Disentangling Multiple Sclerosis and depression: an adjusted depression screening score for patient-centered care

Using latent variables to improve the management of depression among hemodialysis patients

BACKGROUND

Screening for depression can be challenging among hemodialysis patients due to the overlap of depressive symptoms with dialysis or kidney disease related symptoms. The aim of this study was to understand these overlapping symptoms and develop a depression screening tool for better clinical assessment of depressive symptoms in dialysis patients.

METHODS

We surveyed 1,085 dialysis patients between March 1, 2018 and February 28, 2023 at 15 dialysis facilities in Northeast Ohio with the 9-item patient health questionnaire (PHQ-9) and kidney disease quality of life (KDQOL) instrument. To evaluate overlap across questionnaire items, we used structural equation modeling (SEM). We predicted and transformed factor scores to create a hemodialysis-adjusted PHQ-9 (hdPHQ-9). In exploratory analysis (N = 173), we evaluated the performance of the hdPHQ-9 relative to the PHQ-9 that also received a Mini-International Neuropsychiatric Interview.

RESULTS

Our study sample included a high percentage of Black patients (74.6%) and 157 (14.5%) survey participants screened positive for depression (PHQ-9 ≥ 10). The magnitude of overlap was small for (respectively, PHQ-9 item with KDQOLTM item) fatigue with washed out, guilt with burden on family, appetite with nausea and movement with lightheaded. The hdPHQ-9 showed reasonably high sensitivity (0.81 with 95% confidence interval [CI] 0.58, 0.95) and specificity (0.84 with 95% CI 0.77, 0.89); however, this was not a significant improvement from the PHQ-9.

CONCLUSION

There is little overlap between depressive symptoms and dialysis or kidney disease symptoms. The PHQ-9 was found to be an appropriate depression screening instrument for dialysis patients.

Study protocol: exercise training for treating major depressive disorder in multiple sclerosis

BACKGROUND

Major depressive disorder (MDD) is prevalent, yet sub-optimally treated among persons with multiple sclerosis (MS). We propose that exercise training may be a promising approach for treating depression in persons with MS who have MDD. Our primary hypothesis predicts a reduction in depression severity immediately after an exercise training intervention compared with minimal change in an attention control condition, and the reduction will be maintained during a follow-up period.

METHODS

This study involves a parallel-group, assessor-blinded RCT that examines the effect of a 4-month home-based exercise training intervention on depression severity in a sample of persons with MS who have MDD based on the MINI International Neuropsychiatric Interview. The primary outcomes of depression severity are the Patient Health Questionnaire-9 and Hamilton Depression Rating Scale. Participants (N = 146) will be recruited from within 200 miles of the University of Illinois at Chicago and randomized (1:1) into either a home-based exercise training condition or control condition with concealed allocation. The exercise training and social-contact, attention control (i.e., stretching) conditions will be delivered remotely over a 4-month period and supported through eight, 1:1 Zoom-based behavioral coaching sessions guided by social-cognitive theory and conducted by persons who are uninvolved in screening, recruitment, random assignment, and outcome assessment. We will collect outcome data at 0, 4 and 8 months using treatment-blinded assessors, and data analyses will involve intent-to-treat principles.

DISCUSSION

If successful, the proposed study will provide the first Class I evidence supporting a home-based exercise training program for treating MDD in persons with MS. This is critical as exercise training would likely have positive secondary effects on symptoms, cognition, and quality of life, and provide a powerful, behavioral approach for managing the many negative outcomes of MDD in MS. The program in the proposed research is accessible and scalable for broad treatment of depression in MS, and provides the potential for integration in the clinical management of MS.

TRIAL REGISTRATION

The trial was registered on September 10, 2021 at clinicaltrials.gov with the identifier NCT05051618. The registration occurred before we initiated recruitment on June 2, 2023.

Characterizing fatigue phenotypes with other symptoms and clinically relevant outcomes among people with multiple sclerosis

PURPOSE

Fatigue is a common symptom of multiple sclerosis (MS) and can adversely affect all aspect of quality of life. The etiology of fatigue remains unclear, and its treatments are suboptimal. Characterizing the phenotypes of fatigued persons with MS may help advance research on fatigue's etiology and identify ways to personalize fatigue interventions to improve quality of life. The purpose of this study was to identify fatigue phenotypes; examine phenotype stability overtime; and characterize phenotypes by health and function, social and environmental determinants, psychosocial factors, and engagement in healthy behaviors.

METHODS

We conducted a longitudinal study over a 3-month period with 289 fatigued participants with MS. To identify fatigue phenotypes and determine transition probabilities, we used latent profile and transition analyses with valid self-report measures of mental and physical fatigue severity, the mental and physical impact of fatigue, depression, anxiety, and sleep quality. We used ANOVAs and effect sizes to characterize differences among phenotypes.

RESULTS

The best fitting model included six subgroups of participants: Mild Phenotype, Mild-to-Moderate Phenotype, Moderate-to-Severe Phenotype, Severe Phenotype, Fatigue-dominant Phenotype, and Mental Health-dominant Phenotype. The transition analysis indicated that phenotypic membership was highly stable. Variables with a large eta squared effect size included environmental barriers, self-efficacy, and fatigue catastrophizing.

CONCLUSION

These results indicate that the magnitude of fatigue experienced may be more important to consider than the type of fatigue when characterizing fatigue phenotypes. Future research should explore whether tailoring interventions to environmental barriers, self-efficacy, and fatigue catastrophizing reduce the likelihood of transitioning to a more severe phenotype.

Network analysis characterizes key associations between subjective fatigue and specific depressive symptoms in early relapsing-remitting multiple sclerosis

BACKGROUND

Fatigue is common and disabling in multiple sclerosis (MS), yet its mechanisms are poorly understood. In particular, overlap in measures of fatigue and depression complicates interpretation. We applied a multivariate network approach to quantify relationships between fatigue and other variables in early MS.

METHODS

Data were collected from patients with newly diagnosed immunotherapy-naïve relapsing-remitting MS at baseline and month 12 follow-up in FutureMS, a Scottish nationally representative cohort. Subjective fatigue was assessed by Fatigue Severity Scale. Detailed phenotyping included measures assessing each of physical disability, affective disorders, cognitive performance, sleep quality, and structural brain imaging. Network analysis was conducted to estimate partial correlations between variables. Baseline networks were compared between those with persistent and remitted fatigue at one-year follow up.

RESULTS

Data from 322 participants at baseline, and 323 at month 12, were included. At baseline, 154 patients (47.8%) reported clinically significant fatigue. In the network analysis, fatigue severity showed strongest connections with depression, followed by Expanded Disability Status Scale. Conversely, fatigue severity was not linked to objective cognitive performance or brain imaging variables. Even after controlling for measurement of "tiredness" in our measure of depression, four specific depressive symptoms remained linked to fatigue. Results were consistent at baseline and month 12. Overall network strength was not significantly different between groups with persistent and remitted fatigue (4.89 vs 2.90, p = 0.11).

CONCLUSIONS

Our findings support robust links between subjective fatigue and depression in early relapsing-remitting MS. Shared mechanisms between specific depressive symptoms and fatigue could be key targets of treatment and research in MS-related fatigue.

Alternative scoring of the Patient Health Questionnaire-9 in neurological populations: an approach based on a predictive algorithm deriving from individual item scores

OBJECTIVE

The study objective was to assess whether machine learning methods could improve predictive performance of the PHQ-9 for depression in patients with neurological disease. Specifically, we assessed whether a predictive algorithm deriving from all nine items could outperform the tradition of summing the items and applying a cut-point.

METHOD

Data from the NEEDS Study was used (n = 825). Demographic data, PHQ-9 scores, and MDD diagnoses (via the SCID) were obtained. Logistic LASSO, logistic regression, and non-parametric ROC analyses were performed. The ROC curve was used to identify the optimal cut-point for regression-derived predictive algorithms using the Youden method.

RESULTS

The traditional approach to PHQ-9 scoring had a classification accuracy of 85.1% (sensitivity: 84.5%; specificity: 85.2%). The logistic LASSO regression model had a classification accuracy of 85.6% (sensitivity: 83.3%; specificity: 86.1%). The logistic regression model had a classification accuracy of 85.8% (sensitivity: 91.4%; specificity: 84.8%). Both models had similar areas under the curve values (logistic LASSO: 0.9097; logistic regression: 0.9026).

CONCLUSIONS

The current cut-off threshold approach to PHQ-9 scoring and interpretation remains clinically appropriate.

Disentangling self-reported fatigue, depression, and cognitive impairment in people with multiple sclerosis

BACKGROUND

Fatigue is a common problem among people with multiple sclerosis (MS) and can have a negative effect on mental, physical, and social function. Self-reported measures of MS fatigue are often operationalized as a multi-dimensional symptom. However, questions remain about how best to account for the multi-dimensional aspects of self-reported fatigue and whether these aspects are distinct entities. Thus, the purpose of this study was to explore the overlap and distinctions between self-reported measures of the severity and impact of fatigue, between mental and physical fatigue, and between mental fatigue, depressive symptoms, and cognitive impairment.

METHODS

An observational study was conducted with 289 participants with MS . The questionnaires were the Unidimensional Fatigue Impact Scale (UFIS), the Chalder Fatigue Scale (CFS), the Fatigue Scale for Motor and Cognitive Functions (FSMC), the Multiple Sclerosis Neuropsychological Screening Questionnaire (MSNSQ), and the Quality of Life in Neurological Disorders short form for depression (Neuro-QoL). Spearman's correlation coefficient was used to examine the bivariate correlations between composite and subscale scores. Exploratory structural equation modeling (ESEM) was used to determine the factor structure under a pre-specified number of factors to retain in the modeling of multiple items across questionnaires and examine model fit. Subsequently for poor fitting models in an iterative procedure to determine a better fitting multidimensional model, we posited a bifactor confirmatory factor analysis model.

RESULTS

The bivariate correlation analysis revealed that subscales from the same questionnaire measuring different aspects of fatigue had the highest correlations (r = 0.61-0.68), subscales from different questionnaires measuring the same aspect of fatigue had the next highest correlations (r = 0.43-0.60), and subscales from different questionnaires measuring different aspects of fatigue had the lowest correlations (r = 0.34-0.40). Bifactor models with a general fatigue factor and subdomains pertaining to impact, severity, and mental and physical fatigue had relatively good model fits compared to models omitting the subdomains. However, an ESEM model using subscales from the CFS and FSMC fit poorly and did not adequately identify separate factors for mental and physical fatigue. An ESEM model with separate factors for self-reported mental fatigue, depressive symptoms, and cognitive impairment was a good fit.

CONCLUSIONS

The working study hypothesis that fatigue constructs would be moderately correlated yet distinct entities was generally supported by the results of the study. However, we found that our hypothesized separation into a latent dimension existed only when the items or subscales came from the same questionnaire, in which case their level of specificity in terms of target, action, context, and time elements for measuring fatigue were consistent. The implications for the principle of compatibility in measuring self-reported MS fatigue are discussed.

Depression and Inflammatory Markers in Veterans With Multiple Sclerosis

Multiple sclerosis (MS), an inflammatory neurodegenerative disease of the central nervous system (CNS), afflicts over one per thousand people in the United States. The pathology of MS typically involves lesions in several regions, including the brain and spinal cord. The manifestation of MS is variable and carries great potential to negatively impact quality of life (QOL). Evidence that inflammatory markers are related to depression in MS is accumulating. However, there are barriers in precisely identifying the biological mechanisms underlying depression and inflammation. Analysis of cytokines provides one promising approach for understanding the mechanisms that may contribute to MS symptoms.

METHODS

In this pilot study, we measured salivary levels of interleukin (IL)-6, IL-1beta (β), and IL-10 in 24 veterans with MS. Descriptive statistics were reported and Pearson correlation coefficients were obtained between cytokines and depression.

RESULTS

The anti-inflammatory cytokine IL-10 was significantly negatively associated with depression in veterans with MS (r = -0.47, p = .024).

CONCLUSION

Cytokines may be useful for elucidating biological mechanisms associated with the depression and a measure for nurses caring for veterans with MS.

Preliminary validity and test-retest reliability of two depression questionnaires compared with a diagnostic interview in 99 patients with chronic pain seeking specialist pain treatment

Objectives Depression symptomatology is highly prevalent in patients with chronic pain, but accurate identification of major depression may be challenged due to time constraints and diagnostic interviews are therefore not routinely performed in clinical practice. Assessment of depression may be facilitated through the use of full-length depression screening questionnaires with acceptable construct validity and test-retest reliability. However, as previously indicated screening questionnaires may overestimate depression in patients with chronic pain, possibly due to overlapping symptoms. However, the failure to screen for depression may raise a concern for missing relevant cases with depression. The objectives of this study were to (1) quantify the validity of the 9-items Patient-Health Questionnaire (PHQ9) and the Major Depression Inventory (MDI) compared with a diagnostic interview in patients with chronic pain seeking specialist pain treatment, and (2) assess the relative test-retest reliability of PHQ9 and MDI over two weeks. Methods Responses to the PHQ9 and MDI were compared with a Present-State-Examination (PSE) interview in 99 patients with chronic pain referred to interdisciplinary pain treatment. PHQ9 and MDI were completed twice over two weeks. Construct validity were assessed with the area under the curve (AUC) analysis, and performance characteristics derived from 2 × 2 contingency tables in which scores on the screening questionnaires were dichotomized and compared with the classification of clinical depression based on the diagnostic interview. Relative test-retest reliability was assessed with intraclass correlation coefficients (ICC). Results Based on the PSE interview, the prevalence of depression was 22.2%, and according to the PHQ9 and MDI questionnaires the prevalence was 26.3 and 34.3%, respectively. Compared with the diagnostic PSE, the PHQ9 and MDI questionnaires had areas under the curve of 0.83 and 0.88, respectively. Both questionnaires had high negative predictive values (PHQ9: cut-off of 11; MDI: cut-off of 26), but low positive predictive values for all possible scores. ICC values were excellent. Conclusions The PHQ9 and MDI questionnaires reliably identified chronic pain patients unlikely to have clinical depression, but showed limited validity identifying patients with clinical depression. These preliminary results may have clinical implications in depression screening in patients with chronic pain seeking specialist pain treatment. Clinicians in a specialty care pain clinic can use these screening questionnaires to identify patients without depression, but caution should be used when positive cases are identified by PHQ9 or MDI due to the risk of false positives.

Patient-Centered Care for Patients with Depression or Anxiety Disorder: An Integrative Review

People have specific and unique individual and contextual characteristics, so healthcare should increasingly opt for person-centered care models. Thus, this review aimed to identify and synthesize the indicators for the care process of the person with depression and/or anxiety disorders, based on patient-centered care, going through the stages of diagnostic assessment and care planning, including intervention. An integrative literature review with research in seven scientific databases and a narrative analysis were carried out. Twenty articles were included, with indicators for diagnostic evaluation and care/intervention planning being extracted. Care planning focused on people with depression and/or anxiety disorder must be individualized, dynamic, flexible, andparticipatory. It must respond to the specific needs of the person, contemplating the identification of problems, the establishment of individual objectives, shared decision making, information and education, systematic feedback, and case management, and it should meet the patient's preferences and satisfaction with care and involve the family and therapeutic management in care. The existence of comorbidities reinforces the importance of flexible and individualized care planning in order to respond to the specific health conditions of each person.

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

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

REFRESH protocol: a non-inferiority randomised clinical trial comparing internet and teleconference to in-person 'Managing Fatigue' interventions on the impact of fatigue among persons with multiple sclerosis

INTRODUCTION

Multiple sclerosis (MS) is an immune-mediated disease of the central nervous system. It is considered a major cause of non-traumatic disability in young adults. One of the most common and disabling symptoms of MS is fatigue. MS fatigue can impact all aspects of quality of life, including physical, mental and social function. Fortunately, fatigue self-management interventions, such as 'Managing Fatigue: A 6 week energy conservation course', can decrease the impact of fatigue and improve health-related quality of life. The purpose of this study is to compare three modes of delivering the Managing Fatigue intervention-two remote delivery formats (teleconference and internet) and one in-person format-on perceptions of fatigue and its impact on physical, mental and social function.

METHODS AND ANALYSIS

A non-inferiority randomised clinical trial is being conducted to compare the three delivery formats (1:1:1 allocation ratio) among 582 participants with MS living in the Midwestern and Northeastern United States. The hypothesis is that teleconference and internet versions of the intervention are non-inferior to the traditional mode of clinical service delivery (ie, one to one, in person) in terms of the primary outcome of self-reported fatigue impact (ie, Fatigue Impact Scale) and the secondary outcome of health-related quality of life (ie, Multiple Sclerosis Impact Scale). Outcomes are being measured at baseline, 2 months, 3 months and 6 months. The primary analysis tool will be linear mixed effects model. The prespecified inferiority margin for the primary outcome is 10 points. We will also examine whether baseline characteristics (eg, sociodemographic) moderate outcomes of the Managing Fatigue intervention and whether changes in self-efficacy and fatigue self-management behaviours mediate changes in outcomes.

ETHICS AND DISSEMINATION

The protocol is approved centrally by the institutional review board at Case Western Reserve University. Eligible participants give consent before being enrolled and randomised into the study. The study results will be disseminated through relevant advocacy organisations, newsletters to participants, publication in peer-reviewed journals and presentations at scientific conferences.

TRIAL REGISTRATION NUMBER

NCT03550170; Pre-results.

Identify depressive phenotypes by applying RDOC domains to the PHQ-9

Major depression consists of multiple phenotypic traits. Our objective was to characterize depressive phenotypes in the patient health questionnaire (PHQ)-9 using the Research Domain Criteria (RDoC) research framework. Cross-sectional data were examined from the 2013-2014 (N = 5397) and 2015-2016 (N = 5164) National Health and Nutrition Examination Survey, a large, nationally representative U.S. sample. Using both factor analysis and qualitative analysis in mapping scale items along RDoC domains, a four factor model was found to be theoretically appropriate and had an excellent model fit for the PHQ-9. The factor structure consisted of phenotypes describing Negative Valence Systems and Externalizing (anhedonia and depression), Negative Valence Systems and Internalizing (depression, guilt and self-harm), Arousal and Regulatory Systems (sleep, fatigue and appetite) and Cognitive and Sensorimotor Systems (concentration and psychomotor). High correlation between these phenotypes did indicate screening and monitoring for depression study population using a single depression score is likely useful in most circumstances. In multiple indicator multiple cause analysis, differences in the means of the phenotypic traits were found by age, race/ethnicity, sex, and number of comorbidities. Future research should explore whether phenotype expression derived from readily available self-rated depression scales can help to inform more personalized care.

Effect of Multiple Sclerosis on Daily Activities, Emotional Well-being, and Relationships: The Global vsMS Survey

Background

The vsMS survey was conducted to better understand the negative effects of fatigue, cognitive impairment, emotional burden, and decreased physical functioning on the personal, professional, and social lives of individuals with multiple sclerosis (MS).

Methods

The vsMS survey was an online survey conducted in Australia, Canada, France, Italy, Spain, the United Kingdom, and the United States that assessed the impact of MS on individuals' daily activities, emotional well-being, relationships, and employment.

Results

The survey included 1075 participants with relapsing-remitting MS. Almost 42% of participants reported that their ability to perform and manage daily activities had worsened during the previous 2 years. More than 50% reported limitations in daily activities due to fatigue, physical weakness, problems with balance/coordination, heat/cold sensitivity, memory problems, numbness/tingling, trouble concentrating, impaired movement/muscle stiffness, and impaired sleeping. Participants also reported a negative effect on emotional and social factors, including self-esteem, general outlook, well-being, maintaining/starting relationships, ability to progress in their career/keep their job, and ability to cope with life roles.

Conclusions

These data highlight the importance of addressing the impact of MS and the social and emotional disease burdens on daily activities when planning the care of patients with MS.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Psychometric properties of the PHQ-9 depression scale in people with multiple sclerosis: A systematic review

BACKGROUND

Depression affects approximately 25% of people with MS (pwMS) at any given time. It is however under recognised in clinical practice, in part due to a lack of uptake for brief assessment tools and uncertainty about their psychometric properties. The 9-item Patient Health Questionnaire (PHQ-9) is an attractive candidate for this role.

OBJECTIVE

To synthesise published findings on the psychometric properties of the 9-item Patient Health Questionnaire (PHQ-9) when applied to people with multiple sclerosis (pwMS).

DATA SOURCES

PubMed, Medline and ISI Web of Science databases, supplemented by hand-searching of references from all eligible sources.

STUDY ELIGIBILITY CRITERIA

Primary literature written in English and published following peer-review with a primary aim to evaluate the performance of the PHQ-9 in pwMS.

OUTCOME MEASURES

Psychometric performance with respect to appropriateness, reliability, validity, responsiveness, precision, interpretability, acceptability, and feasibility.

RESULTS

Seven relevant studies were identified, these were of high quality and included 5080 participants from all MS disease-course groups. Strong evidence was found supporting the validity of the PHQ-9 as a unidimensional measure of depression. Used as a screening tool for major depressive disorder (MDD) with a cut-point of 11, sensitivity was 95% sensitivity and specificity 88.3% (PPV 51.4%, NPV 48.6%). Alternative scoring systems that may address the issue of overlap between somatic features of depression and features of MS per se are being developed, although their utility remains unclear. However data on reliability was limited, and no specific evidence was available on test-retest reliability, responsiveness, acceptability, or feasibility.

CONCLUSIONS

The PHQ-9 represents a suitable tool to screen for MDD in pwMS. However use as a diagnostic tool cannot currently be recommended, and the potential value for monitoring depressive symptoms cannot be established without further evidence on test-retest reliability, responsiveness, acceptability, and feasibility.

REGISTRATION

PROSPERO register ID: CRD42017067814.

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.

Smokers with MS have greater decrements in quality of life and disability than non-smokers

BACKGROUND

Tobacco smoke plays a pathogenic role in multiple sclerosis (MS) and may accelerate disease progression, yet, some people with MS continue to smoke after disease onset. The average smoker reports diminished health-related quality of life (HRQOL) across many populations.

OBJECTIVES

To describe the relationships between smoking status and HRQOL, disease activity, and global disability in a US population with MS.

METHODS

We compared smokers to non-smokers in 950 responders to the Spring 2014 update survey completed by North American Research Committee on Multiple Sclerosis (NARCOMS) registry participants. HRQOL was assessed using Short Form-12 version 2 (SF-12v2), disease activity was investigated using eight Performance Scales (PS) and three Functionality Scales (FS). Global disability was evaluated using Patient Determined Disease Steps (PDDS) and an item response theory (IRT) summed score based on the PS and FS.

RESULTS

Smokers had lower HRQOL ( p < 0.0001), reported more disease activity ( p < 0.05) and greater deficits in all PS and FS ( p = 6 × 10^-7 to 0.05), except mobility. Smokers and non-smokers did not differ by PDDS but had substantially greater IRT global disability ( p = 2 × 10^-7).

CONCLUSION

Active smoking is meaningfully associated with deficits across multiple domains in people with MS and adds to the growing literature of the need for MS-tailored smoking cessation programs.

Heterogeneous depression trajectories in multiple sclerosis patients

BACKGROUND

Trajectories of depression over time may be heterogeneous in Multiple Sclerosis (MS) patients. Describing these trajectories will help clinicians understand better the progression of depression in MS patients to aid in patient care decisions.

METHODS

Latent class growth analysis (LCGA) was applied to 3507 MS patients using an electronic health records (EHR) data base to identify subgroups of MS patients based on self-reported depression screening (PHQ-9). Latent trajectory classes were used for group comparisons based on baseline clinical characteristics.

RESULTS

Three subgroups were found characterized by high (10.0% [of participants]), wavering above and below moderate (26.2%) and low and variable (63.8%) depression level trajectories. The subpopulation trajectories, respectively, were also characterized by high, moderate and low MS disability at baseline. In contrast, the overall average trajectory was slightly declining and below the moderate depression threshold.

CONCLUSION

The LCGA approach described in this paper and applied to MS patients provides a template for improved use of an EHR data base for understanding heterogeneous depression screening trajectories. Clinicians may use such information to more closely monitor patients that are expected to maintain high or unstable depression levels.

Fatigue and Comorbidities in Multiple Sclerosis

BACKGROUND

Fatigue is commonly reported by people with multiple sclerosis (MS). Comorbidity is also common in MS, but its association with the presence of fatigue or fatigue changes over time is poorly understood.

METHODS

Nine hundred forty-nine people with definite MS were recruited from four Canadian centers. The Fatigue Impact Scale for Daily Use and a validated comorbidity questionnaire were completed at three visits over 2 years. Participants were classified into groups with no fatigue versus any fatigue. Logistic regression was used to determine the relationship between fatigue and each comorbidity at baseline, year 1, year 2, and overall.

RESULTS

The incidence of fatigue during the study was 38.8%. The prevalence of fatigue was greater in those who were older (P = .0004), had a longer time since symptom onset (P = .005), and had greater disability (P < .0001). After adjustment, depression (odds ratio [OR], 2.58; 95% confidence interval [CI], 2.03-3.27), irritable bowel syndrome (OR, 1.71; 95% CI, 1.18-2.48), migraine (OR, 1.69; 95% CI, 1.27-2.27), and anxiety (OR, 1.57; 95% CI, 1.15-2.16) were independently associated with fatigue that persisted during the study. There was also an individual-level effect of depression on worsening fatigue (OR, 1.49; 95% CI, 1.08-2.07).

CONCLUSIONS

Comorbidity is associated with fatigue in MS. Depression is associated with fatigue and with increased risk of worsening fatigue over 2 years. However, other comorbid conditions commonly associated with MS are also associated with persistent fatigue, even after accounting for depression. Further investigation is required to understand the mechanisms by which comorbidities influence fatigue.

Magnitude and concurrence of anxiety and depression among attendees with multiple sclerosis at a tertiary care Hospital in Oman

Background

Anxiety, depression and functional impairments are commonly reported by persons with multiple sclerosis (PwMS) but no data, to our knowledge, has emerged from an Arab Islamic population. The study aims to investigate the prevalence of anxiety, depression and related disabilities among PwMS attending tertiary care in Sultan Qaboos University Hospital (SQUH), one of the urban hospitals in Oman.

Methods

Consecutive and consenting PwMS (n = 57) and healthy subjects (n = 53) completed the following measures: Hospital Anxiety and Depression Scale (HADS) which was used to measure anxiety (cut-point >7) and depression (>7); and Expanded Disability Status Scale (EDSS) to measure the level of disability (≥5). Characteristics such as socio-demographic and clinical variables were also explored.

Results

Fifty seven subjects with multiple sclerosis (MS) met the inclusion criteria. The majority of them were females who were 40 years old or younger and the majority were employed and unmarried. Approximately 86 % of the participants were using beta interferon, 96 % scored ≥5 in EDSS. MS of the Relapsing-Remitting type constituted the majority of the cohort (94 %). Approximately 35 % and 51 % endorsed symptoms of anxiety and depression respectively. The MS group scored significantly higher than controls on HADS measurements of depression and anxiety.

Conclusion

Disability and symptoms of anxiety and depression are common among the PwMS attendees of tertiary care hospital in Oman. Such psychosocial variables have been largely unreported emerging from non-western populations. As these variables are strong indicators of the burden of MS, resolute effort is needed to address such psychosocial dysfunctions in the algorithms of care for PwMS in the Arab Islamic part of the world.

A tutorial on structural equation modeling for analysis of overlapping symptoms in co-occurring conditions using MPlus

Structural equation modeling (SEM) is a very general approach to analyzing data in the presence of measurement error and complex causal relationships. In this tutorial, we describe SEM, with special attention to exploratory factor analysis, confirmatory factor analysis, and multiple indicator multiple cause modeling. The tutorial is motivated by a problem of symptom overlap routinely faced by clinicians and researchers, in which symptoms or test results are common to two or more co-occurring conditions. As a result of such overlap, diagnoses, treatment decisions, and inferences about the effectiveness of treatments for these conditions can be biased. This problem is further complicated by increasing reliance on patient-reported outcomes, which introduces systematic error based on an individual's interpretation of a test questionnaire. SEM provides flexibility in handling this type of differential item functioning and disentangling the overlap. Scales and scoring approaches can be revised to be free of this overlap, leading to better care. This tutorial uses an example of depression screening in multiple sclerosis patients in which depressive symptoms overlap with other symptoms, such as fatigue, cognitive impairment, and functional impairment. Details of how MPlus (Muthén & Muthén, Los Angeles, CA, USA) software can be used to address the symptom overlap problem, including data requirements, code and output are described in this tutorial.