MDNews - Central Pennsylvania

AFFECTING 23.7% OF individuals with multiple sclerosis (MS), depression is the most frequent MS comorbidity. This presents a particular danger, as depression is associated with poorer health behaviors — diet, physical activity and cardiovascular risk management — which can negatively affect MS and other aspects of health. It is therefore important to assess whether the association between depression, vascular disease and mortality differs in people with MS as compared with the general population. A group led by Raffaele Palladino, MD, PhD, FFPH, of the Imperial College of London, undertook research to that end. According to Dr. Palladino, certain results were clear. "[W]e found that people with MS who also have depression have increased risks of incident vascular disease and mortality," he says. "Depression and MS have a synergistic effect on all- cause mortality." UNDERSTANDING THE FINDINGS Dr. Palladino's population-based retrospective matched cohort study accounted for individuals with MS from England and their matched, non-MS controls. Drawing from patient data from Jan. 1, 1987 through Sept. 30, 2018, 84,823 individuals were studied, 12,251 of whom had MS, for a ratio of nearly six controls per MS patient. Of these, 21% (MS) and 9% (control) had baseline depression. Depression among the control group led to a 10-year mortality that was 1.75 times greater than their non-depressed peers. All-cause 10-year mortality among those with MS was found to be 3.88 times greater with MS alone and 5.43 times greater in those with MS and depression. This MS-depression synergy was responsible for 14% of the observed effect on mortality. Depression was more common among young individuals and women within both cohorts. "[The] association between morta lity and depression in individuals with MS . . . is not surprising," says Mark Skeen, MD, a board-certified neurologist at Duke University who focuses on MS and related inflammatory conditions of the brain. "These findings reinforce the importance of screening MS patients for depression, [as] recognizing and addressing depression in MS patients may have as much or more impact on quality of life and mortality as treating the disease itself." While the link between MS, depression and mortality gained confirmation, the specific relationship with vascular disease remains unclear. According to this retrospective study, those with MS were more likely to experience vascular disease, regardless of depression status. The highest incidence of vascular disease occurred among those with MS and depression (2.44 out of 100,000 person-years, compared to 1.17 with MS who are not depressed and 0.66 and 1.34 of controls without and with depression, respectively). A difference was also found between the sexes. Whereas female MS patients with depression had higher incidence of vascular disease than non-depressed female MS patients, there was no difference among men regarding acute coronary syndrome or composite macrovascular disease risk. There also was no increase of cardiovascular mortality among depressed men with MS. Dr. Palladino was not surprised by this. He stated that this finding "might be partially explained by the fact that the underlying vascular risk for men is higher than women." He viewed this information as "adding to the evidence on sex-related differences in vascular mortality." APPLYING THE FINDINGS T r a d it ion a l r i s k f a c t or s for v a s c u l a r d i s e a s e i nc lude hypertension, smoking and diabetes. The results of this study indicate that a new approach to MS care may be appropriate. Depression screening may need to play a la rger role in a patient's journey. " Depression a nd va scu la r disea se may ma ke MS even more disabling," says Dr. Skeen. "Optima l MS care includes addressing a ll aspects of our patients' lives." By screening for depression, there is potentia l to improve qua lity of life and lower morta lity among the population with MS. This is good news, according to Kalina Sanders, MD, board- certified neurologist at Baptist Hea lth in Jacksonville, Fla. A specia list in MS and spasticity management, Dr. Sanders understood that depression a nd vascula r disease increase morta lity risk independently. She suspected the combination would increase that risk. Yet she was unaware of the magnitude of depression's effect on MS patients. This new insight has led Dr. Sanders to applaud the study 's findings, with some reservation. "A lthough it is a robust data set, the population eva luated . . . was predominately Caucasian and from one geographic location. Therefore," she says, "caution should be advised in extrapolating this data to a more diverse population that may have differing risks." W hile the study f indings wa rra nt caution, the connection bet ween MS a nd depression is well established. Providers t herefore oug ht not disrega rd t his a ssociation a nd a l low depression to go undiagnosed a nd unma naged. Rather, these specia lists believe prov iders ought to administer menta l hea lth screenings in a n ef for t to prov ide a l l-a round ca re for the MS patient. W i l l s uc h v i g i l a nc e le a d t o r e duc e d mor t a l it y r i s k ? Dr. Pa l ladino suspects it li kely w i l l, " but ," he says, " t his must be conf irmed by long itudina l data ." Even if it does not impact mor ta lit y, Dr. Skeen sees the benef it, stating that "depression is one of the most common a nd disabling symptoms in MS, a nd it is therefore impor ta nt to better identif y individua ls with depression a nd optima lly ca re for them." The impact of treating depression on mor ta lity a mong MS patients isn't a ll that needs additiona l research. Vascular risk among the MS population a lso warrants further investigation to deter m i ne whet her t he a ssociations a re coi ncidenta l or causa l. A s resea rch continues, clinicia ns may choose to prioritize a ssessing va scula r risk a mong their patients with MS. n M D N E W S . C O M /// M D N E W S C E N T R A L P E N N S y LVA N i A ■ 2 0 2 2 1 5

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