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]

 

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