Estimating annual prevalence of depression and anxiety disorder in multiple sclerosis using administrative data

Clinical dimensions of people with co-occurring obsessive-compulsive and related disorders and multiple sclerosis: a scoping review protocol

INTRODUCTION

Multiple sclerosis (MS) is an immune-mediated demyelinating disease with a significant burden of neuropsychiatric sequelae. These symptoms, including depression and anxiety, are predictors of morbidity and mortality in people with MS. Despite a high prevalence of obsessive-compulsive disorder in MS, potentially shared pathophysiological mechanisms and overlap in possible treatments, no review has specifically examined the clinical dimensions of people with obsessive-compulsive and related disorders (OCRD) and MS. In this scoping review, we aim to map the available knowledge on the clinical dimensions of people with co-occurring OCRD and MS. Understanding the characteristics of this population in greater detail will inform more patient-centred care and create a framework for future studies.

METHODS AND ANALYSIS

We developed a search strategy to identify all articles that include people with co-occurring OCRD and MS. The search strategy (extending to the grey literature) was applied to MEDLINE, Embase, PsycINFO, Cochrane Central Register of Controlled Trials, CINAHL, Web of Science and ProQuest Dissertations & Theses. Records will undergo title and abstract screening by two independent reviewers. Articles meeting inclusion criteria based on title and abstract screening will go on to full-text review by the two independent reviewers. After reaching a consensus about articles for inclusion in the final review, data will be extracted using a standardised extraction form. The extracted data will include clinical characteristics of patients such as age, gender, medication use and severity of MS, among others.

ETHICS AND DISSEMINATION

This scoping review does not require research ethics approval. Results will be shared at national and/or international conferences, in a peer-reviewed journal publication, in a plain language summary and in a webinar for the general public.

A longitudinal study of distress symptoms and work impairment in immune-mediated inflammatory diseases

OBJECTIVE

We investigated the association between distress symptoms (pain, fatigue, depression, anxiety) and work impairment in four patient populations: multiple sclerosis (N = 107), rheumatoid arthritis (N = 40), inflammatory bowel disease (N = 136) and psychiatric disorders (N = 167).

METHODS

Four waves of data collection were completed over three years. The relationship between distress symptoms and overall work impairment was evaluated with univariate and multivariable quantile logistic regression at the 25th, 50th and 75th percentiles. Models were fit to participant average scores and change scores on distress symptom measures. Covariates included sociodemographic factors, comorbidity, physical disability and cognitive function.

RESULTS

In the primary univariate analyses of overall work impairment at the 50th percentile, greater severity of distress symptoms was associated with greater work impairment: pain (average β = 0.27, p < 0.001; change β = 0.08, p < 0.001), fatigue (average β = 0.21, p < 0.001; change β = 0.09, p < 0.001) depression (average, β = 0.35, p < 0.001; change, β = 0.16, p < 0.001), anxiety (average, β = 0.24, p < 0.001; change, β = 0.08, p < 0 0.01). Findings were similar in multivariable analyses.

CONCLUSION

Pain, fatigue, depression, and anxiety symptoms are important determinants of work impairment in persons with immune-mediated diseases and persons with psychiatric disorders. Successful clinical management of these symptoms has potential to improve work-related outcomes across IMIDs.

The prevalence of major depression and generalized anxiety disorder in patients with multiple sclerosis in Saudi Arabia: a cross-sectional multicentered study

Background

Multiple sclerosis (MS) is an autoimmune disease characterized by chronic, progressive neurodegeneration of the central nervous system (CNS), and it is the most common inflammatory neurological disease affecting young adults. Given the chronic, progressive nature of the disease, psychiatric disorders are more prevalent among these patients, as reported in the literature; however, data in Saudi Arabia are limited. This study aimed to estimate the prevalence of major depression and generalized anxiety disorder in patients with MS and their association with different patient demographics.

Methods

This was a cross-sectional, multicentered study that included adult patients with MS from 30 June 2021 to 30 June 2022. Participants were interviewed in person and asked to complete a survey that included general demographics, the Patient Health Questionnaire-9 (PHQ-9), and the Generalized Anxiety Disorder-7 (GAD-7) questionnaire. Other variables related to the patients' conditions, such as MS type and Expanded Disability Status Scale (EDSS) score, were collected from the patient's electronic records. Descriptive statistics were performed, and associations were made using the chi-square, Fisher's exact, and analysis of variance tests, as appropriate.

Results

A total of 192 participants were included in this study. Based on a cutoff score of >10 on the GAD-7 and PHQ-9 scales, the prevalence of generalized anxiety disorder was 26.1% (50), with the majority of participants having minimal anxiety (40%); meanwhile, the prevalence of major depression was 42.7% (n = 82), and most of them had mild depression (30%). Female participants scored significantly higher compared to men on the GAD-7 scale (p = 0.0376), but not on the PHQ-9 scale (p = 0.1134). In addition, no statistically significant association was detected between functional disability (EDSS score) and prevalence of anxiety and depression.

Conclusion

This study demonstrated a high prevalence of generalized anxiety disorder and major depression among patients with MS compared with that in the general population, with women being more affected. As these comorbid disorders could negatively affect the disease course, screening is of paramount significance.

Impact of depression on the perception of fatigue and information processing speed in a cohort of multiple sclerosis patients

BACKGROUND

Information processing speed is commonly impaired in people with multiple sclerosis (PwMS). However, depression and fatigue can affect the cognitive profile of patients: fatigue has a negative impact from the disease's earliest stage and a reduced information processing speed is often associated with higher levels of depression. Therefore, the aim of this study was to investigate the correlations between information processing speed and physical fatigue in a cohort of Italian PwMS from a single center, considering the effect of depression.

METHODS

Two hundred (W = 128; mean age = 39.83 years; SD = 11.86) PwMS, from the Bari University Hospital, underwent testing for processing speed (Symbol Digit Modalities Test [SDMT]), fatigue level (Fatigue Severity Scale [FSS]), and depression (Beck's Depression Inventory [BDI]).

RESULTS

Statistically significant correlations emerged between SDMT and FSS, SDMT and BDI, FSS and BDI. Mediation analyses revealed that while physical fatigue had no significant direct negative effect on information processing speed (z=-0.891; p > 0.05), depression predicted the relationship between fatigue and information processing speed (z=-2.181; p < 0.05).

CONCLUSION

Our findings showed that cognitive performance at SDMT was not affected by patients' perceived level of physical fatigue, but by depression. The presence of a high BDI score mediates the physical fatigue on cognitive performance impact.

The manifestation of affective symptoms in multiple sclerosis and discussion of the currently available diagnostic assessment tools

INTRODUCTION

In addition to physical and cognitive symptoms, patients with multiple sclerosis (MS) have an increased risk of experiencing mental health problems.

METHODS

This narrative review provides an overview of the appearance and epidemiology of affective symptoms in MS such as depression, anxiety, bipolar disorder, euphoria, and pseudobulbar affect. Furthermore, the association between affective symptoms and quality of life and the currently used diagnostic instruments for assessing these symptoms are considered whereby relevant studies published between 2009 and 2021 were included in the review.

RESULTS

Patients with mild and moderate disability more frequently reported severe problems with depression and anxiety than severe mobility problems. Apart from the occurrence of depression, little is known about the association of other affective symptoms such as anxiety, bipolar disorder, euphoria, and pseudobulbar affect and subsyndromal symptoms, which fail to meet the diagnostic criteria but are nevertheless a significant source of distress. Although there are a few recommendations in the research to perform routine screenings for diagnosable affective disorders, a standardized diagnostic procedure to assess subsyndromal symptoms is still lacking. As the applied measurements are diverse and show low accuracy to detect these symptoms, patients who experience affective symptoms are less likely to be identified.

DISCUSSION

In addition to the consideration of definite psychiatric diagnoses, there is an unmet need for a common definition and assessment of disease-related affective symptoms in MS. Future studies should focus on the improvement and standardization of a common diagnostic procedure for subsyndromal affective symptoms in MS to enable integrated and optimal care for patients.

Diagnosis concealment is prevalent in MS, and associated with diagnosis experience

BACKGROUND

Receiving a diagnosis of multiple sclerosis (MS) can be stressful; later, patients may conceal their diagnosis. Here, we aimed to (1) assess prevalence of disclosure and concealment behaviors, and (2) explore whether diagnosis experience is associated with later concealment and if MS provider engagement on this topic modifies concealment.

METHODS

In a survey-based study, MS patients completed DISCO-MS assessing disclosure and concealment and responded to questions about diagnosis experience and practitioner attention to disclosure. Frequency analysis and Pearson's correlations were used in exploratory analyses.

RESULTS

428 adults with MS participated. 49% (N = 201) conceal their diagnosis. Higher education [t(405) = 3.66, p < 0.001], younger age (r = -0.15, p = 0.002), and shorter disease duration (r = -0.18, p = 0.010) were associated with higher concealment. 39% (N = 159) anticipate negative consequences of disclosure. Individuals reporting positive diagnosis experience (26%, N = 102) were less likely to conceal later in disease course compared to those with negative experience (34%, N = 136) [t(233) = 2.483, p = 0.014]. Patients whose MS providers discussed disclosure (23%, N = 73) anticipated less negative consequences of disclosure [t(323) = 2.475, p = 0.014].

CONCLUSIONS

Diagnosis concealment is common in MS. Favorable diagnosis experience and provider attention to the topic of disclosure throughout the MS disease course may influence diagnosis concealment.

Feasibility trial of a telehealth support group intervention to reduce anxiety in multiple sclerosis

OBJECTIVE

Anxiety is common among persons with MS (PwMS), but widely accepted treatments are lacking. Group-based interventions delivered via telehealth are an accessible treatment option requiring clinical trial evidence to support feasibility and initial efficacy. We conducted a pilot feasibility trial of an online support group intervention to reduce anxiety in PwMS.

METHODS

A non-randomized, parallel arm clinical trial was conducted. A total of 31 PwMS were enrolled: 20 completed a 12-week telehealth-delivered support group intervention and 11 were assigned to a survey-only control group. Primary feasibility outcomes were adherence and completion rates. Primary efficacy outcome was anxiety, secondary outcomes were depression, loneliness, distress, self-efficacy, stress, and quality of life.

RESULTS

Twenty-six participants completed the study. Intervention group adherence (75%) and completion (85%) rates were acceptable. Results indicated a medium size between-group effect, suggesting a greater reduction in anxiety in the intervention group compared to the control group [U = 39.50, p = 0.045, r = 0.39]. No group differences in other outcomes were observed.

CONCLUSION

A telehealth-delivered support group intervention appears feasible for further study and shows initial efficacy for the reduction of anxiety in PwMS.

Use of Benzodiazepines and Z-Drugs in Multiple Sclerosis

Objective

Use of benzodiazepines and Z-drugs (non-benzodiazepine sedative hypnotics) is controversial due to adverse health outcomes in the general population. However, little is known about their use in people with multiple sclerosis (MS). We estimated the incidence and prevalence of benzodiazepine and Z-drug use (jointly BZD) in the MS population as compared to an age-, sex- and geographically-matched population without MS, and examined the association of mood/anxiety disorders with the use of BZD over a twenty-year period.

Methods

Using administrative data from Manitoba, Canada, we identified 2,985 persons with incident MS and 14,891 persons without MS matched 5:1 on sex, birth year and region. We applied validated case definitions to identify persons with any mood/anxiety disorder. Dispensations of BZD were identified. To assess the association between MS, mood/anxiety disorders and BZD use we constructed generalized linear models adjusting for age, sex, index year, socioeconomic status, urban/rural residence, physical comorbidities, and health care use. We also examined patterns of BZD use.

Results

In 2016, the crude incidence of benzodiazepine use in the MS cohort was 2.10% (95%CI: 1.43–2.98%), 1.49-fold higher than in the non-MS cohort (1.41%; 95%CI: 1.18–1.67%). The crude incidence of Z-drug use in the MS cohort was 1.77% (95%CI: 1.20–2.51%), 1.78-fold higher than in the non-MS cohort (0.99%; 95%CI: 0.81–1.21%). After adjusting for covariates, among individuals without an active mood/anxiety disorder, the MS cohort had a 39% increased incidence rate of benzodiazepine use and a 72% increased incidence rate of Z-drug use as compared to the non-MS cohort. Among individuals with an active mood/anxiety disorder, the incidence of BZD use did not differ between the MS and non-MS cohorts. A higher proportion of people with MS used BZD for ≥6 months than people without MS.

Conclusion

Use of BZD is more common in people with MS than in general population controls, and use of these agents is in persons with MS is often chronic.

Researching COVID-19 in progressive MS requires a globally coordinated, multi-disciplinary and multi-stakeholder approach-perspectives from the International Progressive MS Alliance

Background

The COVID-19 pandemic has reinforced the importance of research for the health of our society and highlighted the need for stakeholders of the health research and care continuum to form a collaborative and interdependent ecosystem.

Objective

With the world still reeling from waves of the COVID-19 pandemic and adapting to the vaccine rollout at widely different rates, the International Progressive MS Alliance (hereafter Alliance) organized a meeting (April 2021) to consider how the Covid-19 pandemic impacts the health and well-being of people with progressive Multiple Sclerosis (MS).

Methods

We invited the Alliance stakeholders and experts to present what they have learned about SARS-CoV-2 infection and progressive MS and to define future scientific priorities.

Results

The meeting highlighted three priorities for additional focus: (1) the impact of Disease Modifying Therapies (DMTs) on the risk of COVID-19 and on the efficacy of COVID-19 vaccines in people with progressive MS; (2) the long-term impact of COVID-19 and COVID-19 vaccines on the biology of progressive MS; and (3) the impact on well-being of people with progressive MS.

Conclusion

This paper's calls to action could represent a path toward a shared research agenda. Multi-stakeholder and long-term investigations will be required to drive and evolve such an agenda.

The psychological impact of Covid-19 pandemic on people with Multiple Sclerosis: a meta-analysis

Background

Covid-19 pandemic caused relevant psychological consequences in the general population. Since people with Multiple Sclerosis (pwMS) are usually at higher risk of psychological distress than age-matched healthy controls (HC), a meta-analytic study was conducted, aimed at evaluating i) differences between pwMS and HC in the psychological variables during the pandemic, ii) differences in the levels of anxiety, depression, stress, sleep disturbances and quality of life before and during the Covid-19 pandemic in pwMS.

Methods

The literature search on three electronic databases yielded 196 studies (113 after the duplicates removal). Seven studies compared psychological variables between pwMS and HC during the pandemic, while seven studies evaluated the pre- vs during the pandemic differences in pwMS. The following outcomes were selected: depression, anxiety, physical QoL, mental QoL, stress, sleep quality/disturbances. Mean weighted effect sizes (ES) were calculated using Hedges'g, via Prometa3 software.

Results

During the pandemic, pwMS showed higher levels of depression (g = 0.51, p=.001), anxiety (g = 0.41, p=.032), and stress (g = 0.51, p=.016) compared to HC. The comparison on psychological outcomes before and during the pandemic in pwMS revealed no significant increase during the pandemic on levels of anxiety (g = 0.08, p=.380), depression (g = 0.02, p=.772), mental QoL (g= -0.14, p=.060), physical QoL (g = 0.00, p=.986), whereas sleep quality deteriorated during the pandemic (g = 0.52, p<.001).

Conclusions

In agreement with pre-pandemic literature, pwMS showed higher levels of psychological distress than HC also during the Covid-19 pandemic. Contrariwise, longitudinal studies revealed that, in pwMS, the only psychological-associated variable that worsened significantly was the sleep quality, but this outcome was evaluated only in two studies. Future studies will have to assess/evaluate the long-term psychological consequences of the pandemic on 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.

Multiple Sclerosis in Saudi Arabia: Clinical, Social, and Psychological Aspects of the Disease

Introduction

Multiple sclerosis (MS) is a chronic autoimmune disorder that affects the central nervous system characterized by demyelinating lesions that are disseminated in space and time. Depression is a common symptom in MS, and the pathogenesis is multifactorial. In Saudi Arabia, there is limited current literature about the incidence and relationship between depression and MS. This study is an attempt meant to address the point prevalence of depression, risk factors, and relationship to disease-modifying therapy. In addition, we describe several clinical, nutritional, and social aspects of MS.

Methods

A descriptive cross-sectional study was conducted in Jeddah, Saudi Arabia. The target sample in this study consisted of patients in Saudi Arabia with MS. Data collected included a depression questionnaire based on PHQ9, compliance on therapy, the preferred therapy, and the impact of the disease on daily activity and economic state.

Results

A total of 341 Saudi MS patients were enrolled in the present study. The gender distribution showed that 65.4% (n=223) of the study population were females. The mean age of the patients was 34.80±9.907 years. Most of the patients who were included in this study (95.6%) had depressive symptoms in variant levels. Variable changes in depression levels were detected in both genders specifically moderate depression was most common in males (33%) while females had moderately severe depression (38%). Numbers of relapses, future vision, and changes in workout were associated with statistically significant depression levels.

Conclusion

Depressive symptoms are common in patients with MS. Although all disease-modifying therapies are available in Saudi Arabia, MS clinics with multidisciplinary care are not yet efficiently activated. Non-pharmacological interventions such as smoking cessation, exercise, and psychological health should be part of the management of any patient with MS.

Effect of comorbid mood and anxiety disorders on breast and cervical cancer screening in immune-mediated inflammatory disease

We aimed to examine rates of breast and cervical cancer screening in women with immune-mediated inflammatory diseases (IMID), including inflammatory bowel disease (IBD), multiple sclerosis (MS) and rheumatoid arthritis (RA) versus a matched cohort with IMID; and examine the association of psychiatric comorbidity with screening in these populations. We conducted a retrospective cohort study in Manitoba, Canada using administrative data. We identified women with IBD, MS and RA, and controls without these IMID matched on age and region. Annually, we identified individuals with any active mood/anxiety disorder. Using physician claims, we determined the proportion of each cohort who had cervical cancer screening within three-year intervals, and mammography screening within two-year intervals. We modeled the difference in the proportion of the IMID and matched cohorts who underwent mammography; and pap tests using log-binomial regression with generalized estimating equations, adjusting for sociodemographics, comorbidity and immune therapy use. We tested for additive interactions between cohort and mood/anxiety disorder status. During 2006–2016, we identified 17,230 women with IMID (4,623 with IBD, 3,399 with MS, and 9,458 with RA) and 85,349 matched controls. Having an IMID was associated with lower (-1%) use of mammography; however, this reflected a mixture of more mammography in the IBD cohort (+2.9%) and less mammography in the MS (-4.8 to -5.2%) and RA (-1.5%) cohorts. Within the IBD, MS and RA cohorts, having an active mood/anxiety disorder was associated with more mammography use than having an inactive mood/anxiety disorder. The MS and RA cohorts were less likely to undergo Pap testing than their matched cohorts. In the absence of an active mood/anxiety disorder, the IBD cohort was more likely to undergo Pap testing than its matched cohort; the opposite was true when an active mood/anxiety disorder was present. Among women with an IMID, mood/anxiety disorder influence participation in cancer screening.

Multiple sclerosis is associated with higher comorbidity and health care resource use: A population-based, case-control study in a western Mediterranean region

BACKGROUND AND PURPOSE

Comorbidities are common in multiple sclerosis (MS), and have been associated with worse outcomes and increased health care resource usage. We studied the frequency of comorbidities and adverse health behaviors (AHBs) in MS patients in the Mediterranean region of Catalonia.

METHODS

This population-based, case-control study used primary health care information covering 80% of Catalonia's population. Cases were matched by age/sex with randomly chosen controls (ratio = 1:5). Demographic information, comorbidities, AHBs, annual visits, sick leave days, and medication dispensing were studied. The association of comorbidities with MS and the profile of comorbidities according to sex within MS cases were assessed with multivariate logistic regression models, after adjusting for confounding variables. Health care resource usage was analyzed in MS cases compared to controls, and within MS cases in those with compared to those without comorbidities.

RESULTS

Five thousand five hundred forty-eight MS cases and 27,710 controls (70% female, mean age = 48.3 years) were included. Stroke (odds ratio [OR] = 1.54, 95% confidence interval [CI] = 1.17-1.99), epilepsy (OR = 2.46, 95% CI = 1.94-3.10), bipolar disorder (OR = 1.67, 95% CI = 1.17-2.36), and depression (OR = 1.83, 95% CI = 1.70-1.98) were more frequent in MS. Cases were more prone to smoking but less to alcohol intake. Among cases, psychiatric comorbidities were more frequent in women, whereas cardiovascular diseases and AHBs were more frequent in men. MS patients, particularly with comorbidities, had higher health care resource usage than controls.

CONCLUSIONS

Psychiatric comorbidities, stroke, epilepsy, and AHBs are more common in MS patients than in the general population in the western Mediterranean region of Catalonia. The presence of comorbidities increases the health care resource usage in MS patients.

Mental health of people with multiple sclerosis during the COVID-19 outbreak: A prospective cohort and cross-sectional case-control study of the UK MS Register

BACKGROUND

People with MS (pwMS) have had higher rates of anxiety and depression than the general population before the COVID-19 pandemic, placing them at higher risk of experiencing poor psychological wellbeing during the pandemic.

OBJECTIVE

To assess mental health and its social/lifestyle determinants in pwMS during the first wave of the outbreak in the United Kingdom.

METHODS

This is a community-based, prospective longitudinal cohort and cross-sectional case-control online questionnaire study. It includes 2010 pwMS from the UK MS Register and 380 people without MS.

RESULTS

The Hospital Anxiety and Depression Scale scores of pwMS for anxiety and depression during the outbreak did not change from the previous year. PwMS were more likely to have anxiety (using General Anxiety Disorder-7) and/or depression (using Patient Health Questionnaire-9) than controls during the outbreak (OR: 2.14, 95% CI: 1.58-2.91). PwMS felt lonelier (OR: 1.37, 95% CI: 1.04-1.80) reported worse social support (OR: 1.90, 95% CI: 1.18-3.07) and reported worsened exercise habits (OR: 1.65, 95% CI: 1.18-2.32) during the outbreak than controls.

CONCLUSION

Early in the pandemic, pwMS remained at higher risk of experiencing anxiety and depression than the general population. It is important that multidisciplinary teams improve their support for the wellbeing of pwMS, who are vulnerable to the negative effects of the pandemic on their lifestyle and social support.

Depression in multiple sclerosis: Is one approach for its management enough?

BACKGROUND

Major depression disorder (MDD) and severe depression symptoms are highly prevalent in multiple sclerosis (MS). Depression can worsen symptoms of MS and is associated with significantly reduced quality of life and increased risk of suicide. Currently, there is no gold-standard, single treatment available for depression in MS. Pharmacotherapy, cognitive behavior therapy (CBT), and exercise training individually are moderately, yet incompletely, efficacious for managing depression in the general population and MS.

PURPOSE

This review provides an overview of evidence from meta-analyses and systematic reviews for current treatments of depression in persons with MS. This review further develops the rationale for using a combinatory treatment approach in persons with MS.

METHODS

We performed a narrative review of meta-analyses and systematic reviews regarding the current state of evidence for the three most common treatments of depression in persons with MS (i.e., antidepressant medication, cognitive-behavior therapy, and exercise training). We provide a concise assessment of the overall effect of these treatments on depression in the general population and then persons with MS. We further note short-comings of research on these treatments for depression.

CONCLUSION

There is no single, gold-standard treatment for depression in MS, and we proposed that combinatory treatments should be considered for the management of depression in MS. However, there is a paucity of evidence for the use of combinatory therapy on depression and its outcomes in persons with MS, and this supports direct examination of the feasibility and efficacy of such combinatory approaches for MDD in MS.

The emotional disorders associated with multiple sclerosis

Multiple sclerosis (MS) is associated with a high prevalence of emotional and mood disorders. Emotional disorders may worsen during illness progression and affect the quality of life of patients and their families. MS is often associated with depression, with an increased risk of suicide, poor adherence to treatment, decreased functional status, and quality of life. The diagnosis and treatment of emotional and mood disorders in these patients is often challenging since several symptoms of these disorders overlap with those of MS. Other prevalent emotional disorders in MS include bipolar disorder, anxiety disorders, emotional blunting (apathy), and pseudobulbar affect. Early recognition and treatment of these comorbidities could contribute to the reduction of disability and even to decreased mortality. The aim of this chapter is to provide an up-to-date review of mood and emotional disorders that are often associated with MS, focusing on their epidemiology, clinical features, pathogenesis, assessment, and treatment. The interplay between the psychosocial impact of the chronic disability and the demyelinating structural lesions of the brain in precipitating emotional and mood disorders is discussed, as well as its implications for diagnosis and treatment.

The Impact of Psychiatric Comorbidity on Health Care Utilization in Inflammatory Bowel Disease: A Population-based Study

BACKGROUND

Inflammatory bowel disease (IBD) is associated with an increase in psychiatric comorbidity (PC) compared with the general population. We aimed to determine the impact of PC on health care utilization in persons with IBD.

METHODS

We applied a validated administrative definition of IBD to identify all Manitobans with IBD from April 1, 2006, to March 31, 2016, and a matched cohort without IBD. A validated definition for PC in IBD population was applied to both cohorts; active PC status meant ≥2 visits for psychiatric diagnoses within a given year. We examined the association of active PC with physician visits, inpatient hospital days, proportion with inpatient hospitalization, and use of prescription IBD medications in the following year. We tested for the presence of a 2-way interaction between cohort and PC status.

RESULTS

Our study matched 8459 persons with IBD to 40,375 controls. On crude analysis, IBD subjects had ≥3.7 additional physician visits, had >1.5 extra hospital days, and used 2.1 more drug types annually than controls. Subjects with active PC had >10 more physician visits, had 3.1 more hospital days, and used >6.3 more drugs. There was a synergistic effect of IBD (vs no IBD) and PC (vs no PC) across psychiatric disorders of around 4%. This synergistic effect was greatest for anxiety (6% [2%, 9%]). After excluding psychiatry-related visits and psychiatry-related hospital stays, there remained an excess health care utilization in persons with IBD and PC.

CONCLUSION

Inflammatory bowel disease with PC increases health care utilization compared with matched controls and compared with persons with IBD without PC. Active PC further increases health care utilization.

Effect of mood and anxiety disorders on health care utilization in multiple sclerosis

Background:

Little is known about the effects of changes in the presence or absence of psychiatric disorders on health care utilization in multiple sclerosis (MS).

Objective:

To evaluate the association between “active” mood and anxiety disorders (MAD) and health care utilization in MS.

Methods:

Using administrative data from Manitoba, Canada, we identified 4748 persons with MS and 24,154 persons without MS matched on sex, birth year, and region. Using multivariable general linear models, we evaluated the within-person and between-person effects of any “active” MAD on annual physician visits, hospital days, and number of drug classes dispensed in the following year.

Results:

Annually, the MS cohort had an additional two physician visits, two drug classes, and nearly two more hospital days versus the matched cohort. Individuals with any MAD had more physician visits, had hospital days, and used more drug classes than individuals without a MAD. Within individuals, having an “active” MAD was associated with more utilization for all outcomes than not having an “active” MAD, but the magnitude of this effect was much smaller for visits and drugs than the between-person effect.

Conclusion:

Within individuals with MS, changes in MAD activity are associated with changes in health services use.

Dissociable cognitive patterns related to depression and anxiety in multiple sclerosis

BACKGROUND

Individuals with multiple sclerosis (MS) frequently present with depression and anxiety, as well as cognitive impairment, challenging clinicians to disentangle interrelationships among these symptoms.

OBJECTIVE

To identify cognitive functions associated with anxiety and depression in MS.

METHODS

Mood and cognition were measured in 185 recently diagnosed patients (Reserve Against Disability in Early Multiple Sclerosis (RADIEMS) cohort), and an independent validation sample (MEM CONNECT cohort, n = 70). Partial correlations evaluated relationships of cognition to anxiety and depression controlling for age, sex, education, and premorbid verbal intelligence.

RESULTS

In RADIEMS cohort, lower anxiety was associated with better nonverbal memory (rp = -0.220, p = 0.003) and lower depression to better attention/processing speed (rp = -0.241, p = 0.001). Consistently, in MEM CONNECT cohort, lower anxiety was associated with better nonverbal memory (rp = -0.271, p = 0.028) and lower depression to better attention/processing speed (rp = -0.367, p = 0.002). Relationships were unchanged after controlling for T2 lesion volume and fatigue.

CONCLUSION

Consistent mood-cognition relationships were identified in two independent cohorts of MS patients, suggesting that cognitive correlates of anxiety and depression are separable. This dissociation may support more precise models to inform treatment development. Treatment of mood symptoms may mitigate effects on cognition and/or treatment of cognition may mitigate effects on mood.

Comorbidity in Multiple Sclerosis

Comorbidities in patients with multiple sclerosis (MS) has become an area of increasing interest in the recent years. A comorbidity is defined as any additional disease that coexists in an individual with a given index disease and that is not an obvious complication of the index disease. The aim of this review is to describe the current evidence regarding the range of comorbidities in the population with MS reported in different countries and the current knowledge about the influence of comorbidities on the clinical features and therapeutic challenges in MS. Certain comorbidities are more prevalent in people with MS such as depression, anxiety, cerebro- and cardiovascular diseases, and certain autoimmune disorders such as diabetes, thyroid disease, and inflammatory bowel disease. A previous perception of a trend toward a lower overall risk of cancer in patients with MS appears to be challenged, but there is no evidence on any higher occurrence of malignancies in the population with MS. Comorbidities may modify the clinical presentation of MS, and have implications for treatment choice, adherence, and outcome. Several comorbid conditions are associated with increased disability progression, including diabetes, hypertension, and chronic obstructive pulmonary disease. Comorbidities are common in MS from the time of diagnosis and may account for some of the heterogeneity observed in MS, including diagnostic delay, clinical presentation, degree of disability progression, rate of health care utilization, working ability, employment status, and quality of life. Coexisting diseases and polypharmacy increase the complexity of patient management and poses major challenges, particularly with the increasing number of immunosuppressive disease-modifying therapies.

Validity and Reliability of Screening Measures for Depression and Anxiety Disorders in Rheumatoid Arthritis

Objective

To test the validity and reliability of screening instruments for depression and anxiety in rheumatoid arthritis (RA).

Methods

Participants with RA completed the Patient Health Questionnaire (PHQ‐2 or PHQ‐9), the Patient Reported Outcomes Measurement Information System depression short form 8a and anxiety short form 8a, the Hospital Anxiety and Depression Scale anxiety score (HADS‐A) and depression score (HADS‐D), the Overall Anxiety Severity and Impairment Scale, the Generalized Anxiety Disorder 2‐ and 7‐item scales, and the Kessler‐6 scale. Clinical depression and anxiety disorders were confirmed using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I Disorders (SCID‐1) research version. We reported sensitivity, specificity, positive predictive value, and negative predictive value using SCID‐1 diagnoses as the criterion standard. Test–retest reliability was assessed with the intraclass correlation coefficient.

Results

Of 150 participants, 11.3% had SCID‐1–diagnosed depression, 7.3% had SCID‐1–diagnosed generalized anxiety disorder, and 19.3% had any SCID‐1–diagnosed anxiety disorder. For depression, sensitivity ranged from HADS‐D (cut point 11; 35%) to PHQ‐2 (88%) and PHQ‐9 (87%). Specificity ranged from PHQ‐9 (77%) and PHQ‐2 (84%) to HADS‐D (cut point 11; 94%). Positive predictive value ranged from 30% to 43%. Negative predictive value ranged from 92% to 98%. For generalized anxiety disorder, sensitivity ranged from HADS‐A (cut point 11; 45%) to HADS‐A (cut point 8; 91%). Specificity ranged from 81% to 89% for all measures except the HADS‐A (cut point 8; 63%). Intraclass correlation coefficient estimates ranging from 0.69 to 0.88 confirmed good test–retest reliability.

Conclusion

Depression screening instruments had good diagnostic performance; anxiety instruments were more variable. Identified depression and anxiety require clinical confirmation.

Anxiety and depression in Multiple Sclerosis (MS): Antecedents, consequences, and differential impact on well-being and quality of life

BACKGROUND

Individuals with multiple sclerosis (MS) are often plagued by the unpredictability of their disease and have to contend with uncertainty in their life and significant life changes. This can lead to high levels of stress, perceived lack of control, helplessness, and anxiety. Despite these circumstances, anxiety disorders are often overshadowed by depression, which can result in its presence being overlooked and undertreated by many medical professionals.

METHODS

One hundred and eighty three individuals with MS completed a comprehensive online survey assessing depression and anxiety and the demographic and disease risk factors of such, including social support and substance use. Participants also completed measures of MS symptomatology, disease management, psychological well-being, and quality of life to determine the impact of depression and anxiety on outcomes associated with MS.

RESULTS

Findings suggest that both depression and anxiety are prevalent in MS and related to many outcomes. However, based on comparisons of the associations and group comparisons, with a few exceptions, anxiety proved to more impactful than depression when examining these outcomes. When evaluating the risk factors/contributors of anxiety and depression, social support was a consistent predictor. Younger age and shorter disease duration were also associated with anxiety, while lower education and substance use were predictors of depression.

CONCLUSION

Findings suggest that attention to anxiety be given as much as depression as it plays a large role in individuals' perceived health and well-being, which subsequently impacts the severity of symptoms and overall quality of life. Early identification of anxiety and potential substance use and increased social support also appear to be crucial for mitigating the impact of depression and anxiety.

Clinical factors associated with mood affective disorders among adults with cerebral palsy

Objective

To determine individual and aggregated associations of cerebral palsy (CP)-related symptoms and the effect of comorbid neurodevelopmental conditions on mood (affective) disorders among adults with CP.

Methods

Cross-sectional data from 2016 were extracted from a random 20% sample of the Medicare fee-for-service database. International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes were used to identify 18- to -64-year-old beneficiaries with CP, as well as mood (affective) disorders, pain, sleep disorders, fatigue, and comorbid neurodevelopmental conditions (intellectual disabilities [ID], autism spectrum disorders [ASD], and epilepsy).

Results

Four thousand eight hundred twenty-three of the 17,212 adults with CP had mood (affective) disorders (28.0%). After adjusting for age, sex, and race, pain (odds ratio [OR] = 2.15; 99.5% confidence interval [CI] = 1.94-2.39), sleep disorders (OR = 2.43; 99.5% CI = 2.13-2.77), fatigue (OR = 1.38; 99.5% CI = 1.18-1.60), ID (OR = 1.47; 99.5% CI = 1.31-1.63), ASD (OR = 1.44; 99.5% CI = 1.16-1.80), and epilepsy (OR = 0.81; 99.5% CI = 0.73-0.91) were each associated with mood (affective) disorders. When pain, sleep disorders, and fatigue were presented as a count variable, the adjusted odds of mood (affective) disorders increased with the number of factors: 1 factor (OR = 1.99; 99.5% CI = 1.79-2.22), 2 factors (OR = 4.18; 99.5% CI = 3.58-4.89), and all 3 factors (OR = 7.38; 99.5% CI = 5.17-10.53).

Conclusions

Among young and middle-aged adults with CP, mood (affective) disorders were associated with pain, sleep disorders, and fatigue, and increasing co-occurrence of these factors further increased the likelihood of mood (affective) disorders. Further, comorbid neurodevelopmental conditions were also associated with mood (affective) disorders among adults with CP. Study findings could be used to improve screening strategies for mood (affective) disorders among adults with CP in the clinical setting.

Anxiety disorders and medical illness comorbidity and treatment implications

PURPOSE OF REVIEW

To review recent studies which assess comorbidity, that is, prevalence of co-occurrence, relationships and treatment implications between anxiety disorders and various medical illnesses.

RECENT FINDINGS

The prevalence rates of anxiety disorders in patients with medical illnesses are high, with percentage up to 29% in patients with epilepsy, 48.9% in patients with multiple sclerosis, 30.1% in patients with Parkinson's disease, 30% in patients with cardiovascular disease, 47.0% in patients with diabetes mellitus, and so on. The most prevalent anxiety disorders among individuals with somatic illnesses are generalized anxiety disorder and panic disorder. In addition, various medical illnesses are highly prevalent in samples of patients with anxiety disorders. Anxiety disorders co-occurring with medical illnesses have a number of clinical implications, including a greater severity and negative impact on treatment outcome of both medical illnesses and anxiety disorders.

SUMMARY

It is important for clinicians to look for possible anxiety disorders among patients with medical illnesses. Further studies need to ascertain how to best treat individuals suffering from both anxiety disorders and medical illnesses, and focus on the issue of causality when these conditions co-occur.

Novel insights into the mechanisms underlying depression-associated experimental autoimmune encephalomyelitis

Multiple Sclerosis (MS) is a chronic autoimmune disease characterized by neuroinflammation, demyelination and neuroaxonal degeneration affecting >2 million people around the world. MS is often accompanied by psychiatric comorbidities such as major depressive disorder (MDD), which presents a lifetime prevalence of around 50% in MS patients. Experimental Autoimmune Encephalomyelitis (EAE) is an animal model extensively used to study MS. EAE mimics the autoimmune nature of MS, as well as its inflammatory and demyelinating mechanisms also presenting predictive validity. There are important similarities between EAE and MS-associated depression (MSD). The mechanisms shared by these disorders include peripheral inflammation, neuroinflammation, mitochondrial dysfunctions, oxidative stress, nitrosative stress, lowered antioxidant defenses, increased bacterial translocation into the systemic circulation, and microglial pathology. Although the role of the immune-inflammatory system in MDD has been established in the 1990's, only few studies addressed immune pathways as a major determinant of depressive-like behavior in EAE. Therefore, in the present study we aimed at revising the current literature on EAE as an animal model to investigate the comorbidity between MS and MDD. In this regard, we revised the current literature on behavioral alterations in EAE, the possible mechanisms involved in this comorbidity and the potential and limitations of using this animal model to study depressive-like behavior.

Psychiatric disorders in multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is characterized by a large spectrum of symptoms, involving all functional systems. Psychiatric symptoms are common in people with MS (pwMS) having an important impact on quality of life and on some features of MS (fatigue, sleep, disability, adherence to disease-modifying drugs). The main psychiatric disturbances in MS are depressive, bipolar, anxiety, schizophrenic and obsessive-compulsive syndromes.

METHODS

Literature search for original articles and review in the databases, including PubMed and Scopus from 1959 to 2019.

RESULTS AND CONCLUSION

Studies answering the aim of this review were selected and reported. Epidemiological and clinical aspects of psychiatric syndromes (PS) in MS as well as self-report diagnostic scales and radiological correlates of PS in MS are described. Moreover, some radiological studies about primary psychiatric disorders (PD) are reported to underline how gray matter atrophy, white matter abnormalities and corpus callosum involvement in these diseases, as features in common with MS, may explain the more frequent occurrence of PD in MS than in the general population.

Increased Burden of Psychiatric Disorders in Inflammatory Bowel Disease

BACKGROUND

Psychiatric comorbidity in inflammatory bowel disease (IBD) is well known; however, data from a truly representative sample are sparse. We aimed to estimate the incidence and prevalence of psychiatric disorders in an IBD cohort compared with a matched cohort without IBD.

METHODS

Using population-based administrative health data from Manitoba, Canada, we identified all persons with incident IBD from 1989 to 2012 and a general population matched cohort (5:1). We applied validated algorithms for IBD, depression, anxiety disorders, bipolar disorder, and schizophrenia to determine the annual incidence of these conditions post-IBD diagnosis and their lifetime and current prevalence.

RESULTS

There were 6119 incident cases of IBD and 30,573 matched individuals. After adjustment for age, sex, socioeconomic status, region of residence, and year, there was a higher incidence in the IBD cohort compared with controls for depression (incidence rate ratio [IRR], 1.58; 95% confidence interval [CI], 1.41-1.76), anxiety disorder (IRR, 1.39; 95% CI, 1.26-1.53), bipolar disorder (IRR, 1.82; 95% CI, 1.44-2.30), and schizophrenia (IRR, 1.64; 95% CI, 0.95-2.84). Incidence rate ratios were similar for Crohn's disease and ulcerative colitis between males and females and were stable over time. However, within the IBD cohort, the incidence rates of depression, anxiety, and bipolar disorders were higher among females, those aged 18-24 years vs those older than 44 years, urbanites, and those of lower socioeconomic status. The lifetime and current prevalence rates of psychiatric disorders were also higher in the IBD than the matched cohort.

CONCLUSIONS

The incidence and prevalence of psychiatric disorders are elevated in the IBD population.

Increased Burden of Psychiatric Disorders in Rheumatoid Arthritis

OBJECTIVE

We estimated the incidence and prevalence of depression, anxiety disorder, bipolar disorder, and schizophrenia in a population-based cohort with rheumatoid arthritis (RA) as compared to an age-, sex-, and geographically matched cohort without RA.

METHODS

Using population-based administrative health data from Manitoba, Canada, we identified persons with incident RA between 1989 and 2012, and a cohort from the general population matched 5:1 on year of birth, sex, and region of residence. We applied validated algorithms for depression, anxiety disorder, bipolar disorder, and schizophrenia to determine the annual incidence of these conditions after the diagnosis of RA, and their lifetime and annual period prevalence. We compared findings between cohorts using negative binomial regression models.

RESULTS

We identified 10,206 incident cases of RA and 50,960 matched individuals. After adjustment for age, sex, socioeconomic status, region of residence, number of physician visits, and year, the incidence of depression was higher in the RA cohort over the study period (incidence rate ratio [IRR] 1.46 [95% confidence interval (95% CI) 1.35-1.58]), as was the incidence of anxiety disorder (IRR 1.24 [95% CI 1.15-1.34]) and bipolar disorder (IRR 1.21 [95% CI 1.00-1.47]). The incidence of schizophrenia did not differ between groups (IRR 0.96 [95% CI 0.61-1.50]). Incidence rates of psychiatric disorders declined minimally over time. The lifetime and annual period prevalence of depression and anxiety disorder were also higher in the RA than in the matched cohort over the study period.

CONCLUSION

The incidence and prevalence of depression, anxiety disorder, and bipolar disorder are elevated in the RA population as compared to a matched population.