Risk of depression and anxiety in multiple sclerosis and neuromyelitis optica spectrum disorder: A nationwide cohort study in South Korea

BACKGROUND

We investigated the risks of depression/anxiety in patients with multiple sclerosis (pwMS) or patients with neuromyelitis optica spectrum disorder (pwNMOSD).

OBJECTIVES

MS/NMOSD cohorts were collected from Korean National Health Insurance Service, using the International Classification of Diseases-10th and information on Rare Intractable Disease program. Patients who were younger than 20 years, had a previous depression/anxiety, or died in the index year were excluded.

METHODS

Hazard ratios (HRs) of depression/anxiety in pwMS and pwNMOSD from controls matched 1:5 for age, sex, hypertension, diabetes, and dyslipidemia were calculated using Cox regressions with a 1-year lag period and estimated over time.

RESULTS

During a mean follow-up of 4.1 years, adjusted hazard ratios (aHR) for depression were 3.25 (95% confidence interval (CI) = 2.59-4.07) in MS and 2.17 (1.70-2.76) in NMOSD, and aHRs for anxiety were 1.83 (1.49-2.23) in MS and 1.56 (1.26-1.91) in NMOSD. The risks of anxiety/depression did not differ between MS and NMOSD and were highest in the second year after diagnosis of MS/NMOSD. The relative risk of depression was higher in younger pwMS/pwNMOSD, and the relative risk of anxiety was higher in pwMS who was male, had low income, or lived in a non-urban area.

CONCLUSION

The risk of depression and anxiety was increased in pwMS/pwNMOSD.

The significance of cerebrospinal fluid analysis in the differential diagnosis of 564 psychiatric patients: Multiple sclerosis is more common than autoimmune-encephalitis

The analysis of cerebrospinal fluid (CSF) is an essential tool for the differential diagnosis of psychiatric disorders caused by autoimmune inflammation or infections. Clear guidelines for CSF analysis are limited and mainly available for schizophrenia and dementia. Thus, insights into CSF changes in psychiatric patients largely derive from research. We analyzed the clinical and CSF data of 564 psychiatric patients without pre-existing neurological diagnoses from March 1998 to April 2020. Primary aim was to detect previously undiagnosed neurological conditions as underlying cause for the psychiatric disorder. Following CSF analysis, 8 % of patients (47/564) were diagnosed with a neurological disorder. This was the case in 12.0 % (23/193) of patients with affective disorders, 7.2 % (19/262) of patients with schizophrenia, and 4.0 % (23/193) of patients with anxiety disorders. The predominant new diagnoses were multiple sclerosis (19/47) and autoimmune encephalitis (10/47). Abnormal CSF findings without any implications for further treatment were detected in 17.0 % (94/564) of patients. Our data indicates that CSF analysis in patients suffering from psychiatric disorders may uncover underlying organic causes, most commonly multiple sclerosis and autoimmune encephalitis. Our findings imply that the incorporation of CSF analysis in routine psychiatric assessments is potentially beneficial.

The future of diagnosis in clinical neurosciences: Comparing multiple sclerosis and schizophrenia

The ongoing developments of psychiatric classification systems have largely improved reliability of diagnosis, including that of schizophrenia. However, with an unknown pathophysiology and lacking biomarkers, its validity still remains low, requiring further advancements. Research has helped establish multiple sclerosis (MS) as the central nervous system (CNS) disorder with an established pathophysiology, defined biomarkers and therefore good validity and significantly improved treatment options. Before proposing next steps in research that aim to improve the diagnostic process of schizophrenia, it is imperative to recognize its clinical heterogeneity. Indeed, individuals with schizophrenia show high interindividual variability in terms of symptomatic manifestation, response to treatment, course of illness and functional outcomes. There is also a multiplicity of risk factors that contribute to the development of schizophrenia. Moreover, accumulating evidence indicates that several dimensions of psychopathology and risk factors cross current diagnostic categorizations. Schizophrenia shares a number of similarities with MS, which is a demyelinating disease of the CNS. These similarities appear in the context of age of onset, geographical distribution, involvement of immune-inflammatory processes, neurocognitive impairment and various trajectories of illness course. This article provides a critical appraisal of diagnostic process in schizophrenia, taking into consideration advancements that have been made in the diagnosis and management of MS. Based on the comparison between the two disorders, key directions for studies that aim to improve diagnostic process in schizophrenia are formulated. All of them converge on the necessity to deconstruct the psychosis spectrum and adopt dimensional approaches with deep phenotyping to refine current diagnostic boundaries.

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

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

Association between autoimmune diseases of the nervous system and schizophrenia: A systematic review and meta-analysis of cohort studies

INTRODUCTION

Numerous studies have found an association between autoimmune diseases of the nervous system (ADNS) and schizophrenia (SCZ), but the findings remain controversial. We conducted the first meta-analysis to summarize the current evidence from cohort studies that evaluated the association between ADNS and SCZ.

METHODS

PubMed, Web of Science, and Embase were comprehensively searched until May 30, 2022 for articles on the association between ADNS and SCZ. Every included study was reported effect size with 95% CIs for the association between ADNS and SCZ. Meta-regression and subgroup analysis were used to assess the heterogeneity.

RESULTS

A total of 8 cohort studies with 12 cohorts were included in the meta-analysis. We observed a significant association between ADNS and SCZ (RR = 1.42; 95%CI, 1.18-1.72). Subgroup analysis showed that the risk of SCZ was significantly increased when ADNS were used as exposure factors (RR = 1.48; 95%CI, 1.15-1.89), whereas with SCZ did not observe an increased risk of subsequent ADNS (RR = 1.33; 95%CI, 0.92-1.92); multiple sclerosis (MS) was positively associated with SCZ (RR = 1.36; 95%CI, 1.12-1.66), but no significant association was found between Guillain-Barre syndrome (GBS) and SCZ (RR = 1.90; 95%CI, 0.87-4.17). Meanwhile, we found location was the source of heterogeneity.

LIMITATIONS

High heterogeneity was observed (I² = 92.0%), and only English literature was included in the meta-analysis.

CONCLUSIONS

We found a positive association between ADNS and SCZ, and the association was different across the different types of ADNS. The results of the study are helpful for clinicians to carry out targeted preventive measures for ADNS and SCZ.

Tekrarlayan ve düzelen multipl sklerozda mizaç ve karakter: klinik faktörler ve psikiyatrik bozukluklarla ilişkisi

Amaç: Yaşam kalitesi üzerindeki etkilerine rağmen, multipl sklerozda mizaç ve karakter yeterince araştırılmamıştır. Mizaç ve karakter boyutlarını, i, bunların klinik özelliklerle ilişkisini ve depresyon şiddetini etkileyen faktörleri tekrarlayan ve düzelen multiple skleroz (TDMS) hastalarında incelemeyi amaçladık. Gereç ve Yöntem: Bu kesitsel çalışmaya, elverişli örnekleme yöntemiyle 67 hasta (erkek/kadın=12/55) (medyan yaş=30 (18-53)) ve yaş ve cinsiyet açısından eşleştirilmiş 50 sağlıklı kontrol (SK) (erkek/kadın=16/34) (medyan yaş= 26.5 (18-60)) alındı. Mizaç ve Karakter Envanteri, Beck Depresyon ve Beck Anksiyete Envanterleri, DSM-Eksen I Bozuklukları için Yapılandırılmış Klinik Görüşme uygulandı. Bulgular: Hasta grubu içinde, psikiyatrik komorbiditesi olan 45 (MSP), psikiyatrik komorbiditesi olmayan (MSO) 22 hasta bulunuyordu. MSP grubu, MSO grubuna ve SK’lere göre daha yüksek kendilik kaybı gösterdi. MSP grubu ve MSO grubu toplam zarardan kaçınma puanları SK’lere kıyasla yüksekti. Toplam kendini yönetme puanları MSP grubunda SK’lerden düşüktü. EDSS, hastalık süresi, toplam nüks sayısı depresyon şiddetini etkilemezken; yüksek anksiyete (Β=0,416) ve düşük amaçlılık düzeyleri (Β=-1,565) depresyon düzeyini anlamlı derecede etkilemekteydi (R2=0.50, F=32.459). Sonuç: Komorbid psikiyatrik bozukluğu olan ve olmayan hastalar arasında mizaç ve karakter özellikleri açısından farklılıklar gözlendi. Artmış anksiyete düzeyleri; anlamlı hedefler belirleme ve bunlara ulaşmada güçlük, artmış depresyon düzeyleriyle ilişkili olabilir. Gelecek çalışmalar, daha geniş örneklemlerde, baş etme, sağlık davranışları ve dayanıklılığın kendilik kaybı ve psikiyatrik bozukluklar arasındaki aracı ve düzenleyici rolünü inceleyerek, psikiyatrik bozukluklara yönelik müdahalelerin tanımlanmasına yardımcı olabilir. Anksiyete belirtilerinin etkin tedavisi ve yaşam amaçlarının ele alınması, davranışsal müdahalelerin planlanması için olası hedeflerdir.

Association of Exposure to Particulate Matters and Multiple Sclerosis: A Systematic Review and Meta-Analysis

The association between air pollution and multiple sclerosis (MS) is not entirely clear. This meta-analysis was aimed at determining the correlation between particulate matter (PM)2.5, PM10, and MS incidence/relapse. The literature search was performed in EMBASE, Web of Science, PubMed, and the gray literature. Sixteen articles were retrieved, and ten articles were included and evaluated. Three measures of association were used for the meta-analysis: odds ratio (cross-sectional and case-control studies), incidence rate ratio, or hazard ratio (cohort studies). Meta-analysis of those 3 studies on PM2.5 indicated that exposure to PM2.5 was associated with MS relapse and incidence ([95% confidence interval; CI] 1.178 [1.102, 1.279]), p > 0.05. Also, assessment of risk ratio for all studies showed a correlation between PMs (PM10 and PM2.5) and MS incidence and relapse ([95% CI] 1.28, [1.13-1.43]) p < 0.05. Collectively, we found that PM exposure (PM10 and PM2.5) in MS patients associates with the occurrence and relapse of disease.

Selanzylimidazopyridine abolishes inflammation- and stress-induced depressive-like behaviors and decreases oxidonitrosative stress in the prefrontal cortex and hippocampus of mice

The 3-[(4-methoxyphenyl)selanyl]-2-phenylimidazo[1,2-a] pyridine (MPI), a novel organic selenium compound, has been receiving increased attention due to its antioxidant effects and its ability to protect against depression-like behaviours. However, it remains elusive whether MPI is able to reverse depressive-like symptoms and biochemical alterations in mice. In the present work, we explored the ability of MPI (10 mg/kg, i.g.) to reverse inflammation- and stress-induced depression-like behaviours in mice injected with tumour necrosis factor (TNF-α) or submitted to acute restraint stress. Depression-like behaviours were evaluated by the tail suspension and splash test and the open field test was used to evaluate the locomotor activity of mice. The prefrontal cortex and hippocampus of mice were used for the evaluation of parameters of oxidonitrosative stress. Here, we showed that a single administration of MPI abolished the depressive-like behaviours induced by TNF-α and acute restraint stress without having an effect per se. The oxidative and nitrosative stress presented in mice with depression-like behaviours were also decreased by MPI in the prefrontal cortex and hippocampus. Our findings suggest that MPI presents antidepressant-like activity which is associated with the biochemical regulation of oxidative stress in the prefrontal cortex and hippocampus of mice, arising as a promising strategy for the management of depressive symptoms.

Multiple sclerosis is associated with higher comorbidity and health care resource use: A population-based, case-control study in a western Mediterranean region

BACKGROUND AND PURPOSE

Comorbidities are common in multiple sclerosis (MS), and have been associated with worse outcomes and increased health care resource usage. We studied the frequency of comorbidities and adverse health behaviors (AHBs) in MS patients in the Mediterranean region of Catalonia.

METHODS

This population-based, case-control study used primary health care information covering 80% of Catalonia's population. Cases were matched by age/sex with randomly chosen controls (ratio = 1:5). Demographic information, comorbidities, AHBs, annual visits, sick leave days, and medication dispensing were studied. The association of comorbidities with MS and the profile of comorbidities according to sex within MS cases were assessed with multivariate logistic regression models, after adjusting for confounding variables. Health care resource usage was analyzed in MS cases compared to controls, and within MS cases in those with compared to those without comorbidities.

RESULTS

Five thousand five hundred forty-eight MS cases and 27,710 controls (70% female, mean age = 48.3 years) were included. Stroke (odds ratio [OR] = 1.54, 95% confidence interval [CI] = 1.17-1.99), epilepsy (OR = 2.46, 95% CI = 1.94-3.10), bipolar disorder (OR = 1.67, 95% CI = 1.17-2.36), and depression (OR = 1.83, 95% CI = 1.70-1.98) were more frequent in MS. Cases were more prone to smoking but less to alcohol intake. Among cases, psychiatric comorbidities were more frequent in women, whereas cardiovascular diseases and AHBs were more frequent in men. MS patients, particularly with comorbidities, had higher health care resource usage than controls.

CONCLUSIONS

Psychiatric comorbidities, stroke, epilepsy, and AHBs are more common in MS patients than in the general population in the western Mediterranean region of Catalonia. The presence of comorbidities increases the health care resource usage in MS patients.

Risk of depression in multiple sclerosis across disease-modifying therapies

Background:

Depression and use of antidepressants are more common among patients with multiple sclerosis (MS) compared to the general population, but the relation of psychiatric comorbidity to use of different disease-modifying therapies (DMTs) is less clear.

Objective:

To determine whether risk of incident depression or antidepressant use differed across DMTs, and to assess whether depression and antidepressants affected risk of DMT discontinuation and MS relapses.

Methods:

We prospectively followed for 8 years a register-based nationwide cohort of 3803 relapsing-remitting MS patients.

Results:

Patients on rituximab had a lower risk of being diagnosed with depression or initiating antidepressants compared with the reference group treated with interferons (hazard ratio (HR) = 0.72, 95% confidence interval (CI) = 0.54–0.96). Patients diagnosed with depression discontinued interferon treatment to a higher extent than patients without depression (HR = 1.51; 95% CI = 1.15–1.98), as did patients on fingolimod initiating an antidepressant compared to patients who did not initiate an antidepressant (HR = 1.47; 95% CI = 1.04–2.08).

Conclusions:

Our results indicate that the choice of DMT is associated with subsequent risk of depression in MS, but further studies are needed to establish whether there is a causal link. Overall, depression and use of antidepressants displayed limited associations with DMT discontinuation and MS relapse.

Systematic Assessment of Medical Diagnoses Preceding the First Diagnosis of Multiple Sclerosis

OBJECTIVE

To explore the occurrence of diseases and symptoms in the 5 years before diagnosis in patients with multiple sclerosis (MS) in a case-control study.

METHODS

Using ambulatory claims data, we systematically assessed differences in the occurrence of diseases and symptoms in the 5 years before first diagnosis in patients with MS (n = 10,262) compared to patients with 2 other autoimmune diseases, Crohn disease (n = 15,502) and psoriasis (n = 98,432), and individuals without these diseases (n = 73,430).

RESULTS

Forty-three ICD-10 codes were recorded more frequently for patients with MS before diagnosis compared to controls without autoimmune disease. Many of these findings were confirmed in a comparison to the other control groups. A high proportion of these ICD-10 codes represent symptoms suggestive of demyelinating events or other neurologic diagnoses. In a sensitivity analysis excluding patients with such recordings before first diagnosis, no association remained significant. Seven ICD-10 codes were associated with lower odds ratios of MS, 4 of which represent upper respiratory tract infections. Here, the relations with MS were even more pronounced in the sensitivity analysis.

CONCLUSIONS

Our analyses suggest that patients with MS are frequently not diagnosed at their first demyelinating event but often years later. Symptoms and physician encounters before MS diagnosis seem to be related to already ongoing disease rather than a prodrome. The observed association of upper respiratory tract infections with lower odds ratios of MS diagnosis suggests a link between protection from infection and MS that, however, needs to be validated and further investigated.

Depression and multiple sclerosis: A bidirectional Mendelian randomisation study

Depression is common in multiple sclerosis (MS); however, the underlying mechanism for the relationship remains unknown. In this study, we examined a putative causal relationship between depression and MS using a bidirectional Mendelian randomisation (MR) framework. Using the latest genome-wide association study data available, 168 non–major histocompatibility complex (MHC) independent variants associated with MS and 96 independent genetic variants associated with depression susceptibility were used. Maximum likelihood, weighted median, inverse variance weighted method and MR-Egger regression analyses were performed. There was no significant risk for the development of MS in persons carrying variants associated with depression or for risk of depression in individuals who are genetically susceptible to MS.

Stressful life events are associated with the risk of multiple sclerosis

BACKGROUND AND PURPOSE

Unexpected stressful life events may alter immune function and affect susceptibility to autoimmune diseases including multiple sclerosis (MS). Current results from epidemiological investigations examining the role of stress in MS remain inconsistent. The aim was to conduct the hitherto largest population-based case-control study on this topic.

METHODS

Extensive questionnaire information collected on lifestyle environmental factors available for 2930 incident MS cases and 6170 controls were used to assess the association of 10 major life events that had occurred before disease onset with the risk of MS by unconditional logistic regressions, adjusting for potential confounders. Stratified analyses were also performed by sex and time.

RESULTS

Compelling evidence was found for a link between major life events and risk of MS - most events significantly increased disease risk by 17%-30%. It was further observed that women were affected to a greater extent than men under certain stressful scenarios, and that most events that happened recently (≤5 years prior to MS onset) had significant effects on MS, indicating a critical window in disease development.

CONCLUSION

Stressful life events may have an adverse effect on the risk of MS. Research into the mechanisms of this observation may give important clues to triggering pathogenetic events in MS.

Comorbidity in Multiple Sclerosis

Comorbidities in patients with multiple sclerosis (MS) has become an area of increasing interest in the recent years. A comorbidity is defined as any additional disease that coexists in an individual with a given index disease and that is not an obvious complication of the index disease. The aim of this review is to describe the current evidence regarding the range of comorbidities in the population with MS reported in different countries and the current knowledge about the influence of comorbidities on the clinical features and therapeutic challenges in MS. Certain comorbidities are more prevalent in people with MS such as depression, anxiety, cerebro- and cardiovascular diseases, and certain autoimmune disorders such as diabetes, thyroid disease, and inflammatory bowel disease. A previous perception of a trend toward a lower overall risk of cancer in patients with MS appears to be challenged, but there is no evidence on any higher occurrence of malignancies in the population with MS. Comorbidities may modify the clinical presentation of MS, and have implications for treatment choice, adherence, and outcome. Several comorbid conditions are associated with increased disability progression, including diabetes, hypertension, and chronic obstructive pulmonary disease. Comorbidities are common in MS from the time of diagnosis and may account for some of the heterogeneity observed in MS, including diagnostic delay, clinical presentation, degree of disability progression, rate of health care utilization, working ability, employment status, and quality of life. Coexisting diseases and polypharmacy increase the complexity of patient management and poses major challenges, particularly with the increasing number of immunosuppressive disease-modifying therapies.

Non-infectious comorbidity in patients with multiple sclerosis: A national cohort study in Sweden

Background

Comorbidity is of significant concern in multiple sclerosis (MS). Few population-based studies have reported conditions occurring in MS after diagnosis, especially in contemporary cohorts.

Objective

To explore incident comorbidity, mortality and hospitalizations in MS, stratified by age and sex.

Methods

In a Swedish population-based cohort study 6602 incident MS patients (aged ≥18 years) and 61,828 matched MS-free individuals were identified between 1 January 2008 and 31 December 2016, using national registers. Incidence rates (IRs) and incidence rate ratios (IRRs) with 95% CI were calculated for each outcome.

Results

IRs of cardiovascular disease (CVD) were higher among MS patients than MS-free individuals, (major adverse CVD: IRR 1.42; 95% CI 1.12–1.82; hemorrhagic/ischemic stroke: 1.46; 1.05–2.02; transient ischemic attack: 1.65; 1.09–2.50; heart failure: 1.55; 1.15–2.10); venous thromboembolism: 1.42; 1.14–1.77). MS patients also had higher risks of several non-CVDs such as autoimmune conditions (IRR 3.83; 3.01–4.87), bowel dysfunction (2.16; 1.86–2.50), depression (2.38; 2.11–2.68), and fractures (1.32; 1.19–1.47), as well as being hospitalized and to suffer from CVD-related deaths ((1.91; 1.00–3.65), particularly in females (3.57; 1.58–8.06)).

Conclusion

MS-patients experience a notable comorbidity burden which emphasizes the need for integrated disease management in order to improve patient care and long-term outcomes of MS.

Diagnosis-specific sickness absence and disability pension before and after multiple sclerosis diagnosis: An 8-year nationwide longitudinal cohort study with matched references

BACKGROUND

Multiple sclerosis (MS) typically onsets when of working age and may reduce work capacity. Previous studies have examined the risk of sickness absence (SA) and disability pension (DP) among MS patients, however, limited knowledge is available on whether MS patients have an excess risk for SA/DP when compared with the general population in Sweden. Moreover, no information exists on the actual diagnoses for SA and DP among MS patients and whether the patterns of SA/DP diagnoses differs to those without MS. We aimed to explore diagnosis-specific SA and DP among working-aged MS patients both before and after MS diagnosis, in comparison to the levels and distributions of SA and DP diagnoses of a matched reference group and analyze the risk of diagnosis-specific DP.

MATERIALS AND METHODS

Longitudinal Swedish register data of the 2567 MS patients diagnosed with MS in 2009-2012 when aged 25-59 and 10,268 population-based matched references (matched on sex, age, educational level, type of living area, and country of birth) were analysed regarding annual diagnosis-specific SA and DP in the four years before and four years after MS diagnosis. Annual differences in the mean numbers of SA and/or DP net days were calculated with 95% confidence intervals (CI). Hazard ratios (HR) with 95% CI from Cox proportional hazard models were used to compare risks for new all-cause and diagnosis-specific DP after MS diagnosis among the MS patients and references.

RESULTS

The mean SA/DP net days/year increased among MS patients over follow-up, due to both MS and other diagnoses. During follow-up, around 50% of MS patients had some SA/DP compared to 20% of references. The mean days of SA/DP among the MS patients compared to references increased from 10.3 more days (95% CI: 6.6-14.2) four years prior to MS diagnosis to 68.9 days (62.8-75.1) 4 years after MS diagnosis. Although most new DP among MS patients were due to MS, 15% were not. The adjusted HR for all-cause DP was 23.1 (18.1-29.5). MS patients also had higher risks of new DP due to all diagnoses except MS (HR 3.4; 2.4-4.8), musculoskeletal (HR 2.6; 1.1-6.0) and mental (HR 2.0; 1.1-3.6) diagnoses compared with references.

CONCLUSION

MS patients had higher levels of SA/DP days/year than the references, already 4 years before the MS diagnosis, and increasingly so thereafter. The excess of SA/DP prior to MS diagnosis could be related to MS onset. However, the excess of SA/DP days were not all due to MS diagnoses, even after being diagnosed with MS. MS patients had a higher risk of having a new DP after being diagnosed with MS in total, but also for diagnoses other than MS.

Phosphodiesterase-5 inhibitors: Shedding new light on the darkness of depression?

BACKGROUND

Phosphodiesterase-5 inhibitors (PDE5Is) are used to treat erectile dysfunction (ED). Recently, the antidepressant-like effect of PDE5Is was demonstrated in animal models of depression. In clinical settings, PDE5Is were studied only for ED associated depression. Hence, there are no studies evaluating the effects of PDE5Is for the treatment of major depressive disorder (MDD) without ED. In this review article, we aimed to discuss the use of PDE5Is in the context of MDD, highlighting the roles of PDE genes in the development of MDD, the potential mechanisms by which PDE5Is can be beneficial for MDD and the potentials and limitations of PDE5Is repurposing to treat MDD.

METHODS

We used PubMed (MEDLINE) database to collect the studies cited in this review. Papers written in English language regardless the year of publication were selected.

RESULTS

A few preclinical studies support the antidepressant-like activity of PDE5Is. Clinical studies in men with ED and depression suggest that PDE5Is improve depressive symptoms. No clinical studies were conducted in subjects suffering from depression without ED. Antidepressant effect of PDE5Is may be explained by multiple mechanisms including inhibition of brain inflammation and modulation of neuroplasticity.

LIMITATIONS

The low number of preclinical and absence of clinical studies to support the antidepressant effect of PDE5Is.

CONCLUSIONS

No clinical trial was conducted to date evaluating PDE5Is in depressed patients without ED. PDE5Is' anti-inflammatory and neuroplasticity mechanisms may justify the potential antidepressant effect of these drugs. Despite this, clinical trials evaluating their efficacy in depressed patients need to be conducted.

Risk of Schizophrenia and Bipolar Disorder in Patients With Multiple Sclerosis: Record-Linkage Studies

BACKGROUND

The epidemiology of psychiatric comorbidity in multiple sclerosis (MS) remains poorly understood.

OBJECTIVE

We aimed to determine the risk of schizophrenia and bipolar disorder in MS patients.

MATERIAL AND METHODS

Retrospective cohort analyses were performed using an all-England national linked Hospital Episode Statistics (HES) dataset (1999-2016) and to determine whether schizophrenia or bipolar disorder are more commonly diagnosed subsequently in people with MS (n=128,194), and whether MS is more commonly diagnosed subsequently in people with schizophrenia (n=384,188) or bipolar disorder (n=203,592), than would be expected when compared with a reference cohort (~15 million people) after adjusting for age and other factors. Adjusted hazard ratios (aHRs) were calculated using Cox proportional hazards models.

RESULTS

Findings were dependent on whether the index and subsequent diagnoses were selected as the primary reason for hospital admission or were taken from anywhere on the hospital record. When searching for diagnoses anywhere on the hospital record, there was a significantly elevated risk of subsequent schizophrenia (aHR 1.51, 95% confidence interval (CI) 1.40 to 1.60) and of bipolar disorder (aHR 1.14, 95% CI 1.04 to 1.24) in people with prior-recorded MS and of subsequent MS in people with prior-recorded schizophrenia (aHR 1.26, 1.15-1.37) or bipolar disorder (aHR 1.73, 1.57-1.91), but most of these associations were reduced to null when analyses were confined to diagnoses recorded as the primary reason for admission.

CONCLUSION

Further research is needed to investigate the potential association between MS and schizophrenia and/or bipolar disorder as it may shed light on underlying pathophysiology and help identify potential shared risk factors.

Disability worsening among persons with multiple sclerosis and depression: A Swedish cohort study

OBJECTIVE

Depression is common in multiple sclerosis (MS), but its impact on disability worsening has not yet been determined. We explored the risk of disability worsening associated with depression in a nationwide longitudinal cohort.

METHODS

This retrospective cohort study used linked data from 3 Swedish nationwide registries: the MS Register, National Patient Register, and Prescribed Drug Register. Two incident cohorts were developed: cohort 1 included all registered cases of MS in the MS Registry (2001-2014) with depression defined as ≥1 ICD-10 code for depression; and cohort 2 comprised all cases of MS in the MS Registry (2005-2014) with depression defined as ≥1 prescription filled for an antidepressant. Cox regression models were used to compare the risk of reaching sustained disability milestone scores of 3.0, 4.0, and 6.0 on the Expanded Disability Status Scale (EDSS) between persons with MS with and without depression.

RESULTS

Cohort 1 included 5,875 cases; 502 (8.5%) had depression. Cohort 2 had 3,817 cases; 1,289 (33.8%) were prescribed an antidepressant. Persons with depression were at a significantly higher risk of reaching sustained EDSS scores of 3.0, 4.0, and 6.0, with hazard ratios of 1.50 (95% confidence interval [CI] 1.20-1.87), 1.79 (95% CI 1.40-2.29), and 1.89 (95% CI 1.38-2.57), respectively. A similar increased risk among persons exposed to antidepressants was observed, with hazard ratios of 1.37 (95% CI 1.18-1.60), 1.93 (95% CI 1.61-2.31), and 1.86 (95% CI 1.45-2.40) for sustained EDSS scores of 3.0, 4.0, and 6.0, respectively.

CONCLUSION

Persons with MS and comorbid depression had a significantly increased risk of disability worsening. This finding highlights the need for early recognition and appropriate treatment of depression in persons with MS.

Autoimmune Diseases and Psychotic Disorders

The notion of immunological pathways playing a role in the etiology of a subset of psychotic disorders has received increased interest in the last decades. One of the findings that has spiked interest herein, is an apparent link between autoimmune diseases and psychotic disorders. This is supported by genetic findings associating immune-related genetic markers with schizophrenia and clinical studies finding increased levels of inflammatory markers in patients with psychosis. Several large-scale epidemiologic studies have found positive associations between autoimmune diseases and psychosis. Particularly, autoimmune diseases as multiple sclerosis and lupus are known to have higher frequencies of neuropsychiatric symptoms, including psychosis, compared to healthy controls. Cross sectional studies have found higher prevalence of psychiatric diagnoses among those with autoimmune diseases, and longitudinal studies have shown bidirectional associations between several autoimmune diseases and increased risks associated with schizophrenia. Moreover, a family history of autoimmune diseases has been shown to be associated with an increased risk of psychotic disorders and vice versa. In this review we will summarize the epidemiologic evidence on associations between autoimmune diseases and psychosis. Possible mechanisms accountable for the association will be discussed, amongst others the probable role of shared genetic risk factors, the impact of infections on both autoimmunity and the development of psychotic disorders, and the potential role of the microbiome. We discuss the findings on and influence of autoantibodies and dysregulation of T- and B-cells in both disease categories, and why further research hereon is needed. In addition to the potential importance of autoimmunity in etiological mechanisms of psychotic disorders, the association also brings important attention to somatic comorbidity in patients with psychotic disorders.

HLA genetics in bipolar disorder

OBJECTIVE

Bipolar Disorder (BD) is characterized by deregulated adaptive immune processes. Recent genome-wide association studies (GWAS) implicate the major histocompatibility complex (MHC) region in BD. The present study investigates the potential influence of variations in human leukocyte antigen (HLA) on BD risk and/or clinical presentations. This may have relevance to the dysregulated inflammatory processes commonly found in BD.

METHOD

DNAs from 475 BD patients and 195 healthy controls (HC) were genotyped for classical HLA class I and II loci.

RESULTS

We found that: (i) the HLA-A*02~B*44~DRB1*07 sub-haplotype is less prevalent in BD, vs. HC (pc = 2.4 × 10^-2 ); (ii) the 57.1 and the 8.1-derived ancestral haplotypes i.e. HLA-A*02~B*57~Cw*06~DRB1*07~DQB1*09 and HLA-A*02~B*08~Cw*07 are associated with rapid cycling (pc = 1.9 × 10^-3 and 1.05 × 10^-2 , respectively); (iii) the 8.1AH-derived HLA class II-DRB*03~HLA-DQB1*02 sub-haplotype is more frequent in BD patients with a history of suicidal behaviors (pc = 2.1 × 10^-2 ); and (iv) disease onset by an hypomanic episode or by psychotic symptoms are, respectively, more frequent in BD patients bearing the 7.1 AH-derived A*03~B*07~DRB1*15 sub-haplotype (pc = 8.5 × 10^-3 ) and the HLA-A*02~B*07~DRB1*15 sub-haplotype (pc = 4.0 × 10^-2 ).

CONCLUSION

Corroborating the established link between these HLA haplotypes/sub haplotypes and common immune disorders, our findings suggest possible HLA-mediated proinflammatory processes operating in BD.

Costs of illness of multiple sclerosis in Sweden: a population-based register study of people of working age

BACKGROUND

Multiple sclerosis (MS) causes work disability and healthcare resource use, but little is known about the distribution of the associated costs to society.

OBJECTIVES

We estimated the cost of illness (COI) of working-aged individuals with MS, from the societal perspective, overall and in different groups.

METHODS

A population-based study was conducted, using data linked from several nationwide registers, on 14,077 individuals with MS, aged 20-64 years and living in Sweden. Prevalence-based direct and indirect costs in 2010 were calculated, including costs for prescription drug use, specialized healthcare, sick leave, and disability pension.

RESULTS

The estimated COI of all the MS patients were SEK 3950 million, of which 75% were indirect costs. MS was the main diagnosis for resource use, causing 38% of healthcare costs and 67% of indirect costs. The distribution of costs was skewed, in which less than 25% of the patients accounted for half the total COI.

CONCLUSIONS

Indirect costs contributed to approximately 75% of the estimated overall COI of MS patients of working age in Sweden. MS was the main diagnosis for more than half of the estimated COI in this patient group. Further studies are needed to gain knowledge on development of costs over time during the MS disease course.

Increasing prevalence of familial recurrence of multiple sclerosis in Iran: a population based study of Tehran registry 1999-2015

BACKGROUND

Tehran is the capital of Iran with an increasing multiple sclerosis (MS) prevalence. A retrospective population-based study was conducted to evaluate the trends of MS prevalence in Tehran.

METHODS

A population-based survey was conducted for the period 1999 to 2015, based on Iranian MS Society (IMSS) registry system of Tehran, the capital city of Iran. Point regression analysis was applied on MS trend data to find annual percent change (APC). The logistic regression analysis was used to estimate the odds ratio (OR) for individual variables in order to assess factors associating with familial recurrence of MS. P values < 0.05 were considered significant.

RESULTS

MS prevalence has significantly increased during the study period from 1999 to 2015 (56.22 per 100,000). Total point prevalence of MS was 115.94 per 100,000 persons in 2015 compared to general population. Positive family history of MS was observed among 12.4% of patients. The strongest association amongst first-degree relatives was found in siblings, p value ≤ 0.001.

CONCLUSION

MS prevalence is rising in Tehran and this city is one of the regions with highest MS prevalence in Asia. In this sample, the largest proportion of relatives with MS were found among first-degree relatives, particularly siblings. Familial recurrence correlated with relative type.

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.

Association of psychosis, affective disorders and diseases affecting the immune system

Purpose of the article: There are indications of altered immune activity in depressed and psychotic patients compared to healthy controls in several studies. To explore the clinical importance of this phenomenon we examined the relation between different disorders affecting the immune system and psychoses and depression, respectively.

MATERIALS AND METHODS

A total of 276 patients consecutively admitted to a psychiatric acute ward were included in the study. Of these 41 patients fulfilled the criteria for ICD-10 F20-29 (psychotic) diagnosis and 157 patients a F30-39 (affective) diagnosis. Information on diseases affecting the immune system in patients themselves and family members of the patients were obtained by a self-report questionnaire.

RESULTS

Comparing the two groups showed a significant correlation between the F20-29 group and eczema (r = -0.116, p = .037). Comparing what patients reported for family members showed a significantly higher frequency of epilepsy (p = .033) in the F20-29 group. Summarizing all immunological diseases for family members showed a significantly higher frequency in the F30-39 group compared to the F20-29 group (χ² = 4, 82, df = 1, p = .028).

CONCLUSIONS

There may be differences between the F20-29 and F30-39 groups and their family members regarding risk for diseases affecting the immune system. This is in line with different activity of the immune system measured in blood for the disorders and may add information regarding etiology and pathology of these psychiatric diseases. Further studies including a greater number of subjects, as well as confirmation of the immunological diseases through blood samples are needed.

Prevalences of autoimmune diseases in schizophrenia, bipolar I and II disorder, and controls

Previous studies on the relationship between autoimmune diseases, schizophrenia, and bipolar disorder are mainly based on hospital discharge registers with insufficient coverage of outpatient data. Furthermore, data is scant on the prevalence of autoimmune diseases in bipolar subgroups. Here we estimate the self-reported prevalences of autoimmune diseases in schizophrenia, bipolar disorder type I and II, and controls. Lifetime prevalence of autoimmune diseases was assessed through a structured interview in a sample of 9076 patients (schizophrenia N = 5278, bipolar disorder type I N = 1952, type II N = 1846) and 6485 controls. Comparative analyses were performed using logistic regressions. The prevalence of diabetes type 1 did not differ between groups. Hyperthyroidism, hypothyroidism regardless of lithium effects, rheumatoid arthritis, and polymyalgia rheumatica were most common in bipolar disorder. Systemic lupus erythematosus was less common in bipolar disorder than in the other groups. The rate of autoimmune diseases did not differ significantly between bipolar subgroups. We conclude that prevalences of autoimmune diseases show clear differences between schizophrenia and bipolar disorder, but not between the bipolar subgroups.

Depression in multiple sclerosis

Depressive disorders occur in up to 50% of people living with multiple sclerosis (MS). Prevalence estimates are generally 2-3-times higher than those of the general population. Myriad aetiologic factors may contribute to the aetiology of depression in MS including biological mechanisms (e.g. hippocampal microglial activation, lesion burden, regional atrophy), as well as the stressors, threats, and losses that accompany living with an unpredictable and often disabling disease. Some prominent risk factors for depression such as (younger) age, (female) sex, and family history of depression are less consistently associated with depression in MS than they are in the general population. Management of depression in MS has not been well studied, but available data on detection and treatment align with general principles of depression management. While the validity of standard measurement scales has often been questioned, available evidence suggests that standard scales provide valid ratings. Evidence for the effectiveness of depression treatments in MS is limited, but available evidence supports the effectiveness of standard treatment approaches, including both cognitive behavioural therapies and antidepressant medications.

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.

Neuropsychiatric syndromes of multiple sclerosis

Neuropsychiatric signs and symptoms occur frequently in individuals with multiple sclerosis (MS), either as the initial presenting complaint prior to a definitive neurological diagnosis or more commonly with disease progression. However, the pathogenesis of these comorbid conditions remains unclear and it remains difficult to accurately elucidate if neuropsychiatric symptoms or conditions are indicators of MS illness severity. Furthermore, both the disease process and the treatments of MS can adversely impact an individual's mental health. In this review, we discuss the common neuropsychiatric syndromes that occur in MS and describe the clinical symptoms, aetiology, neuroimaging findings and management strategies for these conditions.

Determinants and incidence of depression in multiple sclerosis: A prospective cohort study

OBJECTIVE

To estimate the incidence and explore potential determinants of incidence of depression in MS.

METHODS

A prospective cohort study used a sample of 192 patients from the southern Alberta MS clinic registry. Participants completed baseline risk factor assessment questionnaires using either online, mail or telephone surveys, and completed the Patient Health Questionnaire every 2weeks for 6months to assess depressive symptoms in real time. Risk factors assessed included biopsychosocial variables such as socioeconomic status, illness-related factors, childhood risk factors, psychosocial factors, and health behaviors. Cox proportional hazard models were fit to estimate predictors of incidence.

RESULTS

2-week incidence of depression for females was 0.019 (95% CI 0.013-0.029) and for males was 0.044 (0.026-0.074). Strongest predictor of depression incidence risk included fatigue impact, low mobility, resiliency, self-esteem, self-efficacy, and coping style.

CONCLUSION

Depression in MS exhibits a risk factor profile similar to that of depression in the general population, with the additional impact of MS illness-related factors. Potentially modifiable risk factors, such as coping with stress and resiliency, present opportunities for focus of further research in depression in MS treatment and prevention efforts. Some differences in determinants of incidence were found compared to the prevalence risk factors, highlighting the danger of using cross-sectional data to make assumptions about risk. For example, the finding that depression incidence was higher for men is opposite to the higher depression prevalence estimates found for women as well as the consensus in the literature.

Psychiatric disorders in children with demyelinating diseases of the central nervous system

Introduction:

The profile of psychiatric disorders associated with multiple sclerosis (MS) may differ in children. We aimed to assess the risk of psychiatric disorders in children with MS and other demyelinating diseases, and vice versa.

Patients and methods:

We analyzed linked English Hospital Episode Statistics, and mortality data, 1999–2011. Cohorts were constructed of children admitted with MS and other central nervous system (CNS) demyelinating diseases. We searched for any subsequent episode of care with psychiatric disorders in these cohorts and compared to a reference cohort.

Results:

Children with CNS demyelinating diseases had an increased rate of psychotic disorders (rate ratio (RR) = 5.77 (95% confidence interval (CI) = 2.48–11.41)); anxiety, stress-related, and somatoform disorders (RR = 2.38 (1.39–3.81)); intellectual disability (RR = 6.56 (3.66–10.84)); and other behavioral disorders (RR = 8.99 (5.13–14.62)). In analysis of the pediatric MS cohort as the exposure, there were elevated rates of psychotic disorders (RR = 10.76 (2.93–27.63)), mood disorders (RR = 2.57 (1.03–5.31)), and intellectual disability (RR = 6.08 (1.25–17.80)). In reverse analyses, there were elevated rates of a recorded hospital episode with CNS demyelinating disease after a previous recorded episode with anxiety, stress-related, and somatoform disorders; attention-deficit hyperactivity disorder (ADHD); autism; intellectual disability; and other behavioral disorders.

Conclusion:

This analysis of a national diagnostic database provides strong evidence for an association between pediatric CNS demyelinating diseases and psychiatric disorders, and highlights a need for early involvement of mental health professionals.

Cooccurrences of Putative Endogenous Retrovirus-Associated Diseases

At least 8% of the human genome is composed of endogenous retrovirus (ERV) sequences. ERVs play a role in placental morphogenesis and can sometimes protect the host against exogenous viruses. On the other hand, ERV reactivation has been found to be associated with different diseases, for example, multiple sclerosis (MS), schizophrenia, type 1 diabetes mellitus (T1D), or amyotrophic lateral sclerosis (ALS). Little is known about the cooccurrence of these diseases. If all these diseases are caused by ERV, antiretroviral therapy should perhaps also show some effects in the other diseases. Here, we summarize literature demonstrating that some ERV-associated diseases seem to appear together more often than expected, for example, MS and ALS, MS and T1D, MS and schizophrenia, or ALS and T1D. In contrast, some ERV-associated diseases seem to appear together less frequently than expected, for example, schizophrenia and T1D. Besides, some reports demonstrate amelioration of MS, ALS, or schizophrenia under antiretroviral therapy in human immunodeficiency virus-infected patients. If such results could be confirmed in larger studies, alternative therapy strategies for ERV-associated diseases like MS and schizophrenia might be possible.

Cerebrospinal fluid microglia and neurodegenerative markers in twins concordant and discordant for psychotic disorders

Schizophrenia and bipolar disorder are debilitating psychiatric disorders with partially shared symptomatology including psychotic symptoms and cognitive impairment. Aberrant levels of microglia and neurodegenerative cerebrospinal fluid (CSF) markers have previously been found in schizophrenia and bipolar disorder. We aimed to analyze familial and environmental influences on these CSF markers and their relation to psychiatric symptoms and cognitive ability. CSF was collected from 17 complete twin pairs, nine monozygotic and eight dizygotic, and from one twin sibling. Two pairs were concordant for schizophrenia, and 11 pairs discordant for schizophrenia, schizoaffective disorder or bipolar disorder, and four pairs were not affected by psychotic disorders. Markers of microglia activation [monocyte chemoattractant protein-1 (MCP-1), chitinase 3-like protein 1 (YKL-40), and soluble cluster of differentiation 14 (sCD14)], markers of β-amyloid metabolism (AβX-38, AβX-40, AβX-42 and Aβ1-42), soluble amyloid precursor proteins (sAPP-α and sAPP-β), total tau (T-tau), phosphorylated tau (P-tau), and CSF/serum albumin ratio were measured in CSF using immunoassays. Heritability of the CSF markers was estimated, and associations to psychiatric and cognitive measurements were analyzed. Heritability estimates of the microglia markers were moderate, whereas several neurodegenerative markers showed high heritability. In contrast, AβX-42, Aβ1-42, P-tau and CSF/serum albumin ratio were influenced by dominant genetic variation. Higher sCD14 levels were found in twins with schizophrenia or bipolar disorder compared to their not affected co-twins, and higher sCD14-levels were associated with psychotic symptoms. The study provides support for a significant role of sCD14 in psychotic disorders and a possible role of microglia activation in psychosis.

The Prevalence of Bipolar Disorders and Association With Quality of Life in a Cohort of Patients With Multiple Sclerosis

Clinical observations of mood instability in multiple sclerosis (MS) have led to the hypothesis that bipolar disorder (BD) may be more prevalent in persons with MS than in the general population. This cross-sectional study assesses the prevalence of BD among patients with MS using standardized psychiatric diagnostic interviews and evaluates quality of life. This study demonstrates a higher prevalence of BD in patients with MS compared with the general population. It also reveals the negative impact of BD on quality of life, raises the concern that BD can occur before the onset of neurological symptoms in MS, and suggests that, in some cases, BD may delay diagnosis of MS.

Prescribed psychiatric medication among multiple sclerosis patients before and after disability pension: a register study with matched controls

BACKGROUND

Many multiple sclerosis (MS) patients of working ages have psychiatric comorbidity, and 60 % are on disability pension (DP). It is unknown how DP is associated with MS patients' mental health. The objective of this study was to investigate the association between prescriptions of psychiatric medication and time before and after receiving full-time DP in MS patients compared with matched controls.

METHODS

Nationwide Swedish registers were used to identify 3836 MS patients who were granted DP in 2000-2012 and 19,180 DP controls matched on socio-demographic variables by propensity scores. Patients and controls were organized in groups by year granted DP. Adjusted odds ratios (ORs) with 95 % confidence intervals (CIs) were calculated for being prescribed selective serotonin reuptake inhibitors (SSRIs), benzodiazepines, or sleeping agents in 2006.

RESULTS

Both patients and controls, who were not yet on DP in the study year of 2006, had lower OR compared with those who were granted DP in the same year. The OR increased when being closer to DP. MS patients, who had been granted DP 5-6 years earlier, had a higher risk for prescription of benzodiazepines (OR 1.72; 95 % CI 1.16-2.57) than controls (OR 1.14; 95 % CI 1.14-1.18). These patients also had a higher risk for SSRI prescription when compared directly with controls (OR 1.76; 95 % CI 1.44-2.15).

CONCLUSIONS

MS patients have substantially higher odds ratios for being prescribed psychiatric drugs after DP than other disability pensioners. Further research on the association of DP with the mental health of MS patients is warranted.

Mania secondary to focal brain lesions: implications for understanding the functional neuroanatomy of bipolar disorder

OBJECTIVES

Approximately 3.5 million Americans will experience a manic episode during their lifetimes. The most common causes are psychiatric illnesses such as bipolar I disorder and schizoaffective disorder, but mania can also occur secondary to neurological illnesses, brain injury, or neurosurgical procedures.

METHODS

For this narrative review, we searched Medline for articles on the association of mania with stroke, brain tumors, traumatic brain injury, multiple sclerosis, neurodegenerative disorders, epilepsy, and neurosurgical interventions. We discuss the epidemiology, features, and treatment of these cases. We also review the anatomy of the lesions, in light of what is known about the neurobiology of bipolar disorder.

RESULTS

The prevalence of mania in patients with brain lesions varies widely by condition, from <2% in stroke to 31% in basal ganglia calcification. Mania occurs most commonly with lesions affecting frontal, temporal, and subcortical limbic brain areas. Right-sided lesions causing hypo-functionality or disconnection (e.g., stroke; neoplasms) and left-sided excitatory lesions (e.g., epileptogenic foci) are frequently observed.

CONCLUSIONS

Secondary mania should be suspected in patients with neurological deficits, histories atypical for classic bipolar disorder, and first manic episodes after the age of 40 years. Treatment with antimanic medications, along with specific treatment for the underlying neurologic condition, is typically required. Typical lesion locations fit with current models of bipolar disorder, which implicate hyperactivity of left-hemisphere reward-processing brain areas and hypoactivity of bilateral prefrontal emotion-modulating regions. Lesion studies complement these models by suggesting that right-hemisphere limbic-brain hypoactivity, or a left/right imbalance, may be relevant to the pathophysiology of mania.

Should a psychotic or manic episode be considered an early manifestation of Multiple Sclerosis? A multiple case study

BACKGROUND

Early manifestations of Multiple Sclerosis (MS) can be atypical and misleading, and several case report studies have highlighted that MS onset sometimes takes the form of a psychotic or manic episode.

METHODS

All neurologists belonging to the French Multiple Sclerosis Observatory network were contacted by email and were asked to find patients with MS who presented with a history of psychiatric episode(s) near MS onset.

RESULTS

Seventeen patients were selected that met the criteria of presenting with psychotic or manic symptoms either before the diagnosis of MS (N=8), or at the time of the first neurological episode or shortly after (N=9). Patients with a history of a psychiatric episode occurring before the first neurological episode were diagnosed on average 7 years later than patients with either a first neurological or a mixed (both neurological and psychiatric) episode. However, psychiatric symptoms in the first group and the first neurological symptoms of MS in the second group occurred at a similar age.

CONCLUSION

Based on this multiple case study, we question whether past psychotic or manic episode should be considered equivalent to a first manifestation of MS.

Differences in the burden of psychiatric comorbidity in MS vs the general population

Objective:

We aimed to compare the incidence and prevalence of psychiatric comorbidity in the multiple sclerosis (MS) population and in controls matched for age, sex, and geographic area.

Methods:

Using population-based administrative health data from 4 Canadian provinces, we identified 2 cohorts: 44,452 persons with MS and 220,849 controls matched for age, sex, and geographic area. We applied validated case definitions to estimate the incidence and prevalence of depression, anxiety, bipolar disorder, and schizophrenia from 1995 to 2005. We pooled the results across provinces using meta-analyses.

Results:

Of the MS cases, 31,757 (71.3%) were women with a mean (SD) age at the index date of 43.8 (13.7) years. In 2005, the annual incidence of depression per 100,000 persons with MS was 979 while the incidence of anxiety was 638, of bipolar disorder was 328, and of schizophrenia was 60. The incidence and prevalence estimates of all conditions were higher in the MS population than in the matched population. Although the incidence of depression was higher among women than men in both populations, the disparity in the incidence rates between the sexes was lower in the MS population (incidence rate ratio 1.26; 95% confidence interval: 1.07–1.49) than in the matched population (incidence rate ratio 1.50; 95% confidence interval: 1.21–1.86). Incidence rates were stable over time while prevalence increased slightly.

Conclusions:

Psychiatric comorbidity is common in MS, and more frequently affected the MS population than a matched population, although the incidence was stable over time. Men with MS face a disproportionately greater relative burden of depression when they develop MS than women.

Affective Temperament Profiles in Patients with Multiple Sclerosis: Association with Mood Disorders

INTRODUCTION

The aim of the present study was to screen for bipolarity and to investigate the affective temperaments of patients with multiple sclerosis (MS) and the possible association between the clinical and demographic characteristics of MS patients and temperament profiles.

METHODS

A total of 65 patients with MS and 66 healthy volunteers completed the 32-item hypomania checklist (HCl-32), the Mood Disorder Questionnaire (MDQ), and the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego-Autoquestionnaire (TEMPS-A) tests. The HCl-32, MDQ, and TEMPS-A scores were compared between the patients and healthy volunteers.

RESULTS

MS patients had significantly higher scores for the depressive, cyclothymic, irritable, and anxious domains of the TEMPS-A scale than the control group, whereas relapsing remitting MS (RRMS) patients had higher MDQ and TEMPS-A hyperthymia scores than secondary progressive MS patients. MS patients who were being treated with interferon beta 1-b therapy had significantly higher MDQ scores than those being treated with interferon beta 1-a, glatiramer acetate, or who were without medication. Expanded Disability Status Scale (EDSS) scores were positively correlated with TEMPS-A depressive and hyperthymic temperaments.

CONCLUSION

Our results suggest that higher scores for affective temperament in MS patients indicate subclinical manifestations of mood disorders. Higher hyperthymia scores and manic symptoms detected in the RRMS group could shed light on the relationship between bipolarity and MS. Thus, the screening of bipolarity and affective temperament profiles in MS patients could help clinicians predict future mood episodes and decrease their impact on disease severity.

The aetiology of schizophrenia: what have the Swedish Medical Registers taught us?

OBJECTIVE

To review the last thirty years of studies that, using Swedish population registers, have added to our understanding of the aetiology of schizophrenia SAMPLE INCLUDED/METHODS: A literature search was performed to systematically review all studies that using Swedish Population based registers have investigated the aetiology of schizophrenia. Key authors in the field, predominately from Swedish institutions, were additionally contacted and key journals hand searched, for missing references. A quality assessment methodological review was then conducted on each study. Data was extracted and tabulated on identified aetiological themes

RESULTS

61 articles were included corresponding to 10 identified aetiological themes. Although the majority of included studies were retrospective cohort studies, case control studies were also included where they used population based registers. Confirming previous research, schizophrenia was found to have a multi-factorial aetiological basis with pregnancy and birth factors, parental age, social adversity, genetics, substance misuse, migration and ethnicity, personality, non-psychiatric co-morbidity, psychiatric history and poor cognitive performance all found to be significantly associated with an increased risk of later schizophrenia.

CONCLUSIONS

Although some difficulties exist in analysing the interplay between each of these factors, the Swedish population registers have added considerably to our understanding of each of the presented individual aetiological themes. The ability to study the whole population over several decades has been particularly useful in determining the timing of exposures.