By Dr. Sally Shaw
With so many invisible symptoms in MS, it is hard to pick the ‘worst’. For what it’s worth, I think it’s a pretty tight race between fatigue, cognitive dysfunction, pain, and depression. All seem insidious. All are really hard to communicate effectively to others. All can be difficult to pin down, name and treat. And annoyingly, those well intentioned people around you might try really hard to normalise all four symptoms:
“I get really tired too!”
“I can’t multitask either anymore – it’s your age, not your MS!”,
“Oh I know, I hate it when my legs get stiff after a run!” and of course
“We all have good days and bad days – look on the bright side…!”
Sometimes these suggestions can make living with the invisible symptoms of MS even more difficult.
Depression is a really tricky symptom of MS, in so many ways. So, what do we know about MS and depression?
Well, it’s complicated. Depression, as it affects the general population, is a syndrome. A psychiatric/mood/affective disorder. This form of depression (that, we as a society, are getting better at talking about) is often known by the medical profession as ‘Major Depressive Disorder’. To be diagnosed with depression, one has to meet at least 5 of 9 predetermined criteria. Simple, right? No. It’s not quite that simple in people with MS, because the criteria include poor concentration, fatigue, and altered sleep patterns. When someone comes to see me for psychological counselling, they have already done a screening assessment with their GP to see if they have signs of psychological distress, linked to depression or anxiety. The first question on the screening assessment is ‘In the past four weeks, about how often did you feel tired out for no good reason?’. When I discuss this first question with my clients, I am sure to be met with laughter, rolled eyes or a groan; ‘yeah, well is that because I’m depressed, or because I’ve got shocking MS fatigue?’ one of my clients said. Ah, the complexities of the many invisible symptoms of MS, strike again. It is often hard to navigate around symptoms that exist in both diagnoses of Multiple Sclerosis, and diagnoses of major depressive disorder.
There are also other mood disorders that are seen widely in PwMS.
‘Adjustment Disorder’ observes symptoms of depression as a result of reacting to the diagnosis of MS, or its subsequent challenges. And of course, this makes sense as there can definitely be a reactive component involved in mood changes for people with MS. It’s not easy to be diagnosed with a chronic neurological, potentially degenerative, disease. So, yes, it can take a psychological toll. Meanwhile, another mood disorder called ‘Depressive disorder due to a medical condition’ implies that the MS is causing the symptoms of depression via the inflammation that occurs, or the degeneration of brain matter. Not a response to the diagnosis, or how difficult it may be to live with what MS throws at you, but because of the organic nature of MS in your body itself.
Three very different causes of similar depressive symptoms. Clinicians attempt to differentiate between symptoms of depression that are a result of a major depressive disorder, a reaction to being diagnosed (or living with challenges of MS), and depression that may come with the pathology of MS. As Feinstein et al (2014) point out, a distinction between depression as a symptom, and depression as a syndrome, must be sought (but it’s really hard).
And to top the complexities of depression in MS off, adaptive coping strategies can mitigate the experience of mood changes as well, which means that what you do in response to depressive symptoms, can make them better or worse. Coping strategies are really important – they can be a protective factor against depression and they can help to get rid of depression too. Employing problem-focussed strategies (such as strategic planning or time management) can reduce the sources of stress in your life. Alternatively, a reliance on emotion based approaches (such as distraction, escapism, or drugs or alcohol) won’t be as helpful. Active coping strategies, rather than avoidant strategies, are good. For the most part it makes sense. At times it might seem counterintuitive considering MS is so unpredictable, and the uncertainty is so real (‘I don’t have control anymore’), but the stresses MS brings can still be managed within a framework of active coping and employment of a problem focussed approach.
Looking at the numbers (about 50% of PwMS will experience depression at some point in their life – a figure 2-5 times higher than the general population) it is abundantly clear that there is a strong link between MS and depression. Depression is one of the invisible symptoms of MS that affects more people than you probably think. A proactive approach to treatment of MS related depression is needed, and should offer a more aggressive, multimodal treatment approach.
So, what’s the take away from all of this regarding your mood? Watch out for a persistently low mood, together with a loss of interest or pleasure in daily activities. If you are feeling down or flat, and not getting much joy in the usual things, then you should definitely speak up. Be strategic! Your GP is probably the best place to start. Book a double appointment (it’s best to be able to have more than a few minutes with them to have a chat about how you’ve been feeling), and see what is on offer. It could be medication. It could be counselling. If you’re really lucky it could even be a combination of a few strategies that have been shown in the research to work. Medication, Cognitive Behavioural Therapy (CBT), Exercise, Solution Focussed Therapy, Mindfulness based CBT, Stress Management Training, or even Exercise (did I mention that one already?!) can all be helpful in treating depression experienced by people with MS. Your GP might give you a Mental Health Care Plan and the name of a psychologist who has some expertise in this area (hopefully!), or you can do your own research and take a name or two with you as suggestions.
The bad news is that PwMS are more likely to experience depression at some point in their lives, the cause of which might be complicated, but the good news is that there is more than one option to engage in, in order to treat this invisible symptom of MS.
Feinstein, A., Magalhaes, S., Richard, J., Audet, B. & Moore, C. (2014) The link between multiple sclerosis and depression. Neurology, 10, 507-517.
Fitzgerald, C. & Patten, S. (2008) Is multiple sclerosis patient depressed, stressed, or both? Current Psychiatry 7(4), 79-86.
Goldman Consensus Group. (2005) The Goldman Consensus statement on depression in multiple sclerosis. Multiple Sclerosis, 11, 328-337.
Hind, D., Cotter, J., Thake, A., Bradburn, M., Cooper, C., Isaac, C. & House, A. (2014) Cognitive Behavioural Therapy for the treatment of depression in people with Multiple Sclerosis: A systematic review and meta-analysis. BMC Psychiatry 14:5.
Koch, M.W., Patten, S., Berzins, S., Zhornitsky, S., Greenfield, J., Wall, W. & Metz, L.M. (2015) Depression in multiple sclerosis: a long term longitudinal study. Multiple Sclerosis Journal, 21(1), 76-82.
Mohr, D.C., Hart, S.L., Julian, L. & Tasch, E.S. (2007) Screening for depression among patients with multiple sclerosis: two questions may be enough. Multiple Sclerosis, 13, 215-219.
Shadday, A. (2007). Understanding and Treating Depression in Multiple Sclerosis. Multiple Sclerosis Association of America.