From The MS Information Sourcebook, produced by the National MS Society.
"Depression" is a term commonly applied to a wide variety of emotional states in MS. These may range from feeling down for a few hours on a given day to severe clinical depression that may last for several months. People with MS and all those closely associated with them should be aware that depression in its various forms is common during the course of multiple sclerosis. In fact, studies have suggested that clinical depression, the severest form of depression, is more frequent among people with MS than it is in the general population or in persons with other chronic, disabling conditions. Depression does not indicate weak character and it should not be considered something shameful that needs to be hidden. Depression is not something that a person can control or prevent by willpower or determination. In its most severe forms, depression appears to be a chemical imbalance that may occur at any time, even when life is going well.
While we still do not fully understand the nature of depression in MS, we have learned much about it in recent years:
- Depression may be "reactive"-the result of difficult life situations or stresses. It is easy to understand how a diagnosis of multiple sclerosis, a chronic condition with the potential for progressing to permanent disability, can bring on depression.
- Depression may also be a result of the MS disease process itself, since MS damages the myelin and nerve fibers deep within the brain. If MS damages areas of the brain that are involved in emotional expression and control, a variety of behavioral changes can result, including depression.
- Depression in MS may also be associated with MS-related changes that occur in the immune and/or neuroendocrine systems. For example, there is some evidence that in persons with MS, changes in mood are accompanied by changes in certain immune parameters.
- In contrast to what common sense might suggest, persons with MS who are more severely disabled are not necessarily more likely to be depressed. This may be due to the fact that people in general are resilient and have a remarkable ability to adapt to adverse circumstances. Depression can occur at any point in the course of the disease.
- There is some evidence that people with MS are at increased risk for depression when an exacerbation takes place and disability increases.
- Severe depression can be a life-threatening condition because it may include suicidal feelings. One study found that the risk of suicide was 7.5 times higher among persons with MS than the general population.
- Depression can also be a side effect of some drugs, such as steroids, which may be prescribed for the treatment of MS attacks. There is also some evidence that the interferon medications may trigger or worsen depression in susceptible individuals, although the research on this issue has yielded conflicting results.
- It is also important to keep in mind that depression occurs in people who do not have MS, and is a widespread problem in society in general.
- Depression can occur in children and is underdiagnosed in the elderly.
Distinguishing Depression from Normal Grieving
Depression is often hard to distinguish from grief. Persons with MS may experience losses-for example of the ability to work, to walk, or to engage in certain leisure activities. The process of mourning for these losses may resemble depression. However, grief is generally time-limited and resolves on its own. Moreover, a person experiencing grief may at times be able to enjoy some of life's activities. Clinical depression is more persistent and unremitting, with symptoms lasting at least two weeks and sometimes up to several months. It's important to distinguish between mild, everyday "blues" that we all experience from time to time, grief, and clinical depression. Clinical depression, which must be diagnosed by a mental health professional, is a serious condition that produces flare-ups known as major depressive episodes.
Symptoms of a Major Depressive Episode
- Sadness and or irritability
- Loss of interest or pleasure in everyday activities
- Loss of appetite-or increase in appetite
- Sleep disturbances—either insomnia or excessive sleeping
- Agitation or slowing in behavior
- Feelings of worthlessness or guilt
- Problems with thinking or concentration
- Persistent thoughts of death or suicide
Professional Help May Be Needed
People who are depressed often want to withdraw from activities, and the resulting lack of stimulation further reduces their quality of life, creating a downward spiral. While supportive family and friends may help a person shake off mild depression, psychotherapy and/or antidepressant medication are generally needed to treat the condition adequately and prevent an even deeper depression that is harder to treat. Although support groups may offer some help with milder types of depression, they are not effective in treating severe clinical depression. Psychotherapy and/or antidepressant medication are more effective in treating severe clinical depression.
Several antidepressant drugs are available, but they can be used only under the supervision of a physician. There is quite a bit of variability in response to antidepressant drugs and it may be necessary to try different medications and different doses before an effective medication, or combination of medications is found.
Your chapter of the National MS Society should be able to provide referrals to appropriate professionals in the area it serves.
For Healthcare Professionals
Holland NJ, Halper J (eds.). Multiple Sclerosis: A Self-Care Guide to Wellness (2nd ed.). New York: Demos Medical Publishing, 2005.
—Ch. 16 Coping and Stress Management
Kalb R. (ed.) Multiple Sclerosis: The Questions You Have; The Answers You Need (3rd ed.). New York: Demos Medical Publishing, 2004.
—Ch. 10 Psychosocial Issues
—Ch. 11 Stress and Emotional Issues
Kalb R. (ed.). Multiple Sclerosis: A Guide for Families (3rd ed.). New York: Demos Medical Publishing, 2005.
—Ch. 2 Emotional and Cognitive Issues