Effectiveness of acceptance and commitment therapy for improving quality of life and mood in individuals with multiple sclerosis: A systematic review and meta-analysis


      • ACT for distress in people with MS has variable findings.
      • ACT was found not to reduce anxiety or depression, or improve QoL, significantly.
      • Findings suggest ACT did not improve ACT-targeted processes.
      • A significant small effect of ACT on stress was found.
      • Small samples and wide confidence intervals make drawing conclusions challenging.



      To review the evidence for the effectiveness of Acceptance and Commitment Therapy (ACT) intervention on quality of life and mood, for individuals with Multiple Sclerosis (MS).


      A systematic search was conducted of PsycINFO, CINAHL, Embase, MEDLINE, Web of Science, Scopus and up to 13/01/2022. Grey literature was also searched via ProQuest Dissertations and Theses, and PROSPERO. We included Randomised Controlled Trials (RCTs) published in English, that examined the effectiveness of ACT for people with a diagnosis of MS. We were interested in outcomes of Quality of Life (QoL), mood (e.g., anxiety, depression and stress), and ACT-targeted processes. Methodological quality was assessed using the Cochrane Risk of Bias Tool v2. Where available, the extracted data were entered into a meta-analysis to determine weighted effect size estimates for the outcomes of interest.


      Six studies (191 participants), out of 142 identified, met inclusion criteria. Meta-analyses indicated a statistically significant small effect on stress (SMD = -0.49 [95% CI of -0.89 – -0.08]), in favour of ACT. There were no statistically significant effects of ACT on anxiety (SMD = -0.41 [95% CI of -0.93 – 0.11]), depression (SMD = -0.92 [95% CI of -1.91 – 0.06]), or ACT-targeted processes (SMD = -0.18 [95% CI of -0.62 – 0.25]). There was a small, nonsignificant effect on QoL, in favour of control conditions (SMD=0.39 [95% CI of -0.08 – 0.85]). Methodological quality of the studies was variable; all but one study had at least one high risk of bias.


      Findings suggest a small effect of ACT on reducing stress for people with MS, but not reducing anxiety or depression, or improving quality of life. Due to small sample sizes and few studies within this area, generalisability of findings is limited. Future trials should be pay more attention to methodological rigour.


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        • Adams J.
        • Hillier-Brown F.C.
        • Moore H.J.
        • Lake A.A.
        • Araujo-Soares V.
        • White M.
        • Summerbell C.
        Searching and synthesising ‘grey literature’ and ‘grey information’ in public health: critical reflections on three case studies.
        Syst. Rev. 2016; 5: 1-11
        • Amtmann D.
        • Bamer A.M.
        • Kim J.
        • Chung H.
        • Salem R.
        People with multiple sclerosis report significantly worse symptoms and health related quality of life than the US general population as measured by PROMIS and NeuroQoL outcome measures.
        Disabil. Health J. 2018; 11: 99-107
        • A-Tjak J.
        • Davis M.L.
        • Morina N.
        • Powers M.B.
        • Smits J.A.
        • Emmelkamp P.M.
        A meta-analysis of the efficacy of acceptance and commitment therapy for clinically relevant mental and physical health problems comparative processing of self-perception.
        Psychother. Psychosom. 2014; 84: 30-36
        • Boeschoten R.E.
        • Braamse A.M.J.
        • Beekman A.T.F.
        • Cuijpers P.
        • van Oppen P.
        • Dekker J.
        • Uitdehaag B.M.J.
        Prevalence of depression and anxiety in Multiple Sclerosis: a systematic review and meta-analysis.
        J. Neurol. Sci. 2017; 372: 331-341
        • Cherry K.M.
        • Vander Hoeven E.
        • Patterson T.S.
        • Lumley M.N.
        Defining and measuring “psychological flexibility”: a narrative scoping review of diverse flexibility and rigidity constructs and perspectives.
        Clin. Psychol. Rev. 2021; 84101973
        • das Nair R.
        • de Groot V.
        • Freeman J.
        Beyond current research practice: methodological considerations in MS rehabilitation research (is designing the perfect rehabilitation trial the holy grail or a Gordian knot?).
        Mult. Scler. 2019; 25: 1337-1347
        • Davoodi M.
        • Shameli L.
        • Hadianfard H.
        The effectiveness of acceptance and commitment therapy on chronic fatigue syndrome and pain perception in people with multiple sclerosis.
        Iran. J. Psychiatry Clin. Psychol. 2019; 25: 250-264
        • Dennison L.
        • Yardley L.
        • Devereux A.
        • Moss-Morris R.
        Experiences of adjusting to early stage multiple sclerosis.
        J. Health Psychol. 2011; 16: 478-488
        • Dwan K.
        • Altman D.G.
        • Arnaiz J.A.
        • Bloom J.
        • Chan A.-.W.
        • Cronin E.
        • Decullier E.
        • Easterbrook P.J.
        • Elm E.
        • Gamble C.
        • Ghersi D.
        • Ioannidis J.P.A.
        • Simes J.
        • Williamson P.R.
        Systematic review of the empirical evidence of study publication bias and outcome reporting bias.
        PLoS One. 2008; 3: 1-31
        • Fiest K.M.
        • Walker J.R.
        • Bernstein C.N.
        • Graff L.A.
        • Zarychanski R.
        • Abou-Setta A.M.
        • Patten S.B.
        • Sareen J.
        • Bolton J.M.
        • Marriott J.J.
        • Fisk J.D.
        • Singer A.
        • Marrie R.A.
        Systematic review and meta-analysis of interventions for depression and anxiety in persons with multiple sclerosis.
        Mult. Scler. Relat. Disord. 2016; 5: 12-26
        • Fordham B.
        • Sugavanam T.
        • Edwards K.
        • Stallard P.
        • Howard R.
        • das Nair R.
        • Copsey B.
        • Lee H.
        • Howick J.
        • Hemming K.
        • Lamb S.E.
        The evidence for cognitive behavioural therapy in any condition, population or context: a meta-review of systematic reviews and panoramic meta-analysis.
        Psychol. Med. 2021; 51: 21-29
        • Francis A.W.
        • Dawson D.L.
        • Golijani-Moghaddam N.
        The development and validation of the comprehensive assessment of acceptance and commitment therapy processes (CompACT).
        J. Context. Behav. Sci. 2016; 5: 134-145
        • Gil-González I.
        • Martín-Rodríguez A.
        • Conrad R.
        • Pérez-San-Gregorio M.Á.
        Original research: quality of life in adults with multiple sclerosis: a systematic review.
        BMJ Open. 2020; 10
        • Giovannetti A.M.
        • Quintas R.
        • Tramacere I.
        • Giordano A.
        • Confalonieri P.
        • Uccelli M.M.
        • Solari A.
        • Pakenham K.I.
        A resilience group training program for people with multiple sclerosis: results of a pilot single-blind randomized controlled trial and nested qualitative study.
        PLoS One. 2020; 15: 1-26
        • Gloster A.T.
        • Walder N.
        • Levin M.E.
        • Twohig M.P.
        • Karekla M.
        The empirical status of acceptance and commitment therapy: a review of meta-analyses.
        J. Context. Behav. Sci. 2020; 18: 181-192
        • Graham C.D.
        • Gouick J.
        • Krahe C.
        • Gillanders D.
        A systematic review of the use of acceptance and commitment therapy (ACT) in chronic disease and long-term conditions.
        Clin. Psychol. Rev. 2016; 46: 46-58
        • Graziano F.
        • Calandri E.
        • Borghi M.
        • Bonino S.
        The effects of a group-based cognitive behavioral therapy on people with multiple sclerosis: a randomized controlled trial article.
        Clin. Rehabil. 2014; 28: 264-274
        • Harrison A.M.
        • Mccracken L.M.
        • Jones K.
        • Norton S.
        • Moss-Morris R.
        Using mixed methods case-series evaluation in the development of a guided self-management hybrid CBT and ACT intervention for multiple sclerosis pain.
        Disabil. Rehabil. 2017; 39: 1785-1798
        • Hauer L.
        • Perneczky J.
        • Sellner J.
        A global view of comorbidity in multiple sclerosis: a systematic review with a focus on regional differences, methodology, and clinical implications.
        J. Neurol. 2020; 1: 1-12
      1. Hayes, S. (2021). ACT randomised controlled trials (1986 to present). Association of Conextual Behavioural Science.

        • Hayes S.C.
        • Pistorello J.
        • Levin M.E.
        Acceptance and commitment therapy as a unified model of behavior change.
        Couns. Psychol. 2012; 40: 976-1002
        • Henry J.D.
        • Crawford J.R.
        The short-form version of the depression anxiety stress scales (DASS-21): construct validity and normative data in a large non-clinical sample.
        Br. J. Clin. Psychol. 2005; 44: 227-239
        • Hermann B.P.
        • Vickrey B.
        • Hays R.D.
        • Cramer J.
        • Devinsky O.
        • Meador K.
        • Perrine K.
        • Myers L.W.
        • Ellison G.W.
        A comparison of health-related quality of life in patients with epilepsy, diabetes and multiple sclerosis.
        Epilepsy Res. 1996; 25 (10.1016/0920-1211(96)00024-1): 113-118
        • Higgins J.P.
        • Savović J.
        • Page M.J.
        • Elbers R.G.
        • Sterne J.A.
        Chapter 8: assessing risk of bias in a randomized trial.
        in: Higgins J Thomas J Chandler J Cumpston M Li T Page M Cochrane Handbook for Systematic Reviews of Interventions Version 6.0. Cochrane, 2019
        • Higgins J.
        • Thomas J.
        Cochrane Handbook for Systematic Reviews of Interventions.
        Cochrane Training, 2021 (Version 6.2)
        • Hopewell S.
        • McDonald S.
        • Clarke M.J.
        • Egger M.
        Grey literature in meta-analyses of randomized trials of health care interventions.
        Cochrane Database Syst. Rev. 2007; 2: 1-15
        • Juul S.
        • Gluud C.
        • Simonsen S.
        • Frandsen F.W.
        • Kirsch I.
        • Jakobsen J.C.
        Blinding in randomised clinical trials of psychological interventions: a retrospective study of published trial reports.
        BMJ Evid. Based Med. 2021; 26 (–109): 109
        • Khalifeh-Soltani F.A.S.
        • Borhani M.
        The effectiveness of acceptance and commitment therapy on pain severity, perceived stress, and aggression in patients with multiple sclerosis in Isfahan, Iran.
        Int. J. Body Mind Cult. 2019; 6: 35-41
        • Lovibond P.F.
        • Lovibond S.H.
        The structure of negative emotional states: comparison of the depression anxiety stress scales (DASS) with the beck depression and anxiety inventories.
        Behav. Res. Ther. 1995; 33: 335-343
        • Marrie R.A.
        • Reingold S.
        • Cohen J.
        • Stuve O.
        • Trojano M.
        • Sorensen P.S.
        • Cutter G.
        • Reider N.
        The incidence and prevalence of psychiatric disorders in multiple sclerosis: a systematic review.
        Mult. Scler. J. 2015; 21: 305-317
        • Meek C.
        • Moghaddam N.G.
        • Evangelou N.
        • Oates L.L.
        • Topcu G.
        • Allen C.
        • das Nair R.
        Acceptance-based telephone support around the time of transition to secondary progressive multiple sclerosis: a feasibility randomised controlled trial.
        J. Context. Behav. Sci. 2021; 21: 158-170
        • Mojtabaie M.
        • Khoshcheshm Z.S.
        Psychological problems, biology, psychotherapy: effectiveness of acceptance and commitment therapy (ACT)on reducing symptoms of depression among multiple sclerosis patients.
        Adv. Environ. Biol. 2014; 8: 870-876
      2. MS Trust (2020). Prevalence and incidence of multiple sclerosis. Multiple Sclerosis Trust.

        • Munder T.
        • Barth J.
        Cochrane's risk of bias tool in the context of psychotherapy outcome research.
        Psychother. Res. J. Soc. Psychother. Res. 2018; 28: 347-355
        • National Institute for Health and Care Excellence
        Depression in Adults with a Chronic Physical Health problem: Recognition and Management.
        NICE Guideline CG91, 2009
        • National Institute for Health and Care Excellence
        Multiple Sclerosis in adults: Management.
        NICE Guideline CG186, 2019 (NICE.
        • Nielsen J.
        • Saliger J.
        • Montag C.
        • Markett S.
        • Nöhring C.
        • Karbe H.
        Facing the unknown: fear of progression could be a relevant psychological risk factor for depressive mood states among patients with multiple sclerosis.
        Psychother. Psychosom. 2018; 87: 190-192
        • Nordin L.
        • Rorsman I.
        Cognitive behavioural therapy in multiple sclerosis: a randomized controled pilot study of acceptance and comitment therapy.
        J. Rehabil. Med. 2012; 44: 87-90
        • Ong C.W.
        • Pierce B.G.
        • Petersen J.M.
        • Barney J.L.
        • Fruge J.E.
        • Levin M.E.
        • Twohig M.P.
        A psychometric comparison of psychological inflexibility measures: discriminant validity and item performance.
        J. Context. Behav. Sci. 2020; 18: 34-47
        • Opara J.
        • Jaracz K.
        • Brola W.
        Quality of life in mulptiple sclerosis.
        J. Med. Life. 2010; 3: 352
        • Ost L.G.
        The efficacy of acceptance and commitment therapy: an updated systematic review and meta-analysis.
        Behav. Res. Ther. 2014; : 1-17
        • Page M.
        • Higgins J.
        • Sterne J.
        • et al.
        Chapter 13: assessing risk of bias due to missing results in a synthesis.
        in: Higgins J. Thomas J. Chandler J. Cumpston M. Li T. Page M. Cochrane Handbook for Systematic Reviews of Interventions version 6.2. Cochrane, 2021 (
        • Pakenham K.I.
        • Mawdsley M.
        • Brown F.L.
        • Burton N.W.
        Pilot evaluation of a resilience training program for people with multiple sclerosis.
        Rehabil. Psychol. 2018; 63: 29-42
        • Pappas C.
        • Williams I.
        Grey literature: its emerging importance.
        J. Hosp. Librariansh. 2011; 11: 228-234
        • Proctor B.J.
        • Moghaddam N.G.
        • Evangelou N.
        • das Nair R.
        Telephone-supported acceptance and commitment bibliotherapy for people with multiple sclerosis and psychological distress: a pilot randomised controlled trial.
        J. Context. Behav. Sci. 2018; 9: 103-109
        • Ruiz F.J.
        Acceptance and commitment therapy versus traditional cognitive behavioral therapy: a systematic review and meta-analysis of current empirical evidence.
        Int. J. Psychol. Psychol. Ther. 2012; 12: 333-357
        • Schulz K.F.
        • Altman D.G.
        • Moher D.
        CONSORT 2010 statement: updated guidelines for reporting parallel-group randomized trials.
        Ann. Intern. Med. 2010; : 152
        • Sesel A.L.
        • Sharpe L.
        • Naismith S.L.
        Efficacy of psychosocial interventions for people with multiple sclerosis: a meta-analysis of specific treatment effects.
        Psychother. Psychosom. 2018; 87: 105-111
        • Sheppard S.C.
        • Forsyth J.P.
        • Hickling E.J.
        • Bianchi J.
        A novel application of acceptance and commitment therapy for psychosocial problems associated with multiple sclerosis.
        Int. J. MS Care. 2010; 12: 200-206
        • Simpson R.
        • Booth J.
        • Lawrence M.
        • Byrne S.
        • Mair F.
        • Mercer S.
        Mindfulness based interventions in multiple sclerosis - a systematic review.
        BMC Neurol. 2014; 14: 1-9
        • Sinclair S.J.
        • Siefert C.
        • Slavin-Mulford J.
        • Stein M.
        • Renna M.
        • Blais M.
        Psychometric evaluation and normative data application of the hierarchical dimensional model in clinical assessment view project the role of mindfulness in pain related stress processes and pain experience to an acute cold pressor task view project.
        Eval. Health Prof. 2012; 35: 259-279
      3. Simpson, J., Eccles, F., and Zarotti, N. (2021). Psychological interventions for people with huntingtons disease, parkinsons disease, motor neurone disease, and multiple sclerosis. The British Psychological Society.

      4. The Cochrane Collaboration. (2020). Review manager (RevMan; Version 5.4) [Computer software]. Cochrane Training.

        • Thomas P.W.
        • Thomas S.
        • Hillier C.
        • Galvin K.
        • Baker R.
        Psychological interventions for multiple sclerosis.
        Cochrane Database Syst. Rev. 2006; (2010)
        • Van Kessel K.
        • Moss-Morris R.
        • Willoughby E.
        • Chalder T.
        • Johnson M.H.
        • Robinson E.
        A randomized controlled trial of cognitive behavior therapy for multiple sclerosis fatigue.
        Psychosom. Med. 2008; 70: 205-213
        • WHO
        The world health organization quality of life assessment (WHOQOL): position paper from the world health organization.
        Soc. Sci. Med. 1995; 41: 1403-1409
        • Wilkinson H.
        • das Nair R.
        The psychological impact of the unpredictability of multiple sclerosis: a qualitative literature meta-synthesis.
        Br. J. Neurosci. Nurs. 2013; 9: 172-178