Recognizing and treating common psychiatric disorders in multiple sclerosis

Depression Comorbid With Stroke, Traumatic Brain Injury, Parkinson's Disease, and Multiple Sclerosis: Diagnosis and Treatment

Depression is common among patients with neurologic disorders, and it has long been considered more difficult to treat than depression in the general population. In this review, the authors consider challenges in the diagnosis and treatment of depression among patients with stroke, traumatic brain injury, Parkinson's disease, and multiple sclerosis. For each disorder, the authors discuss the epidemiology and time course of depression as well as review the physiologic and psychological etiologies of depression. In addition, for each disorder, they review screening tools and diagnostic considerations, including differential diagnosis; discuss etiological factors, both neurobiological and psychological; and assess evidence for various depression treatments, including pharmacologic, psychosocial, and neuromodulatory therapies. The evidence suggests that depression is common among patients with neurologic disorders and that it is crucial for general psychiatrists to provide treatment for this population.

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.

Behavioral Treatment of Pseudobulbar Affect: A Case Report

PURPOSE

To determine if it is possible to successfully treat pseudobulbar affect (PBA) using a behavioral approach.

DESIGN AND METHODS

Two experiments were conducted, each a double reversal design with the same single subject in both. The first experiment tested the hypothesis that the rate of PBA could be controlled by manipulation of its consequences. The second experiment tested the hypothesis that use of a self-control procedure would control the rate of PBA.

FINDINGS

Rate of PBA could not be controlled by consequence manipulation, but rate of PBA could be controlled through use of a self-control procedure.

PRACTICE IMPLICATIONS

Pending confirmatory research, behavioral interventions utilizing self-control procedures should be considered in patients with PBA.

Exploring the role of microglia in mood disorders associated with experimental multiple sclerosis

Microglia is increasingly recognized to play a crucial role in the pathogenesis of psychiatric diseases. In particular, microglia may be the cellular link between inflammation and behavioral alterations: by releasing a number of soluble factors, among which pro-inflammatory cytokines, that can regulate synaptic activity, thereby leading to perturbation of behavior. In multiple sclerosis (MS), the most common neuroinflammatory disorder affecting young adults, microglia activation and dysfunction may account for mood symptoms, like depression and anxiety, that are often diagnosed in patients even in the absence of motor disability. Behavioral studies in experimental autoimmune encephalomyelitis (EAE), the animal model of MS, have shown that emotional changes occur early in the disease and in correlation to inflammatory mediator and neurotransmitter level alterations. However, such studies lack a full and comprehensive analysis of the role played by microglia in EAE-behavioral syndrome. We review the experimental studies addressing behavioral symptoms in EAE, and propose the study of neuron-glia interaction as a powerful but still poorly explored tool to investigate the burden of microglia in mood alterations associated to MS.

Psychiatric co-morbidity in multiple sclerosis: The risk of depression and anxiety before and after MS diagnosis

BACKGROUND

Studies of depression and anxiety in multiple sclerosis (MS) patients have reported higher rates in MS patients than the general population.

OBJECTIVE

To estimate the risk of depression and anxiety and the use of tricyclic antidepressant and selective serotonin reuptake inhibitors (SSRI) prescriptions, in the pre-diagnostic and the post-diagnostic period of MS compared to the background population.

METHODS

A cohort of 5084 MS patients was included and matched with a control population of 24,771 persons linked to nationwide registers. Logistic regression analyses were performed estimating odds ratios (OR).

RESULTS

In the pre-diagnostic period, the OR for having a diagnosis of depression and anxiety is 1.4 (95% confidence interval (CI) =1.05-1.88), and the OR of redemption prescriptions of TCAs is 1.90 (CI=1.54-2.34) and OR is 1.34 (CI= 1.20-1.51) for SSRI. In the post-diagnostic period the OR is 1.23 (CI= 0.92-1.64) for depression and anxiety diagnosis. The OR is 6.70 (CI=5.81-7.72) for TCA and OR is 2.46 (CI= 2.25-2.69) for SSRI.

CONCLUSION

During both the pre- diagnostic and post-diagnostic period, MS patient have increased risk of depression and anxiety diagnoses and redemption of antidepressant and anxiolytic prescriptions, compared to the background population.

Bipolar disorder and multiple sclerosis: a case series

Background. The prevalence of psychiatric disturbance for patients with multiple sclerosis (MS) is higher than that observed in other chronic health conditions. We report three cases of MS and bipolar disorder and we discuss the possible etiological hypothesis and treatment options. Observations. All patients fulfilled the McDonald criteria for MS. Two patients were followed up in psychiatry for manic or depressive symptoms before developing MS. A third patient was diagnosed with MS and developed deferred psychotic symptoms. Some clinical and radiological features are highlighted in our patients: one manic episode induced by high dose corticosteroids and one case of a new orbitofrontal MRI lesion concomitant with the emergence of psychiatric symptoms. All patients needed antipsychotic treatment with almost good tolerance for high dose corticosteroids and interferon beta treatment. Conclusions. MRI lesions suggest the possible implication of local MS-related brain damage in development of pure “psychiatric fits” in MS. Genetic susceptibility is another hypothesis for this association. We have noticed that interferon beta treatments were well tolerated while high dose corticosteroids may induce manic fits.

Relationship between disease-modifying therapy and depression in multiple sclerosis

Many prescribers of disease-modifying therapies (DMTs) for multiple sclerosis (MS) believe that interferon beta (IFNβ) is more likely than glatiramer acetate (GA) to increase depression during the course of MS treatment. Therefore, newly diagnosed patients with a history of depression are often placed on GA therapy from the onset of MS treatment. The aim of this study was to examine the relationship between DMT type and depression among patients with relapsing-remitting MS (RRMS). Patients with RRMS who were examined from 2000 to 2007 and who remained on a single course of therapy (either an IFNβ or GA) were included in a retrospective review of medical records. Patients were asked to complete the Beck Depression Inventory (BDI) at treatment initiation and every 6 months thereafter for up to 4 years. Only patients who had completed a BDI within 6 weeks of starting their DMT were included in the analysis. No significant differences in mean change in BDI score were observed from baseline to 48 months between the IFNβ and GA subgroups. Additionally, no significant differences in mean BDI score change were observed between antidepressant-treated and non-antidepressant-treated patients within the IFNβ or GA subgroup. Neither IFNβ nor GA therapy appears to exacerbate depressive symptoms in patients with RRMS who remain on their initial therapy.

Symptomatic treatment and management of multiple sclerosis

The range of symptoms which occur in multiple sclerosis (MS) can have disabling functional consequences for patients and lead to significant reductions in their quality of life. MS symptoms can also interact with each other, making their management challenging. Clinical trials aimed at identifying symptomatic therapies have generally been poorly designed and have tended to be underpowered. Therefore, the evidence base for the management of MS symptoms with pharmacologic therapies is not strong and tends to rely upon open-label studies, case reports, and clinical trials with small numbers of patients and poorly validated clinical outcome measures. Recently, there has been a growing interest in the management of MS symptoms with pharmacologic treatments, and better-designed, randomized, double-blind, controlled trials have been reported. This chapter will describe the evidence base predominantly behind the various pharmacologic approaches to the management of MS symptoms, which in most, if not all, cases, requires multidisciplinary input. Drugs routinely recommended for individual symptoms and new therapies, which are currently in the development pipeline, will be reviewed. More interventional therapies related to symptoms that are refractory to pharmacotherapy will also be discussed, where relevant.

The epidemiology and pathophysiology of pseudobulbar affect and its association with neurodegeneration

Pseudobulbar affect is a disorder resulting from neurologic damage manifesting as sudden, stereotyped affective outbursts that are not reflective of internal emotion. A literature review was completed to examine the current understanding of the epidemiology, characterization, diagnosis, pathophysiology, and treatment of pseudobulbar affect. This review revealed that it is common in neurodegenerative disorders but is poorly recognized, placing significant impacts on patients and their families. The disorder appears to result from a disruption of the cortico-limbic-subcortical-thalamic-pontocerebellar network involved in emotional expression and regulation with resulting disruptions of neurotransmitter systems. Effective treatment is available with agents such as selective serotonin reuptake inhibitors and dextromethorphan combined with quinidine, but further well-designed comparative studies are needed. Advances in technology such as neuroimaging may enhance knowledge about the pathophysiology of this disorder, and help guide future interventions.

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.

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.

Structural brain MR imaging changes associated with obsessive-compulsive disorder in patients with multiple sclerosis

BACKGROUND AND PURPOSE

Psychiatric symptoms occur in approximately 30% of patients with MS. Such symptoms include OCD, which may interfere heavily with the patient's daily life. We hypothesized that the widespread involvement of both GM and WM, which characterizes MS, may be responsible for the occurrence of OCD when specific brain structures are affected. The aim of this study was to evaluate the relationship between GM and WM tissue damage and OCD in patients with MS.

MATERIALS AND METHODS

We evaluated 16 patients with relapsing-remitting MS who had been diagnosed with OCD on the basis of the Diagnostic and Statistical Manual of Mental Disorders (4th edition) and 15 age- and sex-matched patients with relapsing-remitting MS with no psychiatric disorders as a CG. The MR study (1.5T) included 3D T1-weighted fast-field echo sequences, DTI (32 directions), and conventional MRI. Images were processed using SPM5, FSL, and Jim 5.0 software to evaluate VBM, TBSS, and global and regional LV, respectively.

RESULTS

The VBM analysis revealed a set of clusters of reduced GM volume in the OCD group, compared with the CG, located in the right inferior and middle temporal gyri and in the inferior frontal gyrus. TBSS did not detect any differences in the FA values between the 2 groups; global and regional LV values also did not differ significantly between the 2 groups.

CONCLUSIONS

Our study suggests that OCD in MS may be caused by damage in the right frontotemporal cortex.

Diagnosis and treatment of major depressive disorder

Major depressive disorder is a common illness, particularly in patients with medical and neurologic conditions. This article summarizes current data on the epidemiology, diagnosis, and treatment of major depression, with special emphasis on the diagnosis and treatment of depression in medical and neurologic patients. We reviewed the role of pharmacotherapies, psychotherapies, somatic treatments, and alternative remedies and we included practical advice for clinician regarding the timing and sequence of these treatments, the role of standardized depression scales, and the criteria for referrals to specialty consultants.