People affected by MS are at the center of everything we do at ACP, including the newsletter. Each month we include a survey asking for feedback and content ideas for future issues. This month we focus on a topic that many of our readers have asked about – depression and MS.
What is Depression?
Everyone feels sad or down at times, but clinical depression is different. It is a constant feeling of sadness or low mood that lasts for two weeks or more, often interfering with everyday activities. Depression can be mild, moderate or severe, depending on how much it affects your life and you can experience different levels of depression at different times. It can make you lose pleasure in things that were once enjoyable. Some people even have thoughts of suicide. If this is the case, the 988 Suicide & Crisis Lifeline is there to help.
Depression is one of the most common symptoms of MS. Research shows it occurs in up to half of people with MS, which is two to three times higher than the general population. The effects of depression can be devastating. It can make even simple activities a challenge. Many of its symptoms are invisible, which often leads to misunderstandings. Those struggling with depression frequently turn inward, withdraw from family and friends, and stop participating in social activities. Loss of libido is a chief complaint among individuals experiencing depression, which may also damage relationships. There is evidence that depression can impact a person’s ability to work. For a depressed individual with MS, a loss of employment and insurance benefits can have a devastating impact. An individual living with both MS and depression may not be inclined or able to follow his or her treatment plan, which could also have detrimental effects in the long run.
Depression symptoms are complex and vary widely from person to person. Several are also symptoms of MS, such as fatigue, insomnia and cognitive difficulties. These similarities make diagnosing depression challenging in someone with MS. The screening tests for depression are typically in the form of a questionnaire. These instruments can also be used in follow up to assess whether symptoms change with treatment.
There are several different types of depression:
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Major Depression – Distinguished by at least 5 of the above symptoms over a two-week period.
Persistent Depressive Disorder (Dysthmia) – Similar symptoms to major depression, but they are more insidious and less severe, often lasting for at least two years.
Bipolar Disorder (Manic-Depressive Disorder) – Characterized by extreme mood swings. Manic symptoms are typically short-lived and followed by a period of depression.
Seasonal Affective Disorder – Related to the change in seasons. It usually occurs in the fall and winter, when days are shorter.
Two types of depression are influenced by reproductive hormones and primarily occur in women:
Premenstrual Dysphoric Disorder (PMDD) – A severe form of premenstrual syndrome that causes extreme, disruptive mood swings. Symptoms usually begin shortly after ovulation and end once menstruation starts.
Postpartum Depression – Occurs during pregnancy or within one year after birth.
While depression can potentially occur in any person with MS at any point in the course of the disease, a number of factors increase its likelihood. It is nearly twice as likely to occur in women than men. Many aspects of living with MS, and the disease itself, have the potential to cause depression. One imaging study suggests it may be the result of nerve damage in areas of the brain that are associated with mood. Researchers at UCSF conclude that the abnormal immune response that occurs in MS may, in fact, cause depressive symptoms. Some of the medications used to treat MS and manage its symptoms may be linked to depression. Steroids are often prescribed during exacerbations, a time when people with MS are already vulnerable to depressive symptoms. Steroids often cause a short term “high” when first given followed by an emotional plunge once the medication is stopped. Depression is a suspected side effect of interferon beta treatments for MS, although the evidence to support this is mixed. Other illnesses can contribute to depression as well, such as thyroid issues, changes in blood sugar levels, and urinary tract or other infections. Therefore, it is important for anyone struggling with depression to have a physical examination and laboratory testing to rule out any underlying (and treatable) physical cause.
Researchers at Case Western Reserve University identified several risk factors for depression in MS using samples and data from the ACP Repository. They include genetic factors, having a mother with a history of depression, obesity, hypertension, mononucleosis, and obstructive pulmonary disease.
Depression is one of the most treatable of all MS symptoms. The most common medications used are selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs) and tricyclic antidepressants. It’s important to be aware that antidepressants can take six to eight weeks to reach their full effect. As mentioned in our February 2019 newsletter, dietary supplements such as St. John’s wort and ginkgo biloba are thought to help with symptoms of depression. Research suggests that fish oil supplementation can also be beneficial in this regard. Anyone considering dietary supplements should first consult his or her physician as these can cause serious side effects and/or interactions with other medications.
Healthy living can be very helpful in coping with depression. Some useful strategies include:
Studies show the most successful treatment plan for depression is to seek counseling in conjunction with a prescribed drug therapy. A number of professionals are specifically trained to provide objective insight and coping skills to help manage the symptoms of depression, including a psychiatrist, psychologist, social worker, or a counselor. A variety of therapeutic approaches may be used during the counseling process, such as talk therapy and behavioral therapy. Counseling sessions may be conducted individually, with couples, families, or larger groups. Some less traditional therapy options also include phone therapy and online therapy. These options may be attractive to those who are home bound or otherwise unable to attend a counseling session.
The National MS Society’s MS Navigator program provides people living with MS with the information, resources and support they need to combat depression and other challenges in MS.
Despite all of the devastating implications of depression, it is often ignored, and as a result, under-treated. While depression is common in people with MS, it is not universal and shouldn’t be considered normal or expected. A common misconception is that depression can be overcome by willpower or religious belief alone, when, in fact, it is an illness that requires time, attention and treatment. Individuals with MS and their families should pay attention to symptoms of depression and notify their health care provider should any arise. There are effective therapies that can help dispel the gloom and return one to a happier, more peaceful place.
