Depressive symptoms in a treated multiple sclerosis cohort

Neuro-immune crosstalk in depressive symptoms of multiple sclerosis

Depressive disorders can occur in up to 50% of people with multiple sclerosis in their lifetime. If left untreated, comorbid major depressive disorders may not spontaneously remit and is associated with an increased morbidity and mortality. Conversely, epidemiological evidence supports increased psychiatric visit as a significant prodromal event prior to diagnosis of MS. Are there common molecular pathways that contribute to the co-development of MS and psychiatric illnesses? We discuss immune cells that are dysregulated in MS and how such dysregulation can induce or protect against depressive symptoms. This is not meant to be a comprehensive review of all molecular pathways but rather a framework to guide future investigations of immune responses in depressed versus euthymic people with MS. Currently, there is weak evidence supporting the use of antidepressant medication in comorbid MS patients. It is our hope that by better understanding the neuroimmune crosstalk in the context of depression in MS, we can enhance the potential for future therapeutic options.

How I see is how I feel. Identification of illness perception schema and its association with adaptation outcomes in multiple sclerosis - a 5-year prospective study

The aim of the study was to assess the role of illness perception in adaptation to chronic disease among patients with relapsing-remitting multiple sclerosis (RRMS). The differences between the obtained configurations of the illness perception components during four measurements and the model of predictions of the values of adaptation indicators, i.e. depression, anxiety and quality of life during subsequent measurements, were analyzed. Illness representation was assessed at baseline via the Illness Representation Questionnaire–Revised. The adaptation indicators–anxiety, depression (measured by HADS) and quality of life (measured by MSIS-29) were measured at baseline and three more times over a five-year period. The k-means cluster analysis (with two-way and repeated measures ANOVA) was conducted in a group of 90 patients (48.89% women and 51.11% men). Subsequently, the mean values of depression, anxiety, physical and psychological quality of life were compared between the clusters using the Kruskall-Wallis test. Finally, a cross-lagged panel modeled for HADS and MSIS-29 subscales in each measurement occasion (T1-T4). Three different illness perception clusters (Anxious, Realistic and Fatalistic Illness Perception named AIP, RIP and FIP) were composed which differentiated the depression, anxiety, quality of life level and age. FIP showed the lowest adaptation outcomes with small differences between AIP and RIP. It was also significantly characterized by the highest age. The positive adaptation indicators were related to the RIP cluster. The model presented rather satisfactory fit (χ²(48) = 81.05; CFI = .968; TLI = .925; SRMR = .050) with slightly inflated RMSEA = .087 (90%CI .053-.120). Based on initial measurements of individual characteristics, it was possible to predict the functioning of patients after several years. For patients with AIP, the covariance of anxiety and depression was significant, for patients with RIP–depression and anxiety, and for patients with FIP–depression. In addition, each of the variables was a predictor of subsequent measurements in particular time intervals, illustrating the dynamics of changes. Results highlight that illness perceptions formed at the beginning of RRMS are important for the process of adaptation to the disease. Moreover, they showed the differences between the adaptation outcomes supporting the idea that a cognitive representation might be important for the level of psychological functioning.

The Effect of Depression on Health-Related Quality of Life Is Mediated by Fatigue in Persons with Multiple Sclerosis

The interrelations between fatigue, depression and health-related quality of life (HRQoL) in persons with multiple sclerosis (PwMS) are complex, and the directionality of the effects is unclear. To address this gap, the current study used a longitudinal design to assess direct and indirect effects of fatigue and depression on HRQoL in a one-year follow-up survey. A sample of 210 PwMS from the nationwide Swiss MS Registry was used. HRQoL was assessed using the European Quality of Life 5-Dimension 5-Level questionnaire. Path analysis on HRQoL, with fatigue and depression as predictors, was applied. Fatigue was measured by the Modified Fatigue Impact Scale (MFIS), including physical, cognitive and psychosocial subscales, and non-somatic depressive symptomatology was examined with the Beck Depression Inventory-Fast Screen (BDI-FS). Fatigue acted as a fully mediating variable (B = -0.718, SE = 0.253) between non-somatic depressive symptomatology and HRQoL. This indirect effect became apparent in the physical (B = -0.624, SE = 0.250), psychosocial (B = -0.538, SE = 0.256) and cognitive subscales (B = -0.485, SE = 0.192) of fatigue. In contrast, non-somatic depressive symptomatology did not act as a mediator. Our findings provide novel and clinically relevant longitudinal evidence showing that the debilitating effect of non-somatic aspects of depression on HRQoL was fully mediated and therefore explainable via fatigue.

Major depressive disorder subtypes and depression symptoms in multiple sclerosis: What is different compared to the general population?

OBJECTIVE

To compare and characterize major depressive disorder (MDD) subtypes (i.e., pure atypical, pure melancholic and mixed atypical-melancholic) and depression symptoms in persons with multiple sclerosis (PwMS) with persons without MS (Pw/oMS) fulfilling the DSM-5 criteria for a past 12-month MDD.

METHODS

MDD in PwMS (n = 92) from the Swiss Multiple Sclerosis Registry was compared with Pw/oMS (n = 277) from a Swiss community-based study. Epidemiological MDD diagnoses were based on the Mini-SPIKE (shortened form of the Structured Psychopathological Interview and Rating of the Social Consequences for Epidemiology). Logistic and multinomial regression analyses (adjusted for sex, age, civil status, depression and severity) were computed for comparisons and characterization. Latent class analysis (LCA) was conducted to empirically identify depression subtypes in PwMS.

RESULTS

PwMS had a higher risk for the mixed atypical-melancholic MDD subtype (OR = 2.22, 95% CI = 1.03-4.80) compared to Pw/oMS. MDD in PwMS was specifically characterized by a higher risk of the two somatic atypical depression symptoms 'weight gain' (OR = 6.91, 95% CI = 2.20-21.70) and 'leaden paralysis' (OR = 3.03, 95% CI = 1.35-6.82) and the symptom 'irritable/angry' (OR = 3.18, 95% CI = 1.08-9.39).

CONCLUSIONS

MDD in PwMS was characterized by a higher risk for specific somatic atypical depression symptoms and the mixed atypical-melancholic MDD subtype. The pure atypical MDD subtype, however, did not differentiate between PwMS and Pw/oMS. Given the high phenomenological overlap with MS symptoms, the mixed atypical-melancholic MDD subtype represents a particular diagnostic challenge.

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.

Psychiatric side effects of interferon-β in multiple sclerosis

Psychiatric disorders, especially depression, are frequent in patients with multiple sclerosis (MS). They are attributed both to the psychosocial impact of a chronic, usually progressive, disabling illness and to cerebral demyelination. Besides, drugs such as corticosteroids and possibly interferon (IFN) may also have depressogenic effects. Major depressive disorders and/or suicidal ideation are a major concern and efforts to identify and minimize these reactions are of much importance. Psychiatric side effects, particularly depression, are widely reported with IFN-α and have been suspected with IFN-β but are not yet fully established. Our review of the literature revealed that most studies discard an association between IFN-β and depression or suicide. However, few patients, especially those with a history of depression, might be at higher risk for depression when treated with IFN-β. Overall, considering the uncertainty of a link between IFN-β and depression and/or suicide, as well as the complete remission of psychiatric complications after IFN discontinuation and/or antidepressant treatment, physicians should closely monitor the psychiatric status of patients, but should not refrain from including them in IFN-β treatment programs, even when they have past or present depression.

A new way of rapidly screening for depression in multiple sclerosis using Emotional Thermometers

OBJECTIVE

Depression is a common, serious, but under-recognised problem in multiple sclerosis (MS). The primary objective of this study was to assess whether a rapid visual analogue screening tool for depression could operate as a quick and reliable screening method for depression, in patients with MS.

METHOD

Patients attending a regional MS outpatient clinic completed the Emotional Thermometer 7 tool (ET7), the Hospital Anxiety and Depression Scale - Depression Subscale (HADS-D) and the Major Depression Inventory (MDI) to establish a Diagnostic and Statistical Manual, 4th edition (DSM-IV) diagnosis of Major Depression. Full ET7, briefer subset ET4 version and depression and distress thermometers alone were compared with HADS-D and MDI. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and receiver operating characteristic (ROC) curve were calculated to compare the performance of all the screening tools.

RESULTS

In total, 190 patients were included. ET4 performed well as a 'rule-out' screening step (sensitivity 0.91, specificity 0.72, NPV 0.98, PPV 0.32). ET4 performance was comparable to HADS-D (sensitivity 0.96, specificity 0.77, NPV 0.99, PPV 0.37) without need for clinician scoring. The briefer ET4 performed as well as the full ET7.

CONCLUSION

ET are quick, sensitive and useful screening tools for depression in this MS population, to be complemented by further questioning or more detailed psychiatric assessment where indicated. Given that ET4 and ET7 perform equally well, we recommend the use of ET4 as it is briefer. It has the potential to be widely implemented across busy neurology clinics to assist in depression screening in this under diagnosed group.

Anxiety and depression in patients with multiple sclerosis: The mediating effects of perceived social support

BACKGROUND

Social support has been identified as a buffering or intervening variable in stressful life events. Research has demonstrated that greater social support is associated with better mental health in multiple sclerosis (MS), but little is known about its links to specific aspects of mental health. We therefore investigated if and how perceived social support modulates depression, anxiety and fatigue in patients with MS.

METHODS

We recruited 112 patients with MS from three French hospitals and administered a demographic and clinic interview, and self-report measures of perceived social support (Multidimensional Scale of Perceived Social Support), depression and anxiety (Hospital Anxiety and Depression Scale), and fatigue (Fatigue Severity Scale). We then analyzed the relationships between these domains using path analysis.

RESULTS

The causal path model provided an excellent fit for the data (χ² = 9.8, p = .778, standardized root mean square residual = 0.043, comparative fit index = 1.00). Results indicated that the level of social support from friends is a predictor of anxiety symptomatology. Thus, anxiety may have both a direct and an indirect impact on fatigue and depression levels.

CONCLUSIONS

This study highlights the important roles played by perceived social support and anxiety in MS. These should be key pharmacological and non-pharmacological targets for optimizing patient care. (NCT 02-880-553).

Depression in multiple sclerosis

Depressive disorders occur in up to 50% of people living with multiple sclerosis (MS). Prevalence estimates are generally 2-3-times higher than those of the general population. Myriad aetiologic factors may contribute to the aetiology of depression in MS including biological mechanisms (e.g. hippocampal microglial activation, lesion burden, regional atrophy), as well as the stressors, threats, and losses that accompany living with an unpredictable and often disabling disease. Some prominent risk factors for depression such as (younger) age, (female) sex, and family history of depression are less consistently associated with depression in MS than they are in the general population. Management of depression in MS has not been well studied, but available data on detection and treatment align with general principles of depression management. While the validity of standard measurement scales has often been questioned, available evidence suggests that standard scales provide valid ratings. Evidence for the effectiveness of depression treatments in MS is limited, but available evidence supports the effectiveness of standard treatment approaches, including both cognitive behavioural therapies and antidepressant medications.

Depression in epilepsy, migraine, and multiple sclerosis: Epidemiology and how to screen for it

Purpose of review

To provide an overview of the epidemiology of depression in chronic neurologic conditions that can affect individuals throughout the lifespan (epilepsy, migraine, multiple sclerosis [MS]) and examine depression screening tools for adults with these conditions.

Recent findings

Depression is common in neurologic conditions and can be associated with lower quality of life, higher health resource utilization, and poor adherence to treatment. It affects around 20%-30% of those with epilepsy, migraine, and MS, and evidence for a bidirectional association exists for each of these conditions. Depression screening tools generally perform well in neurologic conditions, but are not without limitations.

Summary

Depression is a major contributor to poor outcomes in epilepsy, migraine, and MS. Although psychiatric resources are scarce globally, this is no reason to ignore depression in neurologic conditions. Depression screening tools are available in neurology and should be considered in clinical practice.

NAPS-MS: Natalizumab Effects on Parameters of Sleep in Patients with Multiple Sclerosis

BACKGROUND

Patients with multiple sclerosis (MS) have higher rates of fatigue, mood disturbance, and cognitive impairments than healthy populations. Disease-modifying agents may affect sleep. Although patients taking natalizumab often show improvement in fatigue during the first year of therapy, the mechanism behind this effect is unknown. The aim of the NAPS-MS study was to investigate whether natalizumab affected objective measures of sleep as determined by polysomnography (PSG) and multiple sleep latency testing (MSLT) in patients with MS with fatigue or sleepiness initiating therapy. Additional goals were to evaluate changes in measures of fatigue, mood, and cognition and to correlate these measures with objective sleep measures.

METHODS

Patients underwent PSG and MSLT before their first natalizumab infusion and after their seventh. Patients completed the Modified Fatigue Impact Scale, Fatigue Severity Scale (FSS), Epworth Sleepiness Scale (ESS), and visual analogue scale for fatigue (VAS-F) at their first, fourth, and seventh natalizumab infusions. NeuroTrax cognitive tests and the Hospital Anxiety and Depression Scale (HADS) were performed at the first and seventh natalizumab infusions.

RESULTS

Changes in sleep efficiency, wakefulness after sleep onset, and multiple sleep latency from baseline to 6 months of therapy did not reach significance. The FSS, VAS-F, ESS, and HADS scores were significantly improved after 6 months of therapy; cognitive scores were not significantly improved.

CONCLUSIONS

Although treatment with natalizumab was associated with improvements in fatigue, sleepiness, and mood, changes in objective measures of sleep were not significant.

Eight-year immunogenicity and safety of interferon beta-1a-Avonex®treatment in patients with multiple sclerosis

An open-label extension study of the phase III trial of intramuscular interferon beta-1a (IFNβ-1a-Avonex) was conducted to evaluate the immunogenicity and safety of IFNβ-1a-Avonex over six years in patients with relapsing multiple sclerosis (MS). Patients who participated in the pivotal phase III study were offered enrolment; entry was also open to patients who had not participated. All patients received IFNβ-1a-Avonex 30 mg intramuscularly once weekly for six years, for a treatment duration of up to eight years in patients who received IFNβ-1a-Avonex in the phase III trial. Serum levels of IFNβ antibodies were measured every six months using a screening enzyme-linked immunosorbent assay (ELISA) followed by an antiviral cytopathic effect assay to detect neutralizing antibodies (NAbs) in serum samples positive on ELISA. The incidence of adverse events and laboratory test results assessed safety. Of 382 total patients, 218 had participated in the phase III study (103 placebo, 115 IFNβ-1a-Avonex) and 164 had not participated; 24 of the 164 were IFNβ-naïve. At baseline, 281 patients were negative for IFNβ antibodies (NAb-). NAbs (titre≥ 20) developed at any time over six years in 5% of these patients. Of 140 patients who had been on IFNβ-1b-Betaseron, 49 were positive for NAbs (NAb+) at baseline; 11 of 115 who had been on IFNβ-1a-Avonex were NAb+ at baseline. Thirty-nine of 49 patients who had been on Betaseron and were NAb+ had titres <100; 36 of these 39 seroconverted to NAb-while on IFNβ-1a-Avonex, with a median time of approximately six months. Ten patients who had been on Betaseron had NAb titres ≥ 100; five remained NAb+ during six years on IFNβ-1a-Avonex and five seroconverted to NAb-, but only after at least two years. Five patients who had been on IFNβ-1a-Avonex during the clinical trial were NAb+ with titres <100 at baseline; four seroconverted to NAb-, with a median time of two to three years. Six patients who had been on IFNβ-1a-Avonex had NAb titres ≥100; five of these remained NAb+ at six years. No patient with a NAb titre >1000 seroconverted to NAb-, whether initially treated with IFNβ-1a-Avonex or -Betaseron. Adverse events were similar to those observed in the pivotal phase III trial. Results from this trial indicated that IFNβ-1a-Avonex was associated with a low incidence of NAbs and was well tolerated for up to eight years. Further, the results indicate that persistence of NAbs is dependent on titre and IFNβ product.

Depression and hypomania symptoms are associated with high dose corticosteroids treatment for MS relapses

BACKGROUND

Psychiatric side effects are known to occur with low dose corticosteroids. Standard of care for Multiple Sclerosis (MS) relapses is high dose corticosteroids (HDC), at least 1g/day for 3-5 days, and yet the relationship between this treatment and mood is not known. We sought to determine the frequency and potential predictors of (hypo)manic and depressive symptoms with HDC treatment for MS relapses.

METHODS

Consecutive MS subjects requiring HDC treatment were identified. The Mood Disorders Questionnaire (MDQ) and the Beck Depression Inventory-Fast Screen (BDIFS) were administered for (hypo)manic and depressive symptoms, respectively, prior to HDC, 3 days and one month post-HDC.

RESULTS

Eighty eight subjects completed the study. At relapse diagnosis, the mean BDIFS score was 4.2 (SD 3.1); the mean number of (hypo)manic symptoms endorsed on the MDQ was 4.3 (SD 3.5). Three days after completing HDC, 22.5% had an increase on the BDIFS and 38.2% endorsed more symptoms on the MDQ. A history of depression (p=0.006) and low reported quality of life (p=0.029) predicted an increase on the MDQ; the odds of an increase in (hypo)manic symptoms was 5.6 times higher with a history of any psychiatric disease/substance abuse (p=0.005). No predictors for worsening on the BDIFS were found.

LIMITATIONS

Self-reported measures were used, anxiety was not evaluated and 17 subjects were lost to follow up.

CONCLUSION

Depressive and hypo(manic) symptoms are commonly associated with HDC for MS relapses. It is important for clinicians and MS patients to be aware of this risk.

Depression in multiple sclerosis: The utility of common self-report instruments and development of a disease-specific measure

The ultimate objective of the present investigation was to improve the detection of depression in multiple sclerosis (MS) by comparing common self-report depression measures to a new, modified measure, which takes into account the contribution that symptoms of MS may have on individuals' reports. There has been a longstanding concern regarding the accurate assessment of depression in MS, particularly with regard to the overlap of MS symptomatology and neurovegetative depression symptoms on self-report questionnaires, which may lead to an overdiagnosis of depression in MS. To address these difficulties, we previously proposed a "trunk and branch" of depression in MS. This model allows for the delineation of what symptoms are most reflective of depression in MS. By identifying these symptoms, it was possible to develop a modified Beck Depression Inventory (BDI) in which only the items found to be most related to depression in MS are included in the new measure, the MS Specific BDI (MS-BDI). We compared this measure to common self-report instruments (Beck Depression Inventory-Second Edition, BDI-II; Beck Depression Inventory-Fast Screen, BDI-FS; Chicago Multiscale Depression Inventory, CMDI). Results suggest that cutoffs of 4 on the BDI-FS and 23 on the CMDI Mood subscale are most useful when screening for depression in MS, with a sensitivity for both of 100%, while a cutoff of 19 on the BDI-II, a cutoff of 22 on the CMDI Evaluative scale, and a cutoff of 8 on the MS-BDI had high specificities, suggesting they can be used as to assist in diagnosing depression in MS.

The incidence and prevalence of psychiatric disorders in multiple sclerosis: a systematic review

BACKGROUND

Psychiatric comorbidity is associated with lower quality of life, more fatigue, and reduced adherence to disease-modifying therapy in multiple sclerosis (MS).

OBJECTIVES

The objectives of this review are to estimate the incidence and prevalence of selected comorbid psychiatric disorders in MS and evaluate the quality of included studies.

METHODS

We searched the PubMed, PsychInfo, SCOPUS, and Web of Knowledge databases and reference lists of retrieved articles. Abstracts were screened for relevance by two independent reviewers, followed by full-text review. Data were abstracted by one reviewer, and verified by a second reviewer. Study quality was evaluated using a standardized tool. For population-based studies we assessed heterogeneity quantitatively using the I² statistic, and conducted meta-analyses.

RESULTS

We included 118 studies in this review. Among population-based studies, the prevalence of anxiety was 21.9% (95% CI: 8.76%-35.0%), while it was 14.8% for alcohol abuse, 5.83% for bipolar disorder, 23.7% (95% CI: 17.4%-30.0%) for depression, 2.5% for substance abuse, and 4.3% (95% CI: 0%-10.3%) for psychosis.

CONCLUSION

This review confirms that psychiatric comorbidity, particularly depression and anxiety, is common in MS. However, the incidence of psychiatric comorbidity remains understudied. Future comparisons across studies would be enhanced by developing a consistent approach to measuring psychiatric comorbidity, and reporting of age-, sex-, and ethnicity-specific estimates.

Relationship between disease-modifying therapy and depression in multiple sclerosis

Many prescribers of disease-modifying therapies (DMTs) for multiple sclerosis (MS) believe that interferon beta (IFNβ) is more likely than glatiramer acetate (GA) to increase depression during the course of MS treatment. Therefore, newly diagnosed patients with a history of depression are often placed on GA therapy from the onset of MS treatment. The aim of this study was to examine the relationship between DMT type and depression among patients with relapsing-remitting MS (RRMS). Patients with RRMS who were examined from 2000 to 2007 and who remained on a single course of therapy (either an IFNβ or GA) were included in a retrospective review of medical records. Patients were asked to complete the Beck Depression Inventory (BDI) at treatment initiation and every 6 months thereafter for up to 4 years. Only patients who had completed a BDI within 6 weeks of starting their DMT were included in the analysis. No significant differences in mean change in BDI score were observed from baseline to 48 months between the IFNβ and GA subgroups. Additionally, no significant differences in mean BDI score change were observed between antidepressant-treated and non-antidepressant-treated patients within the IFNβ or GA subgroup. Neither IFNβ nor GA therapy appears to exacerbate depressive symptoms in patients with RRMS who remain on their initial therapy.

Multiple sclerosis disease-modifying therapies: adverse effect surveillance and management

There are five approved, partially effective, parenteral disease-modifying therapies for multiple sclerosis (MS), including three interferon-beta preparations, glatiramer acetate and the antineoplastic agent mitoxantrone. A sixth drug, natalizumab, was withdrawn from the market in 2005 but could return with increased safety measures. Careful surveillance for, and management of, the minor and serious adverse effects associated with these therapies in routine practice provides the best opportunity for maintaining compliance and achieving maximal therapeutic efficacy. This review outlines the strategies for the prevention, identification and management of the complications associated with administration and ongoing use of current MS therapies. These skills will become increasingly important to those caring for MS patients as contemporary treatment regimens become increasingly complex.

Symptomatic treatment and management of multiple sclerosis

The range of symptoms which occur in multiple sclerosis (MS) can have disabling functional consequences for patients and lead to significant reductions in their quality of life. MS symptoms can also interact with each other, making their management challenging. Clinical trials aimed at identifying symptomatic therapies have generally been poorly designed and have tended to be underpowered. Therefore, the evidence base for the management of MS symptoms with pharmacologic therapies is not strong and tends to rely upon open-label studies, case reports, and clinical trials with small numbers of patients and poorly validated clinical outcome measures. Recently, there has been a growing interest in the management of MS symptoms with pharmacologic treatments, and better-designed, randomized, double-blind, controlled trials have been reported. This chapter will describe the evidence base predominantly behind the various pharmacologic approaches to the management of MS symptoms, which in most, if not all, cases, requires multidisciplinary input. Drugs routinely recommended for individual symptoms and new therapies, which are currently in the development pipeline, will be reviewed. More interventional therapies related to symptoms that are refractory to pharmacotherapy will also be discussed, where relevant.

The multiple sclerosis depression rating scale

Depression is a troublesome issue in the lives of people with multiple sclerosis (MS). However, there are many questions about how to measure depression in people with MS. Depression is a syndrome that is characterized by emotional, cognitive and somatic symptoms. Depression scales are usually designed to cover each of these domains but in MS there is concern that cognitive deficits and somatic symptoms related to the illness itself may inflate depressive symptom scores, potentially leading to false-positive ratings. Such misclassification may consume excessive resources in screening programs due to the triggering of unnecessary clinical assessments. In research, such misclassification could lead to bias. In an effort to address these issues, the authors of the article under evaluation have recently developed a new scale, the Multiple Sclerosis Depression Rating Scale.

Depression in multiple sclerosis: a review of assessment and treatment approaches in adult and pediatric populations

Multiple sclerosis is a chronic demyelinating disease affecting one million people worldwide, with a significant burden of psychiatric comorbidity. Depression is the commonest psychiatric manifestation but still remains largely underdiagnosed and undertreated. The present work reviews current knowledge on diagnosis, assessment, and somatic and psychotherapeutic treatment interventions for depression in adult and pediatric populations of patients with multiple sclerosis.

Depression and anxiety in a Portuguese MS population: associations with physical disability and severity of disease

BACKGROUND

Mood disorders, namely depression and anxiety, have been well documented in patients with Multiple Sclerosis (MS). However, the putative associations between clinical features and mood disorders have not been well established.

OBJECTIVES

To detect anxiety and depression in MS patients; and to investigate possible associations with clinical factors.

SUBJECTS AND METHODS

325 consecutive patients with MS and 183 healthy subjects answered the Hospital Anxiety and Depression Scale (HADS), a self-rating questionnaire. Multiple Regression Analysis and Multivariate Analysis of Covariance were applied to assess the effect of demographic and clinical factors on HADS' anxiety and depression scores, using age and disease duration as covariates. Logistic Regression Analysis was used to study the influence of these factors on anxiety and depression, as defined by two different cut-off scores (i.e., 8 and 11).

RESULTS

Levels of anxiety and depression were significantly higher (p<0.001) for MS patients group than healthy subjects. Age, disease duration, age at onset, Kurtzke Expanded Disability Status Scale, and Multiple Sclerosis Severity Scale were positively associated with depression scores. Low education (i.e., <9 years) in MS was significantly associated with more anxiety and depression symptoms.

CONCLUSIONS

The study findings support a close linkage between depressive mood and physical manifestations of MS.

Gender effects on intramuscular interferon beta-1a in relapsing–remitting multiple sclerosis: analysis of 1406 patients

Background: We aimed to evaluate effects of gender on efficacy and safety of intramuscular (IM) interferon beta (IFNβ)-1a in patients with relapsing–remitting MS (RRMS) or clinically isolated syndromes (CIS) characteristic of early MS.

Methods: Pooled data from 1406 (1027 women; 379 men) patients enrolled in five clinical studies of IM IFNβ-1a were analyzed. One analysis examined data for all patients treated with IM IFNβ-1a from all studies. Separate analyses were conducted of pooled IM IFNβ-1a-treated groups from all studies and pooled IFNβ-1a-treated and placebo-treated patients from the placebo-controlled studies. Outcome measures included time to first relapse, annualized relapse rate, time to disability progression, number of gadolinium-enhanced lesions, adverse events, laboratory evaluations, and neutralizing antibodies.

Results: All efficacy assessments indicated similar treatment effects of IM IFNβ-1a in men and women with no significant treatment-by-gender interactions. Women reported more headaches, urinary tract infections, and depression in the analysis; however, these were also common in women who received placebo. Men reported more frequent flu-like symptoms in the placebo-controlled studies only. There were no other differences in the safety profile of IM IFNβ-1a between men and women.

Conclusions: We conclude that no significant gender-related differences were found in the efficacy and safety of IM IFNβ-1a in patients with RRMS or CIS.

A review of disease-modifying therapies for MS: maximizing adherence and minimizing adverse events

BACKGROUND

In a chronic disabling disorder such as multiple sclerosis (MS), adherence to treatment is of critical importance in maximizing benefits of therapy over the long term. Adverse events (AEs) are often cited by patients who discontinue therapy.

METHODS

Databases including Medline, CINAHL, and International Pharmaceutical Abstracts were searched for literature pertaining to adherence and AEs in MS published between January 1970 and August 2008. Clinical studies and case reports of AEs were included, as were papers that outlined factors that influence adherence. An advisory board with extensive experience in managing patients with MS developed guidelines to assist healthcare providers in maximizing adherence to disease-modifying therapy.

DISCUSSION

Internally based factors such as self-image, and externally based factors such as AEs, may influence patients' willingness and ability to adhere to therapy. Management of AEs associated with disease-modifying therapies and other therapies is reviewed, including intramuscular and subcutaneous interferon beta (IFNbeta)-1a, IFNbeta-1b, glatiramer acetate, natalizumab, methylprednisolone, mitoxantrone, cyclophosphamide, methotrexate, azathioprine, and intravenous immunoglobulin.

CONCLUSIONS

Effective management of MS is an ongoing, dynamic process that can enhance patients' adherence to therapy. Healthcare practitioners may address factors influencing adherence among patients with MS by managing treatment expectations, maintaining good communication with the patient, and managing AEs of treatment. Although the guidelines proposed herein originate from a single advisory board, it seems clear that by addressing patient concerns, healthcare practitioners can work with patients to enhance their ability to continue to adhere to their therapies and thereby gain the benefits of their treatment over the long term.

Managing adverse effects of disease-modifying agents used for treatment of multiple sclerosis

BACKGROUND

First-line agents approved in the United States for treatment of relapsing multiple sclerosis (MS) include intramuscular interferon beta (IFNbeta)-1a, subcutaneous (SC) IFNbeta-1a, SC IFNbeta-1b, and SC glatiramer acetate. Intravenous mitoxantrone is the only agent approved for secondary progressive MS, progressive relapsing MS, and worsening relapsing MS. Intravenous natalizumab is approved for relapsing forms of MS generally in patients who have an inadequate response to, or are unable to tolerate, first-line therapies. Corticosteroids are commonly used to treat relapses. This paper reviews the incidence and management of common adverse events (AEs) associated with these treatments.

METHODS

MEDLINE and EMBASE were searched for clinical trials and other publications between 1985 and 2007 reporting AEs associated with MS therapies, using these search terms: multiple sclerosis, interferon, Avonex, Betaseron, Rebif, glatiramer, copolymer 1, Copaxone, mitoxantrone, natalizumab, adverse events.

RESULTS

A class-specific flu-like syndrome associated with IFNbeta can be managed through initial dose escalation and administration of analgesics and antipyretics, prophylactically or symptomatically. Injection-site reactions can occur in patients receiving injectable therapies, particularly SC IFNbeta or glatiramer acetate. The greatest risk to patients receiving mitoxantrone is cardiotoxicity; thus, the cumulative dose is limited. Allergic reactions occur rarely with natalizumab, and there is a potential risk of progressive multifocal leukoencephalopathy. AEs associated with short-term pulse corticosteroid therapy are usually transient and largely resolve after treatment is completed.

CONCLUSIONS

To improve adherence to therapy, it is important to educate patients regarding AEs and to manage AEs proactively.

Recognizing and treating common psychiatric disorders in multiple sclerosis

BACKGROUND

The rate of depression and other psychiatric disorders is greater in multiple sclerosis (MS) than in other chronic conditions or neurologic diseases. This means that clinical neurologists seeing MS patients will frequently be engaged in the diagnosis and treatment of psychiatric distress.

REVIEW SUMMARY

This review provides a summary of what is known about psychiatric dysfunction in MS. It offers information about the current views on the link between various psychiatric disorders and MS. More important, it offers suggestions on how the knowledge from existing research can be integrated into real-world practice.

CONCLUSION

Clinicians need to understand the factors that influence the development of psychiatric disorders in MS, the relationship between disease-modifying therapies and psychiatric distress, and the issues surrounding the treatment of psychiatric conditions in MS. Thorough knowledge of psychiatric dysfunction and MS will allow the clinician to design an effective treatment regimen that helps patients cope with their disease.

Long-term emotional state of multiple sclerosis patients treated with interferon beta

OBJECTIVE

To assess the long-term emotional state of multiple sclerosis (MS) patients treated with interferon beta (IFNbeta) for at least four years.

METHODS

Patients who had started IFNbeta therapy prior to 2000 with a baseline psychological assessment were identified and scheduled for long-term emotional assessment with the following questionnaires--the Hamilton Depression Rating Scale, the Beck Depression Inventory and the State-Trait Anxiety Inventory.

RESULTS

A total of 262 patients started IFNbeta therapy in our MS clinic within the period 1995-1999. Baseline emotional assessment was available from 246 MS patients. Long-term assessment was conducted on 234 patients. After a mean follow-up of 65 months (43-98), 52 patients (22.3%) had withdrawn from IFNbeta therapy. The comparisons, obtained from baseline and follow-up scores, showed an improvement in the depressive and anxiety symptoms of patients who adhered to IFNbeta treatment. Logistic regression analysis indicated that an increase in physical disability and the presence of depressive symptoms at baseline were best predictors for long-term depressive symptoms.

CONCLUSIONS

The present results support the absence of emotional worsening in MS patients treated with IFNbeta for a long period of time. Increased disability and the presence of baseline depressive symptoms predicted the presence of depressive symptoms at follow-up.

Treatment of children and adolescents with tics and Tourette syndrome

Tics, patterned movements distinct from stereotypies, myoclonus, and other hyperkinetic movements, are quite common in children, particularly among those with developmental and psychiatric disorders. Thus, tics can indicate the presence of atypical neurodevelopment or broader difficulties with cognition or mood. Tics are also the cardinal feature of Tourette syndrome, a childhood-onset neurobehavioral disorder characterized by a chronic inability to suppress or an urge to perform patterned, repetitive movements. Patients with Tourette syndrome most commonly have, in addition to tics, symptoms of inattention, hyperactivity, obsessiveness, or anxiety. Achieving the most effective treatment of a child with tics is contingent on proper diagnosis of the movement disorder and thorough assessment for other problems, followed by consideration of both nonpharmacologic and pharmacologic interventions for any and all symptoms interfering with the child's function and quality of life. This review focuses primarily on the diagnosis and medical treatment of tics in children and adolescents with Tourette syndrome.

Managing the symptoms of multiple sclerosis: a multimodal approach

BACKGROUND

Patients with multiple sclerosis (MS) may experience numerous symptoms, including spasticity, fatigue, cognitive dysfunction, depression, bladder dysfunction, bowel dysfunction, sexual dysfunction, and pain.

OBJECTIVE

This article reviews the pharmacologic and nonpharmacologic interventions used to manage the symptoms of MS and discusses how interventions for a particular MS symptom may have an impact on other symptoms.

METHODS

The English-language literature was reviewed through November 2005 using MEDLINE and the Cochrane Database of Systematic Reviews, with no restriction on year. The search terms included multiple sclerosis, disease-modifying therapies, adverse events, and combinations of multiple sclerosis with terms such as spasticity, fatigue, depression, mood disorders, pain, bladder dysfunction, bowel dysfunction, sexual dysfunction, cognitive dysfunction, and quality of life.

RESULTS

The numerous options for the treatment of MS symptoms have shown varying degrees of efficacy and tolerability. Certain symptoms, if left untreated, may precipitate exacerbation of others. For example, spasticity may lead to pain and bladder and bowel dysfunction, whereas fatigue can compromise cognitive function. Similarly, the adverse effects of treatments for certain symptoms may further compromise other aspects of function. For example, the use of antidepressants may lead to sexual dysfunction, and treatments for spasticity and pain may cause sedation, which can worsen fatigue, cognitive dysfunction, and depressed mood.

CONCLUSIONS

MS is associated with numerous symptoms that can be adversely affected by each other and by therapeutic interventions. Careful clinical monitoring and individualization of pharmacologic and non-pharmacologic therapies are recommended to manage the symptoms of MS, with the goals of improving or maintaining function and preserving the patient's quality of life.

L’interféron β1-a IM ne modifie pas le fonctionnement psychologique global de patients atteints de sclérose en plaques rémittente pendant les premiers mois de traitement

INTRODUCTION

Psychological troubles are common in multiple sclerosis but their underlying etiology is still controversial.

METHODS

The objective of this open, non comparative, multicenter study was to assess changes in global psychological functioning in new multiple sclerosis patients during the first 3 months of treatment with intramuscular interferon beta-1a once weekly (Avonex). This functioning was rated every 4 weeks with the GAF (Global Assessment Functioning) scale. Depression measured on MADRS (Montgomery & Asberg Depression Rating Scale), clinical global impression (CGI) on patients'psychological status and clinical as well as biological tolerance were also assessed every 4 weeks.

RESULTS

Five hundred and ninety-nine patients (71.4 percent women), aged 39.4 years were included. No clinically significant difference in mean GAF score between baseline and the end of the first 3 months of interferon beta-1a IM treatment (main evaluation outcome) was found. Similar results were obtained on MADRS scale.

CONCLUSION

No clinically significant alteration of global psychological functioning, including symptoms of depression, was observed during the first 3 months of treatment with interferon beta-1a IM.

Interferon Beta-1a Overdose in a Multiple Sclerosis Patient

OBJECTIVE

To report on a patient with multiple sclerosis (MS) who attempted suicide by taking an overdose of interferon (IFN) beta-1a.

CASE SUMMARY

A 38-year-old man with MS and depressive symptoms self-administered approximately 6 or 7 prefilled syringes containing 44 μg (12 MIU) of subcutaneous IFN beta-1a in a suicide attempt. Clinical examination in the emergency department revealed a modest rise in body temperature and diffuse redness of the skin of the limbs and truncal region. The patient's signs and symptoms resolved over the following 24 hours. IFN beta-1a was temporarily withdrawn and treatment with citalopram, which the patient had spontaneously discontinued before the suicide attempt, was resumed. Laboratory assessment showed no modifications in biochemical and hematologic parameters. The IFN beta-1a concentration in the serum sample taken at 48 hours after the suicide attempt confirmed that the patient had taken a very high dose of IFN.

DISCUSSION

Depression, a common condition in MS patients, was precipitated in this patient by the spontaneous discontinuation of citalopram and not influenced by IFN beta-1a therapy, which the patient resumed at 44 μg 3 times per week.

CONCLUSIONS

This case demonstrates the risks of depression in MS patients and the danger of discontinuing treatment with antidepressants. This report also shows that approximately 264–308 μg of IFN beta-1a, the highest single dose of IFN beta-1a reported taken by a human as of this writing, caused only a transient and self-limiting malaise.

Clinical correlates of CES-D depressive symptom ratings in an MS population

OBJECTIVE

In multiple sclerosis (MS), depression rating scales may be used as case-finding instruments for depressive disorders, but depressive symptom ratings may have clinical implications beyond their case-finding role. The objective of this analysis was to explore this possibility by carrying out descriptive analyses of symptom ratings obtained using the Center for Epidemiological Studies Depression Rating Scale (CES-D) in an MS clinic population.

METHOD

The analysis used cross-sectional baseline data collected from 589 subjects enrolled in a prospective cohort study. Data collection included demographic and clinical information including Extended Disability Status Scale ratings, a 54-item MS Quality of Life Scale and the Fatigue Impact Scale.

RESULTS

Across a spectrum of CES-D scores, correlations with other health indicators were observed. Depressive symptoms were higher in more disabled subjects. CES-D scores were correlated with the emotional well-being dimension of quality of life and with a social fatigue impact dimension. Alternative scoring of the CES-D had a negligible impact on the pattern of correlation.

CONCLUSIONS

CES-D ratings appear to be interpretable beyond the traditional yes/no categorization used in case finding. CES-D ratings are predictive of other clinical parameters in domains relevant to mental health.

Update on depression in neurologic illness: stroke, epilepsy, and multiple sclerosis

The risk of depression is increased in chronic neurologic illness and can adversely affect the course of disease. Recent literature is reviewed for depression in stroke, epilepsy, and multiple sclerosis. Depression can share pathophysiologic aspects of the comorbid illness, such as neurotransmitter pathway disturbances, hypothalamus-pituitary-adrenal pathway disturbances, and changes in immunologic function. Depression also can be a psychologic reaction to the burden of the neurologic condition. Risk factors for development of depression are reviewed. Depression and other medical conditions can have shared symptoms (eg, fatigue, psychomotor retardation) that can complicate the diagnosis of depression in neurologic illness. Proper selection of antidepressant treatment is necessary to avoid worsening the neurologic disorder.

Unrecognised symptoms of depression in a community-based population with multiple sclerosis

BACKGROUND AND AIMS

The association between multiple sclerosis (MS) and depression has been well established but prevalence estimates have varied widely. The aims of this study were to assess the point prevalence of previously unrecognised symptoms of depression in a community-based population with MS and examine their relationship to other disease characteristics.

PATIENTS AND METHODS

Three hundred and seventy six patients with clinically definite or probable MS (Poser criteria) were ascertained during the course of an epidemiological study on two counties in Ireland. Of these 211 agreed to participate in the study. Subjects were examined and a Kurtzke Expanded Disability Status Scale Score and Multiple Sclerosis Functional Composite score rated. Participants also completed a Beck's Depression Inventory-II and a Multiple Sclerosis Impact Scale.

RESULTS

In total 60 (28%) patients had moderate or severe symptoms of depression. Only thirty-five of the 211 patients had a history of depression as defined by a medical diagnosis of depression or prescription of an anti-depressant medication at any time prior to enrollment in the present study, of the remaining 176 patients, 41 (23.3%) had moderate or severe symptoms of depression as assessed by Beck's Depression Inventory-II. The only significant clinical difference between the 41 patients with pronounced depressive symptoms and the 135 less affected was shorter disease duration in the former.

CONCLUSIONS

In this study one in four patients with MS had unrecognised and therefore untreated symptoms of depression. Disability alone is not a good indicator of the likelihood of coexistent depressive symptoms.

Interpreting patient/informant discrepancies of reported cognitive symptoms in MS

Although numerous studies have shown that brain-damaged patients tend to underestimate neuropsychological (NP) impairment when self-ratings are compared to informant ratings, the meaning of such discrepancies is not well studied in multiple sclerosis (MS). We compared patient self- and informant-report questionnaire ratings of NP functioning in 122 MS patients and 37 age- and education-matched normal controls. In addition to completing the Multiple Sclerosis Neuropsychological Questionnaire (MSNQ), participants underwent NP testing and assessment of depression, personality, and neuropsychiatric symptoms. Based on the normal distribution of discrepancy scores, patients were classified according to whether they overestimated or underestimated their cognitive ability, relative to informant ratings. ANOVAs comparing test scores derived from overestimators, underestimators, and accurate estimators were significant for multiple measures of cognitive function, depression, personality, and neuropsychiatric symptoms. Overestimators were characterized by less depression and conscientiousness, and greater degrees of cognitive impairment, euphoric behavioral disinhibition, and unemployment as compared to underestimators. We conclude that patient/informant discrepancy scores on the MSNQ are associated with the aforementioned neuropsychiatric features, and that the MSNQ has potential utility for predicting euphoria and disinhibition syndromes in MS.

Depression in multiple sclerosis: a review

Several studies have reported high rates of depression in multiple sclerosis (MS) with a lifetime prevalence of approximately 50% and an annual prevalence of 20% not uncommon. Concern about the potential of new drug treatments to exacerbate or precipitate depression in MS has led to increased interest in the relation between MS and depression. This review on MS and depression identifies the following key issues: How common is depression in people with MS? Is depression in MS associated with lesions in specific regions of the central nervous system? Is there an increased risk of suicide in MS? Is there a higher than expected incidence of anxiety disorders in MS? Are fatigue and depressed mood related in MS? Is there a relation between depression and cognitive impairment in MS? Which psychosocial variables affect the development of depression in MS? Does treatment with interferon increase the risk of depression? How effective are treatments for MS patients with depression? Each of these issues is briefly reviewed with critical commentary, and some priorities for future research are suggested.