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

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.

Repurposing Ketamine in the Therapy of Depression and Depression-Related Disorders: Recent Advances and Future Potential

Depression represents a prevalent and enduring mental disorder of significant concern within the clinical domain. Extensive research indicates that depression is very complex, with many interconnected pathways involved. Most research related to depression focuses on monoamines, neurotrophic factors, the hypothalamic-pituitary-adrenal axis, tryptophan metabolism, energy metabolism, mitochondrial function, the gut-brain axis, glial cell-mediated inflammation, myelination, homeostasis, and brain neural networks. However, recently, Ketamine, an ionotropic N-methyl-D-aspartate (NMDA) receptor antagonist, has been discovered to have rapid antidepressant effects in patients, leading to novel and successful treatment approaches for mood disorders. This review aims to summarize the latest findings and insights into various signaling pathways and systems observed in depression patients and animal models, providing a more comprehensive view of the neurobiology of anxious-depressive-like behavior. Specifically, it highlights the key mechanisms of ketamine as a rapid-acting antidepressant, aiming to enhance the treatment of neuropsychiatric disorders. Moreover, we discuss the potential of ketamine as a prophylactic or therapeutic intervention for stress-related psychiatric disorders.

Palliative Care Aspects in Multiple Sclerosis

CONTEXT

Multiple sclerosis (MS) is an inflammatory, chronic, demyelinating, and neurodegenerative disorder of central nervous system, determined by an auto-immune dysfunction. Severe disability generally occurs in patients with progressive forms of MS that typically develop either after an earlier relapsing phase or less commonly from disease onset. Despite advances in research to slow the progression of MS, this condition remains a life-limiting disease with symptoms impacting negatively the lives of patients and caregivers.

OBJECTIVES

To analyze the difefrent aspects of palliative cae in patients with MS.

METHODS

To analyse selected literature assessing several palliative care aspects in patients with MS.

RESULTS

People with MS have complex symptoms and different needs. These demands include how to deal with the burden of physical disability, how to organise daily life, restructuring social roles in the family and at work, keeping self-sufficiency in personal care, and preserving personal identity and community roles.

CONCLUSION

An early palliative care approach aims to improve the palliative care skills and competencies of health professionals caring for the patients since the early stage of disease, including those who are actively undergoing disease-targeted therapies, rather than merely providing end-of-life care.

"So at least now I know how to deal with things myself, what I can do if it gets really bad again"-experiences with a long-term cross-sectoral advocacy care and case management for severe multiple sclerosis: a qualitative study

BACKGROUND

Persons with severe Multiple Sclerosis (PwsMS) face complex needs and daily limitations that make it challenging to receive optimal care. The implementation and coordination of health care, social services, and support in financial affairs can be particularly time consuming and burdensome for both PwsMS and caregivers. Care and case management (CCM) helps ensure optimal individual care as well as care at a higher-level. The goal of the current qualitative study was to determine the experiences of PwsMS, caregivers and health care specialists (HCSs) with the CCM.

METHODS

In the current qualitative sub study, as part of a larger trial, in-depth semi-structured interviews with PwsMS, caregivers and HCSs who had been in contact with the CCM were conducted between 02/2022 and 01/2023. Data was transcribed, pseudonymized, tested for saturation and analyzed using structuring content analysis according to Kuckartz. Sociodemographic and interview characteristics were analyzed descriptively.

RESULTS

Thirteen PwsMS, 12 caregivers and 10 HCSs completed interviews. Main categories of CCM functions were derived deductively: (1) gatekeeper function, (2) broker function, (3) advocacy function, (4) outlook on CCM in standard care. Subcategories were then derived inductively from the interview material. 852 segments were coded. Participants appreciated the CCM as a continuous and objective contact person, a person of trust (92 codes), a competent source of information and advice (on MS) (68 codes) and comprehensive cross-insurance support (128 codes), relieving and supporting PwsMS, their caregivers and HCSs (67 codes).

CONCLUSIONS

Through the cross-sectoral continuous support in health-related, social, financial and everyday bureaucratic matters, the CCM provides comprehensive and overriding support and relief for PwsMS, caregivers and HCSs. This intervention bears the potential to be fine-tuned and applied to similar complex patient groups.

TRIAL REGISTRATION

The study was approved by the Ethics Committee of the University of Cologne (#20-1436), registered at the German Register for Clinical Studies (DRKS00022771) and in accordance with the Declaration of Helsinki.

Euthanasia and assisted suicide in neurological diseases: a systematic review

OBJECTIVE

To identify the neurological diseases for which euthanasia and assisted suicide are most frequently requested in the countries where these medical procedures are legal and the specific characteristics of euthanasia in some of these diseases, and to show the evolution of euthanasia figures.

METHODS

We conducted a systematic literature review.

RESULTS

Dementia, motor neuron disease, multiple sclerosis, and Parkinson's disease are the neurological diseases that most frequently motivate requests for euthanasia or assisted suicide. Requests related to dementia constitute the largest group, are growing, and raise additional ethical and legal issues due to these patients' diminished decision-making capacity. In some countries, the ratios of euthanasia requests to all cases of multiple sclerosis, motor neuron disease, or Huntington disease are higher than for any other disease.

CONCLUSIONS

After cancer, neurological diseases are the most frequent reason for requesting euthanasia or assisted suicide.

Depressive symptoms, anxiety and cognitive impairment: emerging evidence in multiple sclerosis

Neuropsychiatric abnormalities may be broadly divided in two categories: disorders of mood, affect, and behavior and abnormalities affecting cognition. Among these conditions, clinical depression, anxiety and neurocognitive disorders are the most common in multiple sclerosis (MS), with a substantial impact on patients' quality of life and adherence to treatments. Such manifestations may occur from the earliest phases of the disease but become more frequent in MS patients with a progressive disease course and more severe clinical disability. Although the pathogenesis of these neuropsychiatric manifestations has not been fully defined yet, brain structural and functional abnormalities, consistently observed with magnetic resonance imaging (MRI), together with genetic and immunologic factors, have been suggested to be key players. Even though the detrimental clinical impact of such manifestations in MS patients is a matter of crucial importance, at present, they are often overlooked in the clinical setting. Moreover, the efficacy of pharmacologic and non-pharmacologic approaches for their amelioration has been poorly investigated, with the majority of studies showing marginal or no beneficial effect of different therapeutic approaches, possibly due to the presence of multiple and heterogeneous underlying pathological mechanisms and intrinsic methodological limitations. A better evaluation of these manifestations in the clinical setting and improvements in the understanding of their pathophysiology may offer the potential to develop tools for differentiating these mechanisms in individual patients and ultimately provide a principled basis for treatment selection. This review provides an updated overview regarding the pathophysiology of the most common neuropsychiatric symptoms in MS, the clinical and MRI characteristics that have been associated with mood disorders (i.e., depression and anxiety) and cognitive impairment, and the treatment approaches currently available or under investigation.

Is trained communication about desire to die harmful for patients receiving palliative care? A cohort study

BACKGROUND

Palliative patients frequently express a desire to die. Health professionals report uncertainty regarding potential risks of addressing it.

AIM

We aim to evaluate effects of desire to die-conversations on palliative patients.

DESIGN

Within a prospective mixed-methods cohort study, we trained health professionals in dealing with desire to die. Afterwards, they held conversations about it with patients. Effects on depressiveness, hopelessness, wish to hasten death, death anxiety, patient-health professional-relationship, and will to live were evaluated at baseline (t0), 1 (t1), and 6 weeks afterwards (t2). Results were analyzed descriptively.

SETTING/PARTICIPANTS

From April 2018 to March 2020, 43 health professionals asked 173 patients from all stationary and ambulatory palliative care settings (within 80 km radius) for participation. Complete assessments were obtained from n = 85 (t0), n = 64 (t1), and n = 46 (t2).

RESULTS

At t1, patients scored significantly lower on depressiveness (med = 8, M = 8.1, SD = 5.4) than at t0 (med = 9.5, M = 10.5, SD = 5.8) with Z = -3.220, p = 0.001 and Cohen's d = 0.42. This was due to medium-severely depressed patients: At t1, their depressiveness scores decreased significantly (med = 9, M = 9.8; SD = 5.1) compared to t0 (med = 14, M = 15.2; SD = 3.9) with Z = -3.730, p ⩽ 0.000 and Cohen's d = 1.2, but others' did not. All other outcomes showed positive descriptive trends.

CONCLUSIONS

Desire to die-conversations through trained health professionals do not harm palliative patients. Results cautiously suggest temporary improvement.

Euthanasia and assisted suicide in neurological diseases: a systematic review

OBJECTIVE

To identify the neurological diseases for which euthanasia and assisted suicide are most frequently requested in the countries where these medical procedures are legal and the specific characteristics of euthanasia in some of these diseases, and to show the evolution of euthanasia figures.

METHODS

We conducted a systematic literature review.

RESULTS

Dementia, motor neuron disease, multiple sclerosis, and Parkinson's disease are the neurological diseases that most frequently motivate requests for euthanasia or assisted suicide. Claims related to dementia constitute the largest group, are growing, and raise additional ethical and legal issues due to these patients' diminished decision-making capacity. In some countries, the ratios of euthanasia requests to all cases of multiple sclerosis, motor neuron disease, or Huntington disease are higher than for any other disease.

CONCLUSIONS

After cancer, neurological diseases are the most frequent reason for requesting euthanasia or assisted suicide.

EAN Guideline on Palliative Care of People with Severe, Progressive Multiple Sclerosis

Background and Purpose: Patients with severe, progressive multiple sclerosis (MS) have complex physical and psychosocial needs, typically over several years. Few treatment options are available to prevent or delay further clinical worsening in this population. The objective was to develop an evidence-based clinical practice guideline for the palliative care of patients with severe, progressive MS. Methods: This guideline was developed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Formulation of the clinical questions was performed in the Patients-Intervention-Comparator-Outcome format, involving patients, carers and healthcare professionals (HPs). No uniform definition of severe MS exists: in this guideline, constant bilateral support required to walk 20 m without resting (Expanded Disability Status Scale score >6.0) or higher disability is referred to. When evidence was lacking for this population, recommendations were formulated using indirect evidence or good practice statements were devised. Results: Ten clinical questions were formulated. They encompassed general and specialist palliative care, advance care planning, discussing with HPs the patient's wish to hasten death, symptom management, multidisciplinary rehabilitation, interventions for caregivers and interventions for HPs. A total of 34 recommendations (33 weak, 1 strong) and seven good practice statements were devised. Conclusions: The provision of home-based palliative care (either general or specialist) is recommended with weak strength for patients with severe, progressive MS. Further research on the integration of palliative care and MS care is needed. Areas that currently lack evidence of efficacy in this population include advance care planning, the management of symptoms such as fatigue and mood problems, and interventions for caregivers and HPs.

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.

EAN guideline on palliative care of people with severe, progressive multiple sclerosis

BACKGROUND AND PURPOSE

Patients with severe, progressive multiple sclerosis (MS) have complex physical and psychosocial needs, typically over several years. Few treatment options are available to prevent or delay further clinical worsening in this population. The objective was to develop an evidence-based clinical practice guideline for the palliative care of patients with severe, progressive MS.

METHODS

This guideline was developed using the Grading of Recommendations Assessment, Development and Evaluation methodology. Formulation of the clinical questions was performed in the Patients-Intervention-Comparator-Outcome format, involving patients, carers and healthcare professionals (HPs). No uniform definition of severe MS exists: in this guideline, constant bilateral support required to walk 20 m without resting (Expanded Disability Status Scale score > 6.0) or higher disability is referred to. When evidence was lacking for this population, recommendations were formulated using indirect evidence or good practice statements were devised.

RESULTS

Ten clinical questions were formulated. They encompassed general and specialist palliative care, advance care planning, discussing with HPs the patient's wish to hasten death, symptom management, multidisciplinary rehabilitation, interventions for caregivers and interventions for HPs. A total of 34 recommendations (33 weak, 1 strong) and seven good practice statements were devised.

CONCLUSIONS

The provision of home-based palliative care (either general or specialist) is recommended with weak strength for patients with severe, progressive MS. Further research on the integration of palliative care and MS care is needed. Areas that currently lack evidence of efficacy in this population include advance care planning, the management of symptoms such as fatigue and mood problems, and interventions for caregivers and HPs.

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.

Follow-Ups with callers of a palliative and hospice care hotline for severely affected multiple sclerosis patients: Evaluation of its impact

BACKGROUND

Palliative and Hospice Care (PHC) focuses on improving quality of life for anyone who has a serious illness. Multiple Sclerosis (MS) patients have significant PHC needs, yet PHC still mostly attends to cancer patients. The implemented and evaluated nationwide PHC-MS hotline (Strupp et al., 2017) appeared to provide a useful service to patients.

OBJECTIVES

Prospective follow-up study to evaluate the impact of the hotline and analyse challenges and possible barriers to integrating PHC services.

METHODS

Information on implementing PHC services was gathered through follow-up hotline consultations utilising a standardised documentary sheet. Data was analysed descriptively and several individual cases are presented.

RESULTS

Of 303 calls to the hotline (54.5% female, mean age 51 years, 87.7% chronic progressive MS, mean duration of illness 17 years, median EDSS 8), for 84 (27.7%) PHC services were indicated. Of these 84 patients, 32 agreed to follow-up calls which were conducted at least once. For 6 (19%) patients, PHC service integration was successful. For 5 (16%) PHC was refused. For 5 (16%) PHC did not fit current patient needs, and for 7 (22%) PHC has not yet been contacted by patients (or caregivers). For a further 9 (28%) follow-ups revealed that no more consultation was possible (e.g., caller lost to follow-up).

CONCLUSION

The PHC approach and its services as well as legislation are still highly focused on cancer care, although patients with long-term neurological conditions would likely benefit greatly from them.

Prediction of Suicidal Ideation among Korean Adults Using Machine Learning: A Cross-Sectional Study

OBJECTIVE

Suicidal ideation (SI) precedes actual suicidal event. Thus, it is important for the prevention of suicide to screen the individuals with SI. This study aimed to identify the factors associated with SI and to build prediction models in Korean adults using machine learning methods.

METHODS

The 2010-2013 dataset of the Korea National Health and Nutritional Examination Survey was used as the training dataset (n=16,437), and the subset collected in 2015 was used as the testing dataset (n=3,788). Various machine learning algorithms were applied and compared to the conventional logistic regression (LR)-based model.

RESULTS

Common risk factors for SI included stress awareness, experience of continuous depressive mood, EQ-5D score, depressive disorder, household income, educational status, alcohol abuse, and unmet medical service needs. The prediction performances of the machine learning models, as measured by the area under receiver-operating curve, ranged from 0.794 to 0.877, some of which were better than that of the conventional LR model (0.867). The Bayesian network, LogitBoost with LR, and ANN models outperformed the conventional LR model.

CONCLUSION

A machine learning-based approach could provide better SI prediction performance compared to a conventional LR-based model. These may help primary care physicians to identify patients at risk of SI and will facilitate the early prevention of suicide.

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.

Suicidal Ideation and Psychological Strain Among Patients Diagnosed With Stomach Cancer: The Mediation of Psychopathological Factors

Patients with stomach cancer are at high risk to experience suicidal ideation. Strain theory of suicide assumes that suicide is preceded by psychological strain. Despite wide international acceptance of the theory, its use with a sample of patients with stomach cancer has not previously been reported. The aims were to examine the relationship between psychological strain and suicidal ideation among patients with stomach cancer and to determine whether psychopathological factors act as mediators. A cross-sectional study was undertaken involving subjects with no history of mental disorder, and questionnaires were administered by face-to-face interview. Patients who experienced more psychological strain, especially coping strain, are more likely to experience suicidal ideation. The mediation effects of hopelessness and psychological distress are significant. Psychological strain, hopelessness, and psychological distress may be the vital factors among patients with stomach cancer in the suicide-risk assessment interview and for care planning and psychological intervention.

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.