Depression in MS
Dr Martin Duddy, Consultant Neurologist, Royal Victoria Infirmary, Newcastle upon Tyne
Open Door - August 2009 pages 12-13
picture: ColorLoose
In an era where people talk publicly about every aspect of their life, open discussion about personal mental health problems remains unusual. It is, therefore, no surprise that depression is underreported, under-recognised and under-treated in people with MS. A perception that depression demonstrates 'lack of moral fibre' can stop people talking about their feelings to family, let alone a health care professional, and frequently people may not admit to themselves the despair, anxiety and fear they feel.
What is depression?
Everyone has periods when their mood is low. It would be odd not to see people with MS go through times when things are hard to deal with emotionally. MS is often diagnosed just at the time of life when we have our highest expectations of financial and social success. It is not surprising to see people angry, frustrated, anxious and disappointed. In some, however, what should be a 'proportionate', passing period becomes a deeper depressive illness: a self-perpetuating state of low mood which itself causes disability, interfering with daily life.
Depression is diagnosed from an individual's own account. There is no blood test or scan to help. We look for certain key themes in what people say and we start to think about depression when people describe low mood on most days, for most of the day, over at least two weeks. People with depression describe loss of pleasure: an inability to get enthusiastic about anything. An event or outing that would, in the past, have been something to look forward to, becomes just a chore. People give up hobbies, pull out of events, stop going out and withdraw from relationships. People with depression may have difficulty getting to sleep as unpleasant thoughts circle in their head or may waken repeatedly in the small hours and be unable to get back to sleep. Eating habits change, either with a loss of interest in food and weight loss, or overeating and weight gain. Someone with MS may focus on all the things they cannot do, losing any sense of self worth, believing others only see their disability. They may perceive themselves as a burden or embarrassment and may blame themselves for their condition.
As the mind is filled with recurrent negative thoughts, there is less capacity to concentrate on other matters, so memory and thinking suffer. The future looks bleak, colourless and pointless. People may toy with the idea that it would be better for everyone if they weren't around. They may find themselves thinking of ways to end it all, and may get as far as making plans to do so.
Some of the features we use to recognise depression (fatigue, reduced concentration or slow thinking) are already common in MS, making the diagnosis difficult. It is important to focus on changes in people's outlook, which is easier the more you know someone, and we listen to what friends and family tell us.
How common is depression in MS?
Depression is common in the general public and commoner in all chronic diseases. The chance of hitting a diagnosis at some point in your life without MS is 20%. In MS, it is 50%: half of all those diagnosed will be medically depressed some time in the illness. This may be recurrent in some and persistent in others. In one study, 28% (just over 1 in 4) people with MS could be labelled as depressed at any one time.
Which people with MS get depressed?
In short, anyone at any time. It is not clearly related to disability or long disease duration, and may be commoner in earlier disease, especially if severe. It is commoner and more severe in people with poor social support. No one is immune, and it's not something you can blame yourself for getting, any more than other MS complications. In rare cases, depression may be due to MS itself, with plaques in certain areas of the brain directly influencing how you feel.
Does it matter?
Depression profoundly reduces quality of life for the individual and those around them. It combines badly with the physical disability of MS, and the net affect often appears more than just adding the two problems, with the depression and physical disability amplifying each other. In MS, depression is important to spot as it is often treatable, unlike many other complications. Unrecognised and untreated, depression can persist and in some cases people act on their suicidal ideas.
Does it go away and can it be treated?
Throughout history, before modern treatments, people have suffered from depression and recovered. A lot of what happens in psychological interventions (including cognitive behavioural therapy, CBT) can happen in day to day life in people with good social support where they can talk through their concerns. There would appear to be some people whose natural coping skills insulate them from getting depressed in the first place and help them deal with it if it happens. Depression is more likely to be severe in people with MS who live alone, have poor social contact, are under financial pressure and who abuse alcohol.
Mild depression may not need treating. However, once symptoms are persistent or severe, it is overly optimistic to hope they will just go away. Treatment is either by psychological intervention ('talking therapies', usually CBT) or with drugs, both well accepted treatments with established efficacy and safety. People are often resistant to the idea of medical treatment, based on preconceived ideas of 'analysis', or worries about dependency or side effects of drugs. Severe depression needs treating. It is important to get advice from your GP or hospital clinic about what level of therapy is appropriate. Preferences for first line treatment vary depending on local expertise.
Some people may feel more comfortable with complementary or alternative medicines. St John's Wort is a herbal medicine useful in mild depression, but is an active drug, not a homeopathic treatment. Your GP needs to know if you are on it as it interacts with other drugs. It is poorly regulated, so not all preparations are the same. It is best to avoid a pure DIY approach and you should always speak to your GP.
Where should someone with MS feeling depressed seek help?
For most people, your GP will know you well and is best placed to recognise depression and to initiate and monitor treatment. For some, an MS nurse or hospital consultant might be easier to contact, or may indeed pick up on unrecognised features as part of routine follow-up. If you find yourself severely down, the Samaritans provide a 24 hour telephone line (08457 90 90 90) and can tide you through until your regular team can be contacted. Friends and family may have experience. The vital thing is to involve other people. Depression can be hard to tackle, and much more so alone. In conclusion, it is hard to be upbeat when discussing depression, but there is comfort in the facts:
- depression is common in MS, and if you have the symptoms, you are not unique, unusual or in any way to blame
- there is help available from your GP and MS clinic
- depression is often mild and transient and may not need treating formally. Even when severe, effective treatments exist
- lots of people with MS have been depressed, have got past it and gone on to have full and rewarding lives.
References
- McGuigan C, Hutchinson M.
Unrecognised symptoms of depression in a community-based population with multiple sclerosis.
Journal of Neurology 2006;253(2):219-223.
Abstract - Bamer AM, et al.
Validation study of prevalence and correlates of depressive symptomatology in multiple sclerosis.
General Hospital Psychiatry 2008;30(4):311-317.
Abstract - Feinstein A, et al.
Structural brain abnormalities in multiple sclerosis patients with major depression.
Neurology 2004 24;62(4):586-590.
Abstract
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