5 Questions on Psychopharmacology and Multiple Sclerosis
Mood disorders are common among patients with multiple sclerosis (MS), and psychotropics are one option for treating this patient population.
At the Consortium of Multiple Sclerosis Centers Annual Meeting 2019, Laura T. Safar, MD, and her colleague Jane Erb, MD, reviewed and updated clinicians on the use of psychotropics among patients with MS.1
Neurology Consultant caught up with Dr Safar after her presentation. Here are her answers to our burning questions.
Laura T. Safar, MD, is an assistant professor of psychiatry at Harvard Medical School, associate neuropsychiatrist at the Brain/Mind Medicine Center at Brigham and Women's Hospital, and the director of BWH Multiple Sclerosis Neuropsychiatry at Brigham and Women's Hospital in Boston, Massachusetts.
NEUROLOGY CONSULTANT: Can you give us an overview of your session?
Laura T. Safar: Psychiatric disorders are highly prevalent in patients with MS, much more so than in the general population. For instance, the lifetime prevalence of major depression in individuals with MS has been estimated, in different studies, to range from 25% to 50%.
The lifetime prevalence of other psychiatric disorders in individuals with MS are as follows:
- Bipolar disorder: about 6%
- Pseudobulbar affect: 10%
- Anxiety disorders: about 25%
- Cognitive disorders: more than 40%
The presence of psychiatric disorders may have a substantially negative impact on the individual’s quality of life, adherence to MS treatment, functional status, and MS treatment outcome. For all these reasons, it is very important to screen for psychiatric disorders, and diagnose and treat the patient properly. Psychopharmacological agents are one option for treating these disorders.
NEURO CON: Which psychotropics are appropriate for which MS patient populations?
LTS: All psychotropics are potentially appropriate for use in patients with MS. The selection of agents must be done case by case according to the individual patient’s psychiatric symptoms, the known therapeutic and side effect profiles of each agent, and other factors such as interactions with other medications.
Antidepressants, antianxiety agents, mood stabilizers, antipsychotics, and cognitive enhancers all have a role in the treatment of psychiatric disorders in individuals with MS. There are specific considerations to take into account when using psychotropics in MS, though. For instance, among the antidepressants, serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), or bupropion can be considered first-line treatments in the general population. For patients with combined depression and anxiety, an SSRI or an SNRI would be preferred.
Examples of commonly used SSRIs are sertraline, citalopram, escitalopram, and fluoxetine. Examples of SNRIs are duloxetine and venlafaxine. For patients with depression and prominent physical and cognitive fatigue—a common MS symptom—an SNRI or bupropion may be preferred over an SSRI, since these medications’ noradrenergic activity may help increase patients’ energy level and cognitive focus. In addition, SNRIs can help reduce certain types of pain, including neuropathic pain.
Consulting a psychiatrist >>
Mood disorders are common among patients with multiple sclerosis (MS), and psychotropics are one option for treating this patient population.
At the Consortium of Multiple Sclerosis Centers Annual Meeting 2019, Laura T. Safar, MD, and her colleague Jane Erb, MD, reviewed and updated clinicians on the use of psychotropics among patients with MS.1
Neurology Consultant caught up with Dr Safar after her presentation. Here are her answers to our burning questions.
Laura T. Safar, MD, is an assistant professor of psychiatry at Harvard Medical School, associate neuropsychiatrist at the Brain/Mind Medicine Center at Brigham and Women's Hospital, and the director of BWH Multiple Sclerosis Neuropsychiatry at Brigham and Women's Hospital in Boston, Massachusetts.
NEUROLOGY CONSULTANT: Can you give us an overview of your session?
Laura T. Safar: Psychiatric disorders are highly prevalent in patients with MS, much more so than in the general population. For instance, the lifetime prevalence of major depression in individuals with MS has been estimated, in different studies, to range from 25% to 50%.
The lifetime prevalence of other psychiatric disorders in individuals with MS are as follows:
- Bipolar disorder: about 6%
- Pseudobulbar affect: 10%
- Anxiety disorders: about 25%
- Cognitive disorders: more than 40%
The presence of psychiatric disorders may have a substantially negative impact on the individual’s quality of life, adherence to MS treatment, functional status, and MS treatment outcome. For all these reasons, it is very important to screen for psychiatric disorders, and diagnose and treat the patient properly. Psychopharmacological agents are one option for treating these disorders.
NEURO CON: Which psychotropics are appropriate for which MS patient populations?
LTS: All psychotropics are potentially appropriate for use in patients with MS. The selection of agents must be done case by case according to the individual patient’s psychiatric symptoms, the known therapeutic and side effect profiles of each agent, and other factors such as interactions with other medications.
Antidepressants, antianxiety agents, mood stabilizers, antipsychotics, and cognitive enhancers all have a role in the treatment of psychiatric disorders in individuals with MS. There are specific considerations to take into account when using psychotropics in MS, though. For instance, among the antidepressants, serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), or bupropion can be considered first-line treatments in the general population. For patients with combined depression and anxiety, an SSRI or an SNRI would be preferred.
Examples of commonly used SSRIs are sertraline, citalopram, escitalopram, and fluoxetine. Examples of SNRIs are duloxetine and venlafaxine. For patients with depression and prominent physical and cognitive fatigue—a common MS symptom—an SNRI or bupropion may be preferred over an SSRI, since these medications’ noradrenergic activity may help increase patients’ energy level and cognitive focus. In addition, SNRIs can help reduce certain types of pain, including neuropathic pain.
