Psychiatric Issues in Multiple Sclerosis

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Multiple sclerosis (MS) is the most common chronic disabling disease of the central nervous system in young adults. Early onset and long duration of disease result in tremendous individual, family, and societal costs as well as reductions in quality of life and work productivity. Persons who have MS have a higher prevalence of a number of psychiatric symptoms and disorders. This article seeks to summarize the existing literature on the epidemiology, impact, and treatment of psychiatric disorders among persons who have MS and to identify the areas in which further research is needed.

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Overview

Multiple sclerosis (MS) is the most common chronic disabling disease of the central nervous system in young adults, affecting 1 in 1000 people in Western countries [1]. MS is a demyelinating disease of the central nervous system; a diagnosis of MS requires the occurrence of at least two neurologic events consistent with demyelination in the central nervous system that are separated temporally and anatomically. Early onset (typically between 20 and 40 years of age) and long duration of disease

Impact of Psychiatric Disorders on Multiple Sclerosis

The most compelling reason to investigate psychiatric disorders among persons who have MS is that reported rates of completed suicide in MS populations are high [10], and psychiatric disorders seem to be the major risk factor for suicidality [11]. Death certificate–based reviews indicate that suicide may be the cause of death as many as 15% of MS clinic patients [12]. In retrospective analyses of completed suicides in MS populations, depression has been the most important risk factor for

Psychiatric Effects of Treatment of Multiple Sclerosis

Pharmacologic treatments for MS include corticosteroids, beta interferon (IFNβ), glatiramer acetate, and immunosuppressants. Corticosteroids, which are used in high doses for short courses to treat acute exacerbations, have been associated with a variety of neuropsychiatric side effects, including increased energy, decreased sleep, and significant mood symptoms such as mood lability, euphoria, and depressed mood [21], [22]. Epidemiologic studies suggest an incidence of neuropsychiatric side

Epidemiology and Clinical Correlates of Depression

Depression may be more common in MS than in other chronic neurologic conditions [36]. The 12-month prevalence of major depressive disorder (MDD) among persons who have MS is 15.7%, nearly double the prevalence of MDD in persons who do not have MS (7.4%) [37]. Reports of the lifetime risk for MDD in MS populations have ranged from 27% to 54% [36], [37], [38]. The prevalence of clinically significant depressive symptoms is much higher [39] than the prevalence of MDD, but few studies have

Anxiety Disorders in Multiple Sclerosis

In contrast to the extensive literature on depression in patients who have MS, less attention has been paid to anxiety disorders. Several studies using self-report scales of anxiety symptoms have found a point prevalence of clinically significant anxiety ranging from 25% to 41% [42], [64], [65]. Only two studies have used structured clinical interviews to evaluate formal diagnoses of anxiety disorders, and both of these found lifetime prevalence rates of 36% [14], [66], which is much higher

Serious Mental Illness in Multiple Sclerosis

Numerous case reports have documented an association between bipolar disorder and MS [68], [69], [70], [71]. Bipolar symptoms may precede other neurologic signs of MS, and there have been reports of MS presenting as frank mania [70], [71]. Affective lability, in particular, may occur in tandem with an MS exacerbation. Some researchers have hypothesized that the comorbidity of bipolar disorder may be related to the location of the MS lesions [69]. Several clinical studies have identified

Substance Use Disorders in Multiple Sclerosis

Alcohol and illicit drug use may be more problematic in people who have MS than in the general population, potentially causing further neurologic damage to an already compromised central nervous system or leading to dangerous interactions with prescription medications. Heavy alcohol use can magnify the subtle cognitive impairment associated with MS [77] and has been shown to cause persistent cognitive impairment, even in persons who do not meet the criteria for alcohol abuse or dependence [78]

Pseudobulbar Affect

In addition to mood disorders, MS patients also may experience disorders of affect, typically an expression of affect that is not representative of the underlying emotion [94]. Some MS patients may laugh or cry out of proportion to or in the absence of the expected feeling, a phenomenon that has been referred to as “pathological laughing and crying,” or pseudobulbar affect (PBA). PBA has been recognized in association with MS for many years, but even today its causes are not well understood.

Resilience and Posttraumatic Growth

Although psychiatric conditions are highly prevalent among individuals living with MS, many persons who have MS do not exhibit clinically significant levels of depression, anxiety, or other serious mental illness. The ability to maintain psychologic well being and functioning in the face of adversity such as loss, trauma, and serious medical illness often is referred to as “resilience” [99]. Being resilient does not mean that the individual never experiences any negative emotions, thoughts, or

Summary

MDD and anxiety disorders are highly prevalent among persons who have MS and have been associated with decreased adherence to MS treatment and poorer functional status and quality of life. Effective treatment is available for MDD, but this disorder continues to be underdetected and undertreated by MS providers. Treatment with pharmacotherapy is particularly challenging in this patient population, given the somatic symptom overlap between MS and depression and the increased burden of side

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