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Depressive symptoms as a predictor of outcome in patients with multiple sclerosis

Mohamed, Saber A.; El-Deib, Osama

Middle East Current Psychiatry: January 2014 - Volume 21 - Issue 1 - p 38–42
doi: 10.1097/01.XME.0000438127.40735.0c
Original articles
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Background Multiple sclerosis (MS) is commonly associated with depression. Depression constitutes a major factor in distressing and disability symptoms among patients with MS.

Objective The study aimed to investigate symptoms of depression in MS and explore its association with the degree of clinical disability.

Patients and methods Thirty-one patients with definite MS, age range 20–50 years, and 20 age-matched and sex-matched healthy controls were recruited for the study. The patients selected were subjected to a physical and psychiatric assessment, psychometric evaluation by Structured Clinical Interview for DSM-IV Axis I Disorder and Beck Depression Inventory for rating of depressive symptoms, and Expanded Disability Status Scale for the estimation of severity of disability symptoms. MRI of the brain and spine was performed for a definite diagnosis of MS.

Results A total of 55% of MS patients have depressive symptoms of varying severity – 9% mild, 40% moderate, and 6% severe. MS patients with the secondary progressive course subtype have more depression and disability symptoms than patients with the relapsing remitting course subtype. Female patients are more likely to be depressed than male patients. We found no significant relation between depressive symptoms and total or regional size of MS by MRI.

Conclusion Depression is common in MS patients and is correlated with the degree of disability in MS disorder.

aDepartment of Psychiatry, Faculty of Medicine, Zagazig University, Zagazig

bDepartment of Neurology, Monfeya University, Monfeya, Egypt

Correspondence to Saber A. Mohamed, MD, Department of Psychiatry, Faculty of Medicine, Zagazig University, 44511 Zagazig, Egypt Tel: +966536938166; e-mail: saberabdel@hotmail.com

Received March 27, 2013

Accepted October 20, 2013

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Introduction

Multiple sclerosis (MS) is a chronic and unpredictable neurological disease commonly associated with a host of symptoms such as sensory and motor deficits, fatigue, ataxia, blindness, pain, cognitive impairment, and depression 1. Clinically significant depression can affect up to 50% of patients with MS over the course of their lifetime. It is associated with an increased morbidity and mortality and is considered by patients as one of the main determinants of their quality of life 2. Patients with MS experience considerable prognostic uncertainly. Neuropsychological impairment is a major predictor of low quality of life, unemployment, and caregiver distress 3.

Changes in mood are among the most disabling and distressing symptoms for individuals diagnosed with multiple scleroses. Depression is more common in MS than in other chronic diseases. The lifetime prevalence rates range from 42 to 54% 4.

The possible relation between MS and depression is of importance in both the understanding of the etiologies of these two common conditions and the potential treatment. Depression in MS may have a different etiology 5. There is a significant correlation between depression and the alteration in the frontal and temporal lobes of the right hemisphere 6. Interferon-γ is the main proinflammatory cytokine produced by activated T-helper cells and is considered as a major effect in the pathogenesis of MS 7 and also related to depression; thus, treatment of depression may provide a novel disease-modifying therapeutic strategy as well as symptomatic treatment for patients with MS 8. Depression may be considered as a reaction to the course of the illness and its effects on both physical and cognitive functions 9.

Studies evaluating the correlation between neuropsychological impairment and findings on MRI show that neuropsychological dysfunction is associated with lesion burden and diffuse disease in normal-appearing brain tissue 3.

This study aimed to investigate symptoms of depression in MS and explore its association with the degree of clinical disability.

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Patients and methods

Patients

Thirty-one right-handed multinational MS patients were recruited for the study. They were diagnosed with definite MS according to the Poster et al. 10 criteria. Twenty right-handed age-matched and sex-matched healthy controls were recruited as a control sample. Patients younger than 15 years old, with a history of head trauma or other central nervous system disorder, alcohol or drug abuse, chronic medical illness that might affect mood (e.g. thyroid and hepatic patients), and those with a history of Axis I diagnosis were excluded from the study. All participants were selected from the Outpatient Neurology Clinic and among employees at the Ahalia Private Hospital in Abu Dhabi, United Arab Emirates, over a 1-year period. The participants provided informed consent for active participation in the study.

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Methods

After approval from the ethical committee was obtained, the patients selected were subjected to the following:

  • Full medical, neurological, and psychiatric assessment including accurate assessment of history, medical examination, and mental state examination.
  • Laboratory investigations: complete blood count, random blood glucose level, hepatic and renal function tests, serum electrolytes (Na, K, and Ca), and drug screening for alcohol, cannabis, and amphetamine.
  • Expanded Disability Status Scale (EDSS): EDSS is a common measure of relapsing-remitting MS disability. Patients’ individual disabilities were classified according to EDSS scores 11 ranging from 0 (normal function) to 10 (death) in steps of 0.5, an EDSS score of less than 3 indicated minimal disability, whereas an EDSS score of greater than 5.0 indicated serious physical and mental limitations.
  • Evoked potentials and MRI for the brain and spinal cord: visual, somatosensory, and brain stem auditory evoked potentials and T2-weighted MRI were performed for all patients for additional confirmation of the diagnosis of MS. A number of measures are used to evaluate MRI lesion size, both total and regional distribution. The results of MRI were correlated with the results of the psychometric examination.
  • Psychometric assessment was carried using the following:
    • Beck Depression Inventory (BDI) 12: BDI is a 21-item self-report rating inventory measuring characteristic attitudes and symptoms of depression. Each item has a score from 0 to 3 according to the severity of the depressive symptoms, with a total score of the inventory of 63. Cut-off scores were used (normal≤9, mild 10–15, moderate 16–29, and severe>30).
    • Structured Clinical Interview for DSM-IV Axis I Disorder (SCID-I).
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Statistical analysis

The data were coded and entered into an IBM compatible personal computer using the statistical package SPSS (version 16). Continuous data were summarized as mean and SD, whereas qualitative data were summarized as percent. The differences between groups were tested using Student’s t-test. The χ2-test was used for qualitative data. The correlation between two continuous groups was assessed using Pearson’s correlation test. The level of significance for all above-mentioned tests was at P value less than 0.05 13.

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Results

Thirty-one MS patients, 36.5±6.23 years of age, 55% women and 45% men (Table 1), mean age of onset of MS 31.35±2.8 years in men and 28.11±2.4 years in women, participated in our study. The mean number of relapses of MS symptoms was 3.97.

Table 1

Table 1

Depressive symptoms were found to be more prevalent in MS patients (55%, 29% men and 26% women) than in control participants (15%, 0% men and 15% women) (Table 2). Moreover, depressive symptoms were statistically more significant in MS patients (14.35±7.82) than in control participants (7.0±2.9) (t=4.75, P=0.035) (Tables 3 and 4). Also, we found that female patients had significantly more severe depressive symptoms (14.8±4.3) than male patients (11.23±2.5) (Table 3). In addition, MS patients with the secondary progressive subtype had significantly more depressive symptoms (18.7±8.44) than those with the relapsing remitting course subtype (11.92±7.5) (t=4.56, P=0.04) (Table 5).

Table 2

Table 2

Table 3

Table 3

Table 4

Table 4

Table 5

Table 5

On overall disability scoring by EDSS, MS patients with the secondary progressive subtype (4.3±0.8) had statistically significantly higher scores than MS patients with the relapsing remitting course subtype (3.1±1.3). However, we found no significant difference between male and female patients in the EDSS scores (Tables 2 and 6).

Table 6

Table 6

Using the Pearson correlation coefficient, a significant positive correlation was found between overall disability as measured by EDSS in the relapsing remitting course subtype of MS with duration of disease and number of relapses. However, there was no significant correlation, in the same model, between the secondary progressive MS subtype and any of the clinical variables (disease duration and age of onset) (Table 7).

Table 7

Table 7

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Discussion

Depression constitutes a major factor in distressing and disability symptoms among patients with MS. The major findings of our work were as follows:

  • Depressive symptoms tend to be both more prevalent and severe in MS patients, particularly women, and in those with the secondary progressive subtype.
  • Patients with the secondary progressive MS subtype have more overall disability than those with the relapsing remitting course MS.
  • Patients with the relapsing remitting MS subtype show a significant positive correlation with disease duration and number of relapses.

Emotional disturbances are common in MS and include disturbances in mood and disturbances of affect 14; yet, patients and their families have little understanding or receive little help with these problems 15.

In the present study, depression was encountered in about 55% of patients (17 patients). This result is in agreement with previous studies 4,14,16. They reported that estimates of depression in MS ranged from 42 to 54%, which is very close to our figures.

Interestingly, we found that 6% of MS patients (two patients) had a severe degree of depression on BDI. This is in partial agreement with Chwastiak et al. 4, who reported severe depression in 29.1% of MS patients. However, at the same time, this finding is in contrast to that obtained by Dalos et al.17, who found that severe emotional disturbances were uncommon in MS patients but more prevalent among those experiencing an exacerbation. This contradictory result might be attributed in part to differences between researches either in the time of examination (remission or relapse), the nature of the sample, or in the psychometric tools used to assess depression.

Moreover, we found that patients with the secondary progressive MS subtype had more depressive symptoms than those with the relapse remitting course MS subtype. This is in agreement with the results of both Rabins et al. 18 and Filippi et al. 19, who reported a significant increase in the prevalence of depressive symptoms in the secondary progressive MS subtype. However, our findings are not in agreement with those of Chwastiak and colleagues 4,20,21. They found no significant differences between both subtypes (secondary progressive and relapse remitting) of MS. These contradictions might be attributed to the differences in the sample size, the nature of the sample, time of assessment (remission or relapse), and the availability of psychiatric services.

Female MS patients experience more severe depression than male patients. This is in agreement with the everyday clinical practice observation of an increase in the incidence of depression in women than in men. This is in agreement with the study by Kessler et al. 22, who reported depression to be 1.7–2 times more common in women than men in the general population. These increments in the severity of depression might be attributed to the fact that women are more prone to exposure to many stressors, social, child bearing, and hormonal, and are more easily able to express themselves in psychiatric terms.

The findings of the present study suggested that there was no significant correlation between depression and severity of the symptoms as measured by EDSS. This result is in agreement with that of the study by Moller et al. 21 and Noy et al. 23, who found that the frequency or severity of depressive episodes in MS patients is independent of the severity of MS. In contrast, Chwastiak et al.4 found that the severity of MS was associated with depressive symptoms as they found that patients with intermediate and advanced illness according to EDSS were 3–6 times more depressed, respectively, than mildly affected patients. Moreover, Koch et al. 24 found that in patients with MS, fatigue and depression are strongly associated with each other, but not with the degree of disability or the speed of disability accumulation.

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Conclusion

Depression is a common feature of MS and is correlated positively with the degree of disability and duration of illness, especially in the relapsing remitting subtype. Proper care and early detection of depression among MS patients might improve the general overall outcome and reduce disability among these patients.

Figure

Figure

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Acknowledgements

Conflicts of interest

There are no conflicts of interest.

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Keywords:

depression; disability; multiple sclerosis

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