Multiple sclerosis may affect many areas of a person’s life. The physical manifestations, such as the effects on walking, hand function, speech and co-ordination, are commonly recognised because they are usually visible to others. There are other effects that remain hidden to many people, including friends and families.
This may be because they are not visible to others (such as pain and fatigue) or they may be hidden because of embarrassment, such as problems with one’s bowel and bladder.
Depression is an emotional challenge that can be quite disturbing for the person who experiences it directly, as well as for those close to the individual.
What is depression?
All of us have periods of feeling “down” or “low”. Depression, in contrast, is a disorder characterised by a persistently low mood, occurring most of the time and lasting for some weeks or more. This is sufficient to cause distress or affect social or work functioning. The low mood is usually accompanied by feelings of being sad or empty.
People with depression often report a loss of interest and pleasure in daily activities and may feel worthless and guilty. In some people, particularly men, their depression is manifest as increased anger and irritability. This may be exaggerated when physical disability limits functioning.
Outward signs of depression may be visible in some people. These include tearfulness and a loss of interest in personal appearance.
People may be irritable, fidgety or less active physically.
How common is depression in people
with MS?
People with MS are more prone to depression, with approximately half experiencing a period of significant depression at least once in their lives. This is quite high when compared to the estimate of the general population, which is 15 per cent. Between 15-30 per cent of people with MS are thought to be depressed at any one time.
It is important to stress that the overall risk of suicide remains very low in the general population, including people with MS. However, recent studies have shown for the first time that the rate of suicide amongst people with MS is significantly higher than in the general population. A considerable number of people with MS have reported considering suicide at one time or another.
What causes depression in people with MS?
The causes of depression are uncertain. It may be understood as a state of abnormal brain function that may be triggered by both external stresses and by underlying brain disease. In MS there are many obvious external triggers, including pain and the effects of the disease on family, housing, work and finances. There is also evidence for brain dysfunction, including increasing depression in persons with MS plaques in specific parts of the brain.
Overlap between depressive symptoms and MS symptoms
People with depression commonly experience physical symptoms. These include disturbances of appetite and sleep, cognitive dysfunction, fatigue, pain and a loss of libido. These are also very common effects of MS and it is difficult to tell what may be causing the problem. If these problems are due predominantly to depression, then appropriate treatment is likely to bring about an improvement.
Managing depression
Identifying depression in people with MS offers considerable hope. In contrast to many complications of the disease for which there are limited treatments, the majority of episodes of depression are not permanent. The management of depression must be tailored for each individual patient. A vital first step is identifying depression and overcoming the stigma related to it. Treatment is built on a combination of addressing precipitating problems, anti-depressant medication and therapeutic counselling. Precipitating problems include social issues such as difficulty with housing and finances.
There may also be relationship issues that need to be addressed. MS affects both partners in a relationship. The loss of physical abilities, sexual function and work, amongst others, may affect both people. Likewise, caring for someone with MS imposes stresses on both people. In these cases, involving partners in counselling may be helpful.
The anti-depressants used include both the traditional medications, such as amitriptyline or dothiapine, and the newer agents such as fluoxetine, paroxetine or citalopram. These medications take at least four weeks to have an effect. Their availability may vary by country. As with all medicines, the anti-depressants have side effects that may limit their tolerability, including drowsiness, a dry mouth, constipation and difficulty passing urine.
They may, however, also be beneficial for treating nerve pain that commonly affects people with MS, as well as helping people with sleep difficulties or an overactive bladder. The newer agents mentioned above have fewer
side effects and may also be helpful if
there is associated anxiety, and in treating fatigue.
Cognitive behavioural therapy (CBT) attempts to identify and address distortions in the way that a person perceives themselves and the world. CBT involves a commitment from the person to work actively, over a fixed period, with the therapist to address their problems. CBT can be as effective as medication in people with mild to moderate depression. When the two are used in combination, there are added benefits.
Other emotion-related challenges
A part of the brain, the frontal lobe is responsible for both control of emotions and their outward expression. People with damage in this area due to MS may experience changes, usually unpredictable, that may or may not be related to the emotion being experienced.
Mood swings
Mood swings can be described as a rapid fluctuation in mood, with alternating euphoria and depression. While many people have experienced mood swings at some time, it appears that people with MS may be more at risk of this problem. Since mood swings can create difficulty within a family or social circle, it is important that the person experiencing them discusses the problem with those around him or her, in order to help avoid misunderstanding. Some people find mood-stabilising medications or anti-depressants helpful, while others find counselling beneficial. The objective of counselling in this case is to help the person to learn effective ways of managing unpredictable changes in mood. Often a combination of these solutions can be helpful.
Disinhibition
MS-related disinhibition, or a loss of control over impulses causing inappropriate behaviour, is a difficult problem to manage and can be very upsetting, especially for the family. Aggressive or sexually inappropriate language or behaviour may be controlled with mood-stabilising drugs, although hospitalisation, in order to follow a more intense medication regimen, may be required in rare cases.
Pathological laughing and crying
Pathological laughing and crying is a symptom in which the person experiences episodes of laughing and crying that occur independently from any emotion. In other words, the manifestation of sobbing or seemingly exaggerated laughter is not the result of what the person is feeling, but an uncontrollable, unpredictable demonstration resulting, apparently, from demyelination in the emotion-centre of the brain. Both the individual and those close to him or her should receive information about this problem since it can be easily misunderstood and very disruptive. Currently there is no definitive treatment for this rare symptom, although clinical trials of dextromethorphan (combined with an agent to sustain therapeutic levels) are underway for people with uncontrollable laughing and/or crying from a variety of neurologic conditions.
Conclusion
Emotional changes are common in MS, and can be as distressing as many physical symptoms. However, help is available and most emotional symptoms can be treated successfully in the majority of people. This may or may not involve the use of drugs. It is important for those affected by MS, either personally or professionally, to remain aware of the potential emotional changes that can arise, so they may ensure that appropriate help is sought and provided.
Pathological laughing and crying can be easily misunderstood and relatively disruptive.
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