MS and the Mind
Depression: The Doctors Are In
by Henry Hample
Depression is a medical issue as much as a spiritual one.
If you are feeling depressed, you are clearly not alone—depression is a major symptom of MS, one that is frequently misunderstood and, worse, frequently under-diagnosed and under-treated.
To learn more, InsideMS spoke with David C. Mohr, PhD, assistant clinical professor and director of medical psychology at the Mt. Zion MS Center of UC San Francisco, and Sarah Minden, MD, assistant professor of psychiatry at Harvard Medical School, senior scientist at Abt Associates in Cambridge, and practicing psychiatrist at Boston’s Brigham and Women’s Hospital.
“The rate of depression in people with MS is very high,” Dr. Minden said. “About 14% of the MS population is currently experiencing a major clinical depression, and we estimate that 42% of all people with MS will endure a major depressive disorder at some point during their lives. This clearly signals a research direction, because we don’t yet know what makes this so in MS. We don’t have the tools we need to sort out the interactions between dysfunctions in the brain and individual reactions to life circumstances. We do know they link together in a vicious circle. They feed each other. And we do know that medication can positively affect the brain chemicals, which lifts the burden and then gives people a chance to work through their life problems with a therapist.”
Dr. Mohr sees patients in individual and family therapy, does neuropsychological evaluations, and teaches graduate-level psychology courses. He is currently conducting research on the relationship between stress, depression, and MS; the treatment of MS depression; and helping people with a fear of needles learn how to self-inject medications.
Dr. Mohr believes there is evidence that depression is related to immune system dysfunction. “When the immune system is activated—like when you get a cold or have the flu—behaviors are activated that look like depression,” he said. “For example, one of the things that most people experience is feeling they don’t want to be around other people. They want to curl up under the covers. Often they have a loss of appetite. These illness behaviors look like depression. And MS is a disease where the immune system is overly active, especially when a person is having an attack or exacerbation. I believe in some cases depression may actually be a symptom of MS—a symptom of the immune-system disregulation.”
The interferon-based disease-modifying drugs have been associated with depression in the FDA-required patient information labels of Avonex, Betaseron, and Rebif. There is a great deal of controversy about this association and no definitive scientific data.
As Dr. Mohr points out, depression and MS are common companions, and the disease-modifying drugs have clear benefits for many people.
Medication … and the couch
“Anyone with MS who feels symptoms of depression that last more than 2 weeks without lifting should be evaluated,” Dr. Minden said. “The symptoms aren’t always feeling sad or crying all the time. Some people simply lose their ability to enjoy things. They are tired and listless, or prone to outbursts of anger. It’s common for family members to accept this as part of MS, or MS fatigue. It is not.”
There are a number of medications used to treat depression. “Finding the right drug and the right dose can take some time,” mused Dr. Mohr, but the picture is much brighter today since the development of a class of antidepressants called SRIs (or serotonin re-uptake inhibitors). These drugs have a very low side-effect profile. Even so, it takes 6 to 8 weeks for any antidepressant to reach full effect.
Both Dr. Mohr and Dr. Minden stress that psychotherapy is an important part of treating depression in people with MS. More than ever, Dr. Mohr said, modern psychotherapy is oriented toward helping people learn what he calls “coping skills”: adopting new patterns of thinking, managing one’s fatigue, compensating for cognitive problems, improving one’s ability to interact with other people, and learning assertiveness techniques.
“Our society’s not very kind to people with disabilities. It’s easy to get angry, frustrated, or feel hopeless—but these feelings don’t get you what you want,” Dr. Mohr said. “Therapy helps people be more assertive, so they get the things they need without getting angry or giving up. We also know that psychotherapy and medication together are more effective for depression than either of them alone,” he concluded.
Dr. Mohr is currently researching a new thesis—that in addition to MS causing depression, depression may have an effect on MS: “There’s some early evidence that depression can increase the immune disregulation associated with MS. So getting treatment for depression may be even more important for people with MS than it is for the general population.”
By and large, he said, “the immune system is still a mystery.” While researchers concentrate on the puzzle, medication and counseling really work for people with depression, both doctors emphasized.
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Henry Hample was managing editor of the Society’s magazine, InsideMS.