Introduction
hysical, psychological, and social symptoms of Multiple Sclerosis (MS) can affect different aspects of life in MS patients. It can disrupt the work-related areas, including instrumental daily living activities, job, education, social participation, and leisure activities. Mood disorders are seen in more than 50% of these patients, of which depression is the most common and can occur in both primary and secondary ways reducing the quality of life in these patients. The probability of suicide in these patients is seven times higher than in healthy individuals [1]. Its causes can be physiological in response to the disease process, psychological in response to the diagnosis, or side effects of drugs that can be associated with fatigue and inability to cope and adapt [2]. Fatigue is the most common symptom reported by MS patients, which affects their progress of cognitive and physical therapy. Fatigue is defined as “a subjective lack of physical and or mental energy that is perceived by the individual or caregiver to interfere with usual and desired activities” [3, 4]. In a study on the effect of depression, fatigue, and cognitive dysfunction on the leisure activities of MS patients using the Nottingham leisure questionnaire, Hosseini et al. reported the effect of depression and fatigue but cognitive dysfunction on leisure [9]. A review of research conducted in Iran indicates that most researchers pay attention to the time spent on each leisure activity [6, 7, 8, 9], while a few of these studies have examined the relationship of leisure time with mental and social health [10], social capital, social duty, leisure satisfaction, gender [11], number of children, level of education and physical activity [9]. 
In an epidemiological study with a large sample, Chwastiak et al. found a strong association between depression and MS severity, but no such association was found between depression and disease progression pattern. They suggested that newly diagnosed patients, patients with extensive functional changes, and those with limited social support should also be evaluated for depression [12]. One of the fields of work in occupational therapists is the evaluation and implementation of therapeutic interventions in the field of leisure for patients with neurological disorders such as MS [13]. However, before presenting any intervention for increasing the ability of MS patients to spend their leisure time, it is necessary to study the concept of this field scientifically and systematically and identify and evaluate its affecting factors. In this way, therapists can help increase their leisure time with appropriate therapeutic interventions. This study investigates the relationship of leisure activities with fatigue and mental health problems (stress, anxiety, and depression) in MS patients. A leisure questionnaire for Iranian MS patients with 5 domains was used, which has not been used in other related studies. 
Materials and Methods
This research is a cross-sectional study. The study population consisted of all MS patients referred to Imam Khomeini Clinic, Mobasher Kashani Hospital, and MS Association in Hamedan City, Iran. For sampling, a convenience sampling method was used. The inclusion criteria were the definitive diagnosis of MS by a neurologist, ability to speak and communicate, and willingness to participate in the study. The exclusion criteria were having other diseases associated with MS, according to the neurologist, and unwillingness to continue participation. According to the Cochran formula and considering Z=1.96, p=0.5, q=0.5, and d=0.1, the sample size was obtained 96.
Data collection tools were first the leisure questionnaire for Iranian MS patients, developed by Hosseini et al. [19]. It has 50 items and 5 subscales of difficult activities, social activities, out-of-home physical activities, art/cultural activities, and spiritual/religious activities. The items are rated on a 4-point Likert-type scale. The validity coefficients for the single measure and average measure of this questionnaire in the pretest phase were 0.826 and 0.905, respectively, and were statistically significant. This result indicates excellent internal consistency between the scores of subscales [20]. The second tool is the Depression, Anxiety, and Stress Scale (DASS) [20]. Each subscale of this tool has 7 items. The final score of DASS is obtained by summing up the scores of each subscale. Each item is rated from 0= “Did not apply to me at all” to 3= “applied to me very much” [20]. The test-retest reliability for the Persian version of DASS is 0.82 [21]. The third tool is the Fatigue Severity Scale (FSS), which was developed by Krupp et al. [23] for use in patients with systemic lupus and MS, including a Visual Analog Fatigue Scale (VAFS) and Expanded Disability Status Scale (EDSS). It has 9 items extracted from the 28 items of the fatigue questionnaire. The validity and reliability of the Persian version of this questionnaire were evaluated by Azimian et al. [24], who reported an Intraclass Correlation Coefficient (ICC) value of 0.93.
After obtaining written informed consent from the participants, the questionnaires were distributed among them in 2019. After collecting data, they were analyzed in SPSS v. 16 software. The Spearman correlation test was used to examine the relationship between the dependent variable (leisure) and two independent variables (fatigue and mental health problems) after examining the normality of data distribution. The Chi-square test was used to examine the relationship between leisure activities and demographic characteristics that are nominal variables.
Results
Demographic information of the participants is presented in Table 1. 


They were 70 females and 29 males, most of whom were married. Most were employed (n=27) or housekeepers (n=27). They had a Mean±SD age of 32.28±8.26 years with a Mean±SD disease duration of 6.83 ±5.63 years. The results of the Chi-square test showed a significant relationship between leisure activities and education level (P=0.003), but other demographic variables had no relationship with leisure activities (Table 2). 


The results of the Spearman correlation test (Table 3) showed that both VAFS (P=0.003) and FSS (P=0.001) scores had a significant relationship with leisure activities. 


Moreover, leisure activities showed a significant relationship with the overall DASS score (P=0.007) and its depression subscale (P=0.001), but not with the subscales of anxiety (P=0.780) and stress (P=0.060). The EDSS score also had a significant relationship with leisure activities (P=0.001). Age (P=0.335) and duration of disease (P=0.297) had no significant relationship with leisure activities.
To examine the relationship of each five domains of the leisure questionnaire with fatigue and mental health problems, we used the Spearman correlation test. As shown in Table 4, the VAFS score showed a significant relationship with social activities (r=0.376), out-of-home physical activities (r=0.202) and art/cultural activities (r=0.186). 


The FSS score showed a high correlation with all five domains of leisure activities. The overall DASS score was significantly associated with spiritual/religious activities (r=0.263), out-of-home physical activities (r=0.213), and art/cultural activities (r=0.205). Regarding DASS subscales, the results showed that anxiety had a significant correlation only with social activities (r=0.259), stress with spiritual/religious activities (r=0.212), and depression with all leisure activities, except with difficult activities (P<0.005).
Discussion and Conclusion
This study’s findings revealed a significant relationship between leisure activities with fatigue and mental health problems in MS patients. No correlation was found between leisure activities and the patient’s age, indicating that leisure time does not change with aging, which may be reasonable. People at any age have their own hobbies and the total leisure time amount is the same. No correlation was found between leisure time and disease duration, although it seems that as the duration of the disease increases, the rate of disability increases, which can affect the amount of leisure time. This issue is probably because the patients try to maintain their leisure time by doing other activities. Gender had no significant relationship with leisure activities; i.e., there was no difference between men and women in the amount of leisure time. Employment status and marital status did not affect the amount of leisure time, either. It means that the MS patients, whether married, single, employed, or unemployed, have a comparable amount of leisure time. Education level, however, showed a significant relationship with leisure activities. A person with a higher level of education has more fun than an illiterate person because educated people have more information about recreation and its effect on the disease.
Fatigue showed a high correlation with all domains of leisure activities. That is, fatigue affects difficult, social, spiritual/religious, out-of-home, and art/cultural activities. Overall, it can reduce the amount of all types of leisure activities. This finding is reasonable because the tired person cannot do leisure activities and prefers to rest more rather than doing something. This finding is consistent with the results of Hosseini et al. [9], who used the Nottingham leisure questionnaire. Khemthong et al. [25] concluded that social leisure time affects the physical health of MS women with fatigue. The stress and anxiety of MS patients in our study only affected their social leisure activities. 
Janssens et al. [26] reported that stress and anxiety exist in MS patients since the onset of the disease. Brown et al. showed that depression leads to fatigue and anxiety in MS patients and vice versa [27]. In our study, depression affected all domains of leisure time in MS patients. Numerous studies have examined the relationship between leisure and depression [5, 23]. Ben Ari et al. concluded that depression affects participation in daily life in MS patients [20]. Molt et al. showed that depression and fatigue affect patients’ leisure time physical activities [25]. In a longitudinal study, Stephens et al. showed that having moderate to severe leisure time physical activities can reduce depression and fatigue in MS patients [26]. No study was found on examining leisure domains among people with MS, but some studies link the physical domain of leisure to fatigue [27, 28]. For example, a study was found by Fjeldstad et al. [32] on the relationship between fatigue and the physical domain of leisure using the FSS and Godin leisure-time exercise questionnaire. Their results showed a significant relationship between the two variables. In a study by Vanner et al. [33], a significant relationship was also found between depression and physical leisure activities. These results are consistent with our findings. Fatigue is one of the most debilitating symptoms of MS, which affects the whole life of a patient.
One of the study’s limitations was the small number of male patients compared to females, which seems acceptable given the proportion of these patients in the community, so the generalization of the results of the present study to men should be made with caution. It is recommended that the relationship between MS patients’ leisure time and other aspects in Iran be investigated in future studies. Moreover, it is recommended to consider the effect of other symptoms of MS such as sleep problems, urinary and fecal control problems, and cognitive problems on the leisure time of MS patients.
Leisure time activities are associated with mental health problems and fatigue in people with MS. In other words, if MS patients suffer from disorders such as fatigue and mental health problems (depression, stress, and anxiety), it can reduce their amount of leisure time.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Hamadan University of Medical Sciences (Code: IR.UMSHA.REC.1397.436)

Funding
This study was extracted from a research project approved by the Deputy for Research and Technology of Hamadan University of Medical Sciences (Code: 9708224844).

Authors' contributions
Both authors equally contributed to preparing this article.

Conflict of interest
The authors declared no conflict of interest.


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