1. Introduction
ultiple Sclerosis (MS) is one of the most important and common diseases of the central nervous system, which causes various clinical symptoms among patients due to inflammation and destruction of myelin sheaths and electrical failure of nerve impulses in the central nervous system and depending on the site of involvement. Depression is more common than chronic neurological diseases in MS patients. Fatigue also is the most debilitating symptom of this disease. Pain self-efficacy can predict performance and coping with chronic pain as well as psychological adjustment in MS patients and is related to self-esteem, depression and self-worth. One of the important concepts in the positive psychology approach is life expectancy. Snyder and Anderson [21] showed that the increased hope can improve the quality of life and promote self-care and general health of patients with chronic physical disorders.
One of the effective methods for treatment of psychological problems in patients with chronic diseases is cognitive-behavioral individual/group therapy. Cognitive-behavioral therapy is a short-term treatment and, by challenging negative automatic thoughts and identifying and modifying cognitive errors, provides the opportunity for the patients to be freed from the shackles of dos and don’ts and idealistic thoughts, to accept the disease face it in a rational way, and to be able to adopt a new and flexible strategy for dealing with the disease symptoms instead of focusing on disabilities and feeling hopelessness about the future.
Given the effect of psychological factors on chronic diseases and the role of chronic diseases such as MS in exacerbating psychological problems, and considering the effectiveness of cognitive-behavioral interventions in patients with chronic diseases, cognitive-behavioral therapy can be able to improve pain self-efficacy, fatigue and depression and increase life expectancy in MS patients. In this regard, this study aims to evaluate the effectiveness of Cognitive-Behavioral Group Therapy (CBGT) in improving pain self-efficacy, fatigue, depression and life expectancy in patients suffering from MS.
2. Methods
This is a quasi-experimental clinical trial with a pretest/posttest design. Participants were 68 patients with MS referred to MS clinics in Razavi Khorasan Province of Iran, who were selected using a convenience sampling technique and based on the inclusion criteria. They were randomly assigned into intervention (n=34) and control (n=34) groups. The data collection tools were Pain Self-Efficacy Questionnaire (PSEQ), Fatigue Severity Scale (FSS), Snyder’s ‎Adult Hope Scale (AHS)‎ ‎and Beck Depression Inventory-Second Edition (BDI-II). The patients in the intervention group participated in ten 2-hour sessions of CBGT, while the control group received no treatment. To analyze the collected data, one-way Analysis of Covariance (ANCOVA) was used in SPSS v. 24 software. 
3. Results
Depression was at severe level in both groups at baseline, but changed to a mild level after treatment in the intervention group. The ANCOVA results of comparing the two study groups in terms of study variables after controlling the pretest scores are presented in Table 1. 


The results showed that CBGT led to increased pain self-efficacy and life expectancy and reduced fatigue and depression in MS patients.
4. Discussion 
The present study showed that CBGT can increase the pain self-efficacy and life expectancy and reduce fatigue and depression in MS patients. Self-efficacy beliefs as part of one’s self-concept are cognitive constructs that arise from life-long learning experiences. In CBGT, through learning emotion regulation skills and cognitive reappraisal, individuals gain the ability to generate positive emotions and modulate negative emotions, which is likely to lead to improved self-efficacy in MS patients. The main techniques of CBGT such as replacing negative thoughts with rational beliefs, imagining, exposure, and cognitive reconstruction can also reduce anxiety and depression and improve life expectancy in MS patients. CBGT reduce fatigue severity and increase its tolerance level by increasing the patient’ awareness of negative thoughts and cognitive errors and by emphasizing active coping strategies such as attempt to perform tasks despite fatigue and disregard for it. Hence, it can be said that the use of various CBGT techniques such as problem-solving have a significant role in reducing fatigue in MS patients. 
The use of a convenience sampling technique and the lack of sufficient time to follow-up the treatment results limited the generalizability of the results. Further studies by using a larger sample size, random sampling technique and a follow-up phase can help generalize the results and confirm the stability of the findings over time. Overall, it can be concluded that the CBGT can significantly affect the pain self-efficacy, fatigue, life expectancy and depression in patients with MS. It can be used along with pain management methods to improve the psychological problems of MS patients and is an effective way to reduce medication therapy and its side effects.

Ethical Considerations
Compliance with ethical guidelines
In order to observe ethical principles, after explaining the study objectives and methods to the participants, a written informed consent was obtained from them. They were assured of the confidentiality of their information. This study obtained its ethical approval from the Research Ethics Committee of Hakim Sabzevari University (Code: IR.HSU.REC.1397.018) and was registered by the Iranian Registry of Clinical Trials (Code: IRCT20150413021727N3).

Funding
The research received funding from the Deputy for Research of Hakim Sabzevari University in Sabzevar, Iran.

Authors contributions
Conceptualization, methodology, editing, finalization of writing, supervision and project management: Hossein Shareh; validation, research, sources and visualization: Both authors; Drafting: Zahra Robati.

Conflicts of interest
The authors declare no conflict of interest.

Acknowledgements
The authors would like to thanks to the Neurologists for patient referral, the Physicians and Personnel of Medical Centers for their cooperation, the MS ‎Association staff in Razavi Khorasan province,‎ and all the patients who participated in this study.



References

1. Miller J. Multiple Sclerosis. In: Ronald P, editor. Merritts text book of, neurology. Philadelphia: Lippincott & Wilkins; 2000.
2. Coleman CI, Sidovar MF, Roberts MS, Kohn C. Impact of mobility impairment on indirect costs and health-related quality of life in multiple sclerosis. Plos One. 2013; 8(1):1-8. [DOI:10.1371/journal.pone.0054756] [PMID] [PMCID]
3. Harizchi ghadim S, Ranjbar Kuchsaryi F, Talebi M, Zakaria M. [Effects of ‘’written emotional expression” on anxiety and depression in patients with multiple sclerosis (Persian)]. Current Journal of Neurology (Iranian Journal Of Neurology). 2013; 8(25):465-75. https://www.sid.ir/en/journal/ViewPaper.aspx?ID=151965
4. Benito-Leon J, Morales JM, Rivera-Navarro J. Health-relife and its relationship to cognitive and emotional functional sclerosis patients. European Journal of Neurology. 2009; 9:497-502. [DOI:10.1046/j.1468-1331.2002.00450.x] [PMID]
5. Schubert DS, Foliart RH. Increased depression in multiple sclerosis patients: A meta-analysis. Psychosomatics. 1993; 34:124-30. [DOI:10.1016/S0033-3182(93)71902-7]
6. José Sá M. Psychological aspects of multiple sclerosis.Clinical Neurology and Neurosurgery. 2008; 110:868-77. [DOI:10.1016/j.clineuro.2007.10.001] [PMID]
7. Gay MC, Vrignaud P, Garitte C, Meunier C. Predictors of depression in multiple sclerosis patient’s. Acta Neurologica Scandinavica. 2010; 121:161-70. [DOI:10.1111/j.1600-0404.2009.01232.x] [PMID]
8. Feinstein A. Multiple Sclerosis and depression. Multiple Sclerosis Journal. 2011; 17(11):1276-81. [DOI:10.1177/1352458511417835] [PMID]
9. Braley TJ; Chervin RD. Fatigue in multiple sclerosis: mechanisms, evaluation, and treatment. Sleep. 2010; 33(8):10617. [DOI:10.1093/sleep/33.8.1061] [PMCID] [PMID]
10. Krupp LB, LaRocca NG, Muir-Nash J, Steinberg AD. The fatigue severity scale. Application to patients with multiple sclerosis and systemic lupus erythematosus. Archives of Neurology. 1989; 46:1121-3. [DOI:10.1001/archneur.1989.00520460115022] [PMID]
11. Edgley K, Sulivan MJL, Dehoux E. A survey of multiple sclerosis: Part 2. Determinants of employment status. Canadian Journal of Rehabilitation. 1991; 4(3):127-32. https://psycnet.apa.org/record/1991-30829-001
12. Salehpoor G, Rezaei S, Hosseininezhad M. [Quality of life in Multiple Sclerosis (MS) and role of fatigue, depression, anxiety, and stress: a bicenter study from north of Iran (Persian)]. Iranian Journal of Nursing and Midwifery Research. 2014; 19(6):593-9. [PMCID] [PMID]
13. Bandura A. Social foundations of thought and action: A social cognitive theory. New Jersey: Prentice-Hall; 1986. https://books.google.com/books?id=HJhqAAAAMAAJ&q=
14. Brister H, Turner JA, Aaron LA, Mancl L. Self-efficacy is associated with pan, functioning, and coping in patients with chronic temporomandibular disorder pain. Journal of Orofacial Pain. 2015; 20(2):115-24. http://www.quintpub.com/userhome/jop/jop_20_2_Brister_3.pdf
15. Shnek ZM, Foley FW, LaRocca NG, Gordon WA, DeLuca J, Schwartzman HG, et al. Helplessness, self-efficacy, cognitive distortions, and depression in Multiple Sclerosis and spinal cord injury. Annals of Behavioral Medicine. 1997; 19(3):287-94. [DOI:10.1007/BF02892293] [PMID]
16. Boroumand A. [Chronic pain, pain self-efficacy and suicidal ideation: The moderating role of pain self-efficacy on relation between depression and suicidal ideation in chronic pain patients (Persian)]. Journal of Fundamentals of Mental Health. 2012; 2(54):152-63. https://jfmh.mums.ac.ir/article_985_14.html?lang=en
17. Yousefi Aghai A, Shaghaghi F, Dehestani M, Barghi Irani Z. [The relationship between Quality of Life (QoL) and psychological capital with illness perception in MS Patients (Persian)]. Health Psychology Journal. 2012; 1(1):32-45. https://www.sid.ir/en/journal/ViewPaper.aspx?id=279916
18. Haghighat F, Zadhoosh S, Rasoolzade-Tabatabaei K, Etemadifar M. [The relationship between pain self-efficacy and pain intensity in Multiple Sclerosis Patients (Persian)]. The Journal of Applied Behavioral Science. 2011; 5(1):47-54. http://www.behavsci.ir/article_67716.html
19. Snyder CR, Lopez SJ. Handbook of Positive Psychology. Oxford: Oxford University Press; 2001. https://books.google.com/books?id=2Cr5rP8jOnsC&printsec=
20. Miri F, Ghodsi P. [The relationship between lifestyle and life expectancy with psychological well-being of patients with Multiple Sclerosis (Persian)]. Depiction of Health. 2018; 8(4): 202-8. https://doh.tbzmed.ac.ir/Article/doh-200
21. Snyder R, Anderson J. Hope and health: measuring the will and ways handbook of social and clinical psychology: the health perspective. New York: Program Press; 1991.
22. Abedini E, Ghanbari-Hashem-Abadi BA, Talebian-Sharif J. [Effectiveness of group therapy based on hope approach on hope and depression in women with Multiple Sclerosis (Persian)]. Journal of Clinical Psychology. 2016; 2(30):1-11. https://www.sid.ir/en/journal/ViewPaper.aspx?id=514930
23. Rezaii A, Refahi Zh, Ahmadikhah MA. [Effectiveness of group logo therapy to reduce depression in patients with cancer (Persian)]. Journal of Psychological Models and Methods. 2012; 2(7):37-46. https://www.sid.ir/fa/journal/ViewPaper.aspx?id=193868
24. Leahy RL, Holland SJ, McGinn LK. Treatment plans and interventions for depression and anxiety disorders. New York: Guilford press; 2012. https://books.google.com/books?id=YIiGLbn6j10C&pg=PA1&dq=
25. Cosio D, Ling J, Siddique J, Mohr DC. The effect of telephone-administered cognitive behavioral therapy on quality of life among patients with Multiple Sclerosis. Annals of Behavioral Medicine. 2011; 41(2):227-34. [DOI:10.1007/s12160-010-9236-y] [PMID] [PMCID]
26. Nazarboland N, Tehranizadeh M, Mozaffarinejad F. [Effectiveness of cognitive behavioral therapy for Multiple Sclerosis (MS) fatigue (Persian)]. International Journal of Behavioral Science. 2017; 11(1):19-24. http://www.behavsci.ir/article_67960.html
27. Bishop M, Stenhoff DM, Shepard L. Psychosocial adaptation and quality of life in Multiple Sclerosis: Assessment of the disability centrality model. The Journal of Rehabilitation. (2007); 73(1):3-12. https://web.b.ebscohost.com/abstract?
28. Bieling PJ, McCabe RE, Antony MM. Cognitive- behavioral therapy in groups. London: Guilford; 2006. https://books.google.com/books?hl=fa&lr=&id=tVtoyte1AEIC&oi=fnd&pg=PP1&dq=
29. Nicholas, M. K. The pain self-efficacy questionnaire: Taking pain into account. European Journal of Pain. 2007; 11(2):153-63.[DOI: 10.1016/j.ejpain.2005.12.008] [PMID]
30. Asghari A, Nicholas M. [An investigation of pain self-efficacy beliefs in Iranian chronic pain patients: a preliminary validation of a translated english-language scale (Persian)]. Pain Medicine. 2009; 1 (4):619-32. [DOI:10.1111/j.1526-4637.2009.00623.x] [PMID]
31. Shahvarughi Farahani A, Azimian M, Fallahpour M, Karimlou M. [Evaluation of reliability and validity of the persian version of Fatigue Severity Scale (FSS) among persons with Multiple Sclerosis (Persian)]. Rehabilitation. 2013; 13(4):84-90. https://www.sid.ir/en/journal/ViewPaper.aspx?id=326191
32. Snyder CR, Harris C, Anderson JR, Holleran SA, Irving LM, Sigmon ST, et al. The will and the ways: development and validation of an individual- differences measure of hope. Journal of Personality and Social Psychology. 1991; 60(4):570-85. [DOI:10.1037/0022-3514.60.4.570] [PMID]
33. Snyder CR, Lopez SG. Positive psychology: the scientific and practical explorations of human strengths. New York: Oxford University Press; 2007.
34. Kermani Z, Khodapanahi M, Heidari M. [Psychometrics features of the Snyder Hopes Scale (Persian)]. Journal of Applied Psychology. 2011; 5(19):7-23. https://www.sid.ir/en/journal/ViewPaper.aspx?ID=256345
35. Beck AT, Steer RA, Garbin MG. Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clinical Psychology Review. 1988; (8):77-100. [DOI:10.1016/0272-7358(88)90050-5]
36. Wang YP, Gorenstein C. Psychometric properties of the Beck Depression Inventory- II: a comprehensive review. Revista Brasileira de Psiquiatria. 2013; (35):416-31. [DOI:10.1590/1516-4446-2012-1048] [PMID]
37. Rajabi GR, Karju Kasmai S. [Sufficiency of psychometric indexes of Persian Beck Depression Inventory (BDI-II) (Persian)]. Journal of Educational Measurement. 2012; 3 (10):139-57. https://www.sid.ir/fa/journal/ViewPaper.aspx?ID=202533
38. 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. Clinical Rehabilitation. 2014; 28(3):264-74. [DOI:10.1177/0269215513501525] [PMID]
39. Moss-Morris R, McCrone P, Yardley L, Van Kessel K, Wills G, Dennison L. A pilot randomised controlled trial of an internet-based cognitive behavioral therapy self-management programme (MS Invigor 8) for multiple sclerosis fatigue. Behaviour Research and Therapy. 2012; 50(6):415-21. [DOI:10.1016/j.brat.2012.03.001] [PMID]
40. Pahlavanzadeh P, Abasi S, Alimohammadi N. [The effect of group cognitive behavioral therapy on stress, anxiety, and depression of women with multiple sclerosis (Persian)]. Iranian Journal of Nursing and Midwifery Research. 2017; 22(4):271-5 [DOI:10.4103/1735-9066.212987] [PMID] [PMCID]
41. Omrani S, Mirzaeian B, Aghabagheri H, Hassanzadeh R, Abedini M. [The effectiveness of cognitive-behavioral therapy on the life expectancy of patients with Multiple Sclerosis (Persian)]. The Journal of Mazandaran University of Medical Sciences. 2012; 22(93):58-65. http://jmums.mazums.ac.ir/article-1-1372-fa.html
42. Van Kessel K, Morris MR, Willoughby E, Chalder T, Johnson MH, Robinson E. A randomized controlled trial of cognitive behavior therapy for multiple sclerosis fatigue. Psychosomatic Medicine. 2008; 70:205-13. [DOI:10.1097/PSY.0b013e3181643065] [PMID]
43. Abasi S, Pahlevanzadeh S, Alimohammadi N. [The effectiveness of group cognitive behavioral therapy on the severity of fatigue in women with multiple sclerosis: A clinical randomized trial (Persian)]. Journal of Clinical Nursing and Midwifery. 2016; 5(2):40-51. http://jcnm.skums.ac.ir/article-1-426-fa.html
44. Hozhir F, Ahadi H, Poorshahbaz A, Rezaee M. [Effectiveness of cognitive behavior therapy on change cognitive representations of illness and promotion of emotional states in patients with Multiple Sclerosis (Persian)]. Journal of Kermanshah University of Medical Sciences. 2010; 15(6):415-26. https://www.sid.ir/fa/journal/ViewPaper.aspx?id=153553
45. Ratajska A, Zurawski J, Healy B, Glanz BI. Computerized cognitive behavioral therapy for treatment of depression in multiple sclerosis. A narrative review of current findings and future directions. International Journal of MS Care. 2019; 21(3):113-23. [DOI:10.7224/1537-2073.2017-094] [PMID] [PMCID]
46. Ghodspour Z, Najafi M, Rahimian Boogar I. [Effectiveness of mindfulness-based cognitive therapy on psychological aspects of quality of life, depression, anxiety, and stress among patients with multiple sclerosis (Persian)]. Journal of Practice in Clinical Psychology. 2018; 6(4):215-22. [DOI:10.32598/jpcp.6.4.215]
47. Isaac V, Walters L, McLachlan CS. Association between self-efficacy, career interest and rural career intent in Australian medical students with rural clinical school experience. BMJ Open. 2015; 5(12):e009574. [DOI:10.1136/bmjopen-2015-009574] [PMID] [PMCID]
48. Zeldin AL. Source and effect of self-efficacy belief of men with career in mathematics science and technology. Journal of African American Males in Education. 2015; 2(2):188-213. https://www.uky.edu/~eushe2/Pajares/ZeldinDissertation2000.PDF
49. Kozak A. Mindfulness in the management of chronic pain: conceptual and clinical considerations. Techniques in Regional Anesthesia and Pain Management. 2008; 12:115-8. [DOI:10.1053/j.trap.2008.01.007]
50. Khadke S, Siddique T. Diverse mechanisms and treatment strategies to confront fatigue in Multiple Sclerosis: A systematic review [version 1; peer review: 2 not approved]. F1000Research. 2019, 8:563. [DOI:10.12688/f1000research.18247.1]
51. Van Den Akker LE, Beckerman H, Collette EH, Eijssen ICJM, Dekker J, et al. Cognitive behavioral therapy positively affects fatigue in patients with multiple sclerosis: Results of a randomized controlled trial. Multiple Sclerosis Journal. 2017; 23(11):1542-53. [DOI:10.1177/1352458517709361] [PMID]
52. Aghabagheri H, Mohammadkhani P, Omrani S, Farahmand V. [The efficacy of mindfulness-based cognitive therapy group on the increase of subjective well-being and hope in patients with Multiple Sclerosis (Persian)]. Journal of Clinical Psychology. 2012; 1(13):23-31. https://www.sid.ir/en/journal/ViewPaper.aspx?id=247171
53. Khayat Sarkar F, Shirazi M. [The effectiveness of cognitive-behavioral therapy on mental toughness and life expectancy of patients with Multiple Sclerosis (Persian)]. Tehran University Medical Journal. 2017; 75(8):593-9. https://www.sid.ir/en/journal/ViewPaper.aspx?id=610610
54. Nosrati R, Momeni KH, Mazdeh M, Karami J. [The relationship between psychological capital and acceptance of the disease with life satisfaction in patients with multiple sclerosis (Persian)]. Journal of Health and Care. 2018; 20(2):114-22. [DOI:10.29252/jhc.20.2.114]
55. Shareh H, Robati Z, Oladi F, Jafarnia V. [The effectiveness of cognitive behavioral group therapy on depression, hope and adjustment in patients with Hepatitis B (Persian)]. Zahedan Journal of Research in Medical Sciences. 2017; 19(5):e9423. [DOI:10.5812/zjrms.9423]
56. Heald A, Barber L, Jones HL, Farman S, Walther A. Service based comparison of group cognitive behavior therapy to waiting list control for chronic fatigue syndrome with regard to symptom reduction and positive psychological dimensions. Medicine. 2019; 98:39. [DOI:10.1097/MD.0000000000016720] [PMID] [PMCID]