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Mental health issues are common among people living with multiple sclerosis (PwMS) during the COVID-19 pandemic.
•
PwMS experienced more severe symptoms of depression and stress compared to general populations during the pandemic.
•
Evidence from longitudinal studies suggests that anxiety, depression and mental health dimensions of quality of life among PwMS were not considerably affected by pandemic-related restrictive measures.
Abstract
Introduction
The global spread of COVID-19 has raised concerns about its possible impact on mental health. People living with multiple sclerosis (PwMS) are considered potentially vulnerable to the mental health effects of the pandemic, as they may be subject to increased social isolation.
Aim
To systematically review the current evidence on the impact of the COVID-19 pandemic on mental health outcomes among PwMS.
Method
We searched four major databases (Medline, EMBASE, PsychInfo and Scopus) and the WHO Global Health COVID-19 research database. We included peer-reviewed primary research studies using validated health-related quality of life (HRQOL) and psychometric screening tools to evaluate mental health outcomes among PwMS during the COVID-19 pandemic. Studies reporting data on the prevalence of mental health disorders, severity of psychological symptoms and contributing demographic and clinical factors for PwMS during the COVID-19 pandemic were included.
Results
Our initial search yielded 268 records; 19 studies (13 cross-sectional, 6 longitudinal) were included. Most were conducted during a peak in the pandemic in the host country via an online platform. The main mental health outcomes were depression, anxiety, stress, sleep quality and HRQOL. The included studies used a variety of outcome assessment tools and study designs. The prevalence of mental health issues such as depression, anxiety and stress were high among PwMS during the pandemic. In addition, compared to control populations, PwMS experienced more severe symptoms of depression and stress during the COVID-19 outbreak. However, results from longitudinal studies demonstrate that the severity of mental health symptoms among PwMS during the pandemic were not significantly different compared with the pre-pandemic period.
Conclusion
Although mental health issues such as anxiety and depression were common among PwMS during the pandemic, current evidence suggests that mental health among PwMS has not been significantly affected by pandemic-related restrictive measures. Instead, the observed differences may be the result of pre-pandemic differences in prevalence and severity. Where possible, future studies should seek to address the methodological issues identified in the included studies to ensure that data collected during the pandemic can be synthesized into recommendations for policy and practice.
). To date, the pandemic has affected 223 countries, areas or territories, and has caused > 113 million known cases and almost 2.5 million confirmed deaths (
). In response to this global health threat and the unprecedented pressures placed on healthcare systems, nearly every country has initiated social distancing measures, gradual or immediate lockdowns, border closures, and/or travel bans. However, these methods, which are aimed at stemming the spread of the virus, have also affected the lives of billions of people, directly and indirectly, by restricting social gatherings, travel, employment, and education. In addition to the social and economic impact of COVID-19, the unpredictability of the situation, unavailability of vaccination, overflow of information, and the dissemination of myths and inaccurate information via social media have led to an increase in concern and confusion for the public (
Prevalence of psychological morbidities among general population, healthcare workers and COVID-19 patients amidst the COVID-19 pandemic: a systematic review and meta-analysis.
Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic.
Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic.
Prevalence of psychological morbidities among general population, healthcare workers and COVID-19 patients amidst the COVID-19 pandemic: a systematic review and meta-analysis.
Psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the COVID-19 pandemic.
), demonstrate that outbreaks increase the risk of mental health issues among patients and healthcare providers, and amongst various subpopulations, including people with chronic health conditions (
). A recent meta-analysis reported that the global prevalence of depression, anxiety, and distress during the COVID-19 pandemic was 31.4%, 31.9%, and 41.1%, respectively. Notably, the risk of depression and anxiety were found to be substantially higher among non-infectious chronic disease patients, quarantined people and COVID-19 patients than in other subpopulations (
). Similarly, results from a national cohort study in UK demonstrated that the prevalence of clinically significant levels of mental health distress increased from 18.9% in 2018–19 to 27.3% by late April 2020, one month into the UK's lockdown (
). Psychiatric comorbidities such as depression and anxiety are more common in PwMS compared to the general population, and these conditions are often considered to be part of the spectrum of MS symptoms (
). A recent meta-analysis of pre-pandemic studies reported that in the early phase of MS, the prevalence of anxiety and depression (as measured by HADS) was 35% (95%CI: 28–41%) and 17% (95%CI: 9–25%), respectively (
on the behalf of the RADAR-CNS Consortium Emotional outcomes in clinically isolated syndrome and early phase multiple sclerosis: a systematic review and meta-analysis.
). Psychiatric comorbidities are major contributors to psychological distress and can influence the disease course, level of fatigue, disability progression and quality of life (QoL) in affected PwMS (
CIHR Team in the Epidemiology and Impact of Comorbidity on Multiple Sclerosis (ECoMS) Health-related quality of life in multiple sclerosis: direct and indirect effects of comorbidity.
CIHR Team in the Epidemiology and Impact of Comorbidity on Multiple Sclerosis Psychiatric comorbidity is associated with disability progression in multiple sclerosis.
As described above, restrictive measures that curtail personal freedoms such as quarantine, social isolation, and social distancing have been imposed to protect society from the rapid spread of COVID-19. However, such laudable preventative measures may impact both the physical and psychosocial well-being of PwMS. PwMS may face disruptions in lifestyle and increased stress as a result of COVID-19 containment measures, such as increased social isolation and delays in medical appointments. This could ultimately lead to adverse effects on their neuropsychological state, adherence to treatment and overall QoL (
). Results from a large online survey among PwMS in the United States showed considerable disruptions in multiple health behaviours and access to MS-related health care during the COVID-19 pandemic. More than two-thirds of respondents reported that they had to cancel a clinical appointment during this period and almost 20% missed an MRI or laboratory test. Furthermore, about 10% reported some level of disease-modifying therapy treatment (DMT) change, including delayed dosage. Importantly, the same cohort reported that COVID-19 has had a significant economic impact on their lives, causing them to change employment, reduce work hours, or even lose their job (
Several systematic reviews and meta-analyses have reported the prevalence of common mental health conditions among the general population and various subpopulations during previous outbreaks such as SARS, MERS, H1N1, as well as the COVID-19 pandemic (
). However, no review has evaluated the current evidence in PwMS. Therefore, the aim of this study is to conduct a rapid systematic review of the existing evidence on impact of the COVID-19 pandemic on mental health outcomes among PwMS.
2. Methods
2.1 Search methodology and study design
We conducted a systematic literature search in four biomedical databases (MEDLINE, PsycInfo, EMBASE and Scopus) for studies published prior to 25 June 2021. The full list of search strategies and the retrieved records are described in Supplementary Table 1. We utilized a combination of terms relating to COVID-19 (e.g., “SARS-CoV-2″ and “coronavirus”), mental health outcomes (e.g., “psychiatric” and “mental health”) and MS-related disease and disease course. We used several keywords for each of the main concepts. We did not limit our search to specific psychiatric disorders; by selecting more general Medical Subject Headings (MeSH) or Map terms, we considered broader outcomes and determinants of mental health and wellbeing. We also conducted a search in the WHO Global Health research database on COVID-19 for additional articles. Duplicate records were removed, and titles and abstracts were reviewed by one reviewer (AZ). The full text of the remaining records was then reviewed by one reviewer (AZ). Study selection was conducted based on the inclusion and exclusion criteria summarized in Table 1, which follows the PICOS convention (population; intervention/exposure; comparison; outcome; study design) (
Table 1Summary of inclusion and exclusion criteria according to PICOS acronym.
Inclusion criteria
Exclusion criteria
Population
People living with MS including pediatric and adult-onset types
–
Intervention/exposure
COVID-19 pandemic and related social distancing and lockdown measures
Conducted prior to the COVID-19 pandemic
Comparison
Any control population was acceptable. Having no control group was also acceptable
–
Outcome
Prevalence of psychiatric disorders, or the level of psychological symptoms or wellbeing measured by a valid psychometric assessment tool, or measurement determinants of mental health outcomes
Used questionnaires that have not been validated to assess mental health-related outcomes
Study design
Observational studies, including cross-sectional studies
Reported the effect of any therapeutic or behavioural intervention; expert opinion; or case report
The following items were extracted from the included studies using a standardized spreadsheet: author name, year of publication, country, study design, sample size, recruitment location, study participants, type of MS, sex, average age, average disease duration, average Expanded Disability Status Scale (EDSS) score, history of psychiatric comorbidity and results of psychometric screening tools. We also recorded the timeframe of the study with respect to the COVID-19 pandemic and related lockdowns (early/during/at the peak), as stated in the included articles. The WHO defines a pandemic peak as the number of new cases rising to the highest observed levels and the peak of the epidemic curve beginning to drop following implementation of adequate surveillance (
). It is noteworthy that the working definition of a pandemic peak and the severity of social and health-related containment and prevention measures depend on country/territory policies and may vary from each other.
2.3 Quality assessment
Two reviewers (AZ and CE) conducted the risk of bias assessment independently, and any conflicts were resolved by a third reviewer (SC). Methodological quality assessment was carried out using the Newcastle-Ottawa Scale (NOS), which contains separate quality assessment instruments for cohort studies (
). The quality of each study was determined for three main domains (selection, comparability, and outcome) according to the tool's assessment criteria (Supplementary Tables 2 and 3). A cohort study could be awarded a maximum of one star for each numbered item within the “Selection” and “Outcome” domains. A maximum of two stars can be awarded for the “Comparability” domain. The final score for each study was calculated as the total number of awarded stars. The higher total number stars indicate better research quality (
). The maximum number of stars for cohort and cross-sectional studies is 9 and 10, respectively. In addition, we used the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) statement for reporting this study (Supplementary Table 4).
2.4 Data synthesis
The included studies were too heterogeneous for a meta-analysis; a small number of studies assessed each outcome, and a wide range of psychometric screening tools were used. Consequently, we conducted a narrative synthesis focused on five major mental health-related outcomes as common themes: anxiety, depression, HRQOL, stress and sleep quality. For each outcome, we discuss the prevalence or frequency of the outcome, the severity of symptoms as measured by psychometric scales, comparisons between PwMS and controls and the comparison over time.
3. Results
Fig. 1 illustrates the flow of studies into this review. In summary, a total of 268 records were returned from the initial searches. After removing duplicate articles, the titles and abstract of 197 records were screened. Of these, 37 articles (18.8%) were deemed eligible for full-text review. Of these, 19 articles (51.3%) were included.
Table 2 presents the characteristics of the included studies. Of the 19 included studies, 13 were cross-sectional, four were longitudinal, and two included both longitudinal and cross-sectional analyses. The included studies assessed a total of 5816 adult MS cases and 30 pediatric (aged ≤ 18 years) MS cases. Eleven studies were conducted in European countries and the remainder were based in Iran (n = 4), the USA (n = 1) and Egypt (n = 1). There were two multicentre studies; one recruited participant from six countries across North America and Europe (
Fear of COVID-19, problems accessing medical appointments, and subjective experience of disease progression, predict anxiety and depression reactions in patients with multiple sclerosis.
). All were conducted during the COVID-19 outbreak but a subset was done during a period of lockdown in the host country. About half of the studies (n = 9) described concurrent public health attempts to limit COVID-19 spread, with governments enforcing a regional or nationwide lockdown/quarantine in the state or country (
The impact of COVID-19 home confinement on neuromuscular performance, functional capacity, and psychological state in Spanish people with multiple sclerosis.
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
Assessment of mental health, knowledge, and attitude of patients with multiple sclerosis and neuromyelitis optica spectrum disorder in response to 2019 novel coronavirus.
Mental health status of relapsing-remitting multiple sclerosis Italian patients returning to work soon after the easing of lockdown during COVID-19 pandemic: a monocentric experience.
The impact of COVID-19 home confinement on neuromuscular performance, functional capacity, and psychological state in Spanish people with multiple sclerosis.
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
Coping with stress during the first wave of the COVID-19 pandemic by Turkish people with multiple sclerosis: the relationship between perceived stress and quality of life.
Fear of COVID-19, problems accessing medical appointments, and subjective experience of disease progression, predict anxiety and depression reactions in patients with multiple sclerosis.
Fear of relapse, social support, and psychological well-being (depression, anxiety, and stress level) of patients with multiple sclerosis (MS) during the COVID-19 pandemic stage.
Assessment of mental health, knowledge, and attitude of patients with multiple sclerosis and neuromyelitis optica spectrum disorder in response to 2019 novel coronavirus.
Are multiple sclerosis patients and their caregivers more anxious and more committed to following the basic preventive measures during the COVID-19 pandemic?.
Mental health status of relapsing-remitting multiple sclerosis Italian patients returning to work soon after the easing of lockdown during COVID-19 pandemic: a monocentric experience.
Depression Anxiety Stress Scales-21 (DASS-21), Short Screening Scale for DSM-IV (SSS DSM-IV), Insomnia Severity Index (ISI).
6
*Data are mean(SD) unless otherwise stated. 1.PwMS: People Living with Multiple Sclerosis, 2. RRMS: Relapsing Remitting MS, 3.PMS: Progressive MS, 4. HC: Healthy controls, NA: Not available. # Study conducted during the local or national state of lockdown + Control group in this study was selected from family members and/or friends not affected by MS.
Coping with stress during the first wave of the COVID-19 pandemic by Turkish people with multiple sclerosis: the relationship between perceived stress and quality of life.
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
Are multiple sclerosis patients and their caregivers more anxious and more committed to following the basic preventive measures during the COVID-19 pandemic?.
Mental health status of relapsing-remitting multiple sclerosis Italian patients returning to work soon after the easing of lockdown during COVID-19 pandemic: a monocentric experience.
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
). All 15 cross-sectional studies reported the severity of mental health symptoms during the COVID-19 pandemic. Of these, eight (53.3%) sampled a control population to compare with PwMS (
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
Assessment of mental health, knowledge, and attitude of patients with multiple sclerosis and neuromyelitis optica spectrum disorder in response to 2019 novel coronavirus.
Are multiple sclerosis patients and their caregivers more anxious and more committed to following the basic preventive measures during the COVID-19 pandemic?.
Are multiple sclerosis patients and their caregivers more anxious and more committed to following the basic preventive measures during the COVID-19 pandemic?.
).All six longitudinal studies reported the severity of mental health symptoms among PwMS prior to or early in the COVID-19 pandemic along with follow-up measures in a lockdown period (
The impact of COVID-19 home confinement on neuromuscular performance, functional capacity, and psychological state in Spanish people with multiple sclerosis.
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
). However, none of the longitudinal studies recruited a control group for prospective comparison.
Most studies did not limit their study population by MS phenotype. However, one study only included participants with primary or secondary progressive MS (
Coping with stress during the first wave of the COVID-19 pandemic by Turkish people with multiple sclerosis: the relationship between perceived stress and quality of life.
The impact of COVID-19 home confinement on neuromuscular performance, functional capacity, and psychological state in Spanish people with multiple sclerosis.
Fear of COVID-19, problems accessing medical appointments, and subjective experience of disease progression, predict anxiety and depression reactions in patients with multiple sclerosis.
Fear of relapse, social support, and psychological well-being (depression, anxiety, and stress level) of patients with multiple sclerosis (MS) during the COVID-19 pandemic stage.
Are multiple sclerosis patients and their caregivers more anxious and more committed to following the basic preventive measures during the COVID-19 pandemic?.
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
Assessment of mental health, knowledge, and attitude of patients with multiple sclerosis and neuromyelitis optica spectrum disorder in response to 2019 novel coronavirus.
Mental health status of relapsing-remitting multiple sclerosis Italian patients returning to work soon after the easing of lockdown during COVID-19 pandemic: a monocentric experience.
Tables 3 and 4 provide the details of quality assessment, including rationale. Among the longitudinal studies (n = 6), two items (comparability domain and selection of the non-exposed cohort sub-domain) were not applicable and were not considered in the overall score. Thus, the maximum achievable number of stars for longitudinal studies was 6. The domain that was best addressed by all longitudinal studies was “outcome” and all the six studies were rated full points in this domain. Conversely, the selection domain was poorly addressed by five of the six studies in this group, due to the use of convenience sampling methods and the study cohort not being representative of PwMS in the community. A total of four studies had ≥ 5 points (
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
All cross-sectional studies (n = 15) had a possible risk of selection bias. All but one study in this group had a high risk of bias related to the representativeness of the sample as their sampling was not random. The sample size was justified and satisfactory (including sample size calculation) in only four (26.7%) cross-sectional studies. Seven (46.7%) studies had a satisfactory recruitment rate or summarized the characteristics of non-respondents. All cross-sectional studies utilized a validated psychometric tool to measure mental health outcomes and clearly described their statistical analyses. In total, only four studies in this group were rated ≥ 7 out of 10 (
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
A wide range of assessment tools were used in the included studies. Detailed descriptions of the HRQOL and psychometric scales used are presented in the Supplementary Table 2.
3.3 Anxiety
Anxiety was the primary outcome variable in 16 (84.2%) of the included studies (
The impact of COVID-19 home confinement on neuromuscular performance, functional capacity, and psychological state in Spanish people with multiple sclerosis.
Fear of COVID-19, problems accessing medical appointments, and subjective experience of disease progression, predict anxiety and depression reactions in patients with multiple sclerosis.
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
Assessment of mental health, knowledge, and attitude of patients with multiple sclerosis and neuromyelitis optica spectrum disorder in response to 2019 novel coronavirus.
Fear of relapse, social support, and psychological well-being (depression, anxiety, and stress level) of patients with multiple sclerosis (MS) during the COVID-19 pandemic stage.
Are multiple sclerosis patients and their caregivers more anxious and more committed to following the basic preventive measures during the COVID-19 pandemic?.
Mental health status of relapsing-remitting multiple sclerosis Italian patients returning to work soon after the easing of lockdown during COVID-19 pandemic: a monocentric experience.
Assessment of mental health, knowledge, and attitude of patients with multiple sclerosis and neuromyelitis optica spectrum disorder in response to 2019 novel coronavirus.
Fear of relapse, social support, and psychological well-being (depression, anxiety, and stress level) of patients with multiple sclerosis (MS) during the COVID-19 pandemic stage.
Are multiple sclerosis patients and their caregivers more anxious and more committed to following the basic preventive measures during the COVID-19 pandemic?.
Mental health status of relapsing-remitting multiple sclerosis Italian patients returning to work soon after the easing of lockdown during COVID-19 pandemic: a monocentric experience.
The impact of COVID-19 home confinement on neuromuscular performance, functional capacity, and psychological state in Spanish people with multiple sclerosis.
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
Fear of COVID-19, problems accessing medical appointments, and subjective experience of disease progression, predict anxiety and depression reactions in patients with multiple sclerosis.
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
Mental health status of relapsing-remitting multiple sclerosis Italian patients returning to work soon after the easing of lockdown during COVID-19 pandemic: a monocentric experience.
Are multiple sclerosis patients and their caregivers more anxious and more committed to following the basic preventive measures during the COVID-19 pandemic?.
) of their sample populations. A Turkish study of pediatric MS (n = 30) found that 100% of the sample reported clinically meaningful anxiety during lockdown (
). It is noteworthy that two studies only reported the average severity of anxiety symptoms in their samples rather than the frequency of different severity groups or categories (
Fear of COVID-19, problems accessing medical appointments, and subjective experience of disease progression, predict anxiety and depression reactions in patients with multiple sclerosis.
Fear of relapse, social support, and psychological well-being (depression, anxiety, and stress level) of patients with multiple sclerosis (MS) during the COVID-19 pandemic stage.
The impact of COVID-19 home confinement on neuromuscular performance, functional capacity, and psychological state in Spanish people with multiple sclerosis.
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
). Two studies found a significant increase in anxiety. A Serbian study reported increased levels of anxiety during a COVID-19 lockdown compared to the pre-pandemic period (HAM-A: 18.9 ± 5.1 vs. 15.8 ± 4.7; p < 0.05) (
). Similarly, a Spanish study found a significant increase in state anxiety (i.e., anxiety about an event) (STAI: 22.1 ± 11.8 vs. 17.40 ± 12.8; p = 0.01) but not in trait anxiety (i.e., anxiety level as a personal characteristic) (STAI: 21.8 ± 9.8 vs. 20.6 ± 11.1; p = 0.19) among PwMS after ease of the lockdown compared with the pre-lockdown period (
The impact of COVID-19 home confinement on neuromuscular performance, functional capacity, and psychological state in Spanish people with multiple sclerosis.
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
). A large longitudinal study in the UK (n = 2226) did not show a significant increase in the severity of anxiety symptoms (HADS-A(IQR): 6 (3–10) vs. 6 (3–10); p = 0.87) or the proportion of sample with a clinically significant anxiety (470 (21.1%) vs. 463 (20.8%);p = 0.72) during the outbreak compared to the year before (
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
Two studies found that PwMS had significantly higher levels of anxiety during lockdown compared to controls: one in Egypt (12.7 ± 10.0 vs. 9.3 ± 6.7; p < 0.001) (
Are multiple sclerosis patients and their caregivers more anxious and more committed to following the basic preventive measures during the COVID-19 pandemic?.
Assessment of mental health, knowledge, and attitude of patients with multiple sclerosis and neuromyelitis optica spectrum disorder in response to 2019 novel coronavirus.
) did not find a difference between PwMS and controls. Similarly, results from a large cross-sectional study (n = 1714 PwMS/269 controls) in the UK did not report significant differences in median symptom severity (GAD-7(IQR): 4(1–8) vs. 4 (1–7);p = 0.81) or frequency of participants with anxiety (19.5% vs. 16.7%; p = 0.29) between PwMS and controls (
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
). Among a pediatric MS sample in Turkey, the average state anxiety level was significantly higher than among age-and sex-matched controls. However, trait anxiety was not significantly different between groups (
Fear of COVID-19, problems accessing medical appointments, and subjective experience of disease progression, predict anxiety and depression reactions in patients with multiple sclerosis.
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
Assessment of mental health, knowledge, and attitude of patients with multiple sclerosis and neuromyelitis optica spectrum disorder in response to 2019 novel coronavirus.
Fear of relapse, social support, and psychological well-being (depression, anxiety, and stress level) of patients with multiple sclerosis (MS) during the COVID-19 pandemic stage.
Are multiple sclerosis patients and their caregivers more anxious and more committed to following the basic preventive measures during the COVID-19 pandemic?.
Mental health status of relapsing-remitting multiple sclerosis Italian patients returning to work soon after the easing of lockdown during COVID-19 pandemic: a monocentric experience.
Fear of COVID-19, problems accessing medical appointments, and subjective experience of disease progression, predict anxiety and depression reactions in patients with multiple sclerosis.
Assessment of mental health, knowledge, and attitude of patients with multiple sclerosis and neuromyelitis optica spectrum disorder in response to 2019 novel coronavirus.
Fear of relapse, social support, and psychological well-being (depression, anxiety, and stress level) of patients with multiple sclerosis (MS) during the COVID-19 pandemic stage.
Are multiple sclerosis patients and their caregivers more anxious and more committed to following the basic preventive measures during the COVID-19 pandemic?.
Mental health status of relapsing-remitting multiple sclerosis Italian patients returning to work soon after the easing of lockdown during COVID-19 pandemic: a monocentric experience.
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
Four studies reported the proportion of PwMS with clinically significant depressive symptoms, which ranged from 12 to 39% during the COVID-19 pandemic (
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
Are multiple sclerosis patients and their caregivers more anxious and more committed to following the basic preventive measures during the COVID-19 pandemic?.
Mental health status of relapsing-remitting multiple sclerosis Italian patients returning to work soon after the easing of lockdown during COVID-19 pandemic: a monocentric experience.
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
). Two studies found a significant increase in depression scores during the pandemic. A multicentre study among progressive MS cases in North America and Europe found significantly higher depression scores (HADS: 6.7 ± 4.6 vs. 5.8 ± 3.7; p = 0.03) during lockdown compared to baseline. Interestingly, this result was mainly driven by the substantial increase in cases from Belgium (HADS: 6.7 ± 6.1; p < 001) whilst the remaining five countries (Denmark, Canada, the United Kingdom, Italy and the USA) reported minor changes (
). A Turkish study also showed a significant increase in depression scores during a pandemic peak compared to the early stages of the outbreak (BDI: 16.4 ± 9.5 vs. 12.6 ± 8.2; p < 0.001) (
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
). A large longitudinal study in the UK (n = 2226) showed that the median depressive symptom severity among PwMS had not significantly changed during the outbreak and lockdown compared to the year before (HADS(IQR): 7 (3–10) vs. 6 (3–10); p = 0.23). Similarly, the proportion of participants with clinically significant depression did not change during the follow-up compared with the year before (475 (21.3%) vs. 470 (21.1%) p = 0.81) (
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
In four of the five studies in which it was assessed, PwMS showed significantly higher levels of depression than healthy controls during the pandemic or lockdown period (
Are multiple sclerosis patients and their caregivers more anxious and more committed to following the basic preventive measures during the COVID-19 pandemic?.
). For example, studies from Italy (n = 612PwMS/674controls, 43.1 vs. 23.1%;p < 0.001) and the UK (n = 1751PwMS/269controls, 32.7 vs. 23.8%; p = 0.003) reported a significantly higher proportion of depression among PwMS compared to controls (
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
Assessment of mental health, knowledge, and attitude of patients with multiple sclerosis and neuromyelitis optica spectrum disorder in response to 2019 novel coronavirus.
Coping with stress during the first wave of the COVID-19 pandemic by Turkish people with multiple sclerosis: the relationship between perceived stress and quality of life.
Coping with stress during the first wave of the COVID-19 pandemic by Turkish people with multiple sclerosis: the relationship between perceived stress and quality of life.
), and one used a multi-attribute utility instrument to assess health state utilities (EuroQol's EQ-5D) and the Multiple Sclerosis Impact Scale (MSIS-29) (
Coping with stress during the first wave of the COVID-19 pandemic by Turkish people with multiple sclerosis: the relationship between perceived stress and quality of life.
). In an online survey in the USA, 4.5% of respondents were below the clinical cut-off for positive affect and wellbeing, which are proxies of emotional health and distress (
). A Turkish study reported the average score of the mental health component of HRQOL (SF-12: 43.2 ± 10.4) among a sample of PwMS without any comparator (
Coping with stress during the first wave of the COVID-19 pandemic by Turkish people with multiple sclerosis: the relationship between perceived stress and quality of life.
Three longitudinal studies used the MSQoL-54 to evaluate HRQOL before or during the early months of COVID-19 pandemic and then again during a lockdown period (
). All studies reported a decline in the average mental health subscale score later in the pandemic compared to pre- or early in the pandemic. However, the reduction was only statistically significant (60.5 ± 10.7 vs. 64.4 ± 9.9; p < 0.001) in one study (
); both found that PwMS had a lower HRQOL. A Serbian study found that PwMS had considerably lower mental health super-dimension scores than healthy controls (47.1 ± 18.4 vs. 77.2 ± 19.7; p < 0.01) (
). Similarly, an Italian study reported significantly higher scores (i.e., worse QoL) in multiple domains of the NeuroQoL instrument, including depression (15.5 ± 7.0 vs. 13.9 ± 5.8; p = 0.005), emotional dyscontrol (17.9 ± 7.0 vs. 16.5 ± 6.3; p = 0.01) and sleep disturbances (16.7 ± 6.0 vs. 15.4 ± 5.5; p = 0.02), among PwMS compared with a control group of family members or friends not living with MS. The latter study accounted for pre-existing psychiatric conditions and comorbidities in their analysis (
Eight studies (42.1%) assessed stress among PwMS during the COVID-19 pandemic. All eight reported the frequency of stress-related symptoms. Four studies assessed stress among PwMS during the COVID-19 pandemic using the DASS-21 (
Assessment of mental health, knowledge, and attitude of patients with multiple sclerosis and neuromyelitis optica spectrum disorder in response to 2019 novel coronavirus.
Fear of relapse, social support, and psychological well-being (depression, anxiety, and stress level) of patients with multiple sclerosis (MS) during the COVID-19 pandemic stage.
Are multiple sclerosis patients and their caregivers more anxious and more committed to following the basic preventive measures during the COVID-19 pandemic?.
Mental health status of relapsing-remitting multiple sclerosis Italian patients returning to work soon after the easing of lockdown during COVID-19 pandemic: a monocentric experience.
Mental health status of relapsing-remitting multiple sclerosis Italian patients returning to work soon after the easing of lockdown during COVID-19 pandemic: a monocentric experience.
Are multiple sclerosis patients and their caregivers more anxious and more committed to following the basic preventive measures during the COVID-19 pandemic?.
Coping with stress during the first wave of the COVID-19 pandemic by Turkish people with multiple sclerosis: the relationship between perceived stress and quality of life.
Coping with stress during the first wave of the COVID-19 pandemic by Turkish people with multiple sclerosis: the relationship between perceived stress and quality of life.
Mental health status of relapsing-remitting multiple sclerosis Italian patients returning to work soon after the easing of lockdown during COVID-19 pandemic: a monocentric experience.
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
Mental health status of relapsing-remitting multiple sclerosis Italian patients returning to work soon after the easing of lockdown during COVID-19 pandemic: a monocentric experience.
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
Assessment of mental health, knowledge, and attitude of patients with multiple sclerosis and neuromyelitis optica spectrum disorder in response to 2019 novel coronavirus.
Are multiple sclerosis patients and their caregivers more anxious and more committed to following the basic preventive measures during the COVID-19 pandemic?.
Assessment of mental health, knowledge, and attitude of patients with multiple sclerosis and neuromyelitis optica spectrum disorder in response to 2019 novel coronavirus.
Are multiple sclerosis patients and their caregivers more anxious and more committed to following the basic preventive measures during the COVID-19 pandemic?.
) found that stress was significantly higher among PwMS compared to healthy controls (Iran: 13.1 ± 9.9 vs. 9.6 ± 8.4; p = 0.02; Egypt: 21.0 ± 12.7 vs. 10.7 ± 8.4; p < 0.001) during the pandemic. Similarly, an Italian cross-sectional study reported that a significantly higher number of PwMS had high levels of perceived stress compared to controls (58% vs. 39.8%; p < 0.001) (
). In contrast, a large study in the UK (n = 1696 PwMS/306 control) found no difference between PwMS and controls in the prevalence of PTSD symptoms during the outbreak (OR: 1.13, 95%CI: 0.84–1.52). Further, this study found that the median PTSD symptom severity was significantly lower in PwMS than controls (IES-R:16(6–32) vs. 20(10–33); p = 0.01) (
Mental health of people with multiple sclerosis during the COVID-19 outbreak: a prospective cohort and cross-sectional case-control study of the UK MS Register.
Mental health status of relapsing-remitting multiple sclerosis Italian patients returning to work soon after the easing of lockdown during COVID-19 pandemic: a monocentric experience.
). One study used the Insomnia Severity Index (ISI) to measure sleep quality in participants with RRMS. This study reported that 28.7% of cases had subthreshold insomnia and 29.6% had moderately severe or severe clinical insomnia (
Mental health status of relapsing-remitting multiple sclerosis Italian patients returning to work soon after the easing of lockdown during COVID-19 pandemic: a monocentric experience.
Sleep quality was longitudinally evaluated in one study. Demir and colleagues used the Pittsburgh Sleep Quality Index (PSQI); they found a significantly higher PSQI score (8.8 ± 1.5 vs. 8.3 ± 1.4; p < 0.001), indicating more acute sleep disturbances, during lockdown compared with the pre-lockdown period among PwMS (
Similarly, only one of the included studies compared sleep quality between PwMS and health controls. In this Italian study, PwMS showed significantly more disturbed sleep than healthy controls (6.9 ± 3.7 vs. 4.7 ± 2.7; p = 0.001) (
To our knowledge, this is the first systematic review to synthesize evidence on the impact of the COVID-19 pandemic on the mental health of PwMS. We identified 19 studies that met our inclusion criteria. Studies reported a variety of mental health-related outcomes including anxiety, depression, HRQOL, stress and sleep quality, and used a variety of tools to measure these outcomes. Due to the observed heterogeneity in measurement scales and in reporting, we decided to focus this review on data synthesis. The available evidence, which was mainly derived from the early stages of the pandemic, indicates that anxiety, depression and stress have been prevalent among PwMS during the COVID-19 pandemic. Further, there is convincing evidence that PwMS experienced more severe symptoms of depression and stress compared to healthy and more limited evidence that PwMS have worse HRQOL compared to controls during the pandemic. However, these results may reflect the status quo, rather than the impact of the COVID-19 epidemic. Longitudinal studies among PwMS demonstrate that anxiety, depression and the mental health dimensions of HRQOL were generally not significantly affected during the pandemic and/or lockdown compared with the period before the COVID-19 outbreak.
Anxiety and depression are prevalent coexisting medical conditions among PwMS (
CIHR Team in Defining the Burden and Managing the Effects of Psychiatric Comorbidity in Chronic Immunoinflammatory Disease Estimating annual prevalence of depression and anxiety disorder in multiple sclerosis using administrative data.
). A recent meta-analysis reported that the overall prevalence of anxiety and depression in the general population during the COVID-19 pandemic was 23.4% (95%CI: 19.9–27.3%) and 23.9% (95% CI: 18.4–30.3%), respectively (
). In our review, with the different scales used by the included studies, the prevalence estimates for anxiety among PwMS during the COVID-19 pandemic ranged from 16 to 31%, which does not seem higher than the meta-analysis estimate of 22.1% (95% CI:15.2%−31.0%) of studies conducted prior to the pandemic (
). For depression, the prevalence estimates of our included studies ranged from 12 to 39%, while the meta-analysis estimate of studies prior to the pandemic was 30.5% (95%CI:26.3%−35.1%) (
). However, three other studies included in this review that only assessed different severity levels of anxiety and depression (i.e., mild to extremely severe) found higher frequencies of severe to extremely severe anxiety and depression than those mentioned above (14–45% of PwMS) (
Are multiple sclerosis patients and their caregivers more anxious and more committed to following the basic preventive measures during the COVID-19 pandemic?.
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