Psychological functioning in primary progressive versus secondary progressive multiple sclerosis

The late onset of emotional distress in people with progressive multiple sclerosis during the Covid-19 pandemic: longitudinal findings from the CogEx study

OBJECTIVE

An earlier follow-up study from the CogEx rehabilitation trial showed little change in symptoms of depression, anxiety and psychological distress during the first COVID-19 lockdown compared to pre-pandemic measurements. Here, we provide a second follow-up set of behavioral data on the CogEx sample.

METHODS

This was an ancillary, longitudinal follow-up study in CogEx, a randomized controlled trial of exercise and cognitive rehabilitation in people with progressive MS involving 11 centres in North America and Europe. Only individuals impaired on the Symbol Digit Modalities Test (SDMT) were included. Participants repeated the COVID Impact survey administered approximately a year later and completed self-report measures of depression, anxiety and MS symptoms that had been obtained at the trial baseline and during the first COVID Impact survey. Participants who completed the second COVID Impact follow-up were included. To identify predictors of the participants' ratings of their mental and physical well-being, step-wise linear regression was conducted.

RESULTS

Of the 131 participants who completed the first COVID impact survey, 74 participants completed the second follow-up survey (mean age 52 (SD = 6.4) years, 62.2% female, mean disease duration 16.4 (SD = 9.0) years, median EDSS 6.0). Pandemic restrictions prevented data collection from sites in Denmark and England (n = 57). The average time between measurements was 11.4 (SD = 5.56) months. There were no significant differences in age, sex, EDSS, disease course and duration between those who participated in the current follow-up study (n = 74) and the group that could not (n = 57). One participant had COVID in the time between assessments. Participants now took a more negative view of their mental/psychological well-being (p = 0.0001), physical well-being (p = 0.0009) and disease course (p = 0.005) compared to their last assessment. Depression scores increased on the HADS-depression scale (p = 0.01) and now exceeded the clinically significant threshold of ≥ 8.0 for the first time. Anxiety scores on the HADS remained unchanged. Poorer mental well-being was predicted by HADS depression scores (p = 0.012) and a secondary-progressive disease course (p = 0.0004).

CONCLUSIONS

A longer follow-up period revealed the later onset of clinically significant depressive symptoms on the HADS and a decline in self-perceptions of mental and physical well-being associated with the COVID-19 pandemic relative to the first follow-up data point.

TRIAL REGISTRATION

The trial was registered on September 20th 2018 at www.

CLINICALTRIALS

gov having identifier NCT03679468. Registration was performed before recruitment was initiated.

Multiple challenges for people after transitioning to secondary progressive multiple sclerosis: a qualitative study

OBJECTIVES

Transitioning to secondary progressive multiple sclerosis (SPMS) is demanding for both patients and healthcare professionals. The particular challenges and the ways patients cope are poorly understood. The present study examines what challenges people face when diagnosed with SPMS by exploring experiences of people who have transitioned recently (up to 5 years).

DESIGN

Semistructured qualitative interviews at two time points a year apart. Interviews were analysed using inductive thematic analysis.

SETTING

UK.

PARTICIPANTS

We interviewed 21 people at baseline and 17 participated in the follow-up interviews.

RESULTS

The majority of participants reported expecting to transition to SPMS, and the diagnosis did not make much difference to them. Participants described increasing emotional and physical challenges after transitioning to SPMS and between the first and second interviews. Planning, using distractions and maintaining social roles helped participants cope with the increased challenges. The same coping strategies were used between the two interviews. Participants felt there was not much left to do regarding the management of their symptoms. A key theme was the sense of abandonment from healthcare services after transitioning to SPMS.

CONCLUSIONS

After transitioning to SPMS, people are faced with multiple challenges. Participants described a lack of directions for symptoms management and lack of support from the healthcare system. An integrated multidisciplinary healthcare approach is crucial at the progressive stage of the disease to alleviate feelings of helplessness and promote symptom management.

Neuroinflammation drives anxiety and depression in relapsing-remitting multiple sclerosis

Objective:

To explore the inflammatory processes in the pathogenesis of psychiatric symptoms and the prognostic value of psychiatric comorbidities in multiple sclerosis (MS).

Methods:

Four hundred five patients with relapsing-remitting (RR) MS underwent psychiatric evaluation by means of Beck Depression Inventory II (BDI-II) and State/Trait Anxiety Inventory (STAI-Y). The inflammatory activity level was assessed by MRI. In a subset of 111 treatment-naive patients, CSF levels of proinflammatory cytokines were determined. Correlation and regression analyses were performed to determine associations between variables.

Results:

Relapsing patients demonstrated greater values of STAI-state and BDI-II compared with remitting patients but comparable trait-anxiety scores. There were no significant differences in psychometric parameters between relapsing and asymptomatic MRI-active patients, highlighting the effect of subclinical inflammation on mood disturbances. A significant reduction of STAI-state and BDI-II scores was recorded, along with the subsiding of neuroinflammation. Interleukin-2 CSF levels were found to correlate with STAI-state, while tumor necrosis factor-α and interleukin-1β correlated with BDI-II. Because emotional disorders were associated with subclinical inflammation, variations of the psychometric profile were able to detect subclinical reactivation earlier. In line with this, high STAI-state values considerably predicted the possibility of disease reactivation.

Conclusions:

Mood alterations are induced by intrathecal inflammation, even though not clinically apparent, and are able to predict inflammatory reactivations in RRMS. Inflammation is therefore a biological event, not less important than the traditional psychosocial factors, involved in mood disorders.

A Cochran-Armitage-type and a score-free global test for multivariate ordinal data

We propose a Cochran-Armitage-type and a score-free global test that can be used to assess the presence of an association between a set of ordinally scaled covariates and an outcome variable within the range of generalized linear models. Both tests are developed within the framework of the well-established 'global test' methodology and as such are feasible in high-dimensional data situations under any correlation and enable adjustment for covariates. The Cochran-Armitage-type test, for which an intimate connection with the traditional score-based Cochran-Armitage test is shown, rests upon explicit assumptions on the distances between the covariates' ordered categories. The score-free test, in contrast, parametrizes these distances and thus keeps them flexible, rendering it ideally suited for covariates measured on an ordinal scale. As confirmed by means of simulations, the Cochran-Armitage-type test focuses its power on set-outcome relationships where the distances between the covariates' categories are equal or close to those assumed, whereas the score-free test spreads its power over a wide range of possible set-outcome relationships, putting more emphasis on monotonic than on non-monotonic ones. Based on the tests' power properties, it is discussed when to favour one or the other, and the practical merits of both of them are illustrated by an application in the field of rehabilitation medicine. Our proposed tests are implemented in the R package globaltest. Copyright © 2016 John Wiley & Sons, Ltd.

Treatment of progressive multiple sclerosis: what works, what does not, and what is needed

Disease-modifying drugs have mostly failed as treatments for progressive multiple sclerosis. Management of the disease therefore solely aims to minimise symptoms and, if possible, improve function. The degree to which this approach is based on empirical data derived from studies of progressive disease or whether treatment decisions are based on what is known about relapsing-remitting disease remains unclear. Symptoms rated as important by patients with multiple sclerosis include balance and mobility impairments, weakness, reduced cardiovascular fitness, ataxia, fatigue, bladder dysfunction, spasticity, pain, cognitive deficits, depression, and pseudobulbar affect; a comprehensive literature search shows a notable paucity of studies devoted solely to these symptoms in progressive multiple sclerosis, which translates to few proven therapeutic options in the clinic. A new strategy that can be used in future rehabilitation trials is therefore needed, with the adoption of approaches that look beyond single interventions to concurrent, potentially synergistic, treatments that maximise what remains of neural plasticity in patients with progressive multiple sclerosis.

Characterization of functioning in multiple sclerosis using the ICF

The objective of this study was to explore whether it is possible to describe based on the International Classification of Functioning, Disability and Health (ICF) relevant aspects of functioning and disability affected in multiple sclerosis (MS) as well as environmental factors relevant to persons with MS. The specific aim was to identify most relevant 'Body functions', 'Body structures', 'Activities and participation', as well as 'Environmental factors' in patients with MS using the ICF. Additionally, different MS forms were compared with respect to the identified problems. A multi-centre study was conducted in an empirical cross-sectional design. Data from 205 individuals with MS were collected in rehabilitation centres: disease related data, socio-demographic data, single interviews based on the Extended ICF Checklist and a patient questionnaire including ratings on general health and functioning status, Beck Depression Inventory II (BDI-II) and Comorbidity Questionnaire (SCQ). The 129 ICF categories identified represent a comprehensive classification of functioning in MS from the clinical perspective. Differences between MS forms were observed for several ICF categories, EDSS, general health and functioning status, but not for BDI and SCQ. The study showed that it is possible to describe based on the ICF the spectrum in functioning and disability affected in MS as well as environmental factors relevant to persons with MS.

Longitudinal assessment of anxiety, depression, and fatigue in people with multiple sclerosis

OBJECTIVES

No longitudinal studies have concurrently evaluated predictors of anxiety, depression, and fatigue in people with multiple sclerosis (PwMS). This study determined factors that best predicted anxiety, depression, and fatigue in MS patients from a large pool of disease, cognitive, life-event stressor (LES), psychosocial, life-style, and demographic factors.

DESIGN

A 2-year prospective longitudinal study evaluated predictors of psychological distress and fatigue in PwMS.

METHODS

One hundred and one consecutive participants with MS were recruited from two MS clinics in Sydney, Australia. LES, anxiety, depression, and fatigue were assessed at baseline and at 3-monthly intervals for 2-years. Disease, cognitive, demographic, psychosocial, and life-style factors were assessed at baseline. Patient-reported relapses were recorded and corroborated by neurologists or evaluated against accepted relapse criteria.

RESULTS

Depression strongly predicted anxiety and fatigue, and anxiety and fatigue strongly predicted later depression. Psychological distress (i.e. anxiety, depression) was also predicted by a combination of unhealthy behaviours (e.g. drug use, smoking, no exercise, or relaxation) and psychological factors (e.g. low optimism, avoidance coping), similar to the results of community-based studies. However, state-anxiety and fatigue were also predicted by immunotherapy status, and fatigue was also predicted by LES and demographics.

CONCLUSIONS

These results suggest that similar factors might underpin psychological distress and fatigue in MS patients and community-well samples, although MS treatment factors may also be important. These results might assist clinicians in determining which MS patients are at greatest risk of developing anxiety, depression, or fatigue.

Clinical and demographical characteristics of primary progressive multiple sclerosis in Isfahan, Iran

Primary progressive multiple sclerosis (PPMS) is an uncommon form of multiple sclerosis (MS) in which the course of disease is progressive from onset. In a retrospective study amongst 1606 MS patients registered in Isfahan MS Society (IMSS) from April 2003 to 31 December 2005, 92 PPMS cases were identified. That means, the frequency of PPMS amongst all included MS patients would be 5.7% (95% CI: 6.7% and 4.7%). The mean expanded disability status scale (EDSS) for the group was 5.09 +/- 1.3. The commonest mode of presentation was motor disturbance in 55 (59.8%), other modes of presentation were, vertigo in 15 (16.3%), visual problems in 12 (13%), sensory disturbances in six (6.5%), and diplopia in four (4.3%). The current [corrected] existing symptoms were motor problems in all 92 (100%), cerebellar symptoms in 46 (50%), and cognitive impairment in only 6[corrected](6.5%). Interestingly, two (2%) were affected by poliomyelitis during childhood and presenting symptom in both was limb weakness. Primary progressive form of MS is less common in Persian population and some of the rates observed in PPMS patients differ from those in other regions, these differences may be due to different ethnicity of Persian patients or to geographical differences.

Coping and quality of life in one hundred and thirty five subjects with multiple sclerosis

INTRODUCTION

and objective The aim of this study was to compare coping strategies and quality of life (QoL) in multiple sclerosis (MS), as they relate to the course of the disease (relapsing-remitting (RR), secondary progressive (SP), primary progressive (PP)), while taking depression and anxiety into account.

METHODS

A total of 135 MS subjects were seen for a semi-structured interview in order to collect socio-demographic and clinical information, after which there was an assessment of their mental and cognitive states (Mini International Neuropsychiatric Interview (MINI), Montgomery and Asberg Depression Rating Scale (MADRS), Depressive Mood Scale (EHD), Hamilton Anxiety (HAMA), Frontal Assessment Battery (FAB)). All subjects then completed three self-report questionnaires; two about coping strategies (Ways of Coping Checklist (WCC), Coping with Health, Injuries and Problems Scale (CHIP)) and one about QoL (SEP59).

RESULTS

The mental health (depression and anxiety) and the psychological and social dimensions of QoL were relatively unaffected. However, after controlling for age and disability, the disease course had a strong effect on both mental health and QoL, with the poorest condition for SPMS and the best condition for PPMS. The SPMS patients tend to use emotional coping strategies extensively, while the PPMS patients use more instrumental strategies.

DISCUSSION

Our study clearly demonstrated that psychological and social well-being were substantially affected by the disease course. These results encourage us to develop interventions focused on coping strategies and which are better adapted to individual patients.

Les troubles de l’humeur et des émotions dans la sclérose en plaques : une revue de la littérature

INTRODUCTION

Even though mood and emotion are closely related concepts, they differ in some ways. This article aims to review the main mood and emotional disorders most often found in Multiple Sclerosis (MS).

STATE OF ART

Studies related to four fields are presented and discussed: assessment tools and methodological problems; prevalence, etiology and symptoms of mood as well as emotional disorders in MS; relationship between cognition and emotion. Beside these main subjects, we tackle some interesting questions which concern patients as well as clinicians, such as the risk of depression and protective factors, the relationship between depression and fatigue and the impact of beta-interferon on depression.

PROSPECTIVES

We focus on a new promising trend aiming to link neuroimaging data to psychological variables.

CONCLUSIONS

These four fields cover a large portion of the questions about mood and emotional disorders in MS. Due to their frequency as well as to their impact on quality of life, specific attention should be given to these disorders.

Relationship between stress and relapse in multiple sclerosis: Part II. Direct and indirect relationships

OBJECTIVE

The aim of this two-year prospective study was to determine which factors were: (i) directly related and/or (ii) indirectly related to multiple sclerosis (MS) relapse. These factors included life-event stressors, disease, demographic, psychosocial and lifestyle factors.

BACKGROUND

Relatively little attention has been paid to the role of non-clinical relapse predictors (other than stressful life-events) in MS, or factors that indirectly impact on the stress-relapse relationship.

METHODS

A total of 101 consecutive participants with MS were recruited from two MS clinics in Sydney, Australia. Stressful life-events, depression, anxiety and fatigue were assessed at study-entry and at three-monthly intervals for two years. Disease, demographic, psychosocial and lifestyle factors were assessed at baseline. Patient-reported relapses were recorded and corroborated by neurologists or evaluated against accepted relapse criteria.

RESULTS

MS relapse was predicted by acute stressor frequency counts, coping responses that utilized social support, and being born in Australia, but not by chronic stressors, disease, demographic, psychosocial or lifestyle factors. No factors were found to indirectly impact on the stress relapse relationship.

CONCLUSIONS

The number rather than severity of stressors was most important in relation to MS relapse risk, along with coping responses that utilized social support, suggesting that MS patients should avoid situations that are likely to generate multiple stressors or which provide few avenues for social support.

Psychological interventions for multiple sclerosis

BACKGROUND

The unpredictable, variable nature of Multiple Sclerosis (MS), and the possibility of increasing disability, means that a diagnosis can have substantial psychological consequences.

OBJECTIVES

To assess the effectiveness of psychological interventions for people with MS.

SEARCH STRATEGY

We searched 19 databases up to December 2004; Cochrane MS Group Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsychINFO, CINAHL and 14 others. We searched reference lists of articles, wrote to corresponding authors of the 13 papers identified by June 2004, and searched for trials in progress using 3 research registers.

SELECTION CRITERIA

Randomised controlled trials of interventions described as wholly or mostly based on psychological theory and practice, in people with MS. Primary outcome measures were disease specific and general quality of life, psychiatric symptoms, psychological functioning, disability, and cognitive outcomes. Secondary outcome measures were number of relapses, pain, fatigue, health care utilisation, changes in medication, and adherence to other therapies.

DATA COLLECTION AND ANALYSIS

Pertinent studies were identified from abstracts by one author. Full papers were independently compared to selection criteria by four authors. Key details were extracted from relevant papers using a standard format, and studies scored on three dimensions of quality. The review is organised into four mini-reviews (MR) dependent on the intervention's target population; people with cognitive impairments (MR1), people with moderate to severe disability (MR2), people with MS (no other criteria) (MR3), and people with depression (MR4).

MAIN RESULTS

Overall 16 studies were identified and included. MR1: three trials (n=145). Some evidence of effectiveness of cognitive rehabilitation on cognitive outcomes, although this was difficult to interpret because of the large number of outcome measures used. MR2: three trials (n=80). One small trial suggesting psychotherapy may help with depression. MR3: seven studies (n=688). Some evidence that cognitive behavioural therapy may help people adjust to, and cope with, having MS (three trials). The other trials were diverse in nature and some difficult to interpret because of multiple outcome measures. MR4: three trials (n=93). Two small studies of cognitive behavioural therapy showed significant improvements in depression.

AUTHORS' CONCLUSIONS

The diversity of psychological interventions identified indicates the many ways in which they can potentially help people with MS. No definite conclusions can be made from this review. However there is reasonable evidence that cognitive behavioural approaches are beneficial in the treatment of depression, and in helping people adjust to, and cope with, having MS.

A longitudinal study of cognition in primary progressive multiple sclerosis

There are few longitudinal studies of cognition in patients with multiple sclerosis, and the results of these studies remain inconclusive. No serial neuropsychological data of an exclusively primary progressive series are available. Cross-sectional analyses have revealed significant correlations between cognition and magnetic resonance imaging (MRI) parameters in primary progressive multiple sclerosis (PPMS). This study investigated cognitive and MRI change in 99 PPMS patients from five European centres for 2 years. They were assessed at 12 month intervals using the Brief Repeatable Battery, a reasoning test, and a measure of depression. The MRI parameters of T1 hypointensity load, T2 lesion load, and partial brain volume were also calculated at each time point. There were no significant differences between the mean cognitive scores of the patients at year 0 and year 2. However, one-third of the patients demonstrated absolute cognitive decline on individual test scores. Results indicated that initial cognitive status on entry into the study was a good predictor of cognitive ability at 2 years. There was only a small number of significant correlations between changes in cognition and changes on MRI, notably T1 hypointensity load with the two attentional tasks (r = -0.266, P = 0.017; r = -0.303, P = 0.012). It is probable that multiple factors underlie this weak relation between the cognitive and MRI measures.

Personality traits in multiple sclerosis (MS) patients with and without fatigue experience

OBJECTIVES

To determine the impact of personality characteristics on feelings of fatigue in multiple sclerosis (MS) patients and to compare the results with the impact of bodily impairment.

PATIENTS AND METHODS

Eighty patients with definite MS (mean age 38.5 +/- 9.0 years, 62 females) were surveyed using questionnaires assessing fatigue experience and personality traits (German Freiburg Personality Inventory-Revised; FPI-R) and by clinical examination assessing the Expanded Disability Status Scale.

RESULTS

Increased levels of "neuroticism", and "excitability" and decreased levels of "extraversion" were found to relate independent of fatigue scores (0.21 < beta < 0.52; 0.05 < P < 0.0001). The impact of these personality traits on fatigue (partial R2 ranging up to 0.32; 0.02 < P < 0.0001) was much higher than the impact of physical impairment (partial R2 ranging up to 0.04; not significant).

CONCLUSION

Our results support a psychological model of fatigue in MS. FPI-R-items over-weighted somatic sources of the fatigue syndrome in MS and may specifically relate to fatigue experience in chronical disorders.

Multiple Sclerosis Impact Scale (MSIS-29): reliability and validity in hospital based samples

BACKGROUND AND AIM

The psychometric properties of rating scales are sample dependent and need evaluations in different samples. The Multiple Sclerosis Impact Scale (MSIS-29), a new patient based rating scale for multiple sclerosis (MS) was predominantly developed from a community based sample derived from the MS Society. A number of important patient characteristics of this sample remain unknown. The aim of the study was to evaluate five psychometric properties of the MSIS-29 in three hospital based samples: people admitted for rehabilitation, people admitted for intravenous corticosteroid treatment for MS relapses, and people with primary progressive MS.

METHODS

People with MS were recruited from the three clinical settings. They completed several health measures. MSIS-29 data were evaluated for data quality, scaling assumptions, acceptability, reliability and validity, and compared with those from a previously reported community based study.

RESULTS

A total of 233 people (rehabilitation p=53; corticosteroids p=76; primary progressive p=104) completed questionnaires. In all samples, missing data were low (<or=2.2%), scaling assumptions were satisfied, and reliability was high (>or=0.91). Correlations between the MSIS-29 and other scales were consistent with a priori hypotheses. Findings were consistent with those from the community samples.

CONCLUSIONS

The psychometric properties of the MSIS-29 are consistent across three hospital based samples, and similar to those in the community samples. These findings further support its use as an outcome measure in different clinical settings.

Assessment of emotional problems in people with multiple sclerosis

OBJECTIVE

To investigate the occurrence of emotional problems in multiple sclerosis (MS) patients. The utility of rating scales used to measure such problems was studied to make recommendations for clinical practice.

DESIGN

Questionnaires were both sent by post and completed with an assistant psychologist at a home visit.

SUBJECTS

Ninety-six MS patients in contact with a rehabilitation consultant.

MEASURES

Patients were assessed using the Guy's Neurological Disability Scale (GNDS), Extended Activities of Daily Living Scale (EADL), Hospital Anxiety and Depression Scale (HAD), Beck Anxiety and Depression Scales (BAI, BDI), Clinical Outcomes in Routine Evaluation Measure (CORE) and the Brief Symptom Inventory (BSI).

RESULTS

Rates of anxiety and depression ranged from 16% to 48% according to the measures used. All mood scales were highly significantly correlated with each other. Disability as measured by the GNDS, but not the EADL, was significantly correlated with all mood measures. Kappa values showed poor correspondence in the classification of cases. Receiver operating characteristic curves indicated an optimum cut-off point of 7/8 on the HAD and 2/3 on the General Health Questionnaire (GHQ-12).

CONCLUSIONS

Rates of emotional problems were low given the highly disabled population studied. The HAD was relatively insensitive in comparison with the BAI and BDI. The GHQ-12 was sensitive and therefore recommended as a short screening measure. An alternative short screen, 'Emotional GNDS', was proposed.