CMSC 2026: Neuropsychiatric care in MS has seen major progress

The understanding and management of neuropsychiatric symptoms such as depression and cognitive difficulties in multiple sclerosis (MS) have advanced substantially, but there’s more progress to be made, said Anthony Feinstein, PhD, a neuropsychiatrist and professor of psychiatry at the University of Toronto.

Feinstein, who delivered the June Halper Memorial Lecture at the Consortium of Multiple Sclerosis Centers (CMSC) annual meeting in Charlotte, North Carolina, said approaches to understanding and treating neuropsychiatric conditions have evolved in the 40 years since the consortium was formed. His talk was titled, “The Journey is the Destination: 40 years of CMSC, 40 years of MS Neuropsychiatry.”

“Over the past four decades, the progress has been absolutely enormous,” Feinstein said in an on-site interview with Multiple Sclerosis News Today. “It’s been a fascinating journey.”

Neuropsychiatrist Anthony Feinstein, PhD, spoke at the Consortium of Multiple Sclerosis Centers conference. (Photo by Lindsey Shapiro)

Many people living with MS experience emotional problems and cognitive difficulties, but these symptoms are often underrecognized and poorly managed with standard MS treatments.

Four decades ago, physicians and scientists were beginning to recognize that depression and cognitive dysfunction in MS were common, but they didn’t know much else, Feinstein said. Depression, in particular, was thought to be a reaction to the stress of living with a chronic disease.

Now, scientists recognize that MS causes physiological changes in the brain, which can in part underlie these problems. Changes in the hippocampus region of the brain have been closely linked to depression, while the thalamus has emerged as a key player in cognitive dysfunction.

Advances in neuroimaging have been “hugely influential” in promoting that understanding, Feinstein said, citing the emergence of MRI scans in the 1980s as “one of these watershed moments in the history of medicine.”

These tools allowed scientists to visualize brain changes that correlated with neuropsychiatric challenges. And they could do so while a person was still alive and able to be treated, rather than having to wait to study the brain until after the patient had died. “It was a transformative moment,” Feinstein said.

The increase in neuropsychiatric research after the rise of neuroimaging led scientists to better understand how common these problems are in MS and how profoundly they affect patients’ everyday lives, he said.

These conditions are now more easily measured as patient-reported outcome measures are routinely incorporated into research and clinical practice.

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Depression, cognition, and life quality

According to Feinstein, some 40% of people with relapsing-remitting MS have cognitive impairments, and the figure rises to somewhere around 70%-90% in people with progressive forms of the disease. A person with MS has about a one in two chance of developing significant depression over their lifetime, with rates about two to three times higher than what’s seen in the general population.

“Depression is probably the single biggest predictor of quality of life, and it’s hard to have a quality of life when you’re feeling sad or depressed,” Feinstein said.

Cognitive dysfunction, meanwhile, “can affect your ability to drive, it can make you more forgetful when it comes to taking your medication, it can impair your day-to-day functional activities and daily living,” Feinstein said.

Depression and cognitive struggles can also have an economic impact, making it harder for a person to find work and stay employed.

Over the years, scientists have gained a better understanding of how to more effectively treat neuropsychiatric problems in MS. Standard antidepressant medications can be effective, but they often come with side effects that make people reluctant to take them, according to Feinstein.

Now, he says, the “treatment of choice” for depression is cognitive behavioral therapy (CBT), a form of talk therapy in which a person learns to evaluate and adjust their negative thinking patterns.

Managing depression is not a one-size-fits-all approach, according to Feinstein. “Not everybody’s going to improve on CBT,” he said. Mindfulness-based therapy, a strategy that focuses on the present moment and helps people accept negative situations without judgment, has proven effective for some people, he said.

Cognitive rehabilitation is playing an increasingly important role in the care of cognitive dysfunction. This approach involves rehabilitation exercises to strengthen the mind, along with real-world strategies to work around cognitive deficits that interfere with daily life.

But while the importance of cognition is now well recognized by neurologists and pharmaceutical companies, the same isn’t quite true for depression, said Feinstein. There’s a need for better medications to manage the condition, he said.

“You might live in areas where it’s hard to get [CBT], so your only resource is medication,” Feinstein said. A potential solution to overcome access issues is virtual CBT, a practice that started gaining popularity during the COVID-19 pandemic. Emerging data show that internet-based therapy is also very effective for managing depression.

As for cognition, “it’s more challenging,” Feinstein said. Still, he said, there have been some promising data on cognitive rehabilitation programs, which can also be delivered online.

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Translating research findings into real-world benefits

Feinstein sees translatability as the major barrier to neuropsychiatric and cognitive care in MS.

“Does [what you find in controlled studies] translate into real-world benefits for people with MS?” he asked. “I mean, you can have nice significance values in terms of your research study, but does it help people with day-to-day functioning?” That’s a question that remains to be answered, he said. “It’s absolutely key that we conquer this barrier, because otherwise we’re dealing with intellectual abstractions, you know, things that look really good on paper … but are they really helping patients?”

Bridging the gap will require working with patients and care partners throughout the research process to identify the best ways to measure the daily-life impact of cognitive and psychiatric symptoms, he said.

For people who are dealing with cognitive or mental health challenges and don’t know how to advocate for themselves, Feinstein’s advice is: “Just ask up front. … Challenge your healthcare provider directly, saying, I think this is a problem. Can you help me address it?”

Patients can also maximize their health by boosting their cognitive reserve, Feinstein said. “You want to keep your brain active,” engaging in activities like exercising, socializing, or learning to play an instrument, he said.

Looking ahead, Feinstein sees emerging therapeutic strategies that could further improve neuropsychiatric care in MS.

“We’re moving into the age of interventional psychiatry,” he said. In particular, transcranial magnetic stimulation (TMS) and deep brain stimulation are treatment modalities gaining traction for depression management.

These approaches work in different ways to deliver electrical stimulation that could help reset brain circuits involved in mood regulation. They’re already used to treat depression, but Feinstein thinks the coming years will see a rise in their use for MS.

“I think it’s going to be interesting to see what comes next in this field,” he said. “These are all hands-on interventions that are getting a lot of press and a lot of interest, and let’s see what they can do.”

Another topic Feinstein is tackling at this year’s CMSC meeting is cannabis use and its potential impacts on cognition.

Many MS patients use cannabis products to manage symptoms such as spasticity and pain, but Feinstein’s research shows that this can come at a cognitive cost, affecting memory, processing speed, and other cognitive skills needed to go about daily life.

While occasional consumption might not have a major negative effect, “when you’re using cannabis every day, three to four times a day, seven days a week, that’s when you start seeing the deficits,” Feinstein said. “You’ve already got a brain that’s vulnerable to cognitive compromise. Now you’re adding a drug that could make it worse.”

Many patients benefit substantially from cannabis’ effects on their symptoms, and are hesitant to stop, even knowing the potential cognitive consequences. Doctors and patients should know the pros and cons, and work together to evaluate what makes the most sense in the individual case, Feinstein said.

“You’ve got to weigh up what are the benefits and what are the risks,” he said. “If you feel that it’s helping you, then you’re probably going to stay on the drug, but if you’re … struggling with your cognition, be very, very careful.”

Ultimately, Feinstein said, the patient’s choice has to be honored. “As one of their doctors, you’ve got to listen,” he said. ” It’s their body, it’s their life.”

Note: The Multiple Sclerosis News Today team is providing live coverage of the Consortium of MS Centers annual meeting, May 27-29. Go here to see the latest stories from the meeting.