In many ways, multiple sclerosis (MS) is among the most frustrating and vicious of human diseases. Although we can readily see the demyelinating effect of MS lesions on postmortem examination, the diagnosis during life is fraught with difficulty. Advances in cerebrospinal fluid analysis and neuroimaging techniques have contributed to a recent revision of diagnostic criteria for MS, yet the majority of patients still wait for years until a definitive diagnosis is reached. They then face a disease that is both highly unpredictable and, in most cases, severely debilitating.

The unpredictable nature of MS is particularly distressing and many patients exist in a persistent state of fear and anxiety about their next MS exacerbation. Despite improved treatments, MS leaves some of the most severely affected patients wheelchair-bound by their early twenties. The more fortunate ones learn to deal with sporadic functional impairments for the rest of their lives. The unpredictable nature of MS leaves its victims always wondering about the next phase of their illness. For some, a more negative but definitive prognosis would be easier to accept than one for which the outcome is so unclear.

To make matters worse, the cause of MS remains an elusive one. Research points to an infectious and/or autoimmune etiology. The disorder is more common among those living in northern hemispheres, afflicts women more often than men, and has a partial genetic basis as evidenced by a greater concordance rate for monozygotic than dizygotic twins that nevertheless, falls far short of what would be expected of an autosomal, Mendelian disease. Drugs that modulate the immune system, from steroids to interferons, are somewhat helpful. Yet despite this, the long-term prognosis for MS has not changed much in recent decades and no therapy exists that addresses the root pathophysiology of the disease—demyelination.

Schizophrenia and obsessive-compulsive disorder (OCD) have historical, clinical, and epidemiological links. The clinical use of atypical neuroleptics (ie, dual serotonin-dopamine antagonists) to treat both conditions sheds a new light on them. We report the first two cases of obsessive-compulsive symptoms (OCS) induced by quetiapine in schizophrenia patients. A case of successful augmentation by quetiapine in refractory OCD is also presented. A review of the literature on OCS induced by atypical neuroleptics follows. This paradoxically induced OCD symptomology in schizophrenia patients administered atypical neuroleptics is discussed from new pathophysiological and clinical perspectives. The discussion emphasizes the prognostic implications of OCS in schizophrenia and available therapies for this comorbidity.

Multiple sclerosis (MS) is the most common cause of neurological disability in young and middle-aged adults. Although Charcot noted behavioral changes associated with MS, nearly a century would elapse before researchers began defining their full extent and severity. Broadly speaking, abnormalities may be divided into those of mood and cognition. Many patients are afflicted with both and it is essential that clinicians are not only aware of this but understand how to detect problems and provide treatment.

The lifetime prevalence of major depression in MS patients approaches 50%. As Scott B. Patten, MD, and colleagues note, these data came from specialist clinics with the potential for ascertainment bias. Shifting their inquiry into a large community-based sample, they report that the rates of mood disorder remain elevated largely in younger MS patients. While it is partly reassuring to find that aging comes with at least one benefit, the gist of this study is to reinforce the message that clinically significant depression is a problem for MS patients. Not only does it adversely affect quality of life and lead to increased suicidal thinking, it exerts more subtle deleterious effects as Peter A. Arnett, PhD, reveals. In a longitudinal study exploring the relationship between depression and cognition, Arnett reports that MS patients with prominent evaluative symptoms of depression (ie, feelings of inferiority, failure) have greater difficulty with cognitive tasks that encompass information processing speed and executive function linked to working memory. A preoccupation with negative thoughts may reduce the cognitive capacity necessary for aspects of attention and working memory.

These data complement the review article of Ralph H.B. Benedict, PhD, ABPP-CN, that focuses on methods of detecting cognitive dysfunction in MS. As with mood disorders, impaired cognition has been linked to difficulties with work, relationships, and, in more extreme cases, basic activities of daily living. Usually, the more subtle pattern of deficits associated with demyelination differ from those seen in cortical-type dementias and will be missed should clinicians rely on screening instruments like the Mini-Mental State Examination. At the same time, the method of choice for eliciting deficits, namely neuropsychological testing is expensive and frequently not readily available. This has meant that alternative instruments, like the Multiple Sclerosis Neuropsychological Screening Questionnaire, assume an added prominence. With good sensitivity, specificity, and ease of administration this informant based scale makes a useful addendum to the neurological examination. It is in the same light that the magnetic resonance imaging (MRI) rating scale by Laury Chamelian, MD, FRCPC, and colleagues should be viewed.

Background: Affective disorders present an important clinical challenge in multiple sclerosis (MS). Due to prohibitive sample size requirements, population-based studies have not yet provided an adequate description of the underlying epidemiology of this association.

Objective: To describe the epidemiology of affective disorders in MS in a general population sample.

Methods: The study presented here accessed administrative data from a universal healthcare insurance plan in the Canadian province of Alberta. Physician billing data recorded in the Alberta Health Care Insurance Plan was used to identify members of the population ≥15 years of age with and without MS. Crude and stratified estimates of the association between affective disorders and MS were made. Logistic regression analysis was used to evaluate statistical interactions and to provide adjusted estimates of the association.

Results: The estimated prevalence of MS in the population within the targeted age range (2.3 million individuals) was 386/100,000 and that of affective disorders was 7.7%. As expected, an association between MS and affective disorders was identified (crude relative prevalence: 2.2). The association varied in strength over age-sex categories. Although the prevalence of affective disorder was higher in women with MS than men with MS, the association of MS with affective disorders was stronger in men. The strength of association declined with age in both men and women. Affective disorder prevalence in people with MS becomes similar to that of the general population in older age groups.

Conclusion: Affective disorders occur with an increased frequency in MS. This is true in men and women and across all relevant age groups, although the association gets weaker with advancing age. Higher frequencies of affective disorder occur in women with MS than in men with MS. The frequency of affective disorder in people with MS is highest in the 25–44 age group, and declines in older age categories.

Background: Lifetime prevalence rates of cognitive dysfunction and depression in multiple sclerosis (MS) have typically been reported to be ∼50%. However, an inconsistent relationship between these two common features of MS has been reported in the literature. Because neurovegetative depression symptoms overlap with MS symptoms, it may be that literature inconsistencies can partly be explained by the fact that only those depression symptom clusters unambiguously reflective of depression are associated with cognitive dysfunction.

Objective: To explore the relationship between different depression symptom clusters and a battery of tests measuring cognitive domains commonly impaired in MS and was examined at two time points 3 years apart.

Methods: The Chicago Multiscale Depression Inventory was employed to measure mood, negative evaluative, and neurovegetative symptom clusters in 53 MS patients who were also administered a battery of neuropsychological tests.

Results: At time point 1, Mood and Evaluative Chicago Multiscale Depression Inventory scales were significantly associated with tasks of complex speeded attention, planning, and working memory. At time point 2, the Evaluative scale was still significantly associated with these domains, in addition to spatial memory; however, all of the significant correlations with the Mood scale dropped out.

Conclusion: These results show that negative evaluative depression symptoms are most consistently predictive of cognitive dysfunction in MS. It may be that negative evaluative depression symptoms use up available cognitive capacity, thus compromising performance on cognitive capacity demanding tasks in MS patients.

Cognitive dysfunction, a common feature of multiple sclerosis (MS), frequently leads to impaired activities of daily living, social skills deficits, diminished social support, and unemployment. There is growing evidence indicating that cognitive impairment is amenable to the effects of medication and behavioral counseling. Unfortunately, routine neuropsychological testing is rare in MS clinics because screening is ineffective and testing strategies are often too cumbersome or expensive. Recent research supports the reliability of a brief screening test called the Multiple Sclerosis Neuropsychological Screening Questionnaire as well as a minimal neuropsychological battery called the Minimal Assessment of Cognitive Function in Multiple Sclerosis. Data indicate that the Multiple Sclerosis Neuropsychological Screening Questionnaire has excellent split-half and test-retest reliability, and that it predicts neuropsychological deficiency with good sensitivity and specificity. Recently acquired data also show that the Minimal Assessment of Cognitive Function in Multiple Sclerosis tests have good test-retest reliability, discriminate MS patients from normal controls, and predict unemployment in MS patients. Thus, these or similar methods should be employed for the routine monitoring of cognitive functioning of MS patients.

Objective: In multiple sclerosis (MS), magnetic resonance imaging (MRI) predictors of cognitive impairment are based on sophisticated computer-generated analyses that are difficult to apply in clinical settings. This study investigated the clinical usefulness of a new visual rating scale, the Cholinergic Pathways Hyperintensities Scale (CHIPS), in detecting cognitive dysfunction.

Methods: Forty clinically definite MS patients underwent a brain MRI. Based on the CHIPS, cholinergic pathway hyperintensities were rated in 10 regions on four axial slices. Computerized hyperintense lesion volumes were also obtained. For cognitive testing, The Neuropsychological Screening Battery for Multiple Sclerosis was used. “Low” and “High” lesion score groups were computed based on the mean of the total CHIPS score. Optimal sensitivity and specificity of the total CHIPS score in detecting cognitive impairment were determined using a receiver operator characteristic curve.

Results: Despite a similar demographic profile, subjects with a “High” lesion score performed significantly worse than the “Low” lesion score group on verbal (P=.007) and visuospatial (P=.02) memory, and on a global index of cognitive functioning (P=.001). Optimal sensitivity (82%) and specificity (83%) were reached with a threshold total CHIPS score of 18 points. Total CHIPS score and total hyperintense lesion load were correlated (σ=0.82, P<.0001).

Conclusion: CHIPS is helpful in clinically predicting cognitive impairment in MS.

Objective: The authors conducted a review and meta-analysis of the literature comparing telepsychiatry with “in-person” psychiatric assessments.

Method: Approximately 380 studies on telepsychiatry published between 1956 and 2002 were identified using MEDLINE, PsycINFO, and cross-referenced bibliographies. Of these, 14 studies with an N>10 compared telepsychiatry with in-person psychiatry (I-P) using objective assessment instruments or satisfaction instruments. Three of these studies compared high bandwidth (HB) with low bandwidth (LB) telepsychiatry.

Results: Fourteen studies of 500 patients met inclusion criteria and were included in the meta-analysis. Telepsychiatry was found to be similar to I-P for the studies using objective assessments. Effect sizes were on average quite small, suggesting no difference between telepsychiatry and I-P. Bandwidth was found to be a significant moderator. Three moderators were tested, effect sizes remained largely heterogeneous, and further analyses are needed to determine the direction of effect. There was no difference between I-P and telepsychiatry between the HB and LB groups, although there are anecdotal data suggesting that H B was slightly superior for assessments requiring detailed observation of subjects.

Conclusion: Out of a large telepsychiatry literature published over the past 40+ years, only a handful of studies have attempted to compare telepsychiatry with I-P directly using standardized assessment instruments that permit meaningful comparisons. However, in those studies, the current meta-analysis concludes there is no difference in accuracy or satisfaction between the two modalities. Over the next few years, we expect telepsychiatry to replace I-P in certain research and clinical situations.