Symptomatic Treatment of MS - European Multiple Sclerosis Platform

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DEPRESSION Depressive syndromes occur in about 50% of MS patients [Chwastiak 2002] demonstrating the need for rigorous treatment of this condition, especially in light of the high rate of attempted and completed suicides. Depression may also restrict the ability of a patient to adhere to a treatment; hence it is important to treat depression to ensure the patients better help themselves manage the disease. The diagnosis of depression, which may be complicated by other MS symptoms like fatigue and cognitive disturbance, requires careful differential diagnosis. Episodic fluctuations of depressive mood or difficult coping have to be distinguished from long-term depressive states and “organic” major depression. Even bipolar affective psychoses in MS patients are present twice as much as in normal population [Schiffer 1990]. Goals of treatment are the reduction of depressive mood by proper guidance and drug treatment when needed, and prevention of suicide. Even if beta interferons were not convincingly shown to cause depression [Zephir 2003; Kappos 2006] one should be alert in any patient at any time since in every day neurological practice some patients have been repeatedley reported to develop depression with the initiation of beta interferon treatment. SPECIFIC TREATMENT COUNSELLING As depression is often masked by somatic symptoms (fatigue, exhaustion, cognitive problems) it should actively be searched for during the consultation. Whenever depression is obvious, a psychiatric examination should precede counselling through the local MS society chapters or by friends and family [Schwartz 1999]. PSYCHOTHERAPY Several studies demonstrate the efficacy of psychotherapy for depression in MS patients [Crawford 1985; Mendoza 2001; Mohr 2001; Mohr 2005]). Mainly cognitive behavioural therapy, that emphasizes active coping strategies with the disease, has been applied, though no preference of a specific psychotherapeutic technique has been worked out. DRUG TREATMENT A Cochrane review emphasizes the efficacy of tricyclic antidepressants as well as of serotonin reuptake inhibitors (SSRI) in depressive patients with other medical illness [Gil 2003]. Treatment with desipramine combined with psychotherapy [Schiffer 1990], with sertraline and psychotherapy [Mohr 2001],and with the monoaminoxidase (MAO) A inhibitor moclobemide [Barak 1999] is effective. The choice of drug used should be adapted to the other symptoms of the patient and to the treatments, as each drug may cause unwanted side-effects like sexual dysfunction (SSRIs) or increased fatigue (mirtazapine [Feinstein 2003]). EMSP, Symptomatic Treatment of Multiple Sclerosis, December 2006 - revised in April 2008 28
RECOMMENDATIONS � Counselling as prophylactic and complementary treatment. � Drug treatment with tricyclic antidepressants, serotonin reuptake inhibitors, noradrenalin reuptake inhibitors, MAO A inhibitors. � Structured psychotherapy using accepted techniques, e.g. cognitive behavioural therapy. 29 EMSP, Symptomatic Treatment of Multiple Sclerosis, December 2006 - revised in April 2008
Page 1 and 2: © EMSP, European Multiple Sclerosi
Page 3 and 4: INTRODUCTION Up to now several evid
Page 5 and 6: SPASTICITY Spasticity in MS is caus
Page 7 and 8: For a discussion of the use of botu
Page 9 and 10: DRUG TREATMENT Oral drug treatment
Page 11 and 12: MS-RELATED PAIN SYNDROMES The frequ
Page 13 and 14: Drug treatment of these pain syndro
Page 15 and 16: BLADDER SYMPTOMS Neurogenic bladder
Page 17 and 18: pressin should only be given to pat
Page 19 and 20: RECOMMENDATIONS � Exclusion of bl
Page 21 and 22: IN CASE OF PREVAILING FAECAL INCONT
Page 23 and 24: placebo [Dula 2000]. Apomorphine ma
Page 25 and 26: Antiepileptics: Primidone may be ef
Page 27: DRUG TREATMENT So far donepezil and
Page 31 and 32: TRIGEMINAL NEURALGIA Drug treatment
Page 33 and 34: OCULOMOTOR SYMPTOMS During the cour
Page 35 and 36: concepts, e.g. Bobath technique, Pr
Page 37 and 38: DYSPHAGIA Estimates on the frequenc
Page 39 and 40: DRUG TREATMENT Pronounced hypersali
Page 41 and 42: REFERENCES 1. Abrams P, Amarenco G,
Page 43 and 44: injections of botulinum toxin in th
Page 45 and 46: 59. Dieterich M, Straube A, Brandt
Page 47 and 48: proposal for classification and nom
Page 49 and 50: 18. Hoverd PA, Fowler CJ (1998) Des
Page 51 and 52: 146. Lewis RW, Witherington R (1997
Page 53 and 54: 175. Multiple Sklerose - Therapie K
Page 55 and 56: 203. Prosiegel M, Heintze M, Wagner
Page 57 and 58: 232. Schwid SR, Petrie MD, McDermot
Page 59 and 60: 260. The FOOD Trial Collaboration (
Page 61 and 62: 288. Yetimalar Y, Gurgor N, Basoglu

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