"My sister wants to kill me": A case report and systematic review of literature of co-occurring multiple sclerosis and psychosis.

Background: Multiple sclerosis (MS) is a neurological disorder with demyelination of neuronal matter, especially of white matter, with multiple episodes occurring temporally. It has been associated with multiple neurological and psychiatric sequelae. Depression and other affective symptoms are commonly associated with MS. Previous research has also suggested that psychotic symptoms may co-occur with MS as well. Material and Methods: A case report was prepared on the patient admitted to the inpatient unit. Subsequently, a systematic literature review of literature was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) model on three databases. Search terms included (MS OR multiple sclerosis) AND (Psychosis OR schizophrenia OR schizoaffective disorder OR psychotic OR hallucination OR delusion). Results: The literature review led to an initial discovery of 2711 hits on PubMed, 1276 hits on PsycINFO, and 5429 hits on Embase. Some patients were diagnosed with MS at an earlier age with a later onset of psychosis, while some were initially diagnosed with psychosis (or schizophrenia) first and subsequently with MS. Psychotic symptoms observed included persecutory delusions, lack of insight, delusions of reference, auditory hallucinations, grandiose delusions, and passivity. The commonly prescribed antipsychotics included risperidone, olanzapine, quetiapine, and aripiprazole. The presence of co-occurring psychosis in MS patients underscores the need for a comprehensive evaluation of symptoms. Conclusion: This case highlights the importance of conducting a magnetic resonance imaging (MRI) brain not only for initial onset psychosis but also for any sudden changes in patients who have had a relatively stable course. Moreover, psychosis can affect treatment adherence in MS, making it all the more critical to identify and manage it promptly.

Treatment Modalities for Chronic Pain in Elderly Patients With Depression: A Systematic Review.

Objective: To review the best pharmacologic and nonpharmacologic interventions in the management of chronic pain in elderly patients with depression.Data Sources: A systematic review of the literature was performed following the PRISMA guidelines and using PubMed. Articles published from 2010 to 2020 were included in the search. Search terms included (major depressive disorder OR MDD OR unipolar depression) AND (chronic pain) AND (elderly).Study Selection: The PubMed search identified 540 articles. All studies were in English and included reports about pain and depression in elderly individuals aged ≥ 65 years.Data Extraction: Articles were reviewed in 2 phases: abstract review followed by full-text review.Results: Abstracts were reviewed for relevance, and a total of 37 articles were identified for full-text review. In this phase, articles not meeting the elderly age criteria (≥ 65 years) or not discussing any treatment modalities were excluded. Nine papers were included after full-text review. The results showed co-occurrence of chronic pain and depression in 13% of the elderly population. Common pain symptoms were related to cancer, back pain, and arthritis.Conclusions: The findings emphasize the importance of individualized assessment of chronic pain in elderly patients with mood disorders such as depression. Since chronic pain and depression are independent risk factors for suicide, it is crucial to complete a thorough history and physical examination and to apply relevant screening tools for both depression and pain.

Pain and suicide: what should we tell our trainees?

Chronic pain is a debilitating medical condition affecting a significant percentage of the population worldwide. Considerable evidence suggests that pain is an independent risk factor for suicide and inadequately managing pain has been identified as a risk for suicidal behaviour. Additionally, medications used to treat pain may also contribute to suicidal behaviour. Extensive research on pain highlights deficiencies in the clinical management on pain with more gaps in care when patients have pain in combination with mental illness and suicidal behaviour. Providing trainees additional knowledge and equipping them with relevant tools to screen and manage chronic pain efficiently is a potential strategy to mitigate suicide risk. Also, trainees need to be educated on how to screen for suicidality in individuals with pain and apply suicide prevention interventions. This paper will emphasise the necessity to improve education about pain, its close relationship with suicide and effective suicide screening as well as management strategies for medical providers. With additional research, it is the hope that novel treatment modalities will be developed to treat pain to improve the quality of life of individuals suffering from this condition and to decrease suicide risk in this patient population.