Validation study of prevalence and correlates of depressive symptomatology in multiple sclerosis

Depression and anxiety in multiple sclerosis. Review of a fatal combination

Depression and anxiety are the most frequent neuropsychiatric symptoms of multiple sclerosis (MS), an autoimmune-mediated demyelinating neurodegenerative disease. Their prevalence is 25-65% and 20-54%, respectively, often associated with chronic fatigue and cognitive impairment, but usually not correlated with motor and other deficits, suggesting different pathophysiological mechanisms. Both disorders often arise before MS diagnosis, lead to faster disability and impair the quality of life. Risk factors are (young) age, genetic and family history burden. While no specific neuropathological data for depression (and anxiety) in MS are available, modern neuroimaging studies showed bilateral fronto-temporal, subcortical and limbic atrophies, microstructural white matter lesions and disruption of frontoparietal, limbic and neuroendocrine networks. The pathogenesis of both depression and anxiety in MS is related to shared mechanisms including oxidative stress, mitochondrial dysfunction, neuroinflammation and neuroendocrine mechanisms inducing complex functional and structural brain lesions, but they are also influenced by social and other factors. Unfortunately, MS patients with anxiety, major depression or suicidal thoughts are often underassessed and undertreated. Current treatment, in addition to antidepressant therapy include transcranial magnetic stimulation, cognitive, relaxation, dietary and other healthcare measures that must be individualized. The present state-of- the-art review is based on systematic analysis of PubMed, Google Scholar and Cochrane Library until May 2024, with focus on the prevalence, clinical manifestation, neuroimaging data, immune mechanisms and treatment options. Depression and anxiety in MS, like in many other neuroimmune disorders, are related, among others, to multi-regional patterns of cerebral disturbances and complex pathogenic mechanisms that deserve further elucidation as a basis for early diagnosis and adequate management to improve the quality of life in this disabling disease.

Sexual Dysfunction in People with Multiple Sclerosis: The Role of Disease Severity, Illness Perception, and Depression

Despite being a common issue in people with multiple sclerosis (pwMS), sexual dysfunction is still underinvestigated. This work aims to assess the potential determinants of sexual dysfunction in pwMS by considering its relationship with disease severity (in terms of global disability), illness perception, and depressive symptoms. In this multicenter study, 1010 pwMS responded to an online survey. A serial mediation model considering negative illness perception and depressive symptoms as mediators of the relationship between disease severity and sexual dysfunction was conducted using the SPSS PROCESS Macro with bias-corrected bootstrapping (5000 samples). Disease severity exerts an indirect effect on sexual dysfunction via illness perception, both independently and through depressive symptoms. However, the results indicated that illness perception plays a more crucial role in sexual dysfunction in pwMS with mild disability than in pwMS with moderate-severe disability. This study suggests that higher disability increases its magnitude by enhancing negative illness perception, that, in turn, affects sexual dysfunction both directly and through depressive symptoms, especially in pwMS with mild disability. Modulating the effect of illness perception by favoring adaptive coping strategies might represent a valid approach to mitigate sexual dysfunction symptoms in MS.

Spatial and temporal distribution of the prevalence of unemployment and early retirement in people with multiple sclerosis: A systematic review with meta-analysis

Background

We aimed to summarise the prevalence of unemployment and early retirement among people with MS and analyze data according to a spatio-temporal perspective.

Methods

We undertook a systematic search of PubMed/MEDLINE, Scopus, SciVerse ScienceDirect, and Web of Science. We included any peer-reviewed original article reporting the prevalence of unemployment and early retirement in the working-age population with MS. We excluded articles off-topic, with other study designs, whose study sample were unlikely to be representative of the MS population and in case of unavailability of the full text or essential information. A random-effects meta-analysis was used to measure overall prevalence estimates of unemployment and early retirement. We used meta-regression and subgroup analysis to evaluate potential moderators of prevalence estimates and the leave-one-out method for sensitivity analyses.

Results

Our research identified 153 studies across 29 countries encompassing 188436 subjects with MS. The pooled overall effect size for unemployment and early retirement was 35.6% (95% CI 32.8–38.4; I² = 99.31) and 17.2% (95% CI 14.6–20.2; I² = 99.13), respectively. The prevalence of unemployment varied according to the year of publication (p < 0.001) and there was a statistically significant decrease in the prevalence of unemployment over time (p = 0.042). Regarding early retirement, only seven (31.8%) estimates obtained from studies that were published before 2010 were below the overall effect size in comparison to 27 (60.0%) estimates extracted from data published between 2010 and 2021 (p = 0.039). There was a significant difference in prevalence according to countries (p < 0.001). Psychiatric illness was an important clinical feature responsible for patients leaving the workforce in regions with a high MS prevalence.

Conclusions

Unemployment and early retirement due to MS remain highly prevalent, despite a slight decline in the last decade. The prevalence of unemployment and early retirement varies globally.

Determining Prevalence of Depression and Covariates of Depression in a Cohort of Multiple Sclerosis Patients

Background

Depression is one of the most common symptoms experienced by multiple sclerosis patients and may be secondary to the disease itself as well as other variables such as age, disease severity and side effects of treatment.

Objective

To determine if there is an association between disease modifying therapies and depression rates based on PHQ9 scores in multiple sclerosis.

Methods

This was a retrospective chart review. Patients followed at the University of Texas Southwestern Multiple Sclerosis and Neuroimmunology Clinic from 2017 to 2020 were included in this study. Patients’ most recent PHQ-9 scores were used. The following data was extracted from patient charts: disease modifying therapy, age, disease duration, gender, antidepressant use and ambulatory status.

Results

Data from our study included 2611 individual PHQ-9 scores. The majority of our patients were female and the mean age across all treatment groups was 50.37 years old. The median disease duration across all treatment groups was 12.74 years. Most patients in this cohort required no ambulatory assistance. 43.86% of patients were on antidepressants and use was correlated with a higher PHQ9 score. The median PHQ 9 score across all treatment groups was 4 (Interquartile range = 7). Across treatment groups, patients on interferon therapy had the lowest PHQ 9 scores with a median of 2.

Conclusions

Our study demonstrated that there were lower PHQ-9 scores among interferon treatment group as compared to other disease modifying therapies and non-treatment groups

Mental Health in Multiple Sclerosis During the COVID-19 Outbreak: A Delicate Balance between Fear of Contagion and Resilience

The current study aimed at exploring the relationship between objective disability, illness perceptions, resilience, fear of COVID-19, and psychological distress (i.e., anxiety, depression, and stress) in people with multiple sclerosis (pwMS) during the second wave of the COVID-19 outbreak. A group of 122 pwMS recruited in an Italian university hospital took part in this cross-sectional monocentric study. Hierarchical multiple linear regression analyses were performed to assess the strength of the hypothesized associations. Results indicated that, differently from cognitive impairment, motor disability was positively associated with anxiety. However, accounting for subjective illness perception, such association was no longer significant. Moreover, accounting for both protective and risk factors in the models, even illness perception was no longer significant, highlighting the central role of resilience and fear of COVID-19 in explaining the negative emotional outcomes. Implications for clinical interventions and psychoeducational trainings are discussed.

Depression, anxiety, and fear of COVID-19 in patients with multiple sclerosis in pandemic era: a cross-sectional study

Background

Depression and anxiety are the two important factors determining quality of life of patients with multiple sclerosis (PWMS). In COVID-19 pandemic era, several factors can provoke mental issues of people and patients. In this cross-sectional study, we aim to estimate the new prevalence of anxious and depressive symptoms and their relating factors in PWMS.

Methods

In this cross-sectional study, we include PWMS who are recruited in the MS clinic of Sina Hospital, Tehran, and are joined in our channel of Telegram media. A self-designed online questionnaire consisted of 4 parts handed out between patients: demographic and clinical data, Beck depression inventory, Beck anxiety inventory, and Fear of COVID-19 Scale. Univariate and multiple logistic regression analyses were performed to find the relating factors of expression of depressive and anxious symptoms in PWMS.

Results

Of a total of 282 participants with the mean age of 35.66 (30.75–40) years, had been suffering from multiple sclerosis for 7.36 (3–10) years, 81.7% were women and 69.1% classified as relapsing–remitting MS. Mean score of BDI was 17.13 ± 11.51 which is classified as minimal-moderate depressive symptoms. 48.6% of patients did not express depressive symptoms (BDI-II ≤ 14) and the others reported some degrees of depression. In the univariate analysis employment (p = 0.015), marital status (p = 0.022), level of education (p = 0.004), number of hospitalization due to MS attacks (p = 0.048), and fear of COVID-19 (p ≤ 0.0001) associated significantly with presence of depressive symptoms. After entering these factors in a binary logistic regression model, level of education (p = 0.019), marital status (p = 0.044), number of hospital admissions due to MS relapses (β = 1.10, p = 0.02), and fear of COVID-19 (β = 1.07, p ≤ 0001) remained significant as relating factors. Mean score of the anxiety calculated 14.54 ± 9.75 and just 3.2% of patients had severe anxiety. Employment (p = 0.045), EDSS score (p = 0.004), and fear of COVID-19 (p ≤ 0.0001) reported relating to anxious symptoms significantly in the univariate analysis. After entering in the logistic regression analysis, EDSS (β = 1.30, p = 0.001) and fear of COVID-19 (β = 1.13, p ≤ 0.0001) remained as significant relating factors of anxious symptoms.

Conclusion

The overall prevalence of depressive symptoms in PWMS in our MS clinic is 51.4% which is obviously higher than other world’s centers which could be due to fear of COVID-19. In addition to fear of COVID-19, presence of depressive symptoms in PWMS is related significantly with level of education, number of hospital admissions due to MS relapses, and marital status. Other side, the patients classified as suffering from anxious symptoms had more severe problems on fear of COVID-19. But it is recommended for future studies to compare patients score in the COVID-19 era with their score before this pandemic.

Emotional outcomes in clinically isolated syndrome and early phase multiple sclerosis: a systematic review and meta-analysis

OBJECTIVE

To study depression, anxiety, suicide risk, and emotional health-related quality of life (HRQoL) in people with clinically isolated syndrome (CIS) and in early phase multiple sclerosis (MS).

METHODS

A systematic literature review was conducted with inclusion criteria of observational studies on outcomes of depression, anxiety, suicide risk, and emotional HRQoL in CIS and within five years since diagnosis of MS. Studies were screened using the Preferred Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines, and study quality was determined for included studies. Meta-analysis and meta-regression were performed if applicable.

RESULTS

Fifty-one studies were included in the systematic review. In early phase MS, meta-analyses of the Hospital Anxiety Depression Scale (HADS) indicated prevalence levels of 17% (95% confidence interval (CI): 9 to 25%; p < .001) for depressive and 35% (95% CI: 28 to 41%; p < .001) for anxiety symptoms. Meta-regression analyses revealed an increase in mean HADS-D and HADS-A associated with larger sample size, and higher HADS-D mean with increased study quality. Similar depressive and anxiety symptoms were observed in CIS, and increased suicide risk and low emotional HRQoL was associated with depressive symptoms in early phase MS. The methodological quality of the studies was considered fair.

CONCLUSIONS

Findings suggest that mild-to-moderate symptoms of depression and anxiety might be prevalent in CIS and in early phase MS. Future research on both clinical populations are needed, especially longitudinal monitoring of emotional outcomes.

Adult Gross Motor Learning and Sleep: Is There a Mutual Benefit?

Posttraining consolidation, also known as offline learning, refers to neuroplastic processes and systemic reorganization by which newly acquired skills are converted from an initially transient state into a more permanent state. An extensive amount of research on cognitive and fine motor tasks has shown that sleep is able to enhance these processes, resulting in more stable declarative and procedural memory traces. On the other hand, limited evidence exists concerning the relationship between sleep and learning of gross motor skills. We are particularly interested in this relationship with the learning of gross motor skills in adulthood, such as in the case of sports, performing arts, devised experimental tasks, and rehabilitation practice. Thus, the present review focuses on sleep and gross motor learning (GML) in adults. The literature on the impact of sleep on GML, the consequences of sleep deprivation, and the influence of GML on sleep architecture were evaluated for this review. While sleep has proven to be beneficial for most gross motor tasks, sleep deprivation in turn has not always resulted in performance decay. Furthermore, correlations between motor performance and sleep parameters have been found. These results are of potential importance for integrating sleep in physiotherapeutic interventions, especially for patients with impaired gross motor functions.

Interplay Between Age and Neuroinflammation in Multiple Sclerosis: Effects on Motor and Cognitive Functions

Aging is one of the main risk factors for the development of many neurodegenerative diseases. Emerging evidence has acknowledged neuroinflammation as potential trigger of the functional changes occurring during normal and pathological aging. Two main determinants have been recognized to cogently contribute to neuroinflammation in the aging brain, i.e., the systemic chronic low-grade inflammation and the decline in the regulation of adaptive and innate immune systems (immunosenescence, ISC). The persistence of the inflammatory status in the brain in turn may cause synaptopathy and synaptic plasticity impairments that underlie both motor and cognitive dysfunctions. Interestingly, such inflammation-dependent synaptic dysfunctions have been recently involved in the pathophysiology of multiple sclerosis (MS). MS is an autoimmune neurodegenerative disease, typically affecting young adults that cause an early and progressive deterioration of both cognitive and motor functions. Of note, recent controlled studies have clearly shown that age at onset modifies prognosis and exerts a significant effect on presenting phenotype, suggesting that aging is a significant factor associated to the clinical course of MS. Moreover, some lines of evidence point to the different impact of age on motor disability and cognitive deficits, being the former most affected than the latter. The precise contribution of aging-related factors to MS neurological disability and the underlying molecular and cellular mechanisms are still unclear. In the present review article, we first emphasize the importance of the neuroinflammatory dependent mechanisms, such as synaptopathy and synaptic plasticity impairments, suggesting their potential exacerbation or acceleration with advancing age in the MS disease. Lastly, we provide an overview of clinical and experimental studies highlighting the different impact of age on motor disability and cognitive decline in MS, raising challenging questions on the putative age-related mechanisms involved.

Suicidal ideation, anxiety, and depression in patients with multiple sclerosis

ABSTRACT Psychiatric disorders frequently occur in patients with multiple sclerosis (MS); however, limited reports are available on these comorbidities. We aimed to investigate the relationships among MS, anxiety, depression, and suicidal ideation. Methods: One hundred and thirty two patients with relapsing-remitting MS were evaluated using the Expanded Disability Status Scale, Beck Depression Inventory-II (BDI-II), Beck Scale for Suicide Ideation (BSI), and Hospital Anxiety and Depression Scale. Results: A hierarchical regression analysis was performed to evaluate the variables. The regression equation significantly predicted the BSI score (R2 = 0.306; adjusted R2 = 0.273; F (9, 125) = 9.18; p < 0.0005), and the BDI-II score was the only variable that contributed significantly to this model (p < 0.0005). Conclusions: A high prevalence of depression and anxiety, and a higher rate of suicidal ideation were identified in MS patients compared to the general population. The presence of depressive symptoms appeared to have a direct influence on the risk of suicide.

The neuropsychiatry of multiple sclerosis

Multiple sclerosis (MS), an immune-mediated demyelinating condition, is the most common neurological disease affecting young adults in the UK. It has a high psychiatric comorbidity and over half of patients have some degree of cognitive impairment that adds to the burden of disability. This article reviews the psychiatric and cognitive manifestations of MS and their detection and treatment. Recent advances in the treatment of the disease are briefly reviewed and the impact of disease-modifying therapies on psychiatric morbidity and cognitive impairment is discussed.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

None.

An 8-year study of people with multiple sclerosis in Isfahan, Iran: Association between environmental air pollutants and severity of disease

The evidence for an impact of ambient air pollution on the incidence and severity of multiple sclerosis (MS) is still limited. In the present study, we assessed the association between daily air pollution levels and MS prevalence and severity in Isfahan city, Iran. Data related to MS patients has been collected from 2008 to 2016 in a referral university clinic. The air quality index (AQI) data, were collected from 6 monitoring stations of Isfahan department of environment. The distribution map presenting the sites of air pollution monitoring stations as well as the residential address of MS patients was plotted on geographical information system (GIS). An increase in AQI level in four areas of the city (north, west, east and south) was associated with higher expanded disability status scale (EDSS) of MS patients[logistic regression odds ratio = 1.01 (95% CI = 1.008,1.012)]. Moreover, significant inverse association between the complete remission after the first attack with AQI level in total areas [logistic regression odds ratio = 0.987 (95% CI = 0.977, 0.997)] was found in crude model. However, after adjustment for confounding variables through multivariate logistic regression, AQI level was associated with degree of complete remission after first attack 1.005 (95% CI = 1.004, 1.006). The results of our study suggest that air pollution could play a role in the severity and remission of MS disease. However, more detailed studies with considering the complex involvement of different environmental factors including sunlight exposure, diet, depression and vitamin D are needed to determine the outcome of MS.

Depression in multiple sclerosis

Depressive disorders occur in up to 50% of people living with multiple sclerosis (MS). Prevalence estimates are generally 2-3-times higher than those of the general population. Myriad aetiologic factors may contribute to the aetiology of depression in MS including biological mechanisms (e.g. hippocampal microglial activation, lesion burden, regional atrophy), as well as the stressors, threats, and losses that accompany living with an unpredictable and often disabling disease. Some prominent risk factors for depression such as (younger) age, (female) sex, and family history of depression are less consistently associated with depression in MS than they are in the general population. Management of depression in MS has not been well studied, but available data on detection and treatment align with general principles of depression management. While the validity of standard measurement scales has often been questioned, available evidence suggests that standard scales provide valid ratings. Evidence for the effectiveness of depression treatments in MS is limited, but available evidence supports the effectiveness of standard treatment approaches, including both cognitive behavioural therapies and antidepressant medications.

Evaluation of an adjustment group forpeople with multiple sclerosis and lowmood: a randomized controlled trial

Background: Mood problems affect many people with multiple sclerosis (MS). The aim was to evaluate the effectiveness of a group treatment based on cognitive behavioural principles.

Methods: People with MS were screened on the General Health Questionnaire 12 (GHQ-12) and Hospital Anxiety and Depression Scale (HAD). Those identified with low mood were invited to take part in a randomized trial comparing the effect of attending an adjustment group with a waiting list control. Patients allocated to the adjustment group received six 2 h group treatment sessions. Outcomes were assessed 4 and 8 months after randomization, blind to group allocation.

Results: Of the 311 patients identified, 221 (71%) met the criteria for low mood and 151 (68%) agreed to take part. Hierarchical regression analyses were conducted to compare the two groups, correcting for baseline mood and disability. At 4 months, group allocation alone was a significant predictor of the primary outcome measure, the GHQ-12. At 8 months, group allocation alone was no longer a significant predictor for GHQ-12 scores, but it was when baseline GHQ-12 and Guy’s Neurological Disability Scale scores were controlled for. Comparison of the area under the curve revealed significant differences between the groups for GHQ-12 ( p = 0.003), HAD Anxiety ( p = 0.013), HAD Depression ( p = 0.004), Beck Depression Inventory ( p = 0.001), MS Self-efficacy ( p = 0.037) and MS Impact Scale Psychological ( p = 0.012).

Conclusion: Patients receiving treatment were less distressed and had less depression and anxiety. There was some evidence of improved self-efficacy and a reduction of the impact of MS on people’s lives.

Social relationships, mental health and wellbeing in physical disability: a systematic review

BACKGROUND

Research has consistently found that favourable exchange with one's proximal social environment has positive effects on both mental health and wellbeing. Adults with physical disabilities may have fewer opportunities of favourable exchange, and therefore the effects on mental health and wellbeing may be less advantageous. The aim of this study is to systematically review quantitative studies exploring associations of social relationships with mental health and wellbeing in persons with physical disabilities.

METHODS

The databases PubMed, PsycINFO and Scopus were searched for relevant studies published between 1995 and 2016. Data was extracted on study and participants' characteristics, independent and dependent variables, used measures and effects sizes of associations between social relationships and mental health or wellbeing. A narrative review was performed to synthesize findings along the constructs social support, social networks, negative social interactions, family functioning and relationship quality.

RESULTS

Of the 63 included studies, 47 were cross-sectional and 16 longitudinal. Most studies included a measure of social support (n = 58), while other concepts were less often studied (social networks n = 6; negative social interaction n = 3; family functioning n = 2; relationship quality n = 1). Over half of studies included depression as outcome (n = 33), followed by wellbeing (n = 14), composite mental health measures (n = 10), anxiety (n = 8), psychological distress (n = 7), posttraumatic stress disorder (n = 3), and hopelessness (n = 1). Although trends for associations of social support with mental health and wellbeing were consistent, around a quarter of studies failed to report significant associations. Social networks were related to depression, but not to other mental health or wellbeing measures. Family functioning, negative social interactions and relationship quality showed consistent associations with mental health and wellbeing, however, only few studies were available.

CONCLUSIONS

This review indicates that social relationships play an important role in mental health and wellbeing in persons with disabilities, although findings are less consistent than in general populations and strength of associations vary between constructs. Integrating persons with disabilities into social networks seems not sufficient and rehabilitation professionals together with affected persons and their peers should ensure that high quality relationships and tailored support are available.

Cognitive Behavioral Therapy for Insomnia (CBT-I) for an Adult With Multiple Sclerosis

Poor sleep quality is more common in patients with multiple sclerosis (MS) than in the general population and is associated with greater disease severity, pain, and poorer quality of life. However, despite its prevalence, sleep problems frequently go untreated or are managed with sleep medication which can be ineffective in the long term and is associated with daytime fatigue and tolerance. In this case study, an individual with MS who had been experiencing sleep problems and had reported dependency on sleep medication was treated with a Cognitive Behavioral Therapy for Insomnia (CBT-I) program over the course of 3 months, with the goal of improving sleep quality while reducing sleep medication. By the end of the treatment, subjective sleep quality had improved, as measured by the Pittsburgh Sleep Quality Index and a sleep diary. Over the course of the treatment, the patient reduced his sleep medication to nil until he was sleeping with no sleep disturbance. Self-reported sleep measures at follow-up showed that these improvements in sleep quality had remained. In addition, scores on self-reported measures of life satisfaction, impact of MS on physical and psychological functioning, and anxiety and depression scores all showed improvements from assessment to follow-up. This case study illustrates a potential non-pharmaceutical treatment option for sleep problems for individuals with MS which is evidence-based in the general population and other comorbid conditions.

Depressive Symptoms Correlate with Disability and Disease Course in Multiple Sclerosis Patients: An Italian Multi-Center Study Using the Beck Depression Inventory

Background

Depression occurs in about 50% of patients with multiple sclerosis. The aims of this study was to investigate the prevalence of depressive symptoms in a multicenter MS population using the Beck Depression Inventory II (BDI II) and to identify possible correlations between the BDI II score and demographic and clinical variables.

Methods

Data were collected in a multi-center, cross-sectional study over a period of six months in six MS centers in Italy using BDI II.

Results

1,011 MS patients participated in the study. 676 subjects were female, with a mean age of 34 years (SD 10.8), mean EDSS of 3.3 (0–8.5) and mean disease duration of 10.3 years (range 1–50 years). 668 (%) subjects scored lower than 14 on the BDI II and 343 (33.9%) scored greater than 14 (14 cut-off score). For patients with BDI>14 multivariate analysis showed a significant difference between EDSS and disease course. BDI II scores for subjects with secondary progressive (SP) MS were significantly different from primary progressive (PP) patients (p < 0.001) but similar to relapsing-remitting (RR) patients. Considering subjects with moderate to severe depressive symptoms (BDI II score from 20–63), in relation to disease course, 11.7% (83/710) had RR MS, 40.7% (96/236) SP and 13.6% (6/44) PP.

Conclusions

Using the BDI II, 30% of the current sample had depressive symptoms. BDI II score correlates with disability and disease course, particularly in subjects with SP MS. The BDI II scale can be a useful tool in clinical practice to screen depressive symptoms in people with MS.

The determinants of depression in a Romanian cohort of multiple sclerosis patients

The aim of the present study was to assess the prevalence of depression in a large multiple sclerosis (MS) patient group and to analyse the physical and psycho-socio-economic factors that influence its frequency and severity. In total, 351 consecutive patients with a diagnosis of MS were included in this study. All the patients completed a survey about their demographic characteristics, marital status, presence of children, employment status, educational level, duration of disease, disease course, duration of treatment and type of disease modifying therapies (DMT). Their disability level was evaluated using the Expanded Disability Status Scale (EDSS). Their depression level was evaluated using the Romanian Version (2012) of the Beck Depression Inventory-II (BDI-II). There was a significant positive correlation between the BDI-II score and the actual age of the patients, their disease duration, EDSS and the number of total relapses. From the EDSS functional scores, only the pyramidal score and the sensitive score presented a significant association with BDI-II in the logistic regression analysis. The BDI-II values decreased significantly with increasing education level. In the case of the retired patients, the BDI-II values were significantly higher. The BDI-II scores were also higher in widowers and divorced patients and in patients with children. There was no significant difference in the BDI-II values between different DMT groups. The main physical and psycho-socio-economic determinants of depression in patients with MS are the physical disability, disease duration, number of relapses, marital status, education level, employment status, and the presence of children, but many unsolved questions remain about the interrelations and relative contributions of these factors, which necessitates further research. The DMTs did not significantly influence the depression level.

The incidence and prevalence of psychiatric disorders in multiple sclerosis: a systematic review

BACKGROUND

Psychiatric comorbidity is associated with lower quality of life, more fatigue, and reduced adherence to disease-modifying therapy in multiple sclerosis (MS).

OBJECTIVES

The objectives of this review are to estimate the incidence and prevalence of selected comorbid psychiatric disorders in MS and evaluate the quality of included studies.

METHODS

We searched the PubMed, PsychInfo, SCOPUS, and Web of Knowledge databases and reference lists of retrieved articles. Abstracts were screened for relevance by two independent reviewers, followed by full-text review. Data were abstracted by one reviewer, and verified by a second reviewer. Study quality was evaluated using a standardized tool. For population-based studies we assessed heterogeneity quantitatively using the I² statistic, and conducted meta-analyses.

RESULTS

We included 118 studies in this review. Among population-based studies, the prevalence of anxiety was 21.9% (95% CI: 8.76%-35.0%), while it was 14.8% for alcohol abuse, 5.83% for bipolar disorder, 23.7% (95% CI: 17.4%-30.0%) for depression, 2.5% for substance abuse, and 4.3% (95% CI: 0%-10.3%) for psychosis.

CONCLUSION

This review confirms that psychiatric comorbidity, particularly depression and anxiety, is common in MS. However, the incidence of psychiatric comorbidity remains understudied. Future comparisons across studies would be enhanced by developing a consistent approach to measuring psychiatric comorbidity, and reporting of age-, sex-, and ethnicity-specific estimates.

Self-management for people with multiple sclerosis: report from the first international consensus conference, november 15, 2010

People with multiple sclerosis (MS) must manage the day-to-day effects of the disease on their lives. Self-management interventions may be helpful in this challenge. An international, multidisciplinary consensus conference was held on November 15, 2010, by the University of Washington's Rehabilitation Research and Training Center for Multiple Sclerosis (MS RRTC), with funding from the Consortium of Multiple Sclerosis Centers (CMSC) and the National Institute on Disability and Rehabilitation Research (NIDRR), to discuss the concept of self-management for people with MS. The specific goals of the consensus conference were as follows: 1) review the current research on self-management and related issues in chronic disability and specifically in MS; 2) review optimal research methodologies, outcome measurement tools, program planning frameworks, and dissemination strategies for self-management research; and 3) establish recommendations on the next steps necessary to develop, adapt, and test self-management interventions for people with MS. The consensus conference and this document are the initial steps toward achieving the stated goals. Participants in the consensus conference concluded that it is necessary to: 1) define an empirically based conceptual model of self-management for people with MS; 2) establish reliable and valid self-management outcome measures; 3) use best practices to validate models of self-management interventions; and 4) plan dissemination and knowledge translation of interventions once their effectiveness is established.

Prevalence and predictors of depression in Iranian patients with multiple sclerosis: a population-based study

Depression is a frequent symptom in multiple sclerosis (MS) which has a negative impact on quality of life and cognitive status. The purpose of this study was to determine the prevalence and associated factors of depression, and status of antidepressant use in Iranian MS patients. One-hundred and sixty patients with definite MS were included. Demographic and clinical characteristics were recorded. Fatigue and depression were evaluated using the fatigue severity scale and Beck depression inventory-II. Cognitive performance and disability were examined by mini-mental status examination and expanded disability status scale. Multiple logistic regressions were used to determine the associated factors of depression and antidepressant use. The prevalence of depression and severe depression was 59.4 and 18.1 %, respectively. However, only 21.1 % of patients were on antidepressant treatment, while the prevalence of unrecognized/untreated depression was found to be as high as 44.1 %. Multivariable analysis showed that fatigue (P < 0.0001, OR = 5.98, 95 % CI = 2.9-12.3) and older age (P = 0.027, OR = 2.24, 95 % CI = 1.09-4.6) were associated with depression in MS patient. A significant association was found between fatigue and antidepressant use (P = 0.001, OR = 6.81, 95 % CI = 2.26-20.48). Our findings demonstrate that depression is significantly associated with fatigue and older age, regardless of other factors. Moreover, despite the high prevalence of depression in MS, most patients do not receive adequate treatment.

Psychiatric symptoms in patients with multiple sclerosis

OBJECTIVES

This study was intended to identify general psychiatric symptoms in multiple sclerosis (MS) patients and to determine the distribution of these psychiatric symptoms by type of MS and degree of disability.

METHODS

One hundred fifty-two volunteers, 76 MS patients and 76 healthy controls, matched in terms of age, gender, marital status, years spent in education and income, were included. Psychiatric symptoms were measured using the Symptom Checklist-90-R, Beck Depression Inventory, State-Trait Anxiety Inventory, Pittsburgh Sleep Quality Index, Padua Inventory, Rosenberg Self-Esteem Scale and Eating Attitude Test. Degree of disability was determined using the Expanded Disability Status Scale (EDSS). In addition to being compared between the patient and control groups, scale scores were also compared between groups established on the basis of relapsing-remitting or progressive forms of MS, neurological disability and ambulatory ability. Correlations were determined between EDSS scores and psychiatric scale scores.

RESULTS

In addition to symptoms of depression, anxiety and sleep impairment in MS patients, we also determined that less studied symptoms such as somatization, obsession, compulsion, interpersonal sensitivity, anger-hostility, phobic anxiety, paranoid ideation, psychoticism, low self-esteem and distorted eating attitudes were also more frequent compared to the healthy controls. Some symptoms were also more prevalent in progressive MS patients compared to relapsing-remitting subjects. Symptoms increase as degree of disability rises and ambulatory capacity declines.

CONCLUSION

Depressive, anxious and sleep impairment symptoms are not the only ones seen in MS patients; other psychiatric symptoms are also common. Further studies are needed to investigate the frequency and causes of these little-investigated symptoms. As seen in patients with a progressive course and greater neurological disability, more psychiatric symptoms develop in patients with more severe disease.

Association of depression and urolithiasis

OBJECTIVES

To study the hypothesis that patients with urolithiasis would have a higher prevalence of depression compared to the general population. Urolithiasis is associated with frequent recurrences. Patients with urolithiasis may develop a chronic condition associated with poor quality of life and depression. The frequency and severity of stones episodes would relate to depression.

METHODS

In an institutional review board-approved study; we prospectively recruited 115 patients who were evaluated for urolithiasis. Patients completed an Emory stone questionnaire covering demographics and a validated CES-D depression questionnaire. Depression scores were compared with U.S. norms. Demographics and clinical variables were analyzed.

RESULTS

On the CES-D depression questionnaire 30.4% of patients scored ≥ 16, a "significant level of physiological distress." The U.S. lifetime prevalence of depression was 16.5%. Determinants of depression included the following: family history of urolithiasis (OR = 3.49, CI = 1.51; 8.07), stone episode within the last 12 months (OR = 2.77, CI = 1.18; 6.53), and >1 emergency room visits for stone disease (OR = 2.61, CI = 1.14; 5.99). Patients with Charlson comorbidity indexes of ≤ 1 were more likely to be depressed than those scoring >1 (OR 2.89, CI = 1.20; 6.95). There were no significant associations with age at first stone, number of lifetime stones, number of surgeries, number of workdays missed, and need for dietary modifications or medications for stone prevention.

CONCLUSIONS

The prevalence of depression in our patient cohort with urolithiasis was substantially greater than societal norms. Multiple stone-related factors were associated with significant psychological distress. Appreciation of this issue may allow better patient care.

Physical activity, social support, and depression: possible independent and indirect associations in persons with multiple sclerosis

The present study examined the pattern of associations among physical activity, social support, mobility disability, perceived stress, and depressive symptoms in relapsing-remitting MS (RRMS). Persons (N = 218) with RRMS completed a battery of questionnaires that was sent and returned through the United States Postal Service (USPS). Bivariate correlation analysis indicated that physical activity and social support were both inversely associated with depressive symptoms (r's = -0.288 and -0.386, p ≤ 0.05, respectively). Multiple linear regression analysis indicated that physical activity (β = -0.21, p = 0.002) and social support (β = -0.37, p = 0.0001) were independently associated with depressive symptoms. Path analysis confirmed that the associations between physical activity and social support with depressive symptoms were indirect via mobility disability and perceived stress. Collectively, the evidence indicates that physical activity and social support are independently and indirectly associated with depression via mobility disability and perceived stress in relapsing-remitting MS. This supports the design of interventions and programs that target physical activity and social support for reducing depressive symptoms among persons with MS.

Impact of psychotherapy on insomnia symptoms in patients with depression and multiple sclerosis

The purpose of the study was to evaluate the prevalence of insomnia in multiple sclerosis patients with comorbid depression, associations between psychological symptoms, multiple sclerosis symptoms and insomnia, and to test effects of a 16-week protocol-based psychotherapy intervention for depression on insomnia symptoms. Participants with multiple sclerosis and depression (n = 127) were randomized to telephone administered cognitive behavioral therapy and telephone administered supportive emotion-focused therapy. Multiple sclerosis functional limitation was measured at baseline. Depression, insomnia, anxiety and quality of life were evaluated at pre treatment, mid treatment (8 weeks), and post treatment (16 weeks). Prevalence of insomnia ≥3 times per week was 78% at pre treatment and 43% at post treatment. Insomnia at baseline was associated with depression, multiple sclerosis related mood symptoms and anxiety. Middle of the night awakenings were associated with swallowing and speech problems. Improvements in insomnia were associated with improvement in depression and anxiety. Participants with residual insomnia were more likely to have major depressive disorder, greater multiple sclerosis severity, elevated anxiety and lower mental components of quality of life. Results demonstrate rates of insomnia in patients with comorbid multiple sclerosis and depression are higher than those reported in the general multiple sclerosis population and additional insomnia treatment is indicated beyond the treatment of comorbid psychological disorders.

Predictors of depression in multiple sclerosis patients

Depression is one of the major problems associated with multiple sclerosis (MS). Several physical and psychological factors tend to interact and make it difficult to pinpoint the predictors of the depression. It seemed particularly important to examine how anxiety and illness evolution (characterized by the functional status) influence the appearance of depression symptoms. Thus, the aim of this article was to clarify the relationship between depression and the factors associated with it. One hundred and fifteen participants living at home recruited through various associations and MS clinics answered socio demographic, medical and psychological questions and questionnaires (depression, anxiety, coping, social support, locus of control, alexithymia, self-esteem). Results show that functional status (EDSS), trait anxiety, alexithymia and satisfaction with social support system are the predicting factors of depression. Trait anxiety and functional status are two predictors that independently and simultaneously lead to the appearance of depression symptoms, with trait anxiety playing a predominant role. Alexithymia and social support indirectly influence the appearance of these symptoms.