Mental Health Should Be Clinical Focus of MG Care, Case Report Argues

Mental health must be a clinical priority when treating people with myasthenia gravis (MG), in addition to caring for physical symptoms, argues a recent case report.

The researchers said mental health crises can exacerbate MG symptoms.

Titled “Comorbid Depressive and Anxiety Symptoms in a Patient with Myasthenia Gravis,” the report was published in the peer-reviewed journal Case Reports in Psychiatry.

MG, an autoimmune disorder in which the immune system mistakenly attacks healthy cells and tissues, is characterized by faulty communication between nerves and muscles.

Akin to a soccer player dribbling a ball down the pitch and kicking it into the net, an electrical signal normally travels along a nerve to a nerve ending, where it sends a molecule called acetylcholine — a neurotransmitter that serves as a chemical messenger — to bind with its receptor on a muscle cell.

In most MG cases, a person’s own antibodies block, alter, or destroy the acetylcholine receptor, preventing muscles from contracting.

Besides physical symptoms, patients with MG frequently experience psychiatric disorders, such as depression, anxiety, and panic disorder. Simultaneous conditions occurring in a patient are called comorbidities.

Although little data exists to explain the association and prevalence of psychiatric disorders with MG, studies show that appropriate psychiatric treatment can help to prevent making physical symptoms worse.

In this study, the researchers reported on a 43-year-old African American woman with MG recently treated at the Interfaith Medical Center, in Brooklyn, N.Y., for acute shortness of breath.

She had been diagnosed with MG 12 years prior and had a medical history of seven intubations — where a flexible plastic tube is inserted down a person’s throat to aid breathing — following acute crises, seizures, asthma, and diabetes mellitus.

She was admitted to intensive care, where she was intubated for two days. She was then transferred to an intermediate-level care unit called a step-down unit, but had to be sent back to intensive care on day four, due to worsening respiratory symptoms.

In intensive care, she was given 60 mg Mestinon (pyridostigmine) four times per day and 40 mg prednisone once daily, which was tapered to just 10 mg per day.

On day five, the patient stated that she felt depressed and anxious. She described poor sleep, fatigue, and feelings of hopelessness associated with being single, homeless, unemployed, and a “burden to her family.”

She reported a history of depression and anxiety, resulting from multiple previous hospitalizations, as well as social stressors.

Concern regarding recurrent myasthenia crises caused her panic attacks, which worsened her shortness of breath.

The patient reported a history of self-medicating with marijuana and cocaine. She had been taking the antidepressant Zoloft (sertraline), but had been “poorly compliant” for the past four years.

Finally, she reported having suicidal thoughts, which had worsened over the preceding six months.

The physicians at the Interfaith Medical Center prescribed her 50 mg Zoloft (sertraline) daily for depression and 50 mg Atarax (hydroxyzine) three times per day for anxiety. She was not prescribed benzodiazepines, both because of the risk of respiratory complications and because of her history of substance abuse.

The patient reportedly responded well to treatment and was discharged on day 10, following the resolution of her symptoms.

Depression is known to associate with impairments to the immune system and there is evidence that altered immunity contributes to the development and exacerbation of depression.

“Therefore, an inflammatory depression may require different therapeutic approaches than reactive depression in MG,” the researchers said.

The investigators noted that MG can seriously impact the quality of a person’s life, affecting employment, job transfers, and income. As such, “mental health must be a clinical focus during the treatment of somatic symptoms during MG,” they said.

More research is needed, the investigators argue, and should focus on the mental health aspects of MG management, “with the goal of optimizing treatment.”