Association between stressful life events and exacerbation in multiple sclerosis: a meta-analysis

Online mindfulness program (COndiVIDere) for people with multiple sclerosis in the time of COVID-19: a pilot longitudinal study

PURPOSE

This study aims to evaluate the feasibility and effectiveness of a mindfulness-based group intervention (The COndiVIDere program) delivered online to people with MS (PwMS) in the time of COVID-19.

MATERIALS AND METHODS

This is a single-arm longitudinal study with a nested qualitative study. The COndiVIDere program is composed of five weekly sessions (1-h each) plus three booster monthly sessions. Data were collected immediately before the beginning of the program, after the five weekly sessions, and at 3- and 6-month follow-ups.

RESULTS

Fifty PwMS participated in the program. Participants improved in anxiety, stress, loneliness and mindfulness ("non-judgmental inner experience" component). Improvements on most outcomes occurred at post-intervention and reached the statistically significant threshold at 3-month follow-up. Mindfulness improvements keep increasing at each time point. Qualitative data confirmed the COndiVIDere program feasibility and the positive psychological impacts on participants. Mindfulness, compassion and the group setting were considered the most important active elements.

CONCLUSIONS

Study findings support COndiVIDere feasibility and effectiveness with PwMS and its broad applicability in this population.

Early Adversity and Socioeconomic Factors in Pediatric Multiple Sclerosis: A Case-Control Study

BACKGROUND AND OBJECTIVES

Psychosocial adversity and stress, known to predispose adults to neurodegenerative and inflammatory immune disorders, are widespread among children who experience socioeconomic disadvantage, and the associated neurotoxicity and proinflammatory profile may predispose these children to multiple sclerosis (MS). We sought to determine associations of socioeconomic disadvantage and psychosocial adversity with odds of pediatric-onset MS (POMS), age at POMS onset, and POMS disease activity.

METHODS

This case-control study used data collected across 17 sites in the United States by the Environmental and Genetic Risk Factors for Pediatric Multiple Sclerosis Study. Cases (n = 381) were youth aged 3-21 years diagnosed with POMS or a clinically isolated demyelinating syndrome indicating high risk of MS. Frequency-matched controls (n = 611) aged 3-21 years were recruited from the same institutions. Prenatal and postnatal adversity and postnatal socioeconomic factors were assessed using retrospective questionnaires and zip code data. The primary outcome was MS diagnosis. Secondary outcomes were age at onset, relapse rate, and Expanded Disability Status Scale (EDSS). Predictors were maternal education, maternal prenatal stress events, child separation from caregivers during infancy and childhood, parental death during childhood, and childhood neighborhood disadvantage.

RESULTS

MS cases (64% female, mean age 15.4 years, SD 2.8) were demographically similar to controls (60% female, mean age 14.9 years, SD 3.9). Cases were less likely to have a mother with a bachelor's degree or higher (OR 0.42, 95% CI 0.22-0.80, p = 0.009) and were more likely to experience childhood neighborhood disadvantage (OR 1.04 for each additional point on the neighborhood socioeconomic disadvantage score, 95% CI 1.00-1.07; p = 0.025). There were no associations of the socioeconomic variables with age at onset, relapse rate, or EDSS, or of prenatal or postnatal adverse events with risk of POMS, age at onset, relapse rate, or EDSS.

DISCUSSION

Low socioeconomic status at the neighborhood level may increase the risk of POMS while high parental education may be protective against POMS. Although we did not find associations of other evaluated prenatal or postnatal adversities with POMS, future research should explore such associations further by assessing a broader range of stressful childhood experiences.

Stress and Multiple Sclerosis - Systematic review and meta-analysis of the association with disease onset, relapse risk and disability progression

OBJECTIVE

This systematic review and meta-analysis address the evidence on the association of psychological stressors with onset of multiple sclerosis, inflammatory disease activity (relapses or new disease activity on magnetic resonance imaging, MRI) and disability progression.

METHODS

PubMed was searched from 1946 to 15 July 2022. Studies and certain stressors were selected when they assessed stressors independent from stress elicited by the disease process itself. Risk of bias was assessed by the CASP Case Control Study Checklist and the CASP Cohort Study Checklist. Normal-Normal Hierarchical Model (NNHM) for random-effects meta-analysis was used in the Bayesian framework.

RESULTS

30 studies reporting data from 26 cohorts reporting on 24.781 cases could be identified. Ten studies addressed stressors and MS disease onset showing a weak to modest effect of psychological stressors. A meta-analysis of three studies investigating diagnosed stress disorders and MS risk showed a 1.87-fold (CI 1.061 to 3.429) increased MS risk. Stress and MS relapse risk were addressed in 19 heterogeneous studies. Meta-analyses from two independent cohorts investigating the same military threat of a population showed a threefold increased risk for relapses in association with war (relapse rate: 3.0, CI 1.56 to 5.81). In addition, two studies confirmed an association of stressful life events and MRI activity. Three studies of stressors and disease progression were included indicating some effect on disease progression.

CONCLUSIONS

Taken together studies indicate a minor to modest impact of psychological stressors on disease onset, inflammatory activity and progression of MS. Possible case-selection bias and lack of confounder analysis were present in many studies.

The association between multiple sclerosis and early psychiatric background

BACKGROUND

The exact cause of Multiple Sclerosis (MS) is unclear. Since its definition in the late 19th century, researchers have repeatedly suggested a connection between the disease and mental state. Studies have shown that mental symptoms tend to precede the initiation of the disease by up to ten years. However, the hypothesis that psychiatric issues might precede MS onset by longer periods has not been empirically established. This study seeks to fill this research gap. The current matched cohort study investigated the possibility that psychiatric conditions may precede the initiation of multiple sclerosis by 15 years or more METHODS: A retrospective analysis utilizing the electronic database of Clalit Health Services (CHS), Israel's largest HMO, compared a group of 9,533 MS-diagnosed female and male individuals with 28,599 non-MS matched controls RESULTS: Logistic regression analysis revealed a significant association (p < 0.001) between MS diagnosis and prior psychiatric conditions, indicating a 93% increased likelihood of psychiatric history among those later diagnosed with MS compared with those who were not CONCLUSIONS: The heightened probability of mental health issues preceding the onset of MS by extended durations suggests a potential etiological role in the development of MS, rather than solely representing a component of the prodromal stage of the disease. Limitations include the retrospective design and the need for prospective studies to validate these associations.

A single-arm, open-label pilot study of neuroimaging, behavioral, and peripheral inflammatory correlates of mindfulness-based stress reduction in multiple sclerosis

Multiple sclerosis (MS) is a chronic neurological disease frequently associated with significant fatigue, anxiety, depression, and stress. These symptoms are difficult to treat, and prominently contribute to the decreases in quality of life observed with MS. The underlying mechanisms of these "silent" symptoms are not well understood and include not just the psychological responses to a chronic disease, but also biological contributions from bidirectional psycho-neuro-immune (dys)regulation of systemic inflammatory biology. To address these issues, we conducted a prospective, observational pilot study to investigate the psychological, biological, and neuroarchitecture changes associated with a mindfulness-based stress reduction (MBSR) program in MS. The overarching hypothesis was that MBSR modulates systemic and central nervous system inflammation via top-down neurocognitive control over forebrain limbic areas responsible for the neurobiological stress response. 23 patients were enrolled in MBSR and assessed pre/post-program with structural 3 T MRI, behavioral measures, hair cortisol, and blood measures of peripheral inflammation, as indexed by the Conserved Transcriptional Response to Adversity (CTRA) profile. MBSR was associated with improvements across a variety of behavioral outcomes, as well as on-study enlargement of the head of the right hippocampus. The CTRA analyses revealed that greater inflammatory gene expression was related to worse patient-reported anxiety, depression, stress, and loneliness, in addition to lower eudaimonic well-being. Hair cortisol did not significantly change from pre- to post-MBSR. These results support the use of MBSR in MS and elucidate inflammatory mechanisms related to key patient-reported outcomes in this population.

A Self-Reported Study on Explanatory Variables of Stress in Multiple Sclerosis Patients: Exploring the Effect of Physical Conditions and Emotion Regulation Processes

BACKGROUND

Multiple sclerosis (MS)-linked stress is frequent, multidetermined and facilitates the onset/exacerbation of MS. However, few explanatory models of stress analysed the joint explanatory effect of emotion regulation and clinical outcomes of MS in those patients.

OBJECTIVE

This study explored whether self-reported MS-related conditions (number of relapses, fatigue and global disability) and specific emotion regulation processes (experiential avoidance and self-compassion) explain stress symptoms in MS patients.

METHODS

The MS sample comprised 101 patients with MS diagnosis receiving treatment in hospitals and recruited through the Portuguese MS Society. The no-MS sample included 134 age-, sex- and years of education-matched adults without MS recruited from the general Portuguese population. Both samples did not report other neurological disorders. Data were collected using self-response measures.

RESULTS

All potential explanatory variables differed significantly between samples, with higher scores found in MS patients. In MS clinical sample, those variables and years of education correlated with stress symptoms and predicted stress symptoms in simple linear regression models. These results allowed their selection as covariates in a multiple linear regression model. Years of education, the number of relapses, fatigue and experiential avoidance significantly predicted 51% of stress symptoms' total variance.

CONCLUSIONS

This study provides preliminary evidence on the importance of clinicians and researchers considering the simultaneous contribution of years of education, the number of perceived relapses, fatigue and experiential avoidance as factors that can increase vulnerability to stress in MS patients. Psychological intervention programmes that tackle these factors and associated stress symptomatology should be implemented.

The Impact of COVID-19 on the Employment of People With Multiple Sclerosis: A Multiple Methods Study

BACKGROUND

The COVID-19 pandemic led to approximately half of the working population in the United Kingdom being unable to work temporarily. This study aims to understand the employment needs and experiences of people with multiple sclerosis (MS) in the UK during this period.

METHODS

Multiple methods were used, including an online survey and follow-up interviews with people with MS who were employed prior to the start of the pandemic restrictions in March 2020.

RESULTS

The online survey was completed by 101 eligible participants and we interviewed 15 of them for qualitative data in the follow-up. Survey data indicated that the work experience of people with MS improved during the pandemic because they were allowed to work from home. However, participants experienced increased feelings of anxiety and loneliness. From the interviews, we extracted 5 themes: (1) the benefits of working from home; (2) the challenges of working during the COVID-19 pandemic; (3) the relevance of managers; (4) returning to "normal"; and (5) the need for vocational support.

CONCLUSIONS

The pandemic showed that MS symptom management was improved by work flexibility (eg, working from home, breaks, flexible working hours); for people with MS, these accommodations improved both their ability to work and their self-perceived productivity. Future research should explore the support needs of people with MS who work remotely and determine whether pandemic-influenced work accommodations are sustainable over time.

Stressful life events and depression and fatigue in people with multiple sclerosis: a cross-sectional analysis of an international cohort

BACKGROUND

Relationships between stressful life events (SLEs) and health outcomes in people living with multiple sclerosis (plwMS), beyond relapse, are not well-established. We examined associations between SLEs and fatigue and symptoms of depression in plwMS.

METHODS

948 participants were queried whether they had experienced any of the 16 SLEs (Holmes-Rahe Social Readjustment Rating Scale) in the preceding 12 months. SLEs were summated to estimate SLE number and SLE load (weighted for the degree of associated stress). Cross-sectional associations between SLE (number, load and individual) and fatigue, and depressive symptoms were examined using log-binomial or log-multinomial regression adjusted for age, sex, relapse symptoms, education, MS type at baseline, disability, fatigue, comorbidity, depression, and antidepressant/antifatigue medications, as appropriate. Sub-analyses restricted to SLEs with a negative emotional impact were performed.

RESULTS

Median SLE number and load were 2 (IQR 1-2) and 57 (IQR 28-97), respectively. SLE number and load were not associated with a higher prevalence of fatigue, or depressive symptoms, even when restricting analyses to SLEs with a perceived negative emotional impact. A new relationship or family member with a negative impact was associated with a threefold and 2.5-fold higher prevalence of depressive symptoms, respectively. Serious illness was associated with a 28% higher prevalence of depressive symptoms.

CONCLUSION

Psychological support for SLEs, and/or intervention targeted to SLE appraisal, may be beneficial in mitigating the adverse effects of SLEs with a perceived negative emotional impact on depressive symptoms in plwMS. Potential associations between serious illness and increased prevalence of depressive symptoms may warrant further investigation.

Heart Rate Variability (HRV) serves as an objective correlate of distress and symptom burden in multiple sclerosis

Background

Autonomic nervous system (ANS) dysfunction is frequently seen in people living with multiple sclerosis (MS). Heart rate variability (HRV) is an easy and objective index for evaluating ANS functioning, and it has been previously used to explore the association between ANS and the experience of symptom burden in other chronic diseases. Given ANS functioning can be influenced by physical and psychological factors, this study investigated whether emotional distress and/or the presence of ANS dysfunction is associated with symptom severity in people living with MS.

Methods

Participants with MS and healthy controls (HC) with no history of cardiac conditions were recruited to self-collect HR data sampled from a chest strap HR monitor (PolarH10). Short-term HR signal was collected for five minutes, and time and frequency HRV analyses were performed and compared between groups. HRV values were then compared to self-reported distress (Kessler Psychological Distress Scale) and MS participants' self-reported measures of symptom burden (SymptoMScreen).

Results

A total of n = 23 adults with MS (51 ± 12 years, 65 % female, median Patient Determined Disease Steps [PDDS]: 3.0) and n = 23 HCs (43 ± 18 years, 40 % female) completed the study procedures. All participants were able to complete the chest strap placement and HR data capture independently. Participants with MS, compared to the HC participants, had a significantly lower parasympathetic activation as shown by lower values of the root mean square of successive differences between normal heartbeats (RMSSD: 21.86 ± 9.84 vs. 43.13 ± 20.98 ms, p = 0.002) and of high-frequency (HF) power band (HF-HRV: 32.69 ± 12.01 vs. 42.39 ± 7.96 nu, p = 0.016), indicating an overall lower HRV in the MS group. Among individuals with MS, HF-HRV was significantly correlated with the severity of self-reported MS symptoms (r = -0.548, p = 0.010). Participants with MS also reported higher levels of distress compared to HC participants (18.32 ± 6.05 vs. 15.00 ± 4.61, p = 0.050), and HRV correlated with the severity of distress in MS participants (r = -0.569, p = 0.007). A significant mediation effect was also observed, with emotional distress fully mediating the association between HRV and symptom burden.

Conclusions

These findings suggest the potential for ANS dysfunction, as measured by HRV (i.e., lower value of HF power), to be utilized as an objective marker of symptom burden in people living with MS. Moreover, it is apparent that the relationship between HRV and symptom burden is mediated by emotional distress.

Psychological symptoms in Multiple Sclerosis and the role of marital status: results from a retrospective single-center study

BACKGROUND

Married people have, on average, better mental health than no married people. Psychological symptoms as anxiety and depression occur frequently in patients with multiple sclerosis (MS), increasing the severity of neurologic disability. The aim of this retrospective study was to investigate the relationship between functional disability and psychological symptoms differentiating by marital status.

METHODS

In this study 150 MS outpatients without a history of psychological disorders were selected from the hospital database. The outpatient procedure for all patients includes the administration of the Expanded Disability Status Scale and the questionnaire Symptoms Checklist-90-Revised (SCL-90-R) a multidimensional self-report inventory, consisting of 90 items covering nine clinical dimensions: somatization (SOM), obsessive-compulsive (OC), interpersonal sensitivity (IS), depression (DEP), anxiety (ANX), hostility (HOS), phobic anxiety (PHOB), paranoid ideation (PAR), psychoticism (PSY), and three global indices of distress: global severity index (GSI), positive symptoms total (PST) and positive symptom distress index (PSDI). According to marital status, subjects were subdivided in single, married (including cohabitants), and divorced (including separated). A nonparametric group comparisons analysis was performed, as well as multivariate analysis which included generalized linear regression models.

RESULTS

Regression results showed that functional disability was a significant predictor for all SCL- 90-R subscales. Moreover, it would seem that the single condition might be a protective factor for the development of psychological symptoms in SM patients. Notably, findings showed that younger subjects were predominantly single and had less psychological symptoms, whereas patients with greater psychological alterations were older in a stable affective couple relationship, presenting an elevation in depression, anxiety, somatization and compulsive, and obsessive scales.

CONCLUSION

Numerous factors contribute to the onset of psychological disorders in multiple sclerosis. Marriage does not represent a protective factor for the development of psychological symptoms in SM patients. Future investigation is needed to ascertain the prevalence and underlying causes of psychological symptoms.

Heterogeneous complement and microglia activation mediates stress-induced synapse loss

Spatially heterogeneous synapse loss is a characteristic of many psychiatric and neurological disorders, but the underlying mechanisms are unclear. Here, we show that spatially-restricted complement activation mediates stress-induced heterogeneous microglia activation and synapse loss localized to the upper layers of the mouse medial prefrontal cortex (mPFC). Single cell RNA sequencing also reveals a stress-associated microglia state marked by high expression of the apolipoprotein E gene (ApoE high ) localized to the upper layers of the mPFC. Mice lacking complement component C3 are protected from stress-induced layer-specific synapse loss, and the ApoE high microglia population is markedly reduced in the mPFC of these mice. Furthermore, C3 knockout mice are also resilient to stress-induced anhedonia and working memory behavioral deficits. Our findings suggest that region-specific complement and microglia activation can contribute to the disease-specific spatially restricted patterns of synapse loss and clinical symptoms found in many brain diseases.

The bidirectional effect of stress and functionality in multiple sclerosis and the interaction role of anxiety, coping and social support

OBJECTIVE

The present study aims to analyse the bidirectional hypothesis between stress and multiple sclerosis with several measures of stress, impairment and functionality, considering also the interaction role of stress-related psychosocial factors such as anxiety, coping and social support.

METHODS

A one-year follow-up was conducted with 26 people with multiple sclerosis. Participants reported i) at baseline, anxiety (State-Trait Anxiety Inventory), and social support (Multidimensional Scale of Perceived Social Support); ii) daily, Ecological Momentary Assessment through self-reported diaries of stressful events and coping strategies; iii) monthly, the perceived stress (Perceived Stress Scale), iv) trimonthly, the self-reported functionality (Functionality Assessment in multiple sclerosis) and v) at baseline and at the end, neurologist rated impairment (Expanded Disability Status Scale). Mixed-effect regression models were conducted.

RESULTS

The bidirectional hypothesis was confirmed with perceived stress and self-reported functionality, which were negatively related in both directions. Coping and anxiety showed an interaction effect: active coping increased functionality only with high levels of stress, and high-trait anxiety showed lower functionality whereas low-trait anxiety showed higher functionality but only with low stress levels.

CONCLUSION

People with multiple sclerosis may benefit from different types of psychological therapies, from gold-standard therapies like Cognitive Behavioural Therapy to third-waves therapies like Dialectical Behaviour Therapy or mindfulness, that focus on dealing with stress and affective symptoms, adjusting to the disease, and to improving their overall quality of life. More research is needed in this field under the biopsychosocial model.

Climate Change and the Urgent Need to Prepare Persons With Multiple Sclerosis for Extreme Hurricanes

Climate change is contributing to increasingly hazardous tropical cyclones that endanger persons living in susceptible coastal and island communities. People living with chronic illness, including multiple sclerosis (MS), face unique challenges and vulnerabilities when exposed to hurricane hazards. Disaster and emergency preparedness requires a customized approach that considers the necessary adaptations to accommodate the mobility, self-care, sensory, cognitive, and communication impairments of persons living with MS. Related considerations include the potential for worsening neurologic signs and symptoms during and after a catastrophic storm. The impact of emotional and financial stresses, as well as disruptions in health care delivery, on this population are also key concerns. This paper addresses the challenges faced by individuals with MS in advance of, during, and in the aftermath of extreme storms. We propose new guidelines on how health care professionals can assist persons with MS when creating tailored disaster readiness and response plans.

Iranian specialists' approach to surgery in patients with multiple sclerosis

Background: Data on perioperative risk stratification in patients with multiple sclerosis (MS) are limited. In this regard, the present study was conducted to investigate Iranian specialists' approach to surgical counseling for patients with MS (PwMS). Methods: 21 MS specialists were asked about 11 case scenarios with different MS disease statuses, disease-modifying therapies (DMTs), and urgency of the operation. The reasons for refusing surgery or factors that have to be considered before surgery were studied. Results: Overall, Fleiss Kappa was estimated to be 0.091 [95% confidence interval (CI): 0.090-0.093, P < 0.001] indicating a very poor level of agreement among responders. Conclusion: PwMS face surgery for various reasons. Risk assessment of surgery, the effect of various drugs such as anesthetics and DMT on patients, as well as many other aspects of MS are issues challenging the practitioners. Clarifying the various dimensions of these issues requires further research.

Genetic Associations Between Stress-Related Disorders and Autoimmune Disease

Objective: Emerging evidence supports a bidirectional phenotypic association between stress-related disorders and autoimmune disease. However, the biological underpinnings remain unclear. Here, the authors examined whether and how shared genetics contribute to the observed phenotypic associations. Methods: Based on data from 4,123,631 individuals identified from Swedish nationwide registers, familial coaggregation of stress-related disorders (any disorder or posttraumatic stress disorder [PTSD]) and autoimmune disease were initially estimated in seven cohorts with different degrees of kinship. Polygenic risk score (PRS) analyses were then performed with individual-level genotyping data from 376,871 participants in the UK Biobank study. Finally, genetic correlation analyses and enrichment analyses were performed with genome-wide association study (GWAS) summary statistics. Results: Familial coaggregation analyses revealed decreasing odds of concurrence of stress-related disorders and autoimmune disease with descending kinship or genetic relatedness between pairs of relatives; adjusted odds ratios were 1.51 (95% CI=1.09–2.07), 1.28 (95% CI=0.97–1.68), 1.16 (95% CI=1.14–1.18), and 1.01 (95% CI=0.98–1.03) for monozygotic twins, dizygotic twins, full siblings, and half cousins, respectively. Statistically significant positive associations were observed between PRSs of stress-related disorders and autoimmune disease, as well as between PRSs of autoimmune disease and stress-related disorders. GWAS summary statistics revealed a genetic correlation of 0.26 (95% CI=0.14–0.38) between these two phenotypes and identified 10 common genes and five shared functional modules, including one module related to G-protein–coupled receptor pathways. Similar analyses performed for PTSD and specific autoimmune diseases (e.g., autoimmune thyroid disease) largely recapitulated the results of the main analyses. Conclusions: This study demonstrated familial coaggregation, genetic correlation, and common biological pathways between stress-related disorders and autoimmune disease.

Clinically Manifest Infections Do Not Increase the Relapse Risk in People with Multiple Sclerosis Treated with Disease-Modifying Therapies: A Prospective Study

BACKGROUND

Many factors are believed to be positively associated with the incidence of relapses in people with multiple sclerosis (MS), including infections. However, their role is still controversial. We aimed to investigate whether symptomatic infections in people with MS increase the risk of relapse in the short, medium, or long term.

MATERIALS AND METHODS

We enrolled consecutive patients with relapsing MS (RMS) from October to December 2018. From enrolment up to September 2020, an online questionnaire investigating the occurrence of infections was sent via WhatsApp^® monthly to the enrolled patients, while in-person visits were performed every six months. When patients complained of symptoms compatible with relapses, they attended an extra in-person visit.

RESULTS

We enrolled 155 patients with RMS, and 88.38% of patients were treated with disease-modifying therapies. In the dataset, 126,381 total patient days, 78 relapses, and 1202 infections were recorded over a period of about 2 years. No increased risk of relapse after clinically manifest infections was found in the short-, medium-, or long-term period. No correlation was found between all infections and the number of relapses (p = 0.212). The main analyses were repeated considering only those infections that had at least two of the following characteristics: duration of infection ≥ 4 days, body temperature > 37° Celsius, and the use of drugs (antibiotics and/or antivirals), and no significant associations were observed.

CONCLUSIONS

No associations between infections and relapses were observed, likely suggesting that disease-modifying therapies may protect against the risk of relapse potentially triggered by infections.

Resilience, Stress, Well-Being, and Sleep Quality in Multiple Sclerosis

(1) Background: Multiple Sclerosis (MS) is a chronic, progressive, immune-mediated disorder that affects the Central Nervous System and is the most common cause of non-traumatic neurological disability in young adults. The study aimed to assess the levels of stress, resilience, well-being, sleep quality, and fatigue in Israeli people with MS (PwMS), and to examine the associations between these factors and the sociodemographic and clinical characteristics. These factors had never before been studied in conjunction in PwMS, nor had they been systematically addressed in Israel, the unique geopolitical situation of which may pose unique challenges. (2) Methods: This was a survey-based, cross-sectional study conducted through an Internet platform. (3) Results: Israeli PwMS who participated in the study were experiencing relatively high levels of stress and low resilience, poor sleep quality, and severe fatigue. The analysis revealed significant associations between resilience and stress, well-being, and anxiety, as well as stress and well-being, resilience, sleep quality, fatigue, and Clinically Isolated Syndrome (CIS). (4) Conclusions: the Israeli PwMS who participated in the study were experiencing higher levels of stress, lower resilience and worse sleep quality than PwMS in other countries, as compared to results previously reported in literature. The findings of this study ought to serve as a call to action for the MS care providers in Israel and warrant further research into the possible causes of the phenomenon and strategies to address it.

Understanding the Effect of Multiple Sclerosis on General and Dimensions of Mental Health

OBJECTIVE

The objective of the current study is to investigate how general and dimensions of mental health are affected by multiple sclerosis (MS).

METHODS

Factor analysis, generalized linear models, and one-sample t-tests were used to analyze data from 78 people with MS with a mean age of 52.19 (S.D. = 12.94) years old and 25.64% males and 38,516 people without MS with a mean age of 49.10 (S.D. = 18.24) years old and 44.27% males from Understanding Society.

RESULTS

The current study found that there are three underlying factors of the GHQ-12 labeled as GHQ-12A (social dysfunction and anhedonia; 6 items), GHQ-12B (depression and anxiety; 4 items), and GHQ-12C (loss of confidence; 2 items), and the general mental health, GHQ-12A (social dysfunction and anhedonia), and GHQ-12C (loss of confidence) are associated with MS.

CONCLUSIONS

Effective mental health management in MS patients is important given mental health in people with MS is linked to the onset of MS and exacerbating disease progression/relapses.

Biopsychosocial Response to the COVID-19 Lockdown in People with Major Depressive Disorder and Multiple Sclerosis

BACKGROUND

Changes in lifestyle, finances and work status during COVID-19 lockdowns may have led to biopsychosocial changes in people with pre-existing vulnerabilities such as Major Depressive Disorders (MDDs) and Multiple Sclerosis (MS).

METHODS

Data were collected as a part of the RADAR-CNS (Remote Assessment of Disease and Relapse-Central Nervous System) program. We analyzed the following data from long-term participants in a decentralized multinational study: symptoms of depression, heart rate (HR) during the day and night; social activity; sedentary state, steps and physical activity of varying intensity. Linear mixed-effects regression analyses with repeated measures were fitted to assess the changes among three time periods (pre, during and post-lockdown) across the groups, adjusting for depression severity before the pandemic and gender.

RESULTS

Participants with MDDs (N = 255) and MS (N = 214) were included in the analyses. Overall, depressive symptoms remained stable across the three periods in both groups. A lower mean HR and HR variation were observed between pre and during lockdown during the day for MDDs and during the night for MS. HR variation during rest periods also decreased between pre- and post-lockdown in both clinical conditions. We observed a reduction in physical activity for MDDs and MS upon the introduction of lockdowns. The group with MDDs exhibited a net increase in social interaction via social network apps over the three periods.

CONCLUSIONS

Behavioral responses to the lockdown measured by social activity, physical activity and HR may reflect changes in stress in people with MDDs and MS. Remote technology monitoring might promptly activate an early warning of physical and social alterations in these stressful situations. Future studies must explore how stress does or does not impact depression severity.

IL-6 and TNF-α responses to acute and regular exercise in adult individuals with multiple sclerosis (MS): a systematic review and meta-analysis

Background

In both the general population and people with multiple sclerosis (PwMS), physical exercise is associated with improved mental well-being. Moreover, there is evidence of the possible protection of physical activity against disease progression in multiple sclerosis (MS). However, the question arises if acute or regular exercise has any impact on the immune system in PwMS. To answer this question, we performed a systematic review and meta-analysis on both plasma and serum cytokine levels (IL-6 and TNF-α) before and after acute and regular exercise among PwMS and compared to healthy controls.

Method

We performed an online search via PubMed, EMBASE, SCOPUS, Web of Science, and Cochrane Library till September 2021 to identify original studies on IL-6 and TNF-α changes after acute and regular exercise in PwMS and controls. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), 11 original studies were included in the meta-analysis. Sensitivity analyses were used to identify the origins of heterogeneity. R 4.0.4 was used to perform the meta-analysis of IL-6 and TNF-α levels before and after acute and regular exercise in PwMS, compared to controls. This study does not qualify for a clinical trial number.

Results

IL-6 levels did neither increase nor decrease after acute and regular exercise in PwMS, and compared to controls (pre- vs. post-intervention: Standardized Mean Difference (SMD) -0.09, 95% CI [−0.29; 0.11], p-value = 0.37, PwMS vs. Control: SMD −0.08, 95% CI [−0.33; 0.16], p-value = 0.47). In PwMS, TNF-α levels decreased after regular exercise and when TNF-α levels of both acute and regular exercise were pooled (pre- vs. post-intervention: SMD −0.51, 95% CI [-0.91; 0.11], p-value = 0.01, PwMS vs. Control: SMD −0.23, 95% CI [−0.66; 0.18], p-value = 0.26). TNF-α levels did neither increase nor decrease after acute and regular exercise in PwMS, when compared to controls.

Conclusion

This systematic review and meta-analysis show that exercise does not lead to significant changes in peripheral levels of IL-6 in PwMS in contrast to the observed response in healthy subjects and other medical contexts. However, regular exercise had a specific anti-inflammatory effect on blood TNF-α levels in PwMS. It remains to be investigated why PwMS display this different exercise-induced pattern of cytokines.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40001-022-00814-9.

Origin of Sex-Biased Mental Disorders: Do Males and Females Experience Different Selective Regimes?

The origins of sex-biased differences in disease and health are of growing interest to both medical researchers and health professionals. Several major factors have been identified that affect sex differences in incidence of diseases and mental disorders. These are: sex chromosomes, sex hormones and female immunity, sexual selection and antagonistic evolution, and differential susceptibility of sexes to environmental factors. These factors work on different time scales and are not exclusive of each other. Recently, a combined Sexual Selection-Sex Hormones (SS-SH) Theory was presented as an evolutionary mechanism to explain sex-biased differences in diseases and mental disorders (Singh in J Mol Evol 89:195-213, 2021). In that paper disease prevalence trends were investigated, and non-sex-specific diseases were hypothesized to be more common in males than in females in general. They showed signs of exceptions to this trend with inflammatory diseases and stress-related mental disorders that were more common in females. We believe that the SS-SH theory requires the consideration of psycho-social stress (PSS) to explain the predominance of female-biased mental disorders and some other exceptions in their findings. Here we present a theory of sex-differential experience of PSS and provide quantitative support for the combined SS-SH-PSS Theory using age-standardized incidence rates (ASIRs) recording the levels of male- and female-bias in data obtained from different countries. The grand theory provides an evolutionary framework for explaining patterns of sex-biased trends in the prevalence of disease and health. Further exploration of women's vulnerability to social factors may help to facilitate new treatments for female-biased diseases.

RETAIN Kentucky: A return-to-work and stay-at-work program for people with disabilities grounded in the conservation of resources theory

This article, the first in the Return-to-Work (RTW) Corner series, summarizes a comprehensive RTW and Stay-at-Work (SAW) program in Kentucky, which is funded by the United States Department of Labor. The program, Retaining Employment and Talent After Injury/Illness Network: Kentucky (RETAIN Kentucky), focuses on RTW and SAW strategies, depending upon participants’ employment status at the time of enrollment in the project. RETAIN Kentucky services are implemented by RTW Coordinators (RTWCs) who help people with non-work-related injuries and illnesses continue in the workforce. The first Phase of RETAIN Kentucky, which lasted for nearly 3 years, is now informing the Phase 2 intervention, which began in October 2021 and will enroll participants for 30 months. In this article, we outline the employment retention problem that RETAIN Kentucky addresses, describe the key features and services of the program, summarize our findings so far, and present future directions for Phase 2.

Major depression favors the expansion of Th17-like cells and decrease the proportion of CD39+Treg cell subsets in response to myelin antigen in multiple sclerosis patients

BACKGROUND

Mood disorders have been associated with risk of clinical relapses in multiple sclerosis (MS), a demyelinating disease mediated by myelin-specific T cells.

OBJECTIVES

We aimed to investigate the impact of major depressive disorder (MDD) and cytokine profile of T-cells in relapsing remitting MS patients.

METHODS

For our study, plasma and PBMC were obtained from 60 MS patients (30 with lifetime MDD) in remission phase. The PBMC cultures were stimulated with anti-CD3/anti-CD28 beads or myelin basic protein (MBP), and effector and regulatory T cell phenotypes were determined by flow cytometry. The cytokine levels, both in the plasma or in the supernatants collected from PBMC cultures, were quantified by Luminex. In some experiments, the effect of serotonin (5-HT) was investigated.

RESULTS

Here, higher Th17-related cytokine levels in response to anti-CD3/anti-CD28 and MBP were quantified in the plasma and PBMC cultures of the MS/MDD group in comparison with MS patients. Further, elevated frequency of CD4+ and CD8+ T cells capable of producing IL-17, IL-22 and GM-CSF was observed in depressed patients. Interestingly, the percentage of myelin-specific IFN-γ+IL-17+ and IFN-γ+GM-CSF+ CD4+ T cells directly correlated with neurological disabilities. In contrast, the occurrence of MDD reduced the proportion of MBP-specific CD39+Tregs subsets. Notably, the severity of both neurological disorder and depressive symptoms inversely correlated with these Tregs. Finally, the addition of 5-HT downregulated the release of Th17-related cytokines in response to anti-CD3/anti-CD28 and myelin antigen.

CONCLUSIONS

In summary, our findings suggested that recurrent major depression, by favoring imbalances of effector Th17 and Treg cell subsets, contributes to MS severity.

A group resilience training program for people with multiple sclerosis: Study protocol of a multi-centre cluster-randomized controlled trial (multi-READY for MS)

Introduction

REsilience and Activities for every DaY (READY) is an Acceptance and Commitment Therapy-based group resilience-training program that has preliminary empirical support in promoting quality of life and other psychosocial outcomes in people with multiple sclerosis (PwMS). Consistent with the Medical Research Council framework for developing and evaluating complex interventions, we conducted a pilot randomized controlled trial (RCT), followed by a phase III RCT. The present paper describes the phase III RCT protocol.

Methods and analysis

This is a multi-centre cluster RCT comparing READY with a group relaxation program (1:1 ratio) in 240 PwMS from eight centres in Italy (trial registration: isrctn.org Identifier: ISRCTN67194859). Both interventions are composed of 7 weekly sessions plus a booster session five weeks later. Resilience (primary outcome), mood, health-related quality of life, well-being and psychological flexibility will be assessed at baseline, after the booster session, and at three and six month follow-ups. If face-to-face group meetings are interrupted because of COVID-19 related-issues, participants will be invited to complete their intervention via teleconferencing. Relevant COVID-19 information will be collected and the COVID-19 Peritraumatic Distress scale will be administered (ancillary study) at baseline and 3-month follow-up. Analysis will be by intention-to-treat to show superiority of READY over relaxation. Longitudinal changes will be compared between the two arms using repeated-measures, hierarchical generalized linear mixed models.

Conclusion

It is expected that his study will contribute to the body of evidence on the efficacy and effectiveness of READY by comparing it with an active group intervention in frontline MS rehabilitation and clinical settings. Results will be disseminated in peer-reviewed journals and at other relevant conferences.

Association between relapses, stress, and depression in people with multiple sclerosis during the COVID-19 pandemic

Background

Stress is a potential trigger for clinical and radiological activity in Multiple Sclerosis (MS). COVID-19 pandemic has been a relevant source of mental distress in people with MS (pwMS) and deeply impacted on disease management.

Objective

To investigate the association between stress, anxiety, depression, and risk of relapse during the COVID-19 pandemic.

Methods

From an electronic database used for clinical practice, we extracted data of relapsing–remitting (RR) or relapsing-progressive (RP) MS patients and calculated the annualized relapse rate (ARR) during 2019 and 2020. From 01/12/2020 to 30/12/2020, enrolled patients were invited to fill in a Google Forms survey to investigate depression, anxiety, stress, and Post-Traumatic Stress Disorder (PTSD).

Results

We selected 216 patients with RR or RP-MS to calculate ARR: compared to 2019, in 2020 there was a significant increase in ARR (p = 0.0142).

Over 216 selected pwMS, 154 completed the survey. Matching the survey responses and incidence of relapses in 2020, there was a significant association between relapses and stress (p = 0.030) and relapses and depression (p = 0.011), but not between relapses and anxiety (p = 0.130) or PTSD (p = 0.279).

Conclusions

Our results support the hypothesis that pandemic-related stress is associated to clinical exacerbations, both as a possible consequence of the COVID-19 impact on MS care.

Central stress processing, T cell responsivity to stress hormones, and disease severity in multiple sclerosis

Epidemiological, clinical and neuroscientific studies support a link between psychobiological stress and multiple sclerosis. Neuroimaging suggests that blunted central stress processing goes along with higher multiple sclerosis severity, neuroendocrine studies suggest that blunted immune system sensitivity to stress hormones is linked to stronger neuroinflammation. Until now, however, no effort has been made to elucidate whether central stress processing and immune system sensitivity to stress hormones are related in a disease-specific fashion, and if so, whether this relation is clinically meaningful. Consequently, we conducted two functional MRI analyses based on a total of 39 persons with multiple sclerosis and 25 healthy persons. Motivated by findings of an altered interplay between neuroendocrine stress processing and T-cell glucocorticoid sensitivity in multiple sclerosis, we searched for neural networks whose stress task-evoked activity is differentially linked to peripheral T-cell glucocorticoid signalling in patients versus healthy persons as a potential indicator of disease-specific CNS–immune crosstalk. Subsequently, we tested whether this activity is simultaneously related to disease severity. We found that activity of a network comprising right anterior insula, right fusiform gyrus, left midcingulate and lingual gyrus was differentially coupled to T-cell glucocorticoid signalling across groups. This network’s activity was simultaneously linked to patients’ lesion volume, clinical disability and information-processing speed. Complementary analyses revealed that T-cell glucocorticoid signalling was not directly linked to disease severity. Our findings show that alterations in the coupling between central stress processing and T-cell stress hormone sensitivity are related to key severity measures of multiple sclerosis.

The psychological benefits of neuropsychological assessment feedback as a psycho-educational therapeutic intervention: A randomized-controlled trial with cross-over in multiple sclerosis

ABSTRACTEvidence supporting the direct therapeutic benefits of neuropsychological assessment (NPA) feedback relies mostly upon post-feedback consumer surveys. This randomized-controlled trial with cross-over investigated the benefits of NPA feedback in multiple sclerosis (MS). Seventy-one participants were randomly allocated to NPA with feedback or a "delayed-treatment" control group. The primary hypotheses were that NPA feedback would lead to improved knowledge of cognitive functioning and improved coping. Outcome instruments were administered by a research assistant blinded to group allocation. At 1-week post-NPA feedback there were no significant group-by-time interaction effects, indicating no improvement. But nor was there any significant deterioration in psychological wellbeing, despite most participants receiving "bad news" confirming cognitive impairment. At 1-month follow-up, within-subjects' analyses not only found no evidence of any delayed deterioration, but showed clinically significant improvement (small-medium effects) in perceived everyday cognitive functioning, MS self-efficacy, stress and depression. Despite lack of improvement in the RCT component at 1-week post-NPA feedback, the absence of deterioration at this time, in addition to significant improvements in perceived cognitive functioning, self-efficacy and mood at follow-up, together with high satisfaction ratings, all support NPA feedback as a safe psycho-educational intervention that is followed by improved psychological wellbeing over time.Trial registration: Uniform Trial Number identifier: U1111-1127-1585.Trial registration: Australian New Zealand Clinical Trials Registry identifier: ACTRN12612000161820.

Explaining stress coping behaviors in patients with multiple sclerosis based on the PRECEDE model: a qualitative directed content analysis

BACKGROUND

Stress can be regarded as one of the consequences of Multiple Sclerosis (MS) and a factor in exacerbating or recurring the symptoms resulting from the disease. This study aimed to explain the stress coping behaviors in patients with MS based on the PRECEDE model.

METHODS

This study is a qualitative directed content analysis research based on the PRECEDE model. Data were obtained through in-depth semi-structured interviews with 26 patients with MS, who were selected using a purposive sampling and maximum diversity in terms of gender, age, education, marital status, and employment. Data collection continued until the saturation occurred. Simultaneously, collected data were analyzed using a qualitative directed content analysis method.

RESULTS

Data analysis led to the identification of 11 sub-categories. Of these, 10 sub-categories were assigned to three categories of predisposing factors (awareness, attitude, self-efficacy, and perceived severity), enabling factors (existence of resources, access to resources, skills of using resources, and educational preferences), and reinforcing factors (social support, important others and behavioral consequences). The social comparison category was a new category identified from the analysis of interviews.

CONCLUSIONS

Based on the results, individual, environmental and social factors play a role in the stress of these patients. Designing programs that lead to their empowerment and improvements in the environmental and social conditions can be effective in controlling stress in these patients. Based on the results, planners can adopt the most appropriate strategies to change these determinants, help reduce stress, and promote the psychological standard of living in these patients.

The Association Between Mental Health Disorders and Non-Infectious Scleritis: A Prevalence Study and Review of the Literature

Chronic inflammatory diseases can cause significant psychosocial stress in affected patients. Few studies have examined the psychological effects of ocular inflammatory disease and no studies have examined the psychological effects of scleritis. In this study we evaluate the prevalence of mental health disorders in scleritis patients and we conduct a comprehensive review of the literature on the mental health effects of ocular inflammatory diseases. 162 patients (195 eyes) presenting to a tertiary care center with scleritis were identified. At least one comorbid mental health disorder was diagnosed in 35 patients (21.6%), most commonly major depression in 11.7%, generalized anxiety disorder in 9.3%, and substance use disorder in 6.2%. There were no significant differences in the length of an episode of scleritis or in the probability of symptom resolution between patients with a mental health disorder and other patients. In a review of the literature, 30 manuscripts met the inclusion criteria. The majority of manuscripts (83.3%) were focused on uveitis patients. Eight of these studies were focused on patients with uveitis in the context of systemic disease. The most commonly reported mental health disorders reported were anxiety and depression. An average of 31.3% of patients with ocular inflammatory disease had depression and 35.0% had anxiety. Similar to other chronic illnesses, ocular inflammatory disease may be a significant psychosocial stressor. Future studies will further elucidate the relationship between these diseases and mental health.

Neural Processes of Psychological Stress and Relaxation Predict the Future Evolution of Quality of Life in Multiple Sclerosis

Health-related quality of life (HRQoL) is an essential complementary parameter in the assessment of disease burden and treatment outcome in multiple sclerosis (MS) and can be affected by neuropsychiatric symptoms, which in turn are sensitive to psychological stress. However, until now, the impact of neurobiological stress and relaxation on HRQoL in MS has not been investigated. We thus evaluated whether the activity of neural networks triggered by mild psychological stress (elicited in an fMRI task comprising mental arithmetic with feedback) or by stress termination (i.e., relaxation) at baseline (T0) predicts HRQoL variations occurring between T0 and a follow-up visit (T1) in 28 patients using a robust regression and permutation testing. The median delay between T0 and T1 was 902 (range: 363–1,169) days. We assessed HRQoL based on the Hamburg Quality of Life Questionnaire in MS (HAQUAMS) and accounted for the impact of established HRQoL predictors and the cognitive performance of the participants. Relaxation-triggered activity of a widespread neural network predicted future variations in overall HRQoL (t = 3.68, p_{family−wise error [FWE]}-corrected = 0.008). Complementary analyses showed that relaxation-triggered activity of the same network at baseline was associated with variations in the HAQUAMS mood subscale on an α_FWE = 0.1 level (t = 3.37, p_FWE = 0.087). Finally, stress-induced activity of a prefronto-limbic network predicted future variations in the HAQUAMS lower limb mobility subscale (t = −3.62, p_FWE = 0.020). Functional neural network measures of psychological stress and relaxation contain prognostic information for future HRQoL evolution in MS independent of clinical predictors.

Acute Response of Stress System in Multiple Sclerosis

Background: It has long been suspected that exposure to stress is a major factor that can increase the risk of Multiple Sclerosis (MS) and exacerbate it, as a stress-related disorder. Therefore, we conducted this study to investigate the response of the hypothalamic-pituitary-adrenal (HPA) axis and sympathetic-adrenal-medullar (SAM) system to acute social stress. Methods: A total of 46 MS patients and 23 age-sex-matched healthy controls were recruited in the study. The Trier Social Stress Test (TSST) was used to induce acute psychosocial stress. We measured salivary cortisol (SC) to evaluate the HPA axis. In addition, electrocardiography (ECG) was recorded to evaluate the SAM system based on the linear and non-linear features of Heart Rate Variation (HRV). Then, SC and HRV were measured before and after the stress exposure. We also used the Depression Anxiety Stress Scale (DASS) and Emotional Visual Analog Scale (EVAS) to conduct the psychometric assessment and evaluate the perceived stress level, respectively. Results: The mean age of the MS group was 35.38 ± 15 years, with a mean disease duration of 7.4 ± 60. Besides, the HC group's mean age was 35.8 ± 9 years. There were no significant differences in demographic features and DASS scores between the two groups. In response to TSST, both MS and healthy individuals showed a significant increase in the SC levels and EVAS scores, as well as changes in the HRV indices. Notably, significant differences were also found between the two groups regarding the basic and post-stress SC levels, EVAS score, and HRV indices. Unlike the HC group, the SC level returned to its baseline after recovery in the MS group, and the sympathetic tone was more sensitive. Conclusions: Our results indicated that both MS and healthy individuals respond to acute stress regarding neuroendocrine assessment; however, patients with multiple sclerosis show some impairments in this response.

Burden of COVID-19 Pandemic Perceived by Polish Patients with Multiple Sclerosis

People with multiple sclerosis (MS) were expected to be particularly affected by the COVID-19 pandemic. The purpose of the study was to evaluate the burden of pandemic, perceived by Polish MS patients, with regard to major contributing factors. The survey, conducted in August/September 2020, included: Perceived Stress Scale (PSS-10), Coping Orientations to Problems Experienced (Brief–COPE), questions on demographic data, MS characteristics, and health-related and social aspects of pandemic burden. Relationships were searched between PSS-10 and Mini-COPE results and other analyzed items, using U Mann–Whitney test, Kruskal–Wallis ANOVA rank test and Spearman rank correlation. The survey was answered by 287 MS patients (208 female, 79 male, aged 21–69 years). Since March 2020, 2.4% of respondents had been positive for COVID-19 and 5.2% had undergone a quarantine. Mean PSS-10 score was 19.99, with moderate or high level of stress in 83.3% of respondents. Problem-focused strategies were more frequently used than emotion-focused strategies (1.76 vs. 1.16). Higher PSS-10 score was associated with comorbidities (H = 4.28), increase in major MS symptoms during the pandemic (21.92 vs. 18.06), experience of healthcare limitations (21.12 vs. 17.98), work-related (22.58 vs. 18.69), financial (22.70 vs. 18.83) and family-related problems (22.54 vs. 17.73) due to pandemic restrictions. A coping model was associated with functional disability and limitations to daily activities (H = 7.81). During the first stage of the pandemic, MS patients reported increased level of stress and preferred problem-focused coping. The level of stress and coping showed more relationships with pandemic impact upon social issues than with MS-related variables.

Identifying the job accommodation needs of American workers with mid-career neurological disabilities: A multiple case study investigation

BACKGROUND: The COVID-19 pandemic has wrought an unprecedented toll on vocational rehabilitation efforts to assist workers with disabilities in maintaining their careers. OBJECTIVE: To demonstrate the use of a psychometrically sound assessment instrument and resource-driven planning procedure to help workers with disabilities resume or retain their employment. METHODS: Four employed people with neurological disabilities who took part in a larger job retention project funded by the United States Department of Labor completed structured interviews to determine their needs for employment accommodations during COVID-19. A trained interviewer administered the Work Experience Survey (WES) in teleconsultation sessions with each participant to identify: (a) barriers to worksite access, (b) difficulties performing essential job functions, (c) concerns regarding continued job mastery, and (d) extent of job satisfaction. RESULTS: Owing primarily to the sequelae of their disabling conditions and less so to social distancing requirements and telecommuting technology, participants reported a wide range of accessibility barriers and difficulties in performing essential functions of their jobs that they believed had the potential to significantly affect their ongoing productivity. Considering the stress and uncertainty that have accompanied the COVID-19 pandemic, it is surprising that the majority of participants reported high levels of job mastery and job satisfaction. CONCLUSION: The interviewer concluded the WES interview by recommending a job accommodation plan, which included suggestions from Job Accommodation Network (JAN) consultants.

The Level of Stress and Coping Strategies in Patients with Multiple Sclerosis and Their Relationships with the Disease Course

Objectives: Stress is supposed to be linked with a background of multiple sclerosis (MS) and the disease course. Design: The study aimed to assess the level of stress and coping strategies in MS patients within a year of follow-up and to investigate the relationships between these aspects and factors related—or not—to MS. Methods: In 65 patients with MS, the Perceived Stress Scale (PSS-10), Type D Scale (DS14) and Coping Orientations to Problems Experienced (COPE) were performed at baseline and after a year. Baseline PSS-10, DS-14 and COPE scores were analyzed with regard to demographics, MS duration, treatment, indices of disability and self-reported stressful events (SEs). Final PSS-10 and COPE results were analyzed with reference to MS activity and SE within a year of follow-up. Results: Initially, 67% of patients reported a moderate or high level of stress and 31% met Type-D personality criteria. Diverse coping strategies were preferred, most of which were problem-focused. The negative affectivity DS-14 subscore (NEG) was correlated with disability level. Non-health-related SEs were associated with higher PSS-10 and NEG scores. After a year, the mean PSS-10 score decreased, while COPE results did not change significantly. Non-health-related SEs were associated with a higher PSS-10 score and less frequent use of acceptance and humor strategies. Those with an active vs. stable MS course during the follow-up did not differ in terms of PSS-10 and COPE results. Conclusions: MS patients experienced an increased level of stress. No significant relationships were found between stress or coping and MS course within a year. Non-health-related factors affected measures of stress more than MS-related factors.

Mindfulness-Based Interventions for the Improvement of Well-Being in People With Multiple Sclerosis: A Systematic Review and Meta-Analysis

OBJECTIVE

The study aims to meta-analytically review studies about the effects of mindfulness-based interventions (MBIs) on well-being of people with multiple sclerosis (MS).

METHODS

Seven electronic databases were searched from June 2018 to September 2018. A systematic review and a meta-analysis were conducted.

RESULTS

Twenty-one studies were included in qualitative synthesis, and 10 studies were included in meta-analysis. MBIs are effective with an overall moderate effect size (Hedges' g = 0.70) in improving well-being in people with MS, with lasting effects at the follow-up (g = 0.55). In particular, MBIs demonstrated to highly reduce stress (g = 1.07) and to improve depression and anxiety symptoms with a moderate to large effect at postintervention (g = 0.77 and g = 0.63, respectively).

CONCLUSIONS

MBIs represent a valid and effective mind-body intervention to improve the well-being of patients with MS. Further studies should investigate which components of MBIs could be more beneficial for patients with progressive MS.

PROSPERO REGISTRATION

CRD42018099704.

The Role of Stress Perception and Coping with Stress and the Quality of Life Among Multiple Sclerosis Patients

Purpose

Multiple sclerosis (MS) is one of the most common neurological disorders and a cause of disability in young adults. Adequate stress management in MS patients may merit the benefits of both physical and psychological well-being. This study aimed to evaluate the quality of life in MS patients and its correlation with stress levels and coping strategies.

Methods

This descriptive and correlational study was conducted among 109 patients diagnosed with relapsing-remitting MS (RRMS). The study was based on a questionnaire designed by the authors and the following standardized questionnaires: the Perceived Stress Scale (PSS-10), the Inventory for Measuring Coping with Stress (Mini-COPE), and the Multiple Sclerosis International Quality of Life Questionnaire (MusiQoL).

Results

Data analysis showed that 47.71% of the patients experienced a high level of stress, and the most often used strategies under challenging situations included seeking emotional support (2.11) and active coping (1.96). Also, it showed that when the level of stress is higher, the QOL in all domains is lower. Coping strategies such as sense of humor, turning to religion, self-distraction, denial, venting, substance use, behavioral disengagement, and self-blame are negatively correlated with the quality of life of MS.

Conclusion

Quality of life in MS patients is negatively affected by a higher level of perceived stress. The use of coping strategies such as active coping, positive reframing, acceptance, and seeking emotional and instrumental support is positively correlated with the quality of life of MS patients.

Randomized controlled evaluation of the psychophysiological effects of social support stress management in healthy women

Considering the high and increasing prevalence of stress, approaches to mitigate stress-related biological processes become a matter of public health. Since supportive social interactions contribute substantially to mental and physical health, we set out to develop a social support stress management intervention and examined its effects on psychophysiological stress responses as well as self-reported stress in healthy women. In a parallel-group randomized controlled trial, registered in the DSRK (DRKS00017427), 53 healthy women were randomly assigned to a social support stress management or a waitlist control condition. All participants underwent a standardized psychosocial stress test where physiological and emotional stress responses were assessed by repeated measurements of cortisol, heart rate, heart rate variability and state anxiety. Also, all participants completed self-report questionnaires of perceived stress and social support at pre-intervention, post-intervention and follow-up four weeks later. Participants in the social support stress management showed a significantly attenuated integrated state anxiety response in comparison to those in the control condition, but conditions did not differ in any of the assessed physiological stress responses. The intervention significantly reduced perceived stress in comparison to the control condition, but perceived stress levels returned to baseline at follow-up. Our results indicated that the intervention had no effect on physiological responses to acute psychosocial stress, even though anxiety responses to stress were attenuated. However, the social support stress management intervention had a significant, albeit transient impact on perceived stress.

Comprehensive Approach to Management of Multiple Sclerosis: Addressing Invisible Symptoms-A Narrative Review

Multiple sclerosis (MS) is a chronic autoimmune inflammatory disease of the central nervous system, leading to neurodegeneration and manifesting as a variety of symptoms. These can include "invisible" symptoms, not externally evident to others, such as fatigue, mood disorders, cognitive impairments, pain, bladder/bowel dysfunction, sexual dysfunction, and vision changes. Invisible symptoms are highly prevalent in people living with MS, with multifactorial etiology and potential to impact the disease course. Patient experiences of these symptoms include both physical and psychosocial elements, which when unaddressed negatively influence many aspects of quality of life and perception of health. Despite the high impact on patient lives, gaps persist in awareness and management of these hidden symptoms. The healthcare provider and patient author experiences brought together here serve to raise the profile of invisible symptoms and review strategies for a team-based approach to comprehensive MS care. We summarize the current literature regarding the prevalence and etiology of invisible symptoms to convey the high likelihood that a person living with MS will contend with one or more of these concerns. We then explore how open communication between people living with MS and their care team, stigma mitigation, and shared decision-making are key to comprehensive management of invisible symptoms. We recommend validated screening tools and technological advancements that may be incorporated into MS care to regularly monitor these symptoms, offering insight into how healthcare providers can both educate and listen to patients, with the goal of improved patient quality of life. By pairing clinical knowledge with an understanding and consideration of the patient perspective, providers will be equipped to foster a patient-centered dialogue that encourages shared decision-making. Invisible symptoms of MS.

Coping with stress during the first wave of the COVID-19 pandemic by Turkish people with Multiple Sclerosis: The relationship between perceived stress and quality of life

Background

Multiple sclerosis (MS) is a chronic inflammatory disease and acute exacerbations are also a part of the clinical course. The presence of the disease and relapses cause stress in people with MS (pwMS). For this reason, stress coping strategies of the patients are important in reducing perceived stress. Our aim in this study is to evaluate which strategies pwMS use during the COVID-19 pandemic, the effect of the strategies on perceived stress, their relationship with relapses and their role on quality of life (QoL).

Methods

An online form including Perceived Stress Scale (PSS; 10 items), Coping with Experienced Problems Scale (Brief-COPE; 28 items) and SF-12 were sent to 340 pwMS under our follow-up.

Results

During the COVID-19 pandemic, we found that the patients used the strategies of turn to religion, planning and acceptance at a high rate. PSS score was high in 23 (11.2%) of the patients. The patients with low perceived stress used the acceptance strategy more (P=0.008). We found a negative correlation between physical component summary (PCS) of SF-12 and denial (r=-0.2, p<0.001) and distraction (r =-0.1, p=0.04). A negative correlation was found between mental component summary (MCS) of SF-12 and behavioral disconnection (r=-0.2, p=0.006). There was a positive correlation between MCS and humor (r=0.1, p=0.04), use of instrumental support (r=0.2, p=0.009), planning (r=0.1, p=0.04), and positive reframing (r=0.2, p=0.002).

Conclusion

PwMS have been successful in coping with stress in the first half of the pandemic with the combination of emotional and problem-focused strategies. Acceptance strategy was highly adopted by patients with low PSS, and the tendency to use the active coping strategy together with the acceptance strategy was high in patients without relapses. Adoption to emotional strategies may have prevented the severe deterioration in QoL in this study group in the early period of Covid-19 pandemic.

Patient and Provider Insights into the Impact of Multiple Sclerosis on Mental Health: A Narrative Review

Multiple sclerosis (MS) is a chronic disease in which the immune system attacks the central nervous system, causing inflammation and neurodegeneration. People living with MS may experience a variety of symptoms as a consequence of this process, including many “invisible” symptoms that are internally manifested and not seen by others. Of the invisible symptoms of MS, which we have reviewed in a companion article, mood and mental health disorders are of particular concern due to their high prevalence and significant impact on patient quality of life. In this review, we showcase the experiences of patient authors alongside perspectives from healthcare provider authors as we promote awareness of the common mental health conditions faced by those living with MS, such as depression, anxiety, adjustment disorder, bipolar disorder, psychosis, and suicidal ideation. Many of these conditions stem in part from the increased stress levels and the many uncertainties that come with managing life with MS, which have been exacerbated by the environment created by the coronavirus disease 2019 (COVID-19) pandemic. A patient-centered interdisciplinary approach, routine screening for mental health changes, and referral to specialists when needed can normalize discussions of mental health and increase the likelihood that people living with MS will receive the support and care they need. Management techniques such as robust social support, cognitive behavioral therapy, mindfulness-based interventions, and/or pharmacotherapy may be implemented to build resilience and promote healthy coping strategies. Increasingly, patients have access to telehealth options as well as digital apps for mental health management. Taken together, these approaches form an integrative care model in which people living with MS benefit from the care of medical professionals, a variety of support networks/resources, and self-management techniques for optimal mental health care.

Coping strategies in relapsing-remitting multiple sclerosis non-depressed patients and their associations with disease activity

Few studies evaluated coping strategies in people with multiple sclerosis (pwMS) in relation to annualized relapse rate (ARR) and lesion load (LL). Overall, results might have been influenced by the inclusion of depressed patients. To investigate the coping strategies and their association to disease activity, we studied relapsing-remitting pwMS accurately selected to avoid the confounding effect of depression. Sixty-seven relapsing-remitting pwMS and 67 healthy subjects (HS) underwent to Coping Orientation to Problems Experienced (I-COPE) and Coping Inventory for Stressful Situation (CISS) and Beck Depression Inventory-II. Cognitive performances, ARR, physical disability and magnetic resonance imaging T2-LL were assessed for correlation with coping and depression scores. pwMS showed lower scores than HSs on social support and turning to religion subscales of I-COPE and on emotion dimension of CISS. In pwMS, higher ARR was related to higher positive attitude and lower score on the turning to religion subscale of I-COPE. The present study revealed a less employment of emotion-based coping strategies in pwMS. A scarce use of faith for support and a frequent adoption of a positive attitude were associated with an increase of MS activity in terms of ARR.

Familial coexistence of demyelinating diseases and familial Mediterranean fever

Familial Mediterranean fever (FMF) is a monogenic autoinflammatory disease characterized by fever and serositis attacks caused by mutations in the MEditerranean FeVer (MEFV) gene encoding the pyrin gene. Gain of the function mutations of the pyrin gene lead to stimulation of pro-inflammatory cytokines. Persistent pro-inflammatory situation in the course of FMF may play a role in the development of some other inflammatory diseases such as Behcet's disease, psoriasis, and vasculitis. Multiple sclerosis (MS), as a demyelinating disorder, is also more commonly seen in FMF patients compared to the general population. There are scarcely any research reporting that these two diseases coexist in more than one person in the same family. We have discovered cases of FMF and demyelinating disorders in five members of two different families. Besides the two families we are reporting, there are only four other families reported so far. Having combined the data of all these six families, we present a case-based review in this study. We aimed to draw attention of physicians to familial co-occurence of FMF and demyelinating disorders and also to discuss possible mechanisms of the coexistence of these two diseases in light of the literature.

Selective serotonin reuptake inhibitor attenuates the hyperresponsiveness of TLR2+ and TLR4+ Th17/Tc17-like cells in multiple sclerosis patients with major depression

Elevated frequency of Th17-like cells expressing Toll-like receptors (TLRs) has been recently associated with relapsing-remitting multiple sclerosis (MS) pathogenesis, a chronic inflammatory demyelinating autoimmune disease of the central nervous system. We aimed to investigate the impact of current major depressive disorder (MDD) on the behaviour of these cells following in vitro stimulation with TLR2, TLR4, TLR5 and TLR9 agonists. Here, the level of both cell proliferation and cytokine production related to Th17/Tc17 phenotypes in response to TLR2 (Pam3C) and TLR4 (LPS) ligands was significantly higher in CD4+ and CD8+ T-cell cultures from MS/MDD patients when compared to non-depressed patients. These cytokine levels were positively associated with neurological disabilities in patients. No difference for responsiveness to TLR5 (flagellin) and TLR9 (ODN) agonists was observed. LPS, but not Pam3C, induced significant IL-10 release, mainly in patients without MDD. Interestingly, more intense expression of TLR2 and TLR4 on these cells was observed in MDD patients. Finally, in vitro addition of serotonin and treatment of MDD patients with selective serotonin reuptake inhibitors (SSRIs) reduced the production of Th17/Tc17-related cytokines by CD4+ and CD8+ T cells in response to Pam3C and LPS. However, only SSRI therapy diminished the frequency and intensity of TLR2 and TLR4 expression on circulating CD4+ and CD8+ T cells. In summary, although preliminary, our findings suggest that adverse events that elevate circulating levels of TLR2 and TLR4 ligands can affect MS pathogenesis, particularly among depressed patients.

Psychological Resilience and Vulnerability as Mediators Between Adverse Life Events and Fatigue, Motor Dysfunction, and Paresthesia in Multiple Sclerosis

OBJECTIVE

Adverse life events have been associated with exacerbating multiple sclerosis (MS) symptoms, but results have been variable, raising the question on the role of other psychological factors. This study examined the role of psychological resilience and vulnerability as mediators between adverse life events on MS symptoms.

METHODS

Participants with MS (N = 1239) were aged 18 to 81 years (mean [SD] = 45.6 [10.4] years), and 84.5% were female. MS symptoms were measured by the modified Fatigue Severity Scale, modified Fatigue Assessment Scale, Motor Dysfunction Assessment Scale, Paraesthesiae Spell Duration Scale, and the Paraesthesiae Cumulative Duration Scale. Psychological measures included the Connor-Davidson Resilience Scale, Resilience Scale for Adults, Psychological Vulnerability Scale, the vulnerability section of the Defence Style Questionnaire, and the Adverse Life Events Assessment Scale. Regression analyses and structural equation modeling were performed.

RESULTS

Adverse life events during the preceding 60 days were associated with fatigue, motor dysfunction, and paresthesia, but with small effect sizes (β from 0.07 to 0.15; p ≤ .014). A structural equation model by which resilience mediated less and vulnerability more MS symptoms after adverse life events during the preceding 60 days showed a statistically significant fit with the data of a moderate to good degree (p < .001; goodness-of-fit statistic = 0.725; root mean square error of approximation = 0.047). Vulnerability played a markedly larger role than did resilience.

CONCLUSION

The results suggest that psychological resilience and vulnerability play mediating roles in the relation between adverse life events and MS symptoms, but other psychological factors also need to be investigated.

Comparison of the Efficacy and Safety of Anti-CD20 B Cells Depleting Drugs in Multiple Sclerosis

Rituximab, ocrelizumab, ofatumumab and ublituximab are disease modifying therapies (DMT) currently used in the treatment of multiple sclerosis (MS) or are in advanced stages of clinical trials. These monoclonal antibodies deplete B cells by targeting the cell surface protein CD20. This review highlights the similarities and major differences between the four agents. We summarize data from various clinical trials of each of these therapeutics and discuss their efficacy and safety. Additional considerations regarding the route of administration and cost are presented. Among the four therapeutics, only ocrelizumab is approved for primary progressive (PP) MS. Infusion/injection related reactions (IRRs) are the most common adverse events associated with all four therapeutics. In phase III trials of ocrelizumab and ofatumumab, the incidence of IRRs was lower with ofatumumab. Ofatumumab is unique among the four therapeutics due to its availability as a subcutaneous injection (SQ). Although SQ administration may be appealing for some patients it may raise concerns regarding medication compliance among physicians. Phase II trials studying ublituximab for the treatment of RMS yielded promising results. Phase III trials are currently comparing the efficacy of ublituximab to teriflunomide.

The emotional disorders associated with multiple sclerosis

Multiple sclerosis (MS) is associated with a high prevalence of emotional and mood disorders. Emotional disorders may worsen during illness progression and affect the quality of life of patients and their families. MS is often associated with depression, with an increased risk of suicide, poor adherence to treatment, decreased functional status, and quality of life. The diagnosis and treatment of emotional and mood disorders in these patients is often challenging since several symptoms of these disorders overlap with those of MS. Other prevalent emotional disorders in MS include bipolar disorder, anxiety disorders, emotional blunting (apathy), and pseudobulbar affect. Early recognition and treatment of these comorbidities could contribute to the reduction of disability and even to decreased mortality. The aim of this chapter is to provide an up-to-date review of mood and emotional disorders that are often associated with MS, focusing on their epidemiology, clinical features, pathogenesis, assessment, and treatment. The interplay between the psychosocial impact of the chronic disability and the demyelinating structural lesions of the brain in precipitating emotional and mood disorders is discussed, as well as its implications for diagnosis and treatment.

The International Classification of Functioning, Disability, and Health (ICF) as a community participation model for people with multiple sclerosis: A hierarchical regression analysis

Multiple sclerosis (MS) is a central nervous system disorder that impacts more than 400,000 people in the U.S. The disease results in multiple functional impairments that are diverse and varied across individuals. Additonally, MS has a profound impact on community participation which, like other rehabilitation outcomes, cannot be explained on the basis of functional limitations alone. The purpose of this study was to develop and evaluate a model of community participation for people living with MS using the World Health Organization (WHO) International Classification of Functioning, Disability, and Health (ICF) framework. The model focused on the roles that personal factors have as predictors of community participation, while also serving as mediators and moderators for the relationship between activity limitation and participation. Results from the hierarchical regression analysis indicated that demographic characteristics (i.e. MS type), personal factors (i.e. core self-evaluations (CSE), MS self-management, resilience, and social skills), and activity limitations accounted for 64% of the variance in participation. Further, mediation analysis indicated that CSE mediated the relationship between activity limitation and community participation. Finally, moderation analysis indicated an interaction effect between educational attainment and MS self-management. Implications for future research in rehabilitation and clinical application are discussed.

Blunted neural and psychological stress processing predicts future grey matter atrophy in multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is characterized by two neuropathological key aspects: inflammation and neurodegeneration. Clinical studies support a prospective link between psychological stress and subsequent inflammatory disease activity. However, it is unknown if a similar link exists for grey matter (GM) degeneration as the key driver of irreversible disability.

METHODS

We tested whether neural network activity triggered in a psychological fMRI stress paradigm (a mental arithmetic task including social evaluation) conducted at a baseline time point predicts future GM atrophy in 25 persons with MS (14 females). Atrophy was determined between the baseline and a follow-up time point with a median delay of 1012 (Rg: 717-1439) days. Additionally, atrophy was assessed in 22 healthy subjects (13 females; median delay 771 [Rg: 740-908] days between baseline and follow-up) for comparison.

RESULTS

An analysis of longitudinal atrophy in patients revealed GM loss in frontal, parietal, and cerebellar areas. Cerebellar atrophy was more pronounced in patients than controls. Future parietal and cerebellar atrophy could be predicted based on activity of two networks. Perceived psychological stress was negatively related to future parietal atrophy in patients and activity of the network predictive of parietal atrophy was positively linked to perceived stress.

CONCLUSIONS

We have shown that blunted neural and psychological stress processing have a detrimental effect on the course of MS and are interrelated. Together with research showing that psychological and neural stress processing can be altered through interventions, our findings suggest that stress processing might constitute an important modifiable disease factor.