Symptom Management

The Many Shadows of MS Related Depression

By Robert Godsall, Ph.D.

There are many causes for depression, each reflecting different influences, yet most of these causes fall into two categories: organic or situational. Organic factors typically reflect biological vulnerabilities, such as family history of depression, while situational factors are most associated with life events, such as loss of a loved one due to death or divorce.

Depression is also associated with physical illnesses, particularly those that are chronic, such as diabetes or MS.  For people with MS, depression is particularly prevalent, as indicated by studies showing that depression is greater in people with MS when compared to other chronic illnesses such as diabetes. In fact, studies have shown that 50 percent of people with MS will likely experience, and be diagnosed with, a major depressive disorder–a base rate that is much higher than the general population or other chronic illnesses. 

Symptoms of depression most commonly include insomnia, significant appetite changes usually resulting in noticeable weight changes, agitation, and fatigue.  All of these symptoms may contribute to behavioral changes such as reduced initiative of usual daily activities (apathy), which is often associated with anhedonia (lack of pleasure in usual daily activities).

Other symptoms include sadness, loss of self-confidence, and decreased cognitive functioning. Finally, thoughts about death may occur, particularly as symptoms worsen and feelings of hopelessness emerge when there is no abatement of symptoms. 

Depression in MS is particularly problematic because of the number of shared symptoms between the two disorders, making depression difficult to diagnose. Fatigue and decreased cognitive functioning are just two examples of conditions common to both depression and MS. 

These symptoms reflect organic aspects of depression, which have resulted in depression being thought of as a symptom of MS. These organic factors are complicated further by the treatments used in MS, many of which may cause physical side-effects affecting the life of the person with MS, or may cause depression themselves. These treatments may cause changes in appetite or sleep, as well as affect the person’s capacity to initiate and engage in pleasurable activities

But depression in MS can also reflect situational factors, because the decreased physical and cognitive functioning associated with the disease progression bring changes in the lives of people with MS. Often they have to give up or alter jobs and careers, or they must make changes in family functioning.  Sometimes they have reduced roles to play, including parenting. 

All of these interactions between MS and depression make it very important to treat depression as part of managing MS to increase optimal functioning in living with MS. Antidepressant medications known as selective serotonin reuptake inhibitors (SSRIs) have been shown to be effective in treating some of the symptoms of depression, such as insomnia, reduced appetite, fatigue, or lethargy. Counseling is also an important part of the treatment of depression, particularly in regards to addressing behavioral symptoms such as social withdrawal.

For many years there has been ongoing debate about which treatment – medication or therapy – has been most effective. In studies evaluating these two groups of treatment, findings have more recently indicated that while medications are important for alleviating the organically based symptoms, it is counseling that is associated with the long-term maintenance of symptom-free functioning, even after the medications have been discontinued.

Interestingly, studies in MS and depression have found that there is no direct relationship between the progression of MS or disability and depression. Rather, the level of depression is more associated with the number of coping strategies that people with MS possess.  Part of coping is the experience of recognizing what aspects of MS can be controlled and which cannot be controlled, and then taking steps to establish control over those aspects that can be controlled.  For this reason, addressing depression, which is very treatable, is important in learning to live with MS.

Dr. Rob Godsall has been part of the Shepherd Center team since 1997 and now works in outpatient services, where he is coordinator of Neuropsychological Services for the Outpatient Clinic and the MS Institute of Shepherd Center.  Dr. Godsall received his doctorate in Clinical Psychology from the Georgia State University Department of Psychology, where his specialty interests were Clinical Neuropsychology and Family Systems Therapy.  Following completion of his clinical internship, where he completed major rotations in Forensic Psychology and Neuropsychology, Dr. Godsall continues to pursue his interests in the impact of family systems on the course of neurological disorders.

 (Last reviewed 10/2009)