Haji Akhoundi, F.

Naser Moghadasi, A.

Sahraian, M.A.

eprints Iran University of Medical Sciences

Contents lists available at ScienceDirectMultiple Sclerosis and Related Disordersjournal homepage: www.elsevier.com/locate/msardCommentaryNeuropsychiatric and cognitive effects of the COVID-19 outbreak onmultiple sclerosis patientsFahimeh Haji Akhoundia, Mohammad Ali Sahraianb, Abdorreza Naser Moghadasib,⁎aNeurology department, Firoozgar Hospital, Iran University of Medical Sciences, Tehran, IranbMultiple Sclerosis Research Center, Neuroscience institute; Tehran University of Medical Sciences, Tehran, IranThe COVID-19 pandemic is the most disastrous pneumonia outbreakto date. Only 3 months after the initial patients were described in thecity of Wuhan in China, hundreds of thousands of confirmed cases havebeen reported worldwide. The aim of this manuscript is to assess howthis pandemic can affect the cognitive and neuropsychiatric functions ofmultiple sclerosis (MS) patients and to propose preventive measures.The neuropsychiatric effects of the viral pandemics on general po-pulation have previously been demonstrated. During the COVID-19pandemic in China, 53.8% of the 1210 respondents in a cross sectionalstudy reported to bear moderate to severe psychological impact of theoutbreak. Being a female, a student or having specific physical symp-toms including coughs, myalgia and chills and a poor self-rated healthstatus were factors associated with the psychological impact, anxietyand depression caused by the pandemic (Wang et al., 2020). Anotherstudy showed anxiety and stress disorder rates to be 23% and 27%respectively among the medical staff of a hospital in China(Huang et al., 2020).Patients with MS are specifically vulnerable to the neuropsychiatricimpacts of the COVID-19 pandemic. Variable degrees of cognitive andneuropsychiatric involvement already exist in MS patients. Cognitivedysfunction affects up to 70% of MS patients. It can be present even inthe early stages of the disease, and is especially pronounced in the in-formation processing speed and immediate and episodic memory do-mains (Oreja-Guevara et al., 2019). Anxiety and depression have beenreported in up to 57% (Butler et al., 2016) and 40% (Feinstein et al.,2014) of these patients respectively which is highly above the rates ingeneral population. Depression and anxiety result in a lower quality oflife, increased fatigue and disability scores, and a more aggressive MScourse (Patel et al., 2018). They have been shown to result in diseaseexacerbations and decreased treatment adherence in MS patients(Mohr and Cox, 2001). Additionally, several studies have shown thatanxiety and depression can further impair cognitive function in MSpatients. Depression negatively affects cognition by direct and indirectmechanisms, through reducing information processing speed and de-leterious effects on cognitive reserve respectively (Lester et al., 2007).Researchers have shown that anxiety harms verbal learning in MS pa-tients, probably through interfering with attention and informationprocessing speed. They have suggested that treatment of anxiety mayimprove cognitive function of MS patients (Vissicchio et al., 2019).Just as any other member of the society, MS patients are disturbedby the emotional distress and health anxiety caused by the COVID-19outbreak. However, patients with MS are known to undertake mala-daptive coping strategies (Amato et al., 2019) which will make themeven more susceptible to the detrimental neuropsychiatric effects of theoutbreak. Most MS patients are on immunosuppressive or im-munomodulatory therapies. Patients on immunosuppressive agents aretheoretically at increased risk of being affected by viral pandemics anda higher level of health anxiety in this group of patients is anticipated.Moreover, MS patients are losing social support; they have no longeraccess to group therapies and cognitive and physical rehabilitationtherapies which could all hypothetically add to the level and stress andanxiety perceived by these patients.The impacts of cognitive dysfunction in MS patients are extensive,hence its treatment have been an area of focus in recent years. Since nopharmacologic agent has proved significant efficacy in symptomatictreatment of cognitive dysfunction in MS patients, physicians aim toundertake preventive strategies for cognitive decline to happen andprogress. This highlights the importance of addressing stress and an-xiety in MS patients particularly during demanding environmentalconditions such as viral outbreaks.Considering the rapid worldwide spread of the COVID-19 outbreak,MS specialists should adapt a strategy to monitor MS patients forneuropsychiatric complications and also opt for applicable treatmentoptions. When planning support strategies special attention should beplaced on patients more at risk to develop cognitive and neu-ropsychiatric complications, including patients with higher level ofdisability, those who are taking immunosuppressive therapies, patientsat a progressive stage and patients with comorbid medical conditions.We suggest monitoring high risk MS patients using easily phone ap-plicable anxiety scales and to consider therapeutic options includingonline support, at home yoga and exercise programs, and antianxietymedications when needed.Long term effects of the neuropsychiatric complications of thispandemic on the cognitive function and disability status of MS patientshttps://doi.org/10.1016/j.msard.2020.102164Received 25 April 2020; Accepted 27 April 2020⁎ Corresponding author: Abdorreza Naser Moghadasi, Sina MS research Center, Sina Hospital, Tehran University of Medical Sciences, Hasan Abad Sq., Tehran, IranE-mail address: abdorrezamoghadasi@gmail.com (A. Naser Moghadasi).Multiple Sclerosis and Related Disorders 41 (2020) 1021642211-0348/ © 2020 Elsevier B.V. All rights reserved.Tis also a subject for future research.Declaration of Competing InterestThe authors declare there is no conflict of interest.FundingThis study is not funded.ReferencesWang, C, Pan, R, Wan, X, Tan, Y, Xu, L, Ho, CS, et al., 2020. Immediate psychologicalresponses and associated factors during the initial stage of the 2019 coronavirusdisease (COVID-19) epidemic among the general population in China. Int J EnvironRes Public Health 17. https://doi.org/10.3390/ijerph17051729.Huang, JZ, Han, MF, Luo, TD, Ren, AK, Zhou, XP, 2020. [Mental health survey of 230medical staff in a tertiary infectious disease hospital for COVID-19]. Zhonghua LaoDong Wei Sheng Zhi Ye Bing Za Zhi 38, E001. https://doi.org/10.3760/cma.j.cn121094-20200219-00063.Butler, E, Matcham, F, Chalder, T, 2016. A systematic review of anxiety amongst peoplewith Multiple Sclerosis. Mult Scler Relat Disord 10, 145–168. https://doi.org/10.1016/j.msard.2016.10.003.Feinstein, A, Magalhaes, S, Richard, JF, Audet, B, Moore, C, 2014. The link betweenmultiple sclerosis and depression. Nat Rev Neurol 10, 507–517. https://doi.org/10.1038/nrneurol.2014.139.Oreja-Guevara, C, Blanco, TA, Ruiz, LB, MÁH, Pérez, Meca-Lallana, V, Ramió-Torrentà, L,2019. Cognitive dysfunctions and assessments in multiple sclerosis. Front Neurol 10,581. https://doi.org/10.3389/fneur.2019.00581.Patel, VP, Walker, LA, Feinstein, A, 2018. Revisiting cognitive reserve and cognition inmultiple sclerosis: A closer look at depression. Mult Scler 24, 186–195. https://doi.org/10.1177/1352458517692887.Mohr, DC, Cox, D, 2001. Multiple sclerosis: Empirical literature for the clinical healthpsychologist. J Clin Psychol 57, 479–499. https://doi.org/10.1002/jclp.1042.Lester, K, Stepleman, L, Hughes, M, 2007. The Association of Illness Severity, Self-Reported Cognitive Impairment, and Perceived Illness Management with Depressionand Anxiety in a Multiple Sclerosis Clinic Population. J Behav Med 30. https://doi.org/10.1007/s10865-007-9095-6.Vissicchio, NA, Altaras, C, Parker, A, Schneider, S, Portnoy, JG, Archetti, R, et al., 2019.Relationship Between Anxiety and Cognition in Multiple Sclerosis. Int J MS Care 21,151–156. https://doi.org/10.7224/1537-2073.2018-027.Amato, MP, Prestipino, E, Bellinvia, A, 2019. Identifying risk factors for cognitive issuesin multiple sclerosis. Expert Rev Neurother 19, 333–347. https://doi.org/10.1080/14737175.2019.1590199.F. Haji Akhoundi, et al. Multiple Sclerosis and Related Disorders 41 (2020) 1021642

Neuropsychiatric and cognitive effects of the COVID-19 outbreak on multiple sclerosis patients

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Neuropsychiatric and cognitive effects of the COVID-19 outbreak on multiple sclerosis patients

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