MS and Depression

Everyone knows what it is to have the blues. You feel down about yourself, your relationships, your job or school, your future. You feel as if you are living half-empty in a world of full cups. But then something good happens and your cup is refilled.

Clinical depression is quite different. It’s a common illness that affects about 1 in 5 people during their lifetime and causes both mental and physical symptoms. These symptoms typically don’t go away in a day or two—they persist for weeks or months. That is because they are signs of an illness at work. So there’s no point telling yourself to “pull yourself out of it”, “think happy thoughts,” or “cheer up”. Depression isn’t a sign that you lack character or willpower. It is a problem, like MS itself, that requires medical attention.

The diagnosis of a chronic illness such as MS represents a real loss in your life. You will need to take time to grieve this diagnosis and the changes it has brought into your life. However, while it is natural to be upset about your diagnosis, there is a difference between this and depression. Depression is now understood to be a symptom of MS—part of the underlying disease process—which can be treated with medications and/or counseling.

When most people are grieving, they want someone to comfort and love them. But when people are depressed, they tend to pull away from others—and this can cause your family and friends to leave you alone, because you have withdrawn from them, when in fact you need them most.

What causes depression?

Little is known about the causes of clinical depression. Some families appear to be more susceptible to depression, but genetics is only part of the story. Psychological triggers (e.g. serious loss, financial problems, stress) and environmental factors also seem to have a role in the development of depression. We now understand that hormonal fluctuations in women can contribute to depression as well; depression is twice as likely to occur in women compared to men.

How common is depression among people with MS?

Clinical depression occurs more frequently in people with a variety of neurological conditions, including MS. About 50% of people with MS will develop depressive symptoms at some point during their lifetime. So the risk of depression is much higher among people with MS than in those without the disease.

How important is it to treat depression?

Very. You may be suffering from depressive symptoms that aren’t severe enough to be diagnosed as depression. But your suffering is still real and still needs to be treated—the risk is that without proper treatment, depressed symptoms may get worse.

Why does depression occur in MS?

Since MS is a chronic, frequently debilitating illness that can play havoc with school, family, and relationships, many people might think: who wouldn’t get depressed about having MS?

In fact, this idea—that depression is simply a reaction to a diagnosis of MS—is a common misperception. Depression doesn’t set in because of a setback or disappointment. It isn’t idle complaining or moodiness.

The causes of depression in MS aren’t well understood. Genetics may be a factor. The MS disease process itself may play a direct or indirect role. The slow progression of nerve damage in the brain may cause depressed symptoms in some individuals. The inflammatory flare-ups in the brain seen during MS relapses have also been linked with the development of depression.

These physical factors undoubtedly contribute to clinical depression. But more important are psychological factors: how we cope with illness, how we perceive ourselves and how we regain a sense of control over our lives.

MS medications and depression

Many people with MS regularly take a beta-interferon or glatiramer acetate to control their disease. In early studies, beta-interferon use was linked to depression in a small number of people, but this association is controversial. If you are diagnosed with depression, it’s prudent to advise both your family doctor and your MS clinic doctor that you are taking a beta- interferon. Depression has not been linked with glatiramer acetateuse.

How depression can build

People can learn to live with tingling and numbness. They can get practical advice from their doctor or nurse on how to deal with physical symptoms. MS symptoms themselves do not necessarily make someone more prone to depression.

What can erode a person’s coping skills is uncertainty. “How will I feel tomorrow?” “Will I be able to go to school?” “Will I have the energy to see my friends?” This sense of uncertainty is very hard. How can you make plans? It would be nice to think ahead, to imagine a picture of yourself enjoying your future. But how can you do that when you don’t know if you’ll be in pain, unable to function, or disabled? The on-again, off-again symptoms of MS also wear a person down. If you were injured in an accident, with time you would learn to accept your injuries and go from there. MS isn’t like that. Even severe MS symptoms can get better, leaving you to think: “Am I okay now?” “Should I just go on and live my life?” But weeks, months, or years later, MS symptoms return. This continuing cycle of hope and disappointment and hope again can sap your energy and optimism.

It’s normal to think sometimes about how life would have been without MS. People often ask, “Why me? Why did this happen to me?” It’s normal to be sad and to grieve for that other person you might have been. It’s not unusual to feel frustrated when you find it difficult to do something that used to be so easy to do.

It is easy to feel angry at MS. Anger is part of a person’s coping mechanism. Anger can help us fight the difficulties we face. But it will become destructive if it just keeps boiling away. If anger starts to define us, it doesn’t overcome barriers anymore—it creates them.

How do I know if I’m depressed?

Detecting depression can be a challenge for healthcare professionals and it is frequently overlooked. Clinical depression is a collection of symptoms that may be quite unique to each individual. Some people may appear sad and tired, others may appear jittery and on edge.

Recognizing depression can be doubly difficult in a person with MS. This is because MS symptoms and depressed symptoms are very similar. When you feel fatigued and dispirited, is it because you’re having a bad day with your MS? Or are you depressed? If you often feel uncertain and frightened about what the future holds, are these feelings “normal” to a person with MS? Or are they really depression?

Two questions can provide some insight as to whether you have depression. Over the past few weeks:

  1. Have you felt down, depressed or hopeless?
  2. Have you lost your interest or pleasure in things that you normally enjoy.

If you answered yes to these questions, it’s important to talk to your doctor about depression.

Suicide

Depression isn’t a benign illness: it causes great pain and suffering and can drive people to thoughts of suicide.

Have you ever thought:

  • “My life is hopeless. There’s nothing to look forward to.”
  • “My family would be better off without me.”
  • “Things would be much easier if I just died.”
  • “I’ve figured out a quick, painless way to end it all.”

If you have had these or similar thoughts, contact a healthcare professional immediately — your doctor, a hospital emergency room, a clinic or crisis centre. Don’t hesitate to seek help.

Suicidal thoughts are part of the syndrome of depression. Like other depressed symptoms, they will ease once you receive proper treatment. Do not suffer in the silence of your thoughts and think about harming yourself. Help is available.

What can I do if I’m depressed?

There are many therapies available that can help to alleviate depression. The first and most important step is to seek help. It’s important to keep in mind that depression is an illness that requires treatment. If it’s left untreated, depressed symptoms may get worse or can persist for weeks or months.

You and your doctor may decide that antidepressant medication is a good choice for you. Antidepressants typically require 4-6 weeks of daily dosing before there is a significant relief of depressed symptoms. Don’t get discouraged—it is important to continue taking the medication until it has had time to work.

Most medications, including antidepressants, have the potential to cause unwelcome side effects. These may include stomach upset (nausea, diarrhea), headache, fatigue or dry mouth. These side effects often go away within a few weeks. However, if your side effects are severe or you are troubled by any of your medication’s effects, talk to your doctor. He or she can adjust your dose or select another medication that may be easier to take.

If you aren’t satisfied with the medication, DO NOT stop taking the drug. Talk to your doctor first. Some medications need to be slowly discontinued to avoid withdrawal effects. Abruptly stopping an antidepressant may also worsen your depressed symptoms.

DO NOT take any prescription or nonprescription antidepressants or any product containing St. John’s Wort (an herbal product) if you are taking a prescription antidepressant. Talk to your doctor before taking a migraine medication. Tell your doctor and pharmacist about all medications you are taking, including prescription, nonprescription or alternative remedies.

Antidepressants should not be mixed with alcohol or any illicit drugs. If you abuse any substances (alcohol, cocaine, amphetamines, etc.), it’s important to know that this can cause or contribute to depression.

Marijuana use is becoming more common among people with MS as a way of relieving MS symptoms, such as spasticity, pain and tremor. However, marijuana can adversely affect mood and frequent marijuana use may contribute to depressive symptoms in some people. Marijuana use is not recommended in people with depressed symptoms or mood swings.

Psychotherapy

Depression can also be treated with psychotherapy, such as cognitive-behavioural therapy (CBT). Simply stated, CBT tries to identify negative thoughts and behaviours that are causing you distress, and teaches you simple techniques to reorient these thoughts/behaviours to a more healthy approach. This can be very helpful in addressing issues such as self-esteem, body image, sexuality, anger and negative beliefs. Interpersonal psychotherapy has also been shown to be effective for depression. This technique focuses on personal relationships and how they may be contributing to depression.

A short-term course of psychotherapy may be completed in 10-20 weeks.

There are two main drawbacks to nondrug therapy. There are few qualified therapists so the waiting time may be lengthy; it may be difficult to find a therapist in some communities. Secondly, therapy can be expensive, so it is best to confirm if psychotherapy is covered by your provincial health plan or private insurer.

Other counseling and support

MS can be very challenging for family members and loved ones as well. Relationship counseling may be helpful to address family issues, sexuality, and how to live with MS.

The MS Society, MS support groups, MS clinic nurses and community groups can also provide support and encouragement. Books by and about people with MS can help to reassure you that you’re not going through this alone. Local religious groups can help you get in touch with your spirituality and provide many useful services.

The key is to find the information and resources that suit your needs and circumstances.

Managing the Emotional and Social Aspects of MS