BOSTON—Neuropsychiatric disorders, particularly depression and anxiety, are more common among people with multiple sclerosis (MS) than among the general population, according to research presented at the 2014 Joint ACTRIMS–ECTRIMS Meeting.
Many of these disorders are treatable, and patients may respond well to medication.
“When you’ve got a disease without cure affecting young and middle-aged people, good symptom management becomes important,” said Anthony Feinstein, MBBCh, PhD, Associate Scientist at Sunnybrook Health Sciences Center in Toronto. Available therapies for neuropsychiatric disorders often can improve quality of life for patients with MS, “so the diagnosis should not be missed,” he added.
One in two patients with MS will develop major depression during his or her lifetime. Changes in appetite, insomnia, fatigue, and diminished ability to concentrate are hallmarks of depression, but MS also may cause these symptoms. Self-report questionnaires such as the Beck Depression Inventory and the Hospital Anxiety and Depression Scale can help neurologists determine whether a patient’s symptoms result from depression. The dexamethasone suppression test also may help confirm a diagnosis of depression. If a patient’s cortisol level remains high after a single dose of dexamethasone, then he or she may have depression.
For patients with MS and depression, a neurologist may first prescribe monotherapy with a selective serotonin reuptake inhibitor (SSRI) such as fluoxetine or paroxetine. If treatment fails, the neurologist may switch to another SSRI or a serotonin–norepinephrine reuptake inhibitor such as venlafaxine or mirtazapine. These agents sometimes cause sexual difficulties, but bupropion or mirtazepine can treat depression effectively without causing this side effect, said Dr. Feinstein. If the patient does not respond to monotherapy, combination therapy may be appropriate. Combination therapy could include an antidepressant plus methylphenidate or lithium carbonate.
If combination therapy is not effective and the patient is severely depressed and suicidal, electroconvulsive therapy (ECT) may be an option. The guidelines for this therapy are strict, and it is “a safe treatment for patients with MS,” said Dr. Feinstein. ECT carries a small risk of MS relapse, so a neurologist should determine whether the patient has active disease. “We give our patients a gadolinium-enhanced MRI before we consider ECT,” said Dr. Feinstein. “If there’s no contrast enhancement and no active disease, we think that ECT is quite safe, and the response rate is excellent.”
Patients who do not want to take medication may benefit from cognitive behavioral therapy (CBT). Evidence suggests that CBT, which Cochrane Review endorses, is as effective for depression as SSRIs. CBT can be administered to individuals, to groups, or by telephone. A variant of CBT called mindfulness-based therapy also has been effective in patients with MS and depression. The advantage of CBT is its lack of side effects, but not every neurologist has access to a cognitive behavioral therapist, said Dr. Feinstein.
Interest in exercise as a treatment for depression has been rising, but no study of exercise has yet had depression relief as its primary end point. Studies in which depression relief was a secondary end point suggest that exercise is beneficial, but until there’s a randomized controlled study of exercise with depression relief as a primary end point, “the jury’s going to be out on this,” said Dr. Feinstein.
Anxiety is more common than depression in patients with MS, and the two disorders often are comorbid. Like depression, anxiety has symptoms that may be ascribed mistakenly to MS. The Hospital Anxiety Depression Scale can help neurologists determine whether a patient with MS has anxiety.
Few researchers have studied the treatment of anxiety in patients with MS, and none have examined pharmacologic therapies. Current data do suggest that CBT is effective, however. Stress inoculation therapy, a form of CBT, is intended to reduce negative thoughts and minimize stress. This therapy “is potentially effective in reducing anxiety,” said Dr. Feinstein. Randomized controlled trials indicate that CBT helps to reduce the anxiety that results from a diagnosis of MS. Needle phobia, which affects compliance with treatment, also can respond well to CBT.
Pseudobulbar Affect and Other Disorders
Approximately 10% of patients with MS have pseudobulbar affect, which responds well to medication. Low-dose amitriptyline, SSRIs, levodopa, and amantadine treat this condition effectively. In addition, the FDA recently approved dextromethorphan–quinidine for the treatment of pseudobulbar affect, and a 2006 study published in Annals of Neurology showed that the combination was effective for patients with pseudobulbar affect and MS. “When you treat this particular syndrome, you’re going to get a response in about 48 to 72 hours,” said Dr. Feinstein. “If you treat someone with major depression with medication, the response time is usually about two weeks.”