Validation of mood measures for people with multiple sclerosis

Self-reported cognitive function mediates the relationship between employment status and cognitive functioning in persons with multiple sclerosis

BACKGROUND

Cognitive impairment (CI) is common in people with MS (PwMS). Evidence is lacking for the self-reported CI's mediation effect on employment status and objective cognitive performance. Self-reported CI was found to be unreliable and seemed to be more associated with depression rather than formal cognitive performance. We hypothesized that the link between subjective and objective assessments of cognitive functions, mood, and employment status may be more complex in PwMS than previously reported.

OBJECTIVE

The aims of this study are the following: (Romero-Pinel et al., 2022) to determine whether employment status could affect performance in cognitive function testing and (Rao et al., 1991) whether their relationship may be mediated by self-reported CI; and (Deluca et al., 2013) to determine whether self-reported depression interacts with self-reported CI in influencing performance in various cognitive domains in PwMS.

METHODOLOGY

A retrospective study was performed involving PwMS who completed the self-report Multiple Sclerosis Neuropsychological Questionnaire (MSNQ), Hospital Anxiety and Depression Scale-depression scale (HADS-D), Minimal Assessment of Cognitive Function in MS (MACFIMS) and had data regarding employment status. Included PwMS were classified as employed or unemployed. A structural equation modeling (SEM) approach was taken due to the advantage of examining multiple cognitive outcomes simultaneously while accounting for shared associations. First, a latent factor of memory and executive functioning modeled the error-free associations between both factors and a processing speed task (SDMT). Next, the model tested for the indirect effect of self-reported cognition (MSNQ) on employment status differences in each outcome (memory, speed, and executive functioning). Finally, we tested interactions between MSNQ and HADS-D on each of the outcomes.

RESULTS

We included 590 PwMS: 72.5% female, mean age 44.2 years (SD = 10.5), mean disease duration 8.6 years (SD 9.0). The majority (n = 455, 77.1%) had relapsing MS; 357 (60.5%) were employed. About half (n = 301, 51%) did not report CI on the MSNQ; of those, 213 (70.8%) were employed. The mean MSNQ for employed PwMS was 24.5 (SD = 10.7) and 29.8 (SD = 11.2) for unemployed PwMS. Employed PwMS had significantly better memory (β = .16, p < .05), executive functioning (β = .25, p < .05), and processing speed (β = .22, p < .05). MSNQ partially indirectly mediated the effect of employment status on memory (Δβ = .03, p < .05) and executive functioning (Δβ = .03, p < .05) and processing speed (Δβ = .04, p < .05), indicating that self-report CI partially explains the influence of employment status on these cognitive domains. The association between MSNQ with both memory and executive functioning was moderated by depression, meaning that in PwMS with high HADS-D scores, MSNQ was more strongly related to worse memory and executive functioning. The final model was an acceptable fit to the data (χ2(87) = 465.07, p < .05; CFI = .90, RMSEA = .08, 90% CI [.06, .09], SRMR = .05) explaining 41.20%, 38.50% and 33.40% of the variability in memory, executive functioning, and processing speed, respectively.

CONCLUSION

Self-reported CI partially explains the associations between employment status and objective cognitive assessment in PwMS. Depression may moderate the relationship between self-reported cognitive assessment and objective cognitive performance. Thus, employment status and mood may guide the interpretation of self-reported CI.

Actual and Imagined Music-Cued Gait Training in People with Multiple Sclerosis: A Double-Blind Randomized Parallel Multicenter Trial

BACKGROUND

Actual and imagined cued gait trainings have not been compared in people with multiple sclerosis (MS).

OBJECTIVE

To analyze the effects of cued motor imagery (CMI), cued gait training (CGT), and combined CMI and cued gait training (CMI-CGT) on motor, cognitive, and emotional functioning, and health-related quality of life in people with MS.

METHODS

In this double-blind randomized parallel-group multicenter trial, people with MS were randomized (1:1:1) to CMI, CMI-CGT, or CGT for 30 minutes, 4×/week for 4 weeks. Patients practiced at home, using recorded instructions, and supported by ≥6 phone calls. Data were collected at weeks 0, 4, and 13. Co-primary outcomes were walking speed and distance, analyzed by intention-to-treat. Secondary outcomes were global cognitive impairment, anxiety, depression, suicidality, fatigue, HRQoL, motor imagery ability, music-induced motivation, pleasure and arousal, self-efficacy, and cognitive function. Adverse events and falls were continuously monitored.

RESULTS

Of 1559 screened patients, 132 were randomized: 44 to CMI, 44 to CMI-CGT, and 44 to CGT. None of the interventions demonstrated superiority in influencing walking speed or distance, with negligible effects on walking speed (η2 = 0.019) and distance (η2 = 0.005) observed in the between-group comparison. Improvements in walking speed and walking distance over time corresponded to large effects for CMI, CMI-CGT, and CGT (η2 = 0.348 and η2 = 0.454 respectively). No severe study-related adverse events were reported.

CONCLUSIONS

CMI-GT did not lead to improved walking speed and distance compared with CMI and CGT alone in people with MS. Lack of a true control group represents a study limitation.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00023978.

Effects of a Remote Multimodal Intervention Involving Diet, Walking Program, and Breathing Exercise on Quality of Life Among Newly Diagnosed People with Multiple Sclerosis: A Quasi-Experimental Non-Inferiority Pilot Study

Background

Interventions involving diet, physical activity, and breathing exercises are shown to be beneficial in managing both fatigue and quality of life (QoL) related to MS; however, the impact of such interventions among people newly diagnosed with clinically isolated syndrome (CIS) or relapsing-remitting multiple sclerosis (RRMS) who decline disease-modifying therapies (DMTs) is unknown.

Methods

A 12-month prospective quasi-experimental non-inferiority trial recruited people newly diagnosed with CIS or RRMS who voluntarily declined DMTs (health behavior group; HB, n = 29) or followed standard of care (SOC, n = 15). Participants in the HB group were remotely coached on the study diet, moderate-intensity walking, and breathing exercises. All participants completed questionnaires validated to assess MS symptoms, including perceived mental and physical QoL (MSQOL54); fatigue (Fatigue Severity Scale, FSS; and Modified Fatigue Impact Scale, MFIS); mood (Hospital Anxiety and Depression Scale, HADS); and cognitive function (Perceived Deficits Questionnaire, PDQ).

Results

During the 12 months, the HB group experienced improvement in scores for mental QoL (MSQOL54 - Mental, 0.24, 95% CI 0.01, 0.47; p = 0.04), fatigue (Total MFIS, -7.26, 95% CI -13.3,-1.18; p = 0.02), and perceived cognitive function (Total PDQ, PDQ-Attention, PDQ-Promemory, and PDQ-Planning, p ≤ 0.03 for all). A between-group difference was observed only for PDQ-Planning (p = 0.048). Non-inferiority analysis revealed that the 12-month changes in means for the HB group were not worse than those for the SOC group with respect to fatigue (FSS, p = 0.02), mood (HDS-Anxiety, p = 0.02; HADS-Depression, p < 0.0001), physical QoL (MSQOL54 - Physical, p = 0.02), or cognitive dysfunction (Total PDQ, p = 0.01).

Conclusion

The multimodal lifestyle intervention for individuals newly diagnosed with CIS or RRMS, who voluntarily decline DMTs, did not yield patient-reported outcomes worse than those observed in the SOC group regarding perceived mental quality of life, mood, fatigue, and cognitive function.

Trial Registration

clinicaltrials.gov identifier: NCT04009005.

Internet-delivered cognitive behavioural therapy programme to reduce depressive symptoms in patients with multiple sclerosis: a multicentre, randomised, controlled, phase 3 trial

BACKGROUND

Depression is three to four times more prevalent in patients with neurological and inflammatory disorders than in the general population. For example, in patients with multiple sclerosis, the 12-month prevalence of major depressive disorder is around 25% and it is associated with a lower quality of life, faster disease progression, and higher morbidity and mortality. Despite its clinical relevance, there are few treatment options for depression associated with multiple sclerosis and confirmatory trials are scarce. We aimed to evaluate the safety and efficacy of a multiple sclerosis-specific, internet-based cognitive behavioural therapy (iCBT) programme for the treatment of depressive symptoms associated with the disease.

METHODS

This parallel-group, randomised, controlled, phase 3 trial of an iCBT programme to reduce depressive symptoms in patients with multiple sclerosis was carried out at five academic centres with large outpatient care units in Germany and the USA. Patients with a neurologist-confirmed diagnosis of multiple sclerosis and depressive symptoms were randomly assigned (1:1:1; automated assignment, concealed allocation, no stratification, no blocking) to receive treatment as usual plus one of two versions of the iCBT programme Amiria (stand-alone or therapist-guided) or to a control condition, in which participants received treatment as usual and were offered access to the iCBT programme after 6 months. Masking of participants to group assignment between active treatment and control was not possible, although raters were masked to group assignment. The predefined primary endpoint, which was analysed in the intention-to-treat population, was severity of depressive symptoms as measured by the Beck Depression Inventory-II (BDI-II) at week 12 after randomisation. This trial is registered at ClinicalTrials.gov, NCT02740361, and is complete.

FINDINGS

Between May 3, 2017, and Nov 4, 2020, we screened 485 patients for eligibility. 279 participants were enrolled, of whom 101 were allocated to receive stand-alone iCBT, 85 to receive guided iCBT, and 93 to the control condition. The dropout rate at week 12 was 18% (50 participants). Both versions of the iCBT programme significantly reduced depressive symptoms compared with the control group (BDI-II between-group mean differences: control vs stand-alone iCBT 6·32 points [95% CI 3·37-9·27], p<0·0001, effect size d=0·97 [95% CI 0·64-1·30]; control vs guided iCBT 5·80 points [2·71-8·88], p<0·0001, effect size d=0·96 [0·62-1·30]). Clinically relevant worsening of depressive symptoms was observed in three participants in the control group, one in the stand-alone iCBT group, and none in the guided iCBT group. No occurrences of suicidality were observed during the trial and there were no deaths.

INTERPRETATION

This trial provides evidence for the safety and efficacy of a multiple sclerosis-specific iCBT tool to reduce depressive symptoms in patients with the disease. This remote-access, scalable intervention increases the therapeutic options in this patient group and could help to overcome treatment barriers.

FUNDING

National Multiple Sclerosis Society (USA).

Assessment of differential item functioning of the PHQ-9, HADS-D and PROMIS-depression scales in persons with and without multiple sclerosis

OBJECTIVE

We tested for the presence of differential item functioning (DIF) in commonly used measures of depressive symptoms, in people with multiple sclerosis (MS) versus people with a psychiatric disorder without MS.

METHODS

Participants included individuals with MS, or with a lifetime history of a depressive or anxiety disorder (Dep/Anx) but no immune-mediated inflammatory disease. Participants completed the Patient Health Questionnaire (PHQ-9), Hospital Anxiety and Depression Scale (HADS), and the Patient Reported Outcome Measurement Information System (PROMIS)-Depression. We assessed unidimensionality of the measures using factor analysis. We evaluated DIF using logistic regression, with and without adjustment for age, gender and body mass index (BMI).

RESULTS

We included 555 participants (MS: 252, Dep/Anx: 303). Factor analysis showed that each depression symptom measure had acceptable evidence of unidimensionality. In unadjusted analyses comparing the MS versus Dep/Anx groups we identified multiple items with evidence of DIF, but few items showed DIF effects that were large enough to be clinically meaningful. We observed non-uniform DIF for one PHQ-9 item, and three HADS-D items. We also observed DIF with respect to gender (one HADS-D item), and BMI (one PHQ-9 item). For the MS versus Dep/Anx groups, we no longer observed DIF post-adjustment for age, gender and BMI. On unadjusted and adjusted analyses, we did not observe DIF for any PROMIS-D item.

CONCLUSION

Our findings suggest that DIF exists for the PHQ-9 and HADS-D with respect to gender and BMI in clinical samples that include people with MS whereas DIF was not observed for the PROMIS-Depression scale.

Effects of N-acetylcysteine on oxidative stress biomarkers, depression, and anxiety symptoms in patients with multiple sclerosis

AIM

N-acetylcysteine (NAC), a thiol-containing antioxidant and glutathione (GSH) precursor, attenuates oxidative stress, and possibly improves psychiatric disorders. This study aimed to evaluate the effects of oral NAC on oxidative stress, depression, and anxiety symptoms in patients with multiple sclerosis (MS).

METHODS

This clinical trial was conducted on 42 MS patients randomly assigned to intervention (n = 21) and control (n = 21) groups. The intervention group received 600 mg of NAC twice daily for 8 weeks, and the control group received a placebo with the same prescription form. An analysis of serum malondialdehyde (MDA), serum nitric oxide (NO), and erythrocyte GSH was carried out on both groups, along with a complete blood count. The Hospital Anxiety and Depression Scale (HADS) was used to assess symptoms of depression (HADS-D) and anxiety (HADS-A).

RESULTS

Compared to the control group, NAC consumption significantly decreased serum MDA concentrations (-0.33 [-5.85-2.50] vs. 2.75 [-0.25-5.22] μmol/L; p = 0.03) and HADS-A scores (-1.6 ± 2.67 vs. 0.33 ± 2.83; p = 0.02). No significant changes were observed in serum NO concentrations, erythrocyte GSH levels, and HADS-D scores (p > 0.05).

CONCLUSIONS

Based on the findings of the present study, NAC supplementation for 8 weeks decreased lipid peroxidation and improved anxiety symptoms in MS patients. The aforementioned results suggest that adjunctive therapy with NAC can be considered an effective strategy for MS management. Further randomized controlled studies are warranted.

Establishing clinically meaningful within-individual improvement thresholds for eight patient-reported outcome measures in people with relapsing-remitting multiple sclerosis

BACKGROUND

As disease-modifying therapies do not reverse the course of multiple sclerosis (MS), assessment of therapeutic success involves documenting patient-reported outcomes (PROs) concerning health-related quality of life, disease and treatment-related symptoms, and the impact of symptoms on function. Interpreting PRO data involves going beyond statistical significance to calculate within-patient meaningful change scores. These thresholds are needed for each PRO in order to fully interpret the PRO data. This analysis of PRO data from the PROMiS AUBAGIO study, which utilized 8 PRO instruments in teriflunomide-treated relapsing-remitting MS (RRMS) patients, was designed to estimate clinically meaningful within-individual improvement thresholds in the same manner, for 8 PRO instruments.

RESULTS

The analytical approach followed a triangulation exercise that considered results from anchor- and distribution-based methods and graphical representations of empirical cumulative distribution functions in PRO scores in groups defined by anchor variables. Data from 8 PRO instruments (MSIS-29 v2, FSMC, MSPS, MSNQ, TSQM v1.4, PDDS, HRPQ-MS v2, and HADS) were assessed from 434 RRMS patients. For MSIS-29 v2, FSMC, MSPS, and MSNQ total scores, available anchor variables enabled both anchor- and distribution-based methods to be applied. For instruments with no appropriate anchor available, distribution-based methods were applied. A recommended value for meaningful within-individual improvement was defined by comparing mean change in PRO scores between participants showing improvement of one or two categories in the anchor variable or those showing no change. A "lower bound" estimate was calculated using distribution-based methods. An improvement greater than the lower-bound estimate was considered "clinically meaningful".

CONCLUSION

This analysis produced estimates for assessing meaningful within-individual improvements for 8 PRO instruments used in MS studies. These estimates should be useful for interpreting scores and communicating study results and should facilitate decision-making by regulatory and healthcare authorities where these 8 PROs are commonly employed.

Association of serum homocysteine, folate, and vitamin B12 and mood following the Swank and Wahls elimination dietary interventions in relapsing-remitting multiple sclerosis: Secondary analysis of the WAVES trial

BACKGROUND

Depression and anxiety are common psychiatric comorbidities among people with multiple sclerosis (MS). Emerging data suggest abnormal serum homocysteine, vitamin B₁₂, and folate levels in people with MS, which are related to a range of neurological disorders, including mood and mental illnesses. Evidence suggests that dietary interventions could affect mood disorders via several pathways. This study aimed to evaluate the impact of the low-saturated fat (Swank) and modified Paleolithic elimination (Wahls) diets, along with a supplement regimen, on mood as assessed by Hospital Anxiety and Depression Scale (HADS), and Mental Health Inventory (MHI). The secondary objective was to identify changes in serum levels of homocysteine, folate, and vitamin B₁₂ and the association and mediation effects between their changes and HADS and MHI scores and their subscales among people with relapsing-remitting MS (RRMS).

METHODS

In a previously conducted randomized parallel-arm trial, participants with RRMS (n = 77) were randomly allocated to either the Swank or Wahls diets at baseline and followed for 24 weeks. Blood was drawn at four study visits spaced 12 weeks apart: (1) run-in, (2) baseline, (3) 12 weeks, and (4) 24 weeks. Serum vitamin B₁₂, folate, and homocysteine were analyzed. HADS and MHI questionnaires were also completed by participants at the four study visits to assess symptoms of depression and anxiety, behavioral control and positive affect respectively.

RESULTS

Significant improvement in severity of depression (HADS-D) and anxiety (HADS-A) symptoms, MHI total, and MHI subscores were seen at 12 and 24 weeks in each diet group. Further, a significant within-group reduction in serum homocysteine and a significant increase in serum vitamin B₁₂ level were observed in both groups at 12 and 24 weeks compared to corresponding baseline values (p ≤ 0.05 for all). All participants exceeded the analytical maximum threshold for folate of 20 nmol/L at 12 and 24 weeks. Changes in serum levels of homocysteine and vitamin B₁₂ were not associated with and did not mediate changes in HADS depression, anxiety, MHI total and four subscales scores (p > 0.05).

CONCLUSION

Participants on both Swank and Wahls dietary interventions, including folate and vitamin B₁₂ supplements, showed significant improvement in mood. However, the favorable effects of both diets on mood were not associated with or mediated by the effect of the diets on serum levels of homocysteine, folate, and vitamin B₁₂ (p > 0.05).

Health related quality of life in the domain of physical activity predicts confirmed disability progression in people with relapsing remitting multiple sclerosis

INTRODUCTION

The diagnosis of the progression phase of Multiple Sclerosis (MS) is still retrospective and based on the objectivation of clinical disability accumulation.

OBJECTIVES

To assess whether the Patient Reported Outcomes Measures (PROMs) scores predict the occurrence of disease progression within three years of follow-up.

METHODS

Observational prospective multicenter study. Stable Relapsing-Remitting MS (RRMS) patients were enrolled. At enrollment, patients completed the following PROMs: Beck Depression Inventory- II, The Treatment Satisfaction Questionnaire for Medications, Medical Outcomes Study Short Form 36- Item (SF36), Fatigue Severity Scale. EDSS was assessed at enrollment and three years later. The outcome measure was defined as the occurrence of confirmed disability progression (CDP) within three years of follow-up. Univariable and multivariable logistic regression models were performed to study the association between the final score of each test and the outcome.

RESULTS

SF36-Physical Functioning (SF36-PF) was the only independent variable associated with the outcome. The ROC curve analysis determined a score of 77.5 at SF36-PF as the cut-off point identifying patients experiencing CDP within three years of follow-up [AUC: 0.66 (95% CI: 0.56-0.75)].

CONCLUSIONS

RRMS patients scoring higher (>77.5) at SF36-PF subscale have a higher likelihood to experience CDP within the next three years.

The association between tobacco smoking and depression and anxiety in people with multiple sclerosis: A systematic review

BACKGROUND

The link between tobacco smoking and Multiple Sclerosis (MS) onset and progression is well-established. While clinical levels of depression and anxiety are highly prevalent in people living with MS (plwMS), and both are recognized as common MS-related symptoms, the relationships between smoking behavior and depression and anxiety are unclear. This systematic review aimed to synthesize evidence on the relationships between current-smoking and former-smoking and depression and anxiety in plwMS.

METHODS

Systematic review of all studies investigating associations between tobacco smoking and depression and anxiety in plwMS was conducted. Relevant studies published before 26 April 2022 were identified by searching seven databases; MEDLINE® (Ovid and PubMed), Embase, CINAHL®, Cochrane Library and PsycInfo), and citation and reference list checking. Joanna Briggs Institute Critical Appraisal Checklists for respective study designs assessed the risk of bias.

RESULTS

Thirteen publications reporting on 12 studies met study inclusion criteria. Nine of 12 studies examining current-smoking and depression in plwMS identified a positive association. Four prospective studies provided evidence supporting a causal smoking-depression relationship, with 1.3-2.3-fold higher depression prevalence found in current-smokers than non-smokers. Three cross-sectional studies found no smoking-depression association. Four of five included studies found current-smoking was associated with anxiety, with three prospective studies indicating anxiety prevalence was around 20% higher in current-smokers. Former-smoking was associated with increased prevalence of depression, but not anxiety.

CONCLUSION

We provide strong evidence for increased depression prevalence in plwMS who are either current-smokers or former-smokers. However, only current-smoking was associated with increased prevalence of anxiety.

Lower corticospinal excitability and greater fatigue among people with multiple sclerosis experiencing pain

Introduction

Persons with multiple sclerosis (MS) frequently report pain that negatively affects their quality of life. Evidence linking pain and corticospinal excitability in MS is sparse. We aimed to (1) examine differences in corticospinal excitability in MS participants with and without pain and (2) explore predictors of pain.

Methods

Sixty-four participants rated their pain severity on a visual analog scale (VAS). Transcranial magnetic stimulation (TMS) and validated clinical instruments characterized corticospinal excitability and subjective disease features like mood and fatigue. We retrieved information on participants' prescriptions and disability status from their clinical records.

Results

Fifty-five percent of participants reported pain that affected their daily functioning. Persons with pain had significantly greater fatigue and lower area under the excitatory motor evoked potential (MEP) recruitment curve (eREC AUC), a measure of total corticospinal excitability. After controlling for age, disability status, and pain medications, increased fatigue and decreased eREC AUC together explained 40% of the variance in pain.

Discussion

Pain in MS is multifactorial and relates to both greater fatigue and lesser corticospinal excitability. Future work should better characterize relationships between these outcomes to develop targeted pain interventions such as neuromodulation.

Summary

We examined pain in MS. Individuals with pain had higher fatigue and lower corticospinal excitability than those without pain. These outcomes significantly predicted self-reported pain.

Anxiety and depression in Charcot-Marie-Tooth disease: data from the Italian CMT national registry

BACKGROUND

There is little information about neuropsychiatric comorbidities in Charcot-Marie-Tooth disease (CMT). We assessed frequency of anxiety, depression, and general distress in CMT.

METHODS

We administered online the Hospital Anxiety-Depression Scale (HADS) to CMT patients of the Italian registry and controls. HADS-A and HADS-D scores ≥ 11 defined the presence of anxiety/depression and HADS total score (HADS-T) ≥ 22 of general distress. We analysed correlation with disease severity and clinical characteristics, use of anxiolytics/antidepressants and analgesic/anti-inflammatory drugs.

RESULTS

We collected data from 252 CMT patients (137 females) and 56 controls. CMT patient scores for anxiety (mean ± standard deviation, 6.7 ± 4.8), depression (4.5 ± 4.0), and general distress (11.5 ± 8.1) did not differ from controls and the Italian population. However, compared to controls, the percentages of subjects with depression (10% vs 2%) and general distress (14% vs 4%) were significantly higher in CMT patients. We found no association between HADS scores and disease duration or CMT type. Patients with general distress showed more severe disease and higher rate of positive sensory symptoms. Depressed patients also had more severe disease. Nineteen percent of CMT patients took antidepressants/anxiolytics (12% daily) and 70% analgesic/anti-inflammatory drugs. Patients with anxiety, depression, and distress reported higher consumption of anxiolytics/antidepressants. About 50% of patients with depression and/or general distress did not receive any specific pharmacological treatment.

CONCLUSIONS

An appreciable proportion of CMT patients shows general distress and depression. Both correlated with disease severity and consumption of antidepressants/anxiolytics, suggesting that the disease itself is contributing to general distress and depression.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Impact of autologous HSCT on the quality of life and fatigue in patients with relapsing multiple sclerosis

In this study, we aimed to assess the quality of life, fatigue, anxiety, and depression after Autologous haematopoietic stem cell transplantation (AHSCT) and to investigate its impact of on separate domains of health status and fatigue in patients with multiple sclerosis (MS). Overall, 18 patients with highly active relapsing MS (mean age 36.3 years, 83.3% female) underwent the AHSCT in Vilnius Multiple Sclerosis center, and we prospectively collected Short Form 36, Health Survey Questionnaire, Fatigue Descriptive Scale, and Hospital Anxiety and Depression Scale beforeand Month3, 12, and 24 after AHSCT. The median score of Expanded Disability Status Scale at Month3 after transplant improved in 14 patients (77.8%). A significant improvement in physical functioning, vitality, and pain was found at Month3 after AHSCT (p < 0.05), which was sustained until Month12 and 24. The improvement in fatigue score was found at Month12 after AHSCT, which was sustained until Month24. Decrease in EDSS score had a positive impact on the better HRQoL outcomes, especially physical and social outcomes. Thus, AHSCT improved quality of life and reduced symptoms of fatigue in patients with highly active relapsing MS. The improvement was determined earlier in the domains of QoL than in the fatigue.

Cross-cultural adaptation, reliability and validity of the Turkish version of the Fear of Relapse Scale (FoR) in individuals with multiple sclerosis

OBJECTIVE

The study aimed to translate and cross-culturally adapt the Fear of Relapse Scale (FoR) into Turkish and determine its psychometric properties.

METHODS

International guidelines were used for the translation and adaptation process. The patients were asked to fill the FoR, Intolerance of Uncertainty (IUS-12) and Depression Anxiety and Stress Scale (DASS-21). One week later, participants refilled the FoR. The test-retest reliability, internal consistency, and construct validity of the FoR were analyzed.

RESULTS

A total of 101 MS patients (37.6 ± 10.0 years, 81.2% women) were included in the research. The test-retest reliability of the FoR was excellent (ICC:0.883; CI:0.64-0.92). The reproducibility of the items of the FoR ranged from 0.2 to 0.8. The Cronbach's alpha coefficient of the FoR was 0.914. The internal consistency of the items was ranged between 0.90 and 0.91 The relationship between FoR with IUS-12, DASS-21 (depression), DASS-21 (anxiety), DASS-21 (stress) was 0.609, 0.641, 0.648 and 0.631, respectively. The correlation coefficients were greater than 0.50 (p < 0.01).

CONCLUSION

The Turkish version of the FoR is a reliable and valid tool to measure relapse fear in patients with MS.

Motor preparation impairment in multiple sclerosis: Evidence from the Bereitschaftspotential in simple and complex motor tasks

OBJECTIVES

Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system, characterized by the accumulation of demyelinating lesions and axonal loss over its course. This study aimed to increase current knowledge of motor preparation in this condition, by assessing the two components of the Bereitschaftspotential (BP1 and BP2), also known as the readiness potential.

METHODS

Twelve patients with MS and ten age- and gender-matched healthy controls (HC) were included. Patients' demographic and clinical data were collected. Participants were asked to perform two different tasks, a simple index extension and a Luria sequence. BP1 and BP2 values were obtained from 18 central electroencephalography electrodes and were compared between the two groups.

RESULTS

Compared to HC, patients with MS showed earlier BP1 onset (i.e., longer latency) in almost all the analyzed scalp regions during index extension. This was also observed during the Luria sequence, but only in the centro-parietal regions. As for BP2 latency, no significant difference was noted between groups during either task. With regard to amplitudes, patients with MS had larger BP1 amplitudes in the right fronto-central area during index extension and greater BP1 and BP2 amplitudes in bilateral centro-parietal and left central regions during the Luria task. BP1 latency was also found to be significantly correlated with disease duration and performance on executive function tests (Trail Making Test).

CONCLUSIONS

This study showed, for the first time, changes in the Bereitschaftspotential in patients with MS. These data reflect prolonged movement preparation in this population and may suggest global alteration of the premotor scheme.

The Complex Interplay Between Trait Fatigue and Cognition in Multiple Sclerosis

Cognitive impairments are frequent in patients with Multiple Sclerosis (MS). Yet, the influence of MS-related symptoms on cognitive status is not clear. Studies investigating the impact of trait fatigue along with anxio-depressive symptoms on cognition are seldom, and even less considered fatigue as multidimensional. Moreover, these studies provided conflicting results.

Twenty-nine MS patients and 28 healthy controls, matched on age, gender and education underwent a full comprehensive neuropsychological assessment. Anxio-depressive and fatigue symptoms were assessed using the HAD scale and the MFIS, respectively. Six composite scores were derived from the neuropsychological assessment, reflecting the cognitive domains of working memory, verbal and visual learning, executive functions, attention and processing speed. Stepwise regression analyses were conducted in each group to investigate if trait cognitive and physical fatigue, depression and anxiety are relevant predictors of performance in each cognitive domain. In order to control for disease progression, patient’s EDSS score was also entered as predictor variable.

In the MS group, trait physical fatigue was the only significant predictor of working memory score. Cognitive fatigue was a predictor for executive functioning performance and for processing speed (as well as EDSS score for processing speed). In the healthy controls group, only an association between executive functioning and depression was observed.

Fatigue predicted cognition in MS patients only, beyond anxio-depressive symptoms and disease progression. Considering fatigue as a multidimensional symptom is paramount to better understand its association with cognition, as physical and cognitive fatigue are predictors of different cognitive processes.

Effects of actual and imagined music-cued gait training on motor functioning and brain activity in people with multiple sclerosis: protocol of a randomised parallel multicentre trial

INTRODUCTION

Motor imagery (MI) refers to the mental rehearsal of a physical action without muscular activity. Our previous studies showed that MI combined with rhythmic-auditory cues improved walking, fatigue and quality of life (QoL) in people with multiple sclerosis (pwMS). Largest improvements were seen after music and verbally cued MI. It is unclear whether actual cued gait training achieves similar effects on walking as cued MI in pwMS. Furthermore, in pwMS it is unknown whether any of these interventions leads to changes in brain activation. The purpose of this study is therefore to compare the effects of imagined and actual cued gait training and a combination thereof on walking, brain activation patterns, fatigue, cognitive and emotional functioning in pwMS.

METHODS AND ANALYSIS

A prospective double-blind randomised parallel multicentre trial will be conducted in 132 pwMS with mild to moderate disability. Randomised into three groups, participants will receive music, metronome and verbal cueing, plus MI of walking (1), MI combined with actual gait training (2) or actual gait training (3) for 30 min, 4× per week for 4 weeks. Supported by weekly phone calls, participants will practise at home, guided by recorded instructions. Primary endpoints will be walking speed (Timed 25-Foot Walk) and distance (2 min Walk Test). Secondary endpoints will be brain activation patterns, fatigue, QoL, MI ability, anxiety, depression, cognitive functioning, music-induced motivation-to-move, pleasure, arousal and self-efficacy. Data will be collected at baseline, postintervention and 3-month follow-up. MRI reference values will be generated using 15 matched healthy controls.

ETHICS AND DISSEMINATION

This study follows the Standard Protocol Items: Recommendations for Interventional Trials-PRO Extension. Ethical approval was received from the Ethics Committees of the Medical Universities of Innsbruck (1347/2020) and Graz (33-056 ex 20/21), Austria. Results will be disseminated via national and international conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

DRKS00023978.

Communication, Coordination, and Security for People with Multiple Sclerosis (COCOS-MS): a randomised phase II clinical trial protocol

INTRODUCTION

Patients with multiple sclerosis (MS) have complex needs that range from organising one's everyday life to measures of disease-specific therapy monitoring to palliative care. Patients with MS are likely to depend on multiple healthcare providers and various authorities, which are often difficult to coordinate. Thus, they will probably benefit from comprehensive cross-sectoral coordination of services provided by care and case management (CCM). Though studies have shown that case management improves quality of life (QoL), functional status and reduces service use, such benefits have not yet been investigated in severely affected patients with MS. In this explorative phase ll clinical trial, we evaluated a CCM with long-term, cross-sectoral and outreaching services and, in addition, considered the unit of care (patients and caregivers).

METHODS AND ANALYSIS

Eighty patients with MS and their caregivers will be randomly assigned to either the control (standard care) or the intervention group (standard care plus CCM (for 12 months)). Regular data assessments will be done at baseline and then at 3-month intervals. As primary outcome, we will evaluate patients' QoL. Secondary outcomes are patients' treatment-related risk perception, palliative care needs, anxiety/depression, use of healthcare services, caregivers' burden and QoL, meeting patients' and caregivers' needs, and evaluating the CCM intervention. We will also evaluate CCM through individual interviews and focus groups. The sample size calculation is based on a standardised effect of 0.5, and one baseline and four follow-up assessments (with correlation 0.5). Linear mixed models for repeated measures will be applied to analyse changes in quantitative outcomes over time. Multiple imputation approaches are taken to assess the robustness of the results. The explorative approach (phase ll clinical trial) with embedded qualitative research will allow for the development of a final design for a confirmative phase lll trial.

ETHICS AND DISSEMINATION

The trial will be conducted under the Declaration of Helsinki and has been approved by the Ethics Commission of Cologne University's Faculty of Medicine. Trial results will be published in an open-access scientific journal and presented at conferences.

TRIAL REGISTRATION NUMBER

German Register for Clinical Studies (DRKS) (DRKS00022771).

Childhood Maltreatment and Psychiatric Comorbidity in Immune-Mediated Inflammatory Disorders

OBJECTIVE

To determine whether childhood maltreatment is associated with immune-mediated inflammatory disorders (IMIDs; multiple sclerosis [MS], inflammatory bowel disease [IBD], and rheumatoid arthritis [RA]). We further aimed to determine the relationship between maltreatment and psychiatric comorbidity in IMIDs and whether these relationships differed across IMID.

METHODS

Six hundred eighty-one participants (MS, 232; IBD, 216; RA, 130; healthy controls, 103) completed a structured psychiatric interview to identify psychiatric disorders, and the Childhood Trauma Questionnaire to evaluate five types of maltreatment: emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect. We evaluated associations between maltreatment, IMID, and psychiatric comorbidity using multivariable logistic regression models.

RESULTS

The prevalence of having ≥1 maltreatment was similar across IMID but higher than in controls (MS, 63.8%; IBD, 61.6%; RA, 62.3%; healthy controls, 45.6%). Emotional abuse was associated with having an IMID (adjusted odds ratio [aOR] = 2.37; 1.15-4.89). In the sex-specific analysis, this association was only present in women. History of childhood maltreatment was associated with a lifetime diagnosis of a psychiatric disorder in the IMID cohort (OR = 2.24; 1.58-3.16), but this association did not differ across diseases. In those with IMID, total types of maltreatments (aOR = 1.36; 1.17-1.59) and emotional abuse (aOR = 2.64; 1.66-4.21) were associated with psychiatric comorbidity.

CONCLUSIONS

Childhood maltreatment is more common in IMID than in a healthy population and is associated with psychiatric comorbidity. Given the high burden of psychiatric disorders in the IMID population, clinicians should be aware of the contribution of maltreatment and the potential need for trauma-informed care strategies.

Assessment and Management of Cognitive and Psychosocial Difficulties for People with Multiple Sclerosis in Ireland: A National Survey of Clinical Practice

BACKGROUND

A recent survey of 109 healthcare professionals explored how UK healthcare professionals typically assess and treat multiple sclerosis (MS)-related cognitive impairment. Little is currently known about what constitutes usual care for cognitive impairment and psychosocial care for people with MS in Ireland.

AIM

The aim of the current research was to survey healthcare professionals (HCPs) who work with people with MS, to understand current assessment and management of cognition and psychosocial care in people with MS in the Republic of Ireland.

METHODS

A cross-sectional survey design was used. Data were collected online through Microsoft forms and through postal responses. The original UK questionnaire was adapted, piloted, and distributed to Irish HCPs. Participants were qualified HCPs who work clinically with people with MS in the Republic of Ireland.

RESULTS

Ninety-eight HCPs completed the survey. Only 34% of those surveyed reported routine screening of cognition for people with MS within their services; approximately, 36% HCPs reported that they did not provide information or services in relation to cognition to people with MS and 39% reported not referring elsewhere when cognitive difficulties were suspected. Out of the 98 HCPs, 47% reported assessing mood difficulties as part of their services, with 14% unsure. In total, 70% of participants reported onward referral took place if mood difficulties were identified. The Montreal Cognitive Assessment was the most commonly administrated cognitive assessment. Cognitive intervention choices were found to be guided by clinical judgement in 75.5% of cases. Discussion. Despite the high importance placed on cognitive and psychosocial care, there is very little consistency in treatment and assessment across services for people with MS in Ireland.

Psychometric Properties of the HADS Measure of Anxiety and Depression Among Multiple Sclerosis Patients in Croatia

Depression and anxiety are common complaints in patients with multiple sclerosis (MS). The study objective was to investigate the factor structure, internal consistency, and correlates of the Croatian version of the Hospital Anxiety and Depression Scale (HADS) in patients with MS. A total of 179 patients with MS and 999 controls were included in the online survey. All subjects completed the HADS and self-administered questionnaires capturing information of demographic, education level, disease-related variables, and the Multiple Sclerosis Impact Scale-29 (MSIS-29). Psychometric properties were examined by estimating the validity, reliability, and factor structure of the HADS in patients with MS. The two HADS subscales (anxiety and depression) had excellent internal consistencies (Cronbach’s α value 0.82–0.83), and factor analysis confirmed a two-factor structure. The convergent validity of the HADS subscales appeared to be good due to the significant correlations between HADS and MSIS-29. Receiver operating characteristic (ROC) analysis indicates that the HADS subscales have a significant diagnostic validity for group differentiation. Hierarchical regression analysis using MSIS-29 subscales as criterion variables showed consistent evidence for the incremental validity of the HADS. The HADS is a reliable and valid self-assessment scale in patients with MS and is suggested to be used in clinical monitoring of the psychiatric and psychological status of patients with MS.

In vivo evidence of functional disconnection between brainstem monoaminergic nuclei and brain networks in multiple sclerosis

BACKGROUND

brainstem monoaminergic (dopaminergic, noradrenergic, and serotoninergic) nuclei (BrMn) contain a variety of ascending neurons that diffusely project to the whole brain, crucially regulating normal brain function. BrMn are directly affected in multiple sclerosis (MS) by inflammation and neurodegeneration. Moreover, inflammation reduces the synthesis of monoamines. Aberrant monoaminergic neurotransmission contributes to the pathogenesis of MS and explains some clinical features of MS. We used resting-state functional MRI (RS-fMRI) to characterize abnormal patterns of BrMn functional connectivity (FC) in MS.

METHODS

BrMn FC was studied with multi-echo RS-fMRI in n = 68 relapsing-remitting MS patients and n = 39 healthy controls (HC), by performing a seed-based analysis, after producing standard space seed masks of the BrMn. FC was assessed between ventral tegmental area (VTA), locus coeruleus (LC), median raphe (MR), dorsal raphe (DR), and the rest of the brain and compared between MS patients and HC. Between-group comparisons were carried out only within the main effect observed in HC, setting p<0.05 family-wise-error corrected (_FWE).

RESULTS

in HC, VTA displayed FC with the core regions of the default-mode network. As compared to HC, MS patients showed altered FC between VTA and posterior cingulate cortex (p<0.05_FWE). LC displayed FC with core regions of the executive-control network with a reduced functional connection between LC and right prefrontal cortex in MS patients (p<0.05_FWE). Raphe nuclei was functionally connected with cerebellar cortex, with a significantly lower FC between these nuclei and cerebellum in MS patients, as compared to HC (p<0.05_FWE).

CONCLUSIONS

our study demonstrated in MS patients a functional disconnection between BrMn and cortical/subcortical efferent targets of central brain networks, possibly due to a loss or a dysregulation of BrMn neurons. This adds new information about how monoaminergic systems contribute to MS pathogenesis and suggests new potential therapeutic targets.

Modifying Diet and Exercise in MS (MoDEMS): Study design and protocol for a telehealth weight loss intervention for adults with obesity & Multiple Sclerosis

Weight loss improves overall health, and reduces inflammation, risk of stroke, heart attack, diabetes, certain cancers, and death among individuals with obesity. Weight loss also improves mobility, increases stamina, and elevates mood. Between 25 and 33% of people with Multiple Sclerosis (pwMS) have obesity. Multiple Sclerosis (MS) and obesity are independently associated with reduced mobility, increased fatigue, and depression. Most behavioral weight loss trials exclude individuals with neurologic disease. Consequently, few studies have examined the effects of weight loss on symptom presentation and health outcomes among pwMS and obesity. This is the first study examining the efficacy of a comprehensive behavioral weight loss intervention designed specifically for pwMS. The purpose of this study is to develop and assess the efficacy of a telehealth administered weight loss intervention tailored for pwMS. Additionally, we aim to determine if weight loss reduces physical and emotional symptoms in individuals with obesity and MS. We will enroll 70 pwMS in a wait-list crossover trial to examine the efficacy of our intervention. If successful, findings will help determine whether we can help participants lose clinically significant weight - and whether weight loss among pwMS and overweight/obesity reduces fatigue, and improves mobility, mood, and quality of life.

Using the multiple sclerosis resiliency scale to identify psychological distress in persons with multiple sclerosis

BACKGROUND

The Multiple Sclerosis Resiliency Scale (MSRS) is the first resilience measure that is specific to multiple sclerosis (MS)-related challenges. In order for the MSRS to be a valuable tool for clinicians, it is important to identify what is a meaningful score. As such, this study aimed to examine the MSRS' ability to identify persons with MS experiencing depression or anxiety symptoms, as determined using clinically significant scores on the Hospital Anxiety and Depression Scale (HADS).

METHODS

Participants (n = 884) were persons with MS who were recruited electronically primarily through the North American Research Committee on MS (NARCOMS). In addition to the MSRS, participants completed the HADS, which was used to categorize them into possible depression and anxiety groups using two criteria from the literature: ≥8 and ≥11. Receiver-operating-characteristic (ROC) curves were run to determine the MSRS total and subscale scores' classification accuracies, with optimal scores for detecting possible depression and anxiety cases determined using the Youden index.

RESULTS

The MSRS total score's classification accuracy ranged between 86.2% and 92.2% for depression, with scores of 70 and 68 for the ≥8 and ≥11 criteria, respectively. For anxiety, the MSRS total score's classification accuracy ranged between 78.1% and 82.8%, with scores of 72 and 71 for the ≥8 and ≥11 criteria, respectively. The Emotional and Cognitive Strategies subscale had the strongest classification accuracy of all the subscales.

CONCLUSIONS

The MSRS can be used to identify persons with MS experiencing mental health difficulties with relatively good classification accuracy, which may help clinicians to triage who needs additional assistance or support.

Fear of COVID-19, problems accessing medical appointments, and subjective experience of disease progression, predict anxiety and depression reactions in patients with Multiple Sclerosis

Background

During the current COVID-19 pandemic there are studies that have suggested a negative impact of the pandemic on the mental health of patients with multiple sclerosis (PwMS). In this sense, several factors may be related to the increase in experiences of anxiety and depression in PwMS during the current pandemic.

Objective

In this study we first explored the reactions of anxiety, depression and fear to COVID-19 in a group of PwMS that belong to the Ibero-American region. Besides, we explored whether having been positive to COVID-19, fear of COVID-19, the obstacles to attend medical appointments during the outbreak and subjective experience of MS progression, could predict the anxiety and depression reactions in our PwMS sample.

Materials and methods

An online cross-sectional survey was conducted on 202 MS patients from six countries (Argentina, Mexico, Spain, Dominican Republic, Venezuela and Cuba). For comparisons between variables an independent-samples t-test and one-way analysis of variance were used. Multiple linear regression was used to evaluate the effects of potential predictor variables over emotional reactions.

Results

Our results showed that PwMS who were positive for COVID-19 reported higher levels of fear of COVID-19 (p<.001) and also higher levels of anxiety (p<.001) compared to non-positive patients. Those patients who had difficulties attending their medical appointments during the outbreak showed higher levels of depression (p=.03) and anxiety (p=.019). Levels of anxiety (p<.001) and depression (p=.006) were also higher among patients with the subjective experience of MS disease progression. The reactions of fear of COVID-19, having been positive to COVID-19, problems attending medical appointments, and subjective experience of MS disease progression showed a high association with the negative impact of the pandemic on mental health of PwMS.

Conclusions

Our results show that the situation generated by the COVID-19 pandemic has had a negative impact on the mental health of PwMS in our sample. Our results also alert to the importance of offering psychological care to patients with multiple sclerosis during the current outbreak, regardless of whether they have been positive for COVID-19.

[Current aspects of neurogenic dysfunctions of the lower urinary tract in multiple sclerosis]

BACKGROUND

In the clinical management of patients with multiple sclerosis (MS), the challenge is to make an early diagnosis and initiate adequate treatment of neurogenic disorders of the lower urinary tract (NLUTD). Various national guidelines provide practical recommendations which are sometimes discordant.

OBJECTIVE

To develop a simple evidence-based algorithm for detecting NLUTD in patients with MS that could be taken as a principle for deriving therapeutic consequences.

MATERIAL AND METHODS

A prospective multicenter study was initiated as a direct result of two multidisciplinary conferences. The aim was to identify statistically and clinically relevant parameters for the routine diagnosis of NLUTD in patients with MS. Urodynamic abnormalities served as the gold standard. At three subsequent consensus conferences, the results of the study were discussed, a diagnostic algorithm was developed and consensus was reached on a first-line treatment.

RESULTS AND DISCUSSION

The proposed algorithm enables the detection of NLUTD in patients with MS with the help of four statistically significant predictors: 1) the residual urine volume, 2) the number of urinary tract infections (UTI) within the last 6 months, 3) the standardized micturition frequency and 4) the presence/absence of urinary incontinence. The newly developed algorithm has proved to be efficient with the following results: approximately 75% of the patients do not need a urodynamic examination for a first-line treatment decision. In 25% of cases, urodynamic examinations are essential for an adequate treatment decision. Routine assessments include the patient medical history, residual urine volume measurement, a micturition diary and a uroflowmetry (optional).

Symptom clusters and quality of life in persons with multiple sclerosis across the lifespan

PURPOSE

To describe symptom clusters based on severity of co-occurring symptoms among adults with multiple sclerosis (MS) by age groups and to further examine symptom clusters as a correlate of quality of life (QOL) by age groups.

METHODS

This cross-sectional study enrolled persons with MS between 20 and 79 years of age who completed measures of fatigue, depression, anxiety, sleep quality, and QOL using the 36-Item Short Form Health Survey. Bivariate correlation and partial correlation analyses examined associations among symptoms, QOL, and MS characteristics. K-means cluster analyses determined symptom clusters among the full sample and pre-determined age groups (i.e., 20-39, 40-59, and 60-79). One-way ANOVAs examined differences in QOL among clusters for the overall sample and by age groups.

RESULTS

Among the overall sample of 205 participants, symptoms were significantly correlated with QOL and three distinct clusters were identified and differentiated by the magnitude of symptom experience (i.e., mild, moderate, and severe). Results were consistent among young and middle-aged adults; however, among older adults two severe sleep problem clusters were identified that were distinguished by moderate versus severe fatigue, depression, and anxiety. ANOVAs among the overall sample indicated that the three symptom clusters varied significantly for both physical component scores, F(2, 202) = 12.03, p < .001, η2 = .10, and mental component scores, F(2, 202) = 137.92, p < .001, η2 = .58; severe symptom cluster was associated with worse QOL. Patterns in the age subgroup ANOVAs were consistent.

CONCLUSIONS

Given the strong association between severity of symptom clusters and QOL, approaches for targeting co-occurring symptoms are critically needed.

Cognitive fatigue in multiple sclerosis is associated with alterations in the functional connectivity of monoamine circuits

Fatigue is a highly prevalent and debilitating symptom in multiple sclerosis, but currently the available treatment options have limited efficacy. The development of innovative and efficacious targeted treatments for fatigue in multiple sclerosis has been marred by the limited knowledge of the underlying mechanisms. One of the hypotheses postulates that multiple sclerosis pathology might cause reduced monoaminergic release in the central nervous system with consequences on motivation, mood and attention. Here, we applied the recently developed Receptor-Enriched Analysis of Functional Connectivity by Targets method to investigate whether patients with high and low fatigue differ in the functional connectivity (FC) of the monoamine circuits in the brain. We recruited 55 patients with multiple sclerosis, which were then classified as highly fatigued or mildly fatigued based on their scores on the cognitive sub-scale of the Modified Fatigue Impact scale. We acquired resting-state functional MRI scans and derived individual maps of connectivity associated with the distribution of the dopamine, noradrenaline and serotonin transporters as measured by positron emission tomography. We found that patients with high fatigue present decreased noradrenaline transporter (NAT)-enriched connectivity in several frontal and prefrontal areas when compared to those with lower fatigue. The NAT-enriched FC predicted negatively individual cognitive fatigue scores. Our findings support the idea that alterations in the catecholaminergic functional circuits underlie fatigue in multiple sclerosis and identify the NAT as a putative therapeutic target directed to pathophysiology.

A Prospective, Observational, Cohort Study to Assess the Efficacy and Safety of Prolonged-Release Fampridine in Cognition, Fatigue, Depression, and Quality of Life in Multiple Sclerosis Patients: The FAMILY Study

Introduction

The efficacy of prolonged-release fampridine (PR-FAM) may extend in multiple sclerosis (MS) beyond walking ability. The objective of this study was to evaluate the effect of PR-FAM treatment on cognition, fatigue, depression, and quality of life (QoL) in adult patients with MS in a real-world setting.

Methods

FAMILY was a multi-center, prospective, observational, real-world cohort study of MS patients receiving PR-FAM in the outpatient setting. Patients were treated as per PR-FAM’s local prescribing information for 6 months. Standardized protocols and questionnaires were used to evaluate changes in cognition (PASAT; Paced Auditory Serial Addition Test), fatigue (MFIS; Modified Fatigue Impact Scale), depression (BDI-II; Beck Depression Inventory-II) and QoL (MusiQoL; MS International Quality-of-Life questionnaire, MSIS-29; Multiple Sclerosis Impact Scale: PHYS and PSYCH subscales) at 3 and 6 months compared to baseline.

Results

In total, 102 eligible patients from 8 sites in Greece were analysed, of whom 92 completed the study and 10 discontinued. At 6 months, PR-FAM treatment resulted in improvements from baseline in PASAT-3′′ (p = 0.044), MFIS (p < 0.001), BDI-II (p < 0.001), MusiQoL (p < 0.001) and MSIS-29-PHYS (p = 0.012) and MSIS-PSYCH (p < 0.001). A positive effect was evident already at 3 months in PASAT-3′′ (ns), MFIS (p = 0.020), BDI-II (p = 0.034), MusiQoL (p = 0.001), MSIS-29-PHYS (ns) and MSIS-29-PSYCH (p < 0.001).

Conclusions

This observational study provides new data to the current literature in support of PR-FAM’s positive effects in cognition, fatigue, depression, and QoL in a large, heterogeneous group of Greek MS patients in the real-world setting.

Trial Registration

ClinicalTrials.gov identifier, NCT03164018.

Supplementary Material

The online version of this article (10.1007/s12325-020-01606-5) contains supplementary material, which is available to authorized users.

Psychometric properties of the Croatian version of the depression, anxiety, and stress scale-21 and multiple sclerosis impact scale-29 in multiple sclerosis patients

OBJECTIVES

Depression, anxiety, stress, and physical disabilities are a common complaint in people with multiple sclerosis (MS), and monitoring of these symptoms are based on self-report questionnaires. The objective of this study was to determine psychometric properties of the Croatian version of the Depression, Anxiety, and Stress Scale-21 (DASS-21) and Multiple Sclerosis Impact Scale-29 (MSIS-29) in people with MS.

MATERIALS AND METHODS

We included data on 163 people with MS registered in the Association of multiple sclerosis societies of Croatia (AMSSC). Patients' demographic information, education level, and disease-related variables were ascertained. DASS-21 was applied for assessing depression, anxiety, and stress, while MSIS-29 scale was used for assessment of the physical and psychological impact of MS disease. Psychometric properties were examined by estimating the validity and reliability of the DASS-21 and MSIS-29 scale. Predictive validity of DASS-21 subscales and relevant demographic and disease-related variables was examined by the hierarchical regression model.

RESULTS

The Croatian version of the three DASS-21 subscales and two MSIS-29 subscales had excellent internal consistencies (Cronbach's alpha coefficients 0.88-0.93) and good convergent validity, as expressed by inter-correlations between DASS-21 and MSIS-29 subscales. Hierarchical regression analysis using MSIS-29 subscales as criterion variables showed consistent evidence for the predictive validity of depression, anxiety, and stress on psychological impact, and predictive validity of age, EDSS, and anxiety on physical impact.

CONCLUSIONS

The Croatian versions of DASS-21 and MSIS-29 are reliable and valid scales in people with MS.

Disruption of brainstem monoaminergic fibre tracts in multiple sclerosis as a putative mechanism for cognitive fatigue: a fixel-based analysis

In multiple sclerosis (MS), monoaminergic systems are altered as a result of both inflammation-dependent reduced synthesis and direct structural damage. Aberrant monoaminergic neurotransmission is increasingly considered a major contributor to fatigue pathophysiology. In this study, we aimed to compare the integrity of the monoaminergic white matter fibre tracts projecting from brainstem nuclei in a group of patients with MS (n = 68) and healthy controls (n = 34), and to investigate its association with fatigue. Fibre tracts integrity was assessed with the novel fixel-based analysis that simultaneously estimates axonal density, by means of 'fibre density', and white matter atrophy, by means of fibre 'cross section'. We focused on ventral tegmental area, locus coeruleus, and raphe nuclei as the main source of dopaminergic, noradrenergic, and serotoninergic fibres within the brainstem, respectively. Fourteen tracts of interest projecting from these brainstem nuclei were reconstructed using diffusion tractography, and compared by means of the product of fibre-density and cross-section (FDC). Finally, correlations of monoaminergic axonal damage with the modified fatigue impact scale scores were evaluated in MS. Fixel-based analysis revealed significant axonal damage - as measured by FDC reduction - within selective monoaminergic fibre-tracts projecting from brainstem nuclei in MS patients, in comparison to healthy controls; particularly within the dopaminergic-mesolimbic pathway, the noradrenergic-projections to prefrontal cortex, and serotoninergic-projections to cerebellum. Moreover, we observed significant correlations between severity of cognitive fatigue and axonal damage within the mesocorticolimbic tracts projecting from ventral tegmental area, as well as within the locus coeruleus projections to prefrontal cortex, suggesting a potential contribution of dopaminergic and noradrenergic pathways to central fatigue in MS. Our findings support the hypothesis that axonal damage along monoaminergic pathways contributes to the reduction/dysfunction of monoamines in MS and add new information on the mechanisms by which monoaminergic systems contribute to MS pathogenesis and fatigue. This supports the need for further research into monoamines as therapeutic targets aiming to combat and alleviate fatigue in MS.

Mental symptoms in MS (MeSyMS): Development and validation of a new assessment

BACKGROUND

Patients with Multiple Sclerosis (MS) have an increased risk of suffering from mental and neuropsychiatric symptoms. So far, a fundamental problem in the clinical care of MS patients is that these symptoms are underdiagnosed and, as a consequence, often remain untreated. Present assessment tools have not been developed to be applied in patients with MS. This study aims to develop and validate a new questionnaire to identify disease-related mental symptoms in MS patients.

METHODS

A questionnaire has been developed by including the following subscales: social and emotional health problems, anxiety, and depression. To evaluate test quality and internal consistency, an item analysis has been conducted. After matching MS patients and control subjects on age and gender, we conducted group comparisons, a Receiver Operating Characteristic (ROC) Curve analysis and a binary logistic regression model.

RESULTS

In total, 314 MS patients and 100 matched control subjects were analysed. After performed item analysis, the questionnaire revealed an excellent internal consistency (α=0.94). Compared to control subjects, MS patients showed significant mental health problems in all three dimensions. In comparison to the subscales, the dimension of social and emotional health problems revealed the highest accuracy (AUC = 0.75; d = 0.948) and turned out to be the only scale that reliably differentiated between the groups.

CONCLUSIONS

MeSyMS constitutes a valid screening instrument to detect mental symptoms in MS. Social and emotional health problems turned out to be the most important aspect when identifying disease-related mental health symptoms in MS.

The emotional disorders associated with multiple sclerosis

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

Transdiagnostic treatment of emotional disorders in people with multiple sclerosis: randomized controlled trial

BACKGROUND

Multiple sclerosis (MS) is a neurodegenerative disease of the central nervous system. MS is significantly associated with a high rate of psychological, behavioral, and emotional consequences. Despite the frequent mental disorders, high rate of psychological comorbidities, and emotional problems in people with MS (PwMS), these conditions are often underdiagnosed and undertreated. This study aimed to examine the efficacy of a group format of the unified protocol for the transdiagnostic treatment of emotional disorders in adult PwMS associated with an emotional disorder.

METHODS

Seventy adult PwMS were randomized using an internet-based computer system to either the unified protocol (n = 35) or treatment as usual condition. The assessment protocol included semi-structured clinical interviews and self-reports evaluating diagnostic criteria, depression, anxiety and worry symptoms, emotional dysregulation, and affectivity.

RESULTS

The parametric test of analysis of covariance, followed the intent to treat analyses, revealed the unified protocol significantly changed depression symptoms (Cohen's d = 1.9), anxiety symptoms (Cohen's d = 2.16), worry symptoms (Cohen's d = 1.27), emotion dysregulation (Cohen's d = 0.44), positive affect (Cohen's d = 1.51), and negative affect (Cohen's d = 1.89) compared with the control group. The unified protocol also significantly improved outcome scores at the end of treatment relative to baseline (p < .001).

CONCLUSION

The findings support that the unified protocol could be an additional efficient psychological treatment for PwMS. Trial registration IRCT, number: IRCT20190711044173N1. Registered 31october 2019, https://en.irct.ir/user/trial/40779/view .

Transdiagnostic treatment of emotional disorders for women with multiple sclerosis: a randomized controlled trial

BACKGROUND

Multiple sclerosis (MS) is a chronic, unpredictable, neurodegenerative disease, significantly associated with psychological, behavioral, cognitive, and emotional consequences. MS is more common in females than males and frequently affects women during their reproductive years. Despite the frequent mental disorders, comorbidities, and emotional problems in People with MS (PwMS), these conditions are too often underdiagnosed and undertreated.

OBJECTIVE

This study aimed to examine the efficacy of a group format of the Unified Protocol (UP) for the Transdiagnostic treatment of depression and anxiety disorders in females with MS.

METHODS

In the present study, Sixty-four adult females diagnosed with MS were randomized to either the UP (n = 32) or treatment-as-usual conditions. The assessment protocol included semi-structured clinical interviews and self-reports evaluating diagnostic criteria, depression, anxiety and worry symptoms, emotional regulation, and affectivity.

RESULTS

Repeated measure analysis of variance (ANOVA) revealed that the UP significantly improved depression scores [Cohen's d = - 2.11, 95% CI (- 2.72, - 1.50)], anxiety scores [Cohen's d = - 3.34, 95% CI (- 4.01, - 2.58)], positive and negative affect scale (PANAS)-positive affect scores [Cohen's d = 1.46, 95% CI (1.46, 2.01)], PANAS-negative affect scores [Coen's d = - 2.21, 95% CI (- 2.84, - 1.60)], difficulties emotion regulation scale scores [Cohen's d = 1.40, 95% CI (- 0.87, - 0.03)], and Worry scale scores [Cohen's d = - 0.45, 95% CI (- 0.95, - 0.04)] at the end of treatment relative to compared to the control condition. Also, treatment gains were maintained at the three-month follow-up (p < 0.001).

CONCLUSION

The findings provide the support that the UP could be an additional efficient psychological treatment for females with MS. ISRCTN Number: ISRCTN95459505.

Transdiagnostic treatment of emotional disorders in people with multiple sclerosis: randomized controlled trial

Background

Multiple sclerosis (MS) is a neurodegenerative disease of the central nervous system. MS is significantly associated with a high rate of psychological, behavioral, and emotional consequences. Despite the frequent mental disorders, high rate of psychological comorbidities, and emotional problems in people with MS (PwMS), these conditions are often underdiagnosed and undertreated. This study aimed to examine the efficacy of a group format of the unified protocol for the transdiagnostic treatment of emotional disorders in adult PwMS associated with an emotional disorder.

Methods

Seventy adult PwMS were randomized using an internet-based computer system to either the unified protocol (n = 35) or treatment as usual condition. The assessment protocol included semi-structured clinical interviews and self-reports evaluating diagnostic criteria, depression, anxiety and worry symptoms, emotional dysregulation, and affectivity.

Results

The parametric test of analysis of covariance, followed the intent to treat analyses, revealed the unified protocol significantly changed depression symptoms (Cohen’s d = 1.9), anxiety symptoms (Cohen’s d = 2.16), worry symptoms (Cohen’s d = 1.27), emotion dysregulation (Cohen’s d = 0.44), positive affect (Cohen’s d = 1.51), and negative affect (Cohen’s d = 1.89) compared with the control group. The unified protocol also significantly improved outcome scores at the end of treatment relative to baseline (p < .001).

Conclusion

The findings support that the unified protocol could be an additional efficient psychological treatment for PwMS.

Trial registration IRCT, number: IRCT20190711044173N1. Registered 31october 2019, https://en.irct.ir/user/trial/40779/view.

The Psychological Impact of COVID-19 Pandemic on People With Multiple Sclerosis

Objective: The coronavirus disease 2019 (COVID-19) has radically changed the world in a few weeks. Italy has been one of the first and most affected countries with more than 30,000 deaths up to now. Public health measures as quarantine or national lockdown are necessary to limit the spread of infectious diseases, but it is unsurprising that depriving people of their liberty has negative psychological effects. This is especially the case for people with chronic diseases, including neurological conditions like multiple sclerosis (MS). People with MS (PwMS) have a higher burden of neuropsychiatric comorbidities and are known to undertake maladaptive coping strategies in stress conditions. The aim of the present study is to investigate the impact of COVID-19 pandemic lockdown on mental health of an Italian cohort of PwMS in comparison with healthy controls (HCs).

Methods: A total of 60 PwMS and 50 HCs (chosen among patients' cohabitants) were asked to answer a Web-based survey. This survey inquired about the impact of COVID-19 on patient's quality of life, job, and daily routine. Mood, fatigue, and sleep quality were evaluated using the Beck Depression Inventory II (BDI-II), the Generalized Anxiety Disease 7 (GAD-7), the Fatigue Severity Scale (FSS), and the Pittsburgh Sleep Quality Index (PSQI).

Results: Overall, patients had higher scores of BDI, FSS, and PSQI, and these differences were statistically significant (p < 0.05). When we looked at the subscores of the BDI, we detected a statistically significant difference for the neurovegetative part—that concerns with sleep, appetite, sex, and quality of sleep (p < 0.05). One out of five patients reported new symptoms or worsening of known symptom, in particular, sensory disturbances, and fatigue. However, no symptoms were severe enough to require hospitalization. When we looked for correlations among variables, we found that there was a significant relationship between unemployment and BDI total score, GAD-7, and PSQI in MS group. The presence of new symptoms or the worsening of symptoms positively related to FSS and to PSQI.

Discussion: We identified that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic had a significant impact on the psychological status of patients with MS. Compared with the general population, PwMS presented a higher burden of depressive symptoms, a worse sleep quality and perceived an increase in fatigue level, one of the most disabling symptoms of MS. The COVID-19 epidemic poses a challenge to psychological resilience. More studies are warranted to better understand the long-term consequences of the pandemic on mental health of vulnerable people during the disease outbreaks.

A Pilot Study to Explore Patient Satisfaction With a Virtual Rehabilitation Program in Multiple Sclerosis: The RehabVR Study Protocol

Background: Virtual reality (VR) has emerged as a promising treatment approach in rehabilitation for patients with multiple sclerosis (MS) due to its potential to increase patient motivation and rehabilitation adherence. One of the key features for rehabilitation adherence is patient satisfaction with the VR rehabilitation (VRR) program, and information on user satisfaction and not only effectiveness is required to systematically include VRR in routine clinical practice. Given that information on patient satisfaction with VRR is scarce, the primary objective of this study is to assess long-term patient satisfaction with a novel VRR program. This program has been specifically designed for MS patients by a multidisciplinary team of specialists, based on an effective conventional rehabilitation (CR) program. Secondarily, discomfort with VRR will be evaluated, and therapy adherence and changes in a variety of domains typically affected by MS will be compared between patients receiving VRR and patients receiving CR. Methods: In this prospective single-center 6-months follow-up study, 32 and 16 MS patients will receive VRR or CR, respectively. Patients will attend twice weekly rehabilitation sessions on site during 4 weeks, and they will continue with rehabilitation at home for five additional months. Satisfaction, assessed by the User Satisfaction Evaluation Questionnaire (USEQ), at 6 months of the VRR program initiation will be the primary outcome. Secondary outcomes include adherence, disability, spasms and spasticity, balance, fatigue, activities of daily living (ADLs), depression, anxiety, work status, cognition, demographic, and clinical characteristics (in the VRR and CR groups), and discomfort (in the VRR group). Outcome measures will be assessed at baseline, and at 1 and 6 months of rehabilitation initiation. Discussion: The study is intended to provide a better understanding of long-term patient satisfaction with a VRR program specifically designed for MS patients. Additionally, the study will provide information on long-term adherence, changes in motor symptoms, cognitive functions and patient-reported outcomes after the rehabilitation program. The results from this study will help to gather valuable knowledge on the use of rehabilitation with a new VR tool in MS patients.

Can We Improve the Monitoring of People With Multiple Sclerosis Using Simple Tools, Data Sharing, and Patient Engagement?

Technological innovation is transforming traditional clinical practice, enabling people with multiple sclerosis (pwMS) to contribute health care outcome data remotely between clinic visits. In both relapsing and progressive forms of multiple sclerosis (MS), patients may experience variable disability accrual and symptoms throughout their disease course. The potential impact on the quality of life (QoL) in pwMS and their families and carers is profound. The introduction of treatment targets, such as NEDA (no evidence of disease activity) and NEPAD (no evidence of progression or active disease), that guide clinical decision-making, highlight the importance of utilizing sensitive instruments to measure and track disease activity and progression. However, the gold standard neurological disability tool—expanded disability severity scale (EDSS)—has universally recognized limitations. With strides made in our understanding of MS pathophysiology and DMT responsiveness, maintaining the status quo of measuring disability progression is no longer the recommended option. Outside the clinical trial setting, a comprehensive monitoring system has not been robustly established for pwMS. A 21st-century approach is required to integrate clinical, paraclinical, and patient-reported outcome (PRO) data from electronic health records, local databases, and patient registries. Patient and public involvement (PPI) is critical in the design and implementation of this workflow. To take full advantage of the potential of digital technology in the monitoring and care and QoL of pwMS will require iterative feedback between pwMS, health care professionals (HCPs), scientists, and digital experts.

The Interactive Web-Based Program MSmonitor for Self-Management and Multidisciplinary Care in Persons With Multiple Sclerosis: Quasi-Experimental Study of Short-Term Effects on Patient Empowerment

BACKGROUND

Empowerment helps persons with a chronic disease to self-manage their condition and increase their autonomy and participation. MSmonitor (Curavista bv) is an interactive Web-based program for self-management and multidisciplinary care in multiple sclerosis (MS). It includes, among others, short questionnaires on fatigue (Modified Fatigue Impact Scale-5 [MFIS-5]) and health-related quality of life (HRQoL, Leeds Multiple Sclerosis Quality of Life [LMSQoL]); long questionnaires on disabilities, perception of disabilities (Multiple Sclerosis Impact Profile), and HRQoL (Multiple Sclerosis Quality of Life-54); a Medication and Adherence Inventory and an Activity Diary. The combination MFIS-5, LMSQoL, and Medication and Adherence Inventory constitutes the Quick Scan.

OBJECTIVE

This study aimed to investigate the short-term effects of MSmonitor on empowerment in patients with MS.

METHODS

We conducted a quasi-experimental study in a general hospital. Of the 180 patients with MS, 125 were eligible, 30 used MSmonitor, and 21 participated in the study (mean age 45.4 years, SD 10.2 years). A total of 24 eligible patients who did not use MSmonitor constituted the control group (mean age 49.3 years, SD 11.4 years). At baseline and at 4 months, we assessed self-efficacy (Multiple Sclerosis Self-Efficacy Scale [MSSES]), participation and autonomy (Impact on Participation and Autonomy [IPA] questionnaire), and self-management (Partners In Health [PIH] questionnaire). Differences between time points and groups were tested with paired t tests and χ² tests.

RESULTS

In the MSmonitor group, follow-up values remained unchanged for MSSES control (P=.19), MSSES function (P=.62), IPA limitations (P=.26), IPA problems (P=.40), PIH recognition and management of symptoms (P=.52), PIH adherence to treatment (P=.80), and PIH coping (P=.73), whereas the PIH knowledge score had improved (mean 27.8, SD 1.7 vs mean 28.7, SD 2.0; P=.02). The overall utilization rate of the program components was 83% and that of the Quick Scan was 95%. In the control group, all outcomes had remained unchanged.

CONCLUSIONS

The results suggest that for first-time users of the MSmonitor program and their health care providers, it may not be justified to expect a short-term improvement in empowerment in terms of self-efficacy, self-management, autonomy, or participation. Furthermore, a lack of effect on empowerment is not because of nonusage of the program components.

Adherence to Physiotherapy-Guided Web-Based Exercise for Persons with Moderate-to-Severe Multiple Sclerosis: A Randomized Controlled Pilot Study

Background

Options to support adherence to physical activity in moderate-to-severe multiple sclerosis (MS) are needed. The primary aim was to evaluate adherence to a Web-based, individualized exercise program in moderate-to-severe MS. Secondary aims explored changes in 29-item Multiple Sclerosis Impact Scale, Hospital Anxiety and Depression Scale (HADS), grip strength, Timed 25-Foot Walk test, and Timed Up and Go (TUG) results.

Methods

Participants were randomized (2:1) to a physiotherapist-guided Web-based home exercise program or a physiotherapist-prescribed written home exercise program. The primary outcome was adherence (number of exercise sessions over 26 weeks). Secondary outcomes were described in terms of means and effect sizes.

Results

There were 48 participants: mean ± SD age, 54.3 ± 11.9 years; disease duration, 19.5 ± 11.0 years; and Patient-Determined Disease Steps scale score, 4.4 ± 1.6. There was no significant difference in mean ± SD adherence in the Web-based group (38.9 ± 28.1) versus the comparator group (34.6 ± 40.8; U = 198.5, P = .208, Hedges' g = 0.13). Nearly 50% of participants (23 of 48) exercised at least twice per week for at least 13 of the 26 weeks. Adherence was highest in the Web-based subgroup of wheelchair users. Medium effect sizes were found for the HADS anxiety subscale and in ambulatory participants for TUG. There were no adverse events.

Conclusions

There was no difference in exercise adherence between the Web-based and active comparator groups. There was no worsening of secondary outcomes or adverse events, supporting the safety of Web-based physiotherapy. More research is needed to determine whether wheelchair users might be most likely to benefit from Web-based physiotherapy.

Motivational interviewing to promote health outcomes and behaviour change in multiple sclerosis: a systematic review

OBJECTIVE

To examine the evidence for motivational interviewing when used to assist individuals with multiple sclerosis manage their healthcare.

DATA SOURCES

The Cochrane, Embase, PsycINFO and PubMed databases were searched for studies published between 1983 and December 2019. The reference lists of included studies were additionally examined and Scopus citation searches conducted.

REVIEW METHODS

Study screening and data extraction were independently completed by two reviewers. Randomised controlled trials comparing motivational interviewing interventions for multiple sclerosis to usual care, wait-list or other active intervention controls were examined. Studies were assessed using the Cochrane Risk of Bias tool. Standardised mean differences (Hedges' g), 95% confidence intervals and P values were calculated for all health and behavioural outcomes.

RESULTS

Ten randomised controlled trials, involving a pooled sample of 987 adults with relapsing-remitting or progressive multiple sclerosis and mild to moderate impairment, were identified. Most trials had a low or unclear risk of methodological bias. Motivational interviewing, when used in conjunction with other counselling or rehabilitation techniques, resulted in significant immediate medium-to-very large improvements in multiple physical, psychological, social and behavioural outcomes (range: g = .34-2.68). Maintenance effects were promising (range: g = .41-1.11), although less frequently assessed (N_studies = 5) and of limited duration (1-7 months). Individual and group-based interventions, delivered in-person or by telephone, were all effective.

CONCLUSIONS

Motivational interviewing is a flexible counselling technique that may improve rehabilitation care for multiple sclerosis. However, evidence for persisting benefits to health outcomes and behaviour is currently limited.

A Dutch validation study of the Multiple Sclerosis Work Difficulties Questionnaire in relapsing remitting multiple sclerosis

PURPOSE

The current study aimed to evaluate the psychometric properties of the Dutch version of the Multiple Sclerosis Work Difficulties Questionnaire-23 (MSWDQ-23).

METHODS

Two hundred and thirty-nine employed persons with multiple sclerosis (MS) and 59 healthy controls completed the MSWDQ-23. To verify the factor structure, a confirmatory factor analysis was conducted. To assess construct validity, the MSWDQ-23 scores were correlated to measures of physical disability, fatigue, cognitive and neuropsychiatric problems, depression, health-related quality of life, and work-related variables. MSWDQ-23 scores were compared within different age groups, gender, education levels, and job types. Predictive validity was assessed using a logistic regression analysis to predict a deterioration in employment status after one year based on MSWDQ-23 scores.

RESULTS

The internal consistency of the MSWDQ-23 was acceptable (α = 0.913, 95% CI = 0.897-0.928) and the results indicated a fair fit. The MSWDQ-23 showed acceptable construct validity, confirming 94% of the hypotheses. The total scale and the psychological/cognitive subscale were able to predict a deterioration in employment status after one year (χ²(1)=18.164, p < 0.001).

CONCLUSIONS

The Dutch version of the MSWDQ-23 is a valid and internally consistent instrument to measure self-reported work difficulties in persons with MS.Implications for rehabilitationThe Dutch version of the 23-item Multiple Sclerosis Work Difficulties Questionnaire (MSWDQ-23) is a reliable and valid tool to measure self-reported work difficulties in people with multiple sclerosis (MS).More psychological and cognitive work difficulties are predictive of a deteriorated employment status after one year.The MSWDQ-23 is a helpful tool for researchers and (occupational) health professionals to identify current work difficulties in persons with MS and identify persons at risk for a deterioration in employment one year later.

Stress management interventions for multiple sclerosis: A meta-analysis of randomized controlled trials

Stress management interventions can help to improve mental health for adults living with multiple sclerosis. However, uncontrolled study designs may overestimate intervention effects. A systematic search of the Embase, PsycINFO, PubMed, and Scopus databases identified eight randomized controlled trials evaluating cognitive behavioral approaches for a pooled sample of 568 adults with multiple sclerosis. Both group and individual-based stress management interventions appear to be effective in promoting self-management of stress. Further research is needed to confirm the optimal timing of stress management interventions across the MS spectrum and strategies to maintain intervention effects.

Comorbid anxiety, depression, and cognition in MS and other immune-mediated disorders

OBJECTIVE

To determine whether anxiety and depression are associated with cognition in multiple sclerosis (MS), and whether these associations are similar in other immune-mediated inflammatory diseases (IMID; including inflammatory bowel disease [IBD] and rheumatoid arthritis [RA]) and in anxious/depressed individuals (ANX/DEP) without an IMID.

METHODS

Participants (MS: n = 255; IBD: n = 247; RA: n = 154; ANX/DEP: n = 308) completed a structured psychiatric interview, the Hospital Anxiety and Depression Scale, and cognitive testing, including the Symbol Digit Modalities Test, the California Verbal Learning Test, and Letter Number Sequencing test. Test scores were converted to age-, sex-, and education-adjusted z scores. We evaluated associations of anxiety and depression with the cognitive z scores using multivariate linear models, adjusting for disease cohort.

RESULTS

All cohorts exhibited higher rates of impairment (i.e., z less than or equal to -1.5) in the domains of processing speed, verbal learning, and delayed recall memory relative to general population norms. Higher levels of anxiety symptoms were associated with slower processing speed, lower verbal learning, and lower working memory performance (all p < 0.001); higher levels of depression symptoms were associated with slower processing speed. These associations did not differ across cohorts.

CONCLUSION

Anxiety and depression are associated with lower cognitive function in MS, with a similar pattern observed in persons with other IMID, including IBD and RA, and persons without an IMID. Managing symptoms of anxiety and of depression in MS, as well as other IMIDs, is important to mitigate their effect on cognition.

Psychiatric comorbidity in multiple sclerosis

AIM

To study the prevalence of psychiatric comorbidities in patients of multiple sclerosis and their association to the degree of disability.

METHOD

Psychiatric symptoms were assessed in 90 patients of multiple sclerosis using GHQ-12, MMSE, HADS, Beck Depression Inventory and AUDIT. Neurological disability was assessed using Expanded Disability Status Scale. Correlations were determined between EDSS scores and psychiatric scale scores.

RESULT

61% of patients had significant psychological distress. Depression was most common (38.8%) which was followed by anxiety symptoms (27.8%). Cognitive functioning was relatively intact in patients with mild to moderate neurological disability. Alcohol abuse was mostly restricted to male gender.

CONCLUSION

Psychiatric illness is highly prevalent in patients of multiple sclerosis leading to poor quality of life and significant distress. Psychiatric disability was higher in patients who had greater deterioration in neurological function. All cases of MS should be assessed for psychiatric morbidities as can be alleviated by appropriate intervention.