Глобальная распространенность и факторы риска суицидальных идеи при множественном склерозе: систематический обзор и мета-анализ.

Introduction

Chronic illnesses are strongly associated with depression and various mental health problems. As a result, patients with chronic diseases often experience negative emotions due to both the psychological and physical burden of their condition, which can exacerbate depressive symptoms [ 1 ]. Adapting to the lifestyle and employment changes imposed by a chronic illness can be deeply challenging and may foster feelings of isolation and loss of identity [ 2 , 3 ]. As social interactions decline, the sense of disconnection can intensify, further contributing to depression. At the same time, persistent physical symptoms such as pain, fatigue, and discomfort may heighten anxiety and depressive symptoms, potentially reducing adherence to treatment and negatively affecting overall health outcomes. In severe cases, this psychological burden may progress to suicidal ideation (SI) and even attempts, particularly among younger individuals [ 2 , 4 ].

Mental disorders are observed in 20%–25% of individuals with diabetes, whereas in patients with cancer, the prevalence exceeds 30% [ 5 , 6 ]. Among neurological diseases, depression affects 14.8% of individuals with Alzheimer's disease and up to 22% of those with Parkinson's disease [ 7 , 8 , 9 ]. As the leading cause of neurological disability in young adults, multiple sclerosis (MS) carries a substantial psychological burden. Up to 50% of patients experience depressive symptoms, underscoring the profound emotional impact of living with this chronic and often unpredictable disease [ 10 , 11 ]. In a study by Sadovnick et al., suicide was identified as the third most common cause of death among patients with MS [ 12 ]. These statistics underscore the considerable mental health challenges these patients face and emphasize the importance of closely monitoring depression and SI within this group.

Functional impairment in MS is a major risk factor for depression, influenced by disease progression and treatment side effects [ 13 ]. It has also been suggested that MS might act as an independent risk factor for the progression of certain vascular diseases, which can have a clear association with depression and suicidal ideation [ 14 ]. While disability levels are typically assessed by clinicians using the Expanded Disability Status Scale (EDSS), self‐reported disability has also been linked to suicidal behavior [ 15 ]. The suicide rate in people with MS is reported to be twice that of the general population, with more than 25% experiencing SI [ 16 , 17 ]. Given that SI is a key precursor to suicide, monitoring this aspect of mental health is crucial in MS care.

Several studies have examined the risk factors for suicidal behavior in MS, identifying associations with disease‐related factors such as depression, progressive disease subtype, and disability level [ 18 ]. Beyond clinical factors, a patient's social and economic environment can also make a meaningful difference. Individuals living in developing countries often face financial strain and limited access to adequate healthcare, which may worsen disease progression and disability. These added burdens can increase psychological distress and, in turn, contribute to a higher risk of suicidal behavior [ 19 ].

Several studies conducted across different regions of the world have reported inconsistent and sometimes contradictory findings regarding the prevalence of suicidal ideation (SI) in patients with MS. A prior meta‐analysis estimated the prevalence of SI among patients with MS to be 13% [ 20 ]; however, updated, more comprehensive data from diverse geographic regions are needed, along with a more thorough evaluation of risk factors for SI in this population. Given the expanding body of evidence on potential determinants of SI in MS, the present systematic review and meta‐analysis was conducted to provide an updated global estimate of SI prevalence and to identify the associated risk factors among patients with MS.

Methods

Inclusion Criteria and Search Strategy

The research question of the present study was structured according to the Population–Condition–Outcome (PCO) framework, as recommended for observational studies. The population (P) consisted of patients diagnosed with multiple sclerosis (MS); the condition/exposure (C) included demographic and clinical risk factors; and the outcome (O) was the presence of suicidal ideation (SI). The present study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines [ 21 ]. We searched the PubMed, Scopus, Web of Science, and Embase databases for studies published from inception through December 2024. The search terms and MeSH terms, including multiple sclerosis and suicide, were searched. Supporting Table 1 presents a complete list of keywords used in the search. Inclusion criteria were studies that investigated the prevalence and risk factors of SI in patients with MS; non‐English studies, case reports, case series, reviews, editorials, and conference abstracts were excluded. Also, the studies that mentioned suicidal attempt or suicidal behavior without SI were excluded. After excluding duplicate studies, two authors, MML and EB, independently screened the titles and abstracts of the remaining studies against the inclusion criteria. In cases of disagreement, the full text of the studies was reviewed, and any discrepancies were resolved through discussion with MAS. The study team included clinicians and researchers with expertise in neurology, epidemiology, and biostatistics. All members of the team have prior experience conducting systematic reviews and meta‐analyses.

Data Extraction

EB and MML independently extracted data with high agreement (kappa > 0.8); in cases of disagreement, a third author (AHB) resolved the issue using the original full text. The following data were extracted from the included studies: the first author's name, year of publication, and country of origin, study design, population definition, mean age, sex, prevalence, and main findings and risk factors of SI in patients with MS. In addition, the SI assessment method, including the Beck Depression Inventory‐II (BDI‐II) [ 22 ], the Beck Scale for Suicide Ideation (BSI) [ 23 ], or the PHQ‐9 (Patient Health Questionnaire‐9) [ 24 ], was extracted.

Quality Assessment

The quality of the included studies was assessed using the Newcastle–Ottawa Scale (NOS), which is designed for observational studies [ 25 ]. A NOS score of at least 7 was considered high quality, 5–6 as moderate quality, and less than 5 as low quality. EB and MML independently assessed the quality, and any disagreement was resolved through discussion with a third author (MAS).

Statistical Analysis

The statistical analyses were performed in R version 4.2.2 (R Core Team [2021], Vienna, Austria). To estimate the overall pooled prevalence, a random effects model was used. DerSimonian and Laird's method, which assumes heterogeneity across studies, was used in the random effects model. The heterogeneity ( I 2 ) was classified as mild (25%–49%), moderate (50%–74%), and high (> 75%) [ 26 ]. Having an I 2 value greater than 50% and a p < 0.05 was defined as a threshold for statistical significance. The random‐effects model was used to integrate the potential heterogeneity among the enrolled studies [ 27 ]. Subgroup analyses by study year and country income level (World Bank classification) were conducted to assess the effects of each. We performed a leave‐one‐out sensitivity analysis to assess the effect of each study. In addition, a random‐effects meta‐analysis was performed after outlier removal. Finally, publication bias was assessed using Egger's test, and funnel plots were visually inspected using the trim‐and‐fill method. All statistical analyses were performed adhering to relevant recommendations for analysis, reporting, and interpretation of clinical research [ 28 ] and “Statistical Analyses and Methods in the Published Literature” (SAMPL) guidelines for reporting statistical analyses [ 29 ].

Results

Literature Search and Included Studies

Characteristics of Included Studies

A total of 2352 records were identified through database searches, which were then reduced to 1246 after duplicates were removed. Of these, 1003 were excluded during title/abstract screening, and 243 were evaluated for eligibility based on their full texts (Figure 1 ). After the exclusion of 225 further studies at this stage, 18 studies were included that investigated the prevalence of SI in patients with MS and the association factors between SI and MS. From the total of 18 included studies in the systematic review [ 15 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 ], 16 were selected for meta‐analysis [ 15 , 30 , 31 , 32 , 33 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 ], details of which are shown in Table 1 . The qualities of the included studies are shown in Supporting Table 2 . As shown in the table, all included studies were of high quality according to the NOS system. Based on World Bank criteria, 14 of the included studies were conducted in high‐income countries, while the remaining four were in upper‐middle‐income countries (three in Iran and one in Brazil). Methodologically, 15 were cross‐sectional studies, two were cohort studies, and one was a qualitative study. Finally, the methods for measuring prevalence rates are discussed in Table 2 . PHQ‐9, BSI, and BDI‐II were among the most frequently used questionnaires for SI measurement.

Characteristics of Participants

Among the included studies, participant numbers ranged from 16 to 3823. Among the total of 8250 patients with MS, 1464 (17.7%) had suicide ideation. The mean age of participants was 44.96 ± 11.4 years, and 28.46% of them were men.

The Prevalence of SI in Patients With MS

Meta‐Analysis of MS Prevalence

The total number of patients with MS included in the meta‐analysis (16 studies) was 8078, of whom 1449 had SI. The random‐effects meta‐analysis of the prevalence of SI in patients with MS yielded a pooled prevalence of 20% (95% CI [15–25]), as shown in Figure 2 as a forest plot. This was associated with high Heterogeneity ( I 2 = 94%) for this outcome.

Removal of Outliers

As shown in Supporting Figure 1 , six outliers were identified in this meta‐analysis. Meta‐analysis after the removal of these outliers revealed that the overall prevalence of SI was changed to 21% (95% CI [16–26]). The heterogeneity was also high in this analysis ( I 2 = 89%).

Subgroup Analysis

Study Year

Upon subgroup analysis by study year, a statistically significant difference was observed between subgroups ( p < 0.01) (Figure 3 ). The single study conducted between 1990 and 1999 reported an SI prevalence of 30.5% (95% CI [26.6–34.6]). The pooled prevalence of SI among patients with MS in studies published from 2000 to 2009 was 29.2% (95% CI [24.8–34.1]). In contrast, among the seven studies conducted between 2010 and 2019, the pooled prevalence decreased to 18.7% (95% CI [12.6–26.9]). Finally, studies conducted from 2020 to 2025 showed a pooled prevalence of 17.2% (95% CI [9.1–30.3]).

Country Income Levels

Subgroup analysis according to country income level demonstrated notable differences in prevalence estimates ( p < 0.001). The pooled prevalence of SI in high‐income countries was 17.1% (95% CI: [12.8–22.7]) (Figure 4 ). In contrast, studies conducted in upper‐middle‐income countries reported a substantially higher pooled prevalence of 31.8% (95% CI [28.4–35.3]) (Figure 4 ).

Sensitivity Analysis

Sensitivity analysis using the leave‐one‐out method was performed; the results are shown in Supporting Figure 2 . It was shown that omitting each study resulted in a prevalence of SI in patients with MS ranging from 19% to 21%.

Publication Bias Assessment

Publication bias assessment was performed by Egger's method, and visual inspection of the funnel plot by the trim‐and‐fill method. Egger's test was not significant for publication bias ( p ‐value = 0.44). Funnel plot assessment, however, revealed asymmetry, and the addition of one study indicated that the prevalence would decrease to 19% (95% CI [14–24]). The funnel plot is shown in Figure 5 .

Risk Factors for SI in Patients With MS

As shown in Table 2 , several risk factors have been attributed to SI in the MS population. Anxiety and depression were the top related risk factors in several of the studies [ 15 , 30 , 32 , 33 , 36 , 38 , 40 , 44 , 45 , 46 ]. Similarly, levels of disability and education level were reported as risk factors of SI in the MS population [ 30 , 32 , 37 , 40 ]. Regarding education level, while Asgarian et al. [ 32 ] reported that higher education was associated with a higher rate of SI, the studies by Romaniuc et al. [ 30 ] and Sariaslani et al. [ 40 ] showed a protective effect of higher education. Disease duration [ 30 , 37 , 41 ] and lack of social support [ 31 , 41 , 43 ] were reported as other significant risk factors for SI in the setting of MS.

Discussion

In this systematic review and meta‐analysis, we estimated the global prevalence of suicidal ideation (SI) among patients with multiple sclerosis (MS) and examined its associated risk factors. Based on 18 studies conducted between 1990 and 2024, which varied in population size, design, and geographical location, we found a pooled lifetime prevalence of SI of 20% (95% CI: 15–25). The most consistently reported risk factors for SI were depression and anxiety.

A considerable degree of heterogeneity was observed across studies. Sensitivity analyses confirmed the robustness of the findings, and therefore, a random‐effects model was applied throughout the analyses. The observed heterogeneity may be explained by variations in sampling methods, sample sizes, study designs, assessment tools for SI, and differences in sociodemographic and clinical characteristics of participants across countries.

Previous literature has reported that the prevalence of suicidal ideation (SI) and suicidal intent among patients with multiple sclerosis (MS) is approximately 18% and 28%, respectively [ 15 , 35 ]. These findings are generally consistent with our results and highlight the considerable burden of suicidality in this population. A meta‐analysis conducted in 2020 reported a global prevalence of SI of 13% (95% CI: 0.09–0.17), which is lower than the pooled estimate observed in our study [ 20 ]. This discrepancy may be related to differences in inclusion criteria, study periods, or a potential increase in SI rates over time. Some studies suggest that global crises, such as the COVID‐19 pandemic, evolving geopolitical tensions, and broader instability, may influence levels of anxiety, loneliness, social isolation, depression, and suicidal ideation in the general population [ 47 , 48 , 49 ]. Additionally, over time, individuals may feel less stigma around discussing their mental health, leading to greater openness in reporting these experiences. Indeed, in the MS setting, some reports suggest that the rate of SI among patients with MS has increased over the past decade [ 20 ]. Furthermore, studies conducted in both developed and developing countries consistently demonstrate that patients with MS experience higher rates of SI compared to the general population [ 4 , 17 , 43 ].

Subgroup analyses by study year and income level revealed significant trends in SI in MS settings. Our analysis indicated a decrease in SI prevalence from the 1990–1999 decade to the 2020–2025 years. In addition, high‐income countries had lower SI prevalence than others (17% vs. 31%). These differences may be attributed to regional variations in the prevalence of depression, anxiety, and other psychiatric disorders, as well as differences in cultural and social environments. Additionally, methodological factors such as the use of different assessment tools, variations in sample size, and study design may contribute to the heterogeneity observed in SI prevalence across studies. It is important to note that all studies representing developing countries in our analysis were conducted in Iran; therefore, the lack of data from other regions limits the generalizability of conclusions regarding global disparities.

Bie et al. reported a 52% increase in the global incidence of anxiety disorders between 1990 and 2021, with a particularly marked rise among women and in regions with a middle sociodemographic index [ 50 ]. In low‐income settings, several contextual stressors may further heighten susceptibility to anxiety and depression, including poverty, substandard housing, financial insecurity, and political instability. These stressors, in addition to the physical and psychological burden of MS, may increase the risk of SI in affected individuals [ 51 , 52 ]. Moreover, underreporting of anxiety disorders and SI in developing countries, due to limited mental health infrastructure, insufficient diagnostic services, and social stigma, may further complicate accurate estimation and cross‐regional comparisons.

Although several psychiatric conditions have been linked to MS [ 53 , 54 , 55 , 56 ], mental health disturbances, particularly depression and anxiety, are the most consistently reported risk factors for suicidal ideation (SI) in this population. Substantial evidence indicates that depression is more prevalent among patients with MS than in the general population, with reported rates ranging from 24% to 54% in people with MS compared with 14.4% to 20.6% in the general U.S. population. Moreover, depressive symptoms tend to be more severe in individuals with MS [ 57 , 58 , 59 ]. A meta‐analysis examining depression in MS reported a pooled mean prevalence of 20.6% for clinical depression and 35.0% for moderate‐to‐severe depressive symptoms [ 60 ].

Consistent with these findings, 13 of the 18 studies included in our meta‐analysis identified depression and anxiety as major risk factors for SI in patients with MS [ 15 , 30 , 32 , 33 , 36 , 38 , 40 , 41 , 42 , 43 , 44 , 45 , 46 ]. Psychological disturbances can substantially impair quality of life, reduce independence in daily activities, and negatively affect employment status, thereby increasing vulnerability to suicidal thoughts and premature mortality. Therefore, early diagnosis, appropriate management, and effective treatment of psychiatric comorbidities are essential components of suicide prevention strategies in this population.

Social support (SS) also emerged as an important protective factor. Several studies reported that patients experiencing SI tended to have lower levels of perceived social support from family and friends [ 31 , 34 , 41 , 42 , 43 ]. Strong social support networks may provide opportunities for emotional expression and problem‐sharing, while buffering the psychological impact of stress, loneliness, hopelessness, and negative cognitions associated with SI.

Educational level was another factor associated with SI in several included studies. Patients with higher educational attainment were less likely to report SI, a finding consistent with previous literature [ 30 , 40 , 61 , 62 ]. This association may reflect greater health literacy, better understanding of treatment options, and improved coping strategies. Additionally, higher education is often linked to better employment opportunities, greater financial stability, and broader social networks, all of which may mitigate the psychological burden of living with MS. Individuals with higher educational levels may also demonstrate greater confidence and hope following diagnosis.

Regarding clinical characteristics, Romania et al. [ 30 ] reported a positive correlation between disease duration and SI, consistent with findings by Bronnum‐Hansen et al. [ 63 ]. In contrast, Knowles et al. found that a longer disease duration correlates with reduced depressive symptom severity in both progressive MS and relapsing‐remitting MS (RRMS), possibly indicating psychological adaptation over time [ 37 ]. These conflicting findings suggest that the relationship between disease duration and SI may be complex and influenced by disease course, coping mechanisms, and individual resilience.

Age‐related associations with SI remain inconsistent. Viner et al. hypothesized that SI is more common in patients aged ≥ 65 years (HR = 4.3, 95% CI 1.7–11.3), whereas Turner et al. reported a higher prevalence of SI among younger patients [ 36 , 39 ]. Additionally, Sariaslani and Viner et al. found no significant age differences between patients with and without SI or suicide [ 39 , 40 ].

Several studies also demonstrated a positive association between SI and disability‐related factors, including limited activity, perceived and actual disability, and physical impairment in patients with MS [ 8 , 30 , 37 , 44 , 64 ]. However, Feinstein's study did not observe a significant association [ 46 ]. Moreover, progressive MS phenotypes have been linked to higher levels of SI compared with relapsing‐remitting MS, possibly due to greater accumulated disability and functional decline [ 36 , 65 ]. Finally, additional risk factors identified across studies included male sex, unmarried status, and the presence of comorbid conditions. These findings are largely consistent with previous research [ 65 , 66 ], further underscoring the multifactorial nature of SI risk in patients with MS.

To the best of our knowledge, this is the first systematic review and meta‐analysis to evaluate the global prevalence of suicidal ideation (SI) among patients with MS with a specific focus on associated risk factors. Nevertheless, several limitations should be acknowledged. First, substantial variability existed across studies in terms of sample size and the instruments used to assess SI. Differences in measurement tools and study design may have influenced prevalence estimates and the identification of associated risk factors, contributing to heterogeneity. Second, in some developing countries, stigma surrounding mental health and suicidal thoughts may lead to underreporting, potentially resulting in underestimation of the true prevalence of SI. Third, there was a notable lack of data from many regions, particularly low‐ and middle‐income countries. This limited geographical representation may affect the generalizability of our findings and restrict firm conclusions regarding global patterns. Finally, the diagnostic criteria for multiple sclerosis were not consistently reported across the included studies. Although most studies relied on an established clinical diagnosis of MS, the absence of standardized reporting of diagnostic criteria may introduce variability in patient selection and comparability across studies. Despite these limitations, our findings provide important insights into the burden and determinants of SI among patients with MS and highlight the need for further high‐quality, multicenter research in diverse settings.

Conclusion

In this systematic review and meta‐analysis, we estimated the pooled prevalence of suicidal ideation (SI) among patients with MS to be 20%, with reported rates ranging from 8% in Canada to 36% in Iran. These findings highlight substantial regional variation in SI prevalence and underscore the need for further investigation, particularly in regions reporting higher rates within this vulnerable population. Our results also indicate that depression, anxiety, level of family and social support, educational attainment, disease duration, and degree of disability are important factors associated with the occurrence of SI in patients with MS. These findings emphasize the critical role of mental health assessment and psychosocial support in the comprehensive management of MS. Future research should focus on evaluating SI prevalence across diverse ethnicities and geographic regions, particularly in underrepresented and low‐ and middle‐income countries. Additionally, further studies are needed to explore other potential contributing factors and to better understand the complex interplay between clinical, psychological, and sociodemographic determinants of SI in this population.

Author Contributions

Elham Bazmi: conceptualization, writing – original draft, visualization, formal analysis. Amir Hossein Behnoush: writing – review and editing, writing – original draft. Mahsa Mohammadi Lapevandani: writing – review and editing, writing – original draft. Moahmmad Taghi Talebian: writing – original draft, writing – review and editing. Shima Jahani: writing – original draft, writing – review and editing. Mohammad Ali Sahraian: writing – original draft, writing – review and editing, data curation, conceptualization, supervision.

Funding

The authors have nothing to report.

Ethics Statement

The study was approved by the Ethics Committee of Tehran University of Medical Sciences, Tehran, Iran (IR.TUMS.SINAHOSPITAL.REC.1404.009) and was conducted in accordance with the Declaration of Helsinki.

Conflicts of Interest

The authors declare no conflicts of interest.

Transparency Statement

The lead author Mohammad Ali Sahraian affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Supporting information

Supporting File

Acknowledgments

The authors would like to thank the Research Development Center of Sina Hospital for their technical assistance and help in data gathering.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

References

1. Ma Y., Xiang Q., Yan C., Liao H., and Wang J., “Relationship Between Chronic Diseases and Depression: The Mediating Effect of Pain,” BMC Psychiatry 21, no. 1 (2021): 436.

2. Asbring P., “Chronic Illness ‐‐ A Disruption in Life: Identity‐Transformation Among Women With Chronic Fatigue Syndrome and Fibromyalgia,” Journal of Advanced Nursing 34, no. 3 (2001): 312–319.

3. Iovino P., Vellone E., Cedrone N., and Riegel B., “A Middle‐Range Theory of Social Isolation in Chronic Illness,” International Journal of Environmental Research and Public Health 20, no. 6 (2023): 4940.

4. Bazmi E., Behnoush A. H., Eskandarieh S., et al., “Suicidal Ideation in Patients With Multiple Sclerosis and Its Association With Clinical and Demographic Characteristics,” Brain and Behavior 15, no. 4 (2025): e70458.

5. Grover S., Bhansali A., Kate N., et al., “Presence of Common Mental Disorders in Patients With Diabetes Mellitus Using a Two‐Stage Evaluation Method,” Indian Journal of Medical Research 141, no. 3 (2015): 364–367.

6. Massie M. J., “Prevalence of Depression in Patients With Cancer,” Journal of the National Cancer Institute Monographs 2004, no. 32 (2004): 57–71.

7. Padovani A., Antonini A., Barone P., et al., “Exploring Depression in Alzheimer's Disease: An Italian Delphi Consensus on Phenomenology, Diagnosis, and Management,” Neurological ScienceS 44, no. 12 (2023): 4323–4332.

8. Huang Y. Y., Gan Y. H., Yang L., Cheng W., and Yu J. T., “Depression in Alzheimer's Disease: Epidemiology, Mechanisms, and Treatment,” Biological Psychiatry 95, no. 11 (2024): 992–1005.

9. Al‐Qahtani Z., Alqahtani A. S. M., Alzuhairi A. M., et al., “The Prevalence of Depression Among Parkinson's Disease Patients in Saudi Arabia: A Cross‐Sectional Study,” Neuropsychiatric Disease and Treatment 21 (2025): 241–256.

10. Solaro C., Gamberini G., and Masuccio F. G., “Depression in Multiple Sclerosis: Epidemiology, Aetiology, Diagnosis and Treatment,” CNS Drugs 32, no. 2 (2018): 117–133.

11. Siegert R. J., “Depression in Multiple Sclerosis: A Review,” Journal of Neurology, Neurosurgery & Psychiatry 76, no. 4 (2005): 469–475.

12. Sadovnick A. D., Eisen K., Ebers G. C., and Paty D. W., “Cause of Death in Patients Attending Multiple Sclerosis Clinics,” Neurology 41, no. 8 (1991): 1193.

13. Feinstein A., Magalhaes S., Richard J. F., Audet B., and Moore C., “The Link Between Multiple Sclerosis and Depression,” Nature Reviews Neurology 10, no. 9 (2014): 507–517.

14. Ketata I. and Ellouz E., “Multiple Sclerosis and Vascular Nexus: A Systematic Review and Meta‐Analysis of Incidence and Mortality,” Revue Neurologique 181, no. 3 (2025): 184–199.

15. Lewis V. M., Williams K., KoKo C., Woolmore J., Jones C., and Powell T., “Disability, Depression and Suicide Ideation in People With Multiple Sclerosis,” Journal of Affective Disorders 208 (2017): 662–669.

16. Feinstein A. and Pavisian B., “Multiple Sclerosis and Suicide,” Multiple Sclerosis Journal 23, no. 7 (2017): 923–927.

17. Kalb R., Feinstein A., Rohrig A., Sankary L., and Willis A., “Depression and Suicidality in Multiple Sclerosis: Red Flags, Management Strategies, and Ethical Considerations,” Current Neurology and Neuroscience Reports 19, no. 10 (2019): 77.

18. Pompili M., Forte A., Palermo M., et al., “Suicide Risk in Multiple Sclerosis: A Systematic Review of Current Literature,” Journal of Psychosomatic Research 73, no. 6 (2012): 411–417.

19. Renaud J., MacNeil S. L., Vijayakumar L., et al., “Suicidal Ideation and Behavior in Youth in Low‐ and Middle‐Income Countries: A Brief Review of Risk Factors and Implications for Prevention,” Frontiers in Psychiatry 13 (2022): 1044354.

20. Kouchaki E., Namdari M., Khajeali N., Etesam F., and Asgarian F. S., “Prevalence of Suicidal Ideation in Multiple Sclerosis Patients: Meta‐Analysis of International Studies,” Social Work in Public Health 35, no. 8 (2020): 655–663.

21. Page M. J., McKenzie J. E., Bossuyt P. M., et al., “The PRISMA 2020 Statement: An Updated Guideline for Reporting Systematic Reviews,” BMJ (Clinical Research Ed) 372 (2021): n71.

22. Beck A. T., Steer R. A., and Brown G. K. Beck Depression Inventory. 1996.

23. Beck A. T., Kovacs M., and Weissman A., “Assessment of Suicidal Intention: The Scale for Suicide Ideation,” Journal of Consulting and Clinical Psychology 47, no. 2 (1979): 343–352.

24. Kroenke K., Spitzer R. L., and Williams J. B. W., “The PHQ‐9: Validity of a Brief Depression Severity Measure,” Journal of General Internal Medicine 16, no. 9 (2001): 606–613.

25. Wells G. A., et al. The Newcastle–Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta‐Analyses. 2000.

26. Higgins J. P. T., Thompson S. G., Deeks J. J., and Altman D. G., “Measuring Inconsistency in Meta‐Analyses,” BMJ 327, no. 7414 (2003): 557–560.

27. Higgins J. P. T., Altman D. G., Gotzsche P. C., et al., “The Cochrane Collaboration's Tool for Assessing Risk of Bias in Randomised Trials,” BMJ 343 (2011): d5928.

28. Assel M., Sjoberg D., Elders A., et al., “Guidelines for Reporting of Statistics for Clinical Research in Urology,” BJU International 123, no. 3 (2019): 401–410.

29. Lang T. A. and Altman D. G., “Basic Statistical Reporting for Articles Published in Biomedical Journals: The “Statistical Analyses and Methods in the Published Literature” or the SAMPL Guidelines,” International Journal of Nursing Studies 52, no. 1 (2015): 5–9.

30. Romaniuc A., Bălaşa R., Ştirbu N., et al., “The Main Determinants for Suicidal Ideation in a Romanian Cohort of Multiple Sclerosis Patients,” Behavioural Neurology 2020 (2020): 2594702.

31. Ariapooran S., Rajabi M., and Goodarzi A., “Relationship Between Social Support, Time Perspective and Suicide Ideations in Patients With Multiple Sclerosis,” Asian Social Science 12, no. 8 (2016): 192–200.

32. Asgarian F. S., Keyhani A., Moghadasi A. N., Sahraian M. A., and Etesam F., “Predictors of Suicidal Ideation Among Iranian Patients With Multiple Sclerosis,” Current Journal of Neurology 19, no. 4 (2020): 154–161.

33. Dickstein L. P., Viguera A. C., Nowacki A. S., et al., “Thoughts of Death and Self‐Harm in Patients With Epilepsy or Multiple Sclerosis in a Tertiary Care Center,” Psychosomatics 56, no. 1 (2015): 44–51.

34. Long D. D. and Miller B. J., “Suicidal Tendency and Multiple Sclerosis,” Health & Social Work 16, no. 2 (1991): 104–109.

35. Gaskill A., Foley F. W., Kolzet J., and Picone M. A., “Suicidal Thinking in Multiple Sclerosis,” Disability and Rehabilitation 33, no. 17–18 (2011): 1528–1536.

36. Turner A. P., Williams R. M., Bowen J. D., Kivlahan D. R., and Haselkorn J. K., “Suicidal Ideation in Multiple Sclerosis,” Archives of Physical Medicine and Rehabilitation 87, no. 8 (2006): 1073–1078.

37. Knowles L. M., Esselman E. C., Turner A. P., et al., “Depressive Symptoms and Suicidal Ideation in Progressive Multiple Sclerosis Compared With Relapsing‐Remitting Multiple Sclerosis: Results From a Cross‐Sectional Survey,” Archives of Physical Medicine and Rehabilitation 102, no. 4 (2021): 694–701.

38. Altura K. C., Patten S. B., Fiest K. M., Atta C., Bulloch A. G., and Jetté N., “Suicidal Ideation in Persons With Neurological Conditions: Prevalence, Associations and Validation of the PHQ‐9 for Suicidal Ideation,” General Hospital Psychiatry 42 (2016): 22–26.

39. Viner R., Patten S. B., Berzins S., Bulloch A. G. M., and Fiest K. M., “Prevalence and Risk Factors for Suicidal Ideation in a Multiple Sclerosis Population,” Journal of Psychosomatic Research 76, no. 4 (2014): 312–316.

40. Sariaslani P., Ghanbari P., and Komasi S., “Correlation of Suicidal Thoughts and Suicide Attempts in Patients With Multiple Sclerosis,” Journal of Kermanshah University of Medical Science 25, no. 3 (2021): e118040.

41. Berkman C. S., Cavallo P. F., Chesnut W. C., and Holland N. J., “Attitudes Toward Physician‐Assisted Suicide Among Persons With Multiple Sclerosis,” Journal of Palliative Medicine 2, no. 1 (1999): 51–63.

42. Strupp J., Ehmann C., Galushko M., et al., “Risk Factors for Suicidal Ideation in Patients Feeling Severely Affected by Multiple Sclerosis,” Journal of Palliative Medicine 19, no. 5 (2016): 523–528.

43. Mikula P., Timkova V., Linkova M., Vitkova M., Szilasiova J., and Nagyova I., “Fatigue and Suicidal Ideation in People With Multiple Sclerosis: The Role of Social Support,” Frontiers in Psychology 11 (2020): 504.

44. Gillespie D. C., Sacripante R., Chandran S., and Foley P., “Suicidal Ideation in the Year Following Diagnosis of Relapsing‐Remitting Multiple Sclerosis: A Longitudinal Perspective,” Multiple Sclerosis and Related Disorders 91 (2024): 105904.

45. Tauil C. B., Grippe T. C., Dias R. M., et al., “Suicidal Ideation, Anxiety, and Depression in Patients With Multiple Sclerosis,” Arquivos de Neuro‐psiquiatria 76, no. 5 (2018): 296–301.

46. Feinstein A., “An Examination of Suicidal Intent in Patients With Multiple Sclerosis,” Neurology 59, no. 5 (2002): 674–678.

47. Farooq S., Tunmore J., Wajid Ali M., and Ayub M., “Suicide, Self‐Harm and Suicidal Ideation During COVID‐19: A Systematic Review,” Psychiatry Research 306 (2021): 114228.

48. Sari E., Er S. T., and Demir E., “Suicide as Globalisation's Black Swan: Global Evidence,” Public Health 217 (2023): 74–80.

49. Stack S., “Contributing Factors to Suicide: Political, Social, Cultural and Economic,” Preventive Medicine 152, no. Pt 1 (2021): 106498.

50. Bie F., Yan X., Xing J., et al., “Rising Global Burden of Anxiety Disorders Among Adolescents and Young Adults: Trends, Risk Factors, and the Impact of Socioeconomic Disparities and COVID‐19 From 1990 to 2021,” Frontiers in Psychiatry 15 (2024): 1489427.

51. Anderson T. L., Valiauga R., Tallo C., et al., “Contributing Factors to the Rise in Adolescent Anxiety and Associated Mental Health Disorders: A Narrative Review of Current Literature,” Journal of Child and Adolescent Psychiatric Nursing 38, no. 1 (2025): e70009.

52. Ridley M., Rao G., Schilbach F., and Patel V., “Poverty, Depression, and Anxiety: Causal Evidence and Mechanisms,” Science 370, no. 6522 (2020): eaay0214.

53. Pucak M. L., Carroll K. A. L., Kerr D. A., and Kaplin A. L., “Neuropsychiatric Manifestations of Depression in Multiple Sclerosis: Neuroinflammatory, Neuroendocrine, and Neurotrophic Mechanisms in the Pathogenesis of Immune‐Mediated Depression,” Dialogues in Clinical Neuroscience 9, no. 2 (2007): 125–139.

54. Ketata I., Ellouz E., and Ketata A., “Psychoses Onset in Multiple Sclerosis: A Systematic Review and Meta‐Analysis,” Revue Neurologique 181, no. 6 (2025): 483–502.

55. Hanna M. and Strober L. B., “Anxiety and Depression in Multiple Sclerosis (MS): Antecedents, Consequences, and Differential Impact on Well‐Being and Quality of Life,” Multiple Sclerosis and Related Disorders 44 (2020): 102261.

56. Ellouz E., Ketata I., Abbes W., Gargouri H., and Bader S., “Psychoses in Pediatric‐Onset Multiple Sclerosis: A Case Report and Systematic Review,” Journal of Child and Adolescent Psychiatric Nursing 37, no. 4 (2024): e70005.

57. Kessler R. C., Petukhova M., Sampson N. A., Zaslavsky A. M., and Wittchen H. U., “Twelve‐Month and Lifetime Prevalence and Lifetime Morbid Risk of Anxiety and Mood Disorders in the United States,” International Journal of Methods in Psychiatric Research 21, no. 3 (2012): 169–184.

58. Marrie R. A., Reingold S., Cohen J., et al., “The Incidence and Prevalence of Psychiatric Disorders in Multiple Sclerosis: A Systematic Review,” Multiple Sclerosis Journal 21, no. 3 (2015): 305–317.

59. Jones K. H., Ford D. V., Jones P. A., et al., “A Large‐Scale Study of Anxiety and Depression in People With Multiple Sclerosis: A Survey Via the Web Portal of the UK MS Register,” PLoS One 7, no. 7 (2012): e41910.

60. Boeschoten R. E., Braamse A. M. J., Beekman A. T. F., et al., “Prevalence of Depression and Anxiety in Multiple Sclerosis: A Systematic Review and Meta‐Analysis,” Journal of the Neurological Sciences 372 (2017): 331–341.

61. Brenner P., Burkill S., Jokinen J., Hillert J., Bahmanyar S., and Montgomery S., “Multiple Sclerosis and Risk of Attempted and Completed Suicide ‐ A Cohort Study,” European Journal of Neurology 23, no. 8 (2016): 1329–1336.

62. de Cerqueira PSA A. C., Godoy‐Barreiros J. M., and de Oliveira e Silva aAEN A. C., “Risk Factors for Suicide in Multiple Sclerosis: A Case‐Control Study,” Jornal Brasileiro de Psiquiatria 64, no. 4 (2015): 303–306.

63. Bronnum‐Hansen H., “Suicide Among Danes With Multiple Sclerosis,” Journal of Neurology, Neurosurgery & Psychiatry 76, no. 10 (2005): 1457–1459.

64. Stenager E. N., Koch‐Henriksen N., and Stenager E., “Risk Factors for Suicide in Multiple Sclerosis,” Psychotherapy and Psychosomatics 65, no. 2 (1996): 86–90.

65. Chwastiak L., Ehde D. M., Gibbons L. E., Sullivan M., Bowen J. D., and Kraft G. H., “Depressive Symptoms and Severity of Illness in Multiple Sclerosis: Epidemiologic Study of a Large Community Sample,” American Journal of Psychiatry 159, no. 11 (2002): 1862–1868.

66. Lynch S. G., Kroencke D. C., and Denney D. R., “The Relationship Between Disability and Depression in Multiple Sclerosis: The Role of Uncertainty, Coping, and Hope,” Multiple Sclerosis Journal 7, no. 6 (2001): 411–416.

Associated Data

Supplementary Materials

Supporting File

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.