One Size Does Not Fit All- The Heterogeneous Mental Health Needs of Individuals with Multiple Sclerosis (MS) Require a Menu of Treatment Options

Background:

Psychiatric disorders are highly prevalent in MS. However, their reported prevalence is highly variable due to the analysis of population-based versus clinic-based data, and a range of methods used to assess the presence of a disorder. This wide heterogeneity is also present in the varied clinical features, demographics, and treatment preferences shown by individuals with MS referred to psychiatric care.

Objectives:

To analyze the factors driving heterogeneity in the clinical presentation and treatment needs of individuals with MS referred to mental health treatment.

Methods:

Analysis of MS referrals to one psychiatrist over last 5 years (255 MS patients) and qualitative survey of clinic’s mental health clinicians.

Results:

• Heterogeneous clinical presentation of psychiatric disorders in MS:

-Neuropsychiatric disorders may present at any point during MS, including before MS diagnosis

-Psychiatric symptoms may follow ‘atypical’ patterns: late onset; presence of visual hallucinations; prominent cognitive complaints

-Health anxiety may cause misattribution of bodily symptoms to MS

 

• Heterogeneous Pathophysiology:

Most patients show several of factors concurrently:

-Heterogeneous MS brain lesions

-Medical comorbidities (DM, OSA) that contribute to psychiatric symptoms

-Primary psychiatric comorbidities

-Psychosocial factors

-CNS- active pharmacological agents

-Psychiatric side effects of MS disease-modifying treatments (DMTs)

 

• Heterogeneity of Life cycle and degree of MS impact

-Psychiatric comorbidities cause increased disability. Diligent treatment can successfully restore functioning

-Longitudinal relationship between psychiatric symptoms and MS course: Psychiatric exacerbations early after diagnosis, after relapses, and due to disability

 

• Patients’ preferences, access, and other factors:

-Stigma or acceptability of mental health treatment

-Preference of psychotherapy Vs psychotropics

-Interactions of psychotropics with DMTs

-Mental health treatment integrated to neurological care, Vs community mental health treatment

-Acceptability of telehealth

-Access to mental health care: Available mental health providers; transportation

-Capacity for Self- management, including use of mental health apps, community, online resources

Conclusions:

The complexity of factors determining the clinical presentation and mental health treatment preferences of individuals with MS require a menu of treatment options to successfully meet these individuals’ needs.