New AAN Guideline on Psychiatric Disorders in MS

Megan Brooks

January 03, 2014

The American Academy of Neurology (AAN) has issued evidenced-based recommendations on screening for, diagnosing, and treating psychiatric disorders in individuals with multiple sclerosis (MS).

"The reason for the guideline is that individuals with MS are at increased risk of emotional disorders. If these disorders are not detected and treated, they can worsen functioning and quality of life, interfere with adherence to treatments for MS, and increase the risk of suicide," Sarah L. Minden, MD, from the Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts, who worked on the guideline, told Medscape Medical News.

"Since most MS patients are in regular contact with neurologists and primary care physicians, providing guidance on improving detection, diagnosis, and treatment practices should help prevent or reduce these negative outcomes," she said.

The guideline was published online December 27 in Neurology and appears in the January 14 print issue of the journal. The recommendations stem from a review of the literature from 1950 to August 2011.

Limited Research

Overall, the panel says they found limited research and few class I studies to guide recommendations.

"Weak evidence shows certain screening tools may help identify, and certain therapies may help treat, emotional disorders in people with MS," Dr. Minden told Medscape Medical News.

"However, for other screening tools, many other therapies, and all diagnostic interviews, more research is needed to know if they are effective.  For many commonly used instruments and therapies, no studies are available," she noted.

The guideline says clinicians "may consider" using the Center for Neurologic Study Emotional Lability Scale to screen for pseudobulbar affect, the General Health Questionnaire for identifying individuals with broadly defined emotional disturbances, and the Beck Depression Inventory and a 2-question screen for identifying individuals with major depressive disorder. All 3 recommendations are level C. 

The guideline panel notes that the evidence is "insufficient to support/refute the use of other screening tools, the possibility that somatic/neurovegetative symptoms affect these tools' accuracy, or the use of diagnostic instruments or clinical evaluation procedures for identifying psychiatric disorders in MS."

For management, the guideline says clinicians may consider a 16-week program of individual telephone-administered cognitive-behavioral therapy for treating depressive symptoms (level C). "Although pharmacologic and nonpharmacologic therapies are widely used to treat depressive and anxiety disorders in individuals with MS, evidence is insufficient to support/refute the use of the antidepressants and individual and group therapies reviewed," the panel says.

For pseudobulbar affect, the guideline says a combination of dextromethorphan and quinidine may be considered (level C).

Key Clinical Questions Remain

"Evidence is insufficient to determine the psychiatric effects in individuals with MS of disease-modifying and symptomatic therapies and corticosteroids; risk factors for suicide; and treatment of psychotic disorders," the guideline notes.

Dr. Minden added in comments to Medscape Medical News, "There is evidence supporting the effectiveness of some pharmacologic therapies for depressed mood and anxiety in people without MS. Many of these therapies have not yet been studied exclusively in the MS population. Despite lack of evidence in individuals with MS, these therapies are commonly used to treat emotional disorders in this population."

Dr. Minden said the guideline is limited to the studies that meet AAN levels of quality for analysis and "much more research is needed in this area."

In particular, the panel says 6 clinical questions for which recommendations were not made deserve further study. They are:

  1. What are the effective treatments for psychotic disorders in individuals with MS?

  2. What clinical evaluation procedures and screening and diagnostic instruments can be used to accurately distinguish between MS fatigue and depression in individuals with MS?

  3. What are the effects of disease-modifying agents on mood and affect in individuals with MS?

  4. What are the effects of corticosteroids on mood and affect in individuals with MS?

  5. What are the effects of symptomatic treatments on mood and affect in individuals with MS?

  6. What are the risk factors for suicidal thinking and behavior among individuals with MS?

The American Academy of Neurology funded development of this evidenced-based guideline. No author received honoraria or financial support for their participation.

Neurology. Published online December 27, 2013. Abstract

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