Suicidal Ideation in Multiple Sclerosis

Suicidal ideation in the year following diagnosis of relapsing-remitting multiple sclerosis: A longitudinal perspective

INTRODUCTION

Suicidal ideation (SI) is common in people with multiple sclerosis (pwMS) who have longstanding illness. Prevalence of SI in the weeks to months following diagnosis is unknown, as are factors associated with SI, and whether SI 'settles' over time for newly diagnosed individuals.

METHODS

We investigated SI in the FutureMS cohort, a nationally-representative relapsing-remitting MS sample (n = 440) recruited within weeks of diagnosis. SI was considered soon ('baseline'; median 60 days) and 12 months after diagnosis. A validated mood screen classified individuals SI/non-SI. We analysed associations of clinico-demographic variables with SI and change in SI status.

RESULTS

SI was present in 12.8 % (95 % CI = 0.10, 0.16) at baseline. Those with SI had greater disability and were more likely to be anxious, depressed, fatigued, report toileting difficulties and spasms. In regression analysis, baseline SI was associated with anxiety (p < 0.001) and depression (p = 0.002), though 16 % of those reporting SI scored just 'mild' for depression. At 12 months, 9.6 % (95 % CI = 0.07, 0.13) reported SI, non-significantly different than baseline. Individuals with poorest SI outcomes over 12 months had greater unemployment, disability, anxiety, depression, fatigue, toileting difficulties and spasms, but in regression analysis no variable was individually associated with SI change.

LIMITATIONS

SI is complex but measured in this study by single-item question.

CONCLUSION

SI soon after MS diagnosis is relatively common, not only when anxiety and depression are present, but also in individuals with only mild depression. Screening for SI is important, allowing clinicians to target support to newly diagnosed individuals.

Exploring suicidal ideation prevalence in multiple sclerosis patients during the COVID-19 pandemic: A study on the relationship between drug use and suicidal ideation

BACKGROUND

The COVID-19 pandemic has exacerbated psychological challenges, leading to increased rates of clinically significant depression and suicidal ideation among MS patients. Despite advancements in MS treatments, there remains a need to investigate the impact of different drugs on the prevalence of suicidal ideation, particularly in the context of the pandemic.

METHOD

This cross-sectional study, conducted in 2021, received ethics approval from the Ethics Committee of Kerman University of Medical Science. The study involved 234 MS patients selected from the MS Association in Kerman Province. Questionnaires were prepared and distributed via Google Drive and WhatsApp, with participants providing informed consent. The collected data were analyzed using SPSS software. Inclusion criteria encompassed adults diagnosed with MS according to specific criteria and willing to complete the questionnaires, while exclusion criteria included unclear diagnostic criteria and lack of cooperation. The instruments included a demographic questionnaire, medication checklist, and the Beck Suicidal Thought Scale questionnaire, which has been validated in Iran.

RESULTS

202 MS patients completed the questionnaires, most of whom were women and married. The prevalence of Suicidal Ideation was 46.5 %, with 8.9 % at high risk. Factors such as gender, marital status, education, occupation, and city did not show statistically significant differences in SI. Patients with SI had a longer duration of illness and were more likely to have seen a psychiatrist. The COVID-19 pandemic affected the necessary care for 44.6 % of patients and worsened symptoms in 28.7 %. Additionally, 30.2 % of patients had seen a psychiatrist, and the prevalence of SI was significantly higher in this group. The study also explored the prevalence of SI with comorbidities and types of drugs used, finding no statistically significant differences.

CONCLUSION

The study revealed a high prevalence of suicide ideation among MS patients, emphasizing the need for tailored comprehensive support. Factors contributing to SI included limited healthcare access, fear of COVID-19 complications, social isolation, and heightened anxiety. Recommendations for healthcare providers stress early diagnosis, personalized treatment plans, and collaborative efforts to enhance the well-being of individuals with MS in Iran post-COVID-19.

Suicidal ideation in people with multiple sclerosis and its association with coping self-efficacy

BACKGROUND

Chronic neurological disease such as multiple sclerosis (MS), is a significant risk factor for psychological distress, which can result in suicidal behaviour. Suicidal ideation (SI) is considered a harbinger of suicide-related mortality. However, so far, little is known about the role of protective factors against SI in MS.

OBJECTIVE

This study aims to assess the association between coping self-efficacy and SI when controlled for sociodemographic variables, clinical variables, sleep-related problems, and depression.

METHODS

The study sample consisted of 162 people with MS, was predominantly female (75.9 %), the mean age was 40.9 ± 11.4 years, the mean disease duration was 11.7 ± 7.1 years, and the mean functional disability score was 3.55 ± 1.1. We used the Coping Self-Efficacy scale (CSE), the General Health Questionnaire-28 (GHQ-28), the Expanded Disability Status Scale (EDSS), the Hospital Anxiety and Depression Scale (HADS), the Pittsburgh Sleep Quality Index (PSQI), and the Multidimensional Fatigue Inventory (MFI). Multiple linear regressions were utilized to statistically analyse the data.

RESULTS

All assessed coping self-efficacy dimensions were significantly associated with SI in MS when controlled for sociodemographic variables, clinical variables, sleep-related problems, and depression. Furthermore, all assessed coping self-efficacy dimensions were able to alleviate the negative association between income, depression and SI.

CONCLUSION

People with MS may significantly benefit from psychological support aimed at promoting coping self-efficacy and utilization of various coping strategies. Problem-focused coping, coping focused on getting support, and coping focused on stopping unpleasant thoughts and feelings seem to have comparable associations with SI, and thus interventions aimed at empowering any of these dimensions may be beneficial in diminishing the severity of SI.

Suicide Ideation, Plans, and Attempts Among Military Veterans vs Nonveterans With Disability

Importance

People with disability are at heightened risk for suicide ideation, planning, and attempt, with risk growing as the number of disabling limitations increases. Military veterans have higher rates of suicide deaths and disability relative to nonveterans.

Objective

To evaluate whether veteran status is associated with greater risk for suicide in those with disability.

Design, Setting, and Participants

This survey study used cross-sectional self-reported data from US adults who participated in the 2015-2020 National Survey on Drug Use and Health. Data were weighted to represent the population. Data analysis was conducted from July to August 2022.

Main Outcomes and Measures

Suicide ideation, planning, and attempt served as primary outcomes. Disability status (present or absent) and number of disabling limitations (1, 2, or ≥3) served as factors. Veteran status was determined based on self-report (veteran or nonveteran). Multivariable logistic regression examined suicide ideation, planning, and attempt as a function of veteran status and disability variables.

Results

Participants included 231 099 US veterans and nonveterans, representing 236 551 727 US adults, of whom 20.03% (weighted n = 47 397 876) reported a disabling limitation, 8.92% were veterans (weighted n = 21 111 727; 16.0% aged 35-49 years; 91.0% men; 6.7% Hispanic; 10.9% non-Hispanic Black; and 78.4% non-Hispanic White) and 91.08% were nonveterans (weighted n = 215 440 000; 25.4% aged 35-49 years; 44.0% male; 16.5% Hispanic; 11.7% non-Hispanic Black; and 63.3% non-Hispanic White). Overall, 4.39% reported suicide ideation, planning, or attempt (weighted n = 10 401 065). Among those with no disability, veteran status was associated with higher risk of suicide planning (adjusted odds ratio [AOR], 1.71; 95% CI, 1.17-2.49). Among those with 1 or 2 disabling limitations, being a veteran was associated with a lower risk of suicide planning (AOR, 0.57; 95% CI, 0.34-0.95) and history of attempt (AOR, 0.46; 95% CI, 0.24-0.88).

Conclusions and Relevance

In this study of how suicide risk differs as a function of disability and veteran status, risk for death by suicide was lower among veterans with disability relative to nonveterans with disability. Veteran status may mitigate risk for suicide given increased receipt of more disability-related care through the Department of Veterans Affairs. Further research would extend this line of inquiry by examining the cause and type of disability as well as perceptions of disability on self-worth. It is possible that physical wounds of war are protective because of the meaning and value of service to one's country.

Differences in suicide risk correlates and history of suicide ideation and attempts as a function of disability type

BACKGROUND

Disability status is associated with correlates of suicide risk (perceived burdensomeness, thwarted belongingness, negative future disposition, felt stigma, suicidal ideation, and suicide attempts).

AIMS

This study aimed to examine whether suicide-related correlates differ significantly as a function of disability type.

METHODS

Individuals with mobility and vision disabilities (N = 102) completed semistructured interviews and online-based questionnaires. Analysis of variance/analysis of covaiance and Fisher's exact tests were conducted to examine whether mean levels of suicide-related correlates differed significantly between individuals with blindness/low vision (n = 63) versus mobility-related (n = 39) disabilities.

RESULTS

No significant between-group differences were observed for most outcomes; however, individuals with vision disabilities reported higher mean levels of felt stigma and positive future disposition than those with mobility-related disabilities.

LIMITATIONS

The limited representation of disabilities among participants precludes generalization to individuals with other forms of disability and the cross-sectional design prevents inference about causality.

CONCLUSIONS

Interventions targeting cognitive processes that underlie suicide risk may be applicable to people with mobility and vision disabilities.

Multiple sclerosis: relationship between locus of control and quality of life in persons with low versus high disability

Background: Health Locus of Control (HLOC) is the degree to which individuals believe that their health outcomes are controlled by ‘external’ factors – environmental forces, chance, fate, other people, or some higher power – or by ‘internal’ factors – their own behavior or action. Most of the literature on HLOC associates an Internal Health Locus of Control (IHLOC) to pro-health behaviors and better health outcomes. However, a few studies also suggest that in chronic illnesses, an External Health Locus of Control (EHLOC) could be beneficial with respect to pro-health behaviors and perceptions of Quality of Life (QoL), challenging assumptions about what leads to the most effective psychological coping in the face of difficult circumstances. Multiple sclerosis (MS) is a chronic immune condition of the central nervous system and the most frequent cause of non-traumatic disability in young adults, often despite treatment. Method: The primary goal of this non-experimental, cross-sectional, quantitative study of 89 individuals with MS was to explore the HLOC of individuals with MS, and to identify whether holding an EHLOC positively impacts the MS patients’ perceived QoL while taking into consideration their level of disability. Results: This research found that individuals with higher disability scores tended to hold more EHLOC beliefs, and that there was a significant correlation between QoL and holding EHLOC beliefs. Conclusion: This study was able to capture the importance of control beliefs in the QoL of individuals with MS with higher disability. The clinical implications of the findingare explored and areas for further research are suggested.

Multiple Sclerosis and the Endogenous Opioid System

Multiple sclerosis (MS) is an autoimmune disease characterized by chronic inflammation, neuronal degeneration and demyelinating lesions within the central nervous system. The mechanisms that underlie the pathogenesis and progression of MS are not fully known and current therapies have limited efficacy. Preclinical investigations using the murine experimental autoimmune encephalomyelitis (EAE) model of MS, as well as clinical observations in patients with MS, provide converging lines of evidence implicating the endogenous opioid system in the pathogenesis of this disease. In recent years, it has become increasingly clear that endogenous opioid peptides, binding μ- (MOR), κ- (KOR) and δ-opioid receptors (DOR), function as immunomodulatory molecules within both the immune and nervous systems. The endogenous opioid system is also well known to play a role in the development of chronic pain and negative affect, both of which are common comorbidities in MS. As such, dysregulation of the opioid system may be a mechanism that contributes to the pathogenesis of MS and associated symptoms. Here, we review the evidence for a connection between the endogenous opioid system and MS. We further explore the mechanisms by which opioidergic signaling might contribute to the pathophysiology and symptomatology of MS.

Impact of Cognitive Impairment on Adults with Multiple Sclerosis and Their Family Caregivers

BACKGROUND

Cognitive impairment is a prominent feature of multiple sclerosis (MS). However, the impact that cognitive symptoms have on daily life, and the effect this has on persons with MS and their relationships with spouses/partners, remains unclear. This qualitative study sought information on the nature of cognitive impairments experienced and the impact of cognitive impairments on the daily lives of adults with MS and their partners to gain further insights into how health care professionals can best support families.

METHODS

Fifteen persons with MS and their spouses/partners participated in separate semistructured telephone interviews.

RESULTS

Six themes and several subthemes were identified: the social impact of cognitive impairments in MS, changes to daily living, relationship quality, communication, ways of coping with MS, and the desire for help in managing MS.

CONCLUSIONS

These results identified types of support that couples needed and wanted; ways that MS affects couples' social lives; that there are difficulties negotiating changes in roles due to cognitive challenges; that there are difficulties coping with the impact of cognitive challenges on daily living; that couples often have difficulty communicating about the impact of cognitive changes on daily living and related issues, which also contributes to relationship strain; and finally, that most participants felt that they did not understand enough about the cognitive symptoms of MS. We outline key areas to address these identified needs.

Depressive Symptoms and Suicidal Ideation in Progressive Multiple Sclerosis Compared With Relapsing-Remitting Multiple Sclerosis: Results From a Cross-sectional Survey

OBJECTIVES

To (1) describe depressive symptom severity and suicidal ideation (SI) in persons with progressive multiple sclerosis (MS); (2) compare depressive symptom severity and SI in persons with progressive MS and persons with relapsing-remitting multiple sclerosis (RRMS); and (3) identify common and unique risk factors for greater depressive symptom severity and SI in persons with progressive MS compared with individuals with RRMS.

DESIGN

Observational, cross-sectional survey study.

SETTING

Community.

PARTICIPANTS

Adults with MS (N=573).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The dependent variables were depression symptoms and any SI measured by the Patient Health Questionnaire-9. Comparisons between groups used t tests and chi-square analyses, and risk factors were tested by examining the interaction of MS subtype (progressive MS and RRMS) and each risk factor in multiple regression models with bootstrapping.

RESULTS

Persons with progressive MS did not differ from persons with RRMS in levels of depressive symptoms or SI. Both groups reported mild depressive symptoms and approximately 10% endorsed SI. Common risk factors for greater depressive symptom severity were younger age, greater disability, greater speech and swallowing problems, and lower household income. Common risk factors for SI were shorter disease duration, greater disability, and greater speech and swallowing problems.

CONCLUSIONS

In this sample, there were no group differences between persons with progressive MS and persons with RRMS in depressive symptom severity and SI. Although both groups reported mild depressive symptoms on average, nearly 1 in 4 persons met criteria for probable major depression, which underscores the importance of screening for and treating depressive disorders in all persons with MS.

Prevalence of Suicidal Ideation in Multiple Sclerosis Patients: Meta-Analysis of International Studies

The aim of this study is to estimate the worldwide prevalence of suicidal ideation in multiple sclerosis patients. Two researchers selected words such as "epidemiology" or "prevalence" or "incidence" and "suicidal ideation in multiple sclerosis" and searched them as relevant keywords in international databases such as PubMed, Web of Science CINAHL, Embase, Psyc INFO, and Scopus. A point prevalence with 95% confidence interval was estimated. The variances of each study were calculated using the binomial distribution formula. Heterogeneity among the studies was tested by a Q-Cochran test with a significance level less than 0.1. Index of changes attributed to heterogeneity (I²) was assessed. From among the 170 total articles found from 2011 to February 2019, we pooled and analyzed the data of eight final eligible studies, based on the inclusion criteria. The prevalence of suicidal ideation in multiple sclerosis patients was estimated as 13% (CI 95% = 0.09-0.17). A subgroup analysis was conducted based on the type of countries; it revealed that prevalence is higher in developed countries (15%; CI 95% = 0.1-0.2). Pooled worldwide prevalence of suicidal ideation in the MS population was calculated at 13% by random effect. It is recommended that training, counseling, and psychological support be used to help these patients.

Anxiety and depression in Multiple Sclerosis (MS): Antecedents, consequences, and differential impact on well-being and quality of life

BACKGROUND

Individuals with multiple sclerosis (MS) are often plagued by the unpredictability of their disease and have to contend with uncertainty in their life and significant life changes. This can lead to high levels of stress, perceived lack of control, helplessness, and anxiety. Despite these circumstances, anxiety disorders are often overshadowed by depression, which can result in its presence being overlooked and undertreated by many medical professionals.

METHODS

One hundred and eighty three individuals with MS completed a comprehensive online survey assessing depression and anxiety and the demographic and disease risk factors of such, including social support and substance use. Participants also completed measures of MS symptomatology, disease management, psychological well-being, and quality of life to determine the impact of depression and anxiety on outcomes associated with MS.

RESULTS

Findings suggest that both depression and anxiety are prevalent in MS and related to many outcomes. However, based on comparisons of the associations and group comparisons, with a few exceptions, anxiety proved to more impactful than depression when examining these outcomes. When evaluating the risk factors/contributors of anxiety and depression, social support was a consistent predictor. Younger age and shorter disease duration were also associated with anxiety, while lower education and substance use were predictors of depression.

CONCLUSION

Findings suggest that attention to anxiety be given as much as depression as it plays a large role in individuals' perceived health and well-being, which subsequently impacts the severity of symptoms and overall quality of life. Early identification of anxiety and potential substance use and increased social support also appear to be crucial for mitigating the impact of depression and anxiety.

The Main Determinants for Suicidal Ideation in a Romanian Cohort of Multiple Sclerosis Patients

Objective

To determine the prevalence of suicidal concerns (SC) in a large multiple sclerosis (MS) patient group and to assess the major determinants that are implicated in their occurrence.

Methods

A total of 349 patients were included in the study. They completed a survey about their demographic characteristics, psycho-socio-economic data, and disease-related information. Their disability level was assessed using the Expanded Disability Status Scale (EDSS) based on the neurological examination performed by the same doctor for every patient and the SC were documented with the Beck Depression Inventory-II questionnaire.

Results

The study included 112 men and 237 women, with a mean age around 42 years old. Suicidal thoughts were more frequent in men, while suicidal intentions in women. Positive correlations were found between SC and depression, EDSS, total number of relapses, disease duration, and level of education. From the EDSS functional scores, only the pyramidal score and the cerebellar score presented a significant correlation with SC. None of the patients with clinically isolated syndrome had SC. The type of disease-modifying therapy, marital and occupational status, and the presence of children did not influence the presence of SC.

Conclusions

The prevalence of SC is higher in patients with MS compared to the general population. Their occurrence is mostly influenced by the disease itself (duration, relapses, acquired disability) and also by depression and lack of education.

Risk Factors for Suicide in a National Sample of Veterans With Multiple Sclerosis

OBJECTIVES

To examine risk factors in the year before suicide in a national sample of United States veterans with multiple sclerosis (MS), as well as means of suicide and receipt of mental health services prior to death.

DESIGN

Case control study. Individuals in the Veterans Affairs MS National Data Repository were linked to the National Death Index Plus to obtain death records, including specific causes of death. Participants were veterans with MS who died by suicide and randomly selected nonsuicide MS controls (5 per participant) who were alive at the time of the index suicide. Mental health disorders and medical comorbidities were identified in the year before death for suicides and during the identical time period for controls.

SETTING

Veterans Health Administration.

PARTICIPANTS

Veterans (N=426) who received treatment for MS in the United States Veterans Health Administration between 1999 and 2011. There were 71 deaths by suicide and 355 randomly selected controls.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

Suicide.

RESULTS

Results from the adjusted multivariable model suggest that the following factors were associated with an increased risk for suicide: male sex (odds ratio [OR], 3.60; 95% confidence interval [CI], 1.35-9.42), depression (OR, 1.82; 95% CI, 1.03-3.23), and alcohol use disorder (OR, 3.10; 95% CI, 1.38-6.96). Half (50.7%) had a mental health appointment in the year before suicide. The primary means of suicide was by firearm (62.0%).

CONCLUSIONS

Routine assessment of suicide risk in individuals with MS is warranted, particularly for those with recent history of depression or alcohol use disorder.

Depression and Suicidality in Multiple Sclerosis: Red Flags, Management Strategies, and Ethical Considerations

Multiple sclerosis (MS) causes physical, emotional, and cognitive changes that impact function and quality of life (QoL). Risk factors for suicidality in MS patients include a high incidence of depression, increased isolation, and reduced function/independence. PURPOSE OF REVIEW: To describe the epidemiology of depression and suicidality in this population, highlight warning signs for suicidal behavior, provide recommendations and resources for clinicians, and discuss ethical decisions related to patient safety vs. right to privacy. RECENT FINDINGS: Fifty percent of MS patients will experience a major depression related to brain MRI factors and disease-related psychosocial challenges. Nevertheless, depression is under-recognized/treated. The standardized mortality ratio (SMR) indicates a suicide risk in the MS population that is twice that in the general population. Given the prevalence of depression and the increased risk of suicide in the MS population, any clinician providing care for these patients must be prepared to recognize and respond to potential warning signs.

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.

Evaluation of a palliative and hospice care telephone hotline for patients severely affected by multiple sclerosis and their caregivers

BACKGROUND AND PURPOSE

Palliative and hospice care (PHC) still mainly focuses on patients with cancer. In order to connect patients severely affected by multiple sclerosis (MS) and caregivers to PHC, a nationwide hotline was implemented to facilitate access to PHC.

METHODS

The hotline was designed in cooperation with the German Multiple Sclerosis Society. Self-disclosed information given by callers was documented using case-report forms supplemented by personal notes. Data were analysed descriptively.

RESULTS

A total of 222 calls were documented in 27 months. The patients' mean age was 51.12 years (range 27-84 years) and mean illness duration was 18 years (range 1 month to 50 years). Inquiries included information on PHC (28.8%) and access to PHC (due to previous refusal of PHC, 5.4%), general care for MS (36.1%), adequate housing (9.0%) and emotional support in crisis (4.5%). A total of 31.1% of callers reported 'typical' palliative symptoms (e.g. pain, 88.4%), 50.5% reported symptoms evolving from MS and 35.6% reported psychosocial problems. For 67 callers (30.2%), PHC services were recommended as indicated.

CONCLUSIONS

The hotline provided insight into the needs and problems of patients severely affected by MS and their caregivers, some of which may be met by PHC. Future follow-up calls will demonstrate if the hotline helped to improve access to PHC beyond providing information. Overall, the hotline seemed to be easily accessible for patients severely affected by MS whose mobility is limited.

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.

Multiple sclerosis and suicide

Mortality rates are elevated in people with multiple sclerosis (MS) relative to the general population. There is, however, some uncertainty whether suicide contributes to this. Epidemiological data suggest that the standardized mortality ratio (SMR) for suicide in MS is approximately twice that of the general population with younger males in the first few years following diagnosis most at risk. Rates of suicidal intent, a potential harbinger of more self-destructive behavior, are also elevated, but the frequency with which intent is followed by suicide is not known. Depression, severity of depression, social isolation, and alcohol abuse are associated with thoughts of suicide. The variables linked with suicide and suicidal intent are therefore well defined and should be readily available from routine clinical inquiry. While vigilance on the part of clinicians is required, particularly in the context of high-risk patients, it is also recognized that prevention is dependent on full disclosure of intent.

An excessive risk of suicide may no longer be a reality for multiple sclerosis patients

BACKGROUND

Few recent studies have shown that there is no longer an increased risk of suicide in patients affected with multiple sclerosis (MS).

OBJECTIVES

To describe suicide cases within a large French MS cohort and assess whether MS patients are at a higher risk of suicide compared with the general population.

METHODS

Data derives from a study on long-term mortality of 27,603 prevalent cases from 15 MS specialist centres. Of 1,569 deceased MS patients (5.7%) on 1 January 2010, 47 were suicides.

RESULTS

The mean time between MS clinical onset and death was 13.5 years (standard deviation (SD): 9.3 years; none within the first 3 years) and was significantly shorter than for MS patients who had died from other causes (mean = 21.4 (SD = 11.6), p < 0.0001). Age at death was also lower (46.3 vs 56.7). The standardized mortality rates were around 1 in several sensitivity analyses, reflecting no excess mortality in MS compared with general population.

CONCLUSION

Our findings indicate that an excess suicide risk may no longer be true for MS patients and highlight the changing profile of cases, occurring later in the disease course. Further studies in population-based registries are needed to confirm and explain these potential changes (e.g. treatments' impact?).

Disability, depression and suicide ideation in people with multiple sclerosis

INTRODUCTION

Depressive symptoms occur frequently in people with Multiple Sclerosis (MS) and rates of suicide ideation are higher than the general population. There is evidence for a direct association between disability and depression, disability and suicide ideation, and depression and suicide ideation in MS. However, the relationship between all three, i.e. the mediating role of depression between disability and suicidal ideation, has not been investigated. Exploring this relationship could highlight risk factors, alerting clinicians to the need for timely intervention.

METHOD

Seventy five people with progressive MS attending two out-patient clinics took part in this cross-sectional study. Participants completed the Beck Suicide Scale, Beck Depression Inventory, Multiple Sclerosis Impact Scale and Guy's Neurological Disability Scale.

RESULTS

Depressive symptoms mediated the relationship between perceived and actual disability and suicide ideation. Different types of disability were associated with suicidality, including: 'tremors' and 'taking longer to do things'. A small sub-group of participants were identified who reported suicide ideation in the presence of only mild levels of depression.

LIMITATIONS

There may be a sample bias in this study as all participants were attending out-patient clinics and receiving support which may not be available to everyone with MS.

CONCLUSION

It is important for clinicians to screen regularly for both depression and suicide ideation, to be alert to specific types of disability for which a higher level of suicide ideation might be present and to consider the possibility of suicidal thoughts being present in people who show minimal or no depressive symptoms.

A Framework of Care in Multiple Sclerosis, Part 2: Symptomatic Care and Beyond

The Consortium of Multiple Sclerosis Centers (CMSC) convened a Framework Taskforce composed of a multidisciplinary group of clinicians and researchers to examine and evaluate the current models of care in multiple sclerosis (MS). The methodology of this project included analysis of a needs assessment survey and an extensive literature review. The outcome of this work is a two-part continuing education series of articles. Part 1, published previously, covered the updated disease phenotypes of MS along with recommendations for the use of disease-modifying therapies. Part 2, presented herein, reviews the variety of symptoms and potential complications of MS. Mobility impairment, spasticity, pain, fatigue, bladder/bowel/sexual dysfunction, cognitive dysfunction, and neuropsychiatric issues are examined, and both pharmacologic and nonpharmacologic interventions are described. Because bladder and bowel symptoms substantially affect health-related quality of life, detailed information about elimination dysfunction is provided. In addition, a detailed discussion about mental health and cognitive dysfunction in people with MS is presented. Part 2 concludes with a focus on the role of rehabilitation in MS. The goal of this work is to facilitate the highest levels of independence or interdependence, function, and quality of life for people with MS.

Neuroinflammation in suicide: Toward a comprehensive model

OBJECTIVES

Suicidal behaviour (SB) entered the DSM-5, underlying a specific biological vulnerability. Then, recent findings suggested a possible role of the immune system in SB pathogenesis. The objective of this review is to present these main immune factors involved in SB pathogenesis.

METHODS

We conducted a review using Preferred Reporting Items for Systematic reviews and Meta-Analysis criteria, and combined ("Inflammation") AND ("Suicidal ideation" OR "Suicidal attempt" OR "suicide").

RESULTS

Post mortem studies demonstrated associations between suicide and inflammatory cytokines in the orbitofrontal cortex, a brain region involved in suicidal vulnerability. Also, microgliosis and monocyte-macrophage system activation may be a useful marker of suicide neurobiology. Kynurenine may influence inflammatory processes, and related molecular pathways may be involved in SB pathophysiology. Few recent studies associated inflammatory markers with suicidal vulnerability: serotonin dysfunction, impulsivity and childhood trauma. Interestingly, the perception of threat that leads suicidal individuals to contemplate suicide may activate biological stress responses, including inflammatory responses.

CONCLUSIONS

Translational projects would be crucial to identify a specific marker in SB disorders, to investigate its clinical correlations, and the interaction between inflammatory cytokines and monoamine systems in SB. These researches might lead to new biomarkers and novel directions for therapeutic strategies.

Palliative care in progressive multiple sclerosis

INTRODUCTION

Multiple sclerosis (MS) is a progressive disease of the central nervous system with unknown etiology. It could be associated with severe disability and losses of physical, psychological and social role functioning over time. People with MS share experiences in common with people affected by diseases with a shorter and clearer terminal phase. Therefore, it is appropriate to offer a palliative care approach to people with severe MS and their caregivers. Areas covered: Benefits for severe MS patients and their caregivers were shown when palliative care was included in their care. However, many neurologists show no interest toward palliative care services for people with severe MS. Misunderstandings about the services of palliative care are still prevalent. Expert commentary: When all results are considered, they show that palliative care for severe MS patients may be beneficial. The five-year view will discuss the barriers of palliative care inclusion for people with severe MS.

Utilized Resources of Hope, Orientation, and Inspiration in Life of Persons with Multiple Sclerosis and Their Association with Life Satisfaction, Adaptive Coping Strategies, and Spirituality

In a cross-sectional survey among 213 patients with multiple sclerosis, we intended to analyze their resources of hope, orientation, and inspiration in life, and how these resources are related to health-associated variables, adaptive coping strategies, and life satisfaction. Resources were categorized as Faith (10 %), Family (22 %), Other sources (16 %), and No answer (53 %). These non-respondents were predominantly neither religious nor spiritual (70 % R-S-). Although R-S- persons are a heterogeneous group with varying existential interest, they did not significantly differ from their spiritual/religious counterparts with respect to physical and mental health or life satisfaction, but for an adaptive Reappraisal strategy and Gratitude/Awe.

Risk Factors for Suicidal Ideation in Patients Feeling Severely Affected by Multiple Sclerosis

BACKGROUND

Being severely affected by multiple sclerosis (MS) brings substantial physical and psychological challenges. Contrary to common thinking that MS is not lethal, there is a higher mortality risk in patients also reflected in alarming rates of assisted suicide, and - where possible - euthanasia.

OBJECTIVE

Analyzing independent variables promoting suicidal ideation in severely affected MS patients.

DESIGN

A self-report questionnaire with 25 needs categories including one self-assessment item "prone to suicidal ideation" was applied.

SETTING/SUBJECTS

Included were patients reporting feeling subjectively severely affected by MS. Of 867 patients addressed, 573 (66.1%) completed the questionnaires.

MEASUREMENTS

32 items being potential risk factors for suicidal ideation were tested for statistical significance using a multivariate logistic regression model with stepwise, backward elimination procedure.

RESULTS

22.1% of 573 patients (median age 51, range 20-83) had suicidal ideation. 48.4% suffered from secondary progressive, 24.7% from relapsing-remitting and 21.9% from primary progressive MS. A set of six statistically significant criteria for suicidal ideation were found. Three items were risk factors for suicidal ideation: the extent to which MS affects leisure time (p < 0.001), depression (p < 0.000), and feeling socially excluded (p < 0.002). Three items reduced the odds of suicidal ideation: having a purpose in life (p < 0.000), being productive (p < 0.000), and having comfort in faith and spiritual beliefs (p < 0.024).

CONCLUSION

This study identified potentially modifiable factors that may help preventing suicide in people with MS. Integrating palliative care (PC) with its multidisciplinary approach could be beneficial to reduce patient's burden.

Opening locked doors: Integrating a palliative care approach into the management of patients with severe multiple sclerosis

Patients severely affected by multiple sclerosis (MS) have a large range of unmet needs. Although initially counterintuitive, specialized palliative care (PC) may be beneficial for these patients and their relatives. PC has advanced greatly in recent years, yet it is still predominantly tumour patients who profit from this. For MS, a first randomized phase II trial has already demonstrated significant benefits for patients and their caregivers when PC was included in their care. However, there are barriers: neurologists not convinced about PC, or PC not taking on MS patients. Studies have shown that misunderstandings and a lack of information among healthcare professionals about the roles and services of PC for MS are still prevalent. This topical review will give an overview of the unmet needs of patients as well as the possible benefits and barriers of PC for MS, and will describe models of services on how to “open locked doors”.

Suicidal ideation among individuals with dysvascular lower extremity amputation

OBJECTIVE

To examine the estimated prevalence and correlates of suicidal ideation (SI) among individuals 1 year after a first lower extremity amputation (LEA).

DESIGN

Cohort survey.

SETTING

Four medical centers.

PARTICIPANTS

A referred sample of patients (N=239), primarily men, undergoing their first LEA because of complications of diabetes mellitus or peripheral arterial disease, were screened for participation between 2005 and 2008. Of these patients, 136 (57%) met study criteria and 87 (64%) enrolled; 70 (80.5%) of the enrolled patients had complete data regarding SI at 12-month follow-up.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

SI, demographic/health information, depressive symptoms, mobility, independence in activities of daily living (ADL), satisfaction with mobility and ADL, medical comorbidities, social support, self-efficacy.

RESULTS

At 12 months postamputation, 11 subjects (15.71%) reported SI; of these, 3 (27.3%) screened negative for depression. Lower mobility, lower satisfaction with mobility, greater impairment in ADL, lower satisfaction with ADL, lower self-efficacy, and depressive symptoms were all correlated with the presence of SI at a univariate level; of these, only depressive symptoms remained significantly associated with SI in a multivariable model.

CONCLUSIONS

SI was common among those with recent LEA. Several aspects of an amputee's clinical presentation, such as physical functioning, satisfaction with functioning, and self-efficacy, were associated with SI, although depression severity was the best risk marker. A subset of the sample endorsed SI in the absence of a positive depression screen. Brief screening for depression that includes assessment of SI is recommended.

High-dose immunosuppressive therapy and autologous hematopoietic cell transplantation for relapsing-remitting multiple sclerosis (HALT-MS): a 3-year interim report

IMPORTANCE

Most patients with relapsing-remitting (RR) multiple sclerosis (MS) who receive approved disease-modifying therapies experience breakthrough disease and accumulate neurologic disability. High-dose immunosuppressive therapy (HDIT) with autologous hematopoietic cell transplant (HCT) may, in contrast, induce sustained remissions in early MS.

OBJECTIVE

To evaluate the safety, efficacy, and durability of MS disease stabilization through 3 years after HDIT/HCT.

DESIGN, SETTING, AND PARTICIPANTS

Hematopoietic Cell Transplantation for Relapsing-Remitting Multiple Sclerosis (HALT-MS) is an ongoing, multicenter, single-arm, phase 2 clinical trial of HDIT/HCT for patients with RRMS who experienced relapses with loss of neurologic function while receiving disease-modifying therapies during the 18 months before enrolling. Participants are evaluated through 5 years after HCT. This report is a prespecified, 3-year interim analysis of the trial. Thirty-six patients with RRMS from referral centers were screened; 25 were enrolled.

INTERVENTIONS

Autologous peripheral blood stem cell grafts were CD34+ selected; the participants then received high-dose treatment with carmustine, etoposide, cytarabine, and melphalan as well as rabbit antithymocyte globulin before autologous HCT.

MAIN OUTCOMES AND MEASURES

The primary end point of HALT-MS is event-free survival defined as survival without death or disease activity from any one of the following outcomes: (1) confirmed loss of neurologic function, (2) clinical relapse, or (3) new lesions observed on magnetic resonance imaging. Toxic effects are reported using National Cancer Institute Common Terminology Criteria for Adverse Events.

RESULTS

Grafts were collected from 25 patients, and 24 of these individuals received HDIT/HCT. The median follow-up period was 186 weeks (interquartile range, 176-250) weeks). Overall event-free survival was 78.4% (90% CI, 60.1%-89.0%) at 3 years. Progression-free survival and clinical relapse-free survival were 90.9% (90% CI, 73.7%-97.1%) and 86.3% (90% CI, 68.1%-94.5%), respectively, at 3 years. Adverse events were consistent with expected toxic effects associated with HDIT/HCT, and no acute treatment-related neurologic adverse events were observed. Improvements were noted in neurologic disability, quality-of-life, and functional scores.

CONCLUSIONS AND RELEVANCE

At 3 years, HDIT/HCT without maintenance therapy was effective for inducing sustained remission of active RRMS and was associated with improvements in neurologic function. Treatment was associated with few serious early complications or unexpected adverse events.

Thoughts of death and self-harm in patients with epilepsy or multiple sclerosis in a tertiary care center

BACKGROUND

Patients with epilepsy or multiple sclerosis (MS) have high risks of depression and increased risks of suicide, but little is known about their risks of suicidal ideation.

OBJECTIVE

We sought to (1) estimate the prevalence of thoughts of being better off dead or of self-harm among patients with epilepsy or MS, (2) identify risk factors for such thoughts, and (3) determine whether any risk factors interact with depression to predict such thoughts.

METHODS

A Cleveland Clinic database provided information on 20,734 visits of 6586 outpatients with epilepsy or MS. Outcome measures were thoughts of death or self-harm (Patient Health Questionnaire [PHQ] item-9), and total score ≥10 for the 8 remaining PHQ items (probable major depression). Generalized estimating equations accounted for repeat visits in tests of associations of PHQ item-9 responses with depression, age, sex, race, household income, disease severity, and quality of life.

RESULTS

Prevalence of thoughts of death or self-harm averaged 14.4% overall (epilepsy, 14.0% and MS, 14.7%). Factors associated with positive PHQ item-9 responses in epilepsy were depression and male sex, modified by poor quality of life. Factors associated with positive PHQ item-9 in MS were depression, male sex, medical comorbidity, and poor quality of life; the effect of depression was worse with greater MS severity and being unmarried.

CONCLUSIONS

Among patients with common neurologic disorders (epilepsy or MS), 14%-15% reported thoughts of death or self-harm associated with illness severity, depression, quality of life, male sex, and being unmarried. Such patients require further evaluation of clinical outcomes and effects of treatment.

Prevalence and risk factors for suicidal ideation in a multiple sclerosis population

OBJECTIVE

To estimate the prevalence, incidence and determinants of suicidal ideation in the multiple sclerosis (MS) population.

METHODS

A sample of 188 subjects were randomly selected from a community-based MS clinic registry and participated in as many as 13 interviews over 6 months. Thoughts of "being better off dead" or of "harming oneself" were assessed using item 9 on the Patient Health Questionnaire, Brief (PHQ-9).

RESULTS

At baseline, the 2-week period prevalence of suicidal ideation was 8.3%. Over the course of 6 months, 22.1% of respondents reported having such thoughts at least once. Survival analysis incorporating baseline PHQ-8 scores as a covariate confirmed that being age 65 and over (HR=4.3, 95% CI 1.7-11.3) and having lower quartile self-efficacy ratings (HR=3.5, 95% CI 1.5-8.2) predicted suicidal ideation. Lower levels of task-oriented coping (treated as a continuous variable) also predicted suicidal ideation after adjustment for depressive symptoms (p=0.015), as did self-reported bladder or bowel symptoms (HR=2.6, 95% CI 1.1-6.0) and difficulties with speaking and swallowing (HR=2.9, 95% CI 1.3-6.8). Associations with MS symptoms were not confounded by depressive symptoms.

CONCLUSION

This study identified several potentially modifiable factors that may be useful for preventing suicide in people with MS.

Clinical management of multiple sclerosis through home telehealth monitoring: results of a pilot project

This study examined the feasibility of using home telehealth monitoring to improve clinical care and promote symptom self-management among veterans with multiple sclerosis (MS). This was a longitudinal cohort study linking mailed survey data at baseline and 6-month follow-up with information from home telehealth monitors. The study was conducted in two large Department of Veterans Affairs (VA) MS clinics in Seattle, Washington, and Washington, DC, and involved 41 veterans with MS. The measures were demographic information and data from a standardized question set using a home telehealth monitor. Participants reported moderate levels of disability (median Expanded Disability Status Scale [EDSS] score, 6.5) and substantial distance from the nearest VA MS clinic (mean distance, 93.6 miles). Of the participants, 61.0% reported current use of MS disease-modifying treatments. A total of 85.4% of participants provided consistent data from home monitoring. Overall satisfaction with home telehealth monitoring was high, with 87.5% of participants rating their experience as good or better. The most frequently reported symptoms at month 1 were fatigue (95.1%), depression (78.0%), and pain (70.7%). All symptoms were reported less frequently by month 6, with the greatest reduction in depression (change of 23.2 percentage points), although these changes were not statistically significant. Home telehealth monitoring is a promising tool for the management of chronic disease, although substantial practical barriers to efficient implementation remain.

Cognitive behavioural therapy for the treatment of depression in people with multiple sclerosis: a systematic review and meta-analysis

BACKGROUND

Depression is a common symptom in people with multiple sclerosis. We systematically reviewed published controlled trials on the effectiveness of cognitive behavioural therapy (CBT) for the treatment of depression in people with multiple sclerosis.

METHODS

Publications were identified using MEDLINE, PsycINFO and the Cochrane Central Register of Controlled Trials to June/July 2013. We combined thesaurus and free-text terms which were synonyms of the concepts multiple sclerosis, depression and cognitive behavioural therapy. We included published controlled trials which compared individual, group CBT, conducted face-to-face or remotely, to no CBT. Two reviewers extracted data to calculate standardized mean differences (SMD) for self-reported symptoms of depression and weighted mean differences (WMD) for the Multiple Sclerosis Impact Scale (MSIS-29), with 95% Confidence Intervals (CIs). We investigated statistical heterogeneity using I².

RESULTS

Seven eligible studies (n = 433) were identified, which evaluated the effect on depression of CBT delivered individually (3 studies), in a group (3 studies) and by computer (1 study). The summary effect (SMD -0.61, 95% CI -0.96 to -0.26, p=0.0006) was reduced (SMD -0.46, 95% CI -0.75 to -0.17, p=0.002) when an outlying study was removed in a sensitivity analysis to examine statistical heterogeneity. Three studies (n=213) observed a direction of effect using the MSIS-29 which was not statistically significant (WMD -4.36, 95% CI -9.33 to 0.62, p=0.09). There was no between-subgroup heterogeneity (I²=0).

CONCLUSIONS

CBT can be an effective treatment for depression in MS. Further research should explore optimal durations and modalities of treatment for patients with different characteristics.

The impact of chronic illness in suicidality: a qualitative exploration

Objectives: To explore the experiences of patients with chronic physical illness in relation to suicidal behaviours and ideas. Design: A qualitative study using semi-structured interviews. Methods: Fourteen patients with either multiple sclerosis or stage 5 chronic kidney disease were interviewed. Grounded theory was used to analyse the data. Results: Suicidal ideation was commonly reported by the study participants, and the relationship between the impact of a chronic physical illness, suicidality and risk factors was described. Several participants reported having planned suicide attempts as a consequence of finding living with their illness intolerable, and some had used non-adherence to treatment as a deliberate method to end their life. Conclusion: The findings suggest suicidality may be a relatively common experience in those with chronic illness facing a future of further losses, and that alongside passive thoughts of not being alive this may also include active thoughts about suicide. Health professionals should be alert to intentional non-adherence to treatment as an attempt to end one's life.

Implications of two-stage depression screening for identifying persons with thoughts of self-harm

OBJECTIVE

Persons with thoughts of self-harm may need evaluation for suicide risk. We examine the prevalence of thoughts of self-harm and whether persons with thoughts of self-harm are identified when two-stage depression screening is used.

METHODS

Data are from the 2005-2010 National Health and Nutrition Examination Surveys. Persons responding positively to question nine of the Patient Health Questionnaire-9 (PHQ-9) are identified as having thoughts of self-harm. We compare two depression cutoff scores for the Patient Health Questionnaire-2 (PHQ-2) to see what percentage of persons with thoughts of self-harm would be identified as needing further screening with the PHQ-9.

RESULTS

The prevalence of thoughts of self-harm was 3.5%. Persons 12-17 years old, poor and reporting fair or poor health were more likely to report thoughts of self-harm. A cutoff score of three on the PHQ-2 identified 49% of persons with thoughts of self-harm for further screening with the PHQ-9. A cut point of two increased the proportion of persons with thoughts of self-harm continuing for further screening to 76%.

CONCLUSIONS

Using a lower cutoff score, two, the PHQ-2 captures more persons with thoughts of self-harm. One quarter of persons with self-harm thoughts may not be identified for further screening when two-stage screening is used.

Faith as a resource in patients with multiple sclerosis is associated with a positive interpretation of illness and experience of gratitude/awe

The aim of this cross-sectional anonymous survey with standardized questionnaires was to investigate which resources to cope were used by patients with multiple sclerosis (MS). We focussed on patients' conviction that their faith might be a strong hold in difficult times and on their engagement in different forms of spirituality. Consecutively 213 German patients (75% women; mean age 43 ± 11 years) were enrolled. Fifty-five percent regarded themselves as neither religious nor spiritual (R-S-), while 31% describe themselves as religious. For 29%, faith was a strong hold in difficult times. This resource was neither related to patients' EDSS scores, and life affections, fatigue, negative mood states, life satisfaction nor to Positive attitudes. Instead it was moderately associated with a Reappraisal strategy (i.e., and positive interpretation of illness) and experience of gratitude/awe. Compared to spiritual/religious patients, R-S- individuals had significantly (P < .0001) lower Reappraisal scores and lower engagement in specific forms of spiritual practices. The ability to reflect on what is essential in life, to appreciate and value life, and also the conviction that illness may have meaning and could be regarded as a chance for development was low in R-S- individuals which either may have no specific interest or are less willing to reflect these issues.

Utility of the Patient Health Questionnaire-9 to assess suicide risk in patients with systemic sclerosis

OBJECTIVE

Item 9 of the Patient Health Questionnaire-9 (PHQ-9), which inquires about both passive thoughts of death and active ideas of self-harm, has been used to assess suicide risk in arthritis. The objectives of this study were 1) to determine the proportion of systemic sclerosis (SSc; scleroderma) patients who responded "yes" to item 9 who endorsed active suicidal ideation in response to more direct questions during a structured clinical interview, and 2) to report whether the PHQ-8, which does not include item 9 from the PHQ-9, performs similarly to the PHQ-9.

METHODS

Patients were recruited from the Canadian Scleroderma Research Group Registry. The PHQ-9 and Composite International Diagnostic Interview (CIDI) depression module were administered during a phone interview. Scores on the PHQ-8 were calculated by removing item 9 from the PHQ-9. Item 9 responses were compared to suicidal ideation and intent in the last year based on the CIDI. Scores on the PHQ-8 and PHQ-9 were compared using Pearson's correlations.

RESULTS

There were 345 patients interviewed, of whom 31 (9.0%) endorsed item 9 of the PHQ-9. Of those, based on the CIDI, 14 (45.2%) had passive thoughts of suicide or death. Only 1 patient (3.2%) had thoughts about suicide in some detail at any point in the last 12 months. The correlation between PHQ-9 and PHQ-8 scores was 0.998.

CONCLUSION

Item 9 appears to identify many patients who do not report active suicidal ideation. The PHQ-8 may be a better option for assessment of depressive symptoms than the PHQ-9 in patients with SSc.

Suicidal Behavior and Neurological Illnesses

OBJECTIVE

Suicidal ideation and behavior have been associated with a variety of neurological illnesses. Studies are ongoing in combat veterans and other groups to examine possible mechanisms and pathways that account for such associations.

METHOD

This article provides a review of the literature on suicide ideation and suicidal behavior in patients with neurological illnesses including publications on veteran's health and military medicine. Studies of suicide attempts and deaths in people with neurological illnesses are also reviewed.

RESULTS

The studies summarized in this review indicate that there are important linkages between suicidal ideation and behavior and neurological conditions, including epilepsy, multiple sclerosis, and amyotrophic lateral sclerosis.

CONCLUSION

Additional studies are needed to further clarify why suicide ideation and suicidal behavior are associated with neurological diseases, in order to improve quality of life, alleviate patient distress, and prevent nonfatal and fatal suicide attempts in veteran and non-veteran populations.

Suicide risk in multiple sclerosis: a systematic review of current literature

BACKGROUND

Studies have shown that suicidal ideation is often revealed among patients suffering from Multiple Sclerosis (MS). Mental health assessment of physically ill patients should form part of routine clinical evaluation, particularly in chronic illness.

OBJECTIVE

The aim of the present paper was to investigate whether there was a relationship between MS and suicidal behavior.

METHODS

A systematic review of the literature was conducted to determine the potential association between MS and suicidal behavior. A total of 12 articles from peer-reviewed journals were considered and selected for this review.

RESULTS

Most studies have documented a higher suicide rate in patients with MS compared to the general population, and suicide was associated with several risk factors: Depression severity, social isolation, younger age, progressive disease subtype, lower income, earlier disease course, higher levels of physical disability, and not driving.

CONCLUSIONS

Clinicians should be aware of the fact that suicidality may occur with higher frequency in MS patients, the available data suggest that the risk of self-harm is higher than expected in MS patients.

Self-reported depression and physical activity in adults with mobility impairments

OBJECTIVE

To test hypothesized associations between depression and physical activity among adults with multiple sclerosis (MS), spinal cord injury (SCI), muscular dystrophy (MD), and postpolio syndrome (PPS).

DESIGN

Cross-sectional survey.

SETTING

Survey responses collected from individuals in the Washington state area (participants with SCI) and across the United States (participants with MS, MD, and PPS).

PARTICIPANTS

Convenience sample of participants were surveyed (N=1676; MD, n=321; PPS, n=388; MS, n=556; SCI, n=411).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The Patient Health Questionnaire-9 (PHQ-9) assessing depressive symptoms and the International Physical Activity Questionnaire (IPAQ) and Godin Leisure Time Exercise Questionnaire (GLTEQ) assessing physical activity.

RESULTS

The average age was 56 years, 64% were women, 92% were white, 86% had a high school degree or higher, and 56% walked with an assistive device or had limited self-mobility. The IPAQ and GLTEQ explained a small but statistically significant and unique amount of the variance in PHQ-9 scores in all diagnostic groups, with no significant differences in the relation by condition, age, or mobility status (IPAQ R(2)=.004; GLTEQ R(2)=.02; both P<.02).

CONCLUSIONS

Both physical activity measures demonstrated a small but statistically significant association with depression in all 4 diagnostic groups. Research is needed to determine longitudinal relations and whether physical activity interventions could promote improved mood in adults with physical disabilities.

The association of depression with pain-related treatment utilization in patients with multiple sclerosis

OBJECTIVE

To better understand the association of depression with pain treatment utilization in a multiple sclerosis (MS) population.

DESIGN

Cross-sectional survey.

SETTING

Community-based survey.

PARTICIPANTS

Convenience sample of 117 individuals with MS.

MAIN OUTCOME MEASURES

Participants provided demographic information, descriptive information on utilization of pain treatments, pain intensity ratings on a 0-10 numerical rating scale, and depressive symptoms on the Patient Health Questionnaire-9 (PHQ-9).

RESULTS

Participants reporting clinical levels of depressive symptoms (PHQ-9 ≥10) reported that they tried more pain treatments previously relative to participants with PHQ-9 <10; however, the two groups did not differ in the number of treatments they were currently using. Additionally, participants with PHQ-9 ≥10 had more visits to providers for pain treatment relative to the group with PHQ-9 <10. In subsequent analyses, results showed that these differences were no longer significant after controlling for level of pain intensity.

CONCLUSIONS

The results demonstrate that depression is not associated with higher pain treatment utilization. These findings support the assertion in previous studies that the mechanism by which depression impacts medical utilization is through increased appointments for nonspecific complaints, not for specific medical problems. While this suggests that treating depression may not be helpful in reducing pain treatment utilization specifically, it remains important to treat depression to reduce pain-related suffering and medical utilization more broadly.

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

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

The PHQ-9 versus the PHQ-8--is item 9 useful for assessing suicide risk in coronary artery disease patients? Data from the Heart and Soul Study

OBJECTIVE

Item 9 of the Patient Health Questionnaire-9 (PHQ-9), which inquires about both passive thoughts of death and active ideas of self-harm, has been used to assess suicide risk. The objectives of this study were (1) to determine the proportion of patients who responded "yes" to Item 9 who endorsed active suicidal ideation in response to more direct questions from a structured clinical interview and (2) to compare the sensitivity and specificity for detecting cases of depression of the PHQ-9 and the PHQ-8, which does not include Item 9, as well as the correlation between the PHQ-8 and PHQ-9.

METHODS

Coronary artery disease (CAD) outpatients were administered the PHQ-9 and the Computerized Diagnostic Interview Schedule (C-DIS). Item 9 responses were compared to suicidal ideation and intent in the last year based on the C-DIS. Scores on the PHQ-8 were obtained by eliminating Item 9 from the PHQ-9. Test characteristics of the PHQ-9 and PHQ-8 were compared.

RESULTS

Of 1022 patients, 110 (10.8%) endorsed Item 9. Of those, only 22 (19.8%) reported thoughts about committing suicide, and only 9 of those (8.1%) reported a suicide plan any time in the last year based on the C-DIS. Correlation between PHQ-9 and PHQ-8 scores was r=0.997. Sensitivity and specificity for the PHQ-9 (54%, 90%) and PHQ-8 (50%, 91%) to detect major depression were similar.

CONCLUSION

Item 9 does not appear to be an accurate suicide screen. The PHQ-8 may be a better option than the PHQ-9 in CAD patients.

Ideação suicida em pacientes internados em enfermarias de clínica médica: prevalência e sintomas depressivos

OBJETIVO: Verificar a frequência de ideação suicida e os sintomas depressivos associados a ela nos pacientes internados em enfermarias de clínica médica. MÉTODOS: Todos os adultos consecutivamente admitidos nas enfermarias de clínica médica de um hospital universitário foram randomizados e avaliados durante a primeira semana de internação. Coletaram-se dados sociodemográficos e aplicaram-se: o Patient Health Questionnaire (a pergunta sobre ideação suicida), o Inventário Beck de Depressão e o índice Charlson de comorbidade física. Utilizaram-se os testes t de Student, do qui-quadrado e a regressão logística. RESULTADOS: Dos 1.092 sujeitos, 79 (7,2%) apresentaram ideação suicida. Na análise multivariada, foram capazes de discriminar esses pacientes, após controlar para sexo, idade, comorbidade física e presença de uma síndrome depressiva, os seguintes sintomas, quando presentes em intensidade moderada a grave: tristeza [RR: 3,18; IC 95% = 1,78-5,65; p < 0,001], sensação de fracasso [RR: 2,01; IC 95% = 1,09-3,72; p = 0,03], perda do interesse nas pessoas [RR: 2,69; IC 95% = 1,47-4,94; p = 0,001] e insônia [RR: 1,74; IC 95% = 1,05-2,89; p = 0,03]. CONCLUSÃO: Os pacientes internados no hospital geral em enfermarias clínicas apresentaram prevalência de 7,2% de ideação suicida. Alguns sintomas, quando presentes em intensidade moderada a grave, deveriam alertar ao clínico-geral para investigar a presença de ideação suicida: tristeza, sensação de fracasso, perda do interesse nas pessoas e insônia.

Suicidal ideation in medical inpatients: psychosocial and clinical correlates

OBJECTIVE

To identify psychosocial and clinical correlates of suicidal ideation in medical inpatients.

METHOD

In a cross-sectional study, all adults consecutively admitted to the medical wards of a University Hospital had their names recorded and were randomized and evaluated during the first week of admission. Suicidal ideation was assessed using Item 9 of Patient Health Questionnaire-9. The Beck Depression Inventory, the Beck Anxiety Inventory, the WHO Subjective well-being scale, the Charlson Comorbidity Index and other numerical rating scales (pain and self-reported physical illness severity) were used. Patients with less than four confidants were considered with poor social support. The Student's t test, Mann-Whitney U test, chi-square test and stepwise logistic regression analysis were used.

RESULTS

Of the 1092 patients who composed the sample, 7.2% reported having suicidal ideation. After adjusting for psychosocial and clinical confounders, prior suicide attempts (OR: 4.41; 95% CI: 2.12-9.15; P<.001), depressive symptoms (OR: 1.11; 95% CI: 1.06-1.17; P<.001), severe anxiety symptoms (OR: 3.04; 95% CI: 1.47-6.26; P=.003) and poor social support (OR: 2.02; 95% CI:1.03-3.96; P=.04) were independently associated with suicidal ideation.

CONCLUSIONS

Three out of the four correlates of suicidal ideation in medical inpatients are potentially modifiable factors: severe anxiety, depressive symptoms and poor social support. The fourth variable, prior suicide attempts, is not modifiable but should serve as a red flag to suspect and investigate current suicide risk. These findings highlight the importance of suicidal ideation as a proxy for the distress that is incumbent upon physicians to manage if they wish to provide excellent and comprehensive inpatient care.