People living with multiple sclerosis (MS) are at a much higher risk for depression and several other psychiatric disorders compared to people without MS. A number of studies show that between 36 and 54 percent of people with MS have major depression, versus approximately 16.2 percent of the general population. (See box, “Prevalence of Psychiatric Disorders in MS Patients vs. General Population.”) In major depression, feelings of sadness, loss, anger, hopelessness, or frustration interfere with daily life for weeks or longer.
Prevalence of Psychiatric Disorders in MS Patients vs. General Population
Studies also show that people with MS have elevated rates of bipolar disorder as well as anxiety, adjustment, and psychotic disorders—and commit suicide at twice the rate of the general population.
Estimated rates of pseudobulbar affect (PBA) in MS patients range from 6.5 percent to as high as 46.2 percent. PBA is characterized by involuntary, uncontrollable outbursts of emotion, such as crying or laughing, which may not be consistent with the individual's mood. The condition is common in neurodegenerative diseases such as MS, amyotrophic lateral sclerosis, Parkinson's disease, and various dementias. (For more Neurology Now coverage of PBA, go to bit.ly/1ewlLgf.)
Scientists don't know for certain if the elevated risk of these psychiatric disorders is an aspect of MS itself—caused or exacerbated by the damage done to the central nervous system as the illness progresses—or a response to living with a chronic illness, a side effect of medications, or a combination of these factors. Recently, the American Academy of Neurology (AAN) convened a panel of experts to review the current medical literature on the subject and develop a guideline for diagnosing and treating psychiatric disorders in MS. Regardless of the reasons for the elevated risk of these disorders, patients, caregivers, and physicians should discuss psychological health as part of a comprehensive approach to managing MS, experts say.
WHAT IS MULTIPLE SCLEROSIS?
MS is the “most common disabling neurological disease of young adults” according to the National Institute of Neurological Disorders and Stroke ( 1.usa.gov/1ktPHAW). In MS, the immune system damages or destroys myelin, a membrane that covers nerve fibers and helps to speed up electrical impulse transmission along nerves. The disease can also damage nerve fibers themselves. These immune system attacks on the brain and spinal cord are commonly known as “flare-ups” or exacerbations. The symptoms of MS are related to the severity of these attacks and the areas in the brain or spinal cord that are affected by these attacks. The most common symptoms of an MS flare-up include muscle weakness and stiffness; difficulty coordinating, walking, and balancing; tingling or burning sensations, not unlike pins and needles; blurred or double vision; and difficulty concentrating. Typically, symptoms first appear between the ages of 20 and 40, although they can also appear in children and the elderly. The MS Association of America estimates that as many as 400,000 people in the United States and 2.3 million worldwide are living with MS.
While MS cannot currently be cured, the illness can be managed. In the last 20 years, a number of drugs have been approved that reduce the frequency of flare-ups and may slow progression of the disease. In addition, medications may be useful to treat the symptoms of MS such as stiffness, tingling, pain, and urinary problems. (To read Neurology Now's “Multiple Sclerosis: The Basics,” go to bit.ly/1fk2ZOk.)
WHAT THE GUIDELINE SAYS
The AAN panel found enough evidence to make a limited number of recommendations about the diagnosis and treatment of psychiatric disorders in MS, according to Pushpa Narayanaswami, M.D., Fellow of the AAN, assistant professor of neurology at Harvard Medical School/Beth Israel Deaconess Medical Center in Boston, MA, and senior author of the guideline.
Specifically, the panel found limited evidence that was enough to recommend three tools to screen for some psychiatric disorders in people with MS; a specific telephone-administered program of cognitive behavioral therapy to alleviate symptoms of major depression in MS; and a combination of dextromethorphan and quinidine to control PBA in MS.
Dr. Narayanaswami emphasizes that while this new guideline is relatively limited because of a lack of evidence—especially with regards to treatment options—that doesn't mean effective treatments aren't available. Many drug and nondrug therapies that work in the general population are also commonly prescribed for MS patients, but these therapies have not been studied separately in people with MS, she says—and more research is needed to establish that they are safe and effective. In addition, patients and caregivers should know that physicians may ask them about psychological symptoms based on the new guideline. (See box, “Summary of the New AAN Guideline.” To read the patient summary of the guideline, go to bit.ly/K2Qtol.)
The report draws needed attention to the elevated risk of psychiatric disorders in people with MS, according to Patricia K. Coyle, M.D., Fellow of the AAN, director of the MS Comprehensive Care Center at Stony Brook University Hospital in Stony Brook, NY. It should encourage patients and doctors to discuss these disorders openly and routinely. “It is very important to recognize and treat depression in MS,” says Dr. Coyle, who was not part of the AAN panel.
Dr. Coyle also notes that the AAN guideline helps validate the Beck Depression Inventory and the two-question screening tool. “These simple, quick, and effective screens are easy to administer. They can be done in any neurologist's office. In fact, patients can complete the questionnaires in the waiting room,” she says. Dr. Coyle encourages patients to ask their doctors for a mental health evaluation and encourages physicians to routinely screen MS patients for depression using the tools recommended in the AAN guideline.
Dr. Coyle and Dr. Narayanaswami agree that physicians should also routinely screen patients with MS for PBA using the simple 7-item self-report questionnaire called the CNS Emotional Lability Scale. The U.S. Food and Drug Administration has approved a combination of the drugs dextromethorphan and quinidine (brand name Nuedexta) to treat PBA.
Dr. Coyle says she was encouraged by the panel's finding that cognitive behavioral therapy has long-lasting benefits in treating depression. The fact that it is administered by telephone makes it even more appealing, because so many MS patients have difficulty with transportation and mobility, according to Dr. Coyle.
CALL FOR MORE RESEARCH
Not enough research has been done to determine which therapies currently being prescribed are most effective for MS patients, according to Drs. Coyle and Narayanaswami. For example, antidepressants are often used in MS patients. The fact that there is not enough evidence to recommend them does not mean they are not effective, according to Dr. Coyle.
Because the jury is still out with regards to many of the treatments and how they work in people with MS, patients should let their physicians know if a particular treatment is not effective or is causing uncomfortable side effects in order to explore other options.
Summary of the New AAN Guideline
RECOMMENDED SCREENING TOOLS
- 1 Beck Depression Inventory and two-question tool to screen for depressive disorder. The Beck Depression Inventory is a 21-item, multiple-choice questionnaire filled out by the patient, who is asked to choose which of four statements best describes his or her feelings. For example, the patient is asked to choose which of the following statements best describes his or her current state: does not feel sad (0); feels sad (1); feels sad all the time (2); is so sad and unhappy all the time that he/she can't stand it (3). The physician totals the numerical values to determine where the patient falls in terms of severity of depression. The 2-question screen asks the patient whether he or she feels depressed, and whether he or she feels diminished interest or pleasure. A “yes” to either question suggests the need for further evaluation for depression.
- 2 CNS Emotional Lability Scale to screen for pseudobulbar affect (PBA). In this seven-item, self-reporting screen used to diagnose PBA, a patient is given a statement such as, “I find myself crying very easily,” and asked to choose from five possible responses each with a numerical value: never applies (1), rarely applies (2), occasionally applies (3), frequently applies (4), or applies most of the time (5). A total score of 13 or more may indicate the patient has PBA.
- 3 General Health Questionnaire to screen for broadly defined emotional disturbances, a 28-item questionnaire used to screen for a range of psychiatric issues. It is divided into four subcategories: anxiety disorders, social dysfunction, somatic symptom and related disorders, and depression. Patients are asked questions such as, “Have you recently been feeling run down and out of sorts?” or “Have you recently lost much sleep over worry?” The patient chooses between the following responses: Not at all (0); No more than usual (0); Rather more than usual (1); Much more than usual (1). The test is scored by awarding a value of zero to the first two responses and a value of one to the second two. A threshold of 4 within a subcategory indicates a person should seek further psychiatric assessment for that particular disorder.
RECOMMENDED TREATMENT THERAPIES
- 1 16-week telephone-administered cognitive behavioral therapy program to alleviate symptoms of depression in MS, a 16-session course of treatment in which a therapist speaks with a patient for one 50-minute session per week. The therapist teaches skills needed to manage and alter thought processes and behaviors that contribute to depression and methods for dealing with stressful situations and interpersonal problems.
- 2 Combination of dextromethorphan and quinidine, approved by the U.S. Food and Drug Administration to treat PBA.