Mindfulness training during brief periods of hospitalization in multiple sclerosis (MS): beneficial alterations in fatigue and the mediating role of depression

Abstract

Objectives: Persons with MS (PwMS) are frequently affected by fatigue and depression. Mindfulness-based interventions may reduce these symptoms in PwMS and consequently their application has been extended to various settings. Only few efforts have been made to explore effects of short-term mindfulness training during brief periods of hospitalization. In the current study, the feasibility and potential effects of short-term mindfulness training on depression, fatigue, rumination and cognition were explored in PwMS in an acute-care hospital setting. Based on previous work, it was further examined whether the relation between trait mindfulness and fatigue prior to and following the intervention was mediated by depression and whether a mediation effect was also observable throughout the intervention.

Methods: A short-term mindfulness training protocol was developed, tailored to the requirements of the acute-care setting. Subsequently, 30 PwMS were recruited sequentially and received mindfulness training during the routine clinical process (median duration in hospital: eight days, number of sessions: four). Participants completed relevant self-report measures (depression, fatigue, rumination) and a neuropsychological assessment before and after training.

Results: Participants reported significantly increased trait mindfulness and decreased depression and fatigue following the intervention. Respective change scores were highly correlated so that increased trait mindfulness was associated with decreased symptoms. In the rumination domain, patients reported a tendency for an increased adaptive ability to engage in distractive behavior during arising negative mood. Other measures of trait rumination and cognition remained relatively stable. Results of the mediation analyses indicated that depression mediated the negative relationship between trait mindfulness and fatigue symptoms at pre and post assessments. With regards to the change scores, an association between mindfulness and cognitive fatigue ceased to be significant when depression was controlled, albeit in this case, the mediation effect did not reach significance.

Conclusion: Results of the current study indicate that short-term mindfulness training during brief periods of hospitalization may be beneficial for PwMS. They further complement previous work by identifying depression as a potential mediator of the antagonistic relationship between mindfulness and fatigue. Based on the current exploratory study, future trials are warranted to address this mechanism of mindfulness training in more detail.

Keywords: Acute-care hospital; Depression; Fatigue; Mindfulness; Multiple sclerosis; Rumination.

Fig. 1

Study procedure. The mindfulness training consisted of four basic training sessions (Sessions 1–4) each with a different topic. It was assumed that the majority of patients would be able to complete these four sessions during their stay. In addition, two optional sessions were offered to patients, who stayed in the hospital for a longer period (Sessions 5–6)

Fig. 2

Schematic outline of the assumed mediation model; path a = regression analysis with depression used as criterion variable and trait mindfulness as predictor, path b = regression analysis with fatigue (i.e., cognitive, physical) as criterion variable and trait mindfulness and depression as predictors; path c = total effect of the model with trait mindfulness as predictor and fatigue (i.e., cognitive, physical) as criterion variable; c’ = direct effect (effect of trait mindfulness on fatigue, i.e., cognitive, physical, while controlling for depression ); the product of path a and b is defined as the indirect effect ab

Fig. 3

Mean scores on outcome parameters across assessments prior to (PRE) and following the mindfulness training (POST), displayed for trait mindfulness (a), depression (b) and physical fatigue (c), with respective p-values below the Bonferroni-corrected threshold of p <.0125. Note that all changes remained significant when the N = 2 cases whose training exceeded six sessions were removed. In case of distraction tendencies (d), there was a trend for an improved adaptive ability to steer attention away from arising negative mood (p = .014). Error bar represent +/- 1 standard deviation; CES-D = Center for Epidemiological Studies Depression Scale; FMI = Freiburg Mindfulness Inventory; RSQ = Response Styles Questionnaire; WEIMuS = Wuerzburger Fatigue Inventory for Multiple Sclerosis; ** = significant at p< .01

Fig. 4

Significant correlations between the change score of trait mindfulness (FMI) and depression (CES-D; a), physical fatigue (WEIMuS, b), and symptom-focused rumination (RSQ, c); CES-D = Center for Epidemiological Studies Depression Scale; FMI = Freiburg Mindfulness Inventory; WEIMuS = Wuerzburger Fatigue Inventory for Multiple Sclerosis; RSQ = Response Styles Questionnaire; R² = R-squared (coefficient of determination)

Fig. 5

Outline of the results of the mediation analyses at T₀ (a)₁ T₁ (b) and for the concurrent change scores (T₁-T₀, c). Results of the regression analyses are depicted as unstandardized B coefficients with respective p-values in parenthesis for each path (path c = total effect of trait mindfulness on fatigue , path c’ = direct effect while controlling for depression); CI = 95% Confidence Interval

Fig. 6

Scatterplots of the correlation between trait mindfulness, fatigue (i.e., cognitive, physical fatigue) and depression with dashed and dotted lines illustrating the cut-off scores for clinically relevant fatigue and depression before (T₀) and after training (T₁); CES-D = Center for Epidemiological Studies Depression Scale, FMI = Freiburg Mindfulness Inventory; WEIMuS = Wuerzburger Fatigue Inventory for Multiple Sclerosis