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MS information for health and social care professionals Depression

Experience of living with MS - as with many other chronic conditions - can undoubtedly result in a depressed mood. This however should be clearly distinguished from major depression, for which there is evidence for considerably increased incidence amongst people with MS[1].

Diagnosis of major depression is often missed by health professionals for very understandable reasons. However, since the suicide rate amongst people with MS has been shown in a study to be 7.5 times higher than in an age-matched population, and since depression is responsive to treatment, the importance of diagnosis and active management cannot be overstressed[2,3].

Somatic or vegetative symptoms (such as sleep or appetite disturbance, poor concentration, fatigue or weight loss) are not particularly useful in the diagnosis of depression in people with MS. This is because they are common symptoms in people with MS who do not have depression.

Symptoms which can aid the diagnosis of depression in people with MS include pervasive low mood (ie low mood all the time and in every situation) for at least two weeks; mood particularly bad at a certain time of day (diurnal variation in mood); negative thoughts about self; the world and the future which are out of context with the level of disability; suicidal ideation and the lack of ability to take pleasure in anything (anhedonia), especially things that would have given pleasure in the past.

It is worth remembering that many of the drugs prescribed for other symptoms of MS can have depressed mood as a side effect. This is especially true of corticosteroids used in the treatment of relapses.

Treatment of depression takes two forms: drug therapy and psychotherapy, often used in combination[4]. Selective serotonin reuptake inhibitors (for example, Prozac) can be useful and imipramine and amitriptyline are also sometimes prescribed. The psychotherapeutic approach may involve identifying the cause of depression, and trying to alter negative patterns of thinking and behaviour into more a positive approach and may include cognitive behavioural therapy.

NICE guidelines suggest that possible factors contributing to depression, such as chronic pain or social isolation, should be examined and where possible interventions undertaken to ameliorate these elements.

Recent work[5] has suggested that anxiety disorders are also common in people with MS but are often overlooked and under treated. Specialist assessment and management is recommended by NICE, with pharmacological treatment through benzodiazepines or antidepressants.

The mnemonic below can be useful in highlighting psychological needs of people with MS.

D - Diagnosis How are you dealing emotionally with the diagnosis?

E - Expression Observe mood and facial expression

P - Pleasure What things do you enjoy most?

R - Remorse Do you feel guilty about things you have or have not done? Do you feel a burden to your family/friends?

E - Explore Past personal or family history or psychiatric illness?

S - Sadness How would you best describe your mood?

S - Stress Do you experience stress and/or anxiety? How do you deal with this? What activities do you avoid due to stress/anxiety? Has your concentration decreased?

I - Insomnia How well do you sleep? Do you experience early morning wakening? Do you experience initial insomnia/ inability to sleep?

O - Others How is illness perceived in your family? How do others perceive your mood?

N - Nutrition How is your appetite? Do you taste and enjoy food? Have you gained/lost weight?

Reproduced by kind permission of Bernie Porter MS Nurse Consultant, The National Hospital for Neurology and Neurosurgery.

References

  1. Remick RA, Sadovnick AD. Depression and suicide in multiple sclerosis. In:Thompson AJ, Polman C, Hohlfeld , editors. Multiple sclerosis: clinical challenges and controversies. London: Martin Dunitz Ltd; 1997. p243-249.
  2. Sadovnick AD, Eisen K, Ebers GC, Paty DW. Cause of death in patients attending multiple sclerosis clinics. Neurology 1991;41(8):1193-1196.
  3. Remick RA, Sadovnick AD. Depression and suicide in multiple sclerosis. In:Thompson AJ, Polman C, Hohlfeld , editors. Multiple sclerosis: clinical challenges and controversies. London: Martin Dunitz Ltd; 1997. p248.
  4. Burnfield A. MS and the blues. MS Matters 1996;7: Suppl 4.
  5. Korosil M, Feinstein A. Anxiety disorders and their clinical correlates in multiple sclerosis patients. Mult Scler 2007;13(1):67-72.