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October2014 Vol.51 Issue:      4 Table of Contents
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Quality of Life and Depression in Egyptian Patients with Multiple Sclerosis

Sadek Helmy1, Amr Hassan1, Mohammed A. Khalil2, Gamal Holeil 3

Departments of Neurology1, Psychiatry2, Cairo University;

Neurology3, Police Hospital; Egypt



ABSTRACT

Background: Mood changes are among the most disabling and distressing symptoms for patients with multiple sclerosis (MS), yet, they receive little understanding and help for this problem. Objective: is to study depression in patients with multiple sclerosis and its impact on their quality of life. Methods: Thirty patients with MS according to McDonald’s criteria 2010 were selected from the outpatient clinic of the Neurology department of the Police Hospital during the period from January 2011 until July 2011. Thirty age and sex matched healthy volunteers were recruited as controls. The patients group was subjected to the following: Full neurological and Psychiatric examination, Expanded disability status scale (EDSS), Short form Health Survey 36 (SF-36) and Beck depression inventory (BDI, while the control group was subject to the same assessment battery apart from EDSS. Results: There were significant differences between the two groups in all items of the SF-36. Patients showed lower scores than the control group members in all items (p= 0.000). A similar difference between both groups was found as regard depression scored by BDI (p= 0.000). All scores of the SF-36 were higher in patients not receiving interferon than those who received it, but these differences were not significant. All Sf-36 scores were negatively correlated to the duration of illness, EDSS and BDI (p= 0.000). Conclusion: Depression is common among patients with MS; it adds to their disability and worsen their quality of life. [Egypt J Neurol Psychiat Neurosurg.  2014; 51(4): 445-450]

 Key Words: Depression, multiple sclerosis, quality of life.

Correspondence to Amr Hasan El Sayed Mohammed, Neurology Department, Cairo University.Tel.: +201006060809   Email: amrhasanneuro@kasralaini.edu.eg.





INTRODUCTION

 

The relationship of mood disorders to multiple sclerosis is multi-factorial and complex, and the extent to which they are direct consequences of the disease process or psychological reactions to, remains unclear. Symptoms of mood disorders in peoples with MS are not different from the symptoms of mood disorders in people without MS, and respond just as well to standard treatments1.Depression was among the first symptoms recognized as being associated with MS 2.In MS, depression may be of a different etiology compared with that of depression in patients who have not MS. Risk factors for major depression in MS included female gender, age less than 35 years, family history of major depression, and a high level of stress 3.

Ozura and Sega proposed that the profile of depression in advanced MS disease might be better described in terms of negative symptoms such as emotional withdrawal, apathy and less with the profile of positive symptoms such as rumination and worry 4.

 

Effects of MS and depression on patients’ life are prominent as regard the quality. Quality of life is defined by the World Health Organization (WHO): “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”5.

It was reported that MS causes marked impairments in cognitive function as well as neuropsychiatric symptoms, both of which have adverse impact on quality of life (QoL) 6.

In addition, many studies reported that depression is one of the strongest predictors of quality of life (QoL) in MS7. Impaired motivation, exhausted coping, negative view of the world and the physical disability that present in depression may affect the quality of life8.

The aim of our work is to study depression among Egyptian patients with multiple sclerosis and its impact on their quality of life.

 

SUBJECTS AND METHODS

 

Subjects

          This study was carried on 30 Egyptian patients with multiple sclerosis who were diagnosed with multiple sclerosis according to McDonald's criteria 9.

          Patients were selected sequentially from the outpatient clinic of Neuropsychiatry Department of the Police Hospital. We included patients from both sexes whose age ranged from 15 to 50 years. We had excluded patients with chronic medical disorders, history of psychiatric disorders or substance intake.

Thirty healthy volunteers were recruited from the medical and paramedical personnel of the same hospital as a control group.

 

Methods

The patients group was subjected to the following battery of assessment:

1.        Thorough Psychiatric and Neurological examination.

2.                Expanded Disability Status Scale (EDSS) 10.

3.                Beck Depression Inventory (BDI) 11.

4.        SF-36 Health Survey12.The Arabic version was used13.

 

The control group was subjected to the same battery of assessment apart from the EDSS.

Expanded disability status scale (EDSS): The degree of disability for all patients was rated according to the EDSS, that provides overall rating of disabilities based on a (0) (normal neurological examination) to (10) death due to MS10.

The Beck Depression Inventory: This is a self-administered scale that is widely used in neurological diseases; it can measure either depression or distress in disabled people. Its cut-off values are as the following: (0-10): no depression; (11-17): mild depression; (18-23): moderate depression and (24-39): severe depression.

The SF-36 Health Survey: The SF-36 consists of eight scaled scores, which are the weighted sums of the questions in their section. Each scale is directly transformed into a 0-100 scale on the assumption that each question carries equal weight. The lower the score the more the disability. A generic health-related quality-of-life (QoL) measure that includes 8 multi-item scales: (1) physical functioning (PF) is a 10-question scale that captures abilities to deal with the physical requirement of life, such as carrying groceries, walking, climbing stairs, and dressing; (2) role physical (RF) is a 4-item scale that measures the extent to which physical capabilities limit activity; (3) bodily pain (BP) is a 2-item scale that evaluates the perceived amount of pain; (4) general health (GH) is a 5-item scale that evaluates general health in terms of personal perception; (5) vitality (VT) is a 4-item scale that assesses feelings of energy and tiredness; (6) social functioning (SF) is a 2-item scale that assesses the extent and amount of time, if any, that physical health or emotional problems interfered with family, friends, and other social interactions during the previous 4 weeks; (7) role emotional (RE) is a 3-item scale that evaluates the extent, if any, to which emotional factors interfere with work or other activities; and (8) mental health (GH) is a 5-item scale that evaluates feelings principally of anxiety and depression. 

The results were analyzed using the Statistical Package of Social Science (SPSS) computer software program, version 16 (Chicago, IL, USA).

 

RESULTS

 

1-                Demographic data:

There is no significant difference between patients and control group regarding the age, sex and marital status, however, statistical significant difference was found as regard the occupation (P-value = 0.001) as shown in Table (1).

 

2-                Results of SF-36 and BDI:

There were highly statistically significant differences between patients and control groups in the eight items of the SF- 36 test. Patients showed much lower scores than the control group members in all items with (p= 0.000).

 

A similar difference between both groups was found as regard depression scored by BDI as shown in Table (2).

 

Among the patients group, 14 patients were receiving interferon B 1b as a disease-modifying therapy, those patients had lower scores in most of the quality of life items as compared to those patients who did not receive interferon, and however, this difference was not statistically significant. Patients receiving interferon Beta 1b had higher scores in BDI as compared to those patients who did not receive interferon but this difference was not also statistically significant as shown in Table (3).

 

3-        Correlations between SF-36, BDI, EDSS and duration of the illness:

Interestingly, all Sf-36 scores were negatively correlated to the duration of illness, EDSS and BDI (p=.000). This means that higher the EDSS, BDI and duration of illness, the lower the scores of SF-36 as shown in Table (4).

 

 

 


Table 1. The demographic data of the patients and control groups.

 

 

Patients

Controls

P-value

Age

Mean

SD

Mean

SD

0.086

31.70

6.80

35.33

9.13

Sex

Male

Female

Male

Female

1.000

10

20

10

20

Occupation

Not Working

Student

Employee

Professional

Not Working

Student

Employee

Professional

0.001*

18

1

7

4

2

6

3

19

Marital state

Single

Married

Divorced

Widowed

Single

Married

Divorced

Widowed

0.038

17

12

1

0

8

22

0

0

 *significant at P<0.01.

Table 2. Results of SF-36 and BDI in patients and control groups.

SF-36

 

N

Mean Rank

P-value

Physical functioning

(PF)

Control

30

45.50

.000*

Patient

30

15.50

Total

60

 

Role physical

(RP)

Control

30

45.50

.000*

Patient

30

15.50

Total

60

 

Bodily pain

(BP)

Control

30

43.50

.000*

Patient

30

17.50

Total

60

 

General health

(GH)

Control

30

45.50

.000*

Patient

30

15.50

Total

60

 

Vitality

(VT)

Control

30

45.50

.000*

Patient

30

15.50

Total

60

 

Social functioning

(SF)

Control

30

45.50

.000*

Patient

30

15.50

Total

60

 

Role functioning

emotional

(RE)

Control

30

45.50

.000*

Patient

30

15.50

Total

60

 

Mental health

(MH)

Control

30

45.50

.000*

Patient

30

15.50

Total

60

 

The Beck depression inventory (BDI)

Control

30

16.35

.000**

Patient

60

44.65

Total

30

 

*significant at P<0.01

 

 

Table 3. Comparison between patients who are on interferon and patients who are not as regard SF-36, EDSS and BDI.

 

SF-36

Interferon

N

Mean Rank

P-value

Physical functioning

(PF)

no interferon

16

16.09

.692

 

received interferon

14

14.82

Total

30

 

Role physical

(RP)

no interferon

16

16.31

.588

 

received interferon

14

14.57

Total

30

 

Bodily pain

(BP)

no interferon

16

16.88

.358

 

received interferon

14

13.93

Total

30

 

General health

(GH)

no interferon

16

16.06

.707

 

received interferon

14

14.86

Total

30

 

Vitality

(VT)

no interferon

16

16.59

.465

 

received interferon

14

14.25

Total

30

 

Social functioning

(SF)

no interferon

16

15.47

.983

 

received interferon

14

15.54

Total

30

 

Role functioning

emotional

(RE)

no interferon

16

15.88

.794

 

received interferon

14

15.07

Total

30

 

Mental health

(MH)

no interferon

16

16.94

.336

received interferon

14

13.86

Total

30

 

The Beck depression inventory (BDI)

no interferon

16

13.62

.209

received interferon

14

17.64

Total

30

 

 

 

Table 4. Correlations between SF-36, BDI, EDSS and duration of illness.

 

 

 

PF

RP

BP

GH

VT

SF

RE

MH

BDI

Correlation Coefficient

-.688*

-.779*

-.823*

-.786

-.794*

-.644*

-.685*

-.778*

P value

.000

.000

.000

.000

.000

.000

.000

.000

N

30

30

30

30

30

30

30

30

EDSS

Correlation Coefficient

-.817*

-.960*

-.956*

-.972*

-.964*

-.888*

-.819*

-.957*

P value

.000

.000

.000

.000

.000

.000

.000

.000

N

30

30

30

30

30

30

30

30

Duration

of illness

Correlation Coefficient

-.661*

-.805*

-.692*

-.786**

-.749*

-.605*

-.538*

-.743*

P value

.000

.000

.000

.000

.000

.000

.002

.000

N

30

30

30

30

30

30

30

30

*significant at P<0.01

 

 


DISCUSSION

 

The relationship of depression to MS is multi-factorial and complex, and the extent to which it is a direct consequence of the disease process or psychological reactions to it remains unclear1. The depressive syndromes associated with MS occur throughout the natural history of the disease, including in patients with very mild forms of MS14.In our study; we found a statistically significant difference between patients and control group regarding Beck Depression Inventory (BDI) score. These results are congruent with the results of several studies that had reported high rates of depression in multiple sclerosis (MS)15-17.

In our study, we found a statistically significant difference between patients and control groups regarding the SF-36 scores denoting the negative impact of multiple sclerosis on the quality of life. Our results are going with Patti et al who assessed health-related quality of life in MS patients using SF-3618. They found that MS patients scored significantly lower than general population in both sexes in all items of SF-36 especially physical domain. In 2014, Mitosek-Szewczyk have reported similar results on a larger MS patients sample (3500 patients)19.

In our study, there was no statistical significant difference in scores of BDI and SF 36 scores between patient treated with interferon Beta 1b and those who are not. There are conflicting results in the published reports regarding the impact of treatment with interferon (IFN) on quality of life in multiple sclerosis patients. Patten et al. found that the quality of life was worse and depression was higher in interferon users suggesting that interferon (IFN) may cause depression de novo or worsen pre-existing depression20. However, Patti et al. (2014) reported that patients on interferon treatment had better quality of life. Differences may be caused by the fact that they measured quality of life longitudinally along two years, when there had been improvement of symptoms and decrease in side effects21.

Moreover, we found that all SF-36 scores were negatively correlated to the EDSS, the duration of illness, and BDI. This means that the higher the disability and the longer duration of illness, the lower the scores of SF-36.These results are matching with a large community sample that found that the severity of multiple sclerosis was more strongly associated with the  depressive symptoms than was pattern of illness22. In an Italian study carried out on 103 patients with multiple sclerosis (MS)to assess their quality of life; depression and disability level were confirmed to be significant and independent predictors of quality of life23.

Based on our findings, we can conclude that patients with MS suffer from depressive symptoms that add to their disability and worsen their quality of life. Depression in patients with MS needs to be addressed and treated promptly.

 

[Disclosure: Authors report no conflict of interest]

 

REFERENCES

 

1.        Minden SL. Mood disorder in multiple sclerosis: diagnosis and treatment. J Neurovirol. 2000;6: l60-7.

2.        Siegert RA, Bernethy D. Depression in multiple sclerosis: a review. J Neurol Neurosurg Psychiatry. 2005;76 (4): 469-75.

3.        Patten S, Metz L, Reimer M. Biopsychosocial correlates of lifetime major depression in a multiple sclerosis population. Mult Scler. 2000; 6: 115-20.

4.        Ǒzura A, Sega S. Profile of depression, experienced distress and capacity for coping with stress in multiple sclerosis patients—A different perspective. Clin Neurol Neurosurgery. 2013; 115: 12–6.

5.        International classification of impairments, disabilities and handicaps. Geneva: World Health Organization;1989.

6.        Caceresa F, Vanottia S, Benedict R. Cognitive and neuropsychiatric disorders among multiple sclerosis patients from Latin America: Results of the RELACCEM study. Mult Scler Rel Dis. 2014; 3: 335–340.

7.        Grossman P, Kappos L, Gensicke H, D'Souza M, Mohr D, Penner L, et al.MS quality of life, depression, and fatigue improve after mindfulness training. Neurology. 2010; 75:1141-9.

8.        Alex M, Calman KC. Quality of life and depression in multiple sclerosis. Neurology .2005; 94: 728-730.

9.        Polman CH, Reingold SC, Banwell B, Clanet M, Cohen JA, Filippi M, et al. Diagnostic criteria for multiple sclerosis: 2010 revisions to the McDonald criteria. Ann Neurol. 2011; 69:292-302.

10.     Kurtzke J. Rating neurologic impairment in multiple sclerosis: an expanded disability status scale (EDSS). Neurology.1983; 33: 1444-52.

11.     Beck AT, Steer RA, GK B BDI-II. Beck Depression Inventory: Second Edition. San Antonio, TX: The Psychological Corporation; 1996.

12.     Ware Jr. SF-36 Health Survey: Manual and Interpretation Guide.  Boston, Mass: The Health Institute, New England Medical Center;1993.

13.     Alabdulmohsin S, Coons S, Draugalis J, Hays R. Translation of the RAND 36-Item Health Survey 1.0 (akaSF-36). Washington: RAND;1997. 

14.     Sullivan MJ, Weinshenker B, Mikail S, Edgley K. Depression before and after diagnosis of multiple sclerosis. Mult Scler. 1995;1:104–8.

15.     Jongen P, Wesnes K, Geel B, Pop P, Sanders E, Schrijver H, et al. Relationship between Working Hours and Power of Attention, Memory, Fatigue, Depression and Self-Efficacy One Year after Diagnosis of Clinically Isolated Syndrome and Relapsing Remitting Multiple Sclerosis. PLoS One. 2014; 9(5): e96444.

16.     Shen Y, Bai L, Gao Y,Cui F, Tan Z, Tao Y, et al. Depressive Symptoms in Multiple Sclerosis from an in Vivo Study with TBSS. Biomed Res Int. 2014; 2014: 148465.

17.     Marck C, Hadgkiss E, Weiland T, van der Meer DM, Pereira NG, Jelinek GA et al. Physical activity and associated levels of disability and quality of life in people with multiple sclerosis: a large international survey. BMC Neurol. 2014; 14: 143.

18.     Patti F, Pozzilli C, Montanari E, Pappalardo A, Piazza L, Levi A, et al., Effects of education level and employment status on HRQOL in early relapsing-remitting multiple sclerosis. Mult Scler. 2007; 13: 783-791.

19.     Mitosek-Szewczyk K, Kułakowska A, Bartosik-Psujek H, Hożejowski R, Drozdowski W, Stelmasiak Z. Quality of life in Polish patients with multiple sclerosis. Adv Med Sci. 2014; 59: 34-8.

20.     Patten SB, Francis G, Metz LM, Lopez-Bresnahan M, Chang P, Curtin F The relationship between depression and interferon beta-1a therapy in patients with multiple sclerosis. Mult Scler. 2005 Apr;11(2):175-81.

21.     Patti F, Pappalardo A, Montanari E, Pesci I, Barletta V, Pozzilli C. Interferon-beta-1a treatment has a positive effect on quality of life of relapsing–remitting multiple sclerosis: Results from a longitudinal study. J Neurol Sci. 2014;337: 180-5.

22.     Chwastiak L, Chde D, Gibbons L. Depressive symptoms and severity of illness in MS: epidemiologic study of a large community sample. Int J Psychiatry Med. 2002; 32(2): 167-8.

23.     Amato MP, Ponziani GP, Rossi F, Liedl CL, Rossi L. Quality of life in multiple sclerosis: the impact of depression, fatigue and disability. Mult Scler. 2001; 7 (5): 340-4.


 

الملخص العربي

 

الاكتئاب وجودة الحياة في مرضي التصلب المتعدد المصريين

 

يعد مرض التصلب المتعدد من أهم الأمراض التي تصيب المادة البيضاء للجهاز العصبي المركزي. لقد وجد أن نسبه الاكتئاب قد تصل إلى أكثر من 50 % في مرضى التصلب المتعدد. أجريت الدراسة على 30 مريض مصابين بالتصلب المتعدد حسب مواصفات ماكدونالد للتصلب المتعدد لعام 2010. وقد تم اختيار العينة من العيادة الخارجية لقسم الأمراض النفسية والعصبية بمستشفى الشرطة طبقا للمواصفات التالية:

1.         العمر يتراوح من 15-50 سنه.

2.         تم استبعاد المرضى الذين يعانون من أي مرض في الجهاز العصبي بخلاف التصلب المتعدد

3.         تم استبعاد المرضى الذين يعانون من أي مرض متوطن بخلاف التصلب المتعدد

4.         تم استبعاد المرضى الذين يعانون من أي مرض نفسي.

وتم اختيار 30 متطوعا أصحاء كمجموعه ضابطه. وقد خضع المرضى للفحوص والاختبارات التالية:

1.         فحص إكلينيكي نفسي وعصبي.

2.         مقياس بيك للاكتئاب.

3.         مقياس كيرتزك لقياس الإعاقة الجسدية.

4.         مقياس نوعية الحياة SF 36

وكانت نتائج البحث كما يلي:

-          ان هناك علاقة ذات دلالة إحصائية بين الإعاقة في مرضى التصلب المتعدد وحدة الاكتئاب.

-          أن هناك علاقة ذات دلالة إحصائية بين نوعية الحياة في مرضى التصلب المتعدد وحدة الاكتئاب.

-          وجد انه كلما طالت فترة مرض التصلب المتعدد؛ كلما زادت حدة الاكتئاب.

-          هناك علاقة طردية بين حدة الاكتئاب ودرجة الإعاقة في مرضى التصلب المتعدد.

-          لا توجد علاقة واضحة بين حدة الاكتئاب واستخدام عقار الانترفيرون في مرضى التصلب المتعدد.

-          أن هناك علاقة ذات دلالة إحصائية بين نوعية الحياة في مرضى التصلب المتعدد ودرجة الاعاقة.

 

ونوصى بما يلي: الاهتمام بأعراض الاكتئاب الذي قد يصاحب مرض التصلب المتعدد منذ تشخيصه وذلك لاكتشافه مبكرا والتعامل معه باستخدام العقاقير والتحليل النفسي.



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