Neuropsychologic status in multiple sclerosis after treatment with glatiramer

Multiple sclerosis, disease modifying treatments and depression: a critical methodological review

BACKGROUND

Major depression affects one in two patients with multiple sclerosis (MS) during the course of their lifetime. This adds to the morbidity associated with the disorder and may contribute to an increased mortality rate because of suicide. Over the past few years, with the advent of disease modifying treatments for MS, a new concern with respect to mood has arisen, namely the possibility that some of these drugs may have depression as a clinically significant side effect.

OBJECTIVE

To ascertain whether disease modifying treatments in MS are associated with the development of depression or the worsening of a depressive illness.

METHODOLOGY

A MEDLINE and PSYCHLIT search focusing on depression and disease modifying treatments going back to 1993 (the publication date of the results of the first randomised, placebo controlled trial). The methodology pertaining to the assessment of depression is critically reviewed. Furthermore, a critical summary is provided of treatment modalities for the depressed MS patient.

RESULTS

There are conflicting data that depression may occur with some disease modifying drugs, particularly interferon beta-1b. However, all studies reveal limitations with respect to the assessment of mood. Some reports, despite omitting details of how mentation was assessed, still comment on the presence or absence of depression. Others suffer from one or more of the following shortcomings: a failure to assess premorbid risk factors for mood disorder; a reliance on one question to assess depression; the utilisation of self report mood rating scales of questionable validity; neglecting to distinguish depression as a symptom from depression as a syndrome (i.e. major depression as defined by the DMS-1V).

CONCLUSIONS

Given the many methodological pitfalls inherent in all studies to date, it is premature to conclude that disease modifying drugs are associated with depression. Evidence suggests that treatment of depression, irrespective of a putative association with a disease modifying agent, is frequently effective. This applies to pharmacotherapy or psychotherapy, although the former may be preferred should depression arise during a course of treatment with a disease modifying agent. Multiple Sclerosis (2000) 6 343 - 348

A 12-week, open trial of donepezil hydrochloride in patients with multiple sclerosis and associated cognitive impairments

Cognitive dysfunction occurs in up to 65% of patients with multiple sclerosis (MS), but there is no effective treatment for the symptoms. The authors conducted a 12-week, open-pilot study to assess the efficacy and tolerability of donepezil HCl administered in patients with MS and cognitive impairment. Seventeen patients at a long-term care facility with Mini-Mental State Examination scores of < or = 25 received 5 mg of donepezil HCl for a 4-week period, followed by 8 weeks of 10 mg of donepezil HCl. Cognitive, neurologic, functional, and behavioral assessments were conducted at baseline and at 4 and 12 weeks. Statistically significant improvement was observed in several cognitive domains including attention, memory, and executive functioning, as well as different aspects of behavior. These data suggest that donepezil HCl merits further study as a potentially viable treatment option for patients with cognitive impairment associated with MS.

Meta-analysis of clinical trials with copolymer 1 in multiple sclerosis

Glatiramer acetate (copolymer 1) was licensed in the USA in 1996 for the treatment of relapsing-remitting multiple sclerosis. In order to assess its efficacy, a meta-analysis of all randomized controlled trials was performed. Two double-blind studies, accounting for a total number of 299 patients, contribute to this analysis. Patients undergoing the treatment have decreased probability of relapse at 12 months (OR 0.17, 95% CI 0.05-0.51, p = 0.002) and of unsustained progression of disability at 24 and 35 months (OR 0.57, 95% CI 0. 34-0.95, p = 0.031, and OR 0.50, 95% CI 0.28-0.90, p = 0.019). These data suggest that glatiramer acetate represents an alternative to interferon treatment in relapsing-remitting multiple sclerosis. However, further evidence of efficacy is required to justify its use in clinical practice.