On: Depression and MS
by Martha M. Jablow 

Revised in 1998 from InsideMS, Vol. 11, No. 3

 

The words depressed and depression are used so casually in everyday conversation that their meaning has become murky. True depression is a disorder that will affect from 5 to 20 percent of Americans during their lifetime. Depression is not a fleeting emotion. It is a persistent disturbance of mood with complex roots in an individual’s physiology and psychology, and it has marked symptoms.

People with MS and other chronic illnesses experience depression more than the general population. When "depression" and "MS" are mentioned in the same breath, some people say, "Of course you’d be depressed if you’d been diagnosed with MS," or "How would you feel if your ability to walk just suffered a major setback?" Such reactions assume that depression is a direct psychological response to a diagnosis or symptoms of MS. That is one explanation, but researchers are also looking at possible physiological causes of depression in people with MS.

The pull-up-your-socks syndrome
While researchers look at brain chemicals and chart the positive effects of medications, many people still believe severe depression can be overcome by will power. "There’s a strange feeling in this country that depression is a character flaw. It is not. There is treatment for depression, and it is curable," said Dr. Randolph B. Schiffer, at the Texas Tech University, School of Medicine, a neurologist and psychiatrist who has done research on the psychological aspects of MS.

Cause or effect?
Dr. David Michaelson, a staff psychiatrist in the neuroendocrinology branch of the National Institute of Mental Health, has studied the interaction between the body’s hormone system, immune system, and central nervous system in people who have both depression and MS. 

 

"There is some evidence to suggest that the physiology of MS may predispose people to depression," said Dr. Michaelson. "At the same time, these people carry the burden of MS—the changes in daily life, the loss of function. We don’t know the answer definitely yet. But whether one becomes depressed in reaction to the illness, or depression is a part of the biology of MS, the fact to remember is there are effective interventions." 

The interferons—an added factor
Beta-interferon drugs are effective treatments for relapsing-remitting MS. The side-effects of Avonex and Betaseron may include depression. If you are using either of these medications, be aware of any symptoms of depression, and discuss them with your physician. 

Is it sadness, grief, or true depression?
Grief and sadness lift a little when something pleasant happens. Depression is heavy; it stays in place. Symptoms of clinical depression are listed following this section. They are quite specific. But recognizing depression is not always easy because some of the symptoms are common to both MS and depression.

"It can be hard to sort out signs and symptoms such as fatigue or loss of energy, which are signs of depression and also signs of MS," Dr. Schiffer said. "Sometimes patients, families, and doctors are slow to recognize depression because it may appear so gradually. One thing I’m sure of is that depressive symptoms tend to be at their worst when MS symptoms are exacerbated." 

Once depression is acknowledged, specialists agree, don’t wait; reach out for professional help.

Symptoms of Depression
The hallmark of these symptoms is their persistence. They linger. They are not the normal, transient "blues" that everyone experiences in response to a sad or distressing event. According to the American Psychiatric Association in its Diagnostic and Statistical Manual of Mental Disorders IV-R, the symptoms of major depression last at least 2 weeks. During that time, the person has 5 or more of the following 9 symptoms on a daily, almost round-the-clock basis.

·        Feelings of hopelessness, sadness, despair

·        Loss of pleasure or interest in most activities

·        Significant weight loss or gain; or increase or decrease in appetite

·        Persistent sleep problems, either insomnia or excessive sleep

·        Ongoing fatigue and loss of energy

·        Feelings of personal worthlessness or inappropriate guilt

·        Inability to concentrate or make decisions

·        Observable restlessness or slowed movement

·        Recurrent thoughts of death, violence, or suicide

The symptoms not only persist over time but also impair daily functioning. Depending on their number and severity, depression is categorized medically as mild, moderate, or severe. 

OK, I need help
To find help, Dr. Schiffer advises asking your neurologist or general medical doctor first. "Ask the one with whom you’re best connected," he said.

Dr. Andrew H. Miller, a psychiatrist at Emory University School of Medicine in Atlanta, Georgia, agreed that people with depression shouldn’t wait for it to go away. "The quality-of-life issues are serious. Treatment can optimize your daily functioning."

The Society office nearest you can give you referrals to mental health professionals who understand MS. Call 1-800-FIGHT MS [1-800-344-4867] and select option #1.

Drug therapy
"If you’re severely depressed, with major impairment in function at home or work, it is best to try antidepressant medication," Dr. Miller said.

For those with mild to moderate symptoms, there is "a choice among psychotherapies and the possibility of medication."

Many types of antidepressants are available, but none are magic bullets. Most work gradually. They may bring some improvement after several days, but the drug’s full effect may not appear for several weeks. If there are no improvements after 6 weeks, the doctor will prescribe a different drug.

"It’s very important to target selected symptoms and to follow them to see if the medication is helping," Dr. Miller said. He pointed out that a person is likely to respond to the same antidepressant drug that has worked well for a family member. Biochemistry runs in families.

Side effects are no longer a major obstacle. The older antidepressants were notorious for causing dry mouth, urinary hesitancy, constipation, blurred vision, fatigue, drowsiness, weight gain, sexual dysfunction, and other unpleasant symptoms. They are now rarely used. The newer agents are generally well tolerated and have far fewer unwanted effects. All side effects should be discussed with your doctor. Often, the drug or the dosage can be altered to provide the best effect with the fewest problems. 

Talk therapy
Very few physicians believe that medication alone cures depression. "Most combine drug therapy with some form of counseling," said Dr. Sarah L. Minden, a psychiatrist who treats patients with MS at Brigham and Women’s Hospital and Harvard Medical School.

Psychiatrists, who are MDs, can prescribe medication as well as provide counseling. Talk therapy can be obtained from certified social workers, psychologists, psychiatric nurses, licensed professional counselors, or other qualified non-physicians, who will seek evaluations by a psychiatrist regarding the selection and monitoring of medication if it is indicated.

Talk therapy takes several forms. It may be time-limited and address a current crisis. It may be supportive and focus on finding ways to cope. Or, it may involve in-depth exploration with the goal of helping a person develop greater self-awareness. The form depends on the individual’s needs, and these may change over time or with the stage of illness.

Therapy can be supplemented by participating in a support group. Ask your Society chapter about support-group programs near you specifically for people with MS.

A good relationship
"No matter what form talk therapy takes, a good ‘fit’ between you and your therapist is essential. You should feel that you can bring up any topic," advised Dr. Michaelson.

"Treatment is very relationship-sensitive," Dr. Schiffer explained. "What’s important is that you see somebody who believes in what he or she is doing, someone with whom you can have a good relationship." This may mean a period of shopping around. Obviously, not every qualified therapist is the right one for you. "Don’t give up on the concept of treatment," Dr. Schiffer said. "When that relationship is developed, it can help you understand your emotions and gain more control over your life."

Disability and depression
"Some people who are profoundly disabled are not depressed—while others are very depressed but not physically disabled at all," Dr. Minden said. Research has shown no correlation between depression and an individual’s degree of disability.

"What makes a person depressed seems to relate to a host of factors," she explained. "Disability may contribute but it’s not an either/or issue. The other factors include genetics, individual coping styles, past and present experiences, and what sorts of social supports a person has. But while we don’t yet know how depression originates, we do know how to treat it."