my next question, the next steps for this line of research. What needs to be studied next?

TI: I think the next steps in this line of research could involve exploring the impact of improved screening on patient outcomes—for example, access to better services, perceived support, day-to-day symptom management. With this initiative, we didn’t look at barriers to implementing formal screening and initiating discussions about invisible MS symptoms in clinical practice, so future studies should focus on identifying and addressing these barriers to strengthen physician and patient engagement and also to optimize screening practices.

LW: I also want to explore how this is working from our physicians’ perspectives. So that’s one of the next steps as well: to try to interview them about how this is working. Is it working? What are they noticing that’s different? Is it helping them to guide their treatment decision-making? So I really think that we need to have both the patient perspective as well as the frontline clinician perspective on how this is working.

IJMSC: Did you have any initial feedback from clinicians, either casually or in development of the next phase?

LW: I think that the response has been quite positive so far. The way that we’ve set it up in the electronic health record is when someone reaches a cutoff for moderate mental health concerns, so moderate depression or moderate anxiety, they get what’s called a best practice advisory pop-up. Literally, they cannot proceed with the clinic visit until they have indicated in the electronic health record that they’ve addressed the issue, so it gives them a reminder to do it.

IJMSC: A quick curveball: I am interested in the resources. Did you find that they were easily available and you just had to gather them? For the best practice tips, was it just compiling information that's already out there and putting it into a package that was available and accessible?

LW: I had a trainee help with this project, [and] we looked at the low- and no-cost options. In Canada, we have universal health care, but that has its limitations, and many services, especially with other health professions besides medicine, are not covered. Some people have extended health insurance. Some don’t, and so many of our patients are in situations where they do not have coverage for external, private services. We wanted to make sure we put in place a resource list of low- and no-cost options, so that’s what we did, and we put it on the MS clinic website, so you don’t have to talk to your physician about it. It’s there, very visible. We have drop-down menus [that] show telephone services, in-person services, distress line services, and so on. It’s quite easy to navigate for them when looking for specific resource information, and we wanted it to be as universally accessible as possible.

"In Canada, we have universal health care, but that has its limitations, and many services, especially with other health professions besides medicine, are not covered. Some people have extended health insurance. Some don’t.... We wanted to make sure we put in place a resource list of low- and no-cost options..." ~LW

IJMSC: As an American, I want to ask a systems question. When you say that some people don't have access, does that mean, say, going to a private mental health provider?Or does that mean that mental health providers are not included in universal coverage?

LW: It’s a complicated question, but essentially, at least in Ontario, which is the jurisdiction that I work in, we have something called OHIP, the Ontario Health Insurance Plan. Everybody who’s a resident of Ontario is covered by that plan, and other provinces have similar plans. So the MS clinic visit is free. They don’t have to pay out of pocket for that, and in our MS clinic, we have physicians, nurses, a physician assistant, but what we don’t have, because of cutbacks to the system, is social work, psychology, OT [occupational therapy], or physio[therapy]. We have a rehabilitation center affiliated with our hospital that does have physio[therapy], OT, a physiatrist, and so on, but in the actual acute care MS clinic, those services don’t exist…. Unless someone is an inpatient where they can get those services for free in the hospital setting, outpatients must pay out of pocket for many of those services, so they must go to private OT, private physio[therapy], or a private psychologist. People who have extended health insurance through their workplace or their spouse’s workplace usually have good coverage for much of that—usually not all of the cost, but much of the cost. But many people with MS are not working because of their illness. They don’t have those extended health benefits through an employer, and so they…have difficulty accessing services like that, at least from a mental health perspective. There are some community-based programs that do provide low- and no-cost options, and those are the ones that we tried to focus on in our resource list. Most people who can afford private services know how to access those, but it’s the folks who are not able to afford those that we really wanted to focus on…. I know they are very different systems.

IJMSC: It’s one of the things that runs constantly in the background as an international journal, but when it comes down to the particular details of each country’s system and coverage limits, coverage inclusions, it does get a bit complicated. Can you give us the 10,000-foot view of how this research fits into the larger world of MS care in general?

LW: It’s about trying to close that gap between research and clinical practice. There are so many amazing researchers out there doing fabulous things, and we need to move toward better implementation…. Even in our own organization, we have implementation scientists, and so we’re getting better at that, but we still have quite a way to go. This project was a good example of that. We know that mental health issues are important, we know that cognitive issues are important, but how can we actually make sure that we’re serving people in a way that they deserve to be served? That’s where we need to do better in terms of actually implementing those things into practice.

IJMSC: One of the pillars of IJMSC and CMSC [Consortium of Multiple Sclerosis Centers] is multidisciplinary care, and I am interested in how it was to get IT involved in the implementation. What was it like to get someone not in clinical care involved?

LW: The IT people here at the hospital are used to working with health care professionals, so they do have a bit more knowledge than an IT person who works [in another field]. When we implemented this in the electronic health record…there was a lot of training that went into it with our IT people and our clinical people and trying to coordinate things. They are quite good at that, and they know things that we don’t about what might work. This best practice advisory was not something I was aware of that could happen in terms of flashing on the screen, and so they gave us information as much as we gave them information. We said, “Here’s what we want to do. We want to implement these questionnaires. We want it to go in MyChart. We want the patients to be able to access it. But what can we actually do with those data? How do we record them? How do we incorporate cutoffs and those kinds of things?” [We had] all sorts of negotiations between us in terms of how to do [what we wanted to] in a way that made sense and that was also accessible to patients…. How do we make it visually appealing? And [what] about things like font size for people with visual acuity difficulties? There’s a lot that goes into it to make the interface something that’s easily accessible.

The other aspect of the interdisciplinary nature of the project [is our team]; I’m a neuropsychologist, and Tamanna is a graduate student. We worked with physicians, nurses, the physician assistant. We also had to work with hospital administration, given that it’s sort of a [quality improvement] project. It was truly multidisciplinary.

IJMSC: Both of you are now pursuing other avenues of research. Ms Islam, what research are you working on now?

TI: We just completed a needs assessment survey looking at unmet patient-reported needs in MS care, with a particular focus on cognitive fatigability. To guide the design of interventions that are responsive to what patients say they need most, we are currently testing a group-based multidimensional behavioral intervention for cognitive fatigability, so continuing our focus on invisible MS symptoms that have a big impact on daily life.

IJMSC: And what about you, Dr Walker?

LW: One of the exciting things that I’m doing is working with a group called MSCanRehab. It’s a group of rehabilitation-focused MS researchers from across Canada—incidentally, all women. They’re the most amazing, brilliant, wonderful women. I have learned so much from working with them. We were fortunate to get funding from the International Progressive MS Alliance, among very few groups globally. We’re looking at pairing brain priming with either transcranial direct current stimulation and/or aerobic exercise with task-specific training for a more comprehensive rehabilitation approach. That initiative is ongoing, and we’ve just applied for stage 2 funding…. One of the other things that I’m doing with another graduate student in my lab…we’ve realized is that there’s very little research in working with the 2SLGBTQAI+ [two-spirit, lesbian, gay, bisexual, transgender, queer, asexual, intersex] community in MS…. It’s a big gap in the literature in terms of how we can better serve [them] so we are currently conducting a scoping review…and we are going to adapt [Tamanna’s needs assessment] to really get a sense of how their needs are the same [as] and different from people who are not in that community. That’s a project that I’m quite excited about.

"I feel like there are too many options when it comes to AI, so we need to be very careful which ones we’re using for which purposes. English is my second language, so I use Grammarly, and I feel like it’s reasonable to use Grammarly, but I recently attended a webinar that was organized by our hospital, and they discouraged us from using ChatGPT..." ~TI

IJMSC: One of the things IJMSC is focusing on this year is the influence and possible influence of artificial intelligence [AI] on clinical care in MS and research writing. I’d love to hear, from both of you, any perspective you have on it, pros and cons that you’ve seen in either area or any experience that you’ve had with it so far.

LW: I’m an old dog compared with Tamanna. I’m really just beginning to see the potential. I think it is a better question for younger colleagues who are starting their careers in terms of seeing how it’s going to go, but I do see great potential for seeing trends and themes in big data…. From more of a clinical perspective, I do think it can streamline charting…. I also think… there are lots of pitfalls with AI, and we need to make sure that it’s informed by valid data. We need to ensure that clinicians, especially emerging clinicians, still have knowledge, reasoning ability, and the ability to synthesize information independent of AI. When you’re dealing with a patient face-to-face or you have an emergent situation, you need to act fast, and it needs to be based on your clinical instincts. I think we need to foster both of those things moving forward.

TI: I feel like there are too many options when it comes to AI, so we need to be very careful which ones we’re using for which purposes. English is my second language, so I use Grammarly, and I feel like it’s reasonable to use Grammarly, but I recently attended a webinar that was organized by our hospital, and they discouraged us from using ChatGPT and encouraged us to use Copilot because ChatGPT…can save information. When you work in a clinical setting, you might want to avoid an AI that saves information…. ChatGPT could be used as a personal assistant if you want to generate some ideas and if you need…to brainstorm, but I wouldn’t recommend it for anything else because it can cite false references and other things. I am very careful when I’m using AI.

Be sure to keep an eye out as we continue to spotlight other IJMSC authors!