The validity and reliability of screening measures for depression and anxiety disorders in multiple sclerosis

Childhood Maltreatment and Psychiatric Comorbidity in Immune-Mediated Inflammatory Disorders

OBJECTIVE

To determine whether childhood maltreatment is associated with immune-mediated inflammatory disorders (IMIDs; multiple sclerosis [MS], inflammatory bowel disease [IBD], and rheumatoid arthritis [RA]). We further aimed to determine the relationship between maltreatment and psychiatric comorbidity in IMIDs and whether these relationships differed across IMID.

METHODS

Six hundred eighty-one participants (MS, 232; IBD, 216; RA, 130; healthy controls, 103) completed a structured psychiatric interview to identify psychiatric disorders, and the Childhood Trauma Questionnaire to evaluate five types of maltreatment: emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect. We evaluated associations between maltreatment, IMID, and psychiatric comorbidity using multivariable logistic regression models.

RESULTS

The prevalence of having ≥1 maltreatment was similar across IMID but higher than in controls (MS, 63.8%; IBD, 61.6%; RA, 62.3%; healthy controls, 45.6%). Emotional abuse was associated with having an IMID (adjusted odds ratio [aOR] = 2.37; 1.15-4.89). In the sex-specific analysis, this association was only present in women. History of childhood maltreatment was associated with a lifetime diagnosis of a psychiatric disorder in the IMID cohort (OR = 2.24; 1.58-3.16), but this association did not differ across diseases. In those with IMID, total types of maltreatments (aOR = 1.36; 1.17-1.59) and emotional abuse (aOR = 2.64; 1.66-4.21) were associated with psychiatric comorbidity.

CONCLUSIONS

Childhood maltreatment is more common in IMID than in a healthy population and is associated with psychiatric comorbidity. Given the high burden of psychiatric disorders in the IMID population, clinicians should be aware of the contribution of maltreatment and the potential need for trauma-informed care strategies.

Recovery From COVID-19 in Multiple Sclerosis: A Prospective and Longitudinal Cohort Study of the United Kingdom Multiple Sclerosis Register

BACKGROUND AND OBJECTIVES

To understand the course of recovery from coronavirus disease 2019 (COVID-19) among patients with multiple sclerosis (MS) and to determine its predictors, including patients' pre-COVID-19 physical and mental health status.

METHODS

This prospective and longitudinal cohort study recruited patients with MS who reported COVID-19 from March 17, 2020, to March 19, 2021, as part of the United Kingdom MS Register (UKMSR) COVID-19 study. Participants used online questionnaires to regularly update their COVID-19 symptoms, recovery status, and duration of symptoms for those who fully recovered. Questionnaires were date stamped for estimation of COVID-19 symptom duration for those who had not recovered at their last follow-up. The UKMSR holds demographic and up-to-date clinical data on participants as well as their web-based Expanded Disability Status Scale (web-EDSS) and Hospital Anxiety and Depression Scale (HADS) scores. The association between these factors and recovery from COVID-19 was assessed using multivariable Cox regression analysis.

RESULTS

Of the 7,977 patients with MS who participated in the UKMSR COVID-19 study, 599 reported COVID-19 and prospectively updated their recovery status. Twenty-eight hospitalized participants were excluded. At least 165 participants (29.7%) had long-standing COVID-19 symptoms for ≥4 weeks and 69 (12.4%) for ≥12 weeks. Participants with pre-COVID-19 web-EDSS scores ≥7, participants with probable anxiety and/or depression (HADS scores ≥11) before COVID-19 onset, and women were less likely to report recovery from COVID-19.

DISCUSSION

Patients with MS are affected by postacute sequelae of COVID-19. Preexisting severe neurologic impairment or mental health problems appear to increase this risk. These findings can have implications in tailoring their post-COVID-19 rehabilitation.

Psychometric Properties of the HADS Measure of Anxiety and Depression Among Multiple Sclerosis Patients in Croatia

Depression and anxiety are common complaints in patients with multiple sclerosis (MS). The study objective was to investigate the factor structure, internal consistency, and correlates of the Croatian version of the Hospital Anxiety and Depression Scale (HADS) in patients with MS. A total of 179 patients with MS and 999 controls were included in the online survey. All subjects completed the HADS and self-administered questionnaires capturing information of demographic, education level, disease-related variables, and the Multiple Sclerosis Impact Scale-29 (MSIS-29). Psychometric properties were examined by estimating the validity, reliability, and factor structure of the HADS in patients with MS. The two HADS subscales (anxiety and depression) had excellent internal consistencies (Cronbach’s α value 0.82–0.83), and factor analysis confirmed a two-factor structure. The convergent validity of the HADS subscales appeared to be good due to the significant correlations between HADS and MSIS-29. Receiver operating characteristic (ROC) analysis indicates that the HADS subscales have a significant diagnostic validity for group differentiation. Hierarchical regression analysis using MSIS-29 subscales as criterion variables showed consistent evidence for the incremental validity of the HADS. The HADS is a reliable and valid self-assessment scale in patients with MS and is suggested to be used in clinical monitoring of the psychiatric and psychological status of patients with MS.

Addressing Depression Symptoms among University Students under COVID-19 Restrictions-The Mediating Role of Stress and the Moderating Role of Resilience

Background: The COVID-19 pandemic has contributed to a decline in mental health globally. Compared to the general population, university students have been identified as a group vulnerable to developing depression symptoms during the pandemic. Social isolation, a signature mental health consequence under physical-distancing regulations, is a known predictor of depression symptoms during the pandemic. Yet, more research is required to understand the mechanism that underpins the isolation–depression association and identify psychological factors that may attenuate the association. The current study aimed to understand the role of stress and resilience in the isolation–depression association among university students. Methods: Data were collected from 1718 university students between 28 and 31 May 2020. Partial least squares structural equation modelling (PLS-SEM) was used to examine the mediating role of perceived stress and the moderating role of resilience in the isolation–depression association. Results: We found that perceived stress partially mediated the association between social isolation and depression symptoms. Both the direct and indirect effects were moderated by participants’ resilience levels. Conclusions: Social isolation during the pandemic may contribute to depression symptoms both directly and through elevated stress levels. As an internal strength, resilience may buffer the adverse effects of isolation and stress on depression symptoms. Targeted interventions including mindfulness and physical exercise training may provide promising results in reducing depression symptoms among university students and should be considered by university administrators particularly during times of imposed physical-distancing measures.

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.

Exploring multimodal hallucinations and disturbances in the basic and bodily self: A cross-sectional study in a non-clinical sample

The bodily self is key to emotional embodiment, which is important for social functioning and emotion regulation. There is a paucity of research systematically assessing how basic and bodily self-disturbances relate to multimodal hallucinations. This study hypothesised that participants with greater hallucination-proneness would report greater degrees of basic and bodily self-disturbance and would demonstrate more ambiguous and less discrete mapping of emotional embodiment. Stage one screened non-clinical participants' degree of hallucination-proneness. Stage two participants completed seven further questionnaires. Hierarchical linear regression modelled the influence of hallucination-proneness and covariates on measures of basic and bodily self-disturbance and sensed presence. Stage two participants also completed a computerised body mapping task (EmBODY) which assessed emotional embodiment. Topographical maps were generated to compare patterns of embodiment between high and low hallucination-proneness groups. 55 respondents participated in stage two, with 18 participants from the high or low hallucination-proneness groups completing EmBODY. In the hierarchical regression analyses, the addition of a measure of hallucination proneness in the final step only increased predictive power where the dependent variable assessed sensed presence (p = 0.035 and p = 0.009, respectively). The EmBODY data revealed that participants with low hallucination-proneness consistently reported more bodily activation across 14 emotional states, whereas the high hallucination-proneness group reported more deactivation. In conclusion, hallucination-proneness was most strongly associated with sensed presence experiences. Patterns of embodiment appeared similar between the two groups, despite consistent differences in activation and deactivation. These findings are exploratory and need to be confirmed in a larger sample.

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 Cannabis-Based Medicine on Neuropathic Pain and Spasticity in Patients with Multiple Sclerosis and Spinal Cord Injury: Study Protocol of a National Multicenter Double-Blinded, Placebo-Controlled Trial

Disease or acquired damage to the central nervous system frequently causes disabling spasticity and central neuropathic pain (NP), both of which are frequent in multiple sclerosis (MS) and spinal cord injury (SCI). Patients with MS and SCI often request treatment with cannabis-based medicine (CBM). However, knowledge about effects, side effects, choice of active cannabinoids (Δ9-tetrahydrocannabinol (THC), cannabidiol (CBD) alone or in combination), and doses of CBM remains limited. Using a double-blind, parallel design in a national multicenter cohort, this study examines the effect of CBM on spasticity and NP. Patients are randomized to treatment with capsules containing either THC, CBD, THC and CBD, or placebo. Primary endpoints are patient-reported pain and spasticity on a numerical rating scale. Other endpoints include quality of life and sleep, depression and anxiety, and relief of pain and spasticity. Side-effects of CBM are described. In a sub-study, the pharmacodynamics (PD) and pharmacokinetics (PK) of oral capsule CBM are examined. We expect that the study will contribute to the literature by providing information on the effects and side-effects of CBD, THC, and the combination of the two for central neuropathic pain and spasticity. Furthermore, we will describe the PD/PK of THC and CBD in a patient population.

Mechanisms of change in depression and anxiety within a mind-body activity intervention for chronic pain

BACKGROUND

Chronic pain is challenging and costly to treat. Depression and anxiety co-occur with chronic pain. Identifying psychosocial mechanisms contributing to emotional outcomes among chronic pain patients can inform future iterations of this intervention.

METHODS

We examined explanatory mechanisms of change in emotional distress following a mind-body and activity intervention among 82 participants (21 - 79 years old, 65.85% female, 80.48% White). With depression and anxiety as outcomes, we hypothesized that potential mediators would include pain catastrophizing, mindfulness, and pain resilience. We used mixed-effects modeling to assess the indirect effects of time on each outcome variable through hypothesized mediators simultaneously.

RESULTS

Improvements in depression from baseline to post-treatment were most explained by pain catastrophizing (b = -2.53, CI = [-3.82, -1.43]), followed by mindfulness (b = -1.21, CI = [-2.15, -0.46]), and pain resilience (b = -0.76, CI = [-1.54, -1.66]). Improvements in anxiety from baseline to post-treatment were most explained by pain catastrophizing(b = -2.16, CI = [-3.45, -1.08]) and mindfulness (b = -1.51, CI = [-2.60, -0.65]), but not by pain resilience, (b = -0.47, CI = [-1.26, 0.17]).

LIMITATIONS

Findings are limited by the lack of a control group, relatively small sample, and two timepoints. However, findings can guide future mind-body intervention efficacy testing trials.

CONCLUSIONS

Pain catastrophizing and mindfulness appear to be important intervention targets to enhance emotional functioning for chronic pain patients, and should be considered simultaneously in interventions for chronic pain.

The effect of national disease-modifying therapy subsidy policy on long-term disability outcomes in people with multiple sclerosis

BACKGROUND

Disease-modifying therapies (DMTs) are used to treat people with relapsing-onset multiple sclerosis (ROMS), but our knowledge is largely limited to their short-term effects.

OBJECTIVE

To determine (1) the impact of national-level DMT subsidy policy on DMT use and health outcomes in people with MS (PwMS) and (2) the long-term effects of DMT on disability and quality of life (QoL; 5-level EQ-5D version (EQ-5D-5L) utility value).

METHODS

This observational cohort study compared Australian and New Zealand populations with different levels of DMT availability 10-20 years post-ROMS diagnosis. Between-country differences were assessed using standardised differences. Associations were assessed with multivariable linear regression models.

RESULTS

We recruited 328 Australians and 256 New Zealanders. The Australian cohort had longer DMT treatment duration, greater proportion of disease course treated and shorter duration between diagnosis and starting DMT. The Australian cohort had lower median Expanded Disability Status Scale (EDSS) (3.5 vs 4.0) and Multiple Sclerosis Severity Score (MSSS) (3.05 vs 3.71) and higher QoL (0.71 vs 0.65). In multivariable models, between-country differences in disability and QoL were largely attributed to differential use of DMT.

CONCLUSIONS

This study provides evidence for the impact of national-level DMT policy on disability outcomes in PwMS. Where DMTs are more accessible, PwMS experienced less disability progression and improved QoL 10-20 years post-diagnosis.

Demographic, clinical, and symptomatic correlates of subjective sleep quality in adults with multiple sclerosis

BACKGROUND

This study examined a comprehensive set of demographic, clinical, and symptomatic variables as correlates of subjective sleep quality in adults with multiple sclerosis (MS).

METHODS

Participants with MS(N=485) completed the Pittsburgh Sleep Quality Index(PSQI), a demographics and clinical characteristics questionnaire, the Patient Determined Disease Steps Scale(PDDS), the Fatigue Severity Scale, and the Hospital Anxiety and Depression Scale. We conducted bivariate Spearman's rho (ρ) correlation analyses and multiple linear regression analysis for identifying variables associated with PSQI scores.

RESULTS

Participants had a mean (standard deviation) age of 55.4 (12.6) years and were mostly female (78%) with a median [interquartile range] PDDS of 2.0[3.0]. Higher levels of fatigue (ρ=0.32), more symptoms of anxiety (ρ=0.39) and depression (ρ=0.36), younger age (ρ=-0.12), lower income status (ρ=-0.13), shorter MS disease duration (ρ=-0.11), being in a minority group (ρ=0.09), and being unemployed (ρ=-0.10) were associated with worse sleep quality. There were no significant associations between gender, marital status, parental status, education level, disability status, or MS disease type and sleep quality. The overall regression model accounted for 26.3% of variance in sleep quality (F[8,229.8]=20.25) and there were significant coefficients for anxiety(β=0.25), fatigue(β=0.18), depression(β=0.16), and employment status(β=-0.12), but not disease duration, age, race, or income level.

DISCUSSION

Participants with higher levels of anxiety, fatigue, and depression and who were unemployed reported worse sleep quality in our sample of adults with MS. These results may identify specific subgroups of the MS population that experience more sleep problems, and therefore are in greatest need for interventions designed to improve sleep impairment.

Patients with Clinically Elevated Depressive Symptoms Report Improvements in Mood, Pain, and Functioning following Participation in Interdisciplinary Pain Rehabilitation

OBJECTIVE

Chronic pain and depression frequently co-occur and exacerbate one another; therefore, it is important to treat both conditions to improve patient outcomes. The current study evaluates an interdisciplinary pain rehabilitation program (IPRP) with respect to the following questions: 1) How do clinically elevated depressive symptoms impact pain-related treatment outcomes? and 2) To what extent does IPRP participation yield reliable and clinically significant change in depressed mood?

METHODS

Participants in this study included 425 adults who engaged in a 10-week IPRP and completed self-report measures of pain, mood, and functioning at intake and discharge. Participants were categorized into 4 groups based on self-reported depressive symptoms (PROMIS Depression): within normal limits (WNL; n = 121), Mild (n = 115), Moderate (n = 153), and Severe (n = 36).

RESULTS

Participants reported significant improvement in pain, pain-related life interference, health-related quality of life, pain catastrophizing, and depressed mood regardless of initial symptom level. In addition, 43.4% of patients with Mild, Moderate, or Severe depressed mood reported reliable and clinically significant improvement in depressive symptoms and 30.3% were in remission at the end of treatment.

CONCLUSIONS

These findings support the assertion that IPRPs represent an effective treatment for patients with comorbid chronic pain and depression and that participation is associated with improvement in both conditions.

Validating the Patient-Reported Outcomes Measurement Information System Short Form v1.0-Anxiety 8a in a sample of young adult cancer survivors: Comparison with a structured clinical diagnostic interview

BACKGROUND

The objective of this study was to validate the Patient-Reported Outcomes Measurement Information System Short Form v1.0-Anxiety 8a (PROMIS-A-SF) against a structured diagnostic interview in order to determine its accuracy and the most appropriate cutoff score for identifying anxiety disorders in young adult cancer survivors (YACSs).

METHODS

Two hundred forty-nine YACSs aged 18 to 40 years (50% male) completed the PROMIS-A-SF and the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID). The SCID was used to determine whether participants met the criteria for an anxiety diagnosis. Receiving operator characteristic analyses were performed to determine the concordance of the PROMIS-A-SF and the SCID as well as cutoff scores with sensitivity (≥0.85) and specificity (≥0.75) appropriate for an anxiety screening measure.

RESULTS

The PROMIS-A-SF was determined to have good overall discrimination in comparison with the SCID (area under the curve, 0.84). A PROMIS-A-SF t-score cutoff ≥ 53.2 (total predictive value, 67.9%) came closest to meeting the study criteria with a sensitivity of 88%, but the specificity was only 65%. In a hypothetical screening example, this cutoff led to moderate levels of missed cases (14%) and a significant proportion of clinical referrals that were unnecessary by SCID criteria (35%). Of the survivors referred for services according to these criteria, less than one-third (29%) would have a SCID anxiety diagnosis.

CONCLUSIONS

The PROMIS-A-SF demonstrated moderately strong concordance with anxiety disorders measured by the SCID, but cutoff scores did not meet study criteria for clinical screening. Although it may not be appropriate as a standalone screener, the PROMIS-A-SF may be useful for assessing anxiety in YACSs when it is incorporated into clinical practice or when it is combined with other measures.

Estimating classification consistency of screening measures and quantifying the impact of measurement bias

Screening measures are used in psychology and medicine to identify respondents who are high or low on a construct. Based on the screening, the evaluator assigns respondents to classes corresponding to different courses of action: Make a diagnosis versus reject a diagnosis; provide services versus withhold services; or conduct further assessment versus conclude the assessment process. When measures are used to classify individuals, it is important that the decisions be consistent and equitable across groups. Ideally, if respondents completed the screening measure repeatedly in quick succession, they would be consistently assigned into the same class each time. In addition, the consistency of the classification should be unrelated to the respondents' background characteristics, such as sex, race, or ethnicity (i.e., the measure is free of measurement bias). Reporting estimates of classification consistency is a common practice in educational testing, but there has been limited application of these estimates to screening in psychology and medicine. In this article, we present two procedures based on item response theory that are used (a) to estimate the classification consistency of a screening measure and (b) to evaluate how classification consistency is impacted by measurement bias across respondent groups. We provide R functions to conduct the procedures, illustrate the procedures with real data, and use Monte Carlo simulations to guide their appropriate use. Finally, we discuss how estimates of classification consistency can help assessment specialists make more informed decisions on the use of a screening measure with protected groups (e.g., groups defined by gender, race, or ethnicity). (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Using the multiple sclerosis resiliency scale to identify psychological distress in persons with multiple sclerosis

BACKGROUND

The Multiple Sclerosis Resiliency Scale (MSRS) is the first resilience measure that is specific to multiple sclerosis (MS)-related challenges. In order for the MSRS to be a valuable tool for clinicians, it is important to identify what is a meaningful score. As such, this study aimed to examine the MSRS' ability to identify persons with MS experiencing depression or anxiety symptoms, as determined using clinically significant scores on the Hospital Anxiety and Depression Scale (HADS).

METHODS

Participants (n = 884) were persons with MS who were recruited electronically primarily through the North American Research Committee on MS (NARCOMS). In addition to the MSRS, participants completed the HADS, which was used to categorize them into possible depression and anxiety groups using two criteria from the literature: ≥8 and ≥11. Receiver-operating-characteristic (ROC) curves were run to determine the MSRS total and subscale scores' classification accuracies, with optimal scores for detecting possible depression and anxiety cases determined using the Youden index.

RESULTS

The MSRS total score's classification accuracy ranged between 86.2% and 92.2% for depression, with scores of 70 and 68 for the ≥8 and ≥11 criteria, respectively. For anxiety, the MSRS total score's classification accuracy ranged between 78.1% and 82.8%, with scores of 72 and 71 for the ≥8 and ≥11 criteria, respectively. The Emotional and Cognitive Strategies subscale had the strongest classification accuracy of all the subscales.

CONCLUSIONS

The MSRS can be used to identify persons with MS experiencing mental health difficulties with relatively good classification accuracy, which may help clinicians to triage who needs additional assistance or support.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The association between childhood maltreatment and pain catastrophizing in individuals with immune-mediated inflammatory diseases

OBJECTIVE

Childhood maltreatment is associated with pain catastrophizing. Both childhood maltreatment and pain catastrophizing are prevalent in certain immune-mediated inflammatory disease (IMID) populations. However, it is unknown whether childhood maltreatment contributes to the high rates of pain catastrophizing in IMID cohorts. We assessed the relationship between childhood maltreatment and pain catastrophizing in individuals with IMID, and whether this differed across IMID.

METHODS

Between November 2014 and July 2016 we recruited individuals with multiple sclerosis (MS), inflammatory bowel disease (IBD), and rheumatoid arthritis (RA). Participants completed the Childhood Trauma Questionnaire-Short Form, the Pain Catastrophizing Scale, and Hospital Anxiety and Depression Scale. We tested the association between childhood maltreatment and pain catastrophizing using multivariable logistic regression.

RESULTS

We included 577 individuals with IMID (MS: 232, IBD: 215, RA: 130). Overall, 265 (46%) participants with IMID reported any childhood maltreatment, with the most common type of maltreatment being emotional neglect. Childhood maltreatment was associated with pain catastrophizing (OR 3.32; 95% CI 1.89-5.85) independent of other risk factors, including sociodemographics and symptoms of anxiety and depression.

CONCLUSION

Pain catastrophizing is highly prevalent in our IMID population, and strongly associated with childhood maltreatment in this population. Interventions that consider childhood maltreatment and pain catastrophizing should be incorporated into the clinical management of IMID patients.

COVID-19 is associated with new symptoms of multiple sclerosis that are prevented by disease modifying therapies

Background

Infections can trigger exacerbations of multiple sclerosis (MS). The effects of the coronavirus disease 2019 (COVID-19) on MS are not known. The aim of this study was to understand the impact of COVID-19 on new and pre-existing symptoms of MS.

Methods

The COVID-19 and MS study is an ongoing community-based, prospective cohort study conducted as part of the United Kingdom MS Register. People with MS and COVID-19 were invited by email to complete a questionnaire about their MS symptoms during the infection. An MS exacerbation was defined as developing new MS symptoms and/or worsening of pre-existing MS symptoms.

Results

Fifty-seven percent (230/404) of participants had an MS exacerbation during their infection; 82 developed new MS symptoms, 207 experienced worsened pre-existing MS symptoms, and 59 reported both. Disease modifying therapies (DMTs) reduced the likelihood of developing new MS symptoms during the infection (OR 0.556, 95%CI 0.316–0.978). Participants with a higher pre-COVID-19 webEDSS (web-based Expanded Disability Status Scale) score (OR 1.251, 95%CI 1.060–1.478) and longer MS duration (OR 1.042, 95%CI 1.009–1.076) were more likely to experience worsening of their pre-existing MS symptoms during the infection.

Conclusion

COVID-19 infection was associated with exacerbation of MS. DMTs reduced the chance of developing new MS symptoms during the infection.

Symptom clusters and quality of life in persons with multiple sclerosis across the lifespan

PURPOSE

To describe symptom clusters based on severity of co-occurring symptoms among adults with multiple sclerosis (MS) by age groups and to further examine symptom clusters as a correlate of quality of life (QOL) by age groups.

METHODS

This cross-sectional study enrolled persons with MS between 20 and 79 years of age who completed measures of fatigue, depression, anxiety, sleep quality, and QOL using the 36-Item Short Form Health Survey. Bivariate correlation and partial correlation analyses examined associations among symptoms, QOL, and MS characteristics. K-means cluster analyses determined symptom clusters among the full sample and pre-determined age groups (i.e., 20-39, 40-59, and 60-79). One-way ANOVAs examined differences in QOL among clusters for the overall sample and by age groups.

RESULTS

Among the overall sample of 205 participants, symptoms were significantly correlated with QOL and three distinct clusters were identified and differentiated by the magnitude of symptom experience (i.e., mild, moderate, and severe). Results were consistent among young and middle-aged adults; however, among older adults two severe sleep problem clusters were identified that were distinguished by moderate versus severe fatigue, depression, and anxiety. ANOVAs among the overall sample indicated that the three symptom clusters varied significantly for both physical component scores, F(2, 202) = 12.03, p < .001, η2 = .10, and mental component scores, F(2, 202) = 137.92, p < .001, η2 = .58; severe symptom cluster was associated with worse QOL. Patterns in the age subgroup ANOVAs were consistent.

CONCLUSIONS

Given the strong association between severity of symptom clusters and QOL, approaches for targeting co-occurring symptoms are critically needed.

Manifestations and impact of the COVID-19 pandemic in neuroinflammatory diseases

Objective

To report initial results of a planned multicenter year‐long prospective study examining the risk and impact of COVID‐19 among persons with neuroinflammatory disorders (NID), particularly multiple sclerosis (MS).

Methods

In April 2020, we deployed online questionnaires to individuals in their home environment to assess the prevalence and potential risk factors of suspected COVID‐19 in persons with NID (PwNID) and change in their neurological care.

Results

Our cohort included 1115 participants (630 NID, 98% MS; 485 reference) as of 30 April 2020. 202 (18%) participants, residing in areas with high COVID‐19 case prevalence, met the April 2020 CDC symptom criteria for suspected COVID‐19, but only 4% of all participants received testing given testing shortages. Among all participants, those with suspected COVID‐19 were younger, more racially diverse, and reported more depression and liver disease. PwNID had the same rate of suspected COVID‐19 as the reference group. Early changes in disease management included telemedicine visits in 21% and treatment changes in 9% of PwNID. After adjusting for potential confounders, increasing neurological disability was associated with a greater likelihood of suspected COVID‐19 (OR_adj = 1.45, 1.17–1.84).

Interpretations

Our study of real‐time, patient‐reported experience during the COVID‐19 pandemic complements physician‐reported MS case registries which capture an excess of severe cases. Overall, PwNID seem to have a risk of suspected COVID‐19 similar to the reference population.

Predisposing Factors for Sexual Dysfunction in Multiple Sclerosis

Sexual dysfunction (SD) in people with multiple sclerosis (pwMS) has a detrimental impact on individual health-related quality of life (HRQoL). It is not clear whether SD in multiple sclerosis (MS) is an independent symptom or merely a byproduct of other symptoms such as depression or anxiety. This cross-sectional study of 93 pwMS determines risk factors for SD in MS based on prevalence, HRQoL, and associated disease outcomes. Diagnosis of SD was determined based on the Multiple Sclerosis Intimacy and Sexuality Questionnaire-19 (MSISQ-19) and correlated with physical disability (measured by Expanded Disability Status scale, EDSS), depression and anxiety [Hospital Anxiety and Depression Scale (HADS)], and HRQoL [Multiple Sclerosis Quality of Life-54 (MSQoL-54)]. Multivariate regression models were performed to determine independent risk factors for SD in pwMS. Almost half of the participants in this study (46%) reported SD. HRQoL was significantly poorer in patients with MS suffering from SD (median [IQR] MSQoL-54 scores: physical subscale 52 [41–68] vs. 81 [69–89], p < 0.001; mental subscale 50 [38–82] vs. 86 [70–89], p < 0.001). In the multivariate model, EDSS was the only independent risk factor for SD (OR 18.1 for EDSS ≥4 [95% CI 3.3–31.4, p < 0.001]), while depression and anxiety were not. We conclude that the risk for SD is growing with increasing EDSS and is independent of depression or anxiety. Screening for SD becomes particularly relevant in patients with growing disability.

Cognitive and motor slowing mediate the relationship between depression and falls in multiple sclerosis patients

OBJECTIVE

Given the limited research concerning the relationship between depression and falls in multiple sclerosis (MS), this study aimed to examine the direct and indirect association between fall history and depressive symptoms.

METHODS

One hundred and forty seven MS patients had completed at least one neuropsychological assessment that included detailed information regarding fall history, as well as measures of depression, motor function, and cognitive processing speed.

RESULTS

Fall history was associated with higher depressive symptoms and poorer overall motor function. Higher self-reported depressive symptoms were associated with higher odds of falls in the last year (OR = 1.64, 95% CI 1.16, 2.31) in an age adjusted model. Cognitive and motor slowing serially mediated the relationship between depressive symptoms and fall history (estimate = 0.060, 95% CI = 0.01, 0.15).

CONCLUSIONS

With the extensive research on the cognitive and motor correlates of falls in MS, our findings suggest that depressive symptoms are also associated with falls in people with MS. Moreover, this study provides preliminary support for a pathway by which depressive symptoms are related to falls in part through their relationships with cognitive and motor slowing.

Depression and anxiety disorders in patients with multiple sclerosis: association with neurodegeneration and neurofilaments

There is increasing evidence that neurofilament light chain (NF-L) can be considered as a biomarker for neuro-axonal damage. This polypeptide can be released into the cerebrospinal fluid (CSF) and the blood, where it can be quantified. The concentration of NF-L is elevated in patients with multiple sclerosis (MS) and psychiatric disorders. We aimed to investigate the NF-L levels in the CSF from treated MS patients and the relationship with depression or anxiety. The study involved three groups: control group (individuals without inflammation), the relapse-remitting multiple sclerosis (RRMS)-untreated group, and the RRMS-Fingo group (RRMS patients who were treated with fingolimod). MS disability was assessed by the Expanded Disability Status Scale, and depression and anxiety were evaluated by a neuropsychologist, using the Hospital Anxiety and Depression Scale, the Beck Depression Inventory-II, and the Beck Anxiety Inventory. Individual CSF samples were collected to measure NF-L levels. The results of the statistical analysis on levels of NF-L in the CSF of control subjects, RRMS-untreated patients, and RRMS-Fingo patients were significant. The relationship between depression and anxiety in RRMS-Fingo patients and NF-L levels was not statistically significant. In conclusion, MS events such as anxiety and depression appear to contribute to the onset of clinical relapses, subclinical cases, and neurodegeneration.

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.

A randomised controlled trial to test the feasibility of online mindfulness programs for people with multiple sclerosis

BACKGROUND

Practicing mindfulness may improve mental health and reduce pain in people with multiple sclerosis (MS). Since participating in face-to-face mindfulness programs can be challenging for people with MS, exploring alternative ways of delivering these programs is necessary. The objective of this trial was to assess feasibility of two different eight-week online mindfulness programs across five domains: recruitment, practicality, acceptability, integration of mindfulness practice, and limited efficacy testing on mental health, quality of life and pain.

METHODS

In a three-arm randomised controlled mixed-method trial, participants were assigned to: 1) Mindfulness for Multiple Sclerosis (M4MS) (n=18); 2) Chair Yoga (n=18); or 3) wait-list control group (n=19) for eight weeks. Daily home practice diaries and weekly reflective journals were collected along with online questionnaires at baseline and post-intervention. Feasibility was assessed using descriptive statistics, multilevel mixed-effects regression, and content analysis.

RESULTS

Online recruitment, online program delivery and online data collection were all found to be feasible. The sign up rate was 65% and overall, 87% of the participant completed the eight-week online programs. The programs were perceived as practical and acceptable by the participants. Integration of mindfulness practice into daily life varied, with time and fatigue reported as common barriers to practice. No statistically significant differences in efficacy measures were found among groups (p>0.05).

CONCLUSION

Online mindfulness programs are feasible and acceptable for people with MS. This study provides useful insights for future trials when designing online mindfulness programs for people with MS.

Anxiety and depression affect performance on the symbol digit modalities test over time in MS and other immune disorders

Background:

Longitudinal studies assessing depression and anxiety effects on cognition in multiple sclerosis (MS) are limited.

Objective:

We tested whether within-person fluctuations in symptoms of depression or anxiety over time affect cognition in persons with MS, inflammatory bowel disease (IBD), rheumatoid arthritis (RA), and a lifetime history of depression/anxiety disorders (DEP/ANX) but without an immune-mediated inflammatory diseases (IMID).

Methods:

We followed participants (MS: 255, IBD: 247, RA: 154, and DEP/ANX: 306) for 3 years. Annually, they completed the hospital anxiety and depression scale (HADS) and cognitive tests including the symbol digit modalities test (SDMT). We evaluated associations of elevated symptoms (scores ⩾ 11) of anxiety (HADS-A) and depression (HADS-D) with SDMT z-scores using multivariable linear models—estimating between-person and within-person effects.

Results:

Participants with MS performed worse on the SDMT than participants in the DEP/ANX cohort (β = −0.68; 95% CI: −0.88, −0.48). Participants with elevated HADS-A scores performed worse on the SDMT than those without elevated scores (β = −0.43; 95% CI: −0.65, −0.21), particularly those with RA. Time-varying within-person elevations in depressive symptoms were associated with worse SDMT performance (β = −0.12; 95% CI: −0.21, −0.021).

Conclusions:

Across persons, elevated symptoms of anxiety adversely affected information processing. Elevated symptoms of depression within-persons over time were associated with declines in information processing speed.

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

Objective

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

Methods

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

Results

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

Conclusion

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

The influence of trait mindfulness on depression in multiple sclerosis: potential implications for treatment

PURPOSE

This study seeks to add to existing literature on depression and illness intrusiveness in chronic disorders by examining, (1) how the perceived intrusiveness of multiple sclerosis (MS) leads to depression, (2) and the mediating role trait mindfulness plays in this relationship METHODS: Participants (N = 755) were persons with MS (PwMS) recruited through the North American Research Committee on MS (NARCOMS) registry (a larger study). Participants completed the Illness Intrusiveness Ratings Scale, the Hospital Anxiety and Depression Scale and the Mindful Attention Awareness Scale. A mediation model assessed if trait mindfulness mediates the relationship between illness intrusiveness and depression RESULTS: Illness intrusiveness predicted trait mindfulness (a =  - 4.54; p < .001), trait mindfulness predicted depression (b =  - .04; p < .001); there was a direct effect of illness intrusiveness on depression (c' = 2.53; p < .001) and an indirect effect on depression (ab = .17, 95% BCa CI [.10, .25]) when trait mindfulness was in the model, which represented a medium size effect, R²_med = .10 [95% CI .07, .14] CONCLUSION: Trait mindfulness mediates the relationship between illness intrusiveness and depression in PwMS. Providers could provide psychoeducation on the benefits of mindfulness and mindfulness-based interventions.

Machine-learning models for depression and anxiety in individuals with immune-mediated inflammatory disease

OBJECTIVE

Individuals with immune-mediated inflammatory disease (IMID) have a higher prevalence of psychiatric disorders than the general population. We utilized machine-learning to identify patient-reported outcome measures (PROMs) that accurately predict major depressive disorder (MDD) and anxiety disorder in an IMID population.

METHODS

Participants with IMID were enrolled in a cohort study and completed a Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID), and multiple PROMs. PROM items were ranked separately for MDD and anxiety disorder by the standardized mean difference between individuals with and without psychiatric disorders. Items were added sequentially to logistic regression (LR), neural network (NN), and random forest (RF) models. Discriminative performance was assessed with area under the receiver operator curve (AUC) and calibration was assessed with Brier scores. Ten-fold cross-validation was used.

RESULTS

Of 637 participants, 75% were female and average age was 51 years. AUC and Brier scores respectively ranged from 0.87-0.91 and 0.07 (i.e., no variation) for MDD models, and from 0.79-0.83 and 0.09-0.11 for anxiety disorder models. In LR and NN, few PROM items were required to obtain optimal discriminatory performance. RF did not perform as well as LR and NN when few PROM items were included.

CONCLUSIONS

Predictive model performance was respectable and revealed insight into PROM items that are predictive of MDD and anxiety disorder. Models that included only the items 'I felt depressed' and 'I felt like I needed help for my anxiety' performed similarly to models that included all items from multiple PROMs.

When investigating depression and anxiety in undergraduate medical students timing of assessment is an important factor - a multicentre cross-sectional study

BACKGROUND

Symptoms of depression and anxiety experienced by undergraduate medical students have become a prominent concern. Evidence about students' depression and anxiety including prevalence, trajectory during medical education, gender differences and comparisons with age-matched peers is conflicting. However few studies of medical students' mental health specify the precise time of assessment. Proximity to examinations may be relevant. Precise identification of the time of data collection might help explain contradictory findings and facilitate provision of more timely support.

METHODS

This study addressed whether: 1)Proximity of final examinations affected students' depression and anxiety symptoms2)Males and females differed in this respect. We analysed data provided by 446 final year students from 6 UK medical schools. These students were a subset of data provided by 14 UK medical schools which participated in an online survey comparing first and final year students and in which final year response rates exceeded 30%. We used the Hospital Anxiety and Depression Scale to assess symptoms of depression and anxiety and the norms to indicate potentially clinically relevant cases. We grouped students into those for whom final exams were imminent i.e. within 2 months of completing the survey (n = 164) and those for whom exams were more distant or had been taken (n = 282). We used parametric and non-parametric tests to compare both groups and gender differences in respect of depression and anxiety sum scores and cases rates.

RESULTS

For both depression and anxiety male and female students facing imminent final exams recorded greater prevalence and significantly higher mean scores. The effect size of differences for anxiety were large. No substantial gender differences were found for depression. Regardless of the timing of final exams female students recorded both significantly higher mean scores and clinically relevant rates for anxiety.

CONCLUSIONS

Proximity to final exams negatively affected the mental health of both male and female final year students. The study suggests that there may be times in the undergraduate medical curriculum when additional or targeted support is needed. It also highlights the need for research to provide a greater specificity of context when investigating medical students' mental health.

Prevalence of anxiety, depression, and stress in patients with multiple sclerosis in Kermanshah-Iran: a cross-sectional study

BACKGROUND

Multiple sclerosis (MS) is a chronic disease that decreases the physical ability and affects the mental health of the patients. This descriptive-analytical study investigated the prevalence of depression, anxiety and stress in MS patients.

METHODS

A total of 87 MS patients were recruited in this study through simple random sampling method using a random number table. Data were collected by Depression, Anxiety, and Stress Scale-21 (DASS-21) and analyzed by descriptive and analytical statistics.

RESULTS

The mean age of the patients was 35.5 ± 9.2 years. Of them, 41 (47.1%) had moderate depression, 34 (39.1%) had moderate anxiety, and 39 (44.8%) had moderate stress. There was a significant relationship between depression and job, education, and economic status of the participants. There was also a significant association between the participants' economic status and anxiety. There was no significant relationship between stress and any of the variables.

CONCLUSION

Given the relatively high prevalence of anxiety, depression, and stress in MS patients as well as the significant relationship between their economic status and depression and anxiety, interventional measures are required to be taken to decrease their problems and to provide a favorable ground for their employment. Periodic examinations by psychologists / psychiatrists and treatment of patients with symptoms of stress, anxiety and depression are also essential.

Patient Health Questionnaire-9 scores do not accurately estimate depression prevalence: individual participant data meta-analysis

OBJECTIVES

Depression symptom questionnaires are not for diagnostic classification. Patient Health Questionnaire-9 (PHQ-9) scores ≥10 are nonetheless often used to estimate depression prevalence. We compared PHQ-9 ≥10 prevalence to Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID) major depression prevalence and assessed whether an alternative PHQ-9 cutoff could more accurately estimate prevalence.

STUDY DESIGN AND SETTING

Individual participant data meta-analysis of datasets comparing PHQ-9 scores to SCID major depression status.

RESULTS

A total of 9,242 participants (1,389 SCID major depression cases) from 44 primary studies were included. Pooled PHQ-9 ≥10 prevalence was 24.6% (95% confidence interval [CI]: 20.8%, 28.9%); pooled SCID major depression prevalence was 12.1% (95% CI: 9.6%, 15.2%); and pooled difference was 11.9% (95% CI: 9.3%, 14.6%). The mean study-level PHQ-9 ≥10 to SCID-based prevalence ratio was 2.5 times. PHQ-9 ≥14 and the PHQ-9 diagnostic algorithm provided prevalence closest to SCID major depression prevalence, but study-level prevalence differed from SCID-based prevalence by an average absolute difference of 4.8% for PHQ-9 ≥14 (95% prediction interval: -13.6%, 14.5%) and 5.6% for the PHQ-9 diagnostic algorithm (95% prediction interval: -16.4%, 15.0%).

CONCLUSION

PHQ-9 ≥10 substantially overestimates depression prevalence. There is too much heterogeneity to correct statistically in individual studies.

Study protocol for a sequential multiple assignment randomized trial (SMART) to improve physical activity in employed women

INTRODUCTION

Physical activity monitors, motivational text messages, personal calls, and group meetings, have proven to be efficacious physical activity interventions. However, individual participant response to these interventions varies drastically. A SMART design (sequential multiple assignment randomized trial) provides an effective way to test interventions that start with an initial treatment and then transition to an augmented treatment for non-responders. We describe a SMART to determine the most effective adaptive intervention to increase physical activity (steps, moderate-to-vigorous physical activity) and improve cardiovascular health among employed women who are not regularly physically active. The SMART uses combinations of four treatments: 1) enhanced physical activity monitor (Fitbit wearable activity monitor and mobile app with goal setting and physical activity prescription), 2) text messages, 3) personal calls, and 4) group meetings.

METHODS

Participants (N = 312) include women ages 18-70 employed at a large academic medical center. Women will be randomized to an initial intervention, either an enhanced physical activity monitor or enhanced physical activity monitor + text messaging. Non-responders to the initial intervention at 2 months will be randomized to either personal calls or groups meetings for the next 6 months. At 8 months, all participants will return to only an enhanced physical activity monitor until their final 12-month assessment.

DISCUSSION

Results of this study will add to the literature on improving physical activity in employed women. This study will identify effective interventions for women who respond to less intensive treatments, while maximizing benefits for those who need a more intensive approach.

Screening young adult cancer survivors with the PROMIS Depression Short Form (PROMIS-D-SF): Comparison with a structured clinical diagnostic interview

BACKGROUND

The current study was conducted to evaluate the Patient-Reported Outcomes Measurement Information System Depression Short Form (PROMIS-D-SF) as a screening measure for young adult cancer survivors (YACS) compared with a structured diagnostic interview.

METHODS

A total of 249 YACS (aged 18-40 years) completed the PROMIS-D-SF and Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (SCID). Based on the SCID, participants were classified as having: 1) an SCID depression diagnosis; 2) depression symptoms without an SCID diagnosis; or 3) no depression symptoms. Receiver operating characteristic analyses evaluated PROMIS-D-SF and SCID concordance and the sensitivity and specificity of PROMIS-D-SF cutoff t -scores.

RESULTS

The PROMIS-D-SF had overall good agreement with the SCID for both depression diagnosis (area under the curve, 0.89) and the presence of depressive symptoms (area under the curve, 0.83). A PROMIS-D-SF cutoff t-score of ≥53.2 came closest to meeting study criteria for detecting a SCID depression diagnosis (sensitivity ≥0.85 and specificity ≥0.75), with a sensitivity of 0.81 and a specificity of 0.74. For identifying survivors with depression symptoms, a t-score cutoff value of 49.4 was found to have slightly superior sensitivity (0.84) and inferior specificity (0.64). In hypothetical screening examples, these cutoff scores led to moderate levels of missed cases (15%-19%) and a high percentage of clinical referrals that were unnecessary by SCID criteria (56%-70%).

CONCLUSIONS

The PROMIS-D-SF demonstrated moderately strong concordance with depressive diagnoses and symptoms measured by the SCID, but cutoff t-scores did not meet study criteria for clinical screening. The PROMIS-D-SF may be useful for assessing depression in YACS, but the limitations in its sensitivity and specificity identified in the current study are likely to limit its usefulness as a stand-alone screening instrument in this population.

Social phobia in immune-mediated inflammatory diseases

OBJECTIVE

Immune-mediated inflammatory diseases (IMID) such as multiple sclerosis (MS), inflammatory bowel disease (IBD) and rheumatoid arthritis (RA) are associated with a high prevalence of psychiatric comorbidity but little is known about the prevalence of social phobia in IMID, or the factors associated with social phobia. We aimed to determine the prevalence of social phobia in MS, IBD and RA, and the factors associated with social phobia in these IMID.

METHODS

We obtained data from the enrollment visit of a cohort study in IMID of whom 654 participants were eligible for this analysis (MS: 254, IBD: 247, RA: 153). Each participant underwent a semi-structured psychiatric interview which identified depression and anxiety disorders including social phobia (lifetime and current), an assessment of disease activity, and reported sociodemographic information.

RESULTS

Overall, 12.8% of participants had a lifetime diagnosis of social phobia (MS: 10.2%, IBD: 13.0%, RA: 17.0%). Social phobia was associated with younger age (OR 0.98; 0.97-1.00), having a high school education or less (OR 1.78; 1.08-2.91), comorbid major depressive disorder (OR 2.79; 1.63-4.78) and comorbid generalized anxiety disorder (OR 2.56; 1.30-5.05). Persons with RA had increased odds of having social phobia as compared to persons with MS (OR 2.26; 1.14-4.48) but not IBD.

CONCLUSION

Persons with IMIDs have a relatively high lifetime prevalence of social phobia, exceeding that reported for the Canadian general population. Strategies aimed at early detection, and effective clinical management of social phobia in IMID are warranted.

Motivational interviewing to promote health outcomes and behaviour change in multiple sclerosis: a systematic review

OBJECTIVE

To examine the evidence for motivational interviewing when used to assist individuals with multiple sclerosis manage their healthcare.

DATA SOURCES

The Cochrane, Embase, PsycINFO and PubMed databases were searched for studies published between 1983 and December 2019. The reference lists of included studies were additionally examined and Scopus citation searches conducted.

REVIEW METHODS

Study screening and data extraction were independently completed by two reviewers. Randomised controlled trials comparing motivational interviewing interventions for multiple sclerosis to usual care, wait-list or other active intervention controls were examined. Studies were assessed using the Cochrane Risk of Bias tool. Standardised mean differences (Hedges' g), 95% confidence intervals and P values were calculated for all health and behavioural outcomes.

RESULTS

Ten randomised controlled trials, involving a pooled sample of 987 adults with relapsing-remitting or progressive multiple sclerosis and mild to moderate impairment, were identified. Most trials had a low or unclear risk of methodological bias. Motivational interviewing, when used in conjunction with other counselling or rehabilitation techniques, resulted in significant immediate medium-to-very large improvements in multiple physical, psychological, social and behavioural outcomes (range: g = .34-2.68). Maintenance effects were promising (range: g = .41-1.11), although less frequently assessed (N_studies = 5) and of limited duration (1-7 months). Individual and group-based interventions, delivered in-person or by telephone, were all effective.

CONCLUSIONS

Motivational interviewing is a flexible counselling technique that may improve rehabilitation care for multiple sclerosis. However, evidence for persisting benefits to health outcomes and behaviour is currently limited.

Risk estimation, anxiety, and breast cancer worry in women at risk for breast cancer: A single-arm trial of personalized risk communication

OBJECTIVE

Elevated anxiety and breast cancer worry can impede mammographic screening and early breast cancer detection. Genetic advances and risk models make personalized breast cancer risk assessment and communication feasible, but it is unknown whether such communication of risk affects anxiety and disease-specific worry. We studied the effect of a personalized breast cancer screening intervention on risk perception, anxiety, and breast cancer worry.

METHODS

Women with a normal mammogram but elevated risk for breast cancer (N = 122) enrolled in the Athena Breast Health risk communication program were surveyed before and after receiving a letter conveying their breast cancer risk and a breast health genetic counselor consultation. We compared breast cancer risk estimation, anxiety, and breast cancer worry before and after risk communication and evaluated the relationship of anxiety and breast cancer worry to risk estimation accuracy.

RESULTS

Women substantially overestimated their lifetime breast cancer risk, and risk communication somewhat mitigated this overestimation (49% pre-intervention, 42% post-intervention, 13% Gail model risk estimate, P < .001). Both general anxiety and breast cancer worry declined significantly after risk communication in women with high baseline anxiety. Baseline anxiety and breast cancer worry were essentially unrelated to risk estimation accuracy, but risk communication increased alignment of worry with accuracy of risk assessment.

CONCLUSIONS

Personalized communication about breast cancer risk was associated with modestly improved risk estimation accuracy in women with relatively low anxiety and less anxiety and breast cancer worry in women with higher anxiety. We detected no negative consequences of informing women about elevated breast cancer risk.

The effect of the eye movement desensitization and reprocessing intervention on anxiety and depression among patients undergoing hemodialysis: A randomized controlled trial

PURPOSE

This study examined the effect of the eye movement desensitization and reprocessing intervention on depression and anxiety in patients undergoing hemodialysis.

DESIGN AND METHODS

In this randomized controlled trial, 90 patients were enrolled. The intervention group received six sessions of the eye movement desensitization and reprocessing intervention. Data were collected before and 2 weeks after the intervention using the Hospital Anxiety and Depression Scale.

FINDINGS

Measured levels of anxiety and depression were significantly reduced in the intervention group compared with preintervention levels and to the control group.

PRACTICE IMPLICATIONS

Nurses can use the eye movement desensitization and reprocessing intervention in clinical practice in combination with psychotropic drugs for the reduction of depression and anxiety in patients undergoing hemodialysis.

Modifiable factors associated with depression and anxiety in multiple sclerosis

OBJECTIVES

Modifiable lifestyle factors are implicated in multiple sclerosis (MS) symptoms but their role in mood is unclear. This study aimed to investigate associations between lifestyle and depression and anxiety in Australian participants with MS.

MATERIALS AND METHODS

Self-reported data from the Australian Multiple Sclerosis Longitudinal Study included the Hospital Anxiety and Depression Scale (HADS) and lifestyle measurements from 1500 participants. SNAP score (range 0-5) was the sum of non-smoking, sufficient fruit/vegetable intake, non-hazardous alcohol consumption, sufficient physical activity and healthy BMI. Analyses by log-binomial and linear regression were adjusted for confounding.

RESULTS

Symptoms of depression and anxiety were prevalent in 27% and 40%, respectively; 20% had both. Mean SNAP score was 2.7/5; only 3% met all healthy lifestyle recommendations. Only 10% reported adequate fruit/vegetable intake, and 22% reported a combination of unhealthy BMI, inadequate physical activity and inadequate nutrition. A healthier SNAP score was associated with lower depression prevalence (adjusted prevalence ratio 0.83 [95% CI 0.75, 0.92] per unit increase) and depression severity (adjusted β-0.44 [95% CI -0.64, -0.24]), but not with anxiety.

CONCLUSIONS

Modifiable lifestyle factors are associated with lower frequency and severity of depression, but not anxiety, in Australian people with multiple sclerosis. The associations between a healthier SNAP score and lower depression are likely bi-directional. SNAP risk factor prevalence and co-occurrence, especially inadequate nutrition and low physical activity, were high among Australians with MS.

Anxiety disorders and medical illness comorbidity and treatment implications

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Gender differences in information needs and preferences regarding depression among individuals with multiple sclerosis, inflammatory bowel disease and rheumatoid arthritis

OBJECTIVE

We assessed the information needs of persons with any of three immune-mediated inflammatory diseases (multiple sclerosis [MS], inflammatory bowel disease [IBD] and rheumatoid arthritis [RA]) regarding depression, as a first step toward developing patient-relevant information resources, ultimately to facilitate self-management and appropriate care. We also compared information needs across genders.

METHODS

We surveyed participants with MS, IBD and RA regarding depression-related information needs including types of treatments, effectiveness, risks, benefits, and perceived helpfulness of treatments. We compared responses between groups using multivariate regression.

RESULTS

328 participants provided complete responses (MS: 141, IBD: 114, RA: 73). Most of the topics queried were perceived as very important, and similarly important for all groups. Women placed higher importance than men on most topics. The most popular formats for receiving information were discussion with a counselor (very preferred: 67.4%) and written information (very preferred: 65.5%); this did not differ between groups.

CONCLUSIONS

Persons affected by MS, IBD and RA are interested in receiving information about multiple topics related to depression treatment, from multiple sources. Women desire more information than men.

PRACTICE IMPLICATIONS

These findings can be used to design information resources to meet information needs regarding depression in MS, IBD and RA.

Stress management interventions for multiple sclerosis: A meta-analysis of randomized controlled trials

Stress management interventions can help to improve mental health for adults living with multiple sclerosis. However, uncontrolled study designs may overestimate intervention effects. A systematic search of the Embase, PsycINFO, PubMed, and Scopus databases identified eight randomized controlled trials evaluating cognitive behavioral approaches for a pooled sample of 568 adults with multiple sclerosis. Both group and individual-based stress management interventions appear to be effective in promoting self-management of stress. Further research is needed to confirm the optimal timing of stress management interventions across the MS spectrum and strategies to maintain intervention effects.

Patient-Reported Outcomes Measurement Information System (PROMIS) Instruments: Reliability and Validity in Veterans Following Orthopedic Surgery

The patient-reported outcomes measurement information system (PROMIS) offers standardized assessment measures of clinically relevant patient-reported outcomes. This study evaluated the reliability and validity of select PROMIS measures with U.S. military veterans following orthopedic surgery. Data for the current study were collected as part of a pilot randomized control trial assessing the efficacy of a 1-day Acceptance and Commitment Therapy workshop on persistent postsurgical pain in at-risk veterans undergoing orthopedic surgery. Sixty-seven participants completed surveys 3 months after surgery. Participants completed the following PROMIS instruments: PROMIS Anxiety Short Form 8a, PROMIS Depression Short Form 8b, and PROMIS Pain Interference Short Form 8a. PROMIS measures were compared to the Generalized Anxiety Disorder 7-Item Scale, the Patient Health Questionnaire 9-Item Scale, and the Brief Pain Inventory Pain Interference subscale, respectively. All three PROMIS measures demonstrated excellent internal consistency (Cronbach's αs ranged from .93 to .96) and each loaded onto a single factor. The PROMIS measures were moderately correlated with their respective comparison measures (r = .69 to .76). The PROMIS anxiety and PROMIS depression measures were highly correlated to one another (r = .91). Findings highlight the potential utility of these PROMIS measures in veterans following orthopedic surgery and the overlap between the PROMIS depression and anxiety measures in this sample.

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.