Depression in multiple sclerosis: a review

Insomnia and fibromyalgia-like symptoms among women diagnosed with relapsing remitting multiple sclerosis in Jordan: Prevalence and correlates

OBJECTIVE

This study investigated the prevalence and correlates of fibromyalgia and insomnia in a sample of Women with Multiple Sclerosis (WMS).

METHODS

The study was cross-sectional in design and recruited a sample of 163 women with Relapsing-Remitting Multiple Sclerosis (RRMS). Fibromyalgia was assessed using the Patient Self-Report Survey (PSRS), following criteria outlined by the American College of Rheumatology. Insomnia was measured using the Arabic version of the Insomnia Severity Index (ISI-A).

RESULTS

The prevalence of fibromyalgia and insomnia was 28.2% (n = 46) and 46.3% (n = 76), respectively. Multivariate analyses were used to determine significant independent correlates. Fibromyalgia was associated with age above 40 years (OR = 2.29, 95% CI = 1.01-5.18, P = .04), high school education (OR = 3.69, 95% CI = 1.62-8.37, P = .002), and non-use of analgesics (OR = .02, 95% CI = .004-.21, P = .001). Insomnia symptoms were significantly associated only with age above 40 years (OR = 2.16, 95% CI = 1.16-4.04, P = .01).

CONCLUSION

These findings highlight the need for increased attention by primary care physicians towards diagnosing and treating fibromyalgia and insomnia among women with RRMS in Jordan, particularly among older women.

Cognitive impairment in multiple sclerosis: from phenomenology to neurobiological mechanisms

Multiple sclerosis (MS) is an autoimmune-mediated disease of the central nervous system characterized by inflammation, demyelination and chronic progressive neurodegeneration. Among its broad and unpredictable range of clinical symptoms, cognitive impairment (CI) is a common and disabling feature greatly affecting the patients' quality of life. Its prevalence is 20% up to 88% with a wide variety depending on the phenotype of MS, with highest frequency and severity in primary progressive MS. Involving different cognitive domains, CI is often associated with depression and other neuropsychiatric symptoms, but usually not correlated with motor and other deficits, suggesting different pathophysiological mechanisms. While no specific neuropathological data for CI in MS are available, modern research has provided evidence that it arises from the disease-specific brain alterations. Multimodal neuroimaging, besides structural changes of cortical and deep subcortical gray and white matter, exhibited dysfunction of fronto-parietal, thalamo-hippocampal, default mode and cognition-related networks, disruption of inter-network connections and involvement of the γ-aminobutyric acid (GABA) system. This provided a conceptual framework to explain how aberrant pathophysiological processes, including oxidative stress, mitochondrial dysfunction, autoimmune reactions and disruption of essential signaling pathways predict/cause specific disorders of cognition. CI in MS is related to multi-regional patterns of cerebral disturbances, although its complex pathogenic mechanisms await further elucidation. This article, based on systematic analysis of PubMed, Google Scholar and Cochrane Library, reviews current epidemiological, clinical, neuroimaging and pathogenetic evidence that could aid early identification of CI in MS and inform about new therapeutic targets and strategies.

Self-reported cognitive function mediates the relationship between employment status and cognitive functioning in persons with multiple sclerosis

BACKGROUND

Cognitive impairment (CI) is common in people with MS (PwMS). Evidence is lacking for the self-reported CI's mediation effect on employment status and objective cognitive performance. Self-reported CI was found to be unreliable and seemed to be more associated with depression rather than formal cognitive performance. We hypothesized that the link between subjective and objective assessments of cognitive functions, mood, and employment status may be more complex in PwMS than previously reported.

OBJECTIVE

The aims of this study are the following: (Romero-Pinel et al., 2022) to determine whether employment status could affect performance in cognitive function testing and (Rao et al., 1991) whether their relationship may be mediated by self-reported CI; and (Deluca et al., 2013) to determine whether self-reported depression interacts with self-reported CI in influencing performance in various cognitive domains in PwMS.

METHODOLOGY

A retrospective study was performed involving PwMS who completed the self-report Multiple Sclerosis Neuropsychological Questionnaire (MSNQ), Hospital Anxiety and Depression Scale-depression scale (HADS-D), Minimal Assessment of Cognitive Function in MS (MACFIMS) and had data regarding employment status. Included PwMS were classified as employed or unemployed. A structural equation modeling (SEM) approach was taken due to the advantage of examining multiple cognitive outcomes simultaneously while accounting for shared associations. First, a latent factor of memory and executive functioning modeled the error-free associations between both factors and a processing speed task (SDMT). Next, the model tested for the indirect effect of self-reported cognition (MSNQ) on employment status differences in each outcome (memory, speed, and executive functioning). Finally, we tested interactions between MSNQ and HADS-D on each of the outcomes.

RESULTS

We included 590 PwMS: 72.5% female, mean age 44.2 years (SD = 10.5), mean disease duration 8.6 years (SD 9.0). The majority (n = 455, 77.1%) had relapsing MS; 357 (60.5%) were employed. About half (n = 301, 51%) did not report CI on the MSNQ; of those, 213 (70.8%) were employed. The mean MSNQ for employed PwMS was 24.5 (SD = 10.7) and 29.8 (SD = 11.2) for unemployed PwMS. Employed PwMS had significantly better memory (β = .16, p < .05), executive functioning (β = .25, p < .05), and processing speed (β = .22, p < .05). MSNQ partially indirectly mediated the effect of employment status on memory (Δβ = .03, p < .05) and executive functioning (Δβ = .03, p < .05) and processing speed (Δβ = .04, p < .05), indicating that self-report CI partially explains the influence of employment status on these cognitive domains. The association between MSNQ with both memory and executive functioning was moderated by depression, meaning that in PwMS with high HADS-D scores, MSNQ was more strongly related to worse memory and executive functioning. The final model was an acceptable fit to the data (χ2(87) = 465.07, p < .05; CFI = .90, RMSEA = .08, 90% CI [.06, .09], SRMR = .05) explaining 41.20%, 38.50% and 33.40% of the variability in memory, executive functioning, and processing speed, respectively.

CONCLUSION

Self-reported CI partially explains the associations between employment status and objective cognitive assessment in PwMS. Depression may moderate the relationship between self-reported cognitive assessment and objective cognitive performance. Thus, employment status and mood may guide the interpretation of self-reported CI.

Robotic assisted and exoskeleton gait training effect in mental health and fatigue of multiple sclerosis patients. A systematic review and a meta-analysis

PURPOSE

Robotic and Exoskeleton Assisted Gait Training (REAGT) has become the mainstream gait training module. Studies are investigating the psychosocial effects of REAGT mostly as secondary outcomes. Our systematic review and meta-analysis aims to investigate the effects of REAGT in MS patients' mental health and fatigue.

MATERIALS AND METHODS

We searched the electronic databases (Scopus, PubMed, Pedro, Cochrane Trials, Dare) for RCT studies fulfilling our inclusion criteria. A meta-analysis of available assessment tools was conducted calculating the summary mean differences in two different timepoints, before and after the intervention using random-effects models.

RESULTS

The systematic search of the electronic databases identified 302 studies. Seven RCT studies were considered eligible for data extraction and meta-analysis, according to our eligibility criteria. We were able to obtain adequate data to proceed with a quantitative synthesis for QoL SF36-MC (Mental Component), QoL SF-36 mental and psychosocial subscales, Multiple Sclerosis Quality of Life-54-Mental Health Composite (MSQoL-54-MHC), Patient's Health Questionnaire (PHQ-9) and Fatigue Severity Scale (FSS).

CONCLUSIONS

Overall, REAGT seems to have a positive effect to Quality of Life, especially in MS patients' perspective of General and Mental Health and a slight positive effect in depression as measured by PHQ-9.Implications for rehabilitationMultiple Sclerosis (MS) decreases physical and non-physical aspects of patients' quality of life perspective.Rehabilitation strategy must take into consideration the non-physical effects of a training intervention.Robotic and Exoskeleton Gait Training has a positive effect in MS patients' non-physical quality of life and a slight positive effect in depression.

Brain connectivity changes underlying depression and fatigue in relapsing-remitting multiple sclerosis: A systematic review

Multiple Sclerosis (MS) is an autoimmune disease affecting the central nervous system, characterised by neuroinflammation and neurodegeneration. Fatigue and depression are common, debilitating, and intertwined symptoms in people with relapsing-remitting MS (pwRRMS). An increased understanding of brain changes and mechanisms underlying fatigue and depression in RRMS could lead to more effective interventions and enhancement of quality of life. To elucidate the relationship between depression and fatigue and brain connectivity in pwRRMS we conducted a systematic review. Searched databases were PubMed, Web-of-Science and Scopus. Inclusion criteria were: studied participants with RRMS (n ≥ 20; ≥ 18 years old) and differentiated between MS subtypes; published between 2001-01-01 and 2023-01-18; used fatigue and depression assessments validated for MS; included brain structural, functional magnetic resonance imaging (fMRI) or diffusion MRI (dMRI). Sixty studies met the criteria: 18 dMRI (15 fatigue, 5 depression) and 22 fMRI (20 fatigue, 5 depression) studies. The literature was heterogeneous; half of studies reported no correlation between brain connectivity measures and fatigue or depression. Positive findings showed that abnormal cortico-limbic structural and functional connectivity was associated with depression. Fatigue was linked to connectivity measures in cortico-thalamic-basal-ganglial networks. Additionally, both depression and fatigue were related to altered cingulum structural connectivity, and functional connectivity involving thalamus, cerebellum, frontal lobe, ventral tegmental area, striatum, default mode and attention networks, and supramarginal, precentral, and postcentral gyri. Qualitative analysis suggests structural and functional connectivity changes, possibly due to axonal and/or myelin loss, in the cortico-thalamic-basal-ganglial and cortico-limbic network may underlie fatigue and depression in pwRRMS, respectively, but the overall results were inconclusive, possibly explained by heterogeneity and limited number of studies. This highlights the need for further studies including advanced MRI to detect more subtle brain changes in association with depression and fatigue. Future studies using optimised imaging protocols and validated depression and fatigue measures are required to clarify the substrates underlying these symptoms in pwRRMS.

The Effects of Aquatic Therapy on Depression, Fatigue, and Balance in Patients with Multiple Sclerosis (MS): a Systematic Review and Meta-Analysis

Background: Fatigue, depression, and balance impairment are common in patients with multiple sclerosis (MS). Aquatic therapy is an exercise program which is effective in improving the well-being of patients with MS. So, we designed this systematic review to estimate the pooled effects of aquatic therapy on depression, fatigue and balance in subjects with MS. Methods:Two independent researchers did a systematic and comprehensive search of PubMed, Scopus, EMBASE, Web of Science, Google Scholar as well as gray literature, including references of the included studies, and conference abstracts. The search was done on October 31st 2022. We extracted data regarding the total number of participants, first author, publication year, country of origin, mean age, EDSS, and results of fatigue, depression and balance. Results:The first search identified 6403 studies. After deleting duplicates, 3347 studies remained, and 86 full texts were evaluated. Ten studies remained for meta-analysis. The pooled standardized mean difference (SMD) of BBS (after-before) was 0.67 (95% CI 0.19-1.16) (I²=11.6%, P=0.3). The pooled SMD of MFIS (after-before) was -0.4 (95% CI -0.71 to -0.09) (I2=21%, P=0.2). The pooled SMD of FSS (after-before) was -1.13 (95% CI -1.95 to -0.3) (I²=82.5%, P=0.003). The pooled SMD of BDI (after-before) was -1.83 (95% CI -2.31 to -1.35) (I²=30.1%, P=0.2). Conclusion:The results of the present systematic review and meta-analysis show that aquatic therapy is effective for depression, fatigue, and balance improvement in subjects with MS.

Cognitive Impairment and Depression in Mastocytosis: A Synthesis of the Literature

PURPOSE OF REVIEW

Symptoms of depression and cognitive dysfunction are commonly reported in mastocytosis. The aims of this review paper are to summarize the current literature on cognitive dysfunction and depressive symptoms, elucidate some of the mechanistic pathways underlying depressive symptoms in mastocytosis, identify gaps in the literature, and offer guidance for future research in this area.

RECENT FINDINGS

The study of cognition and depression in mastocytosis is in its infancy and the methodological flaws of the current literature limit interpretability. There is preliminary evidence that some individuals with mastocytosis might experience mild deficits in memory. On average, depression symptom scores fell within the mild to moderate or sub-syndromal range. Regrettably, only one study utilized a standardized diagnostic instrument to assess major depressive disorder. The authors' tendency to inaccurately equate depressive symptoms with a diagnosis of major depressive disorder presents a notable issue. The prevalence of cognitive deficits and depression appears to be similar to other chronic illnesses. Future work needs to better characterize cognition and characterize "depression" in this population.

MS care: integrating advanced therapies and holistic management

Lifestyle and environmental factors are key determinants in disease causality and progression in neurological conditions, including multiple sclerosis (MS). Lack of exercise, poor diet, tobacco smoking, excessive alcohol intake, social determinants of health, concomitant medications, poor sleep and comorbidities can exacerbate MS pathological processes by impacting brain health and depleting neurological reserves, resulting in more rapid disease worsening. In addition to using disease-modifying therapies to alter the disease course, therapeutic strategies in MS should aim to preserve as much neurological reserve as possible by promoting the adoption of a "brain-healthy" and "metabolically-healthy" lifestyle. Here, we recommend self-regulated lifestyle modifications that have the potential to improve brain health, directly impact on disease progression and improve outcomes in people with MS. We emphasise the importance of self-management and adopting a multidisciplinary, collaborative and person-centred approach to care that encompasses the healthcare team, family members and community support groups.

Autoimmune demyelination alters hypothalamic transcriptome and endocrine function

The hypothalamus is a brain structure that is deputed to maintain organism homeostasis by regulating autonomic function and hormonal production as part of the neuroendocrine system. Dysfunction in hypothalamic activity results in behavioral alterations, depression, metabolic syndromes, fatigue, and infertility. Remarkably, many of these symptoms are associated with multiple sclerosis (MS), a chronic autoimmune disorder of the central nervous system (CNS) characterized by focal demyelination, immune cell infiltration into the brain parenchyma, and neurodegeneration. Furthermore, altered hormonal levels have been documented in MS patients, suggesting the putative involvement of hypothalamic deficits in MS clinical manifestations. Yet, a systematic analysis of hypothalamic function in response to neuroinflammatory stress is still lacking. To fill this gap, here we performed a longitudinal profiling of the hypothalamic transcriptome upon experimental autoimmune encephalomyelitis (EAE)-a murine disease model recapitulating key MS phenotypes at both histopathological and molecular levels. We show that changes in gene expression connected with an anti-inflammatory response start already at pre-onset and persist along EAE progression. Altered levels of hypothalamic neuropeptides were also detected, which possibly underlie homeostatic responses to stress and aberrant feeding behaviors. Last, a thorough investigation of the principal endocrine glands highlighted defects in the main steroidogenic pathways upon disease. Collectively, our findings corroborate the central role of hypothalamic dysfunction in CNS autoimmunity.

Role of NLRP3 Inflammasome in Post-Spinal-Cord-Injury Anxiety and Depression: Molecular Mechanisms and Therapeutic Implications

The majority of research on the long-term effects of spinal cord injury (SCI) has primarily focused on neuropathic pain (NP), psychological issues, and sensorimotor impairments. Among SCI patients, mood disorders, such as anxiety and depression, have been extensively studied. It has been found that chronic stress and NP have negative consequences and reduce the quality of life for individuals living with SCI. Our review examined both human and experimental evidence to explore the connection between mood changes following SCI and inflammatory pathways, with a specific focus on NLRP3 inflammasome signaling. We observed increased proinflammatory factors in the blood, as well as in the brain and spinal cord tissues of SCI models. The NLRP3 inflammasome plays a crucial role in various diseases by controlling the release of proinflammatory molecules like interleukin 1β (IL-1β) and IL-18. Dysregulation of the NLRP3 inflammasome in key brain regions associated with pain processing, such as the prefrontal cortex and hippocampus, contributes to the development of mood disorders following SCI. In this review, we summarized recent research on the expression and regulation of components related to NLRP3 inflammasome signaling in mood disorders following SCI. Finally, we discussed potential therapeutic approaches that target the NLRP3 inflammasome and regulate proinflammatory cytokines as a way to treat mood disorders following SCI.

The relationship between trunk control, spinal posture, and spinal mobility in patients with multiple sclerosis: a cross-sectional study

Background/aim

Trunk control, which plays a key role in balance and mobility, decreases in patients with multiple sclerosis (PwMS) and many parameters such as sensory, motor, and musculoskeletal systems affect trunk control. The aim of this study was to compare trunk control, spinal mobility, and spinal posture in PwMS with healthy controls and investigate the relationship between trunk control with spinal posture and spinal mobility in PwMS.

Materials and methods

The study was completed with 38 PwMS and 38 healthy controls with matched age and sex. Trunk control was evaluated with the Trunk Impairment Scale (TIS). Spinal posture and mobility were evaluated in sagittal and frontal planes using an IDIAG M360 Spinal Mouse. Spinal posture was evaluated in upright, maximum flexion, extension, left and right lateral flexion positions, and spinal mobility was evaluated from upright to flexion, extension, right and left flexion positions in sagittal and frontal planes.

Results

TIS scores, thoracic mobility angles (from upright to flexion and left lateral flexion), lumbar mobility angles (from upright to extension and right lateral flexion) and lumbar posture angle (maximum right lateral flexion) were lower, and thoracic posture angles (upright and maximum extension) were higher in PwMS than healthy controls (p < 0.05). No significant difference was found between other spinal postures and mobility values. In addition, there was only a negative relationship between thoracic spinal mobility from upright to extension and trunk control in PwMS (r = -0.349; p = 0.032).

Conclusion

These findings indicate the importance of early detection of trunk disturbances in PwMS. Thus, even in the early stages of multiple sclerosis, detailed trunk assessment will guide the implementation of comprehensive exercise programs.

Online mindfulness program (COndiVIDere) for people with multiple sclerosis in the time of COVID-19: a pilot longitudinal study

PURPOSE

This study aims to evaluate the feasibility and effectiveness of a mindfulness-based group intervention (The COndiVIDere program) delivered online to people with MS (PwMS) in the time of COVID-19.

MATERIALS AND METHODS

This is a single-arm longitudinal study with a nested qualitative study. The COndiVIDere program is composed of five weekly sessions (1-h each) plus three booster monthly sessions. Data were collected immediately before the beginning of the program, after the five weekly sessions, and at 3- and 6-month follow-ups.

RESULTS

Fifty PwMS participated in the program. Participants improved in anxiety, stress, loneliness and mindfulness ("non-judgmental inner experience" component). Improvements on most outcomes occurred at post-intervention and reached the statistically significant threshold at 3-month follow-up. Mindfulness improvements keep increasing at each time point. Qualitative data confirmed the COndiVIDere program feasibility and the positive psychological impacts on participants. Mindfulness, compassion and the group setting were considered the most important active elements.

CONCLUSIONS

Study findings support COndiVIDere feasibility and effectiveness with PwMS and its broad applicability in this population.

The relation between the symbol digit modalities test, fatigue, depression, and anxiety symptoms in a Belgian MS cohort

BACKGROUND

Multiple sclerosis (MS) is associated with high prevalence of cognitive impairment, ranging from 40 to 80%. The purpose of this single-center retrospective study was to examine the relation between cognitive function, as measured by Symbol Digit Modalities Test (SDMT), with fatigue, anxiety, and depression symptoms in a Belgian cohort of patients with MS.

METHODS

Sociodemographic and clinical data were analyzed in 66 (F:40, M:26) Belgian patients with a diagnosis of MS. The cognitive function was assessed with the oral version of SDMT, depression and anxiety symptoms with the Hospital Anxiety and Depression scale (HAD), fatigue symptoms with the French valid version of the Fatigue Impact Scale in MS (EMIF-SEP), which is a scale composed of four dimensions (cognitive, physical, social, and psychological) allowing a multidimensional evaluation of fatigue.

RESULTS

The multivariate linear regression analysis demonstrated that lower SDMT scores were associated with higher EDSS score and psychological dimension of fatigue symptoms. No association were found between SDMT and anxiety or depression symptoms. Conversely, higher depression and anxiety symptoms were associated with higher total fatigue symptoms, but lower physical dimension of fatigue symptoms. Higher anxiety symptoms were also independently associated with higher social dimension of fatigue symptoms.

CONCLUSION

A complex relationship exists between cognitive performance, fatigue, and neuropsychiatric symptoms in Belgian people with MS. The level of disability and fatigue adversely affects the cognitive function in MS, whereas depression and anxiety seem to not have a significant effect. A more complex relationship exists between fatigue and neuropsychiatric symptoms, with a divergent interplay between the different dimensions of fatigue that supports the multidimensional approach to assessing fatigue in MS.

Real-world effectiveness of fingolimod in patients with multiple sclerosis in Bulgaria

INTRODUCTION

Fingolimod, a sphingosine-1-phosphate receptor agonist used for the treatment of multiple sclerosis (MS). Our goal was to assess the impact of fingolimod on quality of life in patients with relapsing-remitting multiple sclerosis (RRMS) after 2 years of treatment in this real-world study.

PATIENTS AND METHODS

This was a 2-year, prospective, observational study conducted in Bulgaria in RRMS patients treated with fingolimod. Quality of life was assessed using the Bulgarian-language version of the MSQoL-54 scale. The primary endpoint was the change from baseline in the MSQoL-54 score after 2 years of treatment. Secondary endpoints included the change from baseline in the MSQoL-54 score after one year of treatment, furthermore the assessment of depression level using the Hamilton D-17 score.

RESULTS

A total of 87 eligible patients were included in the study with a mean age of 38.7 ± 8.45 years. The median Expanded Disability Status Scale (EDSS) score was 3.5 points. We found statistically significant improvement in 10 subscales at month 12 and in seven subscales at month 24. The mental health composite score increased from 64.0 ± 16.69 points to 67.5 ± 15.94 points at month 24 (p = 0.012). The physical health composite score increased from 61.7 ± 17.61 to 66.3 ± 16.70 (p = 0.001). Depression level measured by the HAM-D17 decreased significantly by month 12 and month 24. The EDSS score decreased or remained stable in more than half of the patients (61.6%). We detected better quality of life in patients with a lower EDSS score.

CONCLUSIONS

Quality of life scores and the depression level are improved in RRMS patients treated with fingolimod over 2 years in real-life setting.

A Comprehensive Evaluation of Multiple Sclerosis-Related Fatigue with a Special Focus on Fatigability

INTRODUCTION

Fatigue is the most common and disabling symptom in multiple sclerosis (MS), being reported by 55% to 78% of patients with MS (PwMS). Etiology of MS-related fatigue remains poorly understood, but an increased neuromuscular fatigability (i.e., greater loss of torque during exercise) could contribute to this phenomenon. This study aimed to characterize the correlates of MS-related fatigue in PwMS using a comprehensive group of physiological and psychosocial measures, with a particular focus on fatigability.

METHODS

Forty-two relapsing-remitting PwMS and 20 healthy subjects were recruited. PwMS were assigned in two groups (high (HF) and low (LF) fatigue) based on two fatigue questionnaires (Fatigue Severity Scale and Modified Fatigue Impact Scale). The main outcomes of this study are derived from incremental cycling completed to task failure (i.e., inability to pedal around 60 rpm). Maximal voluntary contraction (MVC), rating of perceived exertion, and central and peripheral parameters measured using transcranial magnetic and peripheral nerve stimulation were assessed in the knee extensor muscles before, during, and after the fatiguing task. Other potential correlates of fatigue were also tested.

RESULTS

MVC torque decreased to a greater extent for the HF group than LF group after the third common stage of the incremental fatiguing exercise (-15.7% ± 6.6% vs -5.9% ± 13.0%, P < 0.05), and this occurred concurrently with a higher rating of perceived exertion for HF (11.8 ± 2.5 vs 9.3 ± 2.6, P < 0.05). Subjective parameters (depression, quality of life) were worse for HF compared with LF and healthy subjects ( P < 0.001). Moreover, MVC torque loss at the final common stage and maximal heart rate explained 29% of the variance of the Modified Fatigue Impact Scale.

CONCLUSIONS

These results provide novel insight into the relationship between MS-related fatigue and fatigability among PwMS. The HF group exhibited greater performance fatigability, likely contributing to a higher perceived exertion than the LF group when measured during a dynamic task.

The prevalence of depression and anxiety among Iranian people with multiple sclerosis: A systematic review and meta-analysis

BACKGROUND

There is significant inconsistency regarding the prevalence rate of depression and anxiety among people with multiple sclerosis (MS) in Iran. We sought to conduct this comprehensive meta-analysis to assess the prevalence of depression and anxiety in Iranian multiple sclerosis patients.

METHODS

A systematic search was conducted on 14 March 2023 in PubMed/MEDLINE, Web of Science, Scopus, Embase, and Iranian national databases. All studies assessing the prevalence of depression and anxiety among Iranian people with MS were included. We used the NEWCASTLE-OTTAWA tool for quality assessment. We pooled the prevalence of individual studies using the random effect model.

RESULTS

Our systematic search showed 23 articles that meet the eligibility criteria. Most of the included studies were cross-sectional. The most used questionnaire to assess depression and anxiety were Beck Depression Inventory (BDI) and Hospital Anxiety and Depression Scale (HADS), respectively. The overall prevalence of depression and anxiety among Iranian people with MS was 47% (95%CI: 39%-55%%, I2 =94%) and 51% (95%CI: 36%-66%%, I2 =97%), respectively. The results of subgroup and meta-regression analyses showed assessment scale used and the province was significantly associated with the prevalence of the outcomes. Tehran had the most studies published on this topic. The prevalence of depression and anxiety was highest in Kermanshah province. The funnel plot and Egger's regression test did not show a significant source of funnel plot asymmetry for depression (p-value = 0.8138), and anxiety (p-value = 0.8259).

CONCLUSION

Our study indicates that a significant proportion of people with MS in Iran are affected by depression and anxiety.

Internet-delivered cognitive behavioural therapy programme to reduce depressive symptoms in patients with multiple sclerosis: a multicentre, randomised, controlled, phase 3 trial

BACKGROUND

Depression is three to four times more prevalent in patients with neurological and inflammatory disorders than in the general population. For example, in patients with multiple sclerosis, the 12-month prevalence of major depressive disorder is around 25% and it is associated with a lower quality of life, faster disease progression, and higher morbidity and mortality. Despite its clinical relevance, there are few treatment options for depression associated with multiple sclerosis and confirmatory trials are scarce. We aimed to evaluate the safety and efficacy of a multiple sclerosis-specific, internet-based cognitive behavioural therapy (iCBT) programme for the treatment of depressive symptoms associated with the disease.

METHODS

This parallel-group, randomised, controlled, phase 3 trial of an iCBT programme to reduce depressive symptoms in patients with multiple sclerosis was carried out at five academic centres with large outpatient care units in Germany and the USA. Patients with a neurologist-confirmed diagnosis of multiple sclerosis and depressive symptoms were randomly assigned (1:1:1; automated assignment, concealed allocation, no stratification, no blocking) to receive treatment as usual plus one of two versions of the iCBT programme Amiria (stand-alone or therapist-guided) or to a control condition, in which participants received treatment as usual and were offered access to the iCBT programme after 6 months. Masking of participants to group assignment between active treatment and control was not possible, although raters were masked to group assignment. The predefined primary endpoint, which was analysed in the intention-to-treat population, was severity of depressive symptoms as measured by the Beck Depression Inventory-II (BDI-II) at week 12 after randomisation. This trial is registered at ClinicalTrials.gov, NCT02740361, and is complete.

FINDINGS

Between May 3, 2017, and Nov 4, 2020, we screened 485 patients for eligibility. 279 participants were enrolled, of whom 101 were allocated to receive stand-alone iCBT, 85 to receive guided iCBT, and 93 to the control condition. The dropout rate at week 12 was 18% (50 participants). Both versions of the iCBT programme significantly reduced depressive symptoms compared with the control group (BDI-II between-group mean differences: control vs stand-alone iCBT 6·32 points [95% CI 3·37-9·27], p<0·0001, effect size d=0·97 [95% CI 0·64-1·30]; control vs guided iCBT 5·80 points [2·71-8·88], p<0·0001, effect size d=0·96 [0·62-1·30]). Clinically relevant worsening of depressive symptoms was observed in three participants in the control group, one in the stand-alone iCBT group, and none in the guided iCBT group. No occurrences of suicidality were observed during the trial and there were no deaths.

INTERPRETATION

This trial provides evidence for the safety and efficacy of a multiple sclerosis-specific iCBT tool to reduce depressive symptoms in patients with the disease. This remote-access, scalable intervention increases the therapeutic options in this patient group and could help to overcome treatment barriers.

FUNDING

National Multiple Sclerosis Society (USA).

Multiple Sclerosis and Depression: Translation and Adaptation of the Spanish Version of the Chicago Multiscale Depression Inventory and the Study of Factors Associated with Depressive Symptoms

OBJECTIVE

Depressive disorder occurs in up to 50% of persons with Multiple Sclerosis (PwMS). Accurate assessment of depression in MS is essential in clinical settings because depressive symptomatology can affect the clinical course of the disease.

METHODS

We translated, adapted, and tested the Spanish version of the Chicago Multiscale Depression Inventory (CMDI), a specific test to assess depression in neurological disorders. We compare our results with those obtained with previous versions of the questionnaire (English and Italian). Finally, we also analyze the relationship between the results obtained on the CMDI and demographic, clinical, and cognitive variables.

RESULTS

The results obtained with the Spanish version of the CMDI were similar to those observed in previous published versions. We also observed higher depression scores in PwMS (especially in progressive forms) compared with healthy controls. Moreover, depression symptomatology was related to higher disability and fatigue and worse cognitive performance in PwMS.

CONCLUSIONS

The results support the validity of the CDMI in the Spanish population, as well as the association between depression and other characteristic symptoms of MS. These findings also emphasize the importance of good assessment and multidisciplinary treatment of depression in PwMS.

The Early Initiation Advantages of Physical Therapy in Multiple Sclerosis-A Pilot Study

(1) Background: Multiple sclerosis (MS), a chronic progressive neurological disorder which affects the central nervous system (CNS), can result in disorders of all the functions controlled by the CNS: motor, sensory, cognitive and emotional. Physical therapy (PT), conducted through proprioceptive neuromuscular facilitation (PNF) techniques, can be customized to the individual patient's needs and has the potential to improve the patient's evolution. This study aims to establish if PT based on PNF techniques has a beneficial role in MS treatment. (2) Methods: We performed a prospective study on 40 patients who were diagnosed with MS and previously treated only with MS drug treatment (DT). These patients have participated in a PT program throughout one year. At the beginning and at the end of our study, after one year, we have assessed the following parameters: timed walk for 25 feet (Timed 25-Foot Walk test- T25FW test), dexterity of the upper limbs (9-Hole Peg Test-9HPT), disability level (Expanded Disability Status Scale-EDSS) and cognitive function (Paced Auditory Serial Addition Test-PASAT. (3) Results: In subjects in the early stages of MS, lower limb mobility improved significantly, T25FW decreasing from 6.46 to 5.80 (p < 0.001) and upper limb ability increased significantly in the dominant hand, 9HPT decreasing from 17.73 to 16.97 (p = 0.006) and not significantly in the non-dominant hand, 9HPT decreasing from 17.73 to 17.50 (p = 0.255). Furthermore, among these subjects, cognitive performance improved; their PASAT increased from 52.14 to 54.14 (p = 0.036), while the level of disability of these subjects improved only slightly, the EDSS scale evolving from 3.08 to 2.91 (p = 0.650). (4) Conclusions: In patients with early forms of MS, combining DT with a PT program based on PNF techniques results in: regaining muscle strength in the lower limbs, improving coordination while walking, correcting dexterity in the upper limbs and increasing the ability to concentrate.

rTMS ameliorates depression/anxiety-like behaviors in experimental autoimmune encephalitis by inhibiting neurotoxic reactive astrocytes

One third of patients with multiple sclerosis (MS) suffered from depressive symptoms. The pathogenesis of depression in MS patients has been related to innate immune activation in certain regions of the brain such as hippocampus. However, pharmacotherapy lacks sufficient evidence for beneficial effects on depression in MS patients, urging for a novel treatment modality for this mental disorder. Treatment effects of rTMS on depression/anxiety-like behaviors in mice with experimental autoimmune encephalomyelitis (EAE) were assessed by behavioral tests. The role of innate immune response was examined by RNA sequencing, quantitative RT-PCR, and immunofluorescence techniques. Depressive symptom severity and astroglial activation in patients with MS were assessed by Beck Depression Inventory and serum glial fibrillary acidic protein (GFAP), respectively. EAE mice displayed depression/anxiety-like behaviors, which were ameliorated by rTMS. Transcriptome and gene-specific expression analysis of the hippocampus showed significant reduction in transcript levels associated with neurotoxic reactive astrocytes in EAE mice after rTMS treatment. This was confirmed by immunofluorescence studies. Complement component 3d, a marker of neurotoxic reactive astrocytes, was highly expressed in EAE hippocampus, but was reduced to a basal level after rTMS treatment. In patients with MS, astroglial activation, indicated by serum GFAP levels, was significantly elevated in those with moderate or major depressive symptoms. These findings support that the suppression of neurotoxic reactive astrocytes might be a potential target for treatment of depression in patients with MS, and suggest the potential of using rTMS as a potential therapeutic treatment for this disorder.

The moderating roles of self-efficacy and depression in dual-task walking in multiple sclerosis: A test of self-awareness theory

OBJECTIVE

Multiple sclerosis (MS) is a debilitating neurological disease associated with a variety of psychological, cognitive, and motoric symptoms. Walking is among the most important functions compromised by MS. Dual-task walking (DTW), an everyday activity in which people walk and engage in a concurrent, discrete task, has been assessed in MS, but little is known about how it relates to other MS symptoms. Self-awareness theory suggests that DTW may be a function of the interactions among psychological, cognitive, and motor processes.

METHOD

Cognitive testing, self-report assessments for depression and falls self-efficacy (FSE), and walk evaluations [DTW and single-task walk (STW)] were assessed in seventy-three people with MS in a clinical care setting. Specifically, we assessed whether psychological factors (depression and FSE) that alter subjective evaluations regarding one's abilities would moderate the relationships between physical and cognitive abilities and DTW performance.

RESULTS

DTW speed is related to diverse physical and cognitive predictors. In support of self-awareness theory, FSE moderated the relationship between STW and DTW speeds such that lower FSE attenuated the strength of the relationship between them. DTW costs - the change in speed normalized by STW speed - did not relate to cognitive and motor predictors. DTW costs did relate to depressive symptoms, and depressive symptoms moderated the effect of information processing on DTW costs.

CONCLUSIONS

Findings indicate that an interplay of physical ability and psychological factors - like depression and FSE - may enhance understanding of walking performance under complex, real-world, DTW contexts.

Prevalence of comorbidities in patients with multiple sclerosis using administrative data from 2007 to 2016 in Iran

BACKGROUND

Research interest in the impact of comorbidities in MS has been expanding. Based on studies, certain comorbidities are more prevalent in MS population such as depression, anxiety, hypertension and hypercholesterolemia, diabetes, and hypothyroidism.

OBJECTIVE

This study aims to describe the prevalence of comorbidities in MS population based on the health insurance claims data.

METHOD

This retrospective database analysis was conducted using patient-level medicinal and pharmacy claims data from a leading insurance group (Iranian health insurance) in 2007-2016. MS population was identified based on their Disease Modifying Therapies prescribed by a neurologist (qualified to diagnose MS). Comorbidities in MS and non-MS population were assessed by their prescriptions. Crude and age-standardized prevalence rate (ASPR) of coverage of comorbidities in different age and sex groups and their odds ratio versus non-MS population were assessed.

RESULTS

The most common comorbidities were depression (15.50%) and anxiety (10.1%). Hypercholesterolemia, diabetes, hypertension, and hypothyroidism were prevalent in 6%, 3.6%, 3.5%, and 2.7% respectively. Anxiety and depression were more prevalent in middle age group (45-65 years old). But other comorbidities were more prevalent in older age groups. All comorbidities were more prevalent in female except hypertension in patients ≥45 years old. The odds of all comorbidities were higher for male patients with MS rather than their parallel age group in non-MS patients. These also applied for female patients with MS 18-44 years old (except hypertension).

CONCLUSION

Using claims data, the prevalence of taking treatment for selected comorbidities in MS population and their association with sex and age, can guide patients, healthcare providers, and policy makers to help improve MS patients' wellbeing.

Multiple Sclerosis: Inflammatory and Neuroglial Aspects

Multiple sclerosis (MS) represents the most common acquired demyelinating disorder of the central nervous system (CNS). Its pathogenesis, in parallel with the well-established role of mechanisms pertaining to autoimmunity, involves several key functions of immune, glial and nerve cells. The disease's natural history is complex, heterogeneous and may evolve over a relapsing-remitting (RRMS) or progressive (PPMS/SPMS) course. Acute inflammation, driven by infiltration of peripheral cells in the CNS, is thought to be the most relevant process during the earliest phases and in RRMS, while disruption in glial and neural cells of pathways pertaining to energy metabolism, survival cascades, synaptic and ionic homeostasis are thought to be mostly relevant in long-standing disease, such as in progressive forms. In this complex scenario, many mechanisms originally thought to be distinctive of neurodegenerative disorders are being increasingly recognized as crucial from the beginning of the disease. The present review aims at highlighting mechanisms in common between MS, autoimmune diseases and biology of neurodegenerative disorders. In fact, there is an unmet need to explore new targets that might be involved as master regulators of autoimmunity, inflammation and survival of nerve cells.

Saudi Consensus Recommendations on the Management of Multiple Sclerosis: Symptom Management and Vaccination

This article deals with recommendations on the management of symptoms of MS and on the provision of vaccinations in patients receiving disease-modifying therapies (DMTs). Symptoms of MS, such as fatigue, depression, urinary symptoms, spasticity, impairment of gait, and sexual dysfunction, are common in this population. Recognizing and addressing these symptoms is key to maintaining the quality of life of people with MS. Vaccination status should be reviewed and updated prior to initiation of DMTs. In general, vaccination should be avoided for variable periods after the initiation of some DMTs. Live attenuated vaccines are contraindicated and should be considered on a case-by-case basis. These consensus recommendations will present the best practices for vaccination in Saudi Arabia before, during, and after the COVID-19 pandemic. The recommendations will be updated periodically and as needed as new evidence becomes available.

Prospective memory in multiple sclerosis: clinical utility of the Miami Prospective Memory Test

Objective: Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system that frequently affects cognition. Persons with MS (PwMS) complain of difficulties with prospective memory (PM), the capacity to remember to perform an intended action at the appropriate moment in the future. The objective of this study was to assess the clinical utility of the Miami Prospective Memory Test (MPMT) in detecting PM deficits in MS. The test is brief, easy to administer and accessible, and allows direct comparison between scores on event- and time-based conditions. A secondary objective was to examine the relationship between PM performance and cognitive functioning. Method: Eighty-four PwMS between 27 and 78 years old were compared to 50 age-, sex- and education-matched healthy adults on the MPMT. Results: Time-based (TB) scores, but not event-based (EB) scores, were significantly lower in PwMS than in healthy adults. The MPMT showed good internal consistency, and correlations were found with disability assessed by the Expanded Disability Status Scale (EDSS). PM was also correlated with memory and executive/attention functioning. Conclusions: This study supports the clinical utility of the MPMT in assessing the presence of PM deficits in PwMS especially under TB constraints.

Graph-Based Analysis of Brain Connectivity in Multiple Sclerosis Using Functional MRI: A Systematic Review

(1) Background: Multiple sclerosis (MS) is an immune system disease in which myelin in the nervous system is affected. This abnormal immune system mechanism causes physical disabilities and cognitive impairment. Functional magnetic resonance imaging (fMRI) is a common neuroimaging technique used in studying MS. Computational methods have recently been applied for disease detection, notably graph theory, which helps researchers understand the entire brain network and functional connectivity. (2) Methods: Relevant databases were searched to identify articles published since 2000 that applied graph theory to study functional brain connectivity in patients with MS based on fMRI. (3) Results: A total of 24 articles were included in the review. In recent years, the application of graph theory in the MS field received increased attention from computational scientists. The graph-theoretical approach was frequently combined with fMRI in studies of functional brain connectivity in MS. Lower EDSSs of MS stage were the criteria for most of the studies (4) Conclusions: This review provides insights into the role of graph theory as a computational method for studying functional brain connectivity in MS. Graph theory is useful in the detection and prediction of MS and can play a significant role in identifying cognitive impairment associated with MS.

Social Network Characteristics and Correlations With Cognitive, Psychosocial, and Speech Function and Communication Participation for Adults With Multiple Sclerosis: A Pilot Study

PURPOSE

This cross-sectional observational pilot study investigated egocentric social networks for 10 paired sex- and age-matched adults with and without multiple sclerosis (MS). This study also investigated the relationship between social network measures and various disease factors associated with MS. The relationship between social network measures and communication participation restrictions was also examined.

METHOD

Participants completed a seven-item social network survey. Social network structure and composition were quantified. The network organization measures (structure analysis) included the total number of members (network size) and extent to which members are connected (network density). The measured characteristics of people around a participant (composition analysis) included the amount of kin relative to network size (proportion of kin), gender variation (gender diversity index), and age variation (standard deviation of age). Standard clinical neuropsychological, psychosocial, and speech metrics quantified processing speed, memory, depression, fatigue, and sentence intelligibility. Measures of communication participation and MS severity were also obtained.

RESULTS

Matched-pairs tests indicated that the proportion of kin significantly differed between paired participants, whereas all other social network measures were similar. For participants with MS, correlation analyses indicated weak associations between proportion of kin and cognitive, psychosocial, and speech measures. However, strong correlations were found between social network size and processing speed, memory, fatigue, MS severity, and communication participation. Gender diversity index also strongly correlated with depression.

CONCLUSIONS

Results from this pilot study highlight the importance of evaluating egocentric networks in the clinical management of MS, as maintaining nonkin friendships may be difficult for adults with MS making them vulnerable to social isolation. Furthermore, those with small and less diverse networks may experience more severe cognitive and psychosocial problems and limited communication participation.

Anxiety and depression in Charcot-Marie-Tooth disease: data from the Italian CMT national registry

BACKGROUND

There is little information about neuropsychiatric comorbidities in Charcot-Marie-Tooth disease (CMT). We assessed frequency of anxiety, depression, and general distress in CMT.

METHODS

We administered online the Hospital Anxiety-Depression Scale (HADS) to CMT patients of the Italian registry and controls. HADS-A and HADS-D scores ≥ 11 defined the presence of anxiety/depression and HADS total score (HADS-T) ≥ 22 of general distress. We analysed correlation with disease severity and clinical characteristics, use of anxiolytics/antidepressants and analgesic/anti-inflammatory drugs.

RESULTS

We collected data from 252 CMT patients (137 females) and 56 controls. CMT patient scores for anxiety (mean ± standard deviation, 6.7 ± 4.8), depression (4.5 ± 4.0), and general distress (11.5 ± 8.1) did not differ from controls and the Italian population. However, compared to controls, the percentages of subjects with depression (10% vs 2%) and general distress (14% vs 4%) were significantly higher in CMT patients. We found no association between HADS scores and disease duration or CMT type. Patients with general distress showed more severe disease and higher rate of positive sensory symptoms. Depressed patients also had more severe disease. Nineteen percent of CMT patients took antidepressants/anxiolytics (12% daily) and 70% analgesic/anti-inflammatory drugs. Patients with anxiety, depression, and distress reported higher consumption of anxiolytics/antidepressants. About 50% of patients with depression and/or general distress did not receive any specific pharmacological treatment.

CONCLUSIONS

An appreciable proportion of CMT patients shows general distress and depression. Both correlated with disease severity and consumption of antidepressants/anxiolytics, suggesting that the disease itself is contributing to general distress and depression.

Evaluation of the determinants of cognitive dysfunction in patients with multiple sclerosis

Background

Cognitive dysfunction is common among patients with multiple sclerosis (MS); however, the determinants of cognitive dysfunction are still unknown. This study aimed to investigate the determinants of cognitive dysfunction in a relatively large sample of patients with MS for rapid screening.

Results

Fifty-three patients (33.6%) had cognitive dysfunction. According to the Wechsler Memory Scale, patients with relapsing-remitting MS (RRMS) and patients with progressive MS (PMS) had significantly lower scores than the control group. Patients with RRMS compared to the control group were 76.73 ± 8.50 versus 105.58 ± 8.71 (P < 0.01), and patients with PMS compared to the control group were 72.56 ± 6.44 versus 105.58 ± 8.71 (P < 0.01). In patients with RRMS, the factors affecting the emergence of cognitive dysfunction included disability, fatigue, depression, and duration of illness, whereas in patients with PMS, just the disability variable was related to the presence or absence of cognitive dysfunction.

Conclusions

Our findings showed that disability, fatigue, depression, and duration of illness were factors associated with cognitive dysfunction in patients with RRMS. Proper identification of these factors can be helpful in the screening of cognitive dysfunction in this population.

Determining Current Medications Usage within a Cohort of Patients in the UK-A Descriptive Retrospective Study

Swansea University's United Kingdom (UK) Multiple Sclerosis (MS) Register is a platform that contains information on more than 17,600 people with MS living in the UK. The register has been in operation since 2011 and represents comprehensive information about people living with MS in the UK. It is considered the first register of its kind that can link information from patients to clinical data and has been established to answer different information needs about MS. Aim: To elucidate the trends in patterns of medicines currently used by people with MS in the UK MS register. Methods: This study follows an exploratory descriptive design using the UK MS register as data resource. A number of 4516 people completed the EQ-5D survey out of 8736 people who have given their consent to answer online questionnaires which represents around 52% of the register total population. Descriptive analysis and tests were performed with SPSS to address the research objectives. Results: There are several medicine names entered by people with MS in their profiles. These medicines are used either to manage MS symptoms or to treat its associated complications. Among the medicine types revealed in this study, disease modifying drugs (DMDs), muscle relaxants, and anticonvulsants are the medicine types mainly used by people with MS followed by antidepressant and antianxiety medicines. Conclusions: From the antidepressants used most widely, amitriptyline was chosen as a subject medicine for further investigation in the remaining studies of this research due to its high frequency use, the elevated depression rates discovered among people with MS who seek information on it online, and the high online content noted on websites about this medicine.

Effectiveness of a group resilience intervention for people with multiple sclerosis delivered via frontline services

PURPOSE

This study aims to evaluate the effectiveness of an Acceptance and Commitment Therapy-based group resilience intervention (The REsilience and Activities for every DaY program, READY) delivered to people with MS (PwMS) via frontline Italian services.

MATERIALS AND METHODS

This is a single-arm longitudinal study (with a nested qualitative study). READY is composed of seven weekly in-person sessions (2.5-h each) plus a booster session five weeks later. Data were collected immediately before the program, after the booster session, and at 3-months follow-up.

RESULTS

Thirty-three READY groups (237 participants) were run by thirty-three trained psychologists. Participants improved in resilience (primary outcome), anxiety, depression, stress, health-related quality of life (HRQoL), and psychological flexibility and associated processes (acceptance, defusion, and values). Improvements on most outcomes occurred post-intervention and were maintained at a 3-month follow-up. No demographic or illness variables predicted these improvements. Psychological flexibility mediated improvements in resilience, anxiety, depression, stress, and HRQoL. Qualitative data confirmed READY feasibility and the positive psychological impacts on participants.

CONCLUSIONS

Study findings support READY effectiveness with PwMS, its broad applicability in this population, and its delivery through frontline services.IMPLICATIONS FOR REHABILITATIONREADY for MS is a highly structured, brief manualized group intervention.It is effective in improving participants' psychological functioning (resilience, anxiety, depression, stress, HRQoL, psychological flexibility, and related ACT processes).Psychological flexibility mediated the improvements in resilience, anxiety, depression, stress, HRQoL.READY can be effectively delivered through frontline services for PwMS without limitation in terms of participants' demographic and illness characteristics.

Serum and CSF Biomarkers Predict Active Early Cognitive Decline Rather Than Established Cognitive Impairment at the Moment of RRMS Diagnosis

(1) Background: Cognitive impairment (CI) begins early in the evolution of multiple sclerosis (MS) but may only become obvious in the later stages of the disease. Little data is available regarding predictive biomarkers for early, active cognitive decline in relapse remitting MS (RRMS) patients. (2) Methods: 50 RRMS patients in the first 6 months following diagnosis were included. The minimum follow-up was one year. Biomarker samples were collected at baseline, 3-, 6- and 12-month follow-up. Cognitive performance was assessed at baseline and 12-month follow-up; (3) Results: Statistically significant differences were found for patients undergoing active cognitive decline for sNfL z-scores at baseline and 3 months, CSF NfL baseline values, CSF Aβ42 and the Bremso score as well. The logistic regression model based on these 5 variables was statistically significant, χ2(4) = 22.335, p < 0.0001, R2 = 0.671, with a sensitivity of 57.1%, specificity of 97.4%, a positive predictive value of 80% and a negative predictive value of 92.6%. (4) Conclusions: Our study shows that serum biomarkers (adjusted sNfL z-scores at baseline and 3 months) and CSF biomarkers (CSF NfL baseline values, CSF Aβ42), combined with a clinical score (BREMSO), can accurately predict an early cognitive decline for RRMS patients at the moment of diagnosis.

Quantitative spinal cord MRI and sexual dysfunction in multiple sclerosis

Background

Sexual dysfunction (SD) is frequently reported in multiple sclerosis (MS) and is likely related to MS-related damage to the spinal cord (SC).

Objective

To assess associations between SD and quantitative MRI measures in people with MS (pwMS).

Methods

This pilot study included 17 pwMS with SD who completed questionnaires assessing SD, mood, and fatigue. All participants underwent brain, cervical, and thoracic SC-MRI at 3T. Quantitative brain and SC-MRI measures, including brain/SC atrophy, SC lesion count, diffusion-tensor imaging (DTI) indices (fractional anisotropy [FA], mean, perpendicular, parallel diffusivity [MD, λ_⊥, λ_||]) and magnetization-transfer ratio (MTR) were obtained. Associations between quantitative MRI measures and SD were assessed while controlling for the extent of mood and fatigue symptomatology.

Results

Subjects were a mean age of 46.9 years and 29% female. All subjects had self-reported SD (MSISQ-19 = 40.7, SQoL: 55.9) and 65% had a concurrent psychiatric diagnosis. When correlations between SD severity were assessed with individual brain and SC-MRI measures while controlling for psychiatric symptomatology, no associations were found. The only variables showing independent associations with SD were anxiety (p = 0.03), depression (p = 0.05), and fatigue (p = 0.04).

Conclusion

We found no correlations between quantitative MRI measures in the brain and SC and severity of SD in pwMS, but psychiatric symptomatology and fatigue severity demonstrated relationships with SD. The multifactorial nature of SD in pwMS mandates a multidisciplinary approach.

Psychopathological Symptoms Among Chronically Ill Patients During SARS-CoV-2 Pandemic in Poland

Introduction

The global severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic had a drastic psychological and economic impact on the global population. Having a chronic disease during the pandemic is associated with numerous limitations and challenges like regular hospital visits, access to health-care units and getting specialized treatment. In addition, chronically ill patients are at great risk of acquiring the SARS-CoV-2 virus and at experiencing a more severe course of illness, due to comorbid conditions as well as more frequent encounters with health-care workers and other patients in medical facilities. The aim of this study was to examine the psychological disturbances, during the pandemic in chronically ill patients.

Methods

During the cross-sectional survey conducted between May and October 2020, 398 patients with four different chronic conditions (psoriasis, multiple sclerosis and patients who have undergone a kidney transplant or received dialysis). Study sample was examined regarding the occurrence of psychopathological symptoms (General Health Questionnaire 28) and their perceived stress levels (Perceived Stress Scale).

Results

The highest scores were found in the MS group and the lowest scores were found in the kidney transplantation group in every subscale of the GHQ-28. Close to half of the studied population (48.74%, n = 193) patients scored above the cut-off for psychopathology.

Conclusion

As the study was conducted during the SARS-CoV-2 pandemic in Poland, it stands to reason that the pandemic affected the psychological wellbeing of chronically ill patients. A COVID-19 infection, being quarantined and having had contact with a person who was infected, did not significantly affect the outcome measures; however, further research is needed to explore this topic.

Predicting Multiple Sclerosis Outcomes During the COVID-19 Stay-at-home Period: Observational Study Using Passively Sensed Behaviors and Digital Phenotyping

BACKGROUND

The COVID-19 pandemic has broad negative impact on the physical and mental health of people with chronic neurological disorders such as multiple sclerosis (MS).

OBJECTIVE

We presented a machine learning approach leveraging passive sensor data from smartphones and fitness trackers of people with MS to predict their health outcomes in a natural experiment during a state-mandated stay-at-home period due to a global pandemic.

METHODS

First, we extracted features that capture behavior changes due to the stay-at-home order. Then, we adapted and applied an existing algorithm to these behavior-change features to predict the presence of depression, high global MS symptom burden, severe fatigue, and poor sleep quality during the stay-at-home period.

RESULTS

Using data collected between November 2019 and May 2020, the algorithm detected depression with an accuracy of 82.5% (65% improvement over baseline; F₁-score: 0.84), high global MS symptom burden with an accuracy of 90% (39% improvement over baseline; F₁-score: 0.93), severe fatigue with an accuracy of 75.5% (22% improvement over baseline; F₁-score: 0.80), and poor sleep quality with an accuracy of 84% (28% improvement over baseline; F₁-score: 0.84).

CONCLUSIONS

Our approach could help clinicians better triage patients with MS and potentially other chronic neurological disorders for interventions and aid patient self-monitoring in their own environment, particularly during extraordinarily stressful circumstances such as pandemics, which would cause drastic behavior changes.

Unraveling the mystery of white matter in depression: A translational perspective on recent advances

BACKGROUND

Numerous cortical and subcortical structures have been studied extensively concerning alterations of their integrity as well as their neurotransmitters in depression. However, connections between these structures have received considerably less attention.

OBJECTIVE

This systematic review presents results from recent neuroimaging as well as neuropathologic studies conducted on humans and other mammals. It aims to provide evidence for impaired white matter integrity in individuals expressing a depressive phenotype.

METHODS

A systematic database search in accordance with the PRISMA guidelines was conducted to identify imaging and postmortem studies conducted on humans with a diagnosis of major depressive disorder, as well as on rodents and primates subjected to an animal model of depression.

RESULTS

Alterations are especially apparent in frontal gyri, as well as in structures establishing interhemispheric connectivity between frontal regions. Translational neuropathological findings point to alterations in oligodendrocyte density and morphology, as well as to alterations in the expression of genes related to myelin synthesis. An important role of early life adversities in the development of depressive symptoms and white matter alterations across species is thereby revealed. Data indicating that stress can interfere with physiological myelination patterns is presented. Altered myelination is most notably present in regions that are subject to maturation during the developmental stage of exposure to adversities.

CONCLUSION

Translational studies point to replicable alterations in white matter integrity in subjects suffering from depression across multiple species. Impaired white matter integrity is apparent in imaging as well as neuropathological studies. Future studies should focus on determining to what extent influencing white matter integrity is able to improve symptoms of depression in animals as well as humans.

Predictive Value of the Third Ventricle Width for Neurological Status in Multiple Sclerosis

The third ventricle width (3VW) is an easily calculated measure of brain atrophy. The aim of this study was to evaluate the relation of 3VW to cognitive impairment with adjustment for demographic and clinical confounders, including depression, anxiety, and fatigue, as well as to disability in patients with multiple sclerosis (MS). Symbol Digit Modalities Test, California Verbal Learning Test, Brief Visuospatial Memory Test-Revised, Expanded Disability Status Scale (EDSS), Hospital Anxiety and Depression Scale, and Modified Fatigue Impact Scale (MFIS) were analysed in 93 patients with MS. Neuropsychological performance was compared to that of 150 healthy controls. Axial images from 3D FLAIR were used to measure 3VW. In total, 25% of MS patients were impaired in at least two neuropsychological tests. Cognitive impairment and EDSS were associated with 3VW. Age and 3VW were the strongest predictors of cognitive impairment. The multiple regression model including age, 3VW, education, EDSS, and MFIS explained 63% of the variance of neuropsychological tests results, whereas 3VW, age and duration of the disease were significant predictors of EDSS. This study confirms the predictive value of 3VW for neurological status of patients with MS, especially for cognitive impairment after adjustment for demographic and clinical confounders.

Major depression favors the expansion of Th17-like cells and decrease the proportion of CD39+Treg cell subsets in response to myelin antigen in multiple sclerosis patients

BACKGROUND

Mood disorders have been associated with risk of clinical relapses in multiple sclerosis (MS), a demyelinating disease mediated by myelin-specific T cells.

OBJECTIVES

We aimed to investigate the impact of major depressive disorder (MDD) and cytokine profile of T-cells in relapsing remitting MS patients.

METHODS

For our study, plasma and PBMC were obtained from 60 MS patients (30 with lifetime MDD) in remission phase. The PBMC cultures were stimulated with anti-CD3/anti-CD28 beads or myelin basic protein (MBP), and effector and regulatory T cell phenotypes were determined by flow cytometry. The cytokine levels, both in the plasma or in the supernatants collected from PBMC cultures, were quantified by Luminex. In some experiments, the effect of serotonin (5-HT) was investigated.

RESULTS

Here, higher Th17-related cytokine levels in response to anti-CD3/anti-CD28 and MBP were quantified in the plasma and PBMC cultures of the MS/MDD group in comparison with MS patients. Further, elevated frequency of CD4+ and CD8+ T cells capable of producing IL-17, IL-22 and GM-CSF was observed in depressed patients. Interestingly, the percentage of myelin-specific IFN-γ+IL-17+ and IFN-γ+GM-CSF+ CD4+ T cells directly correlated with neurological disabilities. In contrast, the occurrence of MDD reduced the proportion of MBP-specific CD39+Tregs subsets. Notably, the severity of both neurological disorder and depressive symptoms inversely correlated with these Tregs. Finally, the addition of 5-HT downregulated the release of Th17-related cytokines in response to anti-CD3/anti-CD28 and myelin antigen.

CONCLUSIONS

In summary, our findings suggested that recurrent major depression, by favoring imbalances of effector Th17 and Treg cell subsets, contributes to MS severity.

Third wave cognitive behavioural therapies for people with multiple sclerosis: a scoping review

PURPOSE

Multiple sclerosis (MS) is a chronic condition linked to a wide range of psychological difficulties. While traditional cognitive behavioural therapy has been studied extensively with people with MS, much less is known about more recent "third wave" approaches.

METHODS

A scoping review was carried out by performing a systematic search across MEDLINE Complete, PsycINFO, CINAHL, Academic Search Ultimate, and Cochrane Library up to January 2022.

RESULTS

From an initial return of 8306 citations, 35 studies were included, 20 of which were randomised controlled trials (RCTs). These showed that four third wave approaches have been investigated with people with MS to date: acceptance and commitment therapy (ACT), dialectical behaviour therapy (DBT), mindfulness-based stress reduction (MBSR), and mindfulness-based cognitive therapy (MBCT). MBSR and MBCT may be helpful to address a range of psychological difficulties up to three months post-intervention. However, MS-specific adaptations may be required, and more evidence is needed on longer-term effectiveness. Limited evidence is also available for DBT and ACT, but additional research is warranted before any recommendation can be made.

CONCLUSIONS

As third wave approaches keep being refined, further more rigorous investigations are needed to implement them to the benefit of people with MS. Implications for RehabilitationMultiple sclerosis is linked to a wide range of psychological difficulties in adults.Little is currently known on third wave psychotherapies for people with MS.Mindfulness-based stress reduction and mindfulness-based cognitive therapy may be helpful to address a wide range of difficulties in MS.Specific adaptations may be needed to deliver suitable therapies to people with MS.Additional research is warranted to build on preliminary findings for DBT and ACT.

Impact of the covid-19 pandemic on the psychological status and cortisol level of multiple sclerosis patients

This study aimed to compare the changes in psychological status and cortisol level between multiple sclerosis (MS) patients and a healthy control group (HC). One hundred and fifty-five MS patients and 165 HC subjects had completed questionnaires consisting of 36-Item short health survey (SF-36), Hamilton Anxiety Rating Scale (HAM-A), Beck Depression Inventory-II (BDI-II), and fatigue severity score (FSS) before and after (one year from onset) COVID-19 pandemic. The salivary cortisol level was also measured again in 26 MS patients and 14 control individuals. MS patients had lower scores of mental and physical components of quality of life (MCS and PCS), but higher HAM-A, FSS, and BDII scores than HC Before and after COVID-19. There were significant changes in scores of MCS, BDI-II, HAM-A, and FSS after the COVID-19 outbreak in MS patients, but not in PCS score. In HC group, we observed significant changes in scores of MCS, BDI-II, and FSS, but not in scores of PCS and HAM-A. Compared to HC, the MS patients reported greater deterioration in the overall mental health component of their health-related quality of life, and their levels of anxiety and fatigue over the study period. The change of cortisol levels was non-significant with a small effect size.

A group resilience training program for people with multiple sclerosis: Study protocol of a multi-centre cluster-randomized controlled trial (multi-READY for MS)

Introduction

REsilience and Activities for every DaY (READY) is an Acceptance and Commitment Therapy-based group resilience-training program that has preliminary empirical support in promoting quality of life and other psychosocial outcomes in people with multiple sclerosis (PwMS). Consistent with the Medical Research Council framework for developing and evaluating complex interventions, we conducted a pilot randomized controlled trial (RCT), followed by a phase III RCT. The present paper describes the phase III RCT protocol.

Methods and analysis

This is a multi-centre cluster RCT comparing READY with a group relaxation program (1:1 ratio) in 240 PwMS from eight centres in Italy (trial registration: isrctn.org Identifier: ISRCTN67194859). Both interventions are composed of 7 weekly sessions plus a booster session five weeks later. Resilience (primary outcome), mood, health-related quality of life, well-being and psychological flexibility will be assessed at baseline, after the booster session, and at three and six month follow-ups. If face-to-face group meetings are interrupted because of COVID-19 related-issues, participants will be invited to complete their intervention via teleconferencing. Relevant COVID-19 information will be collected and the COVID-19 Peritraumatic Distress scale will be administered (ancillary study) at baseline and 3-month follow-up. Analysis will be by intention-to-treat to show superiority of READY over relaxation. Longitudinal changes will be compared between the two arms using repeated-measures, hierarchical generalized linear mixed models.

Conclusion

It is expected that his study will contribute to the body of evidence on the efficacy and effectiveness of READY by comparing it with an active group intervention in frontline MS rehabilitation and clinical settings. Results will be disseminated in peer-reviewed journals and at other relevant conferences.

Personality traits of patients with multiple sclerosis and their correlation with anxiety and depression levels: A cross‐sectional case–control study

Objective

Multiple sclerosis is a chronic demyelinating disease of the central nervous system that can cause severe disability and impair the quality of life (QoL).

Methods

In the current cross‐sectional, case–control study, we investigated personality traits, anxiety and depression levels, in 101 patients in the case group and 202 individuals as a control group. The personality traits of the participants were collected via the Neuroticism‐Extraversion‐Openness Five‐Factor Inventory (NEO‐FFI) questionnaire. We evaluated the level of anxiety and depression based on the Hospital Anxiety and Depression Scale questionnaire.

Results

Our study showed in patients with disease duration above 1 year, the rates of agreement (29.78), anxiety (8.83), and depression level (6.39) were significantly higher than the control group (27.19, 6.47, and 4.97, respectively). Although patients with disease duration below 1 year showed a higher level of agreement and conscientiousness (29.65 and 34.35, respectively) than controls (26.6 and 30.86, respectively). The level of anxiety and depression in patients with a disability index above 4.5 was significantly higher than patients with a disability index below 1. Patients with a disability index below 1 showed a higher rate of extraversion and agreement and conscientiousness (31.47, 31.53, and 35.07, respectively) than controls (25.5, 26.23, and 3033, respectively). In addition, patients with a disability index above 4.5 showed a higher level of agreement (35.64), conscientiousness (35.5), anxiety (9.64), and depression (7.5) than controls (25.96, 30.71, 6.96, and 4.71, respectively).

Conclusions

In conclusion, anxiety and depression levels were much higher among MS patients compared with controls and the severity of these conditions correlate with the score of the disability index. Therefore, a complete comprehension of these conditions by the neurologist could be vital in improving patients’ QoL and increasing compliance and adherence to pharmacological therapy.

Personality traits of patients with multiple sclerosis and their correlation with anxiety and depression levels: A cross-sectional case-control study

OBJECTIVE

Multiple sclerosis is a chronic demyelinating disease of the central nervous system that can cause severe disability and impair the quality of life (QoL).

METHODS

In the current cross-sectional, case-control study, we investigated personality traits, anxiety and depression levels, in 101 patients in the case group and 202 individuals as a control group. The personality traits of the participants were collected via the Neuroticism-Extraversion-Openness Five-Factor Inventory (NEO-FFI) questionnaire. We evaluated the level of anxiety and depression based on the Hospital Anxiety and Depression Scale questionnaire.

RESULTS

Our study showed in patients with disease duration above 1 year, the rates of agreement (29.78), anxiety (8.83), and depression level (6.39) were significantly higher than the control group (27.19, 6.47, and 4.97, respectively). Although patients with disease duration below 1 year showed a higher level of agreement and conscientiousness (29.65 and 34.35, respectively) than controls (26.6 and 30.86, respectively). The level of anxiety and depression in patients with a disability index above 4.5 was significantly higher than patients with a disability index below 1. Patients with a disability index below 1 showed a higher rate of extraversion and agreement and conscientiousness (31.47, 31.53, and 35.07, respectively) than controls (25.5, 26.23, and 3033, respectively). In addition, patients with a disability index above 4.5 showed a higher level of agreement (35.64), conscientiousness (35.5), anxiety (9.64), and depression (7.5) than controls (25.96, 30.71, 6.96, and 4.71, respectively).

CONCLUSIONS

In conclusion, anxiety and depression levels were much higher among MS patients compared with controls and the severity of these conditions correlate with the score of the disability index. Therefore, a complete comprehension of these conditions by the neurologist could be vital in improving patients' QoL and increasing compliance and adherence to pharmacological therapy.

Association of personality traits with physical function, cognition, and mood in multiple sclerosis

BACKGROUND

Growing literature supports the hypothesis that personality influences health outcomes. Few studies have examined the association between personality traits and key clinical manifestations in persons with multiple sclerosis (pwMS).

OBJECTIVE

To investigate whether personality traits are associated with physical function, cognition, and depression in persons with MS.

METHODS

In this cross-sectional study, we analyzed data from two cohorts (UPMC, n = 365 and CUIMC, n = 129). Participants completed a personality scale (assessing neuroticism, extraversion, openness, agreeableness, and conscientiousness) and validated surveys measuring physical function, cognition, and depression. Stepwise linear regressions were used to evaluate associations between personality traits and outcome measures.

RESULTS

Consistently across cohorts, higher extraversion was associated with better physical function, whereas higher neuroticism was associated with worse depression. In the first cohort, higher extraversion was associated with better cognition, while higher neuroticism was associated with greater risk for memory impairment in the second cohort. Relationships were independent of age and disease duration.

CONCLUSION

Findings suggest a potentially protective role of extraversion, and a harmful role of neuroticism, in MS-specific patient-reported clinical outcomes. Increased understanding of the interplay between personality and health outcomes may inform risk models for physical decline, cognitive impairment, and depression in pwMS.

Psychological impacts of COVID-19 pandemic on individuals living with multiple sclerosis: A rapid systematic review

INTRODUCTION

The global spread of COVID-19 has raised concerns about its possible impact on mental health. People living with multiple sclerosis (PwMS) are considered potentially vulnerable to the mental health effects of the pandemic, as they may be subject to increased social isolation.

AIM

To systematically review the current evidence on the impact of the COVID-19 pandemic on mental health outcomes among PwMS.

METHOD

We searched four major databases (Medline, EMBASE, PsychInfo and Scopus) and the WHO Global Health COVID-19 research database. We included peer-reviewed primary research studies using validated health-related quality of life (HRQOL) and psychometric screening tools to evaluate mental health outcomes among PwMS during the COVID-19 pandemic. Studies reporting data on the prevalence of mental health disorders, severity of psychological symptoms and contributing demographic and clinical factors for PwMS during the COVID-19 pandemic were included.

RESULTS

Our initial search yielded 268 records; 19 studies (13 cross-sectional, 6 longitudinal) were included. Most were conducted during a peak in the pandemic in the host country via an online platform. The main mental health outcomes were depression, anxiety, stress, sleep quality and HRQOL. The included studies used a variety of outcome assessment tools and study designs. The prevalence of mental health issues such as depression, anxiety and stress were high among PwMS during the pandemic. In addition, compared to control populations, PwMS experienced more severe symptoms of depression and stress during the COVID-19 outbreak. However, results from longitudinal studies demonstrate that the severity of mental health symptoms among PwMS during the pandemic were not significantly different compared with the pre-pandemic period.

CONCLUSION

Although mental health issues such as anxiety and depression were common among PwMS during the pandemic, current evidence suggests that mental health among PwMS has not been significantly affected by pandemic-related restrictive measures. Instead, the observed differences may be the result of pre-pandemic differences in prevalence and severity. Where possible, future studies should seek to address the methodological issues identified in the included studies to ensure that data collected during the pandemic can be synthesized into recommendations for policy and practice.

Multimodal Treatment of Nasopharyngeal Carcinoma in Children, Adolescents and Young Adults-Extended Follow-Up of the NPC-2003-GPOH Study Cohort and Patients of the Interim Cohort

Simple Summary

Multimodal treatment of nasopharyngeal carcinoma (NPC) in children and young adults with induction chemotherapy, followed by radiochemotherapy and interferon-β (IFN-β) maintenance, has been successfully applied in studies NPC-91 and NPC-2003 of the German Society of Pediatric Oncology and Hematology (GPOH). We, here, present updated survival rates of the NPC-2003 study cohort after longer follow-up and include 21 additional patients recruited after closure of the study and treated as per the NPC-2003 study protocol (interim cohort) in our survival analysis. Survival rates remain high after extended follow-up and in the larger cohort with EFS and OS of 94% and 97%, respectively, reinforcing the high antitumor efficacy of this multimodal treatment concept. Seven patients with CR after induction therapy received a reduced radiation dose of 54 Gy, and none of them relapsed. Thus, the reduction of radiation dose seems feasible and has the potential to reduce treatment-related late effects in this vulnerable population.

Abstract

Nasopharyngeal carcinoma (NPC) in children and young adults has been treated within two consecutive prospective trials in Germany, the NPC-91 and the NPC-2003 study of the German Society of Pediatric Oncology and Hematology (GPOH). In these studies, multimodal treatment with induction chemotherapy, followed by radio (chemo)therapy and interferon-beta maintenance, yielded promising survival rates even after adapting total radiation doses to tumor response. The outcome of 45 patients in the NPC-2003 study was reassessed after a median follow-up of 85 months. In addition, we analyzed 21 further patients after closure of the NPC-2003 study, recruited between 2011 and 2017, and treated as per the NPC-2003 study protocol. The EFS and OS of 66 patients with locoregionally advanced NPC were 93.6% and 96.7%, respectively, after a median follow-up of 73 months. Seven patients with CR after induction therapy received a reduced radiation dose of 54 Gy; none relapsed. In young patients with advanced locoregional NPC, excellent long-term survival rates can be achieved by multimodal treatment, including interferon-beta. Radiation doses may be reduced in patients with complete remission after induction chemotherapy and may limit radiogenic late effects.

A Quantitative Synthesis of Eight Decades of Global Multiple Sclerosis Research Using Bibliometrics

Bibliometric studies on the field of multiple sclerosis (MS) research are scarce. The aim of this study is to offer an overarching view of the body of knowledge about MS research over eight decades–from 1945 to 2021–by means of a bibliometric analysis. We performed a quantitative analysis of a massive dataset based on Web of Science. The analysis included frequencies, temporal trends, collaboration networks, clusters of research themes, and an in-depth qualitative analysis. A total of 48,356 articles, with 1,766,086 citations were retrieved. Global MS research showed a steady increase with an annual growth rate of 6.4%, with more than half of the scientific production published in the last decade. Published articles came from 98 different countries by 123,569 authors in 3,267 journals, with the United States ranking first in a number of publications (12,770) and citations (610,334). A co-occurrence network analysis formed four main themes of research, covering the pathophysiological mechanisms, neuropsychological symptoms, diagnostic modalities, and treatment of MS. A noticeable increase in research on cognition, depression, and fatigue was observed, highlighting the increased attention to the quality of life of patients with MS. This bibliometric analysis provided a comprehensive overview of the status of global MS research over the past eight decades. These results could provide a better understanding of this field and help identify new directions for future research.

A Narrative Review of Respiratory Impairment, Assessment, and Rehabilitation in Multiple Sclerosis

<b><i>Background:</i></b> Respiratory impairment is a problem seen in people with multiple sclerosis (pwMS) from the early stages of the disease but not frequently recognized by clinicians until the later stages. It is seen in different ways, such as respiratory muscle weakness, change in pulmonary volumes, and decrease in cough efficiency. This situation has consequences affecting individuals’ physical fitness, participation in daily life, and quality of life. <b><i>Summary:</i></b> This review explains possible respiratory impairment mechanisms, related problems, assessment, and rehabilitation approaches in pwMS. <b><i>Key Messages:</i></b> It is recommended a comprehensive assessment of respiratory functions in pwMS regardless of the disease severity and stage. In addition, pulmonary rehabilitation and other exercises can have positive effects on the respiratory functions of pwMS. In future studies, specific training parameters should be determined for pwMS to achieve optimal benefits. There is also a need for studies that apply respiratory muscle training in pwMS who have a high disease severity and limited participation in the activities of daily living.