| Abstract|| |
Background: Psychiatric morbidity may be highly prevalent in transverse myelitis (TM), but data on this aspect are limited.
Aim: To assess psychiatric morbidity in a clinical sample of patients with idiopathic TM compared to patients with a recent stroke.
Materials and Methods: Consecutive patients with idiopathic TM and stroke (30 each) underwent two-stage screening with the General Health Questionnaire-12 (GHQ-12) and Structured Clinical Interview for Axis I DSM-IV Disorders - Clinician Version (SCID I-CV), and ratings of depression, disability levels, and cognitive impairment.
Results: Seventy percent of the patients with TM scored above the cut-off on the GHQ; 30% had a positive diagnosis of a psychiatric disorder. Major depression (17%) was the commonest psychiatric disorder. Mini-Mental State Examination (MMSE) scores indicated cognitive impairment in 23% of patients with TM. Higher GHQ-12 scores were associated with greater disability. These results were similar to those obtained among patients with stroke.
Conclusion: A high prevalence of psychological distress and psychiatric morbidity was found in idiopathic TM. This morbidity was associated with greater disability.
Keywords: Psychiatric morbidity, stroke, transverse myelitis
|How to cite this article:|
Baweja R, Avasthi A, Chakrabarti S, Prabhakar S. Psychiatric morbidity in patients with transverse myelitis and stroke: A comparison. Indian J Psychiatry 2013;55:59-62
| Introduction|| |
Transverse myelitis (TM) is a rare syndrome characterized by focal inflammation within a restricted area of the spinal cord.  The resultant neural dysfunction manifests clinically as acutely/subacutely occurring motor, sensory, and autonomic symptoms. While a third of the patients may recover completely, the rest are left with moderate to severe degrees of permanent physical disability. TM exists on a continuum of neuroinflammatory disorders, which also includes multiple sclerosis, acute disseminated encephalomyelitis, and neuromyelitis optica. TM can present either as an idiopathic condition, or is associated with known inflammatory diseases such as multiple sclerosis, systemic lupus erythematosus, Sjogren syndrome, or neurosarcoidosis.
Psychiatric morbidity, particularly depression, is very common in these disorders. The association between multiple sclerosis and affective disorders has been extensively examined. ,, Studies among clinical and community samples of patients with multiple sclerosis have established that depressive disorders occur at rates higher than among the general population, or most other patients with chronic neurological or medical disorders. The available evidence also suggests that the presence of depression in multiple sclerosis adversely affects patients' quality of life and functioning, and contributes to the higher risk of suicide among them. In contrast, psychiatric morbidity in TM has hardly been explored, though it is commonly believed that rates of depression in TM are at least equal, if not greater, to those of multiple sclerosis.  This prompted the current study, which investigated the extent and nature of psychiatric morbidity in a clinical sample of patients with idiopathic TM, compared to a control group of patients who had suffered a recent stroke.
| Materials and Methods|| |
The study protocol was approved by the research and ethics committees of the institute where it was conducted. Written informed consent was obtained from all participants; patient anonymity and other ethical safeguards were also maintained during the study.
The study group included patients with a diagnosis of idiopathic TM according to the "Transverse Myelitis Consortium Working Group" criteria,  with a duration between 3 and 6 months and physical disability scores >3 on the Modified Rankin Scale.  Subjects were excluded if they had any other chronic neurological disorders, severe speech or cognitive impairment, or were too ill to complete the assessments. Consecutive sampling over 7 months yielded 36 patients of TM; six of these had to be excluded because they did not satisfy the selection criteria or refused consent. The control group included 30 consecutive patients with first episode of stroke (eight exclusions). All control subjects met World Health Organization (WHO) criteria for stroke, ischemic subtype, according to the Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) manual;  had physical disability scores >3 on the Modified Rankin Scale, and were assessed within 3-6 months of the stroke.
All subjects underwent first-stage screening with the Hindi version of General Health Questionnaire-12 (GHQ-12).  Those scoring more than the cut-off score of 3 underwent further psychiatric assessment employing the Structured Clinical Interview for Axis I DSM-IV Disorders - Clinician Version (SCID I-CV).  Cognitive impairment was assessed using the Mini-Mental State Examination (MMSE).  Levels of psychosocial disability were evaluated using the Schedule for Assessment of Psychiatric Disability (SAPD),  an Indian adaptation of the WHO Disability Assessment Schedule-II. Those with depression were additionally rated using the Hamilton Rating Scale for Depression (HDRS). 
| Results|| |
Majority of the patients included were middle-aged males. Most of them were from low-income, urban backgrounds. Comparisons of patients included ( n=60) and those excluded ( n=14) revealed no significant differences on any clinical or demographic parameter, indicating that the study sample was a truly representative one. Patients with TM were significantly younger and less likely to be married. Apart from this, the two groups were identical in their clinical and demographic profile.
A very high (and identical) proportion of patients in both groups scored more than the cut-off on the GHQ-12, and about a third had a positive diagnosis of a psychiatric disorder. Major depressive disorder was the commonest psychiatric category with 17% of the patients with TM qualifying for this diagnosis. This was followed by generalized anxiety disorder (7%), somatoform disorder (3%), and other neurotic disorders (3%). Depression in patients with TM was mainly of the mild/moderate variety as per HDRS scores. Patients with stroke had a comparable profile, with major depression (23%) being the commonest diagnosis followed by other neurotic disorders. Over a fifth of patients with TM (23%) scored less than 23 on the MMSE, indicating cognitive impairment. Though the proportion of such patients (40%) was greater in the stroke group, this difference was not significant. Additionally, the two groups did not differ significantly on measures of psychosocial disability (SAPD scores).
The association of GHQ-12 scores with demographic variables, duration of illness, and levels of physical and psychosocial disability was examined using Spearman's correlation coefficients among patients who had scored more than the cut-off in both groups. Higher total GHQ-12 scores had significant positive correlations only with SAPD subscales of overall disability, social and occupational role in the TM group, and significant positive correlations with all the SAPD subscale scores in the group with stroke. These results are depicted in [Table 1].
|Table 1: Patients with transverse myelitis and stroke: Clinical and demographic profile, psychological distress, and psychiatric morbidity|
Click here to view
| Discussion|| |
The principal finding of this study was the high rates of psychological distress and psychiatric morbidity obtained among patients with idiopathic TM. Seventy percent of the patients with TM scored above the cut-off on the GHQ. This was strikingly similar to the rate of "GHQ-positive" subjects in a previous Indian study of patients with stroke and other spinal cord pathology, including TM.  The prevalence of psychiatric morbidity (30%) and of major depressive disorder (17%) among patients of TM in this study was also similar to that found among patients with different neurological disorders, including stroke, spinal cord injury, demyelinating disorders, neurodegenerative disorders, and epilepsy. ,,, However, comparisons with multiple sclerosis were probably more relevant since TM shares many features with this condition. Unlike TM, psychiatric morbidity has been more comprehensively investigated in multiple sclerosis. Several clinical and community studies have consistently yielded rates of depressive disorder in the range of 14-30% among patients with multiple sclerosis. ,, The prevalence of depression in TM is believed to be comparable, though research data on this aspect are extremely limited.  Consequently, the current study is one of the very few to provide reliable estimates of psychological/psychiatric morbidity, including depression, in a clinical population of patients with idiopathic TM. The results clearly endorse similarities between TM and multiple sclerosis with regard to the high prevalence of depression and other psychiatric disorders. Furthermore, the significant association between psychological distress and psychosocial disability found in this study clearly indicates that patients with psychological/psychiatric morbidity are more disabled than those who do not have such additional morbidity. This replicates the well-known association between severity of distress/depression and levels of disability, which has been demonstrated in several chronic neurological disorders (including multiple sclerosis) and other medical conditions such as cancer or coronary artery disease. ,,
About a quarter of the patients with TM had MMSE scores below the usual cut-off, which was suggestive of cognitive impairment. This could be partly attributed to psychological symptoms. Nevertheless, such impairment is significant because cognitive deficits, either based on MMSE scores or on more extensive neuropsychological assessment, have been reported earlier, both among patients with TM and those with multiple sclerosis.  In this regard, the similarities between patients with TM and stroke in terms of psychological/psychiatric morbidity and cognitive impairment found in this study may also be of some relevance. Patients with stroke were chosen as controls since the disorder mimics TM in many aspects such as onset, nature of symptoms, and range of physical disability. However, the involvement of the brain is more obvious in stroke than in TM, which is traditionally viewed solely as a disorder of the spinal cord.  The fact that both patients with TM and stroke had comparable extents of psychiatric morbidity and cognitive impairment suggests the possibility of brain substrates mediating psychopathology in TM as well. If this is indeed so, immune-mediated brain changes could be the most likely mechanism, as is being increasingly demonstrated in multiple sclerosis. 
Although this study was based on a representative clinical sample of patients and employed standardized methods to detect psychological morbidity, it had several methodological problems. Chief among these was the small size of the study sample, which was obtained from a single tertiary care center. Therefore, the results can only be considered as preliminary, and cannot be generalized unless replicated among larger and more diverse patient populations.
Despite these limitations, certain conclusions are possible. The high prevalence of psychological morbidity documented in this study undoubtedly indicates that this aspect of TM deserves much more research attention. More importantly, clinicians need to be aware of the high prevalence of psychiatric morbidity in TM, as well as its association with distress and disability. Accordingly, a high index of suspicion, early psychiatric consultation, and adequate intervention should be the appropriate standard of care for patients with TM who suffer from depression and other psychiatric disorders.
| References|| |
|1.||Kaplin A. Depression in TM. Transverse myelitis association newsletters. 2003. p. 5. Available from: http://www.myelitis.org/newsletters/v5n2/newsletter5-2-03.htm. [Last accessed on 2010 Jun 26]. |
|2.||Patten SB, Svenson LW, Metz LM. Descriptive epidemiology of affective disorders in multiple sclerosis. CNS Spectr 2005;10:365-71. |
|3.||Chwastiak L, Ehde DM, Gibbons LE, Sullivan M, Bowen JD, Kraft GH. Depressive symptoms and severity of illness in multiple sclerosis: Epidemiologic study of a large community sample. Am J Psychiatry 2002;159:1862-8. |
|4.||Transverse Myelitis Consortium Working Group. Proposed diagnostic criteria and nosology of acute transverse myelitis. Neurology 2002;59:499-505. |
|5.||van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J. Inter-observer agreement for the assessment of handicap in stroke patients. Stroke 1988;19:604-7. |
|6.||World Health Organization. MONICA Manual, Part IV: Event Registration. 1999. Available from: http://www.ktl.fi/publications/monica/manual/part 4/iv-2.htm. [Last accessed on 2005 Jun 16]. |
|7.||Goldberg DP, Hillier VF. A scaled version of the general health questionnaire. Psychol Med 1979;9:139-45. |
|8.||First MB, Spitzer RL, Gibbons M, Williams JBW. Structured clinical interview for axis I DSM-IV axis I disorders, clinician version (SCID-CV). Washington, DC: American Psychiatric Press; 1996. |
|9.||Folstein MF, Folstein SE, McHugh PR. Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189-98. |
|10.||Thara R, Rajkumar S, Valecha V. The schedule for assessment of psychiatric disability-a modification of the das-ii. Indian J Psychiatry 1988;30:47-53. |
|11.||Hamilton M. A rating scale for depression. J Neurol Neurosurg psychiatry 1960;23:560-2. |
|12.||Gupta A, Deepika S, Taly AB, Srivastava A, Surender V, Thyloth M. Quality of life and psychological problems in patients undergoing neurological rehabilitation. Ann Indian Acad Neurol 2008;11:225-30. |
|13.||Schiffer RB. Depression in neurological practice: Diagnosis, treatment, implications. Semin Neurol 2009;29:220-33. |
|14.||Kennedy P, Rogers BA. Anxiety and depression after spinal cord injury: A longitudinal analysis. Arch Phys Med Rehabil 2000;81:932-7. |
|15.||Weisbrot DM, Ettinger AB, Gadow KD, Belman AL, MacAllister WS, Milazzo M. Psychiatric comorbidity in pediatric patients with demyelinating disorders. J Child Neurol 2010;25:192-202. |
|16.||Hays RD, Wells KB, Sherbourne CD, Rogers W, Spritzer K. Functioning and well-being outcomes of patients with depression compared with chronic general medical illnesses. Arch Gen Psychiatry 1995;52:11-9. |
|17.||Mohr DC, Goodkin DE, Islar J, Hauser SL, Genain CP. Treatment of depression is associated with suppression of nonspecific and antigen-specific T (H) 1 responses in multiple sclerosis. Arch Neurol 2001;58:1081-6. |
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None