A peer-reviewed, evidence-based journal for clinicians in the field of neuroscience
Issue link: https://innovationscns.epubxp.com/i/555782
[ V O L U M E 1 2 , N U M B E R 7 – 8 , J U L Y – A U G U S T 2 0 1 5 ] Innovations in CLINICAL NEUROSCIENCE 29 yielding 19 total results. We selected the articles that detailed the effects of ECT on patients with MS and any psychiatric illness. Of these results, t here were only two original case reports and a 2007 review article of 17 case reports. Of those 17 case reports included in the review article, three were discussed at length by the authors and the remaining 14 were summarized. We also reviewed the case reports from the review article that were electronically accessible in their entirety. Additionally, we selected and reviewed several articles that were found via the PubMed databases using the search term multiple sclerosis and depression for background information. BACKGROUND: DEPRESSION AND MS MS is an immune-mediated inflammatory disorder resulting in destruction of oligodendrocytes with nerve demyelination. Multifocal lesions of the central nervous system white matter characterize this disease. The physical symptoms of MS are well established: patients experience neurologic dysfunction resulting in autonomic, sensory, visual, and/or motor deficits. 3–5 Beyond the physical disabilities associated with MS, psychiatric dysfunction is also noted: between 40- and 60-percent of individuals with MS report depressive and anxiety complaints. 3 An increase in incidence of bipolar disorder has also been noted in people with MS. 4 Suicide rates are higher as well. 5 The elevated incidence of depression in MS has several explanations. Depression may be a direct result of neurodegenerative pathology, with neuronal damage causing the mood disorder. Depression is more common in persons with lesions in their brains as opposed to those with lesions only in their spinal cords. 6,7 Frontal and temporal lesions associated with reduced brain tissue volume are also correlated with depression. 5,6 A decrease in the quality of life in patients with MS is also associated with depression. The same applies to pain, fatigue, and/or cognitive impairments related to the presence o f MS. 7 –10 Depression might also be the result of or worsened by interferon- beta, a standard therapy for MS. 5,11 However, one investigation confoundingly revealed that neither interferon-beta nor glatiramir acetate had any negative effect on mood symptoms in patients with relapsing-remitting MS. The high rates of depression in patients with MS are likely to reflect an interaction of the above factors; yet, to date, there is no neurobiological explanation. The relationship between MS, depression, and their treatments remains to be clarified. Thus, for now, the treatment for depression in patients with MS utilizes the same guidelines as the general population. 12 The American Academy of Neurology states that it cannot support or refute the efficacy of any known antidepressant medication or cognitive behavioral therapy. 12 There are no existing data on ECT for treatment-refractory depression comorbid with MS. ECT AND MS: A REVIEW OF CASE REPORTS According to Mattingly et al, 13 magnetic resonance imaging (MRI) scans in an MS patient undergoing ECT evidenced a correlation between the existence of gadolinium-enhancing lesions at baseline and heightened risk for new neurologic dysfunction after ECT. The authors of this case report cite several studies implicating disruption of the blood brain barrier as a risk factor for neurologic decompensation during ECT. Because gadolinium-enhancing lesions (a sign of active MS plaques) have demonstrated increased permeability in the blood brain barrier, the authors hypothesize that gadolinium-enhancing lesions may prove to be a contraindication to ECT, and recommend obtaining a baseline MRI before administration of ECT in patients with MS. 13 A 2007 review by Rasmussen et al 14 of ECT performed on patients w ith MS documented 17 case reports since 1951. 14 Among the three case reports described in detail by Rasmussen et al, 14 there was no documented evidence that a decrease in neurologic functioning occurred. All three cases reported significant mood improvement despite varied severity in the MS courses and pre-treatment neurologic functioning. However, little long-term follow-up was described. Without such data, it is impossible to assess the potential late-effect neurologic deficits that could arise from ECT treatment in patients with MS. All three cases were women, and their ages ranged from 23 to 61 years. Of the remaining 14 cases that were summarized by Rasmussen et al, 14 only a handful reported deterioration of neurologic status; however, these reports afford no conclusive impressions about ECT safety or efficacy in people with MS. Very few of the reviewed case reports included pre- and post- treatment MRI imaging; without this, it is impossible to address the possibility of new brain lesions. In the two case reports we reviewed describing patients with MS and comorbid psychiatric illness who received ECT treatment, the conclusions were conflicting. 15,16 One patient, a 28-year-old man with MS and recurrent catatonia, was successfully treated with ECT and developed no neurologic deficits. However, the other case, 15 a male patient with MS and psychotic depression, experienced a grand mal seizure following his 14th ECT treatment, and the course of ECT was subsequently halted. 16 CONCLUSION ECT appears to be efficacious in treating psychiatric illness in patients with MS. 14,15 Published cases document improvement in psychiatric symptoms; 14,15 yet data