Life with MS

The Relationship Between Depression and MS

By Amy MB Sullivan, Psy.D., and Lucille Carriere, Ph.D.

Depression is a common condition that appears simultaneously in the multiple sclerosis population. It affects quality of life and is linked to worsened disease outcome. In large population studies of individuals diagnosed with MS, the likelihood of major depression varies between 26 and 51 percent. The findings on the frequency of depression in these studies vary depending on the population examined, the measure used, and the time frame evaluated, but there have been consistent results showing a very high prevalence in the MS population. Best estimates of the 30-day prevalence of major depression in the general population are about 3 percent, and in rheumatoid arthritis patients, depression appears in about 15 percent. In comparison to MS patients, depression is three to four times as high as in the general population. Thus, depression is quite common and of significant interest in patients with MS. 
Symptoms and origins
Depression is strongly linked to the quality of life in the MS population. Depression can have a significant and negative effect on functioning in those with MS, particularly as it often strikes individuals in middle adulthood (20-40 years of age) when they may be pursuing college, a career, or raising a family. Symptoms of depression can often overlap with common symptoms associated with MS and, therefore, can be difficult to differentiate.

Signs and symptoms of depression can include:

• Sadness (subjective report of depressed mood most of the day, tearfulness)
• Anger, irritability, worry, and discouragement
• Interest (diminished interest in pleasurable activities)
• Guilt (feelings of worthlessness or guilt)
• Energy (fatigue or loss of energy)*
• Concentration (diminished ability to concentrate or indecisiveness)*
• Appetite (weight loss/gain, increase/decrease in appetite)
• Psychomotor (psychomotor agitation, restlessness, feeling slowed down)*
Sleep (fragmented, initial insomnia, middle insomnia)*
• Suicide (thoughts of death, ideation, intent, plan)
* denotes overlapping symptoms of MS
Depression has been categorized as either primary or secondary in origin, to aid in understanding the possible source of the symptoms. In primary depression, there is no identifiable ‘cause’ or ‘event’ to link to the onset of the symptoms; such symptoms may appear without warning and in absence of any environmental factors. On the other hand, depression identified as secondary in nature may have more clear physical or psychological causes, such as a death in the family, divorce, or job loss. Causes of secondary depressive symptoms may also be biological in origin, such as in the autoimmune mechanisms associated with MS, for example. The precise origin or cause of depression for most people is often difficult to identify, as symptoms are most likely the result of a complex interplay between genetic, psychological, and environmental factors. 
Regardless of the source, recognition of depressive symptoms and early treatment is important to lessen the negative effect on daily functioning and disease symptoms. In fact, research has identified the presence of depressive symptoms during the course of an MS relapse as the biggest predictor of depressive symptoms at two and six months following a relapse (regardless of improvement in disability status). The consequences of untreated depression can be significant for individuals diagnosed with MS, as both quality of life and adherence to MS medications have been found to be lower.
Screening and risk assessment
As a comprehensive care center for MS, the health psychology team at the Mellen Center screens for depression in a variety of ways, including self-report, objective psychological measures, structured interview, and reports from patients’ loved ones. Seeking psychological services at comprehensive MS-focused centers in which medical, rehabilitative, and psychosocial needs are all addressed can be helpful in overall care. Comprehensive care centers are more likely to facilitate collaboration across providers (neurologists, psychologists, social workers, PT/OT, etc.) to improve patient care and also increase accessibility to other types of providers as needed. 
Other neurological conditions can also look similar to depression in those with MS. These include pseudobulbar affect, chronic pain, frontal lobe irritability, dementia, abulia, and severe MS-related fatigue. These other conditions need to be considered and ruled out. When the diagnosis is unclear, we consider neuro-psychological assessment to assist us. There is also a high prevalence of anxiety disorders in the MS population, as well as the presence of adjustment disorder, both of which may need to be addressed.
In addition to the high rates of depression and anxiety, there is also an elevated risk for suicide in the MS population. In fact, research suggests that there is a 7.5 times greater rate of suicide in the MS population than in an age-matched population. This number is slightly higher during the first year of diagnosis and starts to decline after the individual reaches 40 years old. 
The role of health psychology
Because of the increased risk of mental health disorders and, specifically, depression, health psychology is an important part of treatment for a person with MS. Health psychology services at the Mellen Center are most actively used in the following situations:
1) adjustment and coping with the diagnosis and associated fears
2) family and couples adjustment issues, including caregiver burnout and communication issues
3) noncompliance to treatment regiment
4) needle anxiety or phobia
5) pain management related to MS
8) MS-related mood disorders
9) and relaxation skills training
Depression is a challenging condition that should not go untreated. In the stories that follow you can find ways to address the condition. While it was stigmatized in the past, it is now something covered by most healthcare plans. If you need to reach out because of depression, here are some key numbers:
• 800-273-TALK (8255) National Suicide Prevention Lifeline
• 877-Vet2Vet (838-2838) Veterans Peer Support Line
• 800-SUICIDA (784-2432) Spanish Speaking Suicide Hotline
• 877-YOUTHLINE (968-8454) Teen to Teen Peer Counseling Hotline
Amy MB Sullivan, Psy.D. is staff clinical psychologist and the Director of Behavioral Medicine at the Mellen Center for MS Treatment and Research at the Cleveland Clinic. Dr. Sullivan received her doctorate degree at Argosy University-Atlanta, her internship at the University of Cincinnati, and her fellowship at the Cleveland Clinic in Pain Medicine. Prior to her graduate studies, she was a Division 1 basketball player at St. Bonaventure University, where she received her degree in psychology and chemistry.
Lucille Carriere, Ph.D. is a postdoctoral fellow at Mellen Center for MS at the Cleveland Clinic.