Recognizing, Understanding and Treating Depression

Depression can affect anyone, regardless of income, age, gender, nationality, and lifestyle. Nearly 10 percent of the adult American population, or about 18.8 million people, suffer from a depressive illness during the course of an average year. While depression can cause enormous emotional pain and destroy one’s relationships with friends and family, much of this suffering is unnecessary; many effective treatments are available to fight this debilitating illness.

Depression has a way of slowly taking hold, without warning. Many people who suffer from depression are not even aware they are depressed. Instead, they may experience symptoms that seem unrelated, such as changes in sleep habits, energy levels, and appetite.
Depression is the strongest predictor of a reduced quality of life, and may be caused by a number of influences. These include genetics, life situations, environment, chemical imbalances, other medical conditions, and side effects from medications. Depression can range from mild to severe, and for a portion of those severely affected, can even lead to suicidal thoughts and attempts.

Depression is a very treatable illness, and many can enjoy a much better quality of life just by seeing a professional and getting the help they need. Depression is best treated through a combination of medication and psychotherapy (examples include individual, family, and group sessions). In many circumstances, depression may be significantly reduced in a relatively short amount of time.

Incidence and Types of Depression, Gender Differences, and Suicide
While anyone is susceptible to depression, individuals with MS experience a much higher incidence. Specifically, the chance that someone in the general population will become depressed at least once in his or her lifetime is 15 percent. For someone diagnosed with MS, the lifetime prevalence increases to 50 percent, so one of every two people with MS will experience depression at least once. The negative effects of depression on MS are compounded by the fact that depressed individuals may not comply with taking their prescribed medications, and this could cause their condition or other symptoms to worsen.

The three most common types of depression are: (1) major depression, which has a combination of symptoms and interferes with an individual’s ability to enjoy activities and perform typical functions; (2) dysthymia, a less severe form of depression; and (3) bipolar disorder (also known as manic-depressive illness), characterized by significant mood swings, with feelings of great euphoria eventually giving way to extreme depression.

In addition to having a higher incidence of MS, women are twice as likely to experience depression as men, and hormonal factors can play a role. These can be related to menstrual changes, pregnancy, miscarriage, postpartum period, and menopause. Women also may have the added stress of being a caregiver to children and parents, along with the demands of home and work, and sometimes single parenthood. Mothers with disabilities also need support to help them with depressive symptoms relating to the added concern they may feel for their children.

Although fewer men are diagnosed with depression, they are also less likely to admit that they are experiencing any symptoms, and doctors often don’t suspect depressionin men. These may be reasons as to why the suicide rate in men is four times the suicide rate in women. Men who are depressed will often appear irritable, angry, and discour-aged, rather than sad. They may also work excessive hours and/or hide their pain by taking alcohol or drugs.

A portion of depressed individuals are at risk of suicide, and this too is greater for individuals with MS. The biggest predictors of suicide intent in those with MS are (1) severity of the depression, (2) abuse of alcohol, and (3) living alone. A family history of mental illness, higher perceived levels of social stress, and anxiety also contributes to suicidal intent. In a study of individuals with MS who had suicidal intent, one-third had not received any psychological help, and two-thirds (all with major depression and suicidal), had not received any anti-depression medication.

While these are very discouraging statistics, researchers and medical professionals continually point out that effective treatments are available for depression, bipolar disorder, and other emotional or psychological illnesses. Additionally, suicidal intent is a treatable cause of mortality in MS, and can be greatly reduced if recognized and treated in time.

Symptoms of Depression
When diagnosing a major depressive episode, physicians look for five or more of the following nine symptoms to be present during the same two-week period. As noted, a portion of the symptoms listed are also symptoms of MS, which means they may not necessarily indicate depression for someone with MS. These symptoms may be reported by the patient or observed by others, and in general, occur nearly every day.

Symptoms of depression only

• Depressed mood for most of the day
• Greatly reduced interest or pleasure in all, or almost all, activities most of the day
• Significant weight loss or gain, or change in appetite
• Feelings of worthlessness or excessive guilt
• Recurrent thoughts of death or thoughts/plans/attempts of suicide

Symptoms of depression that are also symptoms of MS

• Difficulty sleeping or excessive sleeping
• Significant restlessness or slowing down as observed by others
• Fatigue or loss of energy
• Diminished ability to think, concentrate, or make decisions

Possible Causes ofDepression in MS
The first potential cause of depression in MS is disease activity, especially during an exacerbation. A recent study has shown that three factors are strong predictors of depression during an exacerbation, and significantly relate to the level of depression reported by the patient. These are:

1. Present state of illness (if the individual is having an exacerbation)
2. Uncertainty (about new symptoms and the future)
3. “Emotion-centered” and “escape- avoidance” coping (versus constructive problem solving)

Uncertainty during an exacerbation plays a big role in determining the level of depression that an individual will experience. The healthcare provider may be able to minimize the level of depression by offering reassurance, answering questions, and working to reduce uncertainty whenever possible.

The second potential cause or contributor to depression in MS is neuropathologic changes in areas of the brain (involving lesions and other changes to the brain). While some research does not support this idea, recent studies show that the volume of lesions in the right frontal and temporal lobes can contribute to the severity of depression.

The third potential cause or contributor to depression in MS is neuroendocrine or psychoneuroimmunologic changes. In other words, chemical changes within the body and brain. For instance, studies find that the expression of interferon-gamma (IFN-gamma) and other Th1-type cytokines (pro-inflammatory cells shown to worsen MS) correlates with depression scores during an acute exacerbation. A study also found that the level of depression, as well as IFN-gamma production, declined significantly in individuals with MS over a 16-week treatment period using cognitive behavior therapy.

A fourth potential cause or contributor to depression in MS is reaction to altered life circumstances. Individuals with MS may have a wide range of losses to cope with, which could include physical limitations, financial stress, and changes in employment, activities, and plans for the future. Grieving is a necessary part of adjustment, but the symptoms of grieving are hard to separate from depression.
The fifth potential cause or contributor to depression in MS is medication side effects. First and foremost on the list may be steroids, frequently used to treat exacerbations. These tend to induce a short-term euphoric “steroid high” when first given, only to result in depression when the drug is stopped.

Regarding treatment with interferons (beta-1a – Avonex® and Rebif®, and beta-1b – Betaseron®), some anecdotal reports suggest a possible association between this type of immunotherapy and increased depression. Recent follow-up studies, including data from the SPECTRIMS and PRISMS trials, failed to show a connection between these drugs and depression. While this news is encouraging, medical professionals should always be on the lookout for any signs of depression or suicidal behavior in an individual taking immunomodulating drugs.

Other medications given for symptom management in MS may cause depression as a side effect. Examples include: baclofen (Lioresal®), taken for spasticity; benzodiazepines, taken for dizziness, vertigo or spasticity; and other sedating drugs.

Recommended Treatments for Depression in MS
Effective treatments are available for people with MS who experience depression. These treatments always include two components: medication and psychological counseling. The first helps to turn around feelings of sadness and hopelessness, while the second allows individuals to explore their emotions and develop better ways to cope with the challenges they encounter.

In a meta-analysis of 18 studies of depression in medical illnesses (including MS), individuals treated with anti-depressants were significantly more likely to improve than those given placebo or no treatment. Another study with patients in a long-term nursing facility found that depression significantly improved when treated with cognitive remediation strategies.

Medications, St. John’s Wort, and ECT
The first line of medications include the “selective serotonin reuptake inhibitors” (SSRIs). Serotonin is a compound found in blood platelets and the tissues of the intestinal wall and the central nervous system. It acts as a neurotransmitter and may be involved with inflammation, migraine headaches, and sleep. Serotonin also tends to elevate mood, but its effects are only temporary, as cells “take up” (or absorb) serotonin once it becomes available. SSRIs inhibit the reuptake of serotonin, so it remains in the system longer, and its positive effects may be experienced for longer periods of time.

Fluoxetine (Prozac®), paroxetine (Paxil®), sertraline (Zoloft®), and venlafaxine (Effexor®) are all SSRIs that are commonly used to treat depression in MS. Side effects of these drugs may include headache, sexual dysfunction, nausea, difficulties with sleeping, and anxiety or sedation. (Please note that not everyone experiences the same side effects, and physicians work with their patients to minimize these side effects.) Other antidepressants that are considered to be a “first line of treatment” for depression are bupropion HCL (Welbutrin®), nefazodone (Serzone®), and trazadone (Desyrel®).

All of these agents may be given alone, or various combinations may be prescribed. Attending physicians will start a patient with one medication, and depending on the results and side effects, may change the dose, switch to another drug, or possibly add a second medication. The optimal drug and dose combination depends on each individual and his or her response to a particular treatment regimen. Antidepressants do not have an immediate effect, and typically require between four to eight weeks before reaching their maximum level of benefit.

Sometimes individuals want to stop their medication as soon as they feel better, thinking they no longer need it. Antidepressant medication should be continued for at least four to nine months to prevent depression from returning, and medication for more severe conditions may need to be continued indefinitely. Individuals taking such medications should never alter their dose, stop taking their medication, or combine it with any other medications, without first consulting their doctor.

The predecessors to these drugs were the anticholinergics or tricyclic antidepressants. These were formerly the first treatment choice, but with the introduction of SSRIs and other agents, medications such as imipramine (Tofranil®), amitriptyline (Elavil®), and nortriptyline (Pamelor®), are now considered as options should first-line treatments fail. The side effects of these drugs include dry mouth, constipation, bladder problems, sexual problems, dizziness, drowsiness, and blurred vision. Monoamine oxidase inhibitors (MAOIs) are used for people who do not respond to the other medications already mentioned.

Historically, an extract of the herb St. John’s wort has been used for hundreds of years to treat mental disorders as well as nerve pain. In modern times, this herb has been taken by individuals for mild to moderate depression, anxiety, or sleep disorders. A recent three-year study conducted by the National Institutes of Health found that St. John’s wort was ineffective for treating major depression of moderate severity, but research is ongoing to see if it might have applications in treating milder forms of depression. St. John’s wort, along with other herbal supplements, can have dangerous side effects when taken with other medications. Individuals need to inform their doctor if they are taking any type of herbal supplement.

For those who suffer from depression and standard drug therapies are ineffective, electroshock therapy (ECT) has been refined to a level that is now considered to be safe and effective for most individuals. The possibility exists, however, that for individuals with MS, ECT may have some negative effects on the blood brain barrier. When considering ECT, patients and medical professionals need to weigh the benefits and the risks before making a decision.

Although bipolar disorder is less common in MS than depression, medications are available for those whose mood fluctuates between depression and happiness with hyperactivity. Lithium carbonate (Eskalith®) is the first choice for treating this illness. Other medications include anticonvulsants such as gabapentin (Neurontin®), carbamazepine (Tegretol®), valproate (Depakote®), and lamotrigine (Lamictal®).

Psychological Counseling
Psychological counseling is the second and equally important component for treating depression. Individuals suffering from this condition need to work with a psychiatrist, psychologist, or social worker to discuss their thoughts, behaviors, and outlooks. These medical professionals assist people with their coping skills and help individuals to better adjust to their situations, so they may feel better about themselves.

Different types of individual therapy include: (1) “talking,” which helps people gain insight and resolve problems through verbal exchange with the therapist; (2) “behavioral,” to help individuals find more satisfaction and rewards through their own actions; (3) “interpersonal,” concentrating on problems with personal relationships; (4) “cognitive/behavioral,” helping people to change negative ways of thinking and acting; and (5) “psychodynamic,” which aims to resolve an individual’s conflicted feelings.

In addition to one-on-one counseling and therapy, group sessions may also be beneficial. Support groups and peer counseling help people to see that they are not alone in their feelings, and they may find comfort as well as direction by talking with others who face the same challenges. Spouse and family therapy can be very productive as well, providing the opportunity for people close to someone with MS to get the support, information, and coping skills needed.

Professional Points of View
MSAA’s Chief Medical Officer Jack Burks, MD, specializes in the treatment of MS and stresses the importance of treating depression. “I am always on the lookout for symptoms of depression with the people I treat. Given the high incidence of depression among individuals with MS, as well as a suicide rate much greater than the general population, the need for recognizing symptoms of depression and recommending treatment is crucial.

“What causes depression in MS is not an easy question to answer. Having MS certainly adds stress to one’s life, and depression can result from dealing with stress. But depression can also result from medications, and damage to myelin could be involved. Other medical conditions, such as thyroid disease and urinary tract infection, can cause depression as well. An individual can even appear euphoric when actually suffering from depression.

“For these reasons, I always look at the patient’s entire picture. After making whatever changes are necessary to existing medications and conditions, using a combination of psychotherapy and medication is the most effective means of treatment.

“Psychotherapy is an integral part of treatment. Examples of therapy options include group, peer, family, couple, and individual counseling. Educating family members is important so they understand MS and can provide support to the affected family member. Stress management through bio-feedback is another viable option.

“The big hurdle for many people is to get over the stigma associated with counseling. Individuals need to know that they are not ‘crazy.’ Depression is an illness that needs to be treated. Counseling helps individuals learn how to cope and adjust to one’s changing situation. We all experience “dips” from time-to-time and we need to smooth these out.

“I also recommend that if an individual with MS is going to see a professional regarding depression, he or she should seek someone who is experienced with MS. Depending on their level of dedication and interest, psychiatric social workers and nurse clinicians can also be excellent sources for therapy.

“When prescribing medications, a doctor needs to look at side effects and the patient. Prescribing an SSRI is the first line of treatment, but it is an art, not a science. Doctors need to match the right drug and the right dose with the right person. Going with the non-SSRIs, such as Welbutrin, Serzone, and Desyrel, may result in fewer side effects. Additionally, insurance doesn’t always pay for all of the medications, so I try to first prescribe the appropriate medications that are covered to help with costs to the patient. I am very diligent with treating depression in MS, and I will often try five or six combinations to see what works best.

“Regardless of which medications and forms of therapy best suit an individual diagnosed with depression, the important thing is to get help. Even if one’s physician has not mentioned the possibility of depression, if someone is experiencing some or all of the associated symptoms, he or she needs to inform a medical professional. Depression greatly affects an individual’s quality of life; it can cause additional symptoms, and can even direct a few individuals toward thoughts of suicide. Depression is a serious disorder, and no one should go without treatment.”

Lara Krawchuk, MSW, LSW, MPH, is an instructor at the University of Pennsylvania and staff therapist with the Council for Relationships. She specializes in chronic and life-threatening illnesses in private practice, and commonly works with individuals suffering from anxiety, stress, grief, and loss. She sees both patients and their caregivers, and sessions may be one-on-one, or can include couples, families, and groups.

“Individuals with depression are often experiencing a poor mood, emotional problems, and feelings of hopelessness. They may have many lows, feel totally overwhelmed, and sometimes can’t get out of bed. Having difficulty with relatives can be another sign. Often caregivers will feel similarly, but the way everyone copes may not match. For example, one person may be feeling ‘up’ when the other is ‘down,’ or one may want to be alone and another needs to talk. This too can add to the problem of depression.

“When seeing someone who is depressed, I ask if he or she has spoken with a physician. I need to find out if the depression may be related to a medical problem, and if it can possibly be normalized from a physical aspect. I always assume there is an emotional aspect present with chronic conditions, and these usually respond best to a multi-dimensional approach.

“Several good medications are available to help in the treatment of depression. These may be prescribed by an individual’s family physician or a psychiatrist. I recommend consulting a psychiatrist when someone is suffering from a serious depression. I also may recommend lifestyle changes, exercise, healthy diet, and support groups.

“Talking with the family, communicating with loved ones, and learning coping techniques are important first steps to treating depression. Better communication is a valuable tool for discussing challenges and possible solutions. This can also lead to building new communication skills and better processing of issues.

“Guided imagery is a technique that can be quite helpful. It teaches individuals to focus attention on calming or healing images, and this can be very relaxing as well. Studies have shown that guided imagery can actually help with symptom management by giving the client a sense of control, empowering him or her, and impacting one’s own health through a positive immune response. We may practice this during a session, and it is easy enough that a client can do it at home and in other situations, such as during a medical procedure.

“Journaling is another activity that can be helpful. By writing down one’s feelings, and not just facts, a journal can enable someone to better process problems, feelings, and concerns. This has been shown in literature to improve one’s physical and emotional wellbeing. Some may write regularly while others may only write when times are difficult. Either way, journaling can help individuals gain perspective and insights about areas of concern in their life.

“Talking to a therapist provides the attention that an individual may need but others around them cannot provide. For example, not everyone wants to hear about the pain of a loved one. Family members may be overwhelmed; friends may be scared; and the medical team may be too busy. People need a good listener and someone who understands. Additionally, they don’t need to sugar-coat their words or mask how they feel when talking to a therapist.

“Helping someone to process losses is often needed. People feel grief when sick and experiencing changes within one self. Acknowledging their pain and recognizing that some of the changes are tough, is very important to assisting people with accepting their new self.”

Lara Krawchuk recommends the following resources for more information, along with her notes:

Peace is Every Step: The Path of Mindfulness in Everyday Life
by Thich Nhat Hanh, published by Bantam Books, Inc., “…A wonderful book onmeditation, along the lines of guided imagery.”

Self-Nurture: Learning to Care for Yourself as Effectively as You Care for Everyone Else
by Alice D. Domar and Henry Dreher, published by Penguin USA, “…An excellent resource for self care.”

Journaling for Joy: Writing Your Way to Personal Growth and Freedom
by Joyce Chapman, published by Career Press Inc., “…One of many good books on journaling.”

Staying Well with Guided Imagery
by Belleruth Naparstek, published byWarner Books, Inc., “…Known as the ‘goddess of guided imagery,’ Belleruth also has a website (www.healthjourneys.com) which offers information, books, and tapes on the topic.” Those without access to the internet may call (800) 800-8661.

Anyone in the Philadelphia area interested in therapy may contact Lara Krawchuk at (215) 575-9140 (ext. 8). Individuals in the Pennsylvania, Delaware, or New Jersey area, may call the regional Council for Relationships at (215) 382-6680, and ask for the “chronic illness program.”

Individuals may also contact MSAA’s Helpline at (800) 532-7667 for more information on depression, therapy, or counseling centers that may specialize in MS and depression.

For more information about depression and other related disorders, The National Institute of Mental Health recommends the following associations:

National Institute of Mental Health
Information Resources and Inquiries Branch
Phone: (301) 443-4513
Depression brochures: (800) 421-4211
TTY: (301) 443-8431
Website: www.nimh.nih.gov
E-mail: nimhinfo@nih.gov

National Alliance for the
Mentally Ill (NAMI)
Phone: (800) 950-NAMI (6264)
or (703) 524-7600
Website: www.nami.org
A support and advocacy organization of consumers, families, and friends of people with severe mental illness-over 1,200 state and local affiliates. Local affiliates often give guidance to finding treatment.

Depression & Bipolar
Support Alliance (DBSA)
Phone: (312) 988-1150
Website: www.DBSAlliance.org
Purpose is to educate patients, families, and the public concerning the nature of depressive illnesses. Maintains an extensive catalog of helpful books.

National Foundation for
Depressive Illness, Inc.
Phone: (800) 239-1265
or (212) 696-1088
Website: www.depression.org
A foundation that informs the public about depressive illness and its treatability and promotes programs of research, education, and treatment.

National Mental Health Association (NMHA)
Phone: (800) 969-6642 or (703) 684-7722
TTY: (800) 433-5959
Website: www.nmha.org
An association that works with 340 affiliates to promote mental health through advocacy, education, research, and services.

References:
MSAA’s publication: Multiple Sclerosis – Managing Symptoms, third edition, 2002.

National Institute of Mental Health
Burks J.S., Johnson K.P., Multiple Sclerosis – Diagnosis, Medical Management, and Rehabilitation, Demos Medical Publishing, New York, 2000.

Chwastiak L., et al., Depressive symptoms and severity of illness in multiple sclerosis: epidemiologic study of a large community sample, American Journal of Psychiatry, Nov. 2002, 159 (11), pp. 1862-1868.

Feinstein A., An examination of suicidal intent in patients with multiple sclerosis, Neurology, 2002 (59), pp. 674-678.

Feinstein A., O’Connor P., Feinstein K., Multiple sclerosis, interferon beta-1b and depression: a prospective investigation, Journal of Neurology, July 2002, 249 (7), pp. 815-820.

Harrison T., Stuifbergen A., Disability, social support, and concern for children: depression in mothers with multiple sclerosis, Journal of Obstetric, Gynecologic, and Neonatal Nursing, July-Aug. 2002, 31 (4), pp. 444-453.

Kahl K.G., et al., Expression of tumor necrosis factor-alpha and interferon-gamma mRNA in blood cells correlates with depression scores during an acute attack in patients with multiple sclerosis, Psychoneuroendocrinology, Aug. 2002, 27 (6), pp. 671-681.

Kroencke D.C., Denney D.R., Lynch S.G., Depression during exacerbations in multiple sclerosis: the importance of uncertainty, Multiple Sclerosis, 2001 (7), pp. 237-242.

Lynch S.G., Kroencke D.C., Denney D.R., The relationship between disability and depression in multiple sclerosis: the role of uncertainty, coping, and hope, Multiple Sclerosis, Dec. 2001, 7 (6), pp. 411-416.

Mendoza R.J., Pittenger D.J., Weinstein C.S., Unit management of depression of patients with multiple sclerosis using cognitive remediation strategies: a preliminary study,
Neurorehabilitation and Neural Repair, 2001, 15 (1), pp. 9-14.

Mohr D.C., Goodkin D.E., et al., Treatment of depression is associated with suppression of nonspecific and antigen-specific T(H)1 responses in multiple sclerosis, Archives of Neurology, July 2001, 58 (7), pp. 1081-1086.

Patten S.B., Metz L.M., Interferon beta-1a and depression in secondary-progressive MS: Data from the SPECTRIMS trial, Neurology, 2002 (59), pp. 744-746.

Patten S.B., Metz L.M., Interferon beta-1a and depression in relapsing-remitting MS: an analysis of depression data from the PRISMS clinical trial, Multiple Sclerosis, Aug. 2001, 7 (4), pp. 243-248.

Patti F., et al., The impact of outpatient rehabilitation on quality of life in multiple sclerosis, Journal of Neurology, Aug. 2002, 249 (8), pp. 1027-1033.

Wang G. L., et al., Major depression and quality of life in individuals with multiple sclerosis, International Journal of Psychiatry in Medicine, 2000, 30 (4), pp. 309-317.

Zorzon M., et al., Depression and anxiety in multiple sclerosis. A clinical and MRI study in 95 subjects, Journal of Neurology, May 2001, 248 (5), pp. 416-421. u