Depression is one of the most common and troubling MS symptoms. By some estimates, one in two people with MS will experience depression at some point. This is approximately three times the lifetime incidence in the general population and higher than the rate of depression experienced by people with most other chronic diseases, including other neurological disorders.

The consequences of depression are far reaching and potentially devastating. Depression can interfere with relationships, the ability to earn a living, quality of life, and is associated with a higher overall mortality, including deaths from suicide. Indeed, the risk of suicide in MS is sometimes estimated to be seven times higher than it is among people without MS. Recognizing depression early can ameliorate the potential consequences of depression and is the first step in getting treatment. It is critical that patients—and their families—stay vigilant for signs of depression, such as fatigue, irritability, tearfulness, loss of enjoyment, sleep disturbance and especially thoughts of self harm.

 

But there is good news: depression in MS generally responds well to standard treatments. Based on studies of depression generally, there is strong evidence to support the effectiveness of both medications and some forms of talk therapy, such as cognitive behavioral therapy. There is at least one study done specifically among people with MS that compares the different forms of treatment. In this study, 63 patients with depression were assigned to one of three 16-week treatments:

  1. An individual cognitive behavioral psychotherapy focused on teaching coping skills,
  2. A supportive-expressive group psychotherapy focused on facilitating expression of emotions and provision of social support, or
  3. Zoloft (sertraline), a widely-used antidepressant medication. The cognitive behavioral psychotherapy and Zoloft were equally effective. The supportive expressive group psychotherapy was less effective than the other two interventions studied.

Most experts believe that the best approach to treating depression is generally a combination of both “talk therapy,” such as cognitive behavioral therapy and medications. Of course, specific decisions regarding whether to use medications should be made based on factors that include the severity of the depression and individual values, such as preferring to avoid medications or lack of resources to support other forms of therapy.

There are other issues to consider before beginning treatment, such as whether there may be a medical cause for the depression (e.g., an underlying thyroid problem). A careful review of medications is also critical when symptoms of depression occur. For example, steroids, which are widely used to treat MS exacerbations, can affect mood, especially in the short run. Other medications that are often used in MS can also cause depression, such as baclofen, dantrolene and tizanidine. Furthermore, in some of the Placebo controlled clinical trials involving beta interferons, a higher incidence of depression was seen among those taking interferon than among those taking placebo.

For those who begin therapy with antidepressant medications, it is important to be aware that the onset of effectiveness is gradual. Although some improvement in symptoms may be noted within a few days, it may take up to six weeks to realize the full benefit. If target symptoms persist after six to eight weeks, call your healthcare provider. He or she may increase your dose, add another medication, or prescribe a different medication entirely. Because every clinical situation is unique, there is no one-size-fits-all time to discontinue therapy. Some people stay on medications for a year and some for much longer. Stopping an antidepressant should only be done in close consultation with your healthcare provider. Often, patients begin to feel better after a few months and so discontinue medication, only to find that the depression soon returns. When it is time to do a trial discontinuation of therapy, the medication should be discontinued very slowly, again, only in consultation with your healthcare provider.

There are a few dietary supplements for which there is some evidence of efficacy. In particular, for mild to moderate depression, St. John’s Wort and omega-3 fatty acid may be effective. Although these therapies can be obtained without a prescription, it is best to discuss them with your healthcare provider as depression should not be self-diagnosed or self-treated. Furthermore, there may be drug interactions to consider. For example. St. John’s Wort may interfere with the effectiveness of birth control pills.

by Tom Stewart, J.D., M.S., PA-C
Originally published in InforMS Spring 2009