Table 1

Presenting symptoms and management options for neuropsychiatric disorders in individuals with MS

Neuropsychiatric disorder Principal presenting symptoms Treatment
Depression

  • Pervasive low mood

  • Diurnal mood variation

  • Fatigue

  • Functional change

  • Pessimism/negative thinking patterns

  • Suicidal ideation

Iatrogenic depressive symptoms secondary to use of corticosteroids, baclofen, dantrolene and tizanidine		SSRIs are first line (fluoxetine, sertraline)
TCAs—desipramine
SNRIs especially if comorbid pain (venlafaxine, duloxetine)
Mirtazapine (less sexual dysfunction)
Psychotherapy—CBT, supportive, mindfulness, IPT, exercise and relaxation techniques
Lithium augmentation (diuresis and polyuria may be issues)
ECT for treatment-resistant cases but may increase risk of MS relapse
Bipolar disorder

  • Elated mood

  • Increased energy

  • Talkativeness

  • Overfamiliarity

  • Psychomotor agitation

  • Disinhibition

  • Impulsivity

  • Insomnia

Lithium (risk of diuresis)
Sodium valproate
mania with psychotic symptoms—risperidone, quetiapine, olanzapine, ziprasidone
If steroid-induced mania, consider lithium, phenytoin, olanzapine and/or reduced dose of steroids
Psychosis

  • Hallucinations and  delusions

  • Irritability and agitation

  • Sleep disturbance and grandiosity

  • Blunted affect, flight of ideas, depression, reduced self-care and pressured speech

  • More complex delusions occasionally (erotomanic, nihilistic and misidentification)

Atypical antipsychotics

  • Risperidone

  • Clozapine

  • Aripiprazole

  • Quetiapine

  • Ziprasidone

Typical antipsychotics (ie, chlorpromazine may worsen balance)
Benzodiazepines (may help sedation but may worsen cognitive impairment)
Anxiety disorders

  • GAD

  • Panic disorder

  • OCD

  • Social anxiety disorder

  • Simple phobia (self-injection anxiety)

Anxiety symptoms associated with underlying condition		SSRIs are first-line agents
Other options include

  • Venlafaxine

  • Buspirone

  • Pregabalin

  • Gabapentin

  • Beta-blockers

  • Benzodiazepines (short-term only)

Substance misuse

  • Increased depression

  • Increased suicidal ideation

  • Exacerbate cognitive deficits

  • Coordination difficulties

  • Interact with MS treatments

  • Heightened codependence on carer or family

Symptoms in line with underlying condition		Counselling services appropriate for the substance of misuse
Consider anticraving agents such as acamprosate
Pseudobulbar affect and euphoria

  • Incongruent emotional expression in response to a non-specific stimulus

  • Emotions (laughing/crying) disproportionate to the underlying emotional experience

  • Absence of voluntary control of facial expression

TCAs (amitriptyline, desipramine, nortriptyline)
SSRIs
Levodopa
Amantadine
Dextromethorphan and quinidine

  • B-FS, Beck Fast Screen for Depression in Medically Ill Patients; CBT, cognitive behavioural therapy; CNS-LS, Center for Neurologic Study-Lability Scale; GAD, generalized anxiety disorder; HADS, Hospital Anxiety and Depression Scale; IPT,  interpersonal therapy; MS, multiple sclerosis; NARI, noradrenaline reuptake inhibitor; NaSSA, noradrenergic and specific serotonergic antidepressant; NMDA, N-Methyl-D-aspartate; SNRI, serotonin noradrenergic reuptake inhibitor; SSRI, selective serotonin reuptake inhibitor; TCA, tricyclic antidepressant.