Ms. Kang is a fourth-year medical student, Weill Cornell Medicine, New York, New York. Dr. Kotbi is Associate Professor of Clinical Psychiatry, Weill Cornell Medicine, and Attending Psychiatrist, New York Presbyterian Hospital, New York, New York.
Disclosures The authors report no financial relationships with any company whose products are mentioned in this article, or with manufacturers of competing products.
Ms. A, age 56, presents with depressed mood, anhedonia, irritability, agitation, and recent self-injurious behavior. She also has multiple sclerosis. How can you best help her?
TREATMENT Mood stabilization
We start Ms. A on divalproex sodium, 250 mg 2 times a day, which is eventually titrated to 250 mg every morning with an additional daily 750 mg (total daily dose of 1,000 mg) for mood stabilization. Additionally, quetiapine, 50 mg nightly, is added and eventually titrated to 300 mg to augment mood stabilization and to aid sleep. Before being admitted, Ms. A had been prescribed alprazolam for anxiety; she is switched to longer-acting clonazepam, .5 mg/d, to minimize the potential for withdrawal symptoms while she is hospitalized.
The authors’ observations
Definitive treatments for psychiatric conditions in patients with MS have been lacking, and current recommendations are based on regimens used to treat general psychiatric populations. For example, selective serotonin reuptake inhibitors are frequently considered for treatment of MDD in patients with MS, whereas SNRIs are considered for patients with concomitant neuropathic pain.13 Similarly, lithium and valproic acid (divalproex sodium) are the pharmacotherapies of choice for mood stabilization,2 while CBT appears to be the main psychotherapy showing benefit for patients with MS who are depressed.14 As with any patient, response and reactions to treatment should be closely monitored. Given the lack of definitive regimens, along with the ambiguity of neurologic and psychiatric symptom etiology in terms of physiologic vs psychosocial contributions, the need for trial and error in terms of choice of treatment and optimal dosages becomes essential.
OUTCOME Improved mood, energy
After 2 weeks of inpatient treatment, Ms. A shows improvement in mood lability and energy levels, and she is able to tolerate titration of divalproex sodium and quetiapine to therapeutic levels. She is referred to an outpatient psychiatrist after discharge, as well as a follow-up appointment with her neurologist. On discharge, Ms. A expresses a commitment to treatment and hope for the future.
Bottom Line
Evaluation and treatment of psychiatric manifestations in patients with multiple sclerosis (MS) requires careful attention and focus on the individual’s unique pattern of symptoms, psychosocial stressors, and response to treatment, among other considerations. Treatment for mood disorders in patients with MS are the same as those used for the general psychiatric population.
