Treatment of depression in people who have multiple sclerosis

Clinical Practice Guidelines for the Detection and Treatment of Depression in Multiple Sclerosis: A Systematic Review

Purpose of Review

The association of multiple sclerosis (MS) with depression has been well documented; however, it frequently remains undiagnosed, untreated, or undertreated, with consequences to the person, family, and economy. The aim of this study was to determine the quality, scope, and consistency of available guidelines and consensus statements to guide clinicians managing people with comorbid MS and depression.

Recent Findings

Based on our systematic search of the literature, 6 guidelines and consensus statements met the inclusion criteria. Of these, 4 presented recommendations on depression screening in MS and 5 offered recommendations for treatment. Despite most guidelines presenting evidence-based recommendations, they were generally of low-quality evidence overall. Inconsistencies identified across guidelines and consensus statements included variations in recommendation for routine screening and which screening tool to use. Most guidelines lacked detail, often referring to general population guidelines without describing to what extent they can be applied to people with MS.

Summary

The findings of this review highlight the need to develop high-quality, comprehensive clinical practice guidelines with clear recommendations that can be globally implemented by healthcare clinicians working with people with MS.

The Mediating Role of Stigma, Internalized Shame, and Autonomous Motivation in the Relationship Between Depression, Anxiety, and Psychological Help-Seeking Attitudes in Multiple Sclerosis

BACKGROUND

Depression and anxiety are commonly experienced in individuals with multiple sclerosis (MS) yet little is known about factors associated with psychological help-seeking attitudes in those with MS.

METHOD

The current study investigated whether increased stigma related to chronic illness, internalized shame, and autonomous motivation mediated the relationship between depressive and anxiety symptoms and psychological help-seeking attitudes in individuals with MS. Two hundred fifty-four participants with MS completed an online questionnaire assessing depressive and anxiety symptoms, stigma related to chronic illness, internalized shame, autonomous motivation, and psychological help-seeking attitudes.

RESULTS

Stigma related to chronic illness, internalized shame, and autonomous motivation mediated the relationships between increased depressive symptoms and anxiety symptoms and psychological help-seeking attitudes. The study also found that higher levels of chronic illness-related stigma and internalized shame were associated with more negative psychological help-seeking attitudes and higher autonomous motivation was associated with more positive psychological help-seeking attitudes. There were no direct effects of depressive or anxiety symptoms on psychological help-seeking attitudes.

CONCLUSION

The significant mediating roles of stigma-related chronic illness, internalized shame, and autonomous motivation indicate that these factors may be useful to include in future depression and anxiety intervention studies targeting MS populations.

Computerized Cognitive Behavioral Therapy for Treatment of Depression in Multiple Sclerosis: A Narrative Review of Current Findings and Future Directions

Depression is common in multiple sclerosis (MS), affecting up to 50% of patients at some point in their lifetime. Although the rate of depression in MS is higher than that in the general population and that in patients with other chronic medical conditions, depression in MS is underdiagnosed and undertreated. Antidepressant agents are used empirically in the management of MS-related depression, but evidence specifically demonstrating the efficacy of these medications in patients with MS is sparse. Considerable work suggests that psychological interventions such as cognitive behavioral therapy (CBT) may be effective in the management of depression in MS. Recently there has been an expansion of computerized adaptations of CBT, allowing patients to complete therapy sessions remotely via online programs. This article reviews our current understanding of depression in MS and the role of CBT in its management, focusing on recent developments in computerized formats for CBT. Four computerized CBT programs that have been previously tested in patients with MS are described: Deprexis, MoodGYM, Beating the Blues, and MS Invigor8. We conclude that despite challenges inherent to computerized CBT interventions, such platforms have the potential to positively affect mental health care delivery to the MS patient population.

The Relational Impact of Multiple Sclerosis: An Integrative Review of the Literature Using a Cognitive Analytic Framework

This integrative literature review uses cognitive analytic therapy (CAT) theory to examine the impact of a chronic illness, multiple sclerosis (MS), on relationships and mental health. Electronic searches were conducted in six medical and social science databases. Thirty-eight articles met inclusion criteria, and also satisfied quality criteria. Articles revealed that MS-related demands change care needs and alter relationships. Using a CAT framework, the MS literature was analysed, and five key patterns of relating to oneself and to others were identified. A diagrammatic formulation is proposed that interconnects these patterns with wellbeing and suggests potential “exits” to improve mental health, for example, assisting families to minimise overprotection. Application of CAT analysis to the literature clarifies relational processes that may affect mental health among individuals with MS, which hopefully will inform how services assist in reducing unhelpful patterns and improve coping. Further investigation of the identified patterns is needed.

Depression in Multiple Sclerosis: Epidemiology, Aetiology, Diagnosis and Treatment

Depressive disorders are common in patients with multiple sclerosis, influencing their quality of life and adherence to treatments, as well as becoming more frequent with the progression of the disease and in the secondary progressive form of multiple sclerosis. Patients with multiple sclerosis often experience a typical cluster of symptoms in association with depression, such as fatigue, pain and cognitive impairment. However, the pathogenesis of multiple sclerosis-related depression remains partially unclear, even though genetic, immune-inflammatory and psychosocial factors might be seen to play a role, in addition to the brain structural alterations documented by magnetic resonance imaging studies. The high incidence and burden of depression in people affected with multiple sclerosis are matters of crucial importance. Despite such importance, the efficacy of pharmacologic treatments has been poorly studied and, for the most part, the access to non-pharmacological treatments is partially dependent on the local health system availability. It has been determined that interferon-beta and glatiramer acetate do not cause depressive symptoms; however, no definitive data in this regard are avaible for the newer disease-modifyng medications. In this review, we discuss the diagnosis, prevalence, pathogenesis, clinical aspects, magnetic resonance imaging findings and treatments available in patients experiencing multiple sclerosis-related depression.

A systematic review of the effectiveness of self-management interventions in people with multiple sclerosis at improving depression, anxiety and quality of life

BACKGROUND

Self-management interventions have become increasingly popular in the management of long-term health conditions; however, little is known about their impact on psychological well-being in people with Multiple Sclerosis (MS).

PURPOSE

To examine the effectiveness of self-management interventions on improving depression, anxiety and health related quality of life in people with MS.

METHOD

A structured literature search was conducted for the years 2000 to 2016. The review process followed the PRISMA guidelines, and is registered with PROSPERO (no. CRD42016033925).

RESULTS

The review identified 10 RCT trials that fulfilled selection criteria and quality appraisal. Self-management interventions improved health-related quality of life in 6 out of 7 studies, with some evidence of improvement in depression and anxiety symptoms.

CONCLUSION

Although the results are promising more robust evaluation is required in order to determine the effectiveness of self-management interventions on depression, anxiety and quality of life in people with MS. Evaluation of the data was impeded by a number of methodological issues including incomplete content and delivery information for the intervention and the exclusion of participants representing the disease spectrum. Recommendations are made for service development and research quality improvement.

Depression Treatment among Adults with Multiple Sclerosis and Depression in Ambulatory Care Settings in the United States

Background. There is little information regarding depression treatment patterns among adults with MS and depression in ambulatory settings at national level in the United States (US). Objectives. The objectives of this study were to identify patterns and predictors of depression treatment in ambulatory settings in US among adults with MS and depression. Methods. A cross-sectional study was conducted by pooling multiple years (2005–2011) of National Ambulatory Medical Care Survey and the outpatient department of the National Hospital Ambulatory Medical Care Survey data. The final study sample was comprised of ambulatory visits among adults with MS and depression. Dependent variable of this study was pharmacological treatment for depression with or without psychotherapy. Predictors of depression treatment were determined by conducting multivariable logistic regression. Results. Out of all ambulatory visits involving MS diagnosis, 20.59% also involved a depression diagnosis. Depression treatment was observed in 57.25% of the study population. Fluoxetine was the most prescribed individual antidepressant. Age and total number of chronic diseases were significant predictors of depression treatment. Conclusion. Approximately six out of ten ambulatory visits involving MS and depression recorded some form of depression treatment. Future longitudinal studies should examine health outcomes associated with depression treatment in this population.

Reliability and validity of the Attributional Style Questionnaire- Survey in people with multiple sclerosis

BACKGROUND

The current study aimed to examine the psychometric properties of an attributional style measure that can be administered remotely, to people who have multiple sclerosis (MS).

METHODS

A total of 495 participants with MS were recruited. Participants completed the Attributional Style Questionnaire-Survey (ASQ-S) and two comparison measures of cognitive variables via postal survey on three occasions, each 12 months apart. Internal reliability, test-retest reliability and congruent validity were considered.

RESULTS

The internal reliability of the ASQ-S was good (α > 0.7). The test-retest correlations were significant, but failed to reach the 0.7 set. The congruent validity of the ASQ-S was established relative to the comparisons.

CONCLUSIONS

The psychometric properties of the ASQ-S indicate that it shows promise as a tool for researchers investigating depression in people with MS and is likely sound to use clinically in this population.

A single-group pilot feasibility study of cognitive behavioural therapy in people with multiple sclerosis with depressive symptoms

PURPOSE

The aims were to evaluate (a) the feasibility of face-to-face cognitive behavioural therapy (CBT) in people with MS (PwMS) with depressive symptoms; (b) the feasibility of methods and measurements used; and (c) the outcome of the intervention before the conducting of an equivalence study of comparative methods of face-to-face CBT.

DESIGN

A single-group pilot feasibility study.

PATIENTS

PwMS (n = 15) with sub-threshold to moderate depressive symptoms, recruited at the Karolinska University Hospital, Stockholm, Sweden.

METHODS

The intervention consisted of 15-20 sessions of face-to-face CBT. Feasibility outcomes included recruitment rate, recruitment procedure and adverse events. Primary clinical outcome was the Beck Depression Inventory-II (BDI-II). Follow-ups were conducted after 3 weeks and 3 months. An estimated sample size calculation was conducted.

RESULTS

The face-to-face CBT intervention, methods and measurements used were feasible. The outcome on BDI-II indicated that face-to-face CBT is an effective method for alleviating sub-threshold to moderate depressive symptoms in PwMS.

CONCLUSION

Face-to-face CBT is feasible for use in PwMS aiming at decrease depressive symptoms. For an equivalence study, a screening process for depressive symptoms and two comparative intervention arms including traditional face-to-face CBT and low-intensity face-to-face CBT is recommended. Primary outcomes should include the BDI-II and also assessment of anxiety symptoms. Implications for Rehabilitation Depression is common among people with MS (PwMS), however, depressed PwMS do not always receive adequate treatment for depression which may lead to increased disability and worse health-related quality of life (HRQL). Cognitive behavioural therapy (CBT) is a psychological treatment method that might be beneficial for PwMS with depressive symptoms, but the evidence is still weak and further research is needed. The results from our pilot feasibility study demonstrate that for an effectiveness study of face-to-face CBT for PwMS with sub-threshold to moderate depressive symptoms the following points should be acknowledged. The design of an effectiveness study should be a randomized controlled trial including two treatment arms: traditional face-to-face CBT and a low-intensity face-to-face CBT. To increase the inclusion rate a screening process for depressive symptoms is recommended. Primary outcomes besides the Beck Depression Inventory-II should include the Hospital Anxiety and Depression Scale in order to capture anxiety symptoms and the Multiple Sclerosis Impact Scale-29 to capture HRQL.

Effect of neurofeedback training on depression and fatigue in patients with multiple sclerosis

Depression and fatigue are common symptoms of multiple sclerosis (MS) and are the primary determinants of impaired quality of life in this demyelinating neurological disease. Untreated depression is associated with suicidal ideation, impaired cognitive function and poor adherence to immunomodulatory treatment. For these reasons, systematic screening and management of depressive symptoms and fatigue is recommended for all patients with MS. The objective of this study was to evaluate the effectiveness of neurofeedback in treating depression and fatigue in persons with MS. We conducted a randomized trial with 24 MS patients with primary fatigue and depression. Participants were randomized into two groups: neurofeedback training group (16 sessions of NFB) or treatment as usual. Participants were evaluated at 3 time points (baseline, end of the treatment, and 2-month follow-up) using the Fatigue Severity Scale and Depression subscale of the Hospital Anxiety and Depression Scale as outcome measures. A repeated measures analysis of variance was used to examine differences between the groups. NFB significantly reduced symptoms of depression and fatigue in patients with MS patients, compared to treatment as usual (p < .05), and these effects were maintained the 2-month follow-up (p < .05).

Exploration of Undertreatment and Patterns of Treatment of Depression in Multiple Sclerosis

BACKGROUND

Depression is a common comorbid condition with multiple sclerosis (MS). Historically, however, it has been undertreated. Little is known about the characteristics of those who receive, or do not receive, treatment for depression in the MS population. This study evaluated depression treatment in patients with MS, associated patient characteristics, and probable determinants of antidepressant drug use in those with and without depression.

METHODS

A total of 152 patients with MS completed questionnaires and the Structured Clinical Interview for DSM-IV-TR (SCID) to determine depression status. Tabular analyses and a binary regression model were used to identify patient characteristics associated with antidepressant drug use.

RESULTS

Of participants with major depression according to the SCID, 65% were taking antidepressant medications. With adjustment for successful treatment (antidepressant drug use by those not currently depressed and currently depressed), the prevalence of treated depression increased to 85.7%. Of those receiving treatment for depression, 19% were receiving nonpharmacologic treatment alone, 38% were taking antidepressant drugs only, and 44% were receiving both pharmacologic and nonpharmacologic treatments. Demographic and clinical variables were not statistically significantly associated with antidepressant drug use in those with depression.

CONCLUSIONS

A large proportion of participants with depression in MS are now receiving treatment, a change from previous reports. The adequacy of treatment has become a bigger question because many of the treated patients continued to have depressive symptoms. Further research is needed to identify ways to achieve better outcomes for depression.

A systematic review of the incidence and prevalence of comorbidity in multiple sclerosis: overview

Background:

Comorbidity is an area of increasing interest in multiple sclerosis (MS).

Objective:

The objective of this review is to estimate the incidence and prevalence of comorbidity in people with MS and assess the quality of included studies.

Methods:

We searched the PubMed, SCOPUS, EMBASE and Web of Knowledge databases, conference proceedings, and reference lists of retrieved articles. Two reviewers independently screened abstracts. One reviewer abstracted data using a standardized form and the abstraction was verified by a second reviewer. We assessed study quality using a standardized approach. We quantitatively assessed population-based studies using the I² statistic, and conducted random-effects meta-analyses.

Results:

We included 249 articles. Study designs were variable with respect to source populations, case definitions, methods of ascertainment and approaches to reporting findings. Prevalence was reported more frequently than incidence; estimates for prevalence and incidence varied substantially for all conditions. Heterogeneity was high.

Conclusion:

This review highlights substantial gaps in the epidemiological knowledge of comorbidity in MS worldwide. Little is known about comorbidity in Central or South America, Asia or Africa. Findings in North America and Europe are inconsistent. Future studies should report age-, sex- and ethnicity-specific estimates of incidence and prevalence, and standardize findings to a common population.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Relationship between disease-modifying therapy and depression in multiple sclerosis

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

Work productivity in relapsing multiple sclerosis: associations with disability, depression, fatigue, anxiety, cognition, and health-related quality of life

OBJECTIVES

To characterize work productivity in relapsing multiple sclerosis (MS) by using a work productivity scale and to identify associations between work productivity and disability, depression, fatigue, anxiety, cognition, and health-related quality of life.

METHODS

Three hundred seventy-seven subjects with a clinically isolated syndrome or relapsing remitting MS participated in the study. Subjects underwent neurological examinations and completed patient-reported outcome and cognitive measures. Subjects also completed the Work Productivity and Activity Impairment Questionnaire: General Health to quantify absenteeism (missing work because of health problems), presenteeism (impairment while working), overall work impairment, and daily activity impairment attributable to health problems. Univariate correlations and multivariate models were used to determine the associations between each work productivity variable and clinical, patient-reported outcome, and cognitive measures.

RESULTS

Seventy-six percent of subjects were employed. Fourteen percent of working subjects reported absenteeism, and 47% reported presenteeism. The mean work time lost because of absenteeism was 4%, and the mean work time lost because of presenteeism was 12%. Absenteeism was not significantly associated with disease or patient-reported outcome measures. Statistically significant correlations (0.32-0.53) were found between presenteeism and increasing disability, fatigue, depression, anxiety, and reduced quality of life. No associations were observed between presenteeism and disease duration or cognitive function.

CONCLUSIONS

Subjects with clinically isolated syndrome/relapsing remitting MS reported substantial work productivity losses due to presenteesim. Presenteeism was associated with increasing fatigue, depression, anxiety, and reduced quality of life. It is possible that the early identification and treatment of fatigue and mental health symptoms may improve productivity while working and extend employment for individuals with MS.

Depression in multiple sclerosis: a review of assessment and treatment approaches in adult and pediatric populations

Multiple sclerosis is a chronic demyelinating disease affecting one million people worldwide, with a significant burden of psychiatric comorbidity. Depression is the commonest psychiatric manifestation but still remains largely underdiagnosed and undertreated. The present work reviews current knowledge on diagnosis, assessment, and somatic and psychotherapeutic treatment interventions for depression in adult and pediatric populations of patients with multiple sclerosis.

Patients feeling severely affected by multiple sclerosis: how do patients want to communicate about end-of-life issues?

OBJECTIVE

Investigate multiple sclerosis patients' desire to communicate with their physicians about their disease progression and end-of-life issues.

METHODS

Persons meeting the inclusion criteria of feeling severely affected by MS were invited via the German MS society to complete a needs questionnaire. Replies to questions on physician empathy and wishes about communication regarding disease progression and death and dying were quantitatively analyzed. Endpoints (point 1+2/4+5) of 5-point-likert scales are summarized under results.

RESULTS

573 of 867 questionnaires meeting our criteria were analyzed. In response to a general question 64% (n = 358) indicated a wish for disease progression and death and dying to be addressed by their doctor. A majority (76%, n = 427) considered it important that progression of their disease be discussed, while 44% (n = 246) regard addressing death and dying as unimportant. No objective disease criteria could be identified to explain the wish for communicating end-of-life issues. Doctors who were retrospectively viewed as avoiding raising critical aspects of the illness were perceived as less empathetic (p < 0.001).

CONCLUSION

People with MS have a desire to talk about progression of their disease with their doctors.

PRACTICE IMPLICATIONS

Physicians should be empathetic in raising critical aspects of the patients' illness individually.

A nurse-led mental health service for people with multiple sclerosis

BACKGROUND

Mental health problems are under recognised and under treated in people with multiple sclerosis (MS).

METHOD

A nurse-led project linking MS and mental health services was evaluated. Data on all referrals and management from 2006 to 2008 were collected prospectively.

RESULTS

127 referrals were received. 82% had depression, 53% had anxiety (45% both). 42% were offered case management; 52% received Cognitive Behaviour Therapy (CBT), 55% required initiation or alteration of psychiatric medications and 19% were referred to secondary care; 16% had made suicidal plans. Significant improvements in depression at 6months occurred, but not anxiety or fatigue.

CLINICAL IMPLICATIONS

This service provides a model of mental health provision for patients with long term neurological conditions, in particular MS.

Computerised cognitive behavioural therapy for the treatment of depression in people with multiple sclerosis: external pilot trial

Background

People with multiple sclerosis (MS) are at high risk of depression. We undertook a pilot trial of computerised cognitive behavioural therapy (CCBT) for the treatment of depression in people with MS to test the feasibility of undertaking a full trial.

Methods

Participants with a diagnosis of MS and clinical levels of depression were recruited through out-patient clinics and postal screening questionnaires at two UK centres and randomised to CCBT or usual care. Clinical outcomes included the Beck Depression Inventory (BDI-II) and Multiple Sclerosis Impact Scale (MSIS-29) at baseline, 8 and 21 weeks. Feasibility outcomes included: recruitment rate; reasons for refusal, withdrawal and dropout; feasibility and acceptability of the proposed outcome measures; sample size estimation and variation in and preferences for service delivery.

Results

Twenty-four participants were recruited. The recruitment rate, calculated as the proportion of those invited to fill in a screening questionnaire who were consented into the trial, was 4.1%. Recruitment through out-patient clinics was somewhat slower than through screening questionnaire mail-out but the overall recruitment yield was similar. Of the 12 patients in the CCBT arm, 9 (75%) completed at least four, and 6 completed all 8 CCBT sessions. For completers, the median time (IQR) to complete all eight CCBT sessions was 15 (13 to 20) weeks. Participants expressed concern about the face validity of the Beck Depression Inventory II for the measurement of self-reported depression in people with MS. The MSIS-29 was the patient-reported outcome measure which participants felt best reflected their concerns. The estimated sample size for a full trial is between 180 and 390 participants. NHS partners were not delivering CCBT in community facilities and participants preferred to access CCBT at home, with no one expressing a preference for use of CCBT in an alternative location.

Conclusions

A definitive trial, with a recruitment window of one year, would require the participation of around 13 MS centres. This number of centres could be reduced by expanding the eligibility criteria to include either other neurological conditions or people with more severe depression. The MSIS-29 should be used as a patient-important outcome measurement.

Trial registration

ISRCTN: ISRCTN81846800

The relationships between depression and life activities and well-being of multiple sclerosis patients

Multiple sclerosis (MS) is one of the most disabling neurodegenerative disorders. Depression is the most frequent psychiatric disorder accompanying MS. Although much attention is given to correlations between depression and MS clinical factors, analysis of correlations between depression and life activities (social, household, professional activities and family life) and the well-being of MS patients’ is insufficient. However, improvement of these functions could positively influence the outcomes of MS treatment. The aim of this study was to evaluate relationships between depression, life activities of MS patients, and their proposals how to improve the well-being. Materials and methods. The study lasted three years with 270 adult MS patients involved in it. ICD-10 criteria were used to diagnose depression. Original questionnaire was used to measure life activities and the well-being of the patients. Results. Prevalence of depression was 20.7% with no difference regarding the gender. Almost 84% of depressed respondents indicated, that MS disturbs their family life, 71.4% recommended to assign more attention to MS in general and 64.3% — to include more medications into reimbursement list. Conclusions. MS patients diagnosed with depression significantly more often than non-depressed indicate that MS disturbs their family life; recommend to assign more attention to MS in general and to include more medications into reimbursement list.

Symptomatic management in multiple sclerosis

The development of immunomodulatory therapies for multiple sclerosis (MS) has had significant impact in altering the natural history of the disease. Although these agents reduce relapse rate and MRI-associated disease activity, they are only partially effective and do not ameliorate irreversible axonal injury, which produces much of the symptomatic burden of MS. Treatment of MS-associated symptoms remains an essential cornerstone of comprehensive care of patients with MS and, arguably, more favorably enhances quality of life than do the disease-modifying medications. This article reviews strategies of symptom management in patients with MS.

Effects of whole-body cryotherapy on a total antioxidative status and activities of antioxidative enzymes in blood of depressive multiple sclerosis patients

OBJECTIVES

Oxidative stress (OS) plays an important role in the pathogenesis of multiple sclerosis (MS). In MS patients depression is often observed. Cryotherapy might have an effect on OS. The aim of this study was to compare the effects of whole body cryotherapy (WBCT) on changes in total antioxidative status (TAS) of plasma and activities of antioxidative enzymes in erythrocytes from depressive and non depressive MS patients.

METHODS

Twenty-two MS patients with secondary progressive disease course (12 depressive and 10 non depressive) were treated with 10 exposures in a cryochamber. Before and after WBCT the plasma TAS and the activities of superoxide dismutase (SOD) and catalase (CAT) in the erythrocytes were measured.

RESULTS

The level of TAS in depressive MS group was significantly lower than in non depressive MS (P < 0.0003). WBCT increased the level of TAS in depressive (P < 0.002) more than in non depressive MS patients (P < 0.01). WBCT treatment of MS patients resulted in the significant increase of TAS level in plasma but had no effects on activities of SOD and CAT.

CONCLUSIONS

Our results indicate that WBCT suppresses OS in MS patients, especially in depressive patients.

Challenges in screening for depression in multiple sclerosis

BACKGROUND

Screening has frequently been proposed as a strategy for detection of depression in multiple sclerosis (MS). In a recent study, we found a minimal impact of screening, even when this was coupled with rapidly responsive and evidence-based depression care.

METHODS

In order to explore the challenges involved in screening we analyzed prospective data from the Canadian Impact of MS (CIMS) database, which provides annual ratings on a self-report depression rating scale, the Center for Epidemiologic Studies Depression Rating Scale (CES-D).

RESULTS

Approximately 30% of respondents screened positive at each visit. CES-D ratings correlated fairly strongly from year to year, Pearson's r ranged from 0.65 to 0.73. Approximately 10% of those below the CES-D cut-point at each assessment exceeded the cut-point when rated 1 year later, but only about half of these cases had large (≥10 points) increases in their scores.

CONCLUSIONS

Screening interventions are generally oriented towards early detection, whereas the longitudinal pattern of depressive symptoms in MS appears to be characterized more prominently by a persistent burden of depressive symptoms in a substantial proportion of the population. Resources invested in screening efforts can probably be more effectively deployed in other areas, such as improved long-term clinical management.

The impact of regular physical activity on fatigue, depression and quality of life in persons with multiple sclerosis

BACKGROUND

The purpose of this study was to compare fatigue, depression and quality of life scores in persons with multiple sclerosis who do (Exercisers) and do not (Non-exercisers) regularly participate in physical activity.

METHODS

A cross-sectional questionnaire study of 121 patients with MS (age 25-65 yr) living in Queensland, Australia was conducted. Physical activity level, depression, fatigue and quality of life were assessed using the International Physical Activity Questionnaire, Health Status Questionnaire Short Form 36, Becks Depression Inventory and Modified Fatigue Impact Scale.

RESULTS

52 participants performed at least two 30-min exercise sessions x wk-1 (Exercisers) and 69 did not participate in regular physical activity (Non-exercisers). Exercisers reported favourable fatigue, depression and quality of life scores when compared to Non-exercisers. Significant weak correlations were found between both leisure-time and overall reported physical activity levels and some subscales of the quality of life and fatigue questionnaires. Additionally, some quality of life subscale scores indicated that regular physical activity had a greater benefit in subjects with moderate MS.

CONCLUSION

Favourable fatigue, depression and quality of life scores were reported by persons with MS who regularly participated in physical activity, when compared to persons with MS who were classified as Non-exercisers.

Disease management for depression in an MS clinic

OBJECTIVE

Evidence-based treatments for depression in multiple sclerosis (MS) are available, but their implementation can be challenging. We explored the feasibility and effectiveness of implementing a disease management program for depression in an MS clinic.

METHODS

A non-randomized "before-after" design was used. The University of Calgary MS Clinic performs routine screening for depression using the Center for Epidemiologic Studies Depression Rating Scale (CES-D). During a six month baseline period, the screen results were not systematically acted upon. During a subsequent nine-month study period, a case manager was routinely notified of positive screens. These patients were offered disease management. Major depression was assessed six months later with a blind administration of the Mini Neuropsychiatric Interview (MINI). Quality of life (EQ-5D) and functional status (WHO DAS II) were also measured.

RESULTS

Eighty-three patients were enrolled in the study; 54 were in the disease management group and 29 received treatment as usual. There was a lower frequency of major depression in the intervention group six months post-screening. No differences in quality of life or functional status were seen.

CONCLUSIONS

Disease management approaches for depression were developed in primary care environments and have been adapted for geriatric and diabetic populations. These strategies may require modification for application in MS clinics. While an intervention for depression was effective in those who received it, its impact on the targeted clinical population was reduced by lower than expected rates of participation and higher than expected rates of treatment at baseline.