Anxiety and depression in multiple sclerosis patients around diagnosis

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Abstract

Objectives

To prospectively identify anxiety and depressive symptoms, and their predictors, during the multiple sclerosis (MS) peridiagnostic period.

Methods

The Hospital Anxiety and Depression Scale (HADS) was administered during diagnostic workup (baseline), and one and six months after diagnosis disclosure, to SIMS-Trial participants (ISRCTN81072971).

Results

Of 197 screened patients, 120 (61%) were diagnosed with MS. At baseline, median HADS anxiety (HADS-A) score was 7.0 (interquartile range [IQR] 5.0–9.5), ≥ 8 (anxiety cut-off) in 43% (95% confidence interval [CI] 34%–52%). Median HADS depression (HADS-D) was 3.0 (IQR 1.0–5.0), ≥ 8 (depression cut-off) in 11% (95% CI 5%–16%). Independent predictors of anxiety were female sex (odds ratio [OR] 2.8, 95% CI 1.1–7.2) and HADS-D score (OR 20.8, 95% CI 2.5–175.5). The only predictor of depressive symptoms was HADS-A score (OR 20.0, 95% CI 2.8–260.9). Anxiety symptoms had decreased slightly but significantly (p < 0.001) at six months. Depressive symptoms remained low.

Conclusions

Anxiety was prominent in the period surrounding MS diagnosis disclosure, particularly in women. A slight but significant reduction occurred six months after diagnosis disclosure. Depressive symptoms were less common and stable over time. In addition to sex, depressive symptoms were the only variable independently associated with anxiety.

Introduction

Mood disorders are common in multiple sclerosis (MS) patients. The point prevalence of depression – the most frequently assessed mood disorder – varies from 20 to 50% depending on ascertainment method and study population [1], [2], [3], [4], [5], [6], [7]; lifetime prevalence is 50% [3], [8]. Rates of depression are higher in MS than other chronic illnesses including neurological disorders [9]. Prevalence rates for anxiety are also high (range 20% to 40%) [7], [10], [11], [12], [13], [14].

The period surrounding diagnosis is described as psychologically demanding by MS patients and neurologists [15], [16], [17]. However, few studies have assessed the occurrence of mood disturbances during this period [12], [18], [19], [20] and we are aware of only one study, on 37 patients with clinically isolated syndrome, using validated instruments [21].

The recently completed randomized phase III SIMS-Trial (ISRCTN81072971) showed that an information aid, added to current practice after MS diagnosis disclosure, improved knowledge and also care satisfaction [22]. To monitor a possible unfavourable psychological effect of the intervention, patients completed the Hospital Anxiety and Depression Scale (HADS) [23], [24] at the onset of diagnostic workup, and during follow-up.

Here we present our assessment of anxiety and depressive symptoms in the SIMS-Trial population. We assessed: (a) anxiety and depression symptoms from the start of the MS diagnostic workup to six months after diagnosis communication, and (b) clinical and general characteristics associated with anxiety and depression symptoms at baseline, and with changes over time. We also assessed the psychometric properties of HADS in the screened population.

Section snippets

Patients

The design and findings of the SIMS-Trial (ISRCTN81072971) are presented elsewhere [22; Borreani 2011 submitted]. Briefly, trial participants were adults presenting for possible MS diagnosis at five Italian tertiary MS centres. Institutional review board approval was obtained from of all centres. Patients were informed and asked for consent at the start of diagnostic workup. Consenting patients (n = 197) underwent the baseline visit. Those diagnosed with MS [25] in the succeeding seven months (n = 

HADS

The HADS is a self-assessed questionnaire consisting of 14 multiple-choice (0–3 Likert scale) items probing symptoms of anxiety (7 items) and depression (7 items). HADS anxiety (HADS-A) and depression (HADS-D) scores range from 0 (no symptoms) to 21 (most severe symptoms) [23]. We choose HADS because it is a screening tool with robust psychometric properties, and has been validated in several languages, including Italian [24]. Furthermore, by omitting items assessing somatic symptoms, and

Patients

From March 2008 to June 2009, 197 patients were screened; 120 (61%) were diagnosed with MS and were included in the trial (Table 1). The 77 excluded patients had clinically isolated syndrome (n = 53), other diagnoses (vascular encephalopathy n = 3, myelitis n = 3, cervical spondylosis n = 1, peripheral neuropathy n = 1), received the MS diagnosis after closure of trial enrolment (n = 8), were lost to follow-up (n = 7) or withdrew consent (n = 1). The mean ages of excluded (34.8 years, SD 11.1) and randomized

Discussion

We prospectively assessed mood symptoms in SIMS-Trial participants at start of diagnostic workup, and at one and six months after MS diagnosis disclosure. We found that, while depressive symptoms were uncommon at workup and at follow-up, over 40% of patients had anxiety which persisted at six months in 36% (95% CI 26%–46%) of patients and was particularly prominent in women (Fig. 2). To our knowledge only the Rochester-Toronto MRI Study Group has prospectively assessed anxiety in patients

Conflict of interest

The authors declare that they have no conflict of interest.

Acknowledgments

We thank Don Ward for help with the English, and all the MS patients who participated in the study.

The Fondazione Italiana Sclerosi Multipla (FISM) funded the trial (Grant No. 2007/R/19 to AS) and supported AG with a research fellowship. The funding source had no role in study design, data collection, data analysis, data interpretation, or report writing. The corresponding author had full access to all the data and had final responsibility for decision to submit the paper.

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