Psychiatric morbidity

Psychiatric morbidity is not increased in the early stages of the disease when patients present with isolated neurological symptoms (e.g. optic neuritis), (28) and purely psychiatric presentations without accompanying neurological symptoms do not occur.(29)

Clinical features

Depressive symptoms (irritability, poor concentration, low mood, and anxiety) are commonly reported. In cross-sectional studies they are present in about 50 per cent of patients.(28> The lifetime prevalence for depression is also around 50 per cent.

There is a sevenfold increase in the expected rates of suicide. (39 Risk of suicide is associated with the degree of physical disability and reaches its peak about 10 years from the onset of symptoms, probably at the time when the disease enters a progressive course.

Euphoria is only present in about 10 per cent of patients and is characterized by a state of mild, continuous elation and should be seen as an organic type of personality change.

Emotional lability has a comparable frequency and excessive crying is more frequent than laughter. It tends to be more severe in those with significant symptoms of depression/3!)

Psychotic episodes are uncommon in multiple sclerosis, but brief affective or schizophrenia-like psychoses have been reported in patients with well-established multiple sclerosis, sometimes coinciding with a relapse.(32) Persecutory delusions and lack of insight are common. In most patients these are single episodes lasting 4 to 6 weeks that respond well to symptomatic treatment.

Mechanisms of psychiatric symptoms

Severity of brain disease, as measured by magnetic resonance imaging (MRI) lesion load, and duration of illness are not closely correlated with the presence or severity of depression, but they are a risk factor—as suggested by the much higher prevalence of psychiatric morbidity in patients with multiple sclerosis compared with non-neurological disabled controls.

The degree of the personal and social limitations imposed by the disease correlates more closely with the presence of depression. (28) A genetic predisposition to affective disorder has been reported in multiple sclerosis patients with bipolar illness, but not in those with unipolar disorder.

Euphoria and emotional lability tend to occur in those patients with advanced disease who also exhibit cognitive impairment and are more closely related to the MRI lesion load. MRI lesions tend to cluster around the temporal lobes in those patients with psychotic symptoms.

Treatment

Few studies have assessed the effect of antidepressants in patients with multiple sclerosis. Early studies have suggested that tricyclic antidepressants can be helpful, and clinical experience suggests that the same applies to SSRIs. In any given patient, the side-effects of psychotropic drugs need to be carefully considered for their potential to aggravate or improve neurological symptoms. Emotional lability responds well to small doses of tricyclic antidepressants (e.g. amitriptyline 75 mg) or to SSRIs, but tends to recur when these drugs are discontinued.

Psychotic episodes may require the use of neuroleptics for brief periods, but the long-term use of these drugs is rarely required.

b-Interferon has been reported to increase the severity of depressive symptoms so that patients at risk for depression should be carefully monitored.

Anxiety and Depression 101

Anxiety and Depression 101

Everything you ever wanted to know about. We have been discussing depression and anxiety and how different information that is out on the market only seems to target one particular cure for these two common conditions that seem to walk hand in hand.

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