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Depression and MS

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This is another very important topic that all of us need to understand.  Depression and MS are close companions.  Many people with MS will deal with depression at one time or another during their lives.  We see depression from four main causes.  First, depression is a "primary effect" of Multiple Sclerosis just as vision problems, paresthesias, pain, weakness, spasticity, vertigo and many other things are.  Second, there is a depression known as the "depression of chronic illness."  The stress of dealing with all that is involved with MS can cause a situational depression. Finally, many of the medications used in treating MS and its symptoms cause depression as a side effect.  The first cause is the most important to understand.


The damage to the brain in Multiple Sclerosis often causes depression, just as directly as it causes optic neuritis or weakness.  How this happens is not completely understood.  Many researchers believe that the overall slowing of nerve conductions in the brain is mostly responsible for the creation of depression.  We know it isn't just having a serious and incurable disease.  The incidence of depression in MS is higher than it is in other much more disabling diseases or even fatal diseases like ALS.

Even in the most well-adjusted person MS can cause major depressive episodes.  In people genetically predisposed to depression, with a history of severe depression, it is even more likely that they will be affected by this change in the working of the brain.  At all points, the treating physician must be watchful for the development of signs of depression.  Suicide is a seriously common side effect of this damage to the workings of the brain.  It occurs at least seven times more than in people without MS, including those with other chronic illnesses.  Families and friends of people with MS need to know about this problem that is peculiar to this disease.  The biggest risk of suicide are in those with social isolation, a family history of mental disease, and who are living alone.

Depression is so much a part of the disease that many experts in the field are advocating counting a previous and recent Major Depressive Episode as one of the Clinical Attacks need for diagnosis in the McDonald Criteria. They are suggesting if a person is being worked up for MS and has had a Major Depressive Episode within the previous 2 years, that episode should be counted as an both the attack and as the clinical lesion (the abnormality on exam).

The second cause of depression in MS is the difficulty with the slowing metabolism of inactivity, chronic pain, chronic fatigue, and chronically not "feeling well."  This causes what is called the Depression of Chronic Illness.  Some experts would not list this and would say this is part of the next cause, which is situational.  Others argue that it occurs too readily in people without a predisposition to depression who have a chronic illness.


The third category is the depression caused by living with the disease.  It is hard to cope with the many symptoms of this disease, along with the profound effects MS has on one's life.  Many people with MS are no longer the person they once were.  Their current state just doesn't match the image they have of themselves as a capable, independent and future-filled person.  Many lose their careers.  This is an expensive disease to have.  Not only are the treatments and meds often expensive, but sometimes a person loses their source of income.  This is an isolating disease to have.  Travel is more difficult and people with MS may become home-bound.  This reduces the time that we can spend with family and friends.  Social isolation is a potent cause of depression.

This disease is hard on relationships.  The spouse may suddenly have a caretaking role shoved upon them that they don't want, are not ready for, or are incapable of handling.  Friction can arise over financial  problems.  The person with MS may feel guilty over this change in roles.  The spouse may feel anger at the disease, at the affected loved one, or at the unfairness of it all.  There may be intense frustration at not being able to fix it or make things right.   We see marriages sometimes break up under the burden of MS.  

And a major cause of disruption is the uncertainty of MS.  What will the future bring?  What will TODAY bring?  Can we plan for additional children, for a vacation this year, to go see the folks this weekend?  Never feeling as though anything is certain causes many people with MS to feel loss of control over the little and big things in their lives.


Finally, the medications used in MS may cause depression themselves.  The first to be aware of is the Interferon-beta drugs; Avonex, Rebif, and Betaserson.  Because of their action on the brain functions itself, which may include lowering the production of endorphins, depression must watched for carefully.  People with a signifcant history of depessive disease are not the best candidates for these meds.  Copaxone does not carry this effect to nearly the same degree, if at all.  Another category of meds that have a potential for causing depression as a side effect are the "benzodiazepines" such as Valium (diazepam), Xanax (aprazolam), Klonopin (clonazepam), Ativan (Lorazepam) and there are many others.

So, it is clear that the possibility of depression is inherent in the disease of multiple sclerosis.  It is also a disease that can cause depression by creating severe stresses in the life and many of the meds used can predispose to depression.  How can we tell the difference?  Actually, we can't for the most part.  And it is not relevant to say that this depression is caused by the disease and that depression is cause by the stresses.  The treatment is mostly the same.  Every effort should be made to ease the stresses, relieve the symptoms and reduce meds that can cause the problem.  Depression is not shameful in MS, nor in any other setting.  It should be approached and treated just as any other symptom of a disease that encompasses almost every part of the body and life.

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