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Depression

Hard-to-Spot Signs of Depression in Multiple Sclerosis

The prevalence of major depression in multiple sclerosis approaches 50 percent.

In my multiple sclerosis neuropsychiatry clinic, I see a lot of depression. This is not surprising given that the lifetime prevalence of major depression in people with multiple sclerosis approaches 50 percent. The diagnosis of depression can, however, present a challenge for professionals as well as for caregivers and the loved ones of people with MS.

One reason the symptoms are hard to spot is, quite simply, that both professionals and caregivers or loved ones tend to focus above all on the solely physical disabilities that hinder daily life. It’s understandable: those disabilities, including limited mobility, muscle spasms, and speech impediments, are extremely cumbersome. But there’s another, more subtle reason: the symptoms of MS can overlap with those of depression. For example, fatigue, poor concentration, insomnia, and changes in appetite are all part of the symptom complex of major depression, but these symptoms may also relate directly to multiple sclerosis.

Other signs that might indicate depression include pervasive sadness, persistent irritability, negative thoughts, a drop in self-esteem, and suicidal thinking.

One way not to mistakenly interpret symptoms of MS from those of depression is to use self-report rating scales developed specifically for depression in medically ill people. The one that I favor in my clinic is the Hospital Anxiety and Depression Scale. There is another scale, the Beck Fast Screen for Depression in Medically Ill People, that can also be used. I find that people with multiple sclerosis are quite comfortable filling out these short questionnaires. Both instruments have thresholds that have been validated for people with multiple sclerosis and when scores are beyond these thresholds, the likelihood of a clinically significant depression is high.

It is important not to miss the diagnosis of depression in people with multiple sclerosis for many reasons. First, depression is an important determinant of quality of life. Second, depression can also worsen underlying cognitive difficulties. In particular, it may further slow processing speed and impede working memory. Finally, and most importantly, depression is linked to suicidal intent and attempts. The rate of suicide in people with multiple sclerosis is twice what it is in the general population and it is therefore of cardinal importance that depression is not missed. Moreover, once identified, depression in people with MS is often treatable.

When it comes to treating depression in people with multiple sclerosis, I follow the guidelines of the American Academy of Neurology, which released a consensus paper that I took part in. We reviewed all the treatment data pertaining to depression in MS and concluded that the best approach, based on empirical evidence, is cognitive-behavioral therapy. I am fortunate in my clinical practice, I work with excellent cognitive behavior therapists and I often begin by referring my depressed patients to them.

However, not every person with multiple sclerosis wants cognitive-behavioral therapy. In addition, there are many clinics that will not have access to a cognitive-behavioral therapist. These circumstances open the door to antidepressant medication. Here, there is only a small published literature on randomized control clinical trials. They show that depression does respond to antidepressant medication, albeit modestly and certain individuals may have difficulty with side effects such as dry mouth, constipation, and occasional sexual difficulties. Before I prescribe an antidepressant drug I always explain the benefits of treatment and run through the potential side effects.

In my clinical experience, the sexual side effects can be a stumbling block to a person accepting a prescription. Remember, many people with multiple sclerosis have sexual dysfunction as part of the MS, to begin with, and so the thought of this worsening with medication makes them wary of accepting a prescription. Side effects may occur early on in treatment but frequently dissipate with time.

In a disease like multiple sclerosis where there is no cure, symptom management is the best that one can hope for. It is my clinical experience that treating depression successfully can be transformative for a person with multiple sclerosis and their families.

References

1. Sadovnick AD, Remick RA, Allen J, et al. Depression and multiple sclerosis. Neurology, 1996;46(3):628-632.

2. Feinstein A, Magalhaes S. Richard J-P, Audet B, Moore C. (2014) The link between multiple sclerosis and depression. Nature Review Neurology, 2014, 10(9), 507-517.

3. Honarmand K, Feinstein A. Validation of the Hospital Anxiety and Depression Scale for use with multiple sclerosis patients. Multiple Sclerosis, 2009, 15, 1518-1524

4. Patel V, Feinstein A. The link between depression and performance on the Symbol Digit Modalities Test: mechanisms and clinical significance. Multiple Sclerosis, 2019, 25(1):118-121

5. Feinstein A, Pavisian B. Multiple Sclerosis and suicide. (2017). Multiple Sclerosis Journal, 2017, 23 (7), 923-927.

6. Minden SL, Feinstein A, Kalb RC, et al. Evidence-based guideline: Assessment and management of psychiatric disorders in individuals with MS Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology,2014;82(2):174-181.

7. Koch MW, Glazenborg A, Uyttenboogaart M, Mostert J, De Keyser J. Pharmacologic treatment of depression in multiple sclerosis. Cochrane Database Syst Rev. 2011;(2).

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