Determinants of unemployment in multiple sclerosis (MS): The role of disease, person-specific factors, and engagement in positive health-related behaviors

Published:September 02, 2020DOI:


      • Rates of unemployment are high among individuals with multiple sclerosis (MS), particularly early on in the disease process.
      • The majority of individuals who leave the workforce do within the first three to five years after diagnosis.
      • Identification of the factors that put those “at risk” for leaving the workforce need to be identified so that early intervention can be utilized.
      • The present investigation examines the demographic, disease, and person-specific factors as well as the engagement in health-related behaviors and their associated risk for unemployment in MS.



      : Rates of unemployment among individuals with multiple sclerosis (MS) are as high as 80%.


      : This study examines disease, person-specific factors (e.g., personality, self-efficacy), and health-related behaviors, which may account for individuals leaving the workforce.


      : 252 individuals with MS were enrolled in a prospective study examining the factors related to unemployment in MS. Sixty-seven were “at risk” for leaving the workforce. These individuals were compared to those “not at risk” on measures of disease, person-specific factors, and health-related behaviors.


      : Certain disease factors differentiated those “at risk” and those “not at risk.” In particular, those “at risk” were more likely to have a progressive course and reported greater fatigue, sleep problems, pain, depression, and anxiety. They also reported lower levels of locus of control and MS self-efficacy and engaging in maladaptive coping. On a measure of personality, they endorsed higher levels of neuroticism and lower levels of conscientiousness, extraversion, and agreeableness. Finally, those “not at risk” reported engaging in more positive health-related behaviors. Taken together, disease course, fatigue, MS self-efficacy, and diet/exercise were the most significant factors, accounting for 16% of the variance.


      : Findings suggest that greater consideration and interventions tailored to these factors is warranted, which may assist individuals with MS staying employed and/or making appropriate accommodations.


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        • Amtmann D.
        • Bamer A.M.
        • Cook K.F.
        • Askew R.L.
        • Noonan V.K.
        • Brockway J.A
        University of Washington self-efficacy scale: a new self-efficacy scale for people with disabilities.
        Arch. Phys. Med. Rehabil. 2012; 93: 1757-1765
        • Bauer H.
        • Firnhaber W.
        • Winkler W
        Prognostic criteria in multiple sclerosis.
        Ann. N. Y. Acad. Sci. 1965; 122: 542-551
        • Bishop M.
        • Frain M.P
        The Multiple Sclerosis Self-Management Scale: revision and psychometric analysis.
        Rehabil. Psychol. 2011; 56: 150
        • Buysse D.J.
        • Reynolds C.F.
        • Monk T.H.
        • Berman S.R.
        • Kupfer D.J
        The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research.
        Psychiatry Res. 1989; 28: 193-213
        • Carver C.S.
        • Scheier M.F.
        • Weintraub J.K
        Assessing coping strategies: a theoretically based approach.
        J. Pers Soc. Psychol. 1989; 56: 267
        • Christie G.J.
        • Hamilton T.
        • Manor B.D.
        • et al.
        Do Lifestyle Activities Protect Against Cognitive Decline in Aging? A Review.
        Front. Aging Neurosci. 2017; 9: 381
        • Conway D.S.
        • Thompson N.R.
        • Cohen J.A
        Influence of hypertension, diabetes, hyperlipidemia, and obstructive lung disease on multiple sclerosis disease course.
        Multiple Sclerosis Journal. 2017; 23: 277-285
        • Costa P.T.
        • McCrae R.R
        Revised Neo Personality Inventory (NEO-PI-R) and NEO Five-Factor Inventory (NEO-FFI).
        Psychological Assesment Resources, 1992
        • de Frias C.M.
        • Dixon R.A
        Lifestyle engagement affects cognitive status differences and trajectories on executive functions in older adults.
        Arch. Clin. Neuropsychol. 2013; 29: 16-25
        • Eccles F.J.
        • Simpson J
        A review of the demographic, clinical and psychosocial correlates of perceived control in three chronic motor illnesses.
        Disabil. Rehabil. 2011; 33: 1065-1088
        • Faul F.
        • Erdfelder E.
        • Lang A.-.G.
        • Buchner A
        G* Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences.
        Behav. Res. Methods. 2007; 39: 175-191
        • Fisk J.D.
        • Ritvo P.G.
        • Ross L.
        • Haase D.A.
        • Marrie T.J.
        • Schlech W.F
        Measuring the functional impact of fatigue: initial validation of the fatigue impact scale.
        Clin. Infect. Dis. 1994; 18: S79-S83
        • Fitzgerald K.C.
        • Tyry T.
        • Salter A.
        • et al.
        Diet quality is associated with disability and symptom severity in multiple sclerosis.
        Neurology. 2018; 90: e1-e11
        • Goldberg L.R.
        • Johnson J.A.
        • Eber H.W.
        • et al.
        The international personality item pool and the future of public-domain personality measures.
        J. Res. Pers. 2006; 40: 84-96
        • Harbo H.F.
        • Gold R.
        • Tintoré M
        Sex and gender issues in multiple sclerosis.
        Ther. Adv. Neurol. Disord. 2013; 6: 237-248
        • Harris M.
        • Harris E.
        • Shortus T
        How do we manage patients who become unemployed?.
        Med. J. Aust. 2010; 192: 4
        • Harris M.F.
        • Harris E.
        • Shortus T.D
        How do we manage patients who become unemployed.
        Med. J. Aust. 2010; 192: 98-101
        • Heinonen T.
        • Castrén E.
        • Luukkaala T.
        • Mäkinen K.
        • Ruutiainen J.
        • Kuusisto H
        The retirement rate due to multiple sclerosis has decreased since 1995–A retrospective study in a Finnish central hospital.
        Mult. Scler. Relat. Disord. 2020; 102360
        • Hertzog C.
        • Kramer A.F.
        • Wilson R.S.
        • Lindenberger U
        Enrichment effects on adult cognitive development: can the functional capacity of older adults be preserved and enhanced?.
        Psychological science in the public interest. 2008; 9: 1-65
        • Honan C.A.
        • Brown R.F.
        • Batchelor J
        Perceived cognitive difficulties and cognitive test performance as predictors of employment outcomes in people with multiple sclerosis.
        J. Int. Neuropsychol. Soc. 2015; 21: 156-168
        • James B.D.
        • Wilson R.S.
        • Barnes L.L.
        • Bennett D.A
        Late-life social activity and cognitive decline in old age.
        J. Int. Neuropsychol. Soc. 2011; 17: 998-1005
        • Janlert U.
        Unemployment as a disease and diseases of the unemployed.
        Scand. J. Work Environ. Health. 1997; : 79-83
        • Jones J.E.
        • Hermann B.P.
        • Barry J.J.
        • Gilliam F.
        • Kanner A.M.
        • Meador K.J
        Clinical assessment of Axis I psychiatric morbidity in chronic epilepsy: a multicenter investigation.
        J. Neuropsychiatry Clin. Neurosci. 2005; 17: 172-179
        • Julian L.J.
        • Vella L.
        • Vollmer T.
        • Hadjimichael O.
        • Mohr D.C
        Employment in multiple sclerosis.
        J. Neurol. 2008; 255: 1354-1360
        • Koziarska D.
        • Król J.
        • Nocoń D.
        • Kubaszewski P.
        • Rzepa T.
        • Nowacki P
        Prevalence and factors leading to unemployment in MS (multiple sclerosis) patients undergoing immunomodulatory treatment in Poland.
        PLoS ONE. 2018; 13e0194117
        • LaRocca N.
        • Kalb R.
        • Kendall P.
        • Scheinberg L
        The role of disease and demographic factors in the employment of patients with multiple sclerosis.
        Arch. Neurol. 1982; 39: 256
        • LaRocca N.
        • Kalb R.
        • Scheinberg L.
        • Kendall P
        Factors associated with unemployment of patients with multiple sclerosis.
        J. Chronic. Dis. 1985; 38: 203-210
        • Lin R.
        • Shah C.
        • Svoboda T
        The impact of unemployment on health: a review of the evidence.
        African Journal of Medical Practice. 1995; 2: 176-179
        • Linn M.W.
        • Sandifer R.
        • Stein S
        Effects of unemployment on mental and physical health.
        Am. J. Public Health. 1985; 75: 502-506
        • Lundin A.
        • Lundberg I.
        • Hallsten L.
        • Ottosson J.
        • Hemmingsson T
        Unemployment and mortality—A longitudinal prospective study on selection and causation in 49321 Swedish middle-aged men.
        J. Epidemiol. Community Health. 2010; 64: 22-28
        • Marrie R.
        • Rudick R.
        • Horwitz R.
        • et al.
        Vascular comorbidity is associated with more rapid disability progression in multiple sclerosis.
        Neurology. 2010; 74: 1041-1047
        • McDonald W.I.
        • Compston A.
        • Edan G.
        • et al.
        Recommended diagnostic criteria for multiple sclerosis: guidelines from the International Panel on the diagnosis of multiple sclerosis.
        Ann. Neurol. 2001; 50: 121-127
        • Mohr D.C.
        • Boudewyn A.C.
        • Likosky W.
        • Levine E.
        • Goodkin D.E
        Injectable medication for the treatment of multiple sclerosis: the influence of self-efficacy expectations and infection anxiety on adherence and ability to self-inject.
        Ann. Behav. Med. 2001; 23: 125-132
        • Morrow S.A.
        Anxiety is more important than depression in MS–Yes.
        Multiple Sclerosis Journal. 2018; 24: 440-441
        • Morrow S.A.
        • Drake A.
        • Zivadinov R.
        • Munschauer F.
        • Weinstock-Guttman B.
        • Benedict R.H
        Predicting loss of employment over three years in multiple sclerosis: clinically meaningful cognitive decline.
        Clin. Neuropsychol. 2010; 24: 1131-1145
        • Motl R.W.
        • McAuley E.
        • Snook E.M
        Physical activity and quality of life in multiple sclerosis: possible roles of social support, self-efficacy, and functional limitations.
        Rehabil. Psychol. 2007; 52: 143
        • Nyenhuis D.L.
        • Luchetta T
        The development, standardization, and initial validation of the Chicago Multiscale Depression Inventory.
        J. Pers. Assess. 1998; 70: 386-401
        • O’Connor R.J.
        • Cano S.J.
        • i Torrenta L.R.
        • Thompson A.J.
        • Playford E.D
        Factors influencing work retention for people with multiple sclerosis.
        J. Neurol. 2005; 252: 892-896
        • Pompeii L.A.
        • Moon S.D.
        • McCrory D.C
        Measures of physical and cognitive function and work status among individuals with multiple sclerosis: a review of the literature.
        J. Occup. Rehabil. 2005; 15: 69-84
        • Randolph J.
        • Arnett P.
        • Strober L.
        • et al.
        B-07The Cognitive Health Questionnaire: initial Psychometric Data in a Multisite Multiple Sclerosis Sample.
        Arch. Clin. Neuropsychol. 2014; 29: 539
        • Riazi A.
        • Thompson A.
        • Hobart J.
        Self-efficacy predicts self-reported health status in multiple sclerosis.
        Mult. Scler. 2004; 10: 61-66
        • Ritvo P.
        • Fischer J.
        • Miller D.
        • Andrews H.
        • Paty D.
        • LaRocca N
        Multiple Sclerosis Quality of life Inventory: A User's Manual.
        National Multiple Sclerosis Society, New York1997: 1-65
        • Roessler R.
        • Rumrill P.
        • Hennessey M
        Employment Concerns of People with Multiple Sclerosis: Building a National Employment Agenda.
        Kent State University Center for Disability Studies, Report Submitted to the National Multiple Sclerosis Society, Kent, OH2002
        • Roessler R.T.
        • Rumrill Jr., P.D.
        Multiple sclerosis and employment barriers: a systemic perspective on diagnosis and intervention.
        Work (Reading, Mass). 2002; 21: 17-23
        • Schiavolin S.
        • Leonardi M.
        • Giovannetti A.M.
        • et al.
        Factors related to difficulties with employment in patients with multiple sclerosis: a review of 2002–2011 literature.
        Int. J. Rehabil. Res. 2013; 36: 105-111
        • Schmitt M.M.
        • Goverover Y.
        • DeLuca J.
        • Chiaravalloti N
        Self-efficacy as a predictor of self-reported physical, cognitive, and social functioning in multiple sclerosis.
        Rehabil. Psychol. 2014; 59: 27
        • Schwarzer R.
        • Jerusalem M
        Generalized self-efficacy scale.
        Measures in health psychology: A user's portfolio Causal and control beliefs. 1995; 1: 35-37
        • Shnek Z.M.
        • Foley F.W.
        • LaRocca N.G.
        • Smith C.R.
        • Halper J
        Psychological predictors of depression in multiple sclerosis.
        Neurorehabil. Neural. Repair. 1995; 9: 15-23
        • Simmons R.D.
        • Tribe K.L.
        • McDonald E.A
        Living with multiple sclerosis: longitudinal changes in employment and the importance of symptom management.
        J. Neurol. 2010; 257: 926-936
        • Smith A
        Symbol Digit Modalities Test (SDMT) Manual (revised).
        Western Psychological Services, Los Angeles1982
        • Smith M.M.
        • Arnett P.A
        Factors related to employment status changes in individuals with multiple sclerosis.
        Mult. Scler. 2005; 11: 602-609
        • Smith P.J.
        • Blumenthal J.A.
        • Hoffman B.M.
        • et al.
        Aerobic exercise and neurocognitive performance: a meta-analytic review of randomized controlled trials.
        Psychosom. Med. 2010; 72: 239
        • Solari A.
        • Radice D
        Health status of people with multiple sclerosis: a community mail survey.
        Neurol. Sci. 2001; 22: 307-315
        • Spielberger C.D.
        • Gorsuch R.L
        State-Trait Anxiety Inventory for Adults: Manual, Instrument, and Scoring Guide.
        Mind Garden, Incorporated, 1983
        • Strober L.
        • Chiaravalloti N.
        • Moore N.
        • DeLuca J
        Unemployment in multiple sclerosis (MS): utility of the MS Functional Composite and cognitive testing.
        Multiple Sclerosis Journal. 2013; 18: 6
        • Strober L.
        • Chiaravalloti N.
        • Moore N.
        • DeLuca J
        Unemployment in multiple sclerosis (MS): utility of the MS Functional Composite and cognitive testing.
        Multiple Sclerosis Journal. 2013; 1352458513488235
        • Strober L.B.
        Becker A and Randolph JJ. Role of positive lifestyle activities on mood, cognition, well-being, and disease characteristics in multiple sclerosis.
        Applied Neuropsychology: Adult. 2018; 25: 304-311
        • Strober L.
        • Arnett P
        Unemployment among women with multiple sclerosis: the role of coping and perceived stress and support in the workplace.
        Psychol. Health. Med. 2016; 21: 496-504
        • Strober L.B.
        • Chiaravalloti N.
        • DeLuca J
        Should I stay or should I go? A prospective investigation examining individual factors impacting employment status among individuals with multiple sclerosis (MS).
        Work. 2018; 59: 39-47
        • Strober L.B.
        • Christodoulou C.
        • Benedict R.H.
        • et al.
        Unemployment in multiple sclerosis: the contribution of personality and disease.
        Multiple Sclerosis Journal. 2012; 18: 647-653
        • Uccelli M.M.
        • Specchia C.
        • Battaglia M.
        • Miller D
        Factors that influence the employment status of people with multiple sclerosis: a multi-national study.
        J. Neurol. 2009; 256: 1989-1996
        • Wassem R.
        Self-efficacy as a predictor of adjustment to multiple sclerosis.
        J. Neurosci. Nurs. 1992; 24: 224-229
        • Yadav V.
        • Marracci G.
        • Kim E.
        • et al.
        Low-fat, plant-based diet in multiple sclerosis: a randomized controlled trial.
        Mult. Scler. Relat. Disord. 2016; 9: 80-90