Pediatric-Onset MS 'Strongly Associated' With Psychiatric Disorders, and Vice Versa

Deborah Brauser

September 15, 2016

LONDON — Children and teens with demyelinating diseases of the central nervous system (CNS), including multiple sclerosis (MS), are at increased risk for comorbid psychiatric disorders, new research suggests.

The population-based cohort study compared almost 1100 pediatric patients with demyelinating diseases and under age 18 years to more than 1 million healthy children. It showed that the first group had a significantly higher risk for being hospitalized for psychotic disorders (such as bipolar and schizophrenia), anxiety, intellectual disability, stress-related and somatoform disorders, and behavioral disorders than did the reference group.

Those who had MS only were also at an increased risk for psychotic disorders, intellectual disability, and mood disorders.

Interestingly, the associations appeared to go both ways. Reverse analysis showed that children who first had psychiatric disorders had high rates of developing demyelinating diseases.

The findings were presented here at the Congress of the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS) 2016.

Lead author Julia Pakpoor, academic clinical trainee at Oxford University, United Kingdom, told attendees that the results highlight the importance of involving mental health professionals early on in the treatment of these children.

Julia Pakpoor

"Our study showed that pediatric-onset CNS disease is strongly associated with a wide spectrum of psychiatric disorders — and vice-versa," she later told Medscape Medical News.

Session chair Jaume Sastre-Garriga, MD, PhD, Department of Neurology/Neuroimmunology at the MS Center of Catalonia, Hospital Vall d'Hebron, Barcelona, Spain, called this an important topic that deserves more research.

"Because of the historically low prevalence of pediatric MS, it's an area that has been neglected up until a few year ago," he said. "The results of this study are very interesting, but they need to be replicated."

"Small But Important" Patient Population

The prevalence of pediatric-onset MS is between 3% and 5%, the researchers note. "This happens to this small but important patient set at a time when they're undergoing social, physical, and psychological maturation," Pakpoor said. "But psychiatric comorbidities in this group have not yet been well explored in large sample sizes."

In addition, the investigators wanted to examine whether the prevalence of psychiatric disorders in this age group differed from that in their adult counterparts.

"We know that in large epidemiology studies in adults these comorbidities have been found in individuals with MS, leading to a decrease in medication adherence and a worsening in quality of life. So we thought exploring all of this in younger patients was important for investigators, neurologists, pediatricians, and parents as it may help to guide their care," she said.

The researchers assessed records for 1097 children under age 18 years with CNS demyelinating disease, including a subgroup of 201 who specifically had MS, from mortality data and linked English Hospital Episode Statistics from 1999 to 2011.

In the full group of children with a demyelinating disease, the standardized rate ratio (RR) was 5.8 for psychotic disorders compared with the reference group of children (95% confidence interval [CI], 2.5 - 11.4; P < .001) and 2.4 for risk for anxiety and stress-related/somatoform disorders combined (95% CI, 1.4 - 3.8; P < .001).

The risk for other psychiatric comorbidities ranged from nearly 2-fold to 9-fold higher for the CNS disease group than for the healthy group.

Table 1. Risk for Psychiatric Disorders With vs Without Demyelinating Disease

Disorder RR (95% CI) P Value
Intellectual disability 6.6 (3.7 - 10.8) <.001
Other behavioral disorders 9.0 (5.1 - 14.6) <.001
Any studied disorder 1.6 (1.2 - 1.9) .001

 

"These remained significant with a 1-year minimum interval between first demyelinating disease episode and first psychiatric disorder episode, and remained significant for psychotic disorders, intellectual disability, and other behavioral disorders with a minimum 5-year interval," report the investigators.

When researchers examined just the group with pediatric-onset MS, the RRs were 10.8 for psychotic disorders, 6.1 for intellectual disability, and 2.6 for mood disorders (P= .001, .004, and .02, respectively).

Further analysis showed significantly increased rates of demyelinating disease development after a hospitalization for many psychiatric disorders (P < .001, all comparisons).

Table 2. Risk for Demyelinating Diseases After Psychiatric Disorder

Disorder RR (95% CI)
Intellectual disability 6.3 (2.9 - 12.2)
Attention-deficit/hyperactivity disorder 3.9 (1.8 - 7.5)
Autism 3.8 (2.1 - 6.5)
Anxiety and stress-related somatoform disorders 3.2 (1.7 - 5.4)
Other behavioral disorders 8.3 (5.2 - 12.8)

 

Overall, "I think our most intriguing finding was the association with these diseases and psychotic disorders. To our knowledge that has not been previously reported in a pediatric population," said Pakpoor.

She added that the study raises many questions. "But in the meantime, there is a need for early holistic multidisciplinary care. There needs to be monitoring right at disease onset."

When a meeting delegate asked after the presentation why the role of the parent wasn't addressed, as that could be an important variable in a child's development, Pakpoor admitted that that information would have been helpful.

"Parents need to be incorporated into the mental health process. It's also important that parents are careful in how they handle a child's MS diagnosis," she said, adding that this includes not burdening children with the parents' own stress and fears.

"Interesting," But With Important Limitations

After the session, cochair Dr Sastre-Garriga told Medscape Medical News that a limitation of the study was that it included only admitted patients and "that was an important bias for the interpretation of the results."

"Although the results were very interesting, we need to confirm with other studies using outpatient samples or using both inpatient and outpatient groups."

Pakpoor agreed. "We could only look at a first recorded episode in a hospital record, which is not the same as first diagnosis." She added that the number of those affected could be much higher with the inclusion of nonhospitalized patients.

On the other hand, a hospitalization for intellectual disability or some of the other disorders is not that common, she said. "So we were dealing with the most severe cases — and it could be that the association is strongest in those with increased disorder severity."

Even with the limitations, Dr Sastre-Garriga noted that monitoring kids with MS early is "definitely" a good idea.

"Not only does it not hurt anything, I think it's necessary to use a more multidisciplinary approach. We do that at our center: including all of the specialties," he said.

The study's message, and common sense, show the importance of "always using a holistic approach for this type of patient," said Dr Sastre-Garriga. "And remember that comorbidities are very relevant — and need to be diagnosed and properly treated."

Ms Pakpoor and Dr Sastre-Garriga have disclosed no relevant financial relationships.

Congress of the European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS) 2016. Young Scientific Investigators' session 2, oral presentation 72. Presented September 14, 2016.

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