Expert Support
Multiple Sclerosis and Depression
Dr. Anthony Feinstein, Psychiatrist
Multiple sclerosis is associated with varied behavioural disorders. These range from cognitive dysfunction to changes in mood and anxiety level. The most frequently encountered mood change is that of depression. Research has revealed that one in two people with MS will experience a clinically significant period of depression over the course of their lifetime. These rates are higher than those found in other neurological disorders.
What are the signs of depression?
Depression is not just a matter of low mood. It is also characterized by insomnia or excessive sleeping, feelings of poor self-esteem, guilt, irritability, changes in appetite, loss of sexual energy, pessimistic thoughts about the future and, on occasion, suicidal thoughts. When symptoms like these have been present for two weeks or longer, a person is said to have developed a Major Depression.
There are a number of rating scales that can be used to detect symptoms of depression. Those that have been developed for use in a general medical setting are particularly useful because they focus on core depressive features (e.g., guilt, sadness, poor esteem, etc.) rather than the body-related difficulties (e.g., energy, sleep, appetite) that may be a direct consequence of the demyelinating disease itself. Examples of these self-report scales are the Hospital Anxiety and Depression Scale (HADS) and Beck Fast Screen for Depression in patients with medical illness, both of which have been validated for use in MS populations.
Why is depression important?
Depression is important because it exerts a profoundly negative effect on an individual’s quality of life. Research has shown that people frequently consider depression as one of the most troubling aspects of their multiple sclerosis. This point is further emphasized by data from my research group, which show that one in three people with MS have thoughts of suicide. Suicidal intent is, not surprisingly, closely linked to depression, which makes it very important for depression to be detected and treated. There are also data showing that people with MS who are depressed may have more significant cognitive issues, which further add to the burden of the disease.
It is important to note that depression does not only affect the person with MS, but also spills over to affect family and friends, which can lead to marital breakdown and impaired relationships in general.
Why is depression so common in people with MS?
The reasons why people with MS become depressed are likely multifactorial. In the past, depression was viewed as a reaction to a disabling illness. The “reactive” hypothesis made good, intuitive sense, because people with MS were seen as facing a future of increasing disability in the absence of effective treatments. What is interesting, however, is that with the introduction of disease-modifying treatments, of which several are available, rates of depression did not decline. While this may relate to treatment expectations that are not fulfilled, other causes for depression have begun to emerge. The most important of these causes are the brain changes in people with MS who are depressed, as demonstrated by magnetic resonance imaging (MRI). Recent imaging data have shown that depressed MS patients have more brain lesions and atrophy affecting frontal and temporal brain regions. This suggests that depression may be an integral part of the MS disease itself in some patients.
Can MS treatments cause depression?
Comprehensive reviews of the psychiatric effects of disease-modifying drugs concur that in general, these treatments do not cause depression. Follow-up studies show that people who become depressed on these treatments often have a history of depression before going on treatment. Should a person with MS taking a disease-modifying drug develop depression the depression should be treated without discontinuing the disease-modifying drug.
How can depression be treated?
Depression in people with MS can respond to treatment. Clinical trials have shown that antidepressant medication may lead to symptom improvement and, on occasion, symptom resolution; although side effects such as dry mouth, constipation and sexual difficulties may arise. Changing antidepressant drugs may reduce some of these problems. In addition to medication, cognitive behaviour therapy (CBT) is an effective form of treatment for depression and rivals medication in its efficacy. CBT is usually given at weekly sessions over the course of sixteen weeks. Of note is that CBT may be effectively administered over the telephone to people with MS who cannot make it in for their appointments due to problems with transportation and mobility.
The fact that depression responds well to treatment underscores the importance of detecting symptoms to begin with. Evidence shows that this is not taking place. In a disease such as multiple sclerosis where there is as yet no cure, it is essential that physicians, nurses and clinic coordinators pay attention to detecting and treating symptoms that are reversible in their patients.
If you think you might be experiencing symptoms of depression, please speak with your neurologist, nurse or clinic coordinator to discuss treatment options that may be right for you.
This feature is intended solely for informational purposes and is not a substitute for routine or urgent medical evaluation, treatment or consultation. Dr. Feinstein’s guest editorial should not be construed as a medical opinion aimed at establishing a diagnosis or course of treatment. Individuals who are being treated should not construe information here as replacing or superseding recommendations of their own physician.
