Pharmacological management of depression in patients with multiple sclerosis

ABSTRACT

Introduction: The pharmacotherapeutic management of depression in patients with multiple sclerosis (MS) is a matter of debate that cannot be decided from the evidence available in the current literature. Therefore, its management essentially relies on the clinical experience of the prescribing clinician rather than on evidence-based approaches.

Areas covered: This review provides a clinically oriented critical perspective on the connection between MS and major depressive disorder (MDD) or depression associated with bipolar disorder (BD), focusing on its optimal pharmacotherapy. Both clinical and pharmacological considerations are accounted in order to promote rational pharmacotherapy, both in terms of efficacy and tolerability.

Expert opinion: Despite its clinical burden and relatively frequent occurrence, the interplay of MS and depression still requires further controlled trials to better clarify the appropriate pharmacotherapy across varying ‘diseases categories’ of MS itself, as well as discriminating between depressive symptoms that do not necessarily reach the threshold of either MDD or BD. Additional insight into new mood-tolerated neurological pharmacotherapy for MS is likewise warranted toward a more effective, immune- and patient-tailored pharmacotherapy, while promoting innovation in drug design, with the ultimate goal of enhancing the overall quality life of the affected individual, his/her caregivers, and to reduce the associated economic and social burden.

KEYWORDS:

• Multiple sclerosis
• depression
• bipolar disorder
• major depressive disorder
• psychopharmacology

Article highlights

• MS is a source of major physical and psychosocial impairment to the suffering ones and his/her caregivers, accounting for significant social and economic burden.

• The interplay between depression and MS is yet to be fully characterized in terms of neurobiological and epidemiological underpinnings; optimal management is also elusive since controlled evidence is substantially lacking.

• Psychiatric pharmacotherapy is often prescribed to MS patients with prominent depressive symptoms, whereas neurologic pharmacotherapy could concur to deflated mood in MS.

• Pharmacotherapy of MS↔depression interplay is complex.

• The evidence-based literature specifically addressing the topic of depression associated to MS is virtually absent. Therefore, the clinical psycho-pharmacologist and the prescribing neurologist need to tightly cooperate.

• Disease-modifying pharmacotherapy for MS may seldom induce depression. Balancing the pros and cons by pursuing optimal augmentation with standard antidepressants as well as other psychiatric agents is therefore aimed.

• Additional ad-hoc rating tools for depression, better insights of the immune system involvement across varying MS categories and presentations of depression, as well as tight cooperation between the prescribing neurologist, the clinical psychiatrist and the suffering ones is recommended in order to deliver balanced effective/tolerated pharmacotherapy.

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Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose

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Funding

This manuscript has not been funded.