Assessing and Managing Depression in Multiple Sclerosis

Guideline Watch |
January 7, 2014

Assessing and Managing Depression in Multiple Sclerosis

  1. Robert T. Naismith, MD

Emotional disorders are common and should be assessed in MS clinical practice.

  1. Robert T. Naismith, MD

Sponsoring Organization: Guideline Development Subcommittee of the American Academy of Neurology

Target Population: Neurologists, psychiatrists, primary care providers

Background and Objective

An expert panel reviewed 115 relevant articles on emotional disorders in MS to derive these evidence-based guidelines.

Key Points or Recommendations


  • Undiagnosed and untreated psychiatric illness in MS may lead to reduced quality of life, decreased disease-modifying therapy adherence, worse disease outcomes, and suicide.

  • Patients with MS are at increased risk for major depression and anxiety, adjustment, psychotic, and bipolar disorders.

  • The Beck Depression Inventory (BDI) may be considered to identify major depressive disorder in patients with MS (Level C Recommendation). Scores over 17 may indicate depression and scores of 10 to 17 may indicate dysphoria.

  • Depression can also be screened by inquiring about (1) a depressed mood and (2) diminished interest or pleasure in prior activities (Level C Recommendation).

  • The Center for Neurologic Study Emotional Lability Scale may be used to screen for pseudobulbar affect (Level C Recommendation).


  • Insufficient evidence exists regarding use of individual in-person cognitive behavioral therapy and pharmacologic antidepressants in MS. One trial suggested that a 16-week telephone-administered cognitive behavioral therapy program could be beneficial.

  • For distressing pseudobulbar affect symptoms in MS, dextromethorphan/quinidine may be beneficial (Level C Recommendation).


Psychiatric disorders in MS are common, perhaps resulting from structural brain lesions, and contribute to increased morbidity and mortality but are potentially treatable if detected and appropriately managed. This subcommittee found few studies to guide detection and treatment of emotional disorders in MS. Current practice is based on evidence from outside the MS population. Such practice may be acceptable for now, but future research should help clarify the role and effectiveness of various pharmacologic and nonpharmacologic treatments.

Editor Disclosures at Time of Publication

  • Disclosures for Robert T. Naismith, MD at time of publication Consultant / Advisory board Acorda Therapeutics; Biogen Idec; EMD Serono; Genzyme; Questcor Speaker's bureau Acorda Therapeutics; Bayer Healthcare; Biogen Idec; Genzyme Grant / research support NIH; Acorda Therapeutics; National Multiple Sclerosis Society Leadership positions in professional societies Consortium of MS Centers (Speaker); National Multiple Sclerosis Society (Local Chair of Clinical Advisory Committee; Program Services Committee, Research Advocate, and Research Champion)


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