What is depression?
Depression is a constant feeling of sadness or low mood. Everyone feels sad or down at times but clinical depression is different. It is constantly present and interferes with your everyday activities. Depression can be mild, moderate or severe, depending on how much it affects your life, and you can experience different levels of depression at different times.
If you are depressed you often lose pleasure in things that were once enjoyable, you may give up usual activities such as hobbies and lose interest in seeing friends and family. Some people even feel that life is no longer worth living and have thoughts of suicide.
What causes depression?
Generally, depression is thought to involve changes in brain chemistry that lead to feelings of low mood. Anyone can develop depression at any time in their life without any apparent cause or reason. It is not due to an inability to cope with life, or a weakness or failure of any sort.
Below are some of the experiences that can lead to depression.
You might be more at risk of developing depression if:
- you have experienced a stressful life event such as a relationship break-down or a bereavement
- you have a family history of depression
- you are a woman who has recently given birth
- you are socially isolated
- you have drug or alcohol problems
All these life events are just as likely whether you have MS or not.
Living with MS
The challenges of living with multiple sclerosis can also lead to depression. Living with uncertainty, feeling helpless, experiencing loss of opportunity and the social isolation or stigma that disability may bring can all be factors for developing depression. Increased levels of stress and experiencing symptoms such as poor sleep, chronic pain and overwhelming fatigue can also be contributing factors. Pain and depression tend to amplify each other in MS, so it's important to tackle both with your treatment.
In MS, the relationship between disability and depression is not straightforward. Sometimes depression may start up early in the MS disease course, perhaps around the time someone is coming to terms with the diagnosis. Alternatively, depression may begin later, after having lived with MS for many years. However, many people with MS or severe disability never develop depression.
Site of MS lesions
Studies have shown that depression can also occur as a result of MS itself, because if MS lesions happen to occur in areas of the brain that are associated with mood they can lead to depression.
Side effects of drugs used to treat other MS symptoms
Some drugs prescribed to treat MS can also contribute to depression. These include steroids used to treat MS relapses, muscle relaxants used to treat spasticity and spasms and some disease modifying drugs.
How many people get depression?
Around half of all people with multiple sclerosis will experience depression at some time in their life. This is three times higher than for the general population. Part of this extra risk comes from MS damaging nerves in the brain, and part comes from the experience of living with a complex disease.
People with MS are likely to experience chronic depression, with symptoms lasting a long time, even several years. In MS, depression is unlikely to go away on its own, due to the underlying lesions, but it is very treatable, so get help as soon as you can.
The risk of suicide for people with MS is also significantly higher, with young men within the first five years of MS diagnosis most at risk of ending their own lives.
What can I do if I think I'm depressed?
Clinical depression can be difficult to identify and you may not always be able to recognise depression in yourself, although your family and friends might have noticed changes in you. Your GP, MS nurse or neurologist may also recognise the signs of depression. There is no simple test such as a blood test to find out if you are depressed. Your health professionals rely on descriptions of the symptoms you are experiencing and the effect it is having on your life.
Recognising depression when you have MS can be difficult as you may already have some of the symptoms usually associated with depression such as fatigue, poor concentration and sleep problems. In the absence of infection or relapse, changes or worsening in those symptoms could be a flag for concern.
Signs of depression include:
- low mood all the time for at least two weeks
- negative thoughts about yourself and the future
- not being able to take pleasure in routine things that you have previously enjoyed such as eating, watching TV or talking to friends
- thoughts of suicide
It has also been suggested that in MS, depression causes increased problems with thinking, feeling irritable, frustrated and discouraged.
Talk about it
It is important to let people around you know how you feel. It can be hard to talk about how you are feeling and the stigma that is sometimes associated with mental health problems can also act as a barrier to discussions.
Depression can interfere with your ability to concentrate and so can affect work performance. This may be perceived as laziness or incompetence by your work colleagues if they are unaware of the situation. Can you tell a colleague, HR person or manager about your depression, so that you can get support at work?
Without the right help depression can spiral out of control, so it is important to speak to a GP or another person you trust as early as possible.
Get help with it
Your MS team, GP or neurologist can work with you to find the best approach to treating your depression.
Simply describing the symptoms of depression cannot capture the enormous impact it can have - it can affect personal, social and professional aspects of your life. Depression may make you want to withdraw from intimate or social relationships, family and friends may not recognise that this is due to the condition and may misunderstand this as rejection or disinterest, which in turn can lead to a lack of empathy or sensitivity towards you - this can feed in to the depression and lead to further social withdrawal.
Depression is often accompanied by feelings of despair, uselessness or lack of self-worth. This can lead to self-neglect, you may stop caring for yourself in the way that you usually would, stop following a healthy lifestyle or neglect to take your usual prescribed medication - this may be your MS medication and/or any medication prescribed to treat your depression. Because of the impact depression can have on you and the management of your MS, it is important to seek help.
If life seems unbearable
Studies have found that over a quarter of people with MS think about suicide. This can happen when the future looks bleak and you may think friends and family would be better off if you weren’t around. Whilst many people think about suicide, few go on to carry this out. If you are having thoughts of suicide or you find yourself severely down, the Samaritans provide a free 24 hour telephone line in the UK and Republic of Ireland on 116 123 and can help you through until you can contact your regular team of health professionals. Friends and family can also help - the vital thing is to involve other people even though this may not be easy.
How is depression treated?
There are a number of approaches to treating depression. The best solution for you will depend on the severity of your depression, your personal preferences, sources of support and any past history of depression. Treatments are often used in combination for the best result. Your GP, MS specialist nurse or neurologist will work with you to decide the best course of action. You may be referred to a neuropsychologist where this service is available, or to other members of the mental health team.
NICE has offered useful guidance on what should happen when you talk to a health professional for the first time about depression.
Hayley Bullock, Psychologist
Hayley, from Great Ormond Street Hospital shares her top tips for coping with the emotional side of an MS diagnosis.
Self-management – what can I do?
In mild to moderate depression, self-management is the approach recommended by the NICE guidelines. This may include advice on increasing your levels of physical activity for example through appropriate exercise, adopting healthier lifestyle habits such as eating healthily, giving up smoking, minimising stress, improving your sleep and relaxation or mindfulness techniques.
You may also want to consider accessing support through a self-help group, telephone counselling service, online discussion forum or one of the many mental health charities. Your health professional team will regularly review your progress to ensure that your mood is improving.
Think about signs to look out for if you start to get low again. Mine were things like not contacting friends, not bothering with my appearance and shutting myself away
Recognising your own risk factors can also be really important so keeping a diary of how you feel can be valuable.
St John's wort is an unlicensed herbal remedy that is used by some people to treat their depression. However, concerns about the correct dose, variations between preparations from different manufacturers and the potential for serious drug interactions (including with warfarin and oral contraceptives) mean it is not currently recommended by NICE for the treatment of depression.
Talking therapies or psychological approaches aim to help you identify and overcome negative thought patterns associated with depression. They are usually recommended for mild to moderate cases of depression, and have been shown to be effective in MS. Unfortunately access to talking therapies can be fairly limited on the NHS.
Cognitive behavioural therapy (CBT) is based on the idea that the way you think about a situation affects how you act. In turn, actions can affect how you think and feel. Therefore both the act of thinking (cognition) and behaviour need to change at the same time. Cognitive behavioural therapy has been shown to be effective in treating less severe cases of depression in MS. It can take some time for referral to a psychologist but online courses can help.
NICE guidelines say that CBT can be offered digitally (online or via an app) to both adults and children with mild to moderate depression.
Counselling is a form of therapy that helps you to think about the problems you are experiencing in your life and to identify ways of overcoming or managing them. Counselling is different from other psychological approaches as the therapist has a more passive role and provides more of a listening approach.
Other talking therapies include psychotherapy, family therapy, couples therapy and group therapy. They may be available from your local MS Therapy centre
In moderate to severe depression, or where previous treatment has not been effective, you may be offered antidepressants. Initially you will usually be prescribed the lowest possible dose of a drug. You may not notice any effect immediately, as it typically takes around four weeks for antidepresants to take effect. You will be reviewed regularly to check whether the drug and dose you are taking are effective. Your dose may be increased, or your treatment may be changed if you are not seeing any benefit, or if you are experiencing intolerable side-effects. Some people may start to feel better after a short period of time, but it is important not to stop taking your medication without talking to your health professionals as this can result in your depression coming back.
The drugs used to manage depression vary in the way they work, but they all act by increasing the levels of neurotransmitters in the brain, for example serotonin or dopamine which are thought to boost mood. The most commonly used drugs are called selective serotonin reuptake inhibitors (SSRIs), for example fluoxetine (Prozac) and paroxetine (Seroxat). Other drugs that are sometimes prescribed to treat moderate to severe depression include imipramine or amitriptyline (Triptafen), which can also be used in MS at lower doses to treat neuropathic (nerve) pain, even in the absence of depression.
Severe complicated depression
In rare circumstances, for example if you have had persistent and repeated episodes of severe depression which has resulted in severe self-neglect, or are thought to be a major risk to people close to you, the standard treatments described above may prove ineffective and you may be referred to specialist mental health services where you can receive a tailored programme of treatments in either an inpatient or outpatient setting.
If depression comes back
It is helpful to recognise if you are beginning to feel low again to try and help prevent further episodes, as for some people depression can recur. You might try keeping a diary, or using an app to monitor your social activity, exercise and sleep patterns - you might spot some changes that reflect your drop in mood. Using strategies that have helped you previously, such as CBT, could help you stay well.
- Multiple Sclerosis Journal 2011;17(11):1276-1281. Summary Multiple sclerosis and depression.
- International MS Journal 2010;17(1):3-5. Summary Diagnosing depression in MS in the face of overlapping symptoms.
- Multiple Sclerosis 2011;17(9):1088-1097. Summary Decreased hippocampal volume, indirectly measured, is associated with depressive symptoms and consolidation deficits in multiple sclerosis.
- Nature Reviews Neurology volume 10, pages 507–517 (2014) | Summary The link between multiple scerosis and depression
- Journal of Psychosomatic Research 2014;76(6):465-471. Summary Exercise training improves depressive symptoms in people with multiple sclerosis: results of a meta-analysis.
- BMC Neurology 2014;14:15. Summary Mindfulness based interventions in multiple sclerosis - a systematic review.
- BMC Psychiatry. 2014; 14: 5. Full article Cognitive behavioural therapy for the treatment of depression in people with multiple sclerosis: a systematic review and meta-analysis.
- Cochrane Database of Systematic Reviews 2011;2:CD007295. Summary Pharmacologic treatment of depression in multiple sclerosis.
- Phys Med Rehabil Clin N Am. 2013 Nov;24(4):703-15 Full article Co-occurring depression and pain in multiple sclerosis
- Mult Scler. 2015 Jan;21(1):76-82. Summary Depression in multiple sclerosis: a long-term longitudinal study.
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Living well with MS: a role for psychology?
A team in Surrey set up a psychology service offering CBT and MBCT, approaches that research has shown can help people adapt to and cope with living with MS.