The effects of anxiety on psychiatric morbidity in patients with multiple sclerosis

The influence of depression and anxiety on cognition in people with multiple sclerosis: a cross-sectional analysis

There are conflicting findings about the relationships between depression, anxiety, and cognitive dysfunction in people with multiple sclerosis (MS), and a paucity of research has examined the cumulative influence on cognition of depression plus anxiety. This study aimed to determine whether elevated symptoms of depression and anxiety alone or in combination are associated with worse cognition in people with MS. In this cross-sectional analysis, people with MS consecutively seen at a tertiary neuropsychiatry clinic completed the Hospital Anxiety and Depression Scale for symptoms of depression (HADS-D) and anxiety (HADS-A), and the Minimal Assessment of Cognitive Function in MS for cognitive indices. Accounting for covariates, regression models predicted cognitive indices from scores for HADS-D, HADS-A, and the interaction. Of 831 people with MS, 72% were female, mean age was 43.2 years, and median Expanded Disability Status Scale score was 2.0. Depressive symptoms were independently predictive of lower verbal fluency (Controlled Oral Word Association Test, p < 0.01), verbal learning (California Verbal Learning Test-II (CVLT-II) total learning, p = 0.02), verbal delayed recall (CVLT-II delayed recall, p < 0.01), and processing speed (Symbol Digit Modalities Test, p < 0.01; three-second Paced Auditory Serial Addition Test (PASAT), p = 0.05; two-second PASAT, p = 0.01). Anxiety in people with depression predicted decreased visuospatial function (Judgment of Line Orientation, p = 0.05), verbal learning (p < 0.01), verbal delayed recall (p < 0.01), visuospatial recall (Brief Visuospatial Memory Test-Revised, p = 0.02), and executive function (Delis-Kaplan Executive Function System, p < 0.01). Anxiety alone was not independently predictive of cognition. In conclusion, depression, especially with comorbid anxiety, is associated with cognitive dysfunction in people with MS.

Trajectories and associations of symptoms of mental health and well-being with insulin resistance and metabolic health in women with gestational diabetes

BACKGROUND

Gestational diabetes mellitus (GDM) is characterized by increased insulin resistance and carries perinatal and long-term risks for the mother and her offspring. There is a link between perinatal depression or anxiety and GDM. Mental health problems are associated with higher insulin resistance and could explain the underlying association between GDM and depression or anxiety symptoms. We investigated the trajectories and associations between symptoms of mental health and well-being with insulin resistance and metabolic health in women with GDM.

METHODS

This study included the control group (n = 106) of a randomized controlled trial in women with GDM that were followed-up during pregnancy and up to 1-year postpartum. We measured symptoms of mental health (Edinburgh Postnatal Depression Scale (EPDS), Anxiety subscale of the Hospital Anxiety and Depression Scale (HADS-A), well-being (The World Health Organization Well-Being Index (WHO-5)) and metabolic health, including insulin resistance variables (HOMA-insulin resistance (IR) and Matsuda Index of insulin sensitivity) as well as weight during pregnancy and in the postpartum.

RESULTS

Participants' pre pregnancy weight and BMI were 69.7 kg ± 16.1 and 25.9 kg/m2 ± 5.5 respectively. HOMA-IR was higher during pregnancy compared to 6-8 weeks postpartum and increased between 6-8 weeks and 1-year postpartum (all p < 0.05). Matsuda index decreased between 6-8 weeks and 1-year postpartum (p < 0.001). EPDS scores decreased between pregnancy and both 6-8 weeks and 1-year postpartum (all p < 0.05). HADS-A scores did not change between pregnancy and the postpartum. WHO-5 scores improved significantly from pregnancy and both 6-8 weeks and 1-year postpartum (p < 0.001). Correlation coefficients within outcome at the three different time points were high for metabolic measures and ranged between 0.94 and 0.96 for weight, from 0.77 to 0.89 for HOMA-IR and 0.64 for the Matsuda index (all p < 0.001). Mental health and well-being variables were moderately correlated in all three time points including r = 0.36-0.55 for the EPDS (p < 0.001), r = 0.58 for HADS (p < 0.001), and r = 0.43-0.52 for the WHO-5 (p < 0.01). After adjustment for age and pre-pregnancy BMI, Matsuda index was negatively associated with EPDS scores and positively associated to WHO-5 scores at 6-8 weeks postpartum. No other association between insulin resistance and mental health or well-being outcomes were found.

CONCLUSION

While insulin resistance fluctuated with values being lowest in the early postpartum and increasing thereafter, both depression and well-being scores decreased between pregnancy and the postpartum and did not change in the postpartum period. Intraindividual variability was larger for mental health and well-being than for metabolic health outcomes at different time points, indicating a higher plasticity for mental health and well-being outcomes that could be acted upon. We found only few associations between mental health and well-being and metabolic health outcomes.

Social support in multiple sclerosis: Associations with quality of life, depression, and anxiety

OBJECTIVE

Social support plays a role in the well-being of persons with multiple sclerosis (PwMS). The aims of this study were to compare social support in PwMS with relapsing versus progressive disease, examine the relationships with patient reported outcomes (PROs), and investigate social support longitudinally.

METHODS

For this study, we have performed an analysis of data routinely collected from subjects enrolled in the CLIMB at the Partners MS Center. Subjects (n = 789) completed measures of social support, quality of life (QOL), depression, and anxiety. Relapsing and progressive PwMS were compared using a two sample t-test, and linear regression was used to adjust for other variables. Correlations between social support and PROs were assessed using partial Pearson's correlation coefficient. A random intercept and slope model with a linear trend with time estimated the change over time.

RESULTS

Subjects with relapsing MS reported higher overall social support than subjects with progressive disease (difference in means = -6.7; 95% CI: -10.3, -3.1) as well as higher levels of 3 of the 4 dimensions of social support measured. These differences remained after adjusting for age and gender only, but were attenuated adjusting for age, gender, and depression (adjusted difference in means = -1.2; 95% CI: -5.0, 2.6). Higher overall social support was associated with higher QOL (r = 0.16-0.27), lower depression (r = -0.36), and lower state (r = -0.27) and trait (r = -0.29) anxiety. Social support was mostly stable over time.

CONCLUSION

Social support was associated with QOL, depression, and anxiety in PwMS.

Psychological consequences of COVID-19 pandemic in Italian MS patients: signs of resilience?

BACKGROUND

Anxiety, depression and reduction of quality of life (QoL) are common in people with multiple sclerosis (pwMS). Fear of getting sick from COVID-19, government's lockdown and the imposed social distancing might have had an impact on psychological distress and QoL.

OBJECTIVES

The aim of our study was to investigate anxiety, depression and QoL changes in pwMS during SARS-CoV-2 outbreak and lockdown in Italy.

METHODS

67 pwMS with a previous (less than 6 months) neuropsychological evaluation before SARS-CoV-2 outbreak (T0) were re-evaluated at the time of the outbreak and lockdown in Italy (T1). They underwent a clinical and neurological evaluation and completed the State-Trait Anxiety Inventory (STAI-Y1), the Beck Depression Inventory second edition (BDI-II), and Multiple Sclerosis Quality of Life-54 (MsQoL-54) at T0 and T1. Benjamini-Hochberg procedure was applied to control the false discovery rate.

RESULTS

BDI-II and STAI-Y1 scores did not change between T0 and T1. At T1, MsQoL-54 scores were higher on the satisfaction with sexual life and the social function subscales, and lower on the limitation due to emotional problems subscale.

CONCLUSIONS

This is the first study that evaluated mood and QoL levels before and during the lockdown due to COVID-19 pandemic in pwMS. No worsening of anxiety and depression levels was found. Contrariwise some improvements were noted on QoL, the most reliable regarding the sexual satisfaction and the social function.

Anxiety and depression in Multiple Sclerosis (MS): Antecedents, consequences, and differential impact on well-being and quality of life

BACKGROUND

Individuals with multiple sclerosis (MS) are often plagued by the unpredictability of their disease and have to contend with uncertainty in their life and significant life changes. This can lead to high levels of stress, perceived lack of control, helplessness, and anxiety. Despite these circumstances, anxiety disorders are often overshadowed by depression, which can result in its presence being overlooked and undertreated by many medical professionals.

METHODS

One hundred and eighty three individuals with MS completed a comprehensive online survey assessing depression and anxiety and the demographic and disease risk factors of such, including social support and substance use. Participants also completed measures of MS symptomatology, disease management, psychological well-being, and quality of life to determine the impact of depression and anxiety on outcomes associated with MS.

RESULTS

Findings suggest that both depression and anxiety are prevalent in MS and related to many outcomes. However, based on comparisons of the associations and group comparisons, with a few exceptions, anxiety proved to more impactful than depression when examining these outcomes. When evaluating the risk factors/contributors of anxiety and depression, social support was a consistent predictor. Younger age and shorter disease duration were also associated with anxiety, while lower education and substance use were predictors of depression.

CONCLUSION

Findings suggest that attention to anxiety be given as much as depression as it plays a large role in individuals' perceived health and well-being, which subsequently impacts the severity of symptoms and overall quality of life. Early identification of anxiety and potential substance use and increased social support also appear to be crucial for mitigating the impact of depression and anxiety.

Relationship Between Anxiety and Cognition in Multiple Sclerosis: Implications for Treatment

Background

Anxiety, which is very prevalent in multiple sclerosis (MS) but understudied, has been shown to negatively affect cognition in many different populations. Slowed information processing speed underlies most cognitive impairments in MS, including verbal learning. The aim of this study was to look at how anxiety influences cognition-specifically processing speed and verbal learning-in MS.

Methods

Eligibility criteria were adults (≥18 years) who had a diagnosis of clinically definite MS and had participated in neuropsychological research projects. A retrospective medical record review was conducted on the neuropsychological testing data. Two hierarchical multiple regressions were conducted to determine the unique contributions of processing speed and anxiety on verbal learning in MS, after adjusting for demographic and disability variables. Two separate mediation analyses were conducted to determine the relationship between processing speed, verbal learning, and anxiety.

Results

Participants (N = 141) ranged in age from 18-91 years. Based on the multiple regression analyses, processing speed (β = 0.55, ΔR ² = 0.27, P < .001) and anxiety (β = -0.34, ΔR ² = 0.11, P < .001) were uniquely significant predictors of verbal learning. Based on the mediation analyses, there was a significant indirect effect of anxiety on verbal learning through processing speed (ab = -0.31, 95% CI = -0.60 to -0.09). There was also a significant indirect effect of processing speed on verbal learning through anxiety (ab = -0.05, 95% CI = 0.01 to 0.12).

Conclusions

Results suggest a bidirectional relationship of anxiety and processing speed on verbal learning in MS. Anxiety has a significant effect on cognition and should not be overlooked. Interventions targeting anxiety may improve cognition in MS.

'It's the unknown' - understanding anxiety: from the perspective of people with multiple sclerosis

OBJECTIVE

A qualitative study of PwMS who had clinically significant levels of anxiety was conducted to gain a richer perspective on their experience. The objective was to explore PwMS' experiences of anxiety and their perspectives on causes and outcomes.

DESIGN

Twenty in-depth, semi-structured interviews were conducted with PwMS consecutively recruited from the Neurology Department of a NHS University Hospital. Sixteen had a relapsing-remitting course, three had a secondary progressive course and one person had primary progressive multiple sclerosis (MS). Interviews were recorded, transcribed and analysed using inductive thematic analysis.

RESULTS

Although participants thought different factors had initially triggered their anxiety, being given the diagnosis of MS appeared to be the most significant factor for many participants. Difficulties in the workplace and in relationships, particularly related to perceived dependence on others were also important themes. A wide range of emotional responses and negative thinking patterns were associated with anxiety; this suggested the presence of comorbid depression. Participants were able to acknowledge the positive and negative coping strategies that impacted on their anxiety.

CONCLUSION

This review confirms that anxiety can have many negative implications for PwMS and suggests that early detection and intervention are necessary in order to improve patient's well-being.

Anxiety and depression in patients with multiple sclerosis: The mediating effects of perceived social support

BACKGROUND

Social support has been identified as a buffering or intervening variable in stressful life events. Research has demonstrated that greater social support is associated with better mental health in multiple sclerosis (MS), but little is known about its links to specific aspects of mental health. We therefore investigated if and how perceived social support modulates depression, anxiety and fatigue in patients with MS.

METHODS

We recruited 112 patients with MS from three French hospitals and administered a demographic and clinic interview, and self-report measures of perceived social support (Multidimensional Scale of Perceived Social Support), depression and anxiety (Hospital Anxiety and Depression Scale), and fatigue (Fatigue Severity Scale). We then analyzed the relationships between these domains using path analysis.

RESULTS

The causal path model provided an excellent fit for the data (χ² = 9.8, p = .778, standardized root mean square residual = 0.043, comparative fit index = 1.00). Results indicated that the level of social support from friends is a predictor of anxiety symptomatology. Thus, anxiety may have both a direct and an indirect impact on fatigue and depression levels.

CONCLUSIONS

This study highlights the important roles played by perceived social support and anxiety in MS. These should be key pharmacological and non-pharmacological targets for optimizing patient care. (NCT 02-880-553).

Diagnostic and Clinical Utility of the GAD-2 for Screening Anxiety Symptoms in Individuals With Multiple Sclerosis

OBJECTIVE

To assess the diagnostic and clinical utility of the 2-item Generalized Anxiety Disorder Scale (GAD-2) for screening anxiety symptoms in individuals with multiple sclerosis (MS).

DESIGN

Cross-sectional.

SETTING

University-affiliated MS neurology and rehabilitation center.

PARTICIPANTS

The sample comprised adults (N=99) (ages 19-72; mean ± SD=46.2±13.0; 75% women) with a physician-confirmed MS diagnosis who were receiving care in a university-affiliated MS center. Disease durations ranged from 1 to 37 years (mean ± SD=10.7±8.4).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Participants completed the 7-item Generalized Anxiety Disorder Scale (GAD-7) and GAD-2. Internal consistency was calculated for both measures. Area under the receiver operating characteristics curve (AUC), the 95% confidence interval for the AUC, and Youden's J were calculated to determine the optimal GAD-2 cutoff score for identifying clinically significant anxiety symptoms, as defined by the previously validated GAD-7 cutoff score of ≥8.

RESULTS

Internal consistency was excellent for the GAD-7 (Cronbach α=.91) and acceptable for the GAD-2 (α=.77), and the measures were highly correlated (r=.94). The GAD-2 had excellent overall accuracy for identifying clinically significant anxiety symptoms (AUC=0.97; 95% confidence interval, 0.94-1.00). A GAD-2 cutoff score of ≥3 provided an optimal balance of good sensitivity (0.87) and excellent specificity (0.92) for detecting clinically significant anxiety symptoms. Alternatively, a cutoff score of ≥2 provided excellent sensitivity (1.00) and fair specificity (0.76).

CONCLUSIONS

The GAD-2 is a clinically useful and psychometrically valid tool for screening anxiety symptoms in MS rehabilitation and neurology care settings. Importantly, this tool has the potential to identify individuals with MS who are at risk for anxiety disorders and who may benefit from rehabilitation psychology interventions to ultimately improve functioning and quality of life.

The clinical utility of metacognitive beliefs and processes in emotional distress in people with multiple sclerosis

AIM

Multiple sclerosis (MS) is a chronic demyelinating disease that poses significant life challenges. Depression and anxiety often occur in people with MS (PwMS). An information processing model of psychopathology, the Self-Regulatory Executive Function (S-REF) model specifies that maladaptive metacognitive beliefs play a fundamental role in the development and maintenance of distress. The model also asserts that a style of thinking known as the cognitive attentional syndrome (CAS), which consists of worry and rumination, focusing on sources of threat, and unhelpful coping responses, is common across all psychological conditions. This study investigated for the first time whether metacognitive beliefs explained additional variance in distress in PwMS, after accounting for demographic, clinical, and illness appraisal variables.

METHOD

One hundred and thirty-two participants with MS completed self-report questionnaires measuring distress, fatigue, pain, metacognitive beliefs, illness appraisals, and the CAS. Hierarchical regression modelling was used to test whether metacognitive beliefs accounted for distress. Mediational modelling examined if the CAS mediated the association between metacognitive beliefs and distress.

RESULTS

Metacognitive beliefs made a unique contribution to distress, over and above demographic and clinical variables, and illness appraisals. The CAS fully mediated the relationship between positive metacognitive beliefs and distress, and partially mediated the relationship between negative metacognitive beliefs and distress.

CONCLUSIONS

Metacognitive beliefs are associated with emotional distress in PwMS, and the CAS mediates this relationship. Future studies should examine if modification of metacognitive beliefs and processes in PwMS will lead to effective alleviation of emotional distress.

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.

Screening Tools for Anxiety in People with Multiple Sclerosis: A Systematic Review

Background: Anxiety is prevalent in people with multiple sclerosis (MS). Screening measures are used to identify symptoms of anxiety, but the optimal measure to screen for anxiety disorders in MS has not been established. Methods: We searched the MEDLINE, Embase, PsycINFO, PsycARTICLES Full Text, Cumulative Index to Nursing and Allied Health Literature, Web of Science, and Scopus databases from database inception until August 7, 2015. Two independent reviewers screened abstracts and full-text reports for study inclusion, extracted data, and assessed risk of bias. We included studies that evaluated the criterion validity of anxiety screening tools when measuring anxiety in individuals with well-documented MS, as measured by sensitivity, specificity, and positive and negative predictive values. Results: Of the 3181 abstracts screened, 18 articles were reviewed in full text, of which 4 met the inclusion criteria. The criterion validity of three screening tools was assessed: the Hospital Anxiety and Depression Scale-Anxiety (HADS-A), Beck Anxiety Inventory (BAI), and 7-item Generalized Anxiety Disorder Scale (GAD-7). The HADS-A was validated against the Structured Clinical Interview for DSM-IV, the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) interview, and the BAI. The BAI was validated against the SCAN, and the GAD-7 was validated against the HADS-A. The HADS-A had higher measures of sensitivity and specificity than did the BAI and the GAD-7. Conclusions: Based on this small sample, the HADS-A shows promise as an applicable measure for people with MS. Screening scales used to identify anxiety in MS must be validated against appropriate reference standards.

A systematic review of anxiety amongst people with Multiple Sclerosis

BACKGROUND

Multiple Sclerosis (MS) is a chronic neurological disease, which poses significant psychological challenges. The purpose of this systematic review was to identify factors that are associated with anxiety in people with MS (PwMS). It aimed to examine the strength of evidence for factors associated with anxiety symptoms and identify limitations of existing studies.

METHOD AND RESULTS

One hundred and thirty one studies met inclusion criteria and were included in the review. A narrative synthesis was then conducted. Anxiety was found to be associated with a variety of demographic, physical, psychological, cognitive and social factors. A consistent finding was that anxiety was strongly associated with both high level of disability and low quality of life. A strong association between anxiety and depression was also found.

CONCLUSION

Implications for these results are discussed and a preliminary model of understanding anxiety in the context of MS is outlined. Given the overlap between anxiety and depression, a transdiagnostic treatment approach is suggested. In light of the shortcomings of extant studies, suggestions for future research are offered.

Fatigue and depression in multiple sclerosis: pharmacological and non-pharmacological interventions

Multiple sclerosis (MS) is a neuroinflammatory condition with a prominent progressive neurodegenerative facet that typically affects young- or middle-aged adults. Although physical disabilities have been in the foreground by being easier to assess, there is an increasing interest in mental disabilities and psychiatric co-morbidities, which have a disproportionally high impact on important outcome measures such as quality of life and occupational disability. In particular, cognitive impairment, depression and mental fatigue, which mutually interact with each other, seem to be of importance in this context. In recent decades, major efforts have been invested in developing more effective disease modulatory treatments. This has resulted in novel therapeutic options and awareness of the importance of early intervention. In comparison, good quality and adequately powered studies on symptomatic treatments of fatigue and psychiatric co-morbidities in MS are rare, and awareness of treatment options is much lower. We here review the existing evidence base for symptomatic treatment of fatigue and depression in MS patients. With regard to fatigue, off-label prescription of alertness improving drugs is common, in spite of all but absent evidence of efficacy. In contrast, a number of smaller studies suggest that physical exercise and fatigue management courses may have some clinical benefit. Very few studies have addressed the efficacy of antidepressants and non-pharmaceutical interventions specifically in MS patients. Therefore, treatment guidelines largely rely on data from non-MS populations. In the future, there is a strong motive to direct additional resources to the study of these important aspects of MS.

Coping with Multiple Sclerosis Scale: Reconsideration of the Factorial Structure

BACKGROUND

The Coping with Multiple Sclerosis Scale (CMSS) was developed to assess coping strategies specific to multiple sclerosis (MS). Despite its wide application in MS research, psychometric support for the CMSS remains limited to the initial factor analytic investigation by Pakenham in 2001.

METHODS

The current investigation assessed the factor structure and construct validity of the CMSS. Participants with MS (N = 453) completed the CMSS, as well as measures of disability related to MS (Multiple Sclerosis Impact Scale), quality of life (World Health Organization Quality of Life Brief Scale), and anxiety and depression (Hospital Anxiety and Depression Scale).

RESULTS

The original factor structure reported by Pakenham was a poor fit to the data. An alternate seven-factor structure was identified using exploratory factor analysis. Although there were some similarities with the existing CMSS subscales, differences in factor content and item loadings were found. Relationships between the revised CMSS subscales and additional measures were assessed, and the findings were consistent with previous research.

CONCLUSIONS

Refinement of the CMSS is suggested, especially for subscales related to acceptance and avoidance strategies. Until further research is conducted on the revised CMSS, it is recommended that the original CMSS continue to be administered. Clinicians and researchers should be mindful of lack of support for the acceptance and avoidance subscales and should seek additional scales to assess these areas.

Worries and concerns of patients with multiple sclerosis: development of an assessment scale

This study examined the nature of worry in adult patients with multiple sclerosis (MS) in the UK. A measure of worry in MS was developed and the relationship between worry and standard scale measures of anxiety and depression was examined. Thirty-nine patients with MS and 40 controls completed the new worry scale (WQMS) that was psychometrically evaluated, together with the Penn State Worry Questionnaire (PSWQ), the Hospital Anxiety and Depression Scale (HAD) and a previously developed scale to assess self-efficacy in MS (SESMS). The scores for both anxiety ( t=2.34; p<0.05) and depression ( t=5.52; p<0.01) were higher in MS patients than controls, as was the new scale for worry - the WQMS. A factor analysis (explaining 65.73% of the variance) suggests that the worries of patients may be dichotomized into those concerned with the physical effects of the disease and those relating to the impact on social interaction, family relationships and daily activity in the home and/or work. Worry in patients with MS was associated with a decreased sense of being able to produce positive activities or effect positive outcomes (low self-efficacy). The questionnaire provides a framework for investigation in clinic of specific concerns and level of worry they engender.

Intolerance of Uncertainty: Shaping an Agenda for Research on Coping with Multiple Sclerosis

Multiple sclerosis (MS) is a chronic and progressive neurologic condition that, by its nature, carries uncertainty as a hallmark characteristic. Although all patients face uncertainty, there is variability in how individuals cope with its presence. In other populations, the concept of "intolerance of uncertainty" has been conceptualized to explain this variability such that individuals who have difficulty tolerating the possibility of future occurrences may engage in thoughts or behaviors by which they attempt to exert control over that possibility or lessen the uncertainty but may, as a result, experience worse outcomes, particularly in terms of psychological well-being. This topical review introduces MS-focused researchers, clinicians, and patients to intolerance of uncertainty, integrates the concept with what is already understood about coping with MS, and suggests future steps for conceptual, assessment, and treatment-focused research that may benefit from integrating intolerance of uncertainty as a central feature.

Magnitude and concurrence of anxiety and depression among attendees with multiple sclerosis at a tertiary care Hospital in Oman

Background

Anxiety, depression and functional impairments are commonly reported by persons with multiple sclerosis (PwMS) but no data, to our knowledge, has emerged from an Arab Islamic population. The study aims to investigate the prevalence of anxiety, depression and related disabilities among PwMS attending tertiary care in Sultan Qaboos University Hospital (SQUH), one of the urban hospitals in Oman.

Methods

Consecutive and consenting PwMS (n = 57) and healthy subjects (n = 53) completed the following measures: Hospital Anxiety and Depression Scale (HADS) which was used to measure anxiety (cut-point >7) and depression (>7); and Expanded Disability Status Scale (EDSS) to measure the level of disability (≥5). Characteristics such as socio-demographic and clinical variables were also explored.

Results

Fifty seven subjects with multiple sclerosis (MS) met the inclusion criteria. The majority of them were females who were 40 years old or younger and the majority were employed and unmarried. Approximately 86 % of the participants were using beta interferon, 96 % scored ≥5 in EDSS. MS of the Relapsing-Remitting type constituted the majority of the cohort (94 %). Approximately 35 % and 51 % endorsed symptoms of anxiety and depression respectively. The MS group scored significantly higher than controls on HADS measurements of depression and anxiety.

Conclusion

Disability and symptoms of anxiety and depression are common among the PwMS attendees of tertiary care hospital in Oman. Such psychosocial variables have been largely unreported emerging from non-western populations. As these variables are strong indicators of the burden of MS, resolute effort is needed to address such psychosocial dysfunctions in the algorithms of care for PwMS in the Arab Islamic part of the world.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

In multiple sclerosis anxiety, not depression, is related to gender

Background:

There is a high prevalence of depressive and anxiety disorders in multiple sclerosis (MS), a disease 2.5 times more frequent in females. Contrary to the general population, in whom studies have demonstrated higher rates of depression and anxiety in females, little is known about the impact of gender on psychiatric sequelae in MS patients.

Objectives:

We conducted a retrospective study to try to clarify this uncertainty.

Methods:

Demographic, illness-related and behavioral variables were obtained from a neuropsychiatric database of 896 patients with a confirmed diagnosis of MS. Symptoms of depression and anxiety were obtained with the Hospital Anxiety and Depression Scale (HADS). Gender comparisons were undertaken and predictors of depression and anxiety sought with a linear regression analysis.

Results:

HADS data were available for 711 of 896 (79.35%) patients. Notable gender differences included a higher frequency of primary progressive MS in males ( p = 0.002), higher HADS anxiety scores in females ( p < 0.001), but no differences in HADS depression scores.

Conclusion:

In MS, gender influences the frequency of anxiety only. This suggests that the etiological factors underpinning anxiety and depression in MS are not only different from one another, but also in the case of depression, different from those observed in general population samples.

The 7-item generalized anxiety disorder scale as a tool for measuring generalized anxiety in multiple sclerosis

BACKGROUND

Generalized anxiety disorder (GAD) is common in multiple sclerosis (MS) but understudied. Reliable and valid measures are needed to advance clinical care and expand research in this area. The objectives of this study were to examine the psychometric properties of the 7-item Generalized Anxiety Disorder Scale (GAD-7) in individuals with MS and to analyze correlates of GAD.

METHODS

Participants (N = 513) completed the anxiety module of the Patient Health Questionnaire (GAD-7). To evaluate psychometric properties of the GAD-7, the sample was randomly split to conduct exploratory and confirmatory factor analyses.

RESULTS

Based on the exploratory factor analysis, a one-factor structure was specified for the confirmatory factor analysis, which showed excellent global fit to the data (χ(2) 12 = 15.17, P = .23, comparative fit index = 0.99, root mean square error of approximation = 0.03, standardized root mean square residual = 0.03). The Cronbach alpha (0.75) indicated acceptable internal consistency for the scale. Furthermore, the GAD-7 was highly correlated with the Hospital Anxiety and Depression Scale-Anxiety (r = 0.70). Age and duration of MS were both negatively associated with GAD. Higher GAD-7 scores were observed in women and individuals with secondary progressive MS. Individuals with higher GAD-7 scores also endorsed more depressive symptoms.

CONCLUSIONS

These findings support the reliability and internal validity of the GAD-7 for use in MS. Correlational analyses revealed important relationships with demographics, disease course, and depressive symptoms, which suggest the need for further anxiety research.

Prenatal maternal immune activation increases anxiety- and depressive-like behaviors in offspring with experimental autoimmune encephalomyelitis

Multiple sclerosis (MS) is thought to result from a combination of genetics and environmental factors. Several lines of evidence indicate that significant prevalence of anxiety and depression-related disorders in MS patients can influence the progression of the disease. Although we and others have already reported the consequences of prenatal maternal immune activation on anxiety and depression, less is known about the interplay between maternal inflammation, MS and gender. We here investigated the effects of maternal immune activation with Poly I:C during mid-gestation on the progression of clinical symptoms of experimental autoimmune encephalomyelitis (EAE; a mouse model of MS), and then anxiety- and depressive-like behaviors in non-EAE and EAE-induced offspring were evaluated. Stress-induced corticosterone and tumor necrosis factor-alpha (TNF-α) levels in EAE-induced offspring were also measured. Maternal immune activation increased anxiety and depression in male offspring, but not in females. This immune challenge also resulted in an earlier onset of the EAE clinical signs in male offspring and enhanced the severity of the disease in both male and female offspring. Interestingly, the severity of the disease was associated with increased anxiety/depressive-like behaviors and elevated corticosterone or TNF-α levels in both sexes. Overall, these data suggest that maternal immune activation with Poly I:C during mid-pregnancy increases anxiety- and depressive-like behaviors, and the clinical symptoms of EAE in a sex-dependent manner in non-EAE or EAE-induced offspring. Finally, the progression of EAE in offspring seems to be linked to maternal immune activation-induced dysregulation in neuro-immune-endocrine system.

Resilience, self-efficacy, coping styles and depressive and anxiety symptoms in those newly diagnosed with multiple sclerosis

High levels of depressive and anxiety symptoms have been reported by individuals with multiple sclerosis (MS). This study examined the associations between resilience, self-efficacy and coping and depressive and anxiety symptoms and whether resilience, self-efficacy and coping were predictors of depressive and anxiety symptoms in patients newly diagnosed with MS. A sample of 129 individuals newly diagnosed with MS participated in this cross-sectional study and completed an online questionnaire assessing resilience, self-efficacy, coping and depressive and anxiety symptoms. Results revealed that depressive and anxiety symptoms were significantly associated with problem-focused, emotion-focused and avoidance coping strategies, resilience and self-efficacy. Anxiety symptoms were also significantly associated with employment status and level of disability. Results from hierarchical multiple regression revealed that the resilience subscale of personal competence, the avoidance coping style of substance use and emotion-focused coping styles of venting predicted depressive symptoms and uniquely accounted for 63.8% of the variance in the depression score, F (18, 124) = 10.36, p = .000. Level of disability and employment status accounted for 13.2% of the anxiety score and avoidance coping style of denial and emotion-focused coping style of humour accounted for 36.4% of the variance in the anxiety symptom score, F (15, 112) = 6.37, p = .000. Our findings suggest that resilience and avoidance and emotion-focused coping strategies are predictive of depressive symptoms and anxiety symptoms in those newly diagnosed with MS. Resilience and coping styles may be another target for interventions aimed at managing depressive and anxiety symptoms in those newly diagnosed with MS.

Neurobehavioral burden of multiple sclerosis with nanotheranostics

Multiple sclerosis (MS) is a chronic demyelinating neurological disorder affecting people worldwide; women are affected more than men. MS results in serious neurological deficits along with behavioral compromise, the mechanisms of which still remain unclear. Behavioral disturbances such as depression, anxiety, cognitive impairment, psychosis, euphoria, sleep disturbances, and fatigue affect the quality of life in MS patients. Among these, depression and psychosis are more common than any other neurological disorders. In addition, depression is associated with other comorbidities. Although anxiety is often misdiagnosed in MS patients, it can induce suicidal ideation if it coexists with depression. An interrelation between sleep abnormalities and fatigue is also reported among MS patients. In addition, therapeutics for MS is always a challenge because of the presence of the blood-brain barrier, adding to the lack of detailed understanding of the disease pathology. In this review, we tried to summarize various behavioral pathologies and their association with MS, followed by its conventional treatment and nanotheranostics.

Predictors of anxiety in multiple sclerosis

PURPOSE/OBJECTIVES

The aims of this study were to (1) identify the predictors of symptoms of anxiety, and (2) evaluate the differential association of somatic and nonsomatic symptoms of depression on anxiety over time in persons with multiple sclerosis (MS).

METHOD/DESIGN

Participants were 513 persons with MS who previously enrolled in a study exploring the experience of living with MS and completed a 4-month follow-up survey. The main outcome measure used was the Hospital Anxiety and Depression Scale-Anxiety. Demographic, disease-associated variables (time since onset of MS, Expanded Disability Status Scale Mobility, pain, and fatigue), and Time 1 psychological variables were entered into a hierarchical regression model to examine predictors at baseline for anxiety symptoms at Time 2.

RESULTS

A large portion of the sample was White (92%), female (82%), and had relapsing-remitting MS (57%). After adjusting for demographic and disease related variables, anxiety (β <.001), employment (β = .07), and nonsomatic depressive symptoms (β = .10) at baseline significantly predicted anxiety at Time 2, ps < .05. Interactions revealed significant effects for time since onset of MS and somatic symptoms as well as time since onset and nonsomatic symptoms, ps < .05. Nonsomatic symptoms were more linked to anxiety early in the disease and somatic symptoms were more prominently linked to anxiety later in the disease.

CONCLUSIONS

Findings suggest that nonsomatic symptoms of depression and employment predict anxiety in MS. The relationship between different aspects of depression and anxiety may change over the course of the disease.

The link between multiple sclerosis and depression

Depression--be it a formal diagnosis based on consensus clinical criteria, or a collection of symptoms revealed by a self-report rating scale--is common in patients with multiple sclerosis (MS) and adds substantially to the morbidity and mortality associated with this disease. This Review discusses the prevalence and epidemiology of depression in patients with MS, before covering aetiological factors, including genetics, brain pathology, immunological changes, dysregulation of the hypothalamic-pituitary-adrenal axis, and psychosocial influences. Treatment options such as antidepressant drugs, cognitive-behavioural therapy, mindfulness-based therapy, exercise and electroconvulsive therapy are also reviewed in the context of MS-related depression. Frequent comorbid conditions, namely pain, fatigue, anxiety, cognitive dysfunction and alcohol use, are also summarized. The article then explores three key challenges facing researchers and clinicians: what is the optimal way to define depression in the context of diseases such as MS, in which the psychiatric and neurological symptoms overlap; how can current knowledge about the biological and psychological underpinnings of MS-related depression be used to boost the validity of this construct; and can intervention be made more effective through use of combination therapies with additive or synergistic effects, which might exceed the modest benefits derived from their individual components?

Symptomatic treatment and management of multiple sclerosis

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

Longitudinal study of alexithymia and multiple sclerosis

OBJECTIVE

The aim of this study was to investigate the course of alexithymia and its relation with anxiety and depression in patients with multiple sclerosis (MS), over a period of 5 years.

METHODS

Sixty-two MS patients were examined at two timepoints, 5 years apart, and they answered questionnaires collecting socio-demographic, medical, and psychological data (depression, anxiety, alexithymia).

RESULTS

Our data show that emotional disorders remain stable over time in patients with MS, particularly as regards alexithymia and anxiety. Conversely, the rate of depression decreased between the two evaluations, falling from 40% to 26%. The two dimensions of alexithymia (i.e., difficulty describing and difficulty identifying feelings) were correlated with anxiety and depression, whereas the third component of alexithymia (externally oriented thinking) was independent, and was the only component to change over time, with a significant fall observed at 5 years.

CONCLUSION

Alexithymia was associated with increased severity of anxiety and attack relapses.

Relative contribution of cognitive and physical disability components to quality of life in MS

BACKGROUND

Information on the relative influence of cognitive and physical impairment on the quality of life in multiple sclerosis is currently limited and no scientific consensus has been reached yet.

OBJECTIVE

For this reason, we wanted to examine the relative contribution of cognitive and physical impairment measures comprised in the MSFC test on quality of life in MS.

METHODS

In the National MS Center Melsbroek, patients regularly undergo MSFC and EQ5D measurements. We investigated the correlations between the EQ5D, EQVAS and the MSFC and EDSS scores by the use of ANOVA and multilinear models.

RESULTS

We found a significant correlation between the EQVAS score and cognition in a univariate model. When including EDSS score and MSFC outcomes into the model, cognition was, however, excluded based on the Akaike Information Criterion. Cognition was, on the other hand, a significant predictor for the "Usual Activities" question of the EQ5D.

CONCLUSIONS

Although cognitive performance as measured on the PASAT-3s does not correlate with a patient's perceived quality of life in a multivariate model, it remains an important predictor for the patient's usual activities.

Symptom overlap in anxiety and multiple sclerosis

BACKGROUND

The validity of self-rated anxiety inventories in people with multiple sclerosis (pwMS) is unclear. However, the appropriateness of self-reported depression scales has been widely examined. Given somatic symptom overlap between depression and MS, research emphasises caution when using such scales.

OBJECTIVE

This study evaluates symptom overlap between anxiety and MS in a group of 33 individuals with MS, using the Beck Anxiety Inventory (BAI).

METHODS

Participants underwent a neurological examination and completed the BAI.

RESULTS

A novel procedure using hierarchical cluster analysis revealed three distinct symptom clusters. Cluster one ('wobbliness' and 'unsteady') grouped separately from all other BAI items. These symptoms are well-recognised MS-related symptoms and we question whether their endorsement in pwMS can be considered to reflect anxiety. A modified 19-item BAI (mBAI) was created which excludes cluster one items. This removal reduced the number of MS participants considered 'anxious' by 21.21% (low threshold) and altered the level of anxiety severity for a further 27.27%.

CONCLUSION

Based on these data, it is suggested that, as with depression measures, researchers and clinicians should exercise caution when using brief screening measures for anxiety in pwMS.

Factors affecting anxiety in multiple sclerosis

PURPOSE

Anxiety is common in people with multiple sclerosis (MS). Little is known about the factors related to anxiety. The aim was to identify factors associated with the presence of anxiety.

METHODS

This was a cohort study. Participants were sent questionnaires to measure factors potentially related to anxiety. The factors included disability, depression, self-efficacy, locus of control, general stress, psychological distress and factors specific to MS. Participants with significant levels of anxiety, as measured by the Hospital Anxiety and Depression Scale (HADS), were compared to those who were not anxious.

RESULTS

Of the 157 participants who took part, 89 (57%) were clinically anxious. Participants who were anxious had a lower level of self-efficacy (p < 0.001), higher level of disability (p < 0.001), higher level of depression (p < 0.001) and higher level of stress (p < 0.001). The regression analysis showed that experiencing depression (χ(2) = 5.05, OR = 1.32, p < 0.05) was the only factor that significantly predicted whether someone was anxious or not, accounting for 46% of the variance.

CONCLUSION

There was a high prevalence of anxiety in people with MS. Depression, low levels of self-efficacy, disability and stress increased the likelihood of experiencing anxiety.

Self-assessment of cognition in Multiple Sclerosis: the role of personality and anxiety

OBJECTIVE

: To investigate the role of personality and anxiety to self-report measures of cognition in patients with multiple sclerosis (MS).

BACKGROUND

: Self-report measures of cognition have consistently been shown to correlate better with depressed mood than neuropsychological test performance in patients with MS, with few studies focusing on the role of anxiety and personality.

METHOD

: One hundred eight MS patients completed the following: (a) patient and informant report Multiple Sclerosis Neuropsychological Questionnaire (MSNQ); (b) Hospital Anxiety and Depression Scale; (c) cognitive assessment with the Brief Repeatable Battery of Neuropsychological Tests; and (d) personality assessment using the self-report NEO Five-Factor Inventory.

RESULTS

: Higher patient MSNQ (P-MSNQ) scores (greater reported cognitive dysfunction) were significantly correlated with lower scores on the Paced Auditory Serial Addition Test (PASAT; r=-0.20, P<0.05), increased depression (r=0.45, P<0.01) and anxiety (r=0.54, P<0.01), higher neuroticism (r=0.51, P<0.01), and lower conscientiousness (r=-0.35, P<0.01). After controlling for demographic variables, significant predictors of P-MSNQ scores were anxiety (ΔR=0.272, P<0.001), conscientiousness (ΔR=0.067, P=0.002), and performance on the PASAT (ΔR=0.050, P=0.005). Depression and neuroticism did not contribute significant variance in comparison to anxiety.

CONCLUSIONS

: Overall, patient self-reports of cognition did not correspond well to neuropsychological performance. Anxiety and conscientiousness contributed significantly to patients' perceptions of their cognitive failings and thus should be taken into account when addressing these complaints.

Cognitive and neurobehavioral features in multiple sclerosis

Multiple sclerosis (MS) is the most common nontraumatic neurological condition of early and middle adulthood. Cognitive and neurobehavioral problems associated with this disorder are common. Approximately 50% of MS patients experience lifetime clinical depression, and at least 50% will experience significant cognitive difficulties. Fatigue is also extremely common and disabling in MS and appears to be associated with sleep problems and primary neurological features, in addition to secondary factors, including depression and pain. Quality of life is affected in MS by all of these factors and is an especially salient issue given that patients often live for many years following diagnosis. In this article, we explore the literature on cognitive and neurobehavioral features in MS, provide a commentary on the state of the literature and make suggestions for research directions over the next 5 years that would move the field forward significantly.

Anxiety and depression in multiple sclerosis patients around diagnosis

OBJECTIVES

To prospectively identify anxiety and depressive symptoms, and their predictors, during the multiple sclerosis (MS) peridiagnostic period.

METHODS

The Hospital Anxiety and Depression Scale (HADS) was administered during diagnostic workup (baseline), and one and six months after diagnosis disclosure, to SIMS-Trial participants (ISRCTN81072971).

RESULTS

Of 197 screened patients, 120 (61%) were diagnosed with MS. At baseline, median HADS anxiety (HADS-A) score was 7.0 (interquartile range [IQR] 5.0-9.5), ≥8 (anxiety cut-off) in 43% (95% confidence interval [CI] 34%-52%). Median HADS depression (HADS-D) was 3.0 (IQR 1.0-5.0), ≥8 (depression cut-off) in 11% (95% CI 5%-16%). Independent predictors of anxiety were female sex (odds ratio [OR] 2.8, 95% CI 1.1-7.2) and HADS-D score (OR 20.8, 95% CI 2.5-175.5). The only predictor of depressive symptoms was HADS-A score (OR 20.0, 95% CI 2.8-260.9). Anxiety symptoms had decreased slightly but significantly (p<0.001) at six months. Depressive symptoms remained low.

CONCLUSIONS

Anxiety was prominent in the period surrounding MS diagnosis disclosure, particularly in women. A slight but significant reduction occurred six months after diagnosis disclosure. Depressive symptoms were less common and stable over time. In addition to sex, depressive symptoms were the only variable independently associated with anxiety.

MS quality of life, depression, and fatigue improve after mindfulness training: a randomized trial

OBJECTIVE

Health-related quality of life (HRQOL) is often much reduced among individuals with multiple sclerosis (MS), and incidences of depression, fatigue, and anxiety are high. We examined effects of a mindfulness-based intervention (MBI) compared to usual care (UC) upon HRQOL, depression, and fatigue among adults with relapsing-remitting or secondary progressive MS.

METHODS

A total of 150 patients were randomly assigned to the intervention (n = 76) or to UC (n = 74). MBI consisted of a structured 8-week program of mindfulness training. Assessments were made at baseline, postintervention, and 6 months follow-up. Primary outcomes included disease-specific and disease-aspecific HRQOL, depression, and fatigue. Anxiety, personal goal attainment, and adherence to homework were secondary outcomes.

RESULTS

Attrition was low in the intervention group (5%) and attendance rate high (92%). Employing intention-to-treat analysis, MBI, compared with UC, improved nonphysical dimensions of primary outcomes at postintervention and follow-up (p < 0.002); effect sizes, 0.4-0.9 posttreatment and 0.3-0.5 at follow-up. When analyses were repeated among subgroups with clinically relevant levels of preintervention depression, fatigue, or anxiety, postintervention and follow-up effects remained significant and effect sizes were larger than for the total sample.

CONCLUSIONS

In addition to evidence of improved HRQOL and well-being, these findings demonstrate broad feasibility and acceptance of, as well as satisfaction and adherence with, a program of mindfulness training for patients with MS. The results may also have treatment implications for other chronic disorders that diminish HRQOL.

CLASSIFICATION OF EVIDENCE

This trial provides Class III evidence that MBI compared with UC improved HRQOL, fatigue, and depression up to 6 months postintervention.

The neuropsychiatry of multiple sclerosis: focus on disorders of mood, affect and behaviour

Neuropsychiatric symptoms are common in multiple sclerosis (MS). They include two broad categories of disturbances: abnormalities in cognition, and abnormalities of mood, affect and behaviour. The present review deals with the epidemiology, clinical features, etiology and treatment of disturbances included in the second category, i.e., major depression, fatigue and sleep disorders, bipolar disorder, euphoria, pathological laughing and crying, anxiety, psychosis and personality changes. Major depression is one of the most common neuropsychiatric disorders in MS with an approximate 50% lifetime prevalence rate. Early recognition and management of depression in MS is of major importance because it is a key predictor of morbidity, mortality, quality of life, possibly physical outcome and disease exacerbations, adherence to immunomodulatory treatments and suicide risk in MS patients, as well as of the caregiver's distress and quality of life. The etiopathogenesis of neuropsychiatric disorders in MS has been incompletely investigated. It is postulated that a complex interplay of biological, disease-related, behavioural and psychosocial factors contribute to the pathophysiology of most of them. Management of neuropsychiatric symptoms in MS is often effective, although commonly based on evidence provided by case studies and uncontrolled trials. A comprehensive biopsychosocial neuropsychiatric approach is essential for the optimal care of patients with MS.

Psychosocial adjustment in children and adolescents with a parent with multiple sclerosis: a systematic review

Objective: This systematic review explored the potential impact of parental multiple sclerosis on their offspring. It considered adjustment to parental multiple sclerosis at different developmental stages and the factors associated with good versus poor adjustment.

Data sources: MEDLINE, EMBASE, PsycINFO, CINAHL and Web of Science were searched for studies on children with a parent with multiple sclerosis. Inclusion and exclusion criteria were formulated. Hand-searching journals and reference lists, contacting authors and multiple sclerosis societies for additional unpublished papers complemented the searches.

Review methods: Twenty studies that satisfied the inclusion criteria were included. The research articles were ranked according to a quality assessment checklist and were categorized as good, medium or poor quality.

Results: The review found good evidence to suggest that parental multiple sclerosis has a negative impact on children’s social and family relationships and their psychological well-being. The review also identified potential factors associated with poor adjustment. These factors included parental negative emotions, increased illness severity, family dysfunction, children’s lack of knowledge about the illness and lack of social support. Adolescent children also seemed to be more at risk for psychosocial problems than school-age children.

Conclusions: There is good evidence that parental multiple sclerosis has a negative psychosocial impact on children, especially on adolescents.

The experience of attending a lay-led, chronic disease self-management programme from the perspective of participants with multiple sclerosis

A lay-led, community-based intervention, the Chronic Disease Self-Management Course (CDSMC) is effective for a range of long-term health conditions (e.g. arthritis, heart disease). However, the perceived value and experience of the CDSMC for people with Multiple Sclerosis (MS) has not been examined. The present qualitative study addressed this omission. Ten participants with MS (7 female; age range 35 to 60 years; disease duration 4 to 19 years) were interviewed before attending the CDSMC and at 4-month follow-up. Data were analysed using Framework Analysis. Some participants learned new self-management techniques and reported enhanced confidence (self-efficacy), whereas other participants were already confident in their self-management ability and found the CDSMC acted as a reminder of techniques previously used. Relaxation, pacing, and goal setting were particularly valuable for managing fatigue. Goal setting helped some participants to build confidence. Participants valued meeting similar others including those with different conditions. The CDSMC was an opportunity for social comparison and inspirational role modelling. Improvements to the CDSMC were suggested, including the addition of specific MS information. Overall, the CDSMC was viewed as a valuable source of new skills and a reminder of previously learned self-management skills, particularly in the context of managing fatigue. Gender differences emerged.

Predictors of depression in multiple sclerosis patients

Depression is one of the major problems associated with multiple sclerosis (MS). Several physical and psychological factors tend to interact and make it difficult to pinpoint the predictors of the depression. It seemed particularly important to examine how anxiety and illness evolution (characterized by the functional status) influence the appearance of depression symptoms. Thus, the aim of this article was to clarify the relationship between depression and the factors associated with it. One hundred and fifteen participants living at home recruited through various associations and MS clinics answered socio demographic, medical and psychological questions and questionnaires (depression, anxiety, coping, social support, locus of control, alexithymia, self-esteem). Results show that functional status (EDSS), trait anxiety, alexithymia and satisfaction with social support system are the predicting factors of depression. Trait anxiety and functional status are two predictors that independently and simultaneously lead to the appearance of depression symptoms, with trait anxiety playing a predominant role. Alexithymia and social support indirectly influence the appearance of these symptoms.

Evaluation of an adjustment group for people with multiple sclerosis: a pilot randomized controlled trial

Objective: The aim was to evaluate a group treatment for people with multiple sclerosis and low mood.

Design: Randomized controlled trial.

Setting: Community.

Participants: Patients with multiple sclerosis and low mood, scoring >7 on the Hospital Anxiety and Depression Scales or >2 on the General Health Questionnaire 12.

Interventions: Participants either attended an adjustment group for six, 2-hour group treatment sessions or were on a waiting list to attend the group.

Outcomes: Hospital Anxiety and Depression Scale, General Health Questionnaire 12, Multiple Sclerosis Self Efficacy Scale, Multiple Sclerosis Impact Scale and Short Form 36 administered 3 and 6 months after random allocation.

Results: Of the 219 patients identified, 100 (46%) reported depressive symptoms and 126 (58%) anxiety symptoms. Forty participants were recruited, aged 25—68 (mean 47.7 SD 9.7) and eight were men. Patients allocated to the group intervention reported fewer depressive symptoms than those in the control group (U 109.5, P<0.05) but there were no significant differences in anxiety symptoms, self-efficacy or quality of life.

Conclusion: Depressive symptoms were reduced following group intervention, which suggests this may be an effective psychological treatment and warrants further evaluation.

Validation of the Hospital Anxiety and Depression Scale for use with multiple sclerosis patients

Detecting clinically significant symptoms of depression and anxiety in medically ill patients using self-report rating scales presents a challenge because of somatic confounders. The Hospital Anxiety and Depression Scale (HADS) was developed with this in mind, but has never been validated for a multiple sclerosis population. Our objective was to validate the HADS for multiple sclerosis patients. Multiple sclerosis patients were interviewed for the presence of major depression (n = 180) and anxiety disorders (n = 140) with the Structured Clinical Interview for DSM-IV disorders. A receiver operating characteristic (ROC) analysis was undertaken to assess which HADS cut-off scores give the best yield with respect to diagnoses of major depression and all anxiety disorders defined by the Structured Clinical Interview for DSM-IV. A threshold score of 8 or greater on the HADS depression subscale provides a sensitivity of 90% and specificity of 87.3% (ROC area under the curve 0.938). The same cut-off score gives a sensitivity of 88.5% and a specificity of 80.7% on the anxiety subscale (ROC area under the curve 0.913), but for generalized anxiety disorder only. The study confirms the usefulness of the HADS as a marker of major depression and generalized anxiety disorder, but not other anxiety disorders, in multiple sclerosis patients.

A randomised controlled trial of lay-led self-management for people with multiple sclerosis

OBJECTIVE

To determine the impact of the Chronic Disease Self-Management Course (CDSMC) on people with multiple sclerosis (MS).

METHODS

2-group, randomised, controlled trial with Intervention Group (IG) and Waiting-List Control Group (WLCG). Additional data were collected from a Comparison Group (CG) who chose not to attend the CDSMC. Participants completed baseline questionnaires; IG participants attended the CDSMC immediately; all participants were assessed at 4-months and 12-months.

RESULTS

216 baseline questionnaires were returned; 73% were female, mean age 51.1 years, mean disease duration 12.0 years. Results showed that the CDSMC had an impact on self-management self-efficacy (ES 0.30, p=0.009 for the IG) and MSIS physical status (ES 0.12 for the IG, p=0.005). There were no other statistically significant changes. However, trends towards improvement on depression (ES 0.21 for the IG, p=0.05) and MS self-efficacy (ES 0.16 for the IG, p=0.04) were noted. All improvements were maintained at 12-months. At baseline, CG participants were older, had longer disease duration (p<0.01) and less anxiety (p=0.009) compared to RCT participants.

CONCLUSION

The CDSMC provides some small positive effects for people with MS. Motivation to attend may be linked to psychological distress and disease duration.

PRACTICE IMPLICATIONS

The CDSMC may be of value for those with mild anxiety/depression who need extra support. Attendance early in the disease course is recommended.

Longitudinal assessment of anxiety, depression, and fatigue in people with multiple sclerosis

OBJECTIVES

No longitudinal studies have concurrently evaluated predictors of anxiety, depression, and fatigue in people with multiple sclerosis (PwMS). This study determined factors that best predicted anxiety, depression, and fatigue in MS patients from a large pool of disease, cognitive, life-event stressor (LES), psychosocial, life-style, and demographic factors.

DESIGN

A 2-year prospective longitudinal study evaluated predictors of psychological distress and fatigue in PwMS.

METHODS

One hundred and one consecutive participants with MS were recruited from two MS clinics in Sydney, Australia. LES, anxiety, depression, and fatigue were assessed at baseline and at 3-monthly intervals for 2-years. Disease, cognitive, demographic, psychosocial, and life-style factors were assessed at baseline. Patient-reported relapses were recorded and corroborated by neurologists or evaluated against accepted relapse criteria.

RESULTS

Depression strongly predicted anxiety and fatigue, and anxiety and fatigue strongly predicted later depression. Psychological distress (i.e. anxiety, depression) was also predicted by a combination of unhealthy behaviours (e.g. drug use, smoking, no exercise, or relaxation) and psychological factors (e.g. low optimism, avoidance coping), similar to the results of community-based studies. However, state-anxiety and fatigue were also predicted by immunotherapy status, and fatigue was also predicted by LES and demographics.

CONCLUSIONS

These results suggest that similar factors might underpin psychological distress and fatigue in MS patients and community-well samples, although MS treatment factors may also be important. These results might assist clinicians in determining which MS patients are at greatest risk of developing anxiety, depression, or fatigue.