ABSTRACT

Background:

This study reported on a variety of psychological reactions related to anxiety, sleep quality, depression, fatigue, and quality of life in individuals with multiple sclerosis (MS), related to the Covid-19 quarantine experience.

Objective:

The aim of this study was to investigate the neuropsychiatric effects of the COVID-19 pandemic in MS patients and to analyze the risk factors contributing to psychological stress.

Methods:

The study was designed as a prospective, cross-sectional survey study. Multiple assessment tools that are used in neurological practice, including Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Fatigue Impact Scale (FIS), Pittsburgh Sleep Quality Index (PSQI), and Multiple Sclerosis Quality of Life-54 (MSQOL-54) were administered prospectively both during the early and the peak stages of COVID-19 outbreak (ESO and PSO, respectively). The survey forms were designed using SurveyMonkey and the participants were participating in the survey via a web link and QR code.

Results:

Fifty patients were included in the study. BDI scores, PSQI and FSI measurements, cognitive and social subscale scores and total FIS score, MSQOL-54 measurements, physical and mental subscale scores, and total MSQOL-54 score at PSO were significantly different than those at ESO. The body mass index values of the patients increased significantly at PSO compared to those measured at ESO.

Conclusions:

The results provide a basis for the development of psychological interventions that could minimize the prevalence of sleep disorders and depression and could improve patients’ quality of life during the outbreak.

Keywords:
Coronavirus Infections; Pandemics; Social Isolation; Multiple Sclerosis

RESUMO

Introdução:

Este estudo relatou uma variedade de reações psicológicas relacionadas a ansiedade, qualidade do sono, depressão, fadiga e qualidade de vida em indivíduos com esclerose múltipla (EM), relacionadas à experiência de quarentena de COVID-19.

Objetivo:

O objetivo deste estudo foi investigar os efeitos neuropsiquiátricos da pandemia de Covid-19 em pacientes com EM e analisar os fatores de risco que contribuem para o estresse psicológico.

Métodos:

O estudo foi desenhado como um estudo prospectivo e transversal. Várias ferramentas de avaliação usadas na prática neurológica, incluindo Inventário de Depressão de Beck (Beck Depression Inventory - BDI), Inventário de Ansiedade de Beck (Beck Anxiety Inventory - BAI), Escala de Impacto de Fadiga (Fatigue Impact Scale - FIS), Índice de Qualidade de Sono de Pittsburgh (Pittsburgh Sleep Quality Index - PSQI) e Qualidade de Vida da Esclerose Múltipla-54 (Multiple Sclerosis Quality of Life-54 - MSQOL-54) foram administrados prospectivamente durante o estágio inicial do surto de COVID-19 (EIS) e o estágio de pico do surto de COVID-19 (EPS). Os formulários da pesquisa foram projetados usando o SurveyMonkey e os participantes participaram da pesquisa por meio de um link da web e código QR.

Resultados:

Foram incluídos 50 pacientes no estudo. Os escores BDI, PSQI, FSI, subescala cognitiva e social e escore total do FIS, MSQOL-54, subescala física e mental e MSQOL-54 total no PSO foram significativamente diferentes dos do EIS. Os valores do índice de massa corporal dos pacientes aumentaram significativamente na EPS em comparação com os medidos na EIS.

Conclusões:

Nossos resultados são uma base para o desenvolvimento de intervenções psicológicas que podem minimizar a prevalência de distúrbios do sono e depressão e melhorar a qualidade de vida dos pacientes durante o surto.

Palavras-chave:
Infecções por Coronavírus; Pandemias; Isolamento Social; Esclerose Múltipla

INTRODUCTION

Multiple sclerosis (MS) is a chronic, inflammatory, and autoimmune disease of the central nervous system (CNS) that is triggered by environmental factors and characterized by multifocal zones of inflammation, demyelination, relapse, and remission. The spread of coronavirus disease 2019 (COVID-19) has brought about extensive restrictions that were designated to minimize contact among individuals and have also led to access to health systems, provision of basic needs and travel for the majority of the world population. Patients with chronic diseases, such as MS, were among the first groups subjected to restrictions such as curfews and restricted access to in-hospital services, since these patients had and increased risk of being infected with COVID-19. Both qualitative and quantitative studies have reported on various psychological reactions associated with the Covid-19 quarantine experience, including anxiety, sense of loneliness, sleep deprivation, anger, stress, and concerns about the health of family members¹1. Jeong H, Yim HW, Song YJ, Ki M, Min JA, Cho J, et al. Mental health status of people isolated due to Middle East Respiratory Syndrome. Epidemiol Health. 2016 Nov;38(0):e2016048-0. https://doi.org/10.4178/epih.e2016048
https://doi.org/https://doi.org/10.4178/... ^,22. Reynolds DL, Garay JR, Deamond SL, Moran MK, Gold W, Styra R. Understanding, compliance and psychological impact of the SARS quarantine experience. Epidemiol Infect. 2008 Jul;136(7):997-1007. https://doi.org/10.1017/S0950268807009156
https://doi.org/https://doi.org/10.1017/... ^,33. Bai Y, Lin CC, Lin CY, Chen JY, Chue CM, Chou P. Survey of stress reactions among health care workers involved with the SARS outbreak. Psychiatr Serv. 2004 Sep;55(9):1055-7. https://doi.org/10.1176/appi.ps.55.9.1055
https://doi.org/https://doi.org/10.1176/... ^,44. Robertson E, Hershenfield K, Grace SL, Stewart DE. The psychosocial effects of being quarantined following exposure to SARS: a qualitative study of Toronto health care workers. Can J Psychiatry. 2004 Jun;49(6):403-7. https://doi.org/10.1177/070674370404900612
https://doi.org/https://doi.org/10.1177/... ^,55. Cava MA, Fay KE, Beanlands HJ, McCay EA, Wignall R. The experience of quarantine for individuals affected by SARS in Toronto. Public Health Nurs. 2005 Sep-Oct;22(5):398-406. https://doi.org/10.1111/j.0737-1209.2005.220504.x
https://doi.org/https://doi.org/10.1111/... ^,66. Maunder R, Hunter J, Vincent L, Bennett J, Peladeau N, Leszcz M, et al. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ. 2003 May;168(10):1245-51.. Moreover, a previous study indicated that the hospital staff who were quarantined due to the possibility of a contact with suspected severe acute respiratory syndrome (SARS) cases had an increased prevalence of acute stress disorder³3. Bai Y, Lin CC, Lin CY, Chen JY, Chue CM, Chou P. Survey of stress reactions among health care workers involved with the SARS outbreak. Psychiatr Serv. 2004 Sep;55(9):1055-7. https://doi.org/10.1176/appi.ps.55.9.1055
https://doi.org/https://doi.org/10.1176/... . On the other hand, patients with chronic diseases such as MS are known to be affected more severely by natural disasters and crises⁷7. Akhoundi FH, Sahraian MA, Moghadasi AN. Neuropsychiatric and cognitive effects of the COVID-19 outbreak on multiple sclerosis patients. Mult Scler Relat Disord. 2020 Jun;41:102164. https://doi.org/10.1016/j.msard.2020.102164
https://doi.org/https://doi.org/10.1016/... . In such patients, the psychological and cognitive deterioration associated with numerous factors including keeping abreast of morbidity and mortality rates on a daily basis, social isolation and sense of loneliness, minimal access to all services including healthcare services and clinical visits, termination of public transport modes, and the challenges in access to drugs and in drug management have reached an alarming level. These challenges in access to drugs and in drug management are particularly important because patients with chronic diseases, particularly MS patients, are highly vulnerable and most of these patients suffer from multiple diseases and weakness. Accordingly, these patients need continuous follow-up to ensure their physical and psychological integrity²2. Reynolds DL, Garay JR, Deamond SL, Moran MK, Gold W, Styra R. Understanding, compliance and psychological impact of the SARS quarantine experience. Epidemiol Infect. 2008 Jul;136(7):997-1007. https://doi.org/10.1017/S0950268807009156
https://doi.org/https://doi.org/10.1017/... ^,66. Maunder R, Hunter J, Vincent L, Bennett J, Peladeau N, Leszcz M, et al. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ. 2003 May;168(10):1245-51..

To our knowledge, there are very few studies reporting on the impact of the COVID-19 pandemic on fatigue, sleep quality, depression, anxiety, quality of life, and cognitive functions in MS patients⁷7. Akhoundi FH, Sahraian MA, Moghadasi AN. Neuropsychiatric and cognitive effects of the COVID-19 outbreak on multiple sclerosis patients. Mult Scler Relat Disord. 2020 Jun;41:102164. https://doi.org/10.1016/j.msard.2020.102164
https://doi.org/https://doi.org/10.1016/... ^,88. Capuano R, Altieri M, Bisecco A, d’Ambrosio A, Docimo R, Buonanno D, et al. Psychological consequences of COVID-19 pandemic in Italian MS patients: signs of resilience? J Neurol. 2020 Jul. https://doi.org/10.1007/s00415-020-10099-9
https://doi.org/https://doi.org/10.1007/... . The aim of this study was to investigate the neuropsychiatric effects of the COVID-19 pandemic in MS patients and to analyze the risk factors contributing to psychological stress.

METHODS

Study design

The study was designed as a prospective, cross-sectional survey study. Multiple assessment tools that are used in neurological practice, including the Beck Depression Inventory (BDI), the Beck Anxiety Inventory (BAI), the Fatigue Impact Scale (FIS), the Pittsburgh Sleep Quality Index (PSQI), and the Multiple Sclerosis Quality of Life-54 (MSQOL-54) were administered prospectively both during the early stage of COVID-19 outbreak (ESO) and the peak stage of COVID-19 outbreak (PSO). The study was approved by Local Ethics Committee (Approval No: FÜ- 2020/07-07) and was conducted in accordance with the Declaration of Helsinki.

The ESO data were collected on January 15^th, 2020 (i.e., 13 days after the outbreak of Covid-19 was declared a PHEIC) when there were no national measures taken against the pandemic in Turkey and the PSO data were collected on April 23^rd, 2020 when the pandemic had its peak effects and strict restrictions such as curfews were being imposed by the government in Turkey⁹9. CDC COVID-19 Response Team. Preliminary estimates of the prevalence of selected underlying health conditions among patients with coronavirus disease 2019 - United States, February 12-March 28, 2020. MMWR Morb Mortal Wkly Rep. 2020 Apr;69(13):382-6. https://doi.org/10.15585/mmwr.mm6913e2
https://doi.org/https://doi.org/10.15585... . PSO data began to be collected 3 months after the collection of the ESO data.

Eligibility

Inclusion criteria were: age 18‒45 years, voluntary participation in the study, being followed with a diagnosis of relapsing-remitting MS (RRMS) or secondary progressive MS, an Expanded Disability Status Scale (EDSS) score of ≤4.0¹⁰10. Kurtzke JF. Rating neurologic impairment in multiple sclerosis: an expanded disability status scale (EDSS). Neurology. 1983 Nov;33(11):1444-52. https://doi.org/10.1212/wnl.33.11.1444
https://doi.org/https://doi.org/10.1212/... , and no history of attacks/relapse within the last four weeks. Exclusion criteria were: use of medication for fatigue, ongoing treatment for major sleep disorder, clinical depression, hypothyroidism, and vitamin B12 deficiency, severe balance disorders (cerebrovascular event, peripheral neuropathy, Meniere’s vertigo), history of corticosteroid treatment within the last four weeks, pregnancy, cardiovascular disease, hypertension, and orthopedic problems that could restrict mobility. EDSS assessment was performed in single rooms in non-COVID-19 areas reserved for Neurology patients by a neurologist certified in EDSS (FB; https://www.neurostatus.net).

Data collection

The survey was administered online to avoid face-to-face contact and due to the travel restrictions imposed by the government. The survey form was designed using SurveyMonkey and participants were invited to participate in the survey via a web link and QR code¹¹11. Alessi EJ, Martin JI. Conducting an internet-based survey: benefits, pitfalls, and lessons learned. Soc Work Res. 2010 Jun;34(2):122-8. https://doi.org/10.1093/swr/34.2.122
https://doi.org/https://doi.org/10.1093/... . Participants filled out the survey form easily and safely by using their computers, smartphones, and tablet devices. Employing an online survey due to the nationwide isolation and the risk of Covid-19 infection during the pandemic provided numerous advantages such as time efficiency due to the rapid access to participants. The mean time to complete the survey was 16 min.

Data collection tools

The BDI is a 21-item, self-report inventory used to measure characteristic attitudes and symptoms of depression. In this inventory, a score of ≤9 indicates ‘no depression’, 10‒16 indicates ‘mild depression’, 17‒23 indicates ‘moderate depression’, and ≥24 indicates ‘severe depression’¹²12. Aydemir Ö, Guvenir T, Kuey L, Kultur S. Validity and reliability of Turkish version of hospital anxiety and depression scale. Türk Psikiyatri Derg. 1997;8(4):280-7..

The BAI is a 21-item, self-report inventory used to identify anxiety symptoms and to quantify their intensity. Total score ranges from 0 to 63 and higher total scores indicate more severe anxiety. The clinical classification of scoring results is as follows: 8‒15 suggests mild anxiety, 16-25 suggests moderate anxiety, and 26-63 suggests severe anxiety¹³13. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol. 1988 Dec;56(6):893-7. https://doi.org/10.1037//0022-006x.56.6.893
https://doi.org/https://doi.org/10.1037/... ^,1414. Ulusoy M, Sahin NH, Erkmen H. The Turkish version of the Beck anxiety inventory: psychometric properties. J Cogn Psychother. 1998;12(2):163-72..

The FIS is a self-report 40-item questionnaire used to assess functional limitations attributed to fatigue in MS patients. FIS assesses the physical, cognitive, and social impacts of fatigue during the past month. The total score ranges between 0 and 160, and higher total scores indicate greater impact of fatigue¹⁵15. Fisk JD, Pontefract A, Ritvo PG, Archibald CJ, Murray T. The impact of fatigue on patients with multiple sclerosis. Can J Neurol Sci. 1994 Feb;21(1):9-14. https://doi.org/10.1017/S0317167100048691
https://doi.org/https://doi.org/10.1017/... ^,1616. Armutlu K, Keser İ, Korkmaz N, Akbıyık Dİ, Sümbüloğlu V, Güney Z, et al. Psychometric study of Turkish version of Fatigue Impact Scale in multiple sclerosis patients. J Neurol Sci. 2007;255(1-2):64-8. https://doi.org/10.1016/j.jns.2007.01.073
https://doi.org/https://doi.org/10.1016/...

The PSQI is a self-rated 19-item questionnaire assessing participants’ sleep quality, sleep duration, and sleep disturbances and their severity during the past month. Total score ranges between 0 and 21, which consists of seven sub-scores. Participants with a PSQI ≤5 are classified as ‘good sleepers’ and participants with a PSQI >5 are classified as ‘bad sleepers’¹⁷17. Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989 May;28(2):193-213. https://doi.org/10.1016/0165-1781(89)90047-4
https://doi.org/https://doi.org/10.1016/... ^,1818. Ağargün MY, Kara H, Anlar Ö. The validity and reliability of the Pittsburgh Sleep Quality Index. Türk Psikiyatri Derg. 1996;7(2):107-15..

The MSQOL-54 is a generic scale used to assess the health-related quality of life in individuals with MS. The summary scores are the physical health composite summary and the mental health composite summary, and higher total scores indicate better quality of life¹⁹19. Vickrey BG, Hays RD, Harooni R, Myers LW, Ellison GW. A health-related quality of life measure for multiple sclerosis. Qual Life Res. 1995 Jun;4(3):187-206. https://doi.org/10.1007/BF02260859
https://doi.org/https://doi.org/10.1007/... ^,2020. Idiman E, Uzunel F, Ozakbas S, Yozbatiran N, Oguz M, Callioglu B, et al. Cross-cultural adaptation and validation of multiple sclerosis quality of life questionnaire (MSQOL-54) in a Turkish multiple sclerosis sample. J Neurol Sci. 2006 Jan;240(1-2):77-80. https://doi.org/10.1016/j.jns.2005.09.009
https://doi.org/https://doi.org/10.1016/... .

Statistical analysis

Data were analyzed using SPSS for Windows, version 22.0 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.). Continuous variables were expressed as mean±standard deviation and categorical variables were expressed as frequencies (n) and percentages (%). The ESO and PSO values of the parameters were compared using paired-samples t-test. A p value of <0.05 was considered significant.

RESULTS

Table 1 presents the demographic and clinical characteristics of the 50 patients included in the study. Two patients were excluded from the study since they did not complete the survey. The EDSS score was 2.5 in one patient and ≤2 in the remaining patients (Table 1).

BDI scores at PSO were significantly higher than those at ESO (p<0.01). Additionally, a strong correlation was found between the BDI scores measured at these two stages (r=0.93; p<0.01). However, no significant difference was found between the BAI scores measured at ESO and PSO (15.63±11.27 vs. 18.22±10.53) (p>0.05) (Table 2).

In FSI measurements, the cognitive and social subscale scores and the total FIS score were significantly higher at PSO compared to ESO (p<0.01 for all), whereas no significant difference was found with regard to the physical subscale scores (p>0.05). Moreover, a strong correlation was found between the FSI scores measured at ESO and PSO with regard to the cognitive (r=0.91), physical (r=0.92), and social (r=0.97) subscale scores and the total FSI score (r=0.96) (p<0.01 for all) (Table 2).

In MSQOL-54 measurements, a negative correlation was found between the measurements performed at ESO and PSO with regard to the physical (r=0.91) and mental (r=0.85) subscale scores and the total MSQOL-54 score (r=0.93) (p<0.01 for all). Although a significant difference was found between the MSQOL-54 measurements performed at ESO and PSO with regard to the mental subscale scores and the total MSQOL-54 score (p<0.01 for both), no significant difference was found with regard to the physical subscale scores (p>0.05) (Table 2).

The PSQI measurements indicated that the sleep quality of the patients deteriorated significantly (p<0.01). Moreover, a positive correlation was found between the PSQI scores measured at ESO and PSO (r=0.94; p<0.01) (Table 2).

On the other hand, the body mass index (BMI) values of the patients increased significantly at PSO compared to those measured at ESO (p<0.01) and a positive correlation was found between the measurements performed at these two stages (r=0.91; p<0.01) (Table 2).

DISCUSSION

To our knowledge, there has been no study investigating the neuropsychiatric impact of COVID-19 pandemic in MS patients. Moreover, most studies evaluating MS patients during the pandemic have focused on the treatment of MS with immunomodulatory and/or immunosuppressive agents²¹21. Giovannoni G, Hawkes C, Lechner-Scott J, Levy M, Waubant E, Gold J. The COVID-19 pandemic and the use of MS disease-modifying therapies. Mult Scler Relat Disord. 2020 Apr;39:102073. https://doi.org/10.1016/j.msard.2020.102073
https://doi.org/https://doi.org/10.1016/... ^,2222. Novi G, Mikulska M, Briano F, Toscanini F, Tazza F, Uccelli A, et al. COVID-19 in a MS patient treated with ocrelizumab: does immunosuppression have a protective role? Mult Scler Relat Disord. 2020 Jul;42:102120. https://doi.org/10.1016/j.msard.2020.102120
https://doi.org/https://doi.org/10.1016/... , epidemiology of infected patients²³23. Willis MD, Robertson NP. Multiple sclerosis and the risk of infection: considerations in the threat of the novel coronavirus, COVID-19/SARS-CoV-2. J Neurol. 2020;267(5):1567-9. https://doi.org/10.1007/s00415-020-09822-3
https://doi.org/https://doi.org/10.1007/... , clinical characteristics of COVID-19, and the challenges experienced by MS patients²⁴24. Costa-Frossard L, Moreno-Torres I, Meca-Lallana V, García-Domínguez J, de Estudio ER. EMCAM (Multiple Sclerosis Autonomous Community of Madrid) document for the management of patients with multiple sclerosis during the SARS-CoV-2 pandemic. Rev Neurol. 2020 Apr;70(9):329-40. https://doi.org/10.33588/rn.7009.2020155
https://doi.org/https://doi.org/10.33588... . The present study aimed to investigate the neuropsychiatric effects of the COVID-19 pandemic in MS patients and the risk factors that contribute to psychological stress. Accordingly, the findings of the study will provide useful information to healthcare professionals for preserving the neuropsychosocial wellbeing of MS patients during the COVID-19 pandemic.

Anxiety disorder is an anticipated affective disorder in the context of a pandemic. A previous Chinese study reported that most of their patients had moderate and severe anxiety during the pandemic²⁴24. Costa-Frossard L, Moreno-Torres I, Meca-Lallana V, García-Domínguez J, de Estudio ER. EMCAM (Multiple Sclerosis Autonomous Community of Madrid) document for the management of patients with multiple sclerosis during the SARS-CoV-2 pandemic. Rev Neurol. 2020 Apr;70(9):329-40. https://doi.org/10.33588/rn.7009.2020155
https://doi.org/https://doi.org/10.33588... . In the present study, however, the anxiety levels in MS patients showed no significant increase during the pandemic, which could be attributed to the fact that our patients and their relatives had not been diagnosed with COVID-19 throughout this period. On the other hand, the increased anxiety levels in the Chinese study could be explained by the military state of emergency declared by the Chinese Government to control the rapid spread of the pandemic²⁵25. Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health. 2020 Mar;17(5):1729. https://doi.org/10.3390/ijerph17051729
https://doi.org/https://doi.org/10.3390/... .

The COVID-19 pandemic has been shown to cause depression in a large number of individuals due to its unique environmental stress factors²⁶26. Ozamiz-Etxebarria N, Dosil-Santamaria M, Picaza-Gorrochategui M, Idoiaga-Mondragon N. Stress, anxiety, and depression levels in the initial stage of the COVID-19 outbreak in a population sample in the northern Spain. Cad Saude Publica. 2020 Apr;36(4):e00054020. https://doi.org/10.1590/0102-311X00054020
https://doi.org/https://doi.org/10.1590/... . The present study, similarly to other ones²⁵25. Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health. 2020 Mar;17(5):1729. https://doi.org/10.3390/ijerph17051729
https://doi.org/https://doi.org/10.3390/... ^,2626. Ozamiz-Etxebarria N, Dosil-Santamaria M, Picaza-Gorrochategui M, Idoiaga-Mondragon N. Stress, anxiety, and depression levels in the initial stage of the COVID-19 outbreak in a population sample in the northern Spain. Cad Saude Publica. 2020 Apr;36(4):e00054020. https://doi.org/10.1590/0102-311X00054020
https://doi.org/https://doi.org/10.1590/... , revealed that the depression levels of MS patients increased significantly during the pandemic. On the other hand, in the context of a pandemic, many individuals may suffer significant personal losses and grieving reactions. Additionally, long-term self-isolation, which is mostly the primary strategy employed to minimize the spread of the pandemic, adds up an additional risk layer for depression. Accordingly, the individuals may not be able to tolerate this social deprivation for a long time. In particular, patients with chronic diseases such as MS, who have minimal access to social services, are at greater risk of depression. Moreover, in families in which family members need to live together in the same house for a long time may have frequent arguments. Therefore, they may be at a greater risk of depression. In addition, other stress factors, such as economic loss, can add up another risk layer.

The neuropsychiatric state of MS patients in the context of a pandemic can be overlooked due to their social and internal conflicts, which may lead to the overlooking of their emerging emotions. Physical parameters are the primary factors in the assessment of disability in MS patients. Nevertheless, the evaluation of neuropsychiatric parameters in such patients tends to be more important in the context of traumatic periods such as pandemics, since the symptoms of these patients are often emotional because they are often caused by psychological conflicts²⁷27. Benedict RH, Zivadinov R. Reliability and validity of neuropsychological screening and assessment strategies in MS. J Neurol. 2007 May;254(2):II22-II5. https://doi.org/10.1007/s00415-007-2007-4
https://doi.org/https://doi.org/10.1007/... . In the present study, the MSQOL-54 scores indicated that mental deterioration was more prevalent than physical in our patients. Additionally, the quality of life also decreased in our patients during the pandemic. In long-term traumatic periods such as pandemics, MS patients need to be provided with strategies that could allow them to have a different perspective in terms of interpreting their emotions, thoughts, awareness, and the events occurring in their environment in order to minimize the impact of this exposure. In the present study, the FSI measurements indicated that patients deteriorated in terms of cognitive and social subscales while no significant difference was found with regard to the physical subscale during the pandemic. Knowledge of these factors may help MS patients in their struggle against their illnesses and in reducing their perceived stress²⁸28. Blake H, Bermingham F, Johnson G, Tabner A. Mitigating the psychological impact of COVID-19 on healthcare workers: a digital learning package. Int J Environ Res Public Health. 2020 Apr;17(9):2997. https://doi.org/10.3390/ijerph17092997
https://doi.org/https://doi.org/10.3390/... ^,2929. Jukic I, Calleja-González J, Cos F, Cuzzolin F, Olmo J, Terrados N, et al. Strategies and solutions for team sports athletes in isolation due to COVID-19. Sports. 2020;8(4):56. https://doi.org/10.3390/sports8040056
https://doi.org/https://doi.org/10.3390/... ^,3030. Sun N, Shi S, Jiao D, Song R, Ma L, Wang H, et al. A qualitative study on the psychological experience of caregivers of COVID-19 patients. Am J Infect Control. 2020 Jun;48(6): 592-8. https://doi.org/10.1016/j.ajic.2020.03.018
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https://doi.org/https://doi.org/10.3760/... .

Stress may not be the sole cause of sleep deprivation in the context of a pandemic³²32. Morin CM, Rodrigue S, Ivers H. Role of stress, arousal, and coping skills in primary insomnia. Psychosom Med. 2003 Mar-Apr;65(2):259-67. https://doi.org/10.1097/01.psy.0000030391.09558.a3
https://doi.org/https://doi.org/10.1097/... ^,3333. Sateia MJ. International classification of sleep disorders. Chest. 2014 Nov;146(5):1387-94. https://doi.org/10.1378/chest.14-0970
https://doi.org/https://doi.org/10.1378/... . To date, there have been numerous studies investigating the prevalence and psychological effect of sleep deprivation during the Severe Acute Respiratory Syndrome (SARS) pandemic³⁴34. Brooks SK, Dunn R, Amlôt R, Rubin GJ, Greenberg N. A systematic, thematic review of social and occupational factors associated with psychological outcomes in healthcare employees during an infectious disease outbreak. J Occup Environ Med. 2018 Mar;60(3):248-57. https://doi.org/10.1097/JOM.0000000000001235
https://doi.org/https://doi.org/10.1097/... . However, to our knowledge, there has been no study reporting on sleep quality in MS patients during the COVID-19 pandemic. In our study, MS patients were found to have reduced sleep quality during the COVID-19 pandemic, which was consistent with the findings presented by recent studies conducted with healthy individuals³⁵35. Zhang C, Yang L, Liu S, Ma S, Wang Y, Cai Z, et al. Survey of insomnia and related social psychological factors among medical staff involved in the 2019 novel coronavirus disease outbreak. Front Psychiatry. 2020 Apr;11:306. https://doi.org/10.3389/fpsyt.2020.00306
https://doi.org/https://doi.org/10.3389/... ^,3636. Huang Y, Zhao N. Generalized anxiety disorder, depressive symptoms and sleep quality during COVID-19 outbreak in China: a web-based cross-sectional survey. Psychiatry Res. 2020 Jun;288:112954. https://doi.org/10.1016/j.psychres.2020.112954
https://doi.org/https://doi.org/10.1016/... ^,3737. Yuan S, Liao Z, Huang H, Jiang B, Zhang X, Wang Y, et al. Comparison of the indicators of psychological stress in the population of Hubei Province and non-endemic provinces in China during two weeks during the coronavirus disease 2019 (COVID-19) outbreak in February 2020. Med Sci Monit. 2020 Apr;26:e923767-1-e923767-10. https://doi.org/10.12659/MSM.923767
https://doi.org/https://doi.org/10.12659... . Reduced sleep quality may aggravate the symptoms of chronic diseases as well as reduce treatment response³⁸38. Caminero A, Bartolomé M. Sleep disturbances in multiple sclerosis. J Neurol Sci. 2011 Oct;309(1-2):86-91. https://doi.org/10.1016/j.jns.2011.07.015
https://doi.org/https://doi.org/10.1016/... . Accordingly, multidimensional and multistage studies are needed to investigate sociopsychological factors that could increase sleep quality. It is an undeniable fact that the Covid-19 pandemic has brought about numerous ambiguities, particularly in the realm of healthcare, as well as in the social, psychological, and economic areas.

Interestingly, the BMI values of our patients showed a significant increase over the short period between ESO and PSO (24.07±0.65 vs. 24.21±0.64). When COVID-19 began to spread across the world, people began to consume ultra-processed, high-calorie, and long shelf-life foods. Additionally, opportunities for physical exercise were reduced due to the implementation of restrictions such as social distancing and curfews³⁹39. Lippi G, Henry BM, Sanchis-Gomar F. Physical inactivity and cardiovascular disease at the time of coronavirus disease 2019 (COVID-19). Eur J Prev Cardiol. 2020 Apr;27(9):906-8. https://doi.org/10.1177/2047487320916823
https://doi.org/https://doi.org/10.1177/... . Accordingly, the decreased physical activity and increased food intake during the COVID-19 pandemic could explain the increased BMI in our patients. On the other hand, the causes of increased BMI during the COVID-19 pandemic and the measures that need to be taken could be a research topic for further studies.

In the present study, no patient was diagnosed or suspected with COVID-19 or was in direct or indirect contact with infected patients, nor had undergone any medical consultation regarding COVID-19. Additionally, patients stated having strictly obeyed the curfews and having not left home even for their basic needs throughout the pandemic. In this case, it clearly indicates that they had limited access to daily essentials as well as healthcare services and drugs. The findings of the present study revealed that the patients had increased levels of depression and mental fatigue and decreased quality of life during the COVID-19 pandemic. These findings will provide useful solutions for the development of strategies regarding psychological support and the identification of priority areas in the regions most severely affected by the COVID-19 pandemic. On the other hand, medical and psychological readiness of the general population and a well-established healthcare system are of prime importance in the fight against the pandemic⁴⁰40. Shah K, Kamrai D, Mekala H, Mann B, Desai K, Patel RS. Focus on mental health during the coronavirus (COVID-19) pandemic: applying learnings from the past outbreaks. Cureus. 2020 Mar;12(3):e7405. https://doi.org/10.7759/cureus.7405
https://doi.org/https://doi.org/10.7759/... . Accordingly, our findings have both clinical and political implications. First and foremost, health authorities need to identify high-risk groups based on the sociodemographic profiles of patients in order to be able to perform early psychological interventions. Secondly, the content of psychological interventions should be modified according to the needs of the general population, mainly because the prevalence of neuropsychiatric disturbances increases in the context of a pandemic.

Our study was limited in several ways. First, as the study had a cross-sectional design, the data and analyses derived from the study may not be sufficient for obtaining causal inferences. Second, the study might have a sampling bias, since the participants consisted of volunteers that participated in an online survey. Third, participants with severe fatigue, sleep disorders, psychological comorbidities, and high EDSS were excluded from the study. This causes the population to be more homogeneous than in real life.

In conclusion, our results are likely to form a basis for the development of psychological interventions that could minimize the prevalence of sleep disorders and depression and could improve patients’ quality of life during the Covid-19 pandemic. Our results can also be used to help formulate neuropsychiatric interventions.

ACKNOWLEDGMENTS

We would like to thank all the patients for their cooperation.

REFERENCES

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