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Multiple Sclerosis with Depression

Clinical History
Examination
Investigations
Diagnosis
Treatment
Discussion
References

A 34 year old female patient married, resident of Bangalore, educated up to Pre-university, homemaker, living in a nuclear family belonging to middle socioeconomic status was referred to the psychiatry outpatient department from neurology with complains of sadness & irritability since 3 months.

Patient had a history of Rickettsial fever 5 months back, took treatment  for 15 days & then later she presented with  complaints of blurring of vision for 1 month & difficulty in passing urine for 4 days. Later she was diagnosed with Multiple sclerosis & was on steroid treatment for the last 12 weeks. Since then patient is experiencing sadness & irritability for trivial issues.

She also had easy fatigability for the tasks she previously did without being tired like household chores. She said she was becoming forgetful. She had disturbed sleep & decreased appetite. Patient was worried if she would become better like before and lead her life like before. 

No decrease in interest in previously pleasurable activities.  There are no other co-morbities & there was no significant past history of any psychiatric illness or psychiatric illness in the family.

General physical examination:

Patient is moderately built, adequately nourished, conscious, co-operative, oriented to time, place, person.

Systemic examination:

Revealed no abnormality except brisk lower limb reflexes with bilateral lower limb paucity.

Blood investigations were within normal limits 

MRI brain with bilateral orbital cut plain + contrast done showed – non specific hyperintensities in left fronto-parieto-temporal deep white matter & left periventricular white matter.

Visual evoked potential– showed demyelinating neuropathy in the pre-chiasmatic pathway of both optic nerve.

MRI Brain

Organic mood disorder –Moderate Depression with Multiple sclerosis

WHO ICD10 Criteria: 

1. Depression is characterised by sadness, change in overall activity in a patient with organic condition. The only criteria for inclusion of organic mood disorder in this block is their presumed direct causation by a cerebral or other physical disorder whose presence has been demonstrated independently by means of appropriate physical & laboratory investigation.

2. The affective disorder must follow the presumed organic disease and be judged not to represent an emotional response to the patients knowledge of having symptoms or having the symptom of a concurrent brain disorder.

Differential Diagnosis:?

Drug induced depression (Steroid Induced)

Patient was started on IV methyl prednisolone & switched over to oral steroids 

Prednisolone 10mg 2-2-0,

Pantoprazole 40mg 1-0-0 ,

Benfotiamine +Mecobalamin+ Alpha lipoic acid 1-0-0.

She was started on (SSRI) Escitalopram 10mg OD. Psychological Therapy was initiated 

Depression is common in multiple sclerosis. The prevalence of depression in multiple sclerosis ranges from 19% to 54% depending on the population sample & diagnostic criteria used. Etiologic factors for increasing the prevalence of depression in a demyelinating disease can be both biological and psychosocial and female sex, age< 35 years, family history of depression and a high level of stress are reported as risk factors1.

The prevalence of corticosteroid therapy leading to depression is 10%2. In this case it is difficult to delineate if depression is related to Multiple Sclerosis or Steroid Induced.  As the patient did not have previous psychiatric illness, depression is probably linked to medical condition or the treatment given.

However, since steroid may not be withdrawn in this case, it is important to treat the depression as it directly affects the individual in all aspects of life. The possible adverse affects of depression on disease course are impaired cognitive functioning, treatment adherence, deleterious consequences on quality of life and increased risk of suicide. It may adversely affect the Multiple sclerosis and its management

1. Skokou M, Soubasi E, Gourzis P. Depression in Multiple Sclerosis: A Review of Assessment and Treatment Approaches in Adult and Pediatric Populations. ISRN Neurology. 2012;2012:1-6.

2. Brown E, Chandler P. Mood and Cognitive    Changes During Systemic Corticosteroid Therapy. The Primary Care Companion to The Journal of Clinical Psychiatry. 2001;03(01):17-21.

3. World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders, Clinical descriptions and diagnostic guidelines. Geneva: World Health Organization; 1992.

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