Both depression and suicide rates are high in MS patients, but there are effective treatments
by Darcy Lewis, Contributing Writer, MedPage Today
Reviewed By Jacqueline A. Nicholas, MD, MPH, System Chief, Neuroimmunology & Multiple Sclerosis, OhioHealth Multiple Sclerosis Center, Columbus
When it comes to any kind of chronic condition, patients are all too likely to develop depression as they navigate the associated stresses and challenges. But with the chronic demyelinating disorder multiple sclerosis (MS), there appears to be even deeper connections with depression, noted Scott Patten, MD, PhD, the Cuthbertson and Fischer Chair in Pediatric Mental Health at the University of Calgary in Canada. These include biological mechanisms like hippocampal microglial activation, lesion burden, and regional atrophy.
The relationship between the two conditions is complex, he told MedPage Today. “There was a period in psychiatry when people tried to differentiate the psychological from the biological aspects of depression in MS, asking, for example: Is it the burden of lesions? Is it the location of lesions? The modern perspective, however, is that we should just accept that depression is a biological, psychological, and social entity. You’ll get better outcomes by addressing that multidimensional nature with your patients.”
Diagnosing Depression
It may be worth occasionally revisiting the DSM-V criteria for Major Depressive Disorder. A “Text Revision” interim versionopens in a new tab or window was released in 2022. A diagnosis of depressionopens in a new tab or window requires at least five of these nine criteria:
- Depressed mood
- Loss of interest or pleasure in almost all activities
- Significant (more than 5% in a month) unintentional weight loss/gain or decrease/increase in appetite
- Sleep disturbance (insomnia or hypersomnia)
- Psychomotor changes (agitation or retardation) severe enough to be observable by others
- Tiredness, fatigue, or low energy, or decreased efficiency with which routine tasks are completed
- A sense of worthlessness or excessive, inappropriate, or delusional guilt (not merely self-reproach or guilt about being sick)
- Impaired ability to think, concentrate, or make decisions — indicated by subjective report or observation by others
- Recurrent thoughts of death (not just fear of dying), suicidal ideation, or suicide attempts.
Symptoms must have been present for at least 2 weeks in a row and persist for most of every day. Additionally, the DSM-V requires that symptoms “cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.”
Regarding treatment for comorbid MS and depression, a 2021 reviewopens in a new tab or window noted that the path forward in treating depression is not always clear. “There is currently no gold-standard, single treatment for depression in MS,” the authors wrote. “Combinatory treatments may be efficacious for treating [major depressive disorder] and managing its consequences in MS.”
Cognitive behavioral therapy (CBT) and antidepressants are the two most commonly used therapies in people who have both MS and depression.
CBT is intended to be a short-term therapeutic course to help patients recognize and redirect negative thought patterns during therapy and in the future. The therapist often helps the patient achieve this goal by assigning written homework to aid in self-reflection.
Patten and colleagues explained in a review opens in a new tab or window that while there are robust data indicating the effectiveness of CBT in MS, there are also challenges specific to MS. “Delivery of cognitive behavioral therapy needs to address visual problems, cognitive deficits, and dysgraphia in its use of homework assignments,” the team wrote, noting that all these issues are common symptoms of MS.
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