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MS research update - Bipolar disorder in MS: switching between overly joyful and extremely sad - 09 December 2013

Summary

This study looked at the risk of mood disorders in 201 people with MS attending a clinic in Italy alongside four times as many age and sex-matched controls without MS. The participants were assessed using DSM-IV, a standard way of diagnosing and classifying mental health conditions.

Almost half of people with MS (47%) in the study had experienced a mood disorder which was more than in the control group. Bipolar disorders were the most strongly associated with having MS.

Bipolar disorder, previously known as manic depression, is characterised by alternating times when the person feels depressed and periods when they feel overly joyful (manic). These are different from the normal ups and downs that everyone goes through from time to time.

The researchers believe that bipolar disorder is often unrecognised and so under-diagnosed. They suggest that health professionals should take care to assess people with MS for bipolar disorder when prescribing antidepressants. However, they acknowledge that bipolar disorder is difficult to diagnose as people are more likely to report symptoms of depression and to visit their doctor when depressed. Manic symptoms are often seen by the person experiencing them as times of well-being, or periods between episodes of depression, and not viewed as unusual or unwelcome.

Background

About half of people with MS experience depression at some time. Depression can be the result of living with MS but can also be a symptom caused directly by MS if there is a lesion in an area of the brain involved in mood.

Bipolar disorder, previously known as manic depression, is characterised by alternating times when the person feels depressed and periods when they feel overly joyful (manic). These are different from the normal ups and downs that everyone goes through from time to time.

An overly joyful or overexcited state is called a manic episode, and an extremely sad or hopeless state is called a depressive episode. Extreme changes in energy, activity, sleep and behaviour go along with these changes in mood. A person may be having an episode of bipolar disorder if they have a number of manic or depressive symptoms for most of the day, nearly every day, for at least one or two weeks. Sometimes symptoms are so severe that the person cannot function normally at work, school or home.

How this study was carried out

This study looked at the risk of mood disorders in 201 people with MS attending a clinic in Italy alongside four times as many age and sex-matched controls without MS.

The participants were assessed for mood disorders using DSM-IV, a standard way of diagnosing and classifying mental health conditions, and interview-based assessment tools called ANTAS, SCID and MDQ. Each group was assessed for the likelihood of a range of mood disorders over their whole lifetime. The conditions assessed were:

There are three types of bipolar disorder:

  • Bipolar type 1 disorder, in which the primary symptom presentation is manic, or rapid (daily) cycling episodes of mania and depression
  • Bipolar type 2 disorder, in which the primary symptom presentation is recurrent depression accompanied by hypomanic episodes (a milder state of mania in which the symptoms are not severe enough to cause marked impairment in social or occupational functioning or need for hospitalisation, but are sufficient to be observable by others)
  • Cyclothymic disorder, a chronic state of cycling between hypomanic and depressive episodes that do not reach the diagnostic standard for bipolar disorder

Detailed diagnostic criteria for all the conditions can be found using the links for each above.

What was found

Almost half of people with MS (47%) in the study had experienced a mood disorder which was more than in the control group. The conditions experienced most often by people with MS were major depressive disorders, bipolar disorders type 1 and 2, cyclothymic disorder, mood disorder due to general medical condition and substance induced mood disorders. Bipolar disorders were the most strongly associated with having MS.

What does it mean?

The authors comment that this is the first case controlled study to show that bipolar disorder is associated with MS. They believe that bipolar disorder is often unrecognised and so under-diagnosed. They suggest that health professionals should take care to assess people with MS for bipolar disorder when prescribing antidepressants. However, they acknowledge that bipolar disorder is difficult to diagnose as people are more likely to report symptoms of depression and to visit their doctor when depressed. Manic symptoms are often seen by the person experiencing them as times of well-being, or periods between episodes of depression, and not viewed as unusual or unwelcome.

Carta MG, Moro MF, Lorefice L, et al.
The risk of bipolar disorders in multiple sclerosis..
J Affect Disord. 2013 Nov 19 [Epub ahead of print]
abstract

More about mood changes in MS

Many people find it difficult to talk about mood changes and to seek appropriate support. Living with MS can be challenging and long lasting changes in mood could be due to managing these challenges or directly as a result of MS and its effect on the central nervous system.

Treatment usually works well. This could be antidepressant medication or talking therapies or both. In addition, there are self help groups run by a number of charities who support people with depression, whatever its cause. You can find your local group here:

Depression

It is estimated that about half of all people with multiple sclerosis will experience an episode of depression at some stage. Depression involves persistent sadness lasting more than two weeks, accompanied by other symptoms such as an altered sleep pattern, feelings of hopelessness, guilt and low self esteem, thoughts of death, reduced energy and the inability to concentrate and to take pleasure in anything.

It is important to distinguish clinical depression, which is persistent, from episodes of low mood, which tend to resolve after a period of time.

You can read more about depression in the A to Z of MS.

Inappropriate laughing or crying

Some people with multiple sclerosis find that they laugh or cry with little reason or at inappropriate times. This is because MS lesions have occurred in an area of the brain that is involved in controlling the emotional pathways. These symptoms are called pseudobulbar affect.

This is a physical disorder which occurs, not because someone truly feels happy or sad but because their ability to control the expression of their feelings is disrupted by MS.

You can read more about pseudobulbar affect in the A to Z of MS and in an earlier edition of Research Update.

Bipolar disorder

The study reported above shows that bipolar disorder is common in people with MS. You can read more about bipolar disorder on the NHS Choices website where there is information about symptoms, diagnosis and treatment. Bipolar UK are a charity that specialises in supporting people with bipolar disorder.

Getting help with mood changes

If you are concerned about changes in mood, your MS nurse or GP should be able to refer you to specialist support or may be able to prescribe treatment directly.

Research by topic areas...

Diagnosis

Giampaolo D, Bhigjee A, Retief C, et al.
Guideline for the diagnosis and management of multiple sclerosis: A Southern African perspective.
S Afr Med J. 2013 Jun 5;103(9):670-91.
abstract

Symptoms and symptom management

Koehler J, Amato MP, Oreja-Guevara C, et al.
Clinical case reviews in multiple sclerosis spasticity: experiences from around Europe.
Expert Rev Neurother. 2013 Dec;13(12 Suppl):61-6.
abstract

Gold R, Oreja-Guevara C.
Advances in the management of multiple sclerosis spasticity: multiple sclerosis spasticity guidelines.
Expert Rev Neurother. 2013 Dec;13(12 Suppl):55-9.
abstract

Pozzilli C.
Advances in the management of multiple sclerosis spasticity: experiences from recent studies and everyday clinical practice.
Expert Rev Neurother. 2013 Dec;13(12 Suppl):49-54.
abstract

Gold R.
New insights into multiple sclerosis and advances in multiple sclerosis spasticity management.
Expert Rev Neurother. 2013 Dec;13(12 Suppl):1-2.
abstract

Gold R.
Multiple sclerosis spasticity management - key publications.
Expert Rev Neurother. 2013 Dec;13(12 Suppl):47-8.
abstract

Gold R.
Multiple sclerosis spasticity epidemiology - key publications.
Expert Rev Neurother. 2013 Dec;13(12 Suppl):45-6.
abstract

Gumus H, Akpinar Z, Yilmaz H.
Effects of multiple sclerosis on female sexuality: a controlled study.
J Sex Med. 2013 Dec 2.
abstract

Zettl UK, Henze T, Essner U, et al.
Burden of disease in multiple sclerosis patients with spasticity in Germany: mobility improvement study (Move I).
Eur J Health Econ. 2013 Dec 1. [Epub ahead of print]
abstract

Disease modifying treatments

[No authors given.]
Management of relapsing-remitting multiple sclerosis [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2013 Oct.
Available from http://www.ncbi.nlm.nih.gov/books/NBK169748/
abstract
Read the full text of this paper

Teter B, Agashivala N, Kavak K, et al.
Characteristics influencing therapy switch behavior after suboptimal response to first-line treatment in patients with multiple sclerosis.
Mult Scler. 2013 Nov 25. [Epub ahead of print]
abstract

Hedström A, Alfredsson L, Lundkvist Ryner M, et al.
Smokers run increased risk of developing anti-natalizumab antibodies.
Mult Scler. 2013 Dec 5. [Epub ahead of print]
abstract

Clanet MC, Wolinsky JS, Ashton RJ, et al.
Risk evaluation and monitoring in multiple sclerosis therapeutics.
Mult Scler. 2013 Nov 30. [Epub ahead of print]
abstract

Izquierdo G, O'Connor P, Montalban X, et al.
Five-year results from a phase 2 study of oral fingolimod in relapsing multiple sclerosis.
Mult Scler. 2013 Nov 30. [Epub ahead of print]
abstract

De Stefano N, Comi G, Kappos L, et al.
Efficacy of subcutaneous interferon β-1a on MRI outcomes in a randomised controlled trial of patients with clinically isolated syndromes.
J Neurol Neurosurg Psychiatry. 2013 Nov 29. doi: 10.1136/jnnp-2013-306289. [Epub ahead of print]
abstract

Coyle PK.
Current evaluation of alemtuzumab in multiple sclerosis.
Expert Opin Biol Ther. 2013 Dec 2. [Epub ahead of print]
abstract

Gupta S, Weinstock-Guttman B.
Natalizumab for multiple sclerosis: appraising risk versus benefit, a seemingly demanding tango.
Expert Opin Biol Ther. 2013 Dec 2. [Epub ahead of print]
abstract

Walker A, Watson C, Alexopoulos ST, et al.
A benefit-risk analysis of natalizumab in the treatment of patients with multiple sclerosis when considering the risk of progressive multifocal leukoencephalopathy.
Curr Med Res Opin. 2013 Dec 5. [Epub ahead of print]
abstract

Drugs in development

He D, Guo R, Zhang F, et al.
Rituximab for relapsing-remitting multiple sclerosis.
Cochrane Database Syst Rev. 2013 Dec 6;12:CD009130. [Epub ahead of print]
abstract
Read the full text of this paper

Other treatments

Ruck T, Bittner S, Simon OJ, et al.
Long-term effects of dalfampridine in patients with multiple sclerosis.
J Neurol Sci. 2013 Nov 16.[Epub ahead of print]
abstract

Co-existing conditions

Allen AN, Seminog OO, Goldacre MJ
Association between multiple sclerosis and epilepsy: large population-based record-linkage studies.
BMC Neurol. 2013 Dec 4;13(1):189. [Epub ahead of print]
abstract
Read the full text of this paper

Assessment tools

Farrar JT
Measuring symptoms and wellness in the multiple sclerosis patient: issues in measurement.
Expert Rev Neurother. 2013 Dec;13(12 Suppl):21-6.
abstract

Quality of life

Bassi M, Falautano M, Cilia S, et al.
The coexistence of well- and ill-being in persons with multiple sclerosis, their caregivers and health professionals.
J Neurol Sci. 2013 Nov 19.[Epub ahead of print]
abstract

Causes of MS

Ascherio A.
Environmental factors in multiple sclerosis.
Expert Rev Neurother. 2013 Dec;13(12 Suppl):3-9.
abstract

Paediatric MS

van Pelt ED, Neuteboom RF, Ketelslegers IA, et al.
Application of the 2012 revised diagnostic definitions for paediatric multiple sclerosis and immune-mediated central nervous system demyelination disorders.
J Neurol Neurosurg Psychiatry. 2013 Dec 5.[Epub ahead of print]
abstract

Govender R.
Guideline for the diagnosis and management of multiple sclerosis in children.
S Afr Med J. 2013 Jun 7;103(9):692-5.
abstract

Pena JA, Lotze TE.
Pediatric multiple sclerosis: current concepts and consensus definitions.
Autoimmune Dis. 2013;2013:673947. Epub 2013 Nov 2.
abstract
Read the full text of this paper

Genetics

Oksenberg JR.
Decoding multiple sclerosis: an update on genomics and future directions.
Expert Rev Neurother. 2013 Dec;13(12 Suppl):11-9.
abstract

Psychological aspects

Utz KS, Hankeln TM, Jung L, et al.
Visual search as a tool for a quick and reliable assessment of cognitive functions in patients with multiple sclerosis.
PLoS One. 2013 Nov 25;8(11):e81531.
abstract
Read the full text of this paper

Madan S, Pakenham KI.
The stress-buffering effects of hope on changes in adjustment to caregiving in multiple sclerosis.
J Health Psychol. 2013 Nov 21. [Epub ahead of print]
abstract

Patten SB, Williams JV, Lavorato DH, et al.
Depression as a predictor of occupational transition in a multiple sclerosis cohort.
Funct Neurol. 2013 Dec 3:1-6. [Epub ahead of print]
abstract
Read the full text of this paper

Prognosis

Ristori G, Romano S, Cannoni S, et al.
Effects of Bacille Calmette-Guerin after the first demyelinating event in the CNS.
Neurology. 2013 Dec 4. [Epub ahead of print]
abstract

Bourdette D, Naismith RT.
BCG vaccine for clinically isolated syndrome and MS: Infections and protective immunity.
Neurology. 2013 Dec 4. [Epub ahead of print]
abstract

Weiland TJ, Hadgkiss EJ, Jelinek GA, et al.
The association of alcohol consumption and smoking with quality of life, disability and disease activity in an international sample of people with multiple sclerosis.
J Neurol Sci. 2013 Nov 8. doi:pii: S0022-510X(13)03008-6. 10.1016/j.jns.2013.10.046. [Epub ahead of print]
abstract

Pathophysiology

Warabi Y, Yamazaki M, Shimizu T, et al.
Abnormal nerve conduction study findings indicating the existence of peripheral neuropathy in multiple sclerosis and neuromyelitis optica.
Biomed Res Int. 2013;2013:847670.
abstract
Read the full text of this paper

Filippi M, Rocca MA.
Present and future of fMRI in multiple sclerosis.
Expert Rev Neurother. 2013 Dec;13(12 Suppl):27-31.
abstract

Provision of care

Clavelou P.
Can we optimize our teams? Multidisciplinary care for multiple sclerosis.
Expert Rev Neurother. 2013 Dec;13(12 Suppl):39-44.
abstract

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