Depression can be common in MS. It can be a symptom of MS or a consequence of living with the condition. Depression is different from low mood, it is persistent and can affect all aspects of your life, it is often related to anxiety and stress.
Many of the symptoms associated with depression such as fatigue, constipation and sleep problems are also symptoms of MS, so it can be difficult tease out. However, two simple questions have been devised to establish if you or someone you know is depressed:
- During the last month have you often been bothered by feeling down, depressed or hopeless?
- During the last month have you often been bothered by having little or no pleasure in doing things?
If the answer is "yes" to either of these questions, it is important that you speak to your MS specialist team or GP. It is not usual to feel low all the time.
- Depression it is not unusual or a consequence of your personal actions
- Help is available from your MS specialist nurse, specialist MS clinic and GP
- Depression can be successfully managed and your MS team will work with you to find the approach that’s right for you.
What is depression?
Everyone feels sad at times but clinical depression is different. It is constantly present and interferes with your everyday activities. If you are depressed you lose pleasure in things that were once enjoyable, you may give up usual activities such as hobbies and lose interest in seeing friends and family. Some people even feel that life is no longer worth living and have thoughts of suicide.
Mild depression is when a person has a small number of symptoms that have a limited effect on their daily life.
Moderate depression is when a person has more symptoms that can make their daily life much more difficult than usual.
Severe depression is when a person has many symptoms that can make their daily life extremely difficult.
A person may experience different levels of depression at different times.
What causes depression?
The causes of depression in the general population are not fully understood, but it is thought that an imbalance in brain chemistry causes a drop off in mood. This may be triggered by stressful events in your life such as bereavement and there are also believed to be some genetic factors, so if close members of your family experience depression – it is more likely that you will too. If you have MS there are also additional factors. Below are some of the experiences that can cause depression, it is often more than one.
You might be more at risk of developing depression if:
- you have experienced a stressful life event such as a relationship break-down or a bereavement
- you have a family history of depression
- you are a woman who has recently given birth
- you are socially isolated
- you have drug or alcohol problems.
All these life events are just as likely whether or not you have MS.
Living with MS
The challenges of living with multiple sclerosis can also be trigger factors for depression. Living with uncertainty, feeling helpless, experiencing loss of opportunity and the social isolation that disabilities might bring can all be factors for developing depression. Increased levels of stress and experiencing symptoms such as chronic pain and overwhelming fatigue can also be relevant. However research has shown MS depression isn’t clearly related to disability or long disease duration, and may be more common earlier in the disease, especially if it is severe. The amount of social support that you have can also make a difference, for people who are socially isolated depression can be more severe. What does seem an important factor is how you adjust to living with MS and the kinds of strategies that you use to manage your condition.
Site of MS Lesions
Studies have shown that the presence of MS lesions in areas of the brain that are involved in mood certain parts of the brain can directly alter mood and can therefore cause depression.
Side effects of drugs used to treat other MS symptoms
Drugs prescribed to treat MS symptoms or relapse might, in some cases, also contribute to depression. These include steroids used to treat MS relapse and muscle relaxants used to treat spasticity and spasms.
How many people get depression?
Around half of all people with multiple sclerosis will experience depression at some time, this is three times higher than for the general population. The risk of suicide for people with MS is also significantly higher, young men within the first five years of MS diagnosis have been found to be most at risk of ending their own lives.
What can I do if I think I’m depressed?
It is important to let someone know how you feel. You may not always be able to recognise depression yourself and it can be hard to talk about how you are feeling. The stigma that is sometimes associated with mental health problems can also act as a barrier to discussions. Family and friends can play a key role in helping you to identify or recognise depression. It might be your MS specialist nurse or GP who are well placed to recognise changes in your outlook and mental health especially if you seem them regularly, or it could be your neurologist.
There is no simple test such as a blood test to find out if you are depressed. Your health professionals rely on descriptions of the symptoms you are experiencing and the changes it is making to your life. They will then work with you to find the best approach to treatment.
Recognising depression when you have MS can be difficult as you may already experience some of the symptoms that are usually associated with depression such as fatigue, poor concentration and sleep problems.
The important thing to focus on are changes including:
- low mood all the time and in every situation for at least two weeks
- negative thoughts about yourself and the future which might not be related to the level of disability that you experience
- not being able to take pleasure in routine things such as eating, watching TV or talking to friends that you have previously enjoyed
- thoughts of suicide.
It has also been suggested that in MS depression causes increased problems with thinking, feeling irritable, frustrated and discouraged. Worsening of MS symptoms that you already have in the absence of infection or relapse and deepening of fatigue could also be flags for concern.
If life seems unbearable
Studies have found that over a quarter of people with MS think about suicide. This can happen when the future looks bleak and you may think friends and family would be better off if you weren’t around. Whilst many people think about suicide, few go on to carry this out. If you are having thoughts of suicide or you find yourself severely down, the Samaritans provide a 24 hour telephone line (08457 90 90 90) and can tide you through until you can contact your regular MS team. Friends and family can also help - the vital thing is to involve other people even though this may not be easy.
How is depression treated?
There are a number of approaches may be useful and the best one for you will depend on the severity of your depression. Treatment is often used in combination. Your GP, MS specialist nurse or neurologist will work with you to manage this. You may be referred to a neuropsychologist where this service is available as part of your MS team, or to other members of the mental health team.
NICE has offered useful guidance on what should happen when you talk to a health professional for the first time about depression.
Self- management – what can I do?
In mild to moderate depression, self-management is the approach recommended by NICE guidelines. Your GP or MS specialist nurse will support you and may give advice on increasing your levels of physical activity for example through appropriate exercise, adopting healthier lifestyle habits such as giving up smoking, minimising stress, improving your sleep and relaxation or mindfulness techniques. Your health professionals will follow this up to ensure that your mood is improving.
Think about signs to look out for if you start to get low again. Mine were things like not contacting friends, not bothering with my appearance and shutting myself away
Recognising your own risk factors can also be really important so keeping a diary of how you feel can be valuable.
St John's wort is a herbal remedy that has been used to treat depression but concerns about what might be an appropriate doses and the potential for serious drug interactions mean it is not recommended.
Talking therapies or psychological approaches aim to help you identify and overcome negative thought patterns associated with depression.
Cognitive behavioural therapy (CBT) is based on the idea that the way you think about a situation affects how you act. In turn, actions can affect how you think and feel. It is therefore necessary to change both the act of thinking (cognition) and behaviour at the same time. Cognitive behavioural therapy has been shown to be effective in treating less severe cases of depression in MS. It can take some time for referral to a psychologist but online courses can help.
Counselling is a form of therapy that helps you to think about the problems you are experiencing in your life and to identify ways of overcoming or managing them. Counselling is different often different from other psychological approaches as the therapist has a more passive role and provides a more listening approach.
Other talking therapies include psychotherapy, family therapy, couples therapy, and group therapy. This may be available from your local MS Therapy centre
In moderate to severe cases of depression, or where previous treatment approaches have not been effective, you may be offered antidepressants. The effects of antidepressants may not be immediately noticeable, it usually takes around four weeks for the drug to take effect. Some people may start to feel better after a short period of time, but it is important not to stop taking the medication without talking to your health professionals as this can result in your depression coming back.
There are a number of effective medications that are prescribed for treatment of depression and you should usually be offered one of the medications called a selective serotonin reuptake inhibitors (SSRI), for example fluoxitine (Proxac), paroxitine (Seroxat) others that are sometimes prescribed include imipramine or amitriptyline.
If depression comes back
It is helpful to recognise when you are beginning to feel low as for some people depression can recur. This might include keeping a diary, apps are also in development that can help you to monitor your social activity, exercise and sleep patterns so you can see when they are changing and might reflect your change in mood.
- London: NICE; 2009. Full guideline Depression: the treatment and management of depression in adults.
- London: NICE; 2009. Full guideline Depression in adults with a chronic physical health problem: Treatment and management.
- Multiple Sclerosis Journal 2011;17(11):1276-1281. Summary Multiple sclerosis and depression.
Last updated: 26 September 2015
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