Mood, Behavior, and Medications in MS Mitchell T. Wallin, MD, MPH MS Clinic Director Department of Veterans Affairs Medical Center Washington, DC Assistant.

Mood, Behavior, and Medications in MS

Mitchell T. Wallin, MD, MPHMitchell T. Wallin, MD, MPHMS Clinic Director MS Clinic Director

Department of Veterans Affairs Medical CenterDepartment of Veterans Affairs Medical CenterWashington, DCWashington, DC

Assistant Professor of NeurologyAssistant Professor of NeurologyGeorgetown University Medical SchoolGeorgetown University Medical School

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Topical Outline

I. DepressionI. Depression

II. Mood SwingsII. Mood Swings

III. Anxiety DisordersIII. Anxiety Disorders

IV. Case study and Conclusions IV. Case study and Conclusions

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Emotional Disorders in MS

Disturbances of affectDisturbances of affect Most common conditions (DSM IV):Most common conditions (DSM IV):

Major depressionMajor depression Dysthymic disorder & Bipolar DisorderDysthymic disorder & Bipolar Disorder Panic disorderPanic disorder Generalized anxiety disorderGeneralized anxiety disorder

Relationship to MS is multi-factorial and complex Relationship to MS is multi-factorial and complex but good response to standard treatmentbut good response to standard treatment

Minden, 2000Minden, 200033

Depression in MS

Lifetime prevalence 40-60% for major depression Lifetime prevalence 40-60% for major depression (Sadovnik, 1996)(Sadovnik, 1996)

Point prevalence 15-30%Point prevalence 15-30%

Increased risk of suicide: 3% of 295 patients over Increased risk of suicide: 3% of 295 patients over a six year period (Kahana, 1971; Stenager, 1992)a six year period (Kahana, 1971; Stenager, 1992)

Possible MRI correlate: frontal, parietal and Possible MRI correlate: frontal, parietal and arcuate fasciculus lesions (Berg, 2000; Pujol, arcuate fasciculus lesions (Berg, 2000; Pujol, 1997)1997) 44

Depression scores from a community sample of MS patients (Chwastiak, 2002)

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DSM-IV Criteria for Major DepressionS S Sleep-Insomnia/hypersomniaSleep-Insomnia/hypersomniaA A Appetite or weight changesAppetite or weight changesD D Dysphoria- “bad mood”, irritable, sad Dysphoria- “bad mood”, irritable, sad A A Anhedonia- lack of interest/pleasureAnhedonia- lack of interest/pleasureF F FatigueFatigueA A Agitation/psychomotor retardationAgitation/psychomotor retardationC C ConcentrationConcentrationE E Esteem (low) or guiltEsteem (low) or guiltS S Suicide/thoughts of deathSuicide/thoughts of death Montano, 1994Montano, 1994

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Risk Factors for Suicide in MS

Severity of depressionSeverity of depression Alcohol abuseAlcohol abuse Living aloneLiving alone

Feinstein, 2002Feinstein, 2002

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Differential Diagnosis of Depression in MS

MS Cognitive DysfunctionMS Cognitive Dysfunction FatigueFatigue MedicationsMedications Interferon-betaInterferon-beta

Thyroid dysfunction (Kreisler, 2003)Thyroid dysfunction (Kreisler, 2003) Possible direct effect (CHAMPS)Possible direct effect (CHAMPS)

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Treatment of Depression in MS

MedicationsMedications Tricyclic antidepressants (Nortriptyline)Tricyclic antidepressants (Nortriptyline) SSRIs (Sertraline, Paroxetine)SSRIs (Sertraline, Paroxetine) SNRIs (Venlafaxine)SNRIs (Venlafaxine) NDRI (Buproprion)NDRI (Buproprion) Stimulants (Methylphenidate HCl, Modafinil)Stimulants (Methylphenidate HCl, Modafinil)

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Non-pharmacologic Treatment of Depression in MS

ExerciseExercise PsychotherapyPsychotherapy Electroconvulsive TherapyElectroconvulsive Therapy

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Mood Swings

Emotional lability: rapid oscillations in Emotional lability: rapid oscillations in moodmood

Affective release: unpredictable fits of Affective release: unpredictable fits of crying or laughingcrying or laughing

Euphoria: exaggerated happiness and Euphoria: exaggerated happiness and optimismoptimism

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Treatment of emotional lability in MS

Hypomania during pulsed steroid therapyHypomania during pulsed steroid therapy Dose reduction & slow taper with corticosteroidsDose reduction & slow taper with corticosteroids Divalproex Sodium (Depakote)Divalproex Sodium (Depakote) Lithium CarbonateLithium Carbonate

Cyclothymia or Bipolar disorderCyclothymia or Bipolar disorder Divalproex Sodium (Depakote)Divalproex Sodium (Depakote) Lithium CarbonateLithium Carbonate Carbamazepine (Tegretol) Carbamazepine (Tegretol)

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Treatment of emotional lability in MS

Pathologic laughing or crying:Pathologic laughing or crying: Tricyclic antidepressants (Amitriptyline) Tricyclic antidepressants (Amitriptyline) SSRIs (Sertraline) SSRIs (Sertraline)

Agitation and rageAgitation and rage Haloperidol or QuetiapineHaloperidol or Quetiapine Benzodiazepines (Clonazepam)Benzodiazepines (Clonazepam)

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Assessment of Mood Swings in MS

Evaluate the following with any report of Evaluate the following with any report of any mood swings: any mood swings: Context and timingContext and timing StressStress Untoward effects of medicationsUntoward effects of medications Infection Infection

Unclear to what extent mood changes are Unclear to what extent mood changes are related to MS pathologyrelated to MS pathology

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Anxiety Disorders and MS

Panic attacksPanic attacks Generalized Anxiety DisorderGeneralized Anxiety Disorder Anxiety symptoms associated with Anxiety symptoms associated with

depressiondepression

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Treatment of Anxiety Disorders in MS

Panic Disorder Panic Disorder TCAs (Imipramine) TCAs (Imipramine) SSRIs (Paroxetine)SSRIs (Paroxetine) Benzodiazepines (Clonazepam) Benzodiazepines (Clonazepam) Depakote (Marazziti, 1996)Depakote (Marazziti, 1996)

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Treatment of Anxiety Disorders in MS

Generalized Anxiety DisorderGeneralized Anxiety Disorder Buspirone HCl (Buspar)Buspirone HCl (Buspar) Imipramine HCl (Tofranil)Imipramine HCl (Tofranil) Venlafaxine HCl (Effexor)Venlafaxine HCl (Effexor) Benzodiazepines (Lorazepam)Benzodiazepines (Lorazepam)

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Screening for Emotional Disorders in MS

Depression questions (USPSTF, 2002)Depression questions (USPSTF, 2002) Have you been feeling sad or angry lately?Have you been feeling sad or angry lately? Have you lost interest in or stopped enjoying Have you lost interest in or stopped enjoying

the things that usually give you pleasure?the things that usually give you pleasure? Beck Depression InventoryBeck Depression Inventory Beck Anxiety Inventory Beck Anxiety Inventory Identify patients at high risk for suicideIdentify patients at high risk for suicide Nicholl, 2001Nicholl, 2001

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Case 38 yr old AA female with SP MS, migraine 38 yr old AA female with SP MS, migraine

headaches, and history of depression headaches, and history of depression presented to the clinic with four days of presented to the clinic with four days of agitation, poor attention, racing thoughts, agitation, poor attention, racing thoughts, and inappropriate laughter. EDSS 7.0and inappropriate laughter. EDSS 7.0

Medications: Glatiramer acetate, ITB (stable dose), Gabapentin, Medications: Glatiramer acetate, ITB (stable dose), Gabapentin, Topiramate, Sumatriptan (sc), Fioricet, Diazepam, SertralineTopiramate, Sumatriptan (sc), Fioricet, Diazepam, Sertraline

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Emotional Disorders and MSConclusions

Depression and mood in MS patients fluctuate Depression and mood in MS patients fluctuate over time over time

Screen for mood disorders at each clinic visitScreen for mood disorders at each clinic visit Become familiar with a medication in each of the Become familiar with a medication in each of the

major treatment classesmajor treatment classes Utilize referral networks of mental health Utilize referral networks of mental health

professionals, social workers, and community professionals, social workers, and community resources to assist individual patientsresources to assist individual patients

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