Prevalence of depression and anxiety among myasthenia gravis (MG) patients: A systematic review and meta-analysis

Predicting worsening risk in MGFA class I, II and III myasthenia gravis patients: development and validation of a predictive nomogram

BACKGROUND

Myasthenia gravis (MG), a neuromuscular junction autoimmune disorder, causes skeletal muscle weakness. MG worsening frequently occurs during the disease course, severely impairing quality of life and elevating myasthenic crisis risk. Existing predictive models remain scarce. This study developed a predictive model for MG worsening to facilitate early risk stratification and personalized care.

RESEARCH DESIGN & METHODS

Retrospective analysis included 437 the Myasthenia Gravis Foundation of America (MGFA) class I - III myasthenia gravis patients from December 2019 to September 2024. Sociodemographic, clinical variables and worsening status were analyzed. Predictors were identified via univariate analysis, the Least Absolute Shrinkage and Selection Operator (LASSO) regression, and multivariate logistic regression. Model performance was assessed using receiver operating characteristic (ROC) analysis, calibration curves, and decision curve analysis.

RESULTS

Patients were randomized into training (n = 305) and validation (n = 132) cohorts. Worsening rates were comparable (26.52% vs. 31.15%, p = 0.331). Six predictors emerged: age, MGFA classification, thymectomy history, chills, fatigue, and emotional disturbances (ED). The nomogram demonstrated strong discrimination (AUC: 0.82 training, 0.83 validation) and calibration (Hosmer-Lemeshow p > 0.05). Decision curve analysis confirmed clinical utility at 10-70% probability thresholds.

CONCLUSION

This nomogram integrates accessible clinical variables to stratify MG worsening risk, enabling early intervention. Validation through multicenter prospective studies is warranted to optimize generalizability.

Diabetes mellitus in patients with myasthenia gravis: a systematic review and meta-analysis

OBJECTIVES

With the prolongation of life expectancy in patients with myasthenia gravis, the number of comorbidities is increasing. Diabetes mellitus is one of the main comorbidities faced by patients with myasthenia gravis. However, there is not enough epidemiological information on diabetes mellitus. Given these limitations, the purpose of this study was to review the prevalence of diabetes mellitus in patients with myasthenia gravis and whether the myasthenia gravis is associated with an increased risk of gestational diabetes mellitus.

METHODS

PubMed, Embase, and Web of Science were searched for articles published prior to February 2024. Endnote 21 software was used to manage all relevant records. Review Manager version 5.4 and Stata version 18.0 software were used for the statistical analysis. Funnel plots and Egger's test were used to assess publication bias.

RESULTS

Twenty-four articles met the inclusion criteria and were included in the study. Among 23,516 myasthenia gravis patients, the prevalence of diabetes mellitus was 17% (95% CI 12~22%). In addition, the meta-analysis of the two studies showed that myasthenia gravis was significantly associated with an increased risk of gestational diabetes mellitus (OR = 1.56, 95% CI 1.26~1.93, p < 0.01).

CONCLUSIONS

Among the comorbidities of myasthenia gravis patients, diabetes mellitus is common, and the risk of gestational diabetes mellitus is increased in myasthenia gravis patients. These findings remind us that diabetes mellitus seems to be an important issue in the clinical management of myasthenia gravis patients and requires more attention.

The impacts of the COVID-19 pandemic on Australia's myasthenia gravis patients: A self-reported survey study

INTRODUCTION/AIMS

Previous studies have demonstrated high morbidity and mortality in patients with myasthenia gravis (MG) who acquired COVID-19. We aimed to identify the impact of the pandemic on MG disease control, treatment and quality of life.

METHODS

A prospective observational cohort study was conducted to identify the impact of the COVID-19 pandemic on Australian patients with MG. We conducted an online survey through Myasthenia Alliance Australia from May 2022 to July 2022.

RESULTS

Among the 229 patients who responded to the survey, most patients had three (80; 34.9%) or four (116; 50.7%) doses of the COVID-19 vaccines, 65 (28.4%) had contracted COVID-19, with 6 patients (9.4%) requiring hospitalisation. A large proportion of patients responded that the pandemic had no impact on their MG disease control (123; 53.7%) or treatment (111; 48.5%). Most patients felt the pandemic had either a mild (111; 48.5%) or moderate (50; 21.8%) impact on their mood.

CONCLUSION

Our study provides a snapshot of the types of impacts experienced by myasthenic patients during the pandemic, in particular the psychosocial effects. As we continue to live with COVID-19, clinicians should consider its various impacts in the holistic management of their patients.

Validation and proposal of case definitions for identifying patients with myasthenia gravis

BACKGROUND AND PURPOSE

Public medical insurance data are increasingly used to study myasthenia gravis (MG); however, a validated case definition is lacking. We assessed the clinical characteristics of patients identified according to previously used case definitions.

METHODS

Patients with diagnosis code G70.0 (myasthenia gravis) who visited Severance Hospital between January 2019 and December 2020 were retrospectively analyzed. Three case definitions used in previous epidemiologic studies were applied to the included patients, and their performance was evaluated based on sensitivity, specificity, and positive predictive value (PPV).

RESULTS

A total of 843 patients with diagnosis code G70.0 were identified, and 796 (96.7%) met the clinical diagnostic criteria for MG. All three previously-used case definitions showed a PPV of >98% in identifying clinically diagnosed MG, with sensitivities ranging from 68.7 to 71.1%. Case definition #1 was unable to identify 230 patients with MG: 42.6% were in remission, 23.5% were lost to follow-up, and 25.2% were receiving prescriptions elsewhere. A similar pattern was observed for definitions #2 and #3: Patients with thymoma-associated MG who were followed-up by thoracic surgeons were frequently missed based on the previously used case definitions. A proposed case definition that additionally includes a history of thymoma enhanced the sensitivity to 77.9%, while maintaining a PPV of 99.4%.

CONCLUSION

The previously used case definitions showed a high PPV but were unable to identify patients in remission or followed-up elsewhere. These limitations can be overcome by utilizing a new case definition and expanding the study duration.

The impact of diagnosis delay on European patients with generalised myasthenia gravis

OBJECTIVE

The objective was to determine the mean duration of diagnosis delay for patients with myasthenia gravis from five European countries and explore the impact of >1 year diagnosis delay.

METHODS

Patients with myasthenia gravis (N = 387) from Europe (France/Germany/Italy/Spain/United Kingdom) and their physicians participated in the Adelphi Real World Myasthenia Gravis Disease Specific Programme™. Diagnosis delay (time from symptom onset to diagnosis) was calculated and characteristics described for patients experiencing >1 year and ≤1 year diagnosis delay. Denominators varied according to outcome as missing data were not imputed.

RESULTS

Mean (standard deviation) diagnosis delay was 363.1 (520.9) days, and 27.1% (105 out of 387) of patients experienced diagnosis delay >1 year. Among patients with >1 year and ≤1 year diagnosis delay, respectively, 69.2% (72 out of 104) and 17.4% [45 out of 259] had initially received a different diagnosis (physician-reported); 40.0% (42 out of 105) and 24.1% (68 out of 282) were Myasthenia Gravis Foundation of America class III at the time of the survey (physician-reported); 72.4% (76 out of 105) and 61.3% (173 out of 282) had fatigue (subjective physician reporting from a pre-selected list of symptoms); 30.5% (32 out of 105) and 17.4% (49 out of 282) had anxiety and 21.9% (23 out of 105) and 13.1% (37 out of 282) had depression (both subjective physician reporting from a pre-selected list, Likert-style); and mean (standard deviation) MG-QoL-15r score was 14.4 (5.50) and 12.6 (7.84) (self-reported by N = 43 and N = 74 patients, respectively).

INTERPRETATION

More than a quarter of patients with myasthenia gravis experienced diagnosis delay of >1 year. These patients had a different clinical profile with regards to severity, symptoms, comorbidities and MG-QoL-15r score, compared with patients experiencing ≤1 year diagnosis delay.

Diurnal cognitive functioning in patients with myasthenia gravis with the role of chronotype and depression: a pilot study

Purpose

Myasthenia gravis (MG) is an autoimmune disease manifested by fatigue and weakness of the skeletal muscles. Recent research has indicated that MG patients perform significantly worse than healthy controls in cognitive domains such as attention, verbal fluency, visual learning, and memory. This study aimed to investigate the diurnal fluctuations in cognitive performance in patients with myasthenia gravis in relation to selected clinical and socioeconomic parameters of the disease course, along with the role of chronotype and depression.

Methods

The participants were recruited from a neurology outpatient clinic. Patients' cognitive functions were assessed twice: in the morning and the evening of the same day. Neuropsychological diagnosis included attention, memory, executive, verbal, and visuospatial abilities. Mood was measured with the Beck Depression Inventory-II and Positive and Negative Affect Schedule. The Morningness-Eveningness Questionnaire was used to examine chronotype.

Results

The analyses performed showed no significant differences between subjects and within subjects, apart from semantic fluency. Patients receiving antidepressant treatment obtained better results on attention and working memory tasks.

Conclusions

The data obtained show that diurnal neuropsychological performance in MG patients is associated with depression. Routine assessment and treatment of mood disorders could significantly improve cognitive functioning in myasthenia gravis patients.

Treatment of Depression in Adolescents With Myasthenia Gravis

Myasthenia gravis (MG) is an autoimmune disorder in which, most commonly, there is a production of autoantibodies against the nicotinic acetylcholinergic receptors at the neuromuscular junction, resulting in skeletal muscle weakness. For pediatric patients, literature addressing the psychiatric implications of MG and suitable treatment options for individuals with concurrent psychiatric illnesses is scarce. In this case report, an adolescent with MG and comorbid depression was treated following a suicide attempt via self-poisoning. The patient experienced an improvement of depressive symptoms upon initiating fluoxetine, despite concerns raised by previous studies suggesting that fluoxetine might block acetylcholine receptors at the neuromuscular junction with varying degrees of affinity, potentially worsening MG symptoms. In this case, our patient exhibited sustained control of her MG symptoms without exacerbation once she was started on fluoxetine. This case highlights the value of further investigation into the safety and efficacy of selective serotonin reuptake inhibitors (SSRIs) in the management of depression among pediatric patients with MG.

A Breath of Relief: Oxymetazoline and Flunisolide Nasal Spray in the Management of Myasthenia Gravis Ptosis

The current pharmaceutical management of myasthenia gravis (MG) is widely accepted to be pyridostigmine and prednisone, both known to cause adverse effects and incur significant costs. This treatment may be particularly burdensome for patients primarily complaining of localized ocular MG, and little is known about the management of MG ptosis with topical medications. Oxymetazoline hydrochloride 0.1% ophthalmic solution has recently been approved by the FDA for the treatment of ptosis, but there have been limited studies in MG ptosis and no report to date of symptomatic improvement with the intranasal formulation. This case report discusses a 71-year-old female whose newly diagnosed MG ptosis resolved after three days of intranasal oxymetazoline hydrochloride 0.05%, followed by three days of intranasal flunisolide. Our patient's rapid resolution of symptoms, along with the favorable side effect profile and over-the-counter availability, highlights the promising indication for the use of intranasal oxymetazoline and flunisolide as potential alternatives or adjuncts in MG management. Further research in larger cohorts is necessary to confirm the efficacy of these nasal sprays in treating MG ptosis.

Prevalence of depressive symptoms and suicidal behaviors among Iranian high school students: A systematic review and meta-analysis

AIM

The objective of this meta-analysis was to determine the prevalence of depressive symptoms and suicidal behaviors among high-school students in Iran.

MATERIALS AND METHODS

A comprehensive search strategy was conducted in the following original databases: PubMed, Web of Science (ISI), Scopus, Psycinfo, and national databases, including the Scientific Information Database (SID) and MagIran, from January 1988 through January 2023. Studies that reported the prevalence of depressive symptoms and suicidal behaviors among high school students in Iran were included. Two investigators extracted all relevant data independently. For deriving mean prevalence rates, random-effects meta-analyses were used. We assessed the quality of studies by the Joanna Briggs Institute (JBI).

RESULTS

Total of 67 studies (45,798 participants) were included in the syntheses on depressive symptoms and suicidal ideation. For depressive symptoms, the mean prevalence rate was 48 % (40 %, 55 %). 2804 participants were enrolled for assessing of the prevalence of suicide ideation, and the mean prevalence rate was 21 % (6 %, 36 %). The meta-analysis pooling of the prevalence estimates of suicide attempts was 18 % (15 %, 20 %).

CONCLUSIONS

Approximately half of the high school students experience depressive symptoms and, astonishingly, one in five high school students experiences suicidal ideation, so to identify strategies for preventing and treating depressive symptoms and suicidal behaviors in this special population, further research and policymaking are urgently needed.

Depression: A Contributing Factor to the Clinical Course in Myasthenia Gravis Patients

Background and Objectives: The association between myasthenia gravis (MG) and depression is intricate and characterized by bidirectional causality. In this regard, MG can be a contributing factor to depression and, conversely, depression may worsen the symptoms of MG. This study aimed to identify any differences in the progression of the disease among patients with MG who were also diagnosed with depression as compared to those without depression. Our hypothesis focused on the theory that patients with more severe MG symptoms may have a higher likelihood of suffering depression at the same time. Materials and Methods: One hundred twenty-two male and female patients (N = 122) aged over 18 with a confirmed diagnosis of autoimmune MG who were admitted to the Neurology II department of Myasthenia Gravis, Clinical Institute Fundeni in Bucharest between January 2019 and December 2020, were included in the study. Patients were assessed at baseline and after six months. The psychiatric assessment of the patients included the Hamilton Depression Rating Scale-17 items (HAM-D), and neurological status was determined with two outcome measures: Quantitative Myasthenia Gravis (QMG) and Myasthenia Gravis Activities of Daily Life (MG-ADL). The patients were divided into two distinct groups as follows: group MG w/dep, which comprised 49 MG patients diagnosed with depressive disorder who were also currently receiving antidepressant medication, and group MG w/o dep, which consisted of 73 patients who did not have depression. Results: In our study, 40.16% of the myasthenia gravis (MG) patients exhibited a comorbid diagnosis of depression. Among the MG patients receiving antidepressant treatment, baseline assessments revealed a mean MG-ADL score of 7.73 (SD = 5.05), an average QMG score of 18.40 (SD = 8.61), and a mean Ham-D score of 21.53 (SD = 7.49). After a six-month period, a statistically significant decrease was observed in the MG-ADL (2.92, SD = 1.82), QMG (7.15, SD = 4.46), and Ham-D scores (11.16, SD = 7.49) (p < 0.0001). These results suggest a significant correlation between MG severity and elevated HAM-D depression scores. Regarding the MG treatment in the group with depression, at baseline, the mean dose of oral corticosteroids was 45.10 mg (SD = 16.60). Regarding the treatment with pyridostigmine, patients with depression and undergoing antidepressant treatment remained with an increased need for pyridostigmine, 144.49 mg (SD = 51.84), compared to those in the group without depression, 107.67 mg (SD = 55.64, p < 0.001). Conclusions: Our investigation confirms that the occurrence of depressive symptoms is significantly widespread among individuals diagnosed with MG. Disease severity, along with younger age and higher doses of cortisone, is a significant factor associated with depression in patients with MG. Substantial reductions in MG-ADL and QMG scores were observed within each group after six months, highlighting the effectiveness of MG management. The findings suggest that addressing depressive symptoms in MG patients, in addition to standard MG management, can lead to improved clinical outcomes.

Personality factors in patients with myasthenia gravis: A prospective study

INTRODUCTION

In myasthenia gravis (MG), depression and anxiety have frequently been reported as comorbidities. However, little is known about personality characteristics in MG patients. We aimed to characterise personality traits in MG and to correlate them with disease severity and disease course.

METHODS

The Big Five Inventory data questionnaire was used to investigate personality traits in 44 MG patients and 45 healthy controls similar in age and gender. In 28 MG patients, a caregiver was also available for patient assessments to limit bias associated with social desirability in patients' responses. Patients were assessed with regard to premorbid personality (before manifestation of MG) and to present condition. In addition, anxiety and depression scales (Hospital Anxiety and Depression Scale and Beck Anxiety Inventory) were applied.

RESULTS

Compared to controls, MG patients showed significantly higher levels of neuroticism, whereas openness and extraversion were significantly lower. Agreeableness and conscientiousness did not differ between groups. Neuroticism was influenced by disease severity such as generalization of weakness, presence of thymoma, and bulbar involvement as well as disease duration. Neuroticism correlated with premorbid level of neuroticism but also with depression and anxiety scores.

CONCLUSION

A personality profile of increased neuroticism and lower openness and extraversion in MG patients may contribute considerably to the perception of disease severity. It may also be related to frequent comorbidities such as anxiety and depression. Although premorbid levels of neuroticism were increased, this characteristic may also increase considerably during the course of the disease. The data indicate that muscle weakness in MG is accompanied or even complicated by psychological aspects. Therefore, a psychological and behavioral intervention in addition to the specific pharmacological therapy might be of particular value.

Insights Into the Association Between Myasthenia Gravis and Depression: A Clinical Case Study

Myasthenia gravis (MG) is a serious and debilitating autoimmune disease characterized by muscle weakness, shortness of breath, and issues affecting the eyes, limbs, throat, and speech. Given the intense physical toll of the disease, it is unsurprising that higher rates of depression are observed among MG patients. We present a case involving a 30-year-old female patient who was admitted to the hospital for MG exacerbation and had a psychiatric consultation for worsening depression symptoms. The patient acknowledged symptoms of sad mood, crying spells, anhedonia, fatigue, insomnia, and inappropriate guilt. She admits to psychosocial stressors of her declining health, recent job loss, and low self-esteem due to weight gain. Past medical history includes a thymectomy and a total thyroidectomy that caused postsurgical-acquired hypothyroidism. She is currently on prednisone and pyridostigmine for her MG. The patient has many potential causes of her increased depressive symptoms, including her medications, psychosocial stressors, and her past medical history, in addition to her MG. However, the literature shows higher incidence rates of depression in MG patients compared to both healthy controls and controls with other comparable chronic conditions, as well as shows a positive association between increased depressive symptoms and MG severity. Thus, these findings prompt the consideration of possible physiological interplay between the two diseases and encourage further research into the association between MG and depression.

Oxymetazoline Hydrochloride Eye-Drops as Treatment for Myasthenia Gravis-Related Ptosis: A Description of Two Cases

In this article, we described two patients with myasthenia gravis-related ptosis who experienced sustained improvement with the use of oxymetazoline hydrochloride ophthalmic solution 0.1%. Despite the commonly used treatments for ptosis in myasthenia gravis (MG), such as acetylcholinesterase inhibitors and corticosteroids, complete remission of ptosis is not always achieved, and these treatments are often accompanied by systemic side effects. Our case report suggests the long-term efficacy of daily use of oxymetazoline eye drops in improving ptosis, providing a potential alternative or adjunctive treatment option without significant adverse effects. Further research is necessary to confirm these observations across larger cohorts of MG patients and establish the effectiveness of oxymetazoline eye drops in MG-related ptosis.