Relationships Among Depressive Symptoms, Benefit-Finding, Optimism, and Positive Affect in Multiple Sclerosis Patients After Psychotherapy for Depression

Multiple sclerosis (MS) is a degenerative neurological disease that can severely impair patients' physical functioning, cognition, activity, and energy levels. Depression is common in MS and affects anywhere from 15% to 47% of patients (Chwastiak et al., 2002; Patten, Beck, Williams, Barbui, & Metz, 2003), with lifetime prevalence estimates at 50% (Sadovnick, 1991). Twenty-five percent of MS patients are reported to have unrecognized and untreated depression (McGuigan & Hutchinson, 2006). A shortcoming of psychosocial research on MS patients is that it has largely examined only the negative consequences of MS, focusing on the pain and suffering brought about by the disease. While it is clear that many MS patients do experience depression and disability, patients also frequently report finding benefits in having MS. Benefit-finding, both for MS patients as well as other chronically ill individuals, is considered a marker of successful adaptation to the disease. Mohr and colleagues (Mohr et al., 1999) were the first to publish that MS patients frequently report benefit-finding, defined as the positive changes brought about by MS. Similarly, Pakenham (2005a) found that MS patients as well as their caregivers (2005b) commonly found benefits in the MS experience, such as feeling closer to their families and gaining an enhanced appreciation of life. Many studies have been published on depression and psychological distress in MS (e.g., Janssens et al., 2004; Solari, Ferrari, & Radice, 2006); however, data are less abundant on benefit-finding in MS. Given the scant data on benefit-finding in MS, we examined the growing literature on benefit-finding in chronic illness. Although depression and benefit-finding appear to be common in chronic-illness, their empirical relationship to each other has not been well-understood due to inconsistent findings in the extant literature. A recent meta-analytic review of the relationship between benefit-finding and mental health indices reported greater benefit-finding was significantly related to lower levels of depression but was unrelated to measures of global distress (Helgeson, Reynolds, & Tomich, 2006). The authors suggested that measures of global distress do not distinguish well among indices of negative mood, such as depression, and that researchers should focus on benefit-finding with specific mental health outcomes. While several studies do show a relationship between benefit-finding and depression (see Helgeson et al., 2006, for a review), little research has examined the relationship between these two variables where depression was manipulated, such as in a psychotherapy trial. One study (Antoni et al., 2001; McGregor et al., 2004) reported that a 10-week cognitive–behavioral stress management (CBSM) group produced greater benefit-finding among women who were recently treated for early stage breast cancer, compared to a no-therapy control-group. Women who received CBSM also reported lower depression scores than the control condition. While that intervention was designed to help women cope with breast cancer-related issues and not specifically to decrease depression or increase benefit-finding, the findings suggest that treatment for depression may enhance benefit-finding. We considered two related but conceptually distinct theoretical models of psychological adaptation—the Broaden-and-Build Model and the Expectancy-Value Model—to elucidate the relationship between depression and benefit-finding in chronic illness. First, we examined Barbara Fredrickson's Broaden-and-Build Model (Fredrickson, 2001). According to the Broaden-and-Build Model, positivity (e.g., positive affect, hope, curiosity) promotes resilience in the face of adversity. Negative emotions, such as depression, serve to restrict one's ability to grow; positivity serves to promote approach and exploration and to “broaden” one's mindset and perspectives. Therefore, the theory would lead to the hypothesis that improvements in depression are likely to lead to increased positivity, which should encourage subsequent psychological growth. Within the Broaden-and-Build framework, positive affect may be one mechanism by which depression affects benefit-finding. While Fredrickson has not yet empirically examined benefit-finding as an outcome of positive emotions, her theory generalizes well to benefit-finding in chronic illness. Researchers have documented that positive affect is predictive of higher levels of benefit finding in MS patients (Pakenham, 2005a), breast cancer patients (Antoni et al., 2001; Sears, Stanton, & Danoff-Burg, 2003), and lupus patients (Katz, Flasher, Cacciapaglia, & Nelson, 2001). Furthermore, our own research has shown that improvements in depression after psychotherapy are associated with improved positive affect in MS patients (Hart, Fonareva, Merluzzi, & Mohr, 2005; Mohr et al., 2005). Therefore, we were interested whether increased positive affect mediated the relationship between improved depression and greater levels of benefit-finding in MS patients treated for depression. The second model of psychological adaptation we examined was the Expectancy-Value Model (Carver & Scheier, 1998, 2003). In the context of the Expectancy-Value Model, optimism is a key cognitive mechanism by which individuals structure their behavior to achieve their goals (Scheier & Carver, 1992). Optimism has been defined as “the global expectation that good things will be plentiful in the future and bad things, scarce” (Peterson, 2000). These global positive expectancies are considered a major determinant of whether people continue to pursue valued life goals against the backdrop of chronic illness. An important component of benefit-finding is engaging in goals to overcome adversity (Siegel & Schrimshaw, 2000). However, a deficiency of positive expectancies, perhaps brought on by depression, may thwart efforts to find benefit in MS patients. This idea is supported by the larger literature on optimism, which advocates the idea that as depression improves, optimism increases (Seligman et al., 1988). Therefore, we posited that increased optimism would mediate the relationship between improved depression and greater benefit-finding in MS patients treated for depression. Previous research has found benefit-finding and optimism to be positively related in cancer patients (Antoni et al., 2001; Sears et al., 2003; Urcuyo, Carver, & Antoni, 2005) and HIV/AIDS patients (Davis, Nolen-Hoesksema, & Larson, 1998; Milam, 2004). In Antoni and colleagues (2001) CBSM study, women lower in optimism (vs. higher) were more likely to report significantly higher levels of benefit-finding postintervention. While the relationship between benefit-finding and depression was not examined, women lower in optimism were also more likely to meet criterion for depression at baseline. These findings suggest that a psychotherapeutic intervention has the potential to increase benefit-finding, and one important link may be through decreasing depression and increasing optimism. However, this idea has yet to be empirically tested. The main goal of this study was to examine the application of the Broaden-and-Build and Expectancy-Value models to the relationship of depression and benefit-finding in MS. We hypothesized that treatment for depression would lead to increases in both positive emotions (i.e., positive affect) and positive cognitions (i.e., optimistic expectancies), that would, in turn, enhance benefit-finding. Therefore, these theories, while conceptually distinct, are complementary to one another and were anticipated to facilitate understanding of at least two of the mechanisms by which improved depression is associated with increased benefit-finding after telephone-administered therapy for depression in MS patients.