Recommendations on diagnosis and treatment of depression in patients with multiple sclerosis

The manifestation of affective symptoms in multiple sclerosis and discussion of the currently available diagnostic assessment tools

INTRODUCTION

In addition to physical and cognitive symptoms, patients with multiple sclerosis (MS) have an increased risk of experiencing mental health problems.

METHODS

This narrative review provides an overview of the appearance and epidemiology of affective symptoms in MS such as depression, anxiety, bipolar disorder, euphoria, and pseudobulbar affect. Furthermore, the association between affective symptoms and quality of life and the currently used diagnostic instruments for assessing these symptoms are considered whereby relevant studies published between 2009 and 2021 were included in the review.

RESULTS

Patients with mild and moderate disability more frequently reported severe problems with depression and anxiety than severe mobility problems. Apart from the occurrence of depression, little is known about the association of other affective symptoms such as anxiety, bipolar disorder, euphoria, and pseudobulbar affect and subsyndromal symptoms, which fail to meet the diagnostic criteria but are nevertheless a significant source of distress. Although there are a few recommendations in the research to perform routine screenings for diagnosable affective disorders, a standardized diagnostic procedure to assess subsyndromal symptoms is still lacking. As the applied measurements are diverse and show low accuracy to detect these symptoms, patients who experience affective symptoms are less likely to be identified.

DISCUSSION

In addition to the consideration of definite psychiatric diagnoses, there is an unmet need for a common definition and assessment of disease-related affective symptoms in MS. Future studies should focus on the improvement and standardization of a common diagnostic procedure for subsyndromal affective symptoms in MS to enable integrated and optimal care for patients.

Glatiramer Acetate Immunomodulation: Evidence of Neuroprotection and Cognitive Preservation

Novel, neuroprotective uses of Copaxone (generic name: glatiramer acetate-GA) are being examined, primarily in neurological conditions involving cognitive decline. GA is a well-studied synthetic copolymer that is FDA-approved for immune-based treatment of relapsing remitting multiple sclerosis (RRMS). Clinical studies have explored the potential mechanism of action (MOA) and outcomes of GA immunization in patients. Furthermore, results from these and animal studies suggest that GA has a direct immunomodulatory effect on adaptive and innate immune cell phenotypes and responses. These MOAs have been postulated to have a common neuroprotective impact in several neuroinflammatory and neurodegenerative diseases. Notably, several clinical studies report that the use of GA mitigated MS-associated cognitive decline. Its propensity to ameliorate neuro-proinflammatory and degenerative processes ignites increased interest in potential alternate uses such as in age-related macular degeneration (AMD), amyotrophic lateral sclerosis (ALS), and Alzheimer's disease (AD). Preclinical studies are exploring less frequent subcutaneous administration of GA, such as once weekly or monthly or a single dosing regimen. Indeed, cognitive functions were found to be either preserved, reversed, or improved after the less frequent treatment regimens with GA in animal models of AD. In this systematic review, we examine the potential novel uses of GA across clinical and pre-clinical studies, with evidence for its beneficial impact on cognition. Future investigation in large-size, double-blind clinical trials is warranted to establish the impact of GA immunomodulation on neuroprotection and cognitive preservation in various neurological conditions.

Diagnosis and Treatment of Multiple Sclerosis: A Review

IMPORTANCE

Multiple sclerosis (MS) is an autoimmune-mediated neurodegenerative disease of the central nervous system characterized by inflammatory demyelination with axonal transection. MS affects an estimated 900 000 people in the US. MS typically presents in young adults (mean age of onset, 20-30 years) and can lead to physical disability, cognitive impairment, and decreased quality of life. This review summarizes current evidence regarding diagnosis and treatment of MS.

OBSERVATIONS

MS typically presents in young adults aged 20 to 30 years with unilateral optic neuritis, partial myelitis, sensory disturbances, or brainstem syndromes such as internuclear ophthalmoplegia developing over several days. The prevalence of MS worldwide ranges from 5 to 300 per 100 000 people and increases at higher latitudes. Overall life expectancy is less than in the general population (75.9 vs 83.4 years), and MS more commonly affects women (female to male sex distribution of nearly 3:1). Diagnosis is made based on a combination of signs and symptoms, radiographic findings (eg, magnetic resonance imaging [MRI] T2 lesions), and laboratory findings (eg, cerebrospinal fluid-specific oligoclonal bands), which are components of the 2017 McDonald Criteria. Nine classes of disease-modifying therapies (DMTs), with varying mechanisms of action and routes of administration, are available for relapsing-remitting MS, defined as relapses at onset with stable neurologic disability between episodes, and secondary progressive MS with activity, defined as steadily increasing neurologic disability following a relapsing course with evidence of ongoing inflammatory activity. These drugs include interferons, glatiramer acetate, teriflunomide, sphingosine 1-phosphate receptor modulators, fumarates, cladribine, and 3 types of monoclonal antibodies. One additional DMT, ocrelizumab, is approved for primary progressive MS. These DMTs reduce clinical relapses and MRI lesions (new T2 lesions, gadolinium-enhancing lesions). Efficacy rates of current DMTs, defined by reduction in annualized relapse rates compared with placebo or active comparators, range from 29%-68%. Adverse effects include infections, bradycardia, heart blocks, macular edema, infusion reactions, injection-site reactions, and secondary autoimmune adverse effects, such as autoimmune thyroid disease.

CONCLUSIONS AND RELEVANCE

MS is characterized by physical disability, cognitive impairment, and other symptoms that affect quality of life. Treatment with DMT can reduce the annual relapse rate by 29% to 68% compared with placebo or active comparator.

Safety and efficacy of memantine for multiple sclerosis-related fatigue: A pilot randomized, double-blind placebo-controlled trial

BACKGROUND

Fatigue is one of the most common symptoms in patients with multiple sclerosis (MS). Currently, there is no approved medication for MS-related fatigue.

OBJECTIVE

In this study, we aim to evaluate the safety and efficacy of memantine for improving fatigue in patients with MS.

METHODS

This was a pilot randomized, double-blind, placebo-controlled clinical trial. Eligible patients with relapsing-remitting MS (RRMS) according to the McDonald criteria were randomized to receive either memantine (20 mg/day) or placebo and were assessed at baseline and three months after treatment. The change in the severity of fatigue was determined by the Modified Fatigue Impact Scale (MFIS).

RESULTS

Sixty-four patients were randomly allocated to the memantine (n = 32) and placebo (n = 32) groups. Sixteen patients in the memantine group and 24 patients in the placebo group completed the study. The mean [95% CI] absolute change in MFIS scores from baseline did not differ significantly between the memantine (-5.8 [-12.7 to 1.0]) and placebo (-4.0 [-10.6 to 2.7]) groups (between-group difference: -1.9 [-11.7 to 7.8], P = .702). No serious adverse events were reported, except for dizziness and sedation in four patients in the experimental arm, which resulted in discontinuation.

CONCLUSION

This trial failed to prove any clinical efficacy of memantine for the management of MS-related fatigue. Although memantine was generally well-tolerated, adverse events were among the major causes of dropout in this study.

Improved Detection and Evaluation of Depression in Patients with Chronic Kidney Disease: Validity and Reliability of Screening (PHQ-2) and Diagnostic (BDI-FS-Fr) Tests of Depression in Chronic Kidney Disease

Objective

Depression is underdiagnosed and thus undertreated. This study aimed to validate the French version of the PHQ-2 (Patient Health Questionnaire-2) and BDF-FS-Fr (Beck Depression Inventory-Fast Screen-France) on patients with chronic kidney disease (CKD) living in France.

Method

A cross-sectional study was conducted on 109 patients of the Centre universitaire de maladies rénales, Centre Hospi-talier Universitaire (CHU) de Caen (37 patients with CKD on pre-dialysis and grafting stage, 36 grafted patients, and 36 dialyzed patients).

Statistical Approach

Test parameters and statistical aspects of assessing diagnostic and screening tests were used, including knowledge of and ability to calculate, sensitivity, specificity, positive and negative predictive values, diagnostic odds ratios, and the use of ROC (receiver operating characteristic) curves.

Results

PHQ-2 and BDI-FS-Fr statistical parameters for depression tested very positively and had a satisfactory AUC (area under the curve). The PHQ-2 had a satisfactory AUC > 0.70, sensitivity > 0.60, and specificity > 0.80. The BDI-FS-Fr had a satisfactory area under the curve (0.859) with sensitivity (83%) and specificity (0.859); and internal consistency (α = 0.668). The PHQ-2 and BDI-FS-Fr showed good internal and external validity of structure, construct validity, criterion validity, discriminant validity, internal consistency, and factorial validity.

Conclusion

The French versions of the PHQ-2 and BDI-FS have highly favorable psychometric properties. These instruments are valid self-assessment tools for screening and evaluating depression, its intensity, and its evolution. The PHQ-2 and BDI-FS-Fr thus have very good psychometric properties and are useful tools for researchers and practitioners. Regarding clinical practice in the hospital, clinicians and nurses can use the PHQ-2 to screen quickly for depression during routine consultations, during hospitalization, and in dialysis centers. The 7 items of the BDI-FS-Fr enable us to assess the depressive state, thereby avoiding a false diagnosis of depression among CKD patients in a clinical setting.

Resilience and depression/anxiety symptoms in multiple sclerosis and neuromyelitis optica spectrum disorder

BACKGROUND

Depression and anxiety are common in multiple sclerosis (MS) and recently, studies on these symptoms in neuromyelitis optica spectrum disorder (NMOSD) are increasing. Previous studies suggest that these symptoms have negative effects on the quality of life. Resilience has garnered more interest as one of the protective factors that works to prevent psychiatric symptoms in past decades. There exist a few studies, however, regarding the effects of resilience on these psychiatric symptoms in MS/NMOSD.

OBJECTIVE

The aim of this study was to clarify the relationships between resilience, psychiatric symptoms, and QOL in patients with MS/NMOSD.

METHOD

Seventy-seven patients with MS/NMOSD participated in this study. They completed several questionnaires (Beck Depression Inventory-Second edition, Hospital Anxiety and Depression Scale, the Japanese version of the Resilience scale [RS], and Japanese version of Multiple Sclerosis Quality of Life-54). We also collected demographic and clinical data including age, sex, physical disability level (measured with the Expanded Disability Status Scale [EDSS]), and disease duration of the participants.

RESULTS

The EDSS scores showed significant negative correlations with QOL, unlike disease duration, which did not correlate with either the psychiatric symptoms or QOL. Additionally, there was no significant correlation between RS scores and EDSS scores or disease duration. We also found that resilience showed a significant negative correlation with psychiatric symptoms, and positive correlation with QOL.

CONCLUSION

These results suggest that resilience may serve to prevent or reduce depression/anxiety symptoms and maintain the QOL regardless of the physical disability level.

Validity of Arabic version of the two-question Quick Inventory of Depression (QID-2-Ar): Screening for multiple sclerosis in an Arab environment and during the Syrian war

PURPOSE

This study aimed to validate the Arabic version of the two-question Quick Inventory of Depression (QID-2-Ar) in multiple sclerosis (MS) patients living in Syria during the war.

METHODS

A total of 100 Syrian MS patients, aged 18-60 years, were recruited at Damascus Hospital and Ibn Al-Nafees Hospital to validate the QID-2-Ar, including analyses of its screening test parameters and its construct validity.

RESULTS

The QID-2-Ar screening parameters for depression tested very positively, and its construct validity was also favorable (P<0.01).

CONCLUSION

The QID-2-Ar is a good screening test for detecting depression. Using a threshold score of ≥1 rather than 2 resulted in more depressed patients being correctly identified. The Arabic version of the QID-2-Ar also has highly favorable psychometric properties. It is valid for assessing depression, especially the two main depressive symptoms (depressive mood and anhedonia) listed in DSM-V. This is a useful tool for researchers and practitioners, and a threshold score of 2 on the QID-2-Ar is recommended to be more certain that all those with depression are detected without having to use a complete depression questionnaire such as the Beck Depression Inventory (BDI)-II.

Mental Health Comorbidity in MS: Depression, Anxiety, and Bipolar Disorder

Among individuals with multiple sclerosis (MS), mental health comorbidities play a significant role in contributing to secondary disability and detracting from quality of life. This review examines current evidence surrounding three mental health issues of particular relevance to MS: depression, anxiety, and bipolar disorder. We review what is known of the prevalence, correlates, screening mechanisms, and current treatment of each issue and provide recommendations for future areas of research.

Characterizing the phenotype of multiple sclerosis–associated depression in comparison with idiopathic major depression

Background:

Depression is a common co-morbidity in patients with multiple sclerosis (MS). While somatic symptoms of MS correlate with depression levels, it is unclear whether the clinical presentation of MS-associated depression differs from patients with “idiopathic” major depressive disorder (MDD).

Objective:

To compare the clinical phenotype of depression among MS and idiopathic MDD patients.

Methods:

Mean relative contribution of individual Beck Depression Inventory-II (BDI-II) items was evaluated among n = 139 patients with relapsing-remitting MS and n = 85 MDD patients without somatic illness. Next, comparisons were repeated in n = 38 MS with clinically relevant depressive symptoms (BDI-II > 19) and n = 38 MDD patients matched for sex, age, and depression severity. Finally, the underlying construct of depression was compared across groups using confirmatory factor analysis (CFA).

Results:

Comparisons on a whole-group level produced the expected differences along somatic/non-somatic symptoms. However, when appropriately controlling for depression severity, age, and sex, only four items contributed differentially to BDI-II total scores in MS versus MDD. CFA suggested that the underlying depression construct is essentially identical in both groups.

Conclusion:

The clinical phenotype of “idiopathic” MDD and MS-associated depression appears similar when adequately examined. The relevance of these findings for psychotherapeutic approaches for MS-associated depression should be explored in future studies.

Risk factors for suicide in multiple sclerosis: a case-control study

ABSTRACT Objective To evaluated the prevalence and the suicide risk in a Brazilian sample of patients with multiple sclerosis (MS) and to identify potential factors associated with the risk of suicide. A study was performed with outpatient with MS. The risk of suicide and the presence of psychiatric disorders were assessed by version 5.0 of the Mini-International Neuropsychiatric Interview (MINI). The sample of patients at risk for suicide was matched by sex and age to a control group of patients with MS. Results Eight point three percent of the patients had a past history of attempted suicide, and 8.3% had a current suicide risk, totaling 16.6%. The results of this study suggest that the risk factors associated with suicide in this population are depression, marital status single, widowed or divorced, and lower education level.

Lifestyle factors, demographics and medications associated with depression risk in an international sample of people with multiple sclerosis

BACKGROUND

Depression is the most common co-morbidity for people with Multiple Sclerosis (MS); irrespective of disease severity, depression has the greatest impact on quality of life. An emerging paradigm in the treatment of depression is lifestyle medicine. There is significant potential to prevent and treat depression through modification of lifestyle risk factors for people with MS. This study sought to understand the association between lifestyle risk factors, medication and depression risk through the analysis of self-reported data from a large international sample of people with MS.

METHODS

This cross-sectional analysis recruited a total of 2459 participants via Web 2.0 platforms. Survey data included socio-demographics; a range of lifestyle risk factors; medication; disease variables and depression risk using the Patient Health Questionnaire-2 (PHQ-2).

RESULTS

In total approximately one fifth (19.3%) of our sample screened positive for depression (PHQ-2 score ≥3). Several demographic factors were significantly associated with this depression risk in bivariate analysis. Regression analyses showed that poor diet, low levels of exercise, obesity, smoking, marked social isolation and taking interferon were associated with greater depression risk. Participants who supplemented with omega 3s, particularly flaxseed oil, had frequent fish consumption, supplemented with vitamin D, meditated, and had moderate alcohol consumption had significantly reduced depression risk.

CONCLUSIONS

This study demonstrates a significant association between modifiable lifestyle factors and depression risk. Planned longitudinal follow up may clarify causality. Clinicians and people with MS should be aware of the wide range of modifiable lifestyle factors that may reduce depression risk as part of a comprehensive secondary and tertiary preventive medical approach to managing MS.