Psych · Consultation-liaison psychiatry
Multiple sclerosis psychiatry
Also known as MS depression · Multiple sclerosis neuropsychiatry · Pseudobulbar affect MS · MS cognitive impairment psychiatry · Suicide multiple sclerosis · MS psychiatric comorbidity · Interferon depression MS
Exam-exhaustive fellowship topic on the psychiatry of multiple sclerosis: depression and suicide risk, anxiety, pseudobulbar affect, cognitive impairment, steroid and DMT interfaces, AAN psychiatric guidance, and joint CL–neurology management. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- Elevated suicide risk in MS — never dismiss hopelessness as 'understandable given the diagnosis'
- Brief involuntary laughing or crying out of proportion to mood — think pseudobulbar affect, not only depression
- Pulse corticosteroids for relapse — window for mania, insomnia, and psychosis; plan observation
- New cognitive failure threatening work or safety — do not attribute solely to low mood without structured assessment
- Stopping an effective DMT for mild mood change without neurology co-management is unsafe
- Severe depression with psychosis, catatonia, or active suicidal intent needs urgent psychiatry pathway
Meet the patient
A 34-year-old woman with relapsing-remitting MS is in the infusion suite crying. She apologises immediately and says she is not sad. It happened twice yesterday, once in a meeting, and each episode lasted under a minute. She also mentions, almost in passing, that she has stopped seeing friends and that some mornings she cannot see the point.[4][9][11]
Two separate things are happening in that paragraph, and the examiner wants both named. One is the mask — pseudobulbar affect. One is the mood, and it is the one that can kill her.[9][10][11]
References16ShowHide
- [1]Goldman Consensus Group The Goldman Consensus statement on depression in multiple sclerosis Mult Scler, 2005.PMID 15957516
- [2]Boeschoten RE, Braamse AMJ, Beekman ATF, et al. Prevalence of depression and anxiety in Multiple Sclerosis: A systematic review and meta-analysis J Neurol Sci, 2017.PMID 28017241
- [3]Minden SL, Feinstein A, Kalb RC, et al. Evidence-based guideline: assessment and management of psychiatric disorders in individuals with MS: report of the Guideline Development Subcommittee of the American Academy of Neurology Neurology, 2014.PMID 24376275
- [4]Feinstein A Multiple sclerosis and depression Mult Scler, 2011.PMID 22058085
- [5]Feinstein A, Magalhaes S, Richard JF, Audet B, Moore C The link between multiple sclerosis and depression Nat Rev Neurol, 2014.PMID 25112509
- [6]Chwastiak L, Ehde DM, Gibbons LE, et al. Depressive symptoms and severity of illness in multiple sclerosis: epidemiologic study of a large community sample Am J Psychiatry, 2002.PMID 12411220
- [7]Ehde DM, Kraft GH, Chwastiak L, et al. Efficacy of paroxetine in treating major depressive disorder in persons with multiple sclerosis Gen Hosp Psychiatry, 2008.PMID 18164939
- [8]Mohr DC, Hart SL, Julian L, et al. Telephone-administered psychotherapy for depression Arch Gen Psychiatry, 2005.PMID 16143732
- [9]Feinstein A, Pavisian B Multiple sclerosis and suicide Mult Scler, 2017.PMID 28327056
- [10]Kalb R, Feinstein A, Rohrig A, Sankary L, Willis A Depression and Suicidality in Multiple Sclerosis: Red Flags, Management Strategies, and Ethical Considerations Curr Neurol Neurosci Rep, 2019.PMID 31463644
- [11]Ghaffar O, Chamelian L, Feinstein A Neuroanatomy of pseudobulbar affect: a quantitative MRI study in multiple sclerosis J Neurol, 2008.PMID 18297331
- [12]Pioro EP, Brooks BR, Cummings J, et al. Dextromethorphan plus ultra low-dose quinidine reduces pseudobulbar affect Ann Neurol, 2010.PMID 20839238
- [13]Rao SM, Leo GJ, Bernardin L, Unverzagt F Cognitive dysfunction in multiple sclerosis. I. Frequency, patterns, and prediction Neurology, 1991.PMID 2027484
- [14]Patten SB, Williams JV, Metz LM Anti-depressant use in association with interferon and glatiramer acetate treatment in multiple sclerosis Mult Scler, 2008.PMID 17986504
- [15]Chwastiak LA, Ehde DM Psychiatric issues in multiple sclerosis Psychiatr Clin North Am, 2007.PMID 17938046
- [16]McKay KA, Tremlett H, Fisk JD, et al. Psychiatric comorbidity is associated with disability progression in multiple sclerosis Neurology, 2018.PMID 29523642