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Diagnosing and Treating Depression in Multiple Sclerosis

Depression and MS

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Updated December 05, 2008

Many people are reluctant to seek help for depression, perhaps because they are embarrassed or think that they should be able to “get over it” themselves. Compounding the problem is the fact that many cases of depression in people with multiple sclerosis (MS) get missed by their doctors, as both the patients and doctors are so focused on the physical symptoms of MS and the neurological exam, that they neglect to talk about feelings of sadness or loss of interest in previously favorite things.

Depression is nothing to be ashamed of and it is not your fault. In people with MS, it is caused by complex physical, chemical and/or emotional processes and interactions that not even doctors and researchers understand fully. The good news is that depression is treatable in the hands of the right doctor.

What Kind of Doctor Will I See for Depression?

Although all physicians can prescribe antidepressant medications, it is highly recommended that you see a psychiatrist for your depression. The treatment of depression requires careful monitoring and individualized treatment plans. A psychiatrist has experience with all forms of depression and has observed the effects of different medications firsthand. She will be able to tell you what to expect and ask the right questions to allow her to adjust your dose over time to ensure the best response possible.

It is also ideal if you can find a psychiatrist who treats other patients with MS. Many of the symptoms of MS (such as fatigue, cognitive problems, physical slowness and problems sleeping) mimic the symptoms of depression and vice versa. Additionally, some of the interferon-based medications for MS, such as Avonex and Betaseron, have depression as a side effect. A doctor who has experience with both MS and depression will be able to “untangle” your symptom list and determine the best course of treatment for you.

The best way to find a psychiatrist who has experience with MS is to ask your neurologist or the physician who is taking care of your MS for a referral. You can also contact the main office or your local chapter of the National Multiple Sclerosis Society at 1.800.FIGHTMS for the names of doctors experienced with both depression and MS in your area.

What Medical Tests Will be Performed?

Since there is no blood test or other “biomarker” test for depression, your doctor will arrive at a diagnosis by listening to your story about why you sought treatment, asking you a series of questions and observing your behavior during the appointment.

You will probably be asked about a list of your specific symptoms (such as sadness, tiredness, pessimism, problems sleeping, feelings of guilt, etc.), how long you have had each symptom and how severe your symptoms are. The doctor will also ask you about history of depression and treatment, any drug and alcohol use, other current medications, relatives with history of depression and if you have ever had thoughts of hurting yourself or committing suicide. While many of these questions may be uncomfortable, it is important that you answer honestly. This will help the doctor figure out the best treatment for you.

Medications for Depression

There are several classes of medications for depression. Those most commonly used today are:
  • Selective Serotonin Reuptake Inhibiters (SSRIs): Prozac® (fluoxetine), Zoloft® (sertraline), Celexa® (citalopram) and Paxil® (paroxetine), among other SSRIs, are all used to treat depression, as well as anxiety disorders. These and other SSRIs differ from each other in terms of potential side effects.
  • Selective Serotonin and Norepinephrine Reuptake Inhibitors (SSNRIs): Effexor® (venlafaxine) and Cymbalta® (duloxetine hydrochloride) are members of a new class of drugs, the SSNRIs. Clinical studies have shown that the SSNRIs may be more effective in treating severe major depressive disorder and treatment-resistant depression than SSRI antidepressants and tricyclic antidepressants in some patients. In fact, Effexor was shown in studies to be more effective than other medications in promoting remission of depression, which is a complete return to the normal functioning a patient had prior to their symptoms. Cymbalta is also used to treat neuropathic pain.
  • Tricyclic Antidepressants: The tricyclic antidepressants, such as Elavil® (amitriptyline) and Pamelor® (nortriptyline), tend to have side effects which can make other MS symptoms feel worse, by causing drowsiness, constipation or difficulty passing urine. Therefore, they are not usually used as a first-line treatment for depression in MS. However, for treatment-resistant depression, they may be used alone or in combination with other medications.

It is important to be aware that antidepressants can take six to eight weeks to reach their full effect. You should expect to have regular appointments with your doctor, especially when starting a new treatment, so she can monitor your response to the therapy and look for possible side effects to determine if the medication should be increased, decreased or changed. Remember, it is rare that the perfect medication in the perfect dosage is prescribed the first time, as everyone is unique in their response. Successful treatment of depression requires patience and cooperation from both the doctor and patient, but the reward is worth the effort.

Other Interventions

Research has shown that the most effective treatment for depression in MS is a combination of treatment with antidepressant medications and "talk therapy" or psychotherapy. Your psychiatrist may provide psychotherapy himself or work closely with a psychotherapist to which he can refer you. Also, your local MS Society chapter can give you a list of MS support groups in your area or therapists experienced in working with people with MS.

Sources:

Goldman Consensus statement on depression in multiple sclerosis. Multiple Sclerosis. 2005; 11, 328-337.

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