Practice Points
- Clinicians caring for people with multiple sclerosis (MS) need to recognize the importance of social satisfaction and assess it.
- Social satisfaction is negatively associated with both anxiety and depression for people with MS.
- Clinicians can reinforce the benefits of social satisfaction by discussing ways the person with MS can engage socially with others and facilitating referrals to and/or consulting with behavioral medicine professionals and other relevant providers to help them access additional support.
For people with multiple sclerosis (MS), psychotherapy can have a sizable treatment impact. Given that the prevalence of mood disorders for people with MS is higher than average, it is important to address their mental health concerns.1,2 Although both individual and group treatment modalities offer benefits, group therapy offers a unique opportunity for treatment from a behavioral medicine professional and connection with peers. The findings from research in MS and other chronic illnesses have shown that group treatment can improve depression and anxiety symptoms, minimize social isolation, increase a sense of support, improve psychosocial adjustment, and help people learn and process with people similar to them.3-8 A particularly valuable benefit of participating in group therapy is the ability to connect socially and establish solidarity with others,9 as research findings demonstrate that group therapy can facilitate deeper intrapersonal connections.10 People with MS participating in group therapy also found that connecting and communicating with others in the group was beneficial, which affected how they interacted with others in their support system.11 The potential positive influences of group therapy are vast.
The ability to connect socially with others in a group is worth further study, as social satisfaction is associated with mental health and well-being. Social satisfaction can be defined as contentment with one’s social relationships and activities. In a literature review on social connectedness, a component of social satisfaction, data showed that social support can serve as a protective factor against depressive symptoms.12 More specific to social satisfaction and well-being, researchers found that social satisfaction and its components are important contributors to perceived well-being.13-15 Social connectedness is particularly important for individuals living with MS given that MS symptoms can lead to potential social isolation,16 that the COVID-19 pandemic worsened social health outcomes for some people with MS,17 and that social isolation is associated with lower levels of general life satisfaction.18
Researchers have described the importance of social connectedness and social integration for individuals with MS and found that perceived social support was a positive predictor for psychological well-being.19 The findings from recent research from Australia examining social satisfaction and social connectedness show a link between social satisfaction and accruing multiple chronic conditions.20 Based on their findings, Xu and colleagues stated, “Social connections (eg, social relationship satisfaction) should be considered a public health priority in chronic disease prevention and intervention.”20 Ultimately, social satisfaction is important to understand and measure to contribute to the knowledge base on mental health and well-being.
Given the importance of social connectedness for people with MS and knowing the potential benefits of group therapy, this study was designed to measure the relationships between social satisfaction and depression and social satisfaction and anxiety for people with MS participating in group therapy vs people with MS participating in individual psychotherapy.
We hypothesize that (1) people with MS in group therapy will report higher social satisfaction than people with MS not in group therapy, (2) perceived social satisfaction will be negatively related to depression and anxiety scores, (3) MS disease characteristics and demographic variables (eg, age, sex, race, ethnicity, marital status, education, and employment) will be significantly and uniquely correlated with perceived social satisfaction, and (4) social satisfaction will mediate the relationship between treatment type (group vs individual therapy) and depression and anxiety.
Methods
The current study, approved by the Cleveland Clinic institutional review board (IRB; 23-1326), is a retrospective review of data from the Quality of Life in Neurological Disorders (Neuro-QOL) measure within the Multiple Sclerosis Performance Test (MSPT; data collected from the Mellen Center Clinical Data Registry, IRB 19-1105). The MSPT is a battery of neurological performance tests and qualitative patient-reported outcome (PRO) measures administered via a tablet-based application developed at the Cleveland Clinic. The Neuro-QOL is a self-report measure that provides a more comprehensive assessment of functioning via domains such as lower extremity functioning, upper extremity functioning, cognition, sleep, fatigue, depression, anxiety, behavioral and emotional dyscontrol, participation in social roles and activities, stigma, well-being, and satisfaction in social roles.21,22 Additional data, including Patient Health Questionnaire (PHQ-9) depression scores, Generalized Anxiety Disorder scale (GAD-7) scores, Patient-Determined Disease Steps (PDDS) scores, MS disease characteristics, and demographic information (ie, age, sex, race, ethnicity, marital status, education, and employment) were assessed via the MSPT database and an EPIC/Clarity record review. Of note, outcomes data are collected as part of routine patient care. The study population included adult individuals diagnosed with MS who have received or are currently receiving group or individual psychotherapy treatment at the Mellen Center for Multiple Sclerosis Treatment and Research within the Cleveland Clinic and who have completed the Neuro-QOL measure.
Participant Inclusion Criteria
Participants were 18 years or older; had a diagnosis of MS; had completed the Neuro- QOL, PHQ-9, or GAD-7 at least once during the study period; and had participated in 3 or more group therapy sessions with a Mellen Center behavioral medicine clinician (treatment group) or 3 or more individual psychotherapy sessions with a Mellen Center behavioral medicine clinician (control group).
Participants in the group therapy treatment group included people with MS who had been referred to behavioral medicine and evaluated by a Mellen Center health psychologist or a trainee under health psychologist supervision. In collaborative treatment planning, group therapy was discussed as a possible and appropriate treatment option, and participants opted for group therapy for various reasons (eg, clinical appropriateness, availability, interest in group treatment, desire to connect with others). The group treatment participants had participated in 1 or more of the following MS groups offered at the Mellen Center: a general MS support group, a young professionals’ support group, or a men’s support group.
Descriptive statistics summarized the overall sample and stratified it by treatment type (group vs individual therapy). Means with SDs or medians with IQRs were used for continuous variables, and frequencies with percentages were used for categorical variables. Comparisons were made using 2-sample t tests or Wilcoxon rank sum tests for continuous variables and χ2 tests or Fisher exact tests for categorical variables. Neuro-QOL (or other PRO) scores were examined using the baseline score (ie, score closest to but before the first therapy session), last available score after at least 3 therapy sessions, and change in score (last score – pretherapy score). In the case of multiple scores obtained after the individual’s last therapy session, the score closest to and within 3 months of the last therapy session was used as the last available score. Comparisons between the 2 groups were made using people who improved by the minimal clinically important difference (MCID) for each scale. The MCID for each of the Neuro-QOL scales of interest is 5 points.23,24
For hypothesis 1, a multivariable linear regression model was fit, where Neuro-QOL satisfaction with social roles t score was the dependent variable and treatment type was the independent variable of interest. Demographics and clinical characteristics were included as covariates.
For hypothesis 2, separate multivariable linear regression models were fit, where Neuro-QOL anxiety and depression t scores were the dependent variables and Neuro-QOL social satisfaction t score was the independent variable of interest. Demographics and clinical characteristics were included as covariates.
For hypothesis 3, the model that was fit in hypothesis 1 was examined to determine which demographics and clinical characteristics were independently associated with Neuro-QOL satisfaction with social roles t score.
To complete the analysis for mediation for hypothesis 4, multivariable linear regression models were planned, where the last available Neuro-QOL anxiety and Neuro-QOL depression t scores were dependent variables and treatment type (group therapy vs individual therapy) was the independent variable of interest. Because Neuro-QOL satisfaction with social roles was not associated with any of the dependent variables (Neuro-QOL anxiety and depression), social satisfaction could not mediate the relationship between treatment type and either anxiety or depression, and thus, no further analysis was warranted. Missing data were handled with multivariate imputation by chained equations. A total of 20 imputed data sets were created. Computations and mediation analyses were performed in R version 4.3.1. All tests were 2-sided, and significance was set at P = .05.
Results
Between September 14, 2015, and October 4, 2023, a total of 1072 people with MS engaged in at least 1 psychotherapy session. We removed 505 who participated in fewer than 3 sessions and an additional 154 patients who did not complete the Neuro-QOL, PHQ-9, or GAD-7. Thus, 413 participants were included in the final sample: 85 in group therapy and 328 in individual therapy. The Figure shows the sample selection process. Compared with people in individual therapy, people in group therapy were significantly less likely to be women (63.5% vs 76.2%; P = .026), had significantly more therapy visits (median, 12 vs 5; P < .001), and had significantly longer treatment time between first and last therapy session (median, 19 vs 10 months; P = .001). For all other variables examined, there were no significant differences between the 2 therapy types. See Table 1 for descriptive statistics and clinical characteristics.
Baseline scores for Neuro-QOL, PHQ-9, and GAD-7 were available for 198 (47.9%), 256 (62.0%), and 272 (65.9%) participants, respectively. Median time from baseline Neuro-QOL score to first therapy session was 100 days (IQR, 52-226). Last available scores for Neuro-QOL, PHQ-9, and GAD-7 were available for
214 (51.8%), 268 (64.9%), and 380 (92.0%) participants, respectively. All 413 participants completed at least 1 scale either at baseline or in follow-up.
When comparing social satisfaction between therapy groups, therapy type was not significantly associated with Neuro-QOL social satisfaction (baseline, last available score, or change in score). Further, therapy type was not associated with any of the other PRO scales (Neuro-QOL anxiety, Neuro-QOL depression, GAD-7 total score, or PHQ-9 total score; see Table 2).
In determining whether social satisfaction was negatively associated with anxiety and depression, after adjusting for covariates, Neuro-QOL social satisfaction t score was negatively associated with all 4 PROs, except for GAD-7 score change. An example interpretation is for baseline scores for Neuro-QOL anxiety: After adjusting for covariates, for each 1-point increase in baseline Neuro-QOL social satisfaction t score, the baseline Neuro-QOL anxiety t score decreased by 0.53 points on average (β estimate = –0.53; 95% CI, –0.68 to –0.37; P < .001).
When examining which clinical characteristics and demographics were associated with social satisfaction, for baseline score and last available score, the years of education factor was positively associated with Neuro-QOL social satisfaction t score. For each additional year of education a participant had, the baseline Neuro-QOL social satisfaction t score increased by 0.41 points. Worse PDDS scores were negatively associated with Neuro-QOL social satisfaction t scores for both baseline score and last available score. Compared with participants with a PDDS of 0 (normal), participants with a 1, 2, or 3 (mild, moderate, or gait disability) scored 3.88 points lower on baseline Neuro-QOL social satisfaction t score and those who had a 4, 5, 6, or 7 (early cane, late cane, bilateral support, wheelchair/scooter) scored 6.40 points lower on baseline Neuro-QOL social satisfaction t score. For the last available score model, White race was associated with higher Neuro-QOL social satisfaction t scores. Compared with Black participants, Asian participants, multiracial participants, or participants who identified as other races, White participants had last available Neuro-QOL social satisfaction t scores that were 1.67 points higher on average. None of the variables examined were associated with a change in Neuro-QOL social satisfaction t scores. The results of the multivariable linear regression models where Neuro-QOL social satisfaction t score was the dependent variable are shown in Table 3.
Discussion
Our research findings suggest that there is no significant association between individual or group counseling and reported social satisfaction. Although other research supports the benefits of connecting via MS support groups—with regard to reducing anxiety and depression and positively impacting satisfaction with life, specifically25—the results from our study do not support differences in reported social satisfaction or anxiety and depression scores for people in group vs individual therapy. Next, our research confirms that social satisfaction is negatively associated with both anxiety and depression for people with MS in therapy. This is an important finding for clinical consideration. In acknowledging that mood disorders are more prevalent for people with MS,2 social satisfaction is a factor worthy of further attention. Finally, results from this study also show that variables such as increased education and White race were positively associated with reported social satisfaction whereas worse PDDS scores were negatively associated with reported social satisfaction. This outcome demonstrates the necessity of considering demographic and disease variables and how they may influence potential psychosocial outcomes for people with MS.
An interesting data point is that the difference in reported social satisfaction scores was not statistically significant across therapy treatment type in this study. Though it is possible that neither treatment type had a significant impact on social satisfaction, the foundational social tenets of group psychotherapy (eg, cohesion, universality, and interpersonal learning) and the strong support for connection between patients and providers in individual therapy26-28 lead us to believe there is some impact on social satisfaction for people with MS engaged in psychotherapy and that these therapies should not be overlooked as important components of patient care. The lack of statistically significant difference between individual and group psychotherapy may suggest that provider-patient alliance moderated the relationship between social satisfaction and anxiety and depression given the evidence-based support for the importance of that relationship in psychotherapy.26,28 That is, all participants in this study were engaged with a behavioral medicine provider, regardless of psychotherapy treatment type. It is possible that the connection experienced, rather than the treatment type, moderated the relationship between social satisfaction and anxiety and depression.
Another important finding is the negative association between social satisfaction and anxiety and depression scores. Providers must recognize the importance of social satisfaction as well as anxiety and depression in both assessing and addressing concerns in people with MS. Providers from all medical backgrounds should discuss perceived social support with their patients and offer appropriate recommendations and referrals as warranted. Health psychologists are trained to assist patients in managing the overlap between physical health, mental health, and psychosocial factors. Occupational therapists, physical therapists, social workers, and art and music therapists also fulfill important roles in helping patients to actively address social satisfaction concerns and influence mental health outcomes. National patient support networks, such as the Multiple Sclerosis Association of America and the National MS Society, can provide referrals and also have patient-led social support groups. By working together, an MS care team can take a multidisciplinary approach to assessing and addressing social satisfaction and positively impact mental health outcomes.
Finally, that certain demographic and disease-specific variables are associated with reported social satisfaction is notable. Knowing that variables such as race, education level, and perception of disability likely influence perceived social satisfaction, providers can and should take a more nuanced approach to bolster support for patients accordingly. This finding reinforces the importance of approaching MS care in ways that honor a patient’s unique identity and experiences while also considering relevant contextual factors that may help inform treatment.
This study has several limitations. It is observational and retrospective and thus more prone to selection bias and the effects of unmeasured confounders. Data were from a single tertiary care institution and may not be generalizable. We did not have complete sets of PRO data, particularly for the Neuro-QOL scales, for which approximately 50% of participants were missing data at either baseline or last follow-up. We attempted to mitigate this issue using multiple imputation, which assumes missing data are missing at random. This may not be true. It is possible that the missing scores were better or worse than those of participants who had complete scores available.
Conclusions
Perceived social satisfaction is an important consideration in the care of people with MS. Clinicians should use the findings that social satisfaction is negatively associated with anxiety, depression, and perceived disability to inform treatment approaches and recommendations. Providers must also acknowledge the influence of demographics and social determinants of health on social satisfaction and related mental health outcomes. Comprehensive MS care involves treating the whole person and considering psychosocial contexts as integral components of care. Future research is warranted to bolster our understanding of social satisfaction and contributors in this realm for people with MS. Further exploration of outcomes across treatment types, specifically group vs individual psychotherapy, may inform treatment planning and elucidate possible benefits. Ultimately, assessing and addressing perceived social satisfaction is a worthwhile endeavor to offer complete, quality care to the MS community.
