Comparing the Effectiveness and Durability of Acceptance and Commitment Therapy, Cognitive Behavioral Therapy, and Their Combination with Repetitive Transcranial Magnetic Stimulation on Sleep Quality in Patients with Multiple Sclerosis

Atieh Maddah; Nooshin Taghinezhad; Azita Amirfakhraei; Kobra Hajializadeh

Authors

Atieh Maddah PhD. Student, Department of Psychology, BA.C., Islamic Azad University, Bandar Abbas, Iran Author https://orcid.org/0009-0002-9293-2755
Nooshin Taghinezhad Assistant Professor, Department of Psychology, BA.C., Islamic Azad University, Bandar Abbas, Iran Corresponding Author https://orcid.org/0000-0001-9088-9314
Azita Amirfakhraei Associate Professor, Department of Psychology, BA.C., Islamic Azad University, Bandar Abbas, Iran Author https://orcid.org/0000-0002-3753-0924
Kobra Hajializadeh Associate Professor, Department of Psychology, BA.C., Islamic Azad University, Bandar Abbas, Iran Author https://orcid.org/0000-0002-6931-0635

Keywords:

Multiple Sclerosis, Sleep Quality, Acceptance and Commitment Therapy, Cognitive Behavioral Therapy, Repetitive Transcranial Magnetic Stimulation

Abstract

This study aimed to compare the effectiveness and durability of Acceptance and Commitment Therapy (ACT), Cognitive Behavioral Therapy (CBT), and the combination of each intervention with repetitive transcranial magnetic stimulation (rTMS) on sleep quality in patients with multiple sclerosis. This applied quantitative study used a longitudinal multigroup quasi-experimental design with pretest, posttest, and follow-up assessments. The statistical population consisted of patients with a confirmed diagnosis of multiple sclerosis in Kerman, Iran, in 2025. Seventy-five eligible patients were selected through convenience sampling and randomly allocated to five groups of 15 participants: ACT, CBT, ACT + rTMS, CBT + rTMS, and control. The ACT and CBT groups received 12 weekly 90-minute group sessions. Participants in the combined groups additionally received 30 sessions of high-frequency rTMS over the left dorsolateral prefrontal cortex at 10 Hz and 120% of the resting motor threshold. Sleep quality was assessed using the Pittsburgh Sleep Quality Index at pretest, posttest, and follow-up. Data were analyzed using mixed repeated-measures analysis of variance with Greenhouse-Geisser correction and Bonferroni-adjusted post hoc comparisons in SPSS version 26. The mixed repeated-measures analysis revealed significant effects of group, F(4,70) = 10.35, p < .001, partial η² = .372, time, F(1.52,106.36) = 248.69, p < .001, partial η² = .780, and Group × Time interaction, F(6.08,106.36) = 15.90, p < .001, partial η² = .476. Bonferroni-adjusted comparisons showed that all four intervention groups had significantly better sleep quality than the control group at both posttest and follow-up (all p < .001). The largest posttest effect relative to the control group was observed for CBT + rTMS (d = 3.26), followed by CBT (d = 3.10), ACT (d = 2.07), and ACT + rTMS (d = 1.92). ACT, CBT, and their combinations with rTMS significantly improved sleep quality in patients with multiple sclerosis, and the effects remained evident at follow-up, with CBT + rTMS showing the strongest immediate therapeutic effect.

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