The 7-item generalized anxiety disorder scale as a tool for measuring generalized anxiety in multiple sclerosis

Health, Wellness, and the Effect of Comorbidities on the Multiple Sclerosis Disease Course: Tackling the Modifiable

Multiple sclerosis (MS) is a disease of the central nervous system characterized by inflammatory demyelination and neurodegeneration. Numerous disease-modifying therapies for MS exist but are only partially effective, making it essential to optimize all factors that may influence the course of the disease. This includes conscientious management of both mental and physical comorbidities, as well as a comprehensive strategy for promoting wellness in patients with MS. Thoughtful engagement of those living with MS through shared decision making and involvement of a multidisciplinary team that includes primary care, relevant specialists, psychology, and rehabilitation is likely to lead to better outcomes.

A contribution to the French validation of the clinical anxiety scale amongst health care workers in Switzerland

BACKGROUND

Anxiety disorders are frequent but remain often underdiagnosed and undertreated. Hence, valid screening instruments are needed to enhance the diagnostic process. The Clinical Anxiety Scale (CAS) is a 25-item anxiety screening tool derived from the Hamilton Anxiety Scale (HAM-A). However, this scale is not available in French. The General anxiety disorder - 7 (GAD-7) scale, which has been validated in French, is a 7-item instrument with good psychometric properties. This study contributes to the validation of an adapted French version of the CAS, using the GAD-7 as the reference.

METHODS

A forward-backward English-French-English translation of the CAS was performed according to standard practice. The French versions of the CAS and GAD-7 were completed by 127 French speaking healthcare professionals. CAS internal consistency was assessed using Crohnbach's alpha, and test-retest reliability was tested after 15 days in a subsample of 30 subjects. Convergent validity with GAD-7 was assessed using Pearson's correlation coefficient. Test-retest reliability was explored using one-way random effects model to calculate the intra-class correlation coefficient (ICC).

RESULTS

French CAS showed excellent internal consistency (Cronbach's alpha 0.97), high convergent validity with GAD-7 (Pearson's R 0.81, p < 0.001), and very good test-retest reliability (ICC = 0.97, 95% CI 0.93-0.98).

CONCLUSION

The proposed French version of the CAS showed high reliability and validity that need to be further investigated in different populations.

Quality of Life in Patients With Confirmed and Suspected Spinal CSF Leaks

BACKGROUND AND OBJECTIVES

Spontaneous intracranial hypotension (SIH) is a debilitating condition typically producing orthostatic headache limiting upright time. SIH is often difficult to diagnose and treat, negatively affecting quality of life (QoL) in patients with the disorder. We studied QoL in patients with confirmed and suspected SIH using standardized instruments, including suicidality.

METHODS

We performed a cross-sectional survey of adult patients with confirmed and clinically suspected SIH evaluated in our Headache and Facial Pain Program from 2016 to 2022. Using an online data collection tool (REDCap V 11.2.2), participants completed validated questionnaires assessing general well-being (SF-36), depression (PHQ-9), generalized anxiety disorder-7 (GAD-7), spiritual well-being during chronic illness therapy (FACIT-Sp-12), and headache impact (HIT-6). Subsequently, we interviewed willing participants to administer the Columbia-Suicide Severity Rating Scale (C-SSRS) assessing suicidal behavior and ideation.

RESULTS

A total of 234 patients met inclusion criteria and were invited to participate in the study, and 95 patients (59 confirmed and 36 clinically suspected) completed the questionnaires. The average age of the cohort was 51.1 years (SD: 15.5), predominantly female (69.5%), White (91.6%), and married (69.5%). Three-quarters (74.5%) scored within the most severe headache category (HIT-6). SF-36 scores were significantly inferior (p < 0.0001) to the general population and lower than reported values for patients with multiple sclerosis and idiopathic intracranial hypertension. Almost half (49.1%) of respondents scored in the moderate depression range or worse (>10), and 25.4% scored with moderate anxiety or worse (>10). FACIT-Sp-12 scores were significantly worse (p < 0.0001) in symptomatic participants than in the validation cohorts of patients with AIDS and cancer. Of the 67 respondents who completed the C-SSRS, more than half (64.2%) endorsed a wish to be dead, and 22.4% had demonstrated suicidal behavior. Patients with symptom-free SIH (n = 22) scored significantly better than symptomatic patients, comparable with the general population.

DISCUSSION

Based on our single-center cohort, SIH is associated with severe headache pain and high rates of depression, anxiety, and disability, affecting basic activities of daily living. Individuals with confirmed and suspected spinal CSF leaks scored similarly on these measures including suicidality. Outcomes were comparable with the general population after successful treatment or spontaneous remission. Improved identification and treatment of SIH are imperative to improve patients' QoL.

Anxiety in Response to Sustaining Spinal Cord Injuries and Disorders: When Should Clinicians Be Concerned?

OBJECTIVE

To recommend a cut-off score for the brief 2-item Generalized Anxiety Disorder (GAD-2) measure for persons with spinal cord injuries/disorders (PwSCI/D) and to estimate anxiety occurrence within this population using the full 7-item Generalized Anxiety Disorder (GAD-7).

DESIGN

Multicenter retrospective analyses.

SETTING

One inpatient rehabilitation center and 2 community sites for PwSCI/D.

PARTICIPANTS

PwSCI/D 18 years or older (N=909) were included for analysis using retrospectively collected GAD-2 and GAD-7 data.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE(S)

Occurrence of anxiety symptoms were compared using cut-off scores of ≥8 and ≥10 on the GAD-7. A cut-off score recommendation for the GAD-2 was determined using ROC curve, and sensitivity and specificity analyses.

RESULTS

Occurrence of anxiety symptoms was 21% using a GAD-7 cut-off of ≥8 and 15% using a cut-off of ≥10. Analyses indicated optimal sensitivity for a GAD-2 score of ≥2 when a GAD-7 cut-off of ≥8 was used.

CONCLUSIONS

Anxiety occurrence is elevated among PwSCI/D compared with the general population. For PwSCI/D, it is recommended that a cut-off score of ≥2 is used for the GAD-2 to maximize sensitivity and that a threshold of ≥8 is used for the GAD-7 to ensure the maximum number of individuals presenting with symptoms of anxiety are recognized for diagnostic interview. Study limitations are discussed.

Assessing attitudes towards insulin pump therapy in adults with type 1 diabetes: Italian validation of the Insulin Pump Attitudes Questionnaire (IT-IPA questionnaire)

AIMS

The aim of the study was to adapt the German version of the insulin pump therapy (IPA) questionnaire to Italian (IT-IPA) and to evaluate its psychometric properties in adults with type 1 diabetes.

METHODS

We conducted a cross-sectional study, data were collected through an online survey. In addition to IT-IPA, questionnaires evaluating depression, anxiety, diabetes distress, self-efficacy, and treatment satisfaction were administered. The six factors identified in the IPA German version were assessed using confirmatory factor analysis; psychometric testing included construct validity and internal consistency.

RESULTS

The online survey was compiled by 182 individuals with type 1 diabetes: 45.6% continuous subcutaneous insulin infusion (CSII) users and 54.4% multiple daily insulin injection users. The six-factor model had a very good fit in our sample. The internal consistency was acceptable (Cronbach's α = 0.75; 95% IC [0.65-0.81]). Diabetes treatment satisfaction was positively correlated with a positive attitude towards CSII therapy (Spearman's rho = 0.31; p < 0.01), less Technology Dependency, higher Ease of Use, and less Impaired Body Image. Furthermore, less Technology Dependency was associated with lower diabetes distress and depressive symptoms.

CONCLUSIONS

The IT-IPA is a valid and reliable questionnaire evaluating attitudes towards insulin pump therapy. The questionnaire can be used for clinical practice during consultations for shared decision-making to CSII therapy.

Palliative Care Interventions Effects on Psychological Distress: A Systematic Review & Meta-Analysis

BACKGROUND

Managing psychological distress is an objective of palliative care. No meta-analysis has evaluated whether palliative care reduces psychological distress.

OBJECTIVES

Examine the effects of palliative care on depression, anxiety, and general psychological distress for adults with life-limiting illnesses and their caregivers.

DESIGN

We searched PubMed, PsycInfo, Embase, and CINAHL for randomized clinical trials (RCTs) of palliative care interventions. RCTs were included if they enrolled adults with life-limiting illnesses or their caregivers, reported data on psychological distress at 3 months after study intake, and if authors had described the intervention as "palliative care."

RESULTS

We identified 38 RCTs meeting our inclusion criteria. Many (14/38) included studies excluded participants with common mental health conditions. There were no statistically significant improvements in patient or caregiver anxiety (patient SMD: -0.008, P = 0.96; caregiver SMD: -0.21, P = 0.79), depression (patient SMD: -0.13, P = 0.25; caregiver SMD -0.27, P = 0.08), or psychological distress (patient SMD: 0.26, P = 0.59; caregiver SMD: 0.04, P = 0.78).

CONCLUSIONS

Psychological distress is not likely to be reduced in the context of a typical palliative care intervention. The systemic exclusion of patients with common mental health conditions in more than 1/3 of the studies raises ethical questions about the goals of palliative care RCTS and could perpetuate inequalities.

The prevalence and risk factors of anxiety in multiple sclerosis: A systematic review and meta-analysis

Background

Patients with multiple sclerosis (MS) suffer from repetitive neurological deterioration, while anxiety may play a significant role in the disease's progression.

Objective

To explore the prevalence of anxiety in MS and to investigate the risk factors related to anxiety in MS patients.

Methods

An analysis of four databases, PubMed, Web of Science, EMBASE, and Cochrane Library, has been conducted to determine the prevalence or risk factors for anxiety in MS published before May 2021.

Results

In total, 32 studies were found to be eligible. Anxiety prevalence was estimated to be 36% based on the pooled estimates [the 95% confidence interval (CI) = [0.30-0.42], I ² = 98.4%]. Significant risk factors for developing of anxiety were as follows: age at survey [the weighted mean difference (WMD) = 0.96, 95% CI = [0.86-1.06], I ² = 43.8%], female [the odd ratio (OR) = 1.78, 95% CI = [1.38-2.30], I ² = 0%], living together (OR 2.83, 95% CI = [1.74-4.59], I ² = 0%), past psychiatric history (OR 2.42, 95% CI = [1.56-3.75], I ² = 0%), depression (OR 7.89, 95% CI = [3.71-16.81], I ² = 0%), not taking MS medication (OR 2.33, 95% CI = [1.29-4.21], I ² = 77.8%), relapsing-remitting MS (RRMS) (OR 1.50, 95% CI = [0.94-2.37], I ² = 53.5%), and baseline Expanded Disability Status Scale (EDSS) (OR 0.84, 95% CI = [0.48-1.21], I ² = 62.2%).

Conclusion

An estimated 36% of people with MS suffer from anxiety. And anxiety rates in MS patients are significantly associated with age, gender, living together, prior psychiatric history, depression, drug compliance, RRMS, and baseline EDSS.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=287069, identifier CRD42021287069.

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.

Strengthening Mental Abilities with Relational Training (SMART) in multiple sclerosis (MS): study protocol for a feasibility randomised controlled trial

Background

Multiple sclerosis (MS) is a chronic condition of the central nervous system, affecting around 1 in every 600 people in the UK, with 130 new diagnoses every week. Cognitive difficulties are common amongst people with MS, with up to 70% experiencing deficits in higher-level brain functions—such as planning and problem-solving, attention, and memory. Cognitive deficits make it difficult for people with MS to complete everyday tasks and limit their abilities to work, socialise, and live independently. There is a clear need—and recognised research priority—for treatments that can improve cognitive functioning in people with MS. The absence of effective cognitive interventions exacerbates burdens on the services accessed by people with MS—requiring these services to manage sequelae of untreated cognitive deficits, including reduced quality of life, greater disability and dependence, and poorer adherence to disease-modifying treatments. Our planned research will fill the evidence gap through developing—and examining the feasibility of trialling—a novel online cognitive rehabilitation programme for people with MS (SMART). The SMART programme directly trains relational skills (the ability to flexibly relate concepts to one another) based on theory that these skills are critical to broader cognitive functioning.

Methods

The primary objective of this study aims to conduct a feasibility study to inform the development of a definitive trial of SMART for improving cognitive functioning in people with MS. The secondary objective is to develop the framework for a cost-effectiveness analysis alongside a definitive trial, and the exploratory objective is to assess the signal of efficacy.

Discussion

As a feasibility trial, outcomes are unlikely to immediately effect changes to NHS practice. However, this is a necessary step towards developing a definitive trial—and will give us a signal of efficacy, a prerequisite for progression to a definitive trial. If found to be clinically and cost-effective, the latter trial could create a step-change in MS cognitive rehabilitation—improving service delivery and optimising support with limited additional resources.

Trial registration

Registration ID: ClnicalTrials.gov: NCT04975685—registered on July 23rd, 2021.

Protocol version: 2.0, 25 November 2021

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01152-7.

The impact of socioeconomic status on mental health and health-seeking behavior across race and ethnicity in a large multiple sclerosis cohort

BACKGROUND

Psychiatric symptoms are common in multiple sclerosis (MS) and may contribute to worse MS outcomes. Previous studies suggest the burden of symptoms may vary by race, ethnicity and socioeconomic status (SES). Our objective was to expand upon this previous work and explore the associations between SES, race, and ethnicity, as predictors of psychiatric symptoms, mental health attitudes, and health-seeking behavior in patients with MS.

METHODS

Persons with MS answered a national web-based survey including demographic characteristics (including race, ethnicity and measures of SES), mental health attitudes, the Patient Health Questionnaire-9 (PHQ-9), the Generalized Anxiety Disorder 7-item (GAD-7) scale, the Modified Fatigue Impact Scale 5-item version (MFIS-5), and the Alcohol Use Disorders Identification Test (AUDIT). The survey also queried mental health availability and perceptions of care. We measured neighborhood-level SES (nSES) of each participant using the Agency for Healthcare Research and Quality (AHRQ) index that was calculated from 5-digit postal codes. Other indicators of participant-level SES included education level and self-reported household income. We assessed the association between race, ethnicity, and neighborhood/participant-level SES indicators and affective symptom burden using generalized linear models that were adjusted for age, sex, and MS characteristics.

RESULTS

2095 participants answered the survey (mean AHRQ index 54.6 ± 5.4, age 51.3 ± 12.2 years, 7% Black/African American, 5.4% Hispanic/Latino, and 81.8% female). Those in the lowest quartile of nSES (most disadvantaged) were more likely to be either Black/African American or Hispanic/Latino as compared to those in highest quartile (least disadvantaged). Those in the lowest quartile of nSES had higher mean MFIS-5 (1.02 points; 95% CI: 0.39, 1.43), PHQ-9 (1.24 points; 95% CI: 0.49, 1.98), and GAD-7 (0.69 points; 95% CI: -0.01, 1.38) scores relative to those in the highest quartile. Of those who consumed alcohol (n = 1489), participants in the lowest AHRQ quartile had lower mean AUDIT scores (-0.73 points; 95% CI: -1.18, -0.29) as compared to those in higher quartiles. Race and ethnicity were not associated with self-reported psychiatric symptom burden in this cohort. SES was also associated with self-reported improvement of symptoms after receiving mental health care. A higher proportion of Black/African American (44.1% vs 30.2%, p = 0.003) and Hispanic/Latino (49.1% vs 30.6%, p<0.001) participants were more likely to report they would "definitely go" receive mental health care if services were co-located with their MS care as compared to white and Non-Hispanic/Latino participants, respectively.

CONCLUSION

Higher SES was associated with a lower burden of psychiatric symptoms and with a higher likelihood of self-reported symptom recovery after receiving mental health treatment. Attitudes regarding mental health care delivery in MS varied according to racial and ethnic background. Future longitudinal studies in more diverse populations should assess whether co-location of mental health services with MS care helps to reduce the gap between access and need of mental health care in MS.

Assessment of anxiety in Mexican persons living with HIV using a culturally-adapted version of the GAD-7 test

Our aim was to assess the severity of anxiety in PLWHA in Mexico City and obtain the psychometric properties of the culturally-adapted Spanish version of GAD-7. Thirteen percent of participants presented moderate to severe symptoms. Reliability (α = 0.82) and construct validity (single-factor explained 48.9% of variance) were evaluated in 411 participants. Confirmatory Factor Analysis was performed in a second sample of 527 participants. Model fit adequately (CFI = 0.991; CMIN/DF = 1.924; RMSEA = 0.042; and SRMR = 0.026). The adapted version of GAD-7 was adequate for the assessment of anxiety in Mexican PLWHA.

Impact of Action Video Gaming Behavior on Attention, Anxiety, and Sleep Among University Students

Background

Recently, there has been an increase in the prevalence of action video gaming among adolescents and young adults. This has made video gaming a topic of interest for behavioral and higher brain cognitive function researchers. The present study investigated the impact and consequences of action video gaming on human behavior—specifically, attention, anxiety levels, and sleep patterns.

Objective

The study aimed to investigate the potential associations between action video gaming and attention, anxiety, and sleep.

Methods

Recruited participants (N = 97) were asked to independently complete an online questionnaire consisting of 4 sections: demographic data, gaming behavior, 8-item Epworth Sleepiness Scale, and 7-item Generalized Anxiety Disorders Scale. Participants were further divided into 2 groups (expert and non-expert video gamers) based on the number of hours they spent on action video games. After completing the questionnaires, the patients attended an on-site session, where they completed a validated psychological online battery test that assessed their sustained attention.

Results

The mean age of the participants was 21 years. There was a significant difference in attention between expert and non-expert video gamers; when exposed to stimuli, expert gamers displayed significantly shorter reaction times than the non-expert gamers (p < 0.05). Both groups showed a non-significant decrease in attention span throughout time. The data demonstrated no statistically significant difference in anxiety levels or daytime sleepiness between expert and non-expert video gamers, and minimal to mild anxiety levels were reported in most expert and non-expert gamers.

Conclusion

Expert video gamers were significantly more attentive compared to non-expert gamers, and most participants showed low levels of generalized anxiety. Accordingly, expanding our knowledge on the effects of action video games on attention span is important for creatively using games in the field of education, especially for those who suffer from attention deficit hyperactivity disorders.

Validity and reliability of the Generalized Anxiety Disorder-7 (GAD-7) among university students of Bangladesh

This study investigated the reliability and factorial validity of General Anxiety Disorder-7 (GAD-7) in the context of university students in Bangladesh. The research aimed to assess whether the original one-dimensional model or a model containing both somatic and cognitive-emotional factors is appropriate. A repeated cross-sectional survey design based on convenience sampling was used to collect data from 677 university students. The factor structure of the GAD-7 was assessed by exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), and its convergent validity was determined by investigating its correlations with Patient Health Questionnaire-9 (PHQ-9) and Patient Health Questionnaire Anxiety-Depression Scale (PHQ-ADS). Results showed excellent reliability of GAD-7 as measured by Cronbach's α. CFA suggested that a modified one-factor model is appropriate for the sample. This model provided high values of comparative fit index (CFI), goodness of fit index (GFI), and Tucker Lewis Index (TLI), low value of standardized root mean square residual (SRMR) and a non-significant root mean square error of approximation (RMSEA). Correlation between GAD-7 and PHQ-9 was 0.751 and 0.934 between GAD-7 and PHQ-ADS. Overall, the study provided support for modified unidimensional structure for GAD-7 and showed high internal consistency along with good convergent validity.

Psychometric properties of the Generalized Anxiety Disorder-7 Scale in Ethiopian university students

The prevalence of anxiety and its associated factors in Ethiopians necessitates availability of a valid questionnaire tool to screen for this disorder. Therefore, this study aimed to assess the factor structure, its stability, and psychometric measures of the Generalized Anxiety Disorder-7 Scale GAD-7) in Ethiopian university students. A cross-sectional study with random sampling was carried out in students (n = 354, age = 21.79 ± 4.49) attending Mizan-Tepi University, Ethiopia. The GAD-7, the Perceived Stress Scale (PSS), and a sociodemographic questionnaire were completed by participants. The unidimensional model of the GAD-7 showed configural, metric, scalar, and strict invariance among gender groups. The Cronbach's alpha (0.77), item-total score correlations (r = .51-.72, p < .01), and inter-item correlations (all significant, p < .05) indicated adequate internal consistency. GAD-7 scale scores correlated significantly with the PSS, suggesting desired convergent validity. The GAD-7 has good psychometric validity with Ethiopian university students.

Examining the optimal cutoff values of HADS, PHQ-9 and GAD-7 as screening instruments for depression and anxiety in irritable bowel syndrome

BACKGROUND

Self-rating scales are frequently used to screen for anxiety and depression in patients with irritable bowel syndrome (IBS). Different cutoff values are recommended in literature, and guidelines have suggested the use of other screening instruments over time. The aim of this study was to assess the correlation between the most commonly used psychological screening instruments for anxiety and depression in IBS and to compare custom cutoff scores for these instruments.

METHODS

Irritable bowel syndrome patients (n = 192) completed several questionnaires including the Hospital Anxiety and Depression Scale (HADS, HADS-A and HADS-D subscale), Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7). Agreement at different cutoff points, for depressive and anxiety disorder, was assessed by use of the Gwet AC1 coefficient.

KEY RESULTS

Hospital Anxiety and Depression Scale (HADS)-D and PHQ-9 scores, and HADS-A and GAD-7 scores showed high correlations (r_s  = 0.735 and r_s  = 0.805, respectively). For depressive disorder, a Gwet AC1 value of 0.829 was found when recommended cutoff points from literature were compared (PHQ-9 cutoff ≥10, HADS-D cutoff ≥8). For anxiety disorder, a Gwet AC1 value of 0.806 was found when recommended cutoff points from literature were compared (GAD-7 cutoff ≥10, HADS-A cutoff ≥8). Even higher agreements were found when higher HADS cutoff values were chosen, with impact on sensitivity and specificity.

CONCLUSIONS & INFERENCES

Custom cutoff values deem the HADS subscales (HADS-D and HADS-A) concordant to PHQ-9 and GAD-7 scores. The choice of a cutoff value has substantial impact on sensitivity/specificity and is dependent on patient population, setting, and the purpose of use.

Sociodemographic and clinical factors associated with depression, anxiety, and general mental health in people with multiple sclerosis during the COVID-19 pandemic

Background People with multiple sclerosis (PwMS) may be at increased risk for psychological distress during COVID-19. We study the self-reported mental health of U.S. PwMS during COVID-19, prior to vaccine rollout. Methods A cross-sectional survey was distributed online to PwMS through iConquerMS (12/18/2020-02/10/2021). Depressive and anxiety symptom burdens and general mental health status were measured via the Patient-Health Questionnaire-9, Generalized Anxiety Disorder-7, and PROMIS Global Mental Health scales. Linear regression models assessed associations between mental health variables and age, sex, disability status, comorbidities, and social determinants of health. Results Of 610 U.S. PwMS (mean age 56 years, standard deviation 11, range 20-85; female, 81%; relapsing remitting disease, 62%; previous depression diagnosis, 40%), the prevalences of moderate-to-severe depressive and anxiety symptom burden were 27.4% and 14.7%, respectively; 55.1% endorsed fair/poor general mental health. PwMS who tested positive for COVID-19 (n = 47, 7.7%) reported higher depressive and anxiety symptom burdens (p < 0.05). Increased disability status score and social determinants of health were each associated with more depressive symptoms and worse general mental health. Younger age was associated with increased depressive and anxiety symptom burdens and worse general mental health. Female sex was associated with greater anxiety symptoms. Conclusion There are specific associations for worse mental health among PwMS during COVID-19 that reflect a combination of clinical, demographic, and social determinants of health. Multidisciplinary care teams and vigilance are important to address the ongoing mental health impacts of COVID-19 in PwMS.

Quality of life in individuals newly diagnosed with multiple sclerosis or clinically isolated syndrome

BACKGROUND

Little is known about quality of life (QOL) at the time of multiple sclerosis (MS) or clinically isolated syndrome (CIS) diagnosis and how it evolves in the critical adjustment period immediately following a new diagnosis.

OBJECTIVES

To (1) describe QOL trajectory in the first year post-MS/CIS diagnosis and (2) examine associations of demographic and biopsychosocial factors with QOL at baseline and as it evolves over the first year post-MS/CIS diagnosis.

METHODS

Participants were N = 250 individuals newly diagnosed with MS or CIS. Participants completed self-report assessments of QOL, demographics, and biopsychosocial factors at 1, 2, 3, 6, 9, and 12 months post-diagnosis using validated measures.

RESULTS

At 1-month post-diagnosis, QOL M = 75.2/100 with subsequent assessments revealing consistent ratings on average. Modelling revealed a small number of variables that were predictive of QOL at baseline and/or change in QOL over time.

CONCLUSION

QOL in the first year post-MS/CIS diagnosis was, on average, high and stable. A subset of modifiable factors across the biopsychosocial spectrum was associated with baseline level of QOL and change in QOL over time. The stability in QOL suggests that patients can be assessed early after diagnosis for key variables that are predictive of both current and future QOL.

Ketamine-assisted psychotherapy for trauma-exposed patients in an outpatient setting: A clinical chart review study

Trauma exposure across the lifespan produces risks for posttraumatic stress disorder (PTSD), depression, anxiety, as well as global disability in functioning. This retrospective clinical chart review is the first of its kind to assess the utility of sublingual ketamine-assisted body-centered psychotherapy in trauma-exposed patients in a real world clinic setting. De-identified clinical records data on self-reported symptom measures were retrospectively analyzed for patients (N = 18; M age = 45.22, SD = 12.90) entering ketamine-assisted psychotherapy treatment in an outpatient clinic between 2018 and 2020. Patients who completed six sessions of ketamine therapy reported meaningful (e.g., medium effect size) improvements in PTSD symptoms (P = 0.058; d = −0.48) and global disability in functioning (P = 0.050; d = −0.52) and statistically significant and meaningful improvements in depression (P = 0.019; d = −0.53). There were no improvements in anxiety symptoms. Sublingual ketamine-assisted psychotherapy was associated with heterogenous clinical utility among patients with trauma-exposure in an outpatient setting. This study was underpowered and unrepresentative of the population of ketamine patients in the United States. Replication of these findings is needed with larger and more diverse patient samples.

Fear of COVID-19, problems accessing medical appointments, and subjective experience of disease progression, predict anxiety and depression reactions in patients with Multiple Sclerosis

Background

During the current COVID-19 pandemic there are studies that have suggested a negative impact of the pandemic on the mental health of patients with multiple sclerosis (PwMS). In this sense, several factors may be related to the increase in experiences of anxiety and depression in PwMS during the current pandemic.

Objective

In this study we first explored the reactions of anxiety, depression and fear to COVID-19 in a group of PwMS that belong to the Ibero-American region. Besides, we explored whether having been positive to COVID-19, fear of COVID-19, the obstacles to attend medical appointments during the outbreak and subjective experience of MS progression, could predict the anxiety and depression reactions in our PwMS sample.

Materials and methods

An online cross-sectional survey was conducted on 202 MS patients from six countries (Argentina, Mexico, Spain, Dominican Republic, Venezuela and Cuba). For comparisons between variables an independent-samples t-test and one-way analysis of variance were used. Multiple linear regression was used to evaluate the effects of potential predictor variables over emotional reactions.

Results

Our results showed that PwMS who were positive for COVID-19 reported higher levels of fear of COVID-19 (p<.001) and also higher levels of anxiety (p<.001) compared to non-positive patients. Those patients who had difficulties attending their medical appointments during the outbreak showed higher levels of depression (p=.03) and anxiety (p=.019). Levels of anxiety (p<.001) and depression (p=.006) were also higher among patients with the subjective experience of MS disease progression. The reactions of fear of COVID-19, having been positive to COVID-19, problems attending medical appointments, and subjective experience of MS disease progression showed a high association with the negative impact of the pandemic on mental health of PwMS.

Conclusions

Our results show that the situation generated by the COVID-19 pandemic has had a negative impact on the mental health of PwMS in our sample. Our results also alert to the importance of offering psychological care to patients with multiple sclerosis during the current outbreak, regardless of whether they have been positive for COVID-19.

Comprehensive Approach to Management of Multiple Sclerosis: Addressing Invisible Symptoms-A Narrative Review

Multiple sclerosis (MS) is a chronic autoimmune inflammatory disease of the central nervous system, leading to neurodegeneration and manifesting as a variety of symptoms. These can include "invisible" symptoms, not externally evident to others, such as fatigue, mood disorders, cognitive impairments, pain, bladder/bowel dysfunction, sexual dysfunction, and vision changes. Invisible symptoms are highly prevalent in people living with MS, with multifactorial etiology and potential to impact the disease course. Patient experiences of these symptoms include both physical and psychosocial elements, which when unaddressed negatively influence many aspects of quality of life and perception of health. Despite the high impact on patient lives, gaps persist in awareness and management of these hidden symptoms. The healthcare provider and patient author experiences brought together here serve to raise the profile of invisible symptoms and review strategies for a team-based approach to comprehensive MS care. We summarize the current literature regarding the prevalence and etiology of invisible symptoms to convey the high likelihood that a person living with MS will contend with one or more of these concerns. We then explore how open communication between people living with MS and their care team, stigma mitigation, and shared decision-making are key to comprehensive management of invisible symptoms. We recommend validated screening tools and technological advancements that may be incorporated into MS care to regularly monitor these symptoms, offering insight into how healthcare providers can both educate and listen to patients, with the goal of improved patient quality of life. By pairing clinical knowledge with an understanding and consideration of the patient perspective, providers will be equipped to foster a patient-centered dialogue that encourages shared decision-making. Invisible symptoms of MS.

Patient and Provider Insights into the Impact of Multiple Sclerosis on Mental Health: A Narrative Review

Multiple sclerosis (MS) is a chronic disease in which the immune system attacks the central nervous system, causing inflammation and neurodegeneration. People living with MS may experience a variety of symptoms as a consequence of this process, including many “invisible” symptoms that are internally manifested and not seen by others. Of the invisible symptoms of MS, which we have reviewed in a companion article, mood and mental health disorders are of particular concern due to their high prevalence and significant impact on patient quality of life. In this review, we showcase the experiences of patient authors alongside perspectives from healthcare provider authors as we promote awareness of the common mental health conditions faced by those living with MS, such as depression, anxiety, adjustment disorder, bipolar disorder, psychosis, and suicidal ideation. Many of these conditions stem in part from the increased stress levels and the many uncertainties that come with managing life with MS, which have been exacerbated by the environment created by the coronavirus disease 2019 (COVID-19) pandemic. A patient-centered interdisciplinary approach, routine screening for mental health changes, and referral to specialists when needed can normalize discussions of mental health and increase the likelihood that people living with MS will receive the support and care they need. Management techniques such as robust social support, cognitive behavioral therapy, mindfulness-based interventions, and/or pharmacotherapy may be implemented to build resilience and promote healthy coping strategies. Increasingly, patients have access to telehealth options as well as digital apps for mental health management. Taken together, these approaches form an integrative care model in which people living with MS benefit from the care of medical professionals, a variety of support networks/resources, and self-management techniques for optimal mental health care.

Clinical utility of the GAD-7 in identifying anxiety disorders after traumatic brain injury

To determine if the GAD-7 provides incremental value, predicting a final diagnosis of an anxiety disorder after traumatic brain injury (TBI). Retrospective analysis of archival data of 100 patients with TBI, who underwent neuropsychological evaluation 1-12 months after injury. Receiver Operating Characteristic analysis determined the optimal cutoff point for clinically significant symptoms on the GAD-7. Hierarchical logistic regression analyses determined the relative contributions of premorbid psychiatric history, injury severity, and GAD-7 results in predicting a final diagnosis of anxiety disorder. GAD-7 cutoff point of ≥7 yielded the best combination of sensitivity and specificity regarding a final diagnosis of anxiety disorder. Within hierarchical logistic regression models, injury severity did not statistically significantly add to prior psychiatric history in predicting a final diagnosis of anxiety disorder. When GAD-7 was added, it made a statistically significant contribution in accounting for such a diagnosis and increased sensitivity from 71% to 91%. The GAD-7 holds diagnostic utility as a screening measure for anxiety disorders in patients with TBI. It should not be used in isolation but as part of a more comprehensive interview and history. The GAD-7 can benefit clinicians in assisting with timelier identification and treatment of symptoms of anxiety.

Mental symptoms in MS (MeSyMS): Development and validation of a new assessment

BACKGROUND

Patients with Multiple Sclerosis (MS) have an increased risk of suffering from mental and neuropsychiatric symptoms. So far, a fundamental problem in the clinical care of MS patients is that these symptoms are underdiagnosed and, as a consequence, often remain untreated. Present assessment tools have not been developed to be applied in patients with MS. This study aims to develop and validate a new questionnaire to identify disease-related mental symptoms in MS patients.

METHODS

A questionnaire has been developed by including the following subscales: social and emotional health problems, anxiety, and depression. To evaluate test quality and internal consistency, an item analysis has been conducted. After matching MS patients and control subjects on age and gender, we conducted group comparisons, a Receiver Operating Characteristic (ROC) Curve analysis and a binary logistic regression model.

RESULTS

In total, 314 MS patients and 100 matched control subjects were analysed. After performed item analysis, the questionnaire revealed an excellent internal consistency (α=0.94). Compared to control subjects, MS patients showed significant mental health problems in all three dimensions. In comparison to the subscales, the dimension of social and emotional health problems revealed the highest accuracy (AUC = 0.75; d = 0.948) and turned out to be the only scale that reliably differentiated between the groups.

CONCLUSIONS

MeSyMS constitutes a valid screening instrument to detect mental symptoms in MS. Social and emotional health problems turned out to be the most important aspect when identifying disease-related mental health symptoms in MS.

Psychometric Properties of the General Anxiety Disorders-7 Scale Using Categorical Data Methods: A Study in a Sample of University Attending Ethiopian Young Adults

BACKGROUND

Few studies have investigated the psychometric validation of the General Anxiety Disorders-7 Scale (GAD-7) using appropriate data assumptions. This study examined the reliability, factorial validity, divergent validity, and item analysis of the GAD-7 using categorical data methods in a sample of Ethiopian young adults.

METHODS

A sample of 270 students in the age group (18-20 years) was recruited during February-May of 2017 in this cross-sectional study using simple random sampling. The participants completed a tool for socio-demographic details, the GAD-7, and the Perceived Stress Scale-10 (PSS-10).

RESULTS

The cumulative variance rule (> 40%), the scree test, Kaiser's criteria (Eigenvalues > 1), and the parallel analysis found a 1-factor model for the GAD-7 (factor loadings, 0.38 to 0.63). Fit indices suggested a 1-factor model: the tests applied included the weighted root mean square residual (0.030), comparative fit index (1.000), the goodness of fit index (1.00), root mean square error of approximation (0.037) and the non-normed fit index (1.00). McDonald's Omega (0.772) implied that the scores had adequate internal consistency. Divergent validity was supported by significant but weak correlations that were found between the GAD-7 and PSS-10 scores (r = 0.11 to 0.25, p<0.05).

CONCLUSION

The psychometric validity of the GAD-7 in Ethiopian university attending young adults was supported by the categorical data method.

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.

Identifying Predictors of Psychological Distress During COVID-19: A Machine Learning Approach

Scientific understanding about the psychological impact of the COVID-19 global pandemic is in its nascent stage. Prior research suggests that demographic factors, such as gender and age, are associated with greater distress during a global health crisis. Less is known about how emotion regulation impacts levels of distress during a pandemic. The present study aimed to identify predictors of psychological distress during the COVID-19 pandemic. Participants (N = 2,787) provided demographics, history of adverse childhood experiences, current coping strategies (use of implicit and explicit emotion regulation), and current psychological distress. The overall prevalence of clinical levels of anxiety, depression, and post-traumatic stress was higher than the prevalence outside a pandemic and was higher than rates reported among healthcare workers and survivors of severe acute respiratory syndrome. Younger participants (<45 years), women, and non-binary individuals reported higher prevalence of symptoms across all measures of distress. A random forest machine learning algorithm was used to identify the strongest predictors of distress. Regression trees were developed to identify individuals at greater risk for anxiety, depression, and post-traumatic stress. Somatization and less reliance on adaptive defense mechanisms were associated with greater distress. These findings highlight the importance of assessing individuals' physical experiences of psychological distress and emotion regulation strategies to help mental health providers tailor assessments and treatment during a global health crisis.

The Psychological Impact of COVID-19 Pandemic on People With Multiple Sclerosis

Objective: The coronavirus disease 2019 (COVID-19) has radically changed the world in a few weeks. Italy has been one of the first and most affected countries with more than 30,000 deaths up to now. Public health measures as quarantine or national lockdown are necessary to limit the spread of infectious diseases, but it is unsurprising that depriving people of their liberty has negative psychological effects. This is especially the case for people with chronic diseases, including neurological conditions like multiple sclerosis (MS). People with MS (PwMS) have a higher burden of neuropsychiatric comorbidities and are known to undertake maladaptive coping strategies in stress conditions. The aim of the present study is to investigate the impact of COVID-19 pandemic lockdown on mental health of an Italian cohort of PwMS in comparison with healthy controls (HCs).

Methods: A total of 60 PwMS and 50 HCs (chosen among patients' cohabitants) were asked to answer a Web-based survey. This survey inquired about the impact of COVID-19 on patient's quality of life, job, and daily routine. Mood, fatigue, and sleep quality were evaluated using the Beck Depression Inventory II (BDI-II), the Generalized Anxiety Disease 7 (GAD-7), the Fatigue Severity Scale (FSS), and the Pittsburgh Sleep Quality Index (PSQI).

Results: Overall, patients had higher scores of BDI, FSS, and PSQI, and these differences were statistically significant (p < 0.05). When we looked at the subscores of the BDI, we detected a statistically significant difference for the neurovegetative part—that concerns with sleep, appetite, sex, and quality of sleep (p < 0.05). One out of five patients reported new symptoms or worsening of known symptom, in particular, sensory disturbances, and fatigue. However, no symptoms were severe enough to require hospitalization. When we looked for correlations among variables, we found that there was a significant relationship between unemployment and BDI total score, GAD-7, and PSQI in MS group. The presence of new symptoms or the worsening of symptoms positively related to FSS and to PSQI.

Discussion: We identified that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic had a significant impact on the psychological status of patients with MS. Compared with the general population, PwMS presented a higher burden of depressive symptoms, a worse sleep quality and perceived an increase in fatigue level, one of the most disabling symptoms of MS. The COVID-19 epidemic poses a challenge to psychological resilience. More studies are warranted to better understand the long-term consequences of the pandemic on mental health of vulnerable people during the disease outbreaks.

Evaluation of an internet-based intervention for service members of the German armed forces with deployment-related posttraumatic stress symptoms

BACKGROUND

The present study was designed to evaluate the efficacy of a therapist-guided internet-based cognitive-behavioral therapy (iCBT) intervention for service members of the German Armed Forces with posttraumatic stress disorder (PTSD). The iCBT was adapted from Interapy, a trauma-focused evidence-based treatment based on prolonged exposure and cognitive restructuring. It lasted for 5 weeks and included 10 writing assignments (twice a week). The program included a reminder function if assignments were overdue, but no multimedia elements. Therapeutic written feedback was provided asynchronously within one working day.

METHODS

Male active and former military service members were recruited from the German Armed Forces. Diagnoses were assessed with the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) and the Mini-International Neuropsychiatric Interview. Psychopathology was assessed at pre-treatment, post-treatment, and 3-month follow-up. Severity of PTSD was the primary outcome and anxiety was the secondary outcome. Participants were randomly allocated to a treatment group that received iCBT immediately or to a waitlist group that received iCBT after 6 weeks. Due to the overall small sample size (n = 37), the two groups were collapsed for the statistical analyses. Change during the intervention period was investigated using latent-change score models.

RESULTS

Improvements in the CAPS-5 were small and not statistically significant. For anxiety, small significant improvements were observed from pre- to follow-up assessment. The dropout rate was 32.3%.

CONCLUSIONS

The low treatment utilization and the high dropout rate are in line with previous findings on treatment of service members. The interpretation of the current null results for the efficacy of iCBT is limited due to the small sample size, however for military samples effect estimates were also smaller in other recent studies. Our results demonstrate the need to identify factors influencing treatment engagement and efficacy in veterans.

TRIAL REGISTRATION

Australian Clinical Trials Registry ACTRN12616000956404.

Mental Illness and BRCA1/2 Genetic Testing Intention Among Multiethnic Women Undergoing Screening Mammography

OBJECTIVES

To examine associations between patient-reported mental illness diagnosis and symptoms and BRCA1/2 genetic testing intention among women undergoing screening mammography.

SAMPLE & SETTING

100 multiethnic women of lower socioeconomic status who were undergoing mammography screening and met family history criteria for BRCA1/2 genetic testing.

METHODS & VARIABLES

Descriptive and bivariate nonparametric statistics and multivariate logistic regression were used to examine associations between mental illness and genetic testing intention. Variables were anxiety, depression, patient-reported mental illness diagnosis and symptoms, and testing intention.

RESULTS

Prevalence rates of mental illness symptoms were 36% for clinically significant depression and 36% for anxiety. Although 76% of participants intended to undergo genetic testing, only 5% had completed testing. History of mental illness and elevated levels of anxiety and depressive symptoms were positively correlated with testing intention in the bivariate analysis. In multivariate analysis, only younger age and less education were associated with testing intention.

IMPLICATIONS FOR NURSING

Future studies should address psychosocial needs and other competing barriers at the patient, provider, and healthcare system levels to increase access to BRCA1/2 genetic testing among multiethnic women.

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.

Benefits of Individualized Feedback in Internet-Based Interventions for Depression: A Randomized Controlled Trial

BACKGROUND

Even though there is an increasing number of studies on the efficacy of Internet-based interventions (IBI) for depression, experimental trials on the benefits of added guidance by clinicians are scarce and inconsistent. This study compared the efficacy of semistandardized feedback provided by psychologists with fully standardized feedback in IBI.

METHODS

Participants with mild-to-moderate depression (n = 1,089, 66% female) from the client pool of a health insurance company participated in a cognitive-behavioral IBI targeting depression over 6 weeks. Individuals were randomized to weekly semistandardized e-mail feedback from psychologists (individual counseling; IC) or to automated, standardized feedback where a psychologist could be contacted on demand (CoD). The contents and tasks were identical across conditions. The primary outcome was depression; secondary outcomes included anxiety, rumination, and well-being. Outcomes were assessed before and after the intervention and 3, 6, and 12 months later. Changes in outcomes were evaluated using latent change score modeling.

RESULTS

Both interventions yielded large pre-post effects on depression (Beck Depression Inventory-II: dIC = 1.53, dCoD = 1.37; Patient Health Questionnaire-9: dIC = 1.20, dCoD = 1.04), as well as significant improvements of all other outcome measures. The effects remained significant after 3, 6, and 12 months. The groups differed with regard to attrition (IC: 17.3%, CoD: 25.8%, p = 0.001). Between-group effects were statistically nonsignificant across outcomes and measurement occasions.

CONCLUSION

Adding semistandardized guidance in IBI for depression did not prove to be more effective than fully standardized feedback on primary and secondary outcomes, but it had positive effects on attrition.

Test Performance Characteristics of the AIR, GAD-7, and HADS-Anxiety Screening Questionnaires for Anxiety in Chronic Obstructive Pulmonary Disease

Rationale: Anxiety is a common comorbidity of chronic obstructive pulmonary disease (COPD) that is associated with higher morbidity and mortality. We evaluated three anxiety screening questionnaires: the Generalized Anxiety Disorder 7-Item Scale (GAD-7), the Hospital Anxiety and Depression Scale Anxiety subscale (HADS-A), and the Anxiety Inventory for Respiratory Disease (AIR).Objectives: To evaluate and compare the test performance characteristics of three anxiety screening questionnaires, using the Mini-International Neuropsychiatric Interview (MINI), version 7.0, as the "gold standard."Methods: Individuals with COPD were recruited at 16 centers. The MINI and questionnaires were administered by trained research coordinators at an in-person visit and readministered by telephone 2-4 weeks later. A composite score for the presence of any Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V) anxiety disorder was computed, based on the MINI as the gold standard, compared with a participant screening positive on self-report measures for these analyses.Results: Two hundred and twenty eligible individuals with COPD were enrolled; 219 completed the study. Eleven percent were identified as having a DSM-V anxiety disorder, based on the MINI. Elevated anxiety symptoms based on questionnaires were 38% for the AIR, 30% for the GAD-7, and 20% for the HADS-A. Area under the receiver operating characteristic curve (AUC) was highest for the GAD-7 (0.78; 95% confidence interval [CI], 0.69-0.87), followed by the HADS-A (0.74; 95% CI, 0.64-0.84) and the AIR (0.66; 95% CI, 0.56-0.76). The AUC for the GAD-7 was significantly greater than for the AIR (P = 0.014). Sensitivity was not statistically different among the questionnaires: 77% for the GAD-7, 63% for the HADS-A, and 66% for the AIR. The HADS-A had the highest specificity, 85%, which was significantly higher than that of the GAD-7 (77%; P < 0.001) and the AIR (65%; P < 0.001); GAD-7 specificity was higher than AIR specificity (P < 0.001).Conclusions: Symptoms of anxiety among patients with COPD as identified by screening questionnaires were common and significantly higher than the prevalence of anxiety disorder meeting DSM-V criteria. The GAD-7, the HADS-A and the AIR questionnaires had fair to moderate psychometric properties as screening tools for anxiety in individuals with COPD, indicating the need for improved measures for this patient population.

Diagnostic and Clinical Utility of the GAD-2 for Screening Anxiety Symptoms in Individuals With Multiple Sclerosis

OBJECTIVE

To assess the diagnostic and clinical utility of the 2-item Generalized Anxiety Disorder Scale (GAD-2) for screening anxiety symptoms in individuals with multiple sclerosis (MS).

DESIGN

Cross-sectional.

SETTING

University-affiliated MS neurology and rehabilitation center.

PARTICIPANTS

The sample comprised adults (N=99) (ages 19-72; mean ± SD=46.2±13.0; 75% women) with a physician-confirmed MS diagnosis who were receiving care in a university-affiliated MS center. Disease durations ranged from 1 to 37 years (mean ± SD=10.7±8.4).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Participants completed the 7-item Generalized Anxiety Disorder Scale (GAD-7) and GAD-2. Internal consistency was calculated for both measures. Area under the receiver operating characteristics curve (AUC), the 95% confidence interval for the AUC, and Youden's J were calculated to determine the optimal GAD-2 cutoff score for identifying clinically significant anxiety symptoms, as defined by the previously validated GAD-7 cutoff score of ≥8.

RESULTS

Internal consistency was excellent for the GAD-7 (Cronbach α=.91) and acceptable for the GAD-2 (α=.77), and the measures were highly correlated (r=.94). The GAD-2 had excellent overall accuracy for identifying clinically significant anxiety symptoms (AUC=0.97; 95% confidence interval, 0.94-1.00). A GAD-2 cutoff score of ≥3 provided an optimal balance of good sensitivity (0.87) and excellent specificity (0.92) for detecting clinically significant anxiety symptoms. Alternatively, a cutoff score of ≥2 provided excellent sensitivity (1.00) and fair specificity (0.76).

CONCLUSIONS

The GAD-2 is a clinically useful and psychometrically valid tool for screening anxiety symptoms in MS rehabilitation and neurology care settings. Importantly, this tool has the potential to identify individuals with MS who are at risk for anxiety disorders and who may benefit from rehabilitation psychology interventions to ultimately improve functioning and quality of life.

Somatic Symptoms of Depression and Anxiety in People with Multiple Sclerosis

Background

People with multiple sclerosis (MS) are at increased risk for depression and anxiety. The symptoms of MS are often similar to the somatic or physical symptoms of depression and anxiety (fatigue, trouble concentrating). This study examined whether MS symptoms and effects biased the assessment of somatic symptoms of anxiety and depression.

Methods

People with MS (n = 513) completed a survey about MS symptoms, treatments, and distress. The Patient Health Questionnaire-9 assessed depression, and the patient-report version of the Primary Care Evaluation of Mental Disorders assessed anxiety. Participants were grouped into low versus high MS symptoms based on self-reported symptoms and as high versus low disability by the Expanded Disability Status Scale (EDSS). Groups were compared using differential item functioning analysis.

Results

No bias was found on somatic symptoms of depression comparing high versus low MS symptom groups (P > .15) or comparing groups based on EDSS scores (P > .29). Two anxiety symptoms (fatigue and muscle tension) showed bias comparing high versus low MS symptom groups (P < .01) and comparing high versus low groups based on EDSS scores (P ≤ .01). Intraclass correlations suggested a small effect due to bias in the somatic symptoms of anxiety.

Conclusions

Somatic symptoms of depression are unlikely to be biased by MS symptoms. However, the use of certain somatic symptoms to assess anxiety may be biased for those with high MS symptoms.

Implementation of a Guided, Digital Cognitive Behavioral Program for Anxiety in Primary Care: Preliminary Findings of Engagement and Effectiveness

BACKGROUND

Implementation of digital behavioral health programs in primary care (PC) can improve access to care for patients in need.

INTRODUCTION

This study provides preliminary data on user engagement and anxiety symptom change among patients referred by their PC provider to a guided, mobile cognitive behavioral program, Lantern.

MATERIALS AND METHODS

Adults aged 20-65 years with at least mild anxiety (GAD-7 ≥ 5) during routine clinical screening in two PC practices were offered Lantern. The primary outcome was self-reported anxiety collected at baseline and 2 months. Linear mixed effects modeling was used to examine anxiety symptom reduction from baseline to 2 months. Post hoc analyses evaluated how number of units completed, number of techniques practiced, and days of usage impacted symptom change.

RESULTS

Sixty-three participants signed up for Lantern and had both baseline and 2- month GAD-7. A mixed effects model adjusted for age, gender, medical complexity score, and physical health found a significant effect of time on GAD-7 (β = -2.08, standard error = 0.77, t(62) = -2.71, p = 0.009). Post hoc analyses indicated that mean number of units, techniques, and usage days did not significantly impact GAD-7 change over 2 months. However, there was significantly greater improvement in anxiety in participants who completed at least three techniques.

DISCUSSION

Results benchmark to previous studies that have found statistically significant symptom change among participants after 4-9 weeks of face-to-face or Internet-based cognitive behavioral therapy (CBT).

CONCLUSIONS

This study suggests that use of Lantern is associated with anxiety reduction and provides proof-of-concept for the dissemination and implementation of guided, CBT-based mobile behavioral health interventions in PC settings.

Factor structure and construct validity of the Generalized Anxiety Disorder 7-item (GAD-7) among Portuguese college students

: The Generalized Anxiety Disorder 7-item (GAD-7) scale has been presented as a reliable and valid measure to assess generalized anxiety symptoms in several clinical settings and among the general population. However, some researches did not support the original one-dimensional structure of the GAD-7 tool. Our main aim was to examine the factor structure of GAD-7 comparing the one-factor model fit with a two-factor model (3 somatic nature symptoms and 4 cognitive-emotional nature symptoms) in a sample of college students. This validation study with data collected cross-sectionally included 1,031 Portuguese college students attending courses in the six schools of the Polytechnic Institute of Coimbra, Coimbra, Portugal. Measures included the GAD-7, Hospital Anxiety and Depression Scale (HADS) and the University Student Risk Behaviors Questionnaire. Confirmatory factor analysis (CFA) procedures confirmed that neither factor structure was well fitting. Thus, a modified single factor model allowing the error terms of items associated with relaxing difficulties and irritability to covary was an appropriate solution. Additionally, this factor structure revealed configural and metric invariance across gender. A good convergent validity was found by correlating global anxiety and depression. However, this measure showed a weak association with consumption behaviors. Our results are relevant to clinical practice, since the comprehensive approach to GAD-7 contributes to knowing generalized anxiety symptoms trajectory and their correlates within the university setting.

Mental Health Comorbidity in MS: Depression, Anxiety, and Bipolar Disorder

Among individuals with multiple sclerosis (MS), mental health comorbidities play a significant role in contributing to secondary disability and detracting from quality of life. This review examines current evidence surrounding three mental health issues of particular relevance to MS: depression, anxiety, and bipolar disorder. We review what is known of the prevalence, correlates, screening mechanisms, and current treatment of each issue and provide recommendations for future areas of research.

Depression and Age at First Neurology Appointment Associated with Receipt of Behavioral Medicine Services Within 1 Year in a Multiple Sclerosis Population

BACKGROUND

Patients with multiple sclerosis (MS) newly seen by a neurologist may benefit from early psychological intervention owing to the reciprocal relationship between stress and disease progression. However, it is uncertain what factors contribute to patients' receiving these services.

METHODS

Logistic regression analysis of prospectively gathered data evaluated how demographic and disease characteristics and emotional/physical health factors contributed to referral to receive behavioral medicine (BM) services within 1 year of their first neurology appointment at the Mellen Center for Multiple Sclerosis at the Cleveland Clinic. Survival analyses then evaluated whether this resulted in earlier receipt of services.

RESULTS

Although many factors were associated with receiving BM services during univariate analyses (age, race, marital status, years since MS onset, depression, stress, and quality of life), when considering multivariable interactions, only two variables remained significant: age (odds ratio [OR] = 0.86, 95% confidence interval [CI], 0.80-0.92) and depression (OR = 1.56, 95% CI, 1.39-1.75). Survival analyses did not show differences in time to BM services for stratifications of age or depression scores.

CONCLUSIONS

Younger patients and patients with more severe depression were more likely to receive BM services within 1 year of their first neurology appointment. Future research will focus on evaluating whether these are also the patients in greatest need of services or whether they are simply more open to receiving them.

The Relationship between Psychosocial Factors and Cognition in Multiple Sclerosis

INTRODUCTION

Multiple sclerosis (MS) is a common disorder in some regions of the world, with over 2.3 million people diagnosed worldwide. Cognitive impairment is one of the earliest symptoms to present in the course of the disease and can cause significant morbidity. We proposed a study to explore the psychosocial predictors of cognitive impairment in MS patients in Saudi Arabia, a previously unexplored patient population.

METHODS

Demographic data, depression scale (PHQ9), symptom burden (PHQ15), anxiety (GAD7), disease duration, and Montreal Cognitive Assessment (MOCA) scores were collected from 195 patients in a neurology clinic in Ryiadh, Saudi Arabia. Univariate and multiple regression analyses were conducted to identify variables that are significantly associated with cognitive impairment.

RESULTS

Variables that were identified to be significantly associated with cognition, p < 0.05, were education level, disease duration, and family history.

DISCUSSION

Both education level and disease duration were variables identified in previous studies. We showed family history to be a significant variable, and no association was found with depression or anxiety, which is unique to our study population.

CONCLUSIONS

We identified several psychosocial predictors that are associated with cognition in our patient population. It was also noted that a difference exists between patient populations, highlighting the need for further studies in specific geographical regions.

Examination of an Internet-Delivered Cognitive Behavioural Pain Management Course for Adults with Fibromyalgia: A Randomized Controlled Trial

Fibromyalgia (FM) is a common and often debilitating chronic pain condition. Research shows that symptoms of depression and anxiety are present in up to three quarters of individuals with FM. Of concern, most adults with FM cannot access traditional face-to-face cognitive behavioural pain management programs, which are known to be beneficial. Given known difficulties with treatment access, the present study sought to explore the efficacy and acceptability of a previously developed Internet-delivered cognitive behavioural pain management course, the Pain Course, for adults with FM. The five-lesson course was delivered over eight weeks and was provided with brief weekly contact, via telephone and secure email, with a guide throughout the course. Participants were randomized either to the Pain Course (n = 30) or to a waiting-list control group (n = 30). Symptoms were assessed at pre-treatment, post-treatment and 4-week follow-up. Completion rates (87%) and satisfaction ratings (86%) were high. Improvements were significantly greater in treatment group participants compared to waiting-list group participants on measures of FM (Cohen's d =.70; 18% reduction), depression (Cohen's d =.63-.72; 20-28% reduction), pain (Cohen's d =.87; 11% improvement) and fear of pain (Cohen's d =1.61; 12% improvement). Smaller effects were also observed on measures of generalized anxiety and physical health. The changes were maintained at four-week follow-up. The current findings add to existing literature and highlight the specific potential of Internet-delivered cognitive behavioural pain management programs for adults with FM, especially as a part of stepped-care models of care. Future research directions are described.

Screening Tools for Anxiety in People with Multiple Sclerosis: A Systematic Review

Background: Anxiety is prevalent in people with multiple sclerosis (MS). Screening measures are used to identify symptoms of anxiety, but the optimal measure to screen for anxiety disorders in MS has not been established. Methods: We searched the MEDLINE, Embase, PsycINFO, PsycARTICLES Full Text, Cumulative Index to Nursing and Allied Health Literature, Web of Science, and Scopus databases from database inception until August 7, 2015. Two independent reviewers screened abstracts and full-text reports for study inclusion, extracted data, and assessed risk of bias. We included studies that evaluated the criterion validity of anxiety screening tools when measuring anxiety in individuals with well-documented MS, as measured by sensitivity, specificity, and positive and negative predictive values. Results: Of the 3181 abstracts screened, 18 articles were reviewed in full text, of which 4 met the inclusion criteria. The criterion validity of three screening tools was assessed: the Hospital Anxiety and Depression Scale-Anxiety (HADS-A), Beck Anxiety Inventory (BAI), and 7-item Generalized Anxiety Disorder Scale (GAD-7). The HADS-A was validated against the Structured Clinical Interview for DSM-IV, the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) interview, and the BAI. The BAI was validated against the SCAN, and the GAD-7 was validated against the HADS-A. The HADS-A had higher measures of sensitivity and specificity than did the BAI and the GAD-7. Conclusions: Based on this small sample, the HADS-A shows promise as an applicable measure for people with MS. Screening scales used to identify anxiety in MS must be validated against appropriate reference standards.

The challenge of comorbidity in clinical trials for multiple sclerosis

OBJECTIVE

We aimed to provide recommendations for addressing comorbidity in clinical trial design and conduct in multiple sclerosis (MS).

METHODS

We held an international workshop, informed by a systematic review of the incidence and prevalence of comorbidity in MS and an international survey about research priorities for studying comorbidity including their relation to clinical trials in MS.

RESULTS

We recommend establishing age- and sex-specific incidence estimates for comorbidities in the MS population, including those that commonly raise concern in clinical trials of immunomodulatory agents; shifting phase III clinical trials of new therapies from explanatory to more pragmatic trials; describing comorbidity status of the enrolled population in publications reporting clinical trials; evaluating treatment response, tolerability, and safety in clinical trials according to comorbidity status; and considering comorbidity status in the design of pharmacovigilance strategies.

CONCLUSION

Our recommendations will help address knowledge gaps regarding comorbidity that interfere with the ability to interpret safety in monitored trials and will enhance the generalizability of findings from clinical trials to "real world" settings where the MS population commonly has comorbid conditions.

Prevalence of Depression and Anxiety among Patients with Multiple Sclerosis Attending the MS Clinic at Sheikh Khalifa Medical City, UAE: Cross-Sectional Study

Depression and anxiety are reported to be prevalent in patients with MS, with prevalence rates ranging from 20% to 50%. Unfortunately, the rates, patterns, and risk factors are not well studied in our Middle East region, and, to our knowledge, not at all in UAE. Using standardized screening tools, we observed that 17% and 20% of 80 patients seen in MS clinic had scores consistent with major depression and anxiety disorders, respectively, at a rate that was not statistically different when compared to age and sex matched controls. None of the studied variables including duration of the disease, EDSS scores, age, gender, and the level of education had any significant correlation with the rates of both disorders. Almost two-thirds of the patients with scores consistent with major depression and anxiety were not on antidepressant and antianxiety medications.