Depression
Recent studies have shown that between 40 to 60% of those with multiple sclerosis (MS) suffer from depression at some point over the course of the illness, and have reported risks for suicide ranging from 3 to 15%. There's some evidence that depression in MS is not only due to the social and psychologic impact of it, but to the location of the actual physical damage. Depression may have biologic effects, such as increasing production of inflammatory cytokines which could exacerbate the disease itself. Neurologists should assess patients for depression during every visit even if there are no obvious signs of it. People at highest risk for suicide are those who live alone, those with a history of an emotional disorder (depression, anxiety, alcohol abuse), a family history of mental illness, and people with high social stress.

While sometimes depression is a reaction to the effects that MS is having on their lives, often it's directly caused by MS itself. Depression can also be a side effect of the interferon disease-modifying therapies (Avonex, Rebif and Betaseron). Regardless of the cause, it's important to seek help for depression and talk to your doctor. About 10% of MS patients also are affected by other mental illnesses such as anxiety and paranoia. Around 5% also suffer from "laughing/weeping syndrome," also called involuntary emotional expression disorder (IEED) or pseudobulbar affect, which causes the person to experience periods of laughing or crying which is unrelated to their mood or an event.

This point needs to be clearly understood - If you feel very sad, depressed, or have no interest in anything, you need to see your doctor at once. You might begin with your neurologist since they should know what you are going through or you can even call your local MS Society Chapter for recommendations for a psychiatrist. It's important to see a psychiatrist that deals with and understands MS, as the depression criteria needs to be interpreted and applied correctly, and the right medications prescribed, or changed if they are contributing to the problem.

Depression and MS have a complicated relationship, since either one can aggravate the other. Depression has many of the same symptoms as MS, making it hard to tell which disorder is to blame. Just like with MS, depression is treatable. We all have enough to deal with and depression can affect the course of our illness, because it can impact how well we want to take care of ourselves.

Distinguishing between sadness and depression is important. Sadness is a normal emotion that everyone experiences at different points in their life. It's felt that 50% of those with MS have symptoms of minor or major depression at some point in their lives. It's estimated that around 15% of people with MS are depressed at any time. If depression is left untreated, there's a chance that it can lead to suicide. Studies have shown that people with MS are between 2 and 8 times as likely to commit suicide as the general population.

Basic Criteria for Clinical Depression:
Sadness
You are depressed, sad, or tearful most of the time. Can be noticed by you, but it's also important if others notice it.
Loss of Interest
You have lost interest or pleasure in most of the things you previously liked to do.
Appetite Change
Your appetite is much less or much greater than usual. You have lost or gained weight (more than 5% in a month) without trying to diet or gain.
Sleep Problems
You have a lot of trouble sleeping or sleep too much every day.
Psychomotor Agitation
You are so agitated and restless or slowed down that other people notice.
Fatigue
You are tired and have no energy.
Feelings of Guilt
You feel worthless or excessively guilty about things you have done or not done.
Cognitive Problems
You have trouble concentrating, organizing your thoughts or making decisions on a daily basis.
Suicidal Thoughts
You feel you would be better off dead or have thoughts about killing yourself.

Additional Criteria for Clinical Depression:
● The symptoms are severe enough to upset your daily routine, seriously impair your work, or interfere with your relationships.
● The depression doesn't have a specific cause like alcohol, drugs, medication side effect or physical illness. (This can be confusing since MS does cause depression, and it can be a side effect of some of the MS disease-modifying therapies or other medications. It's important to see a physician who is used to treating depression in MS, so that the criteria can be appropriately interpreted and applied.)
● Your depression is not just a normal reaction to the death of a loved one.
● You may also feel or experience: uncontrollable crying, irritability, unexplained aches and pains, stomach ache and digestive problems, decreased sex drive or headaches.

MS Depression may result from:

Reactive or Situational Depression

Depression can be a reaction to being diagnosed with MS, as well as the onset of new symptoms which limit the ability to do things or cause discomfort. It can also come from the reactions of friends or spouses. Depression can also be caused by the fear of the unknown, as you ask yourself questions concerning your future ability to be able to live the life that you planned.

Organic Depression

Depression may also be the result of demyelination of key areas of the brain, although studies have failed to pinpoint which areas these are. Scar tissue can form in areas of the brain that control emotions. It can also be unrelated to MS, especially if there is a history of depression in your family. An estimated 15% of the general population will experience a depressive episode in their lifetimes.

Medication Side Effect

Depression may also develop as a side effect to certain drugs used to treat MS, such as Betaseron and Avonex. Also, steroids can cause periods of hyperactivity and euphoria, followed by a "letdown" period.

Distinguishing Depression from Normal Grieving
What distinguishes depression from grief? Biological influences of depression are varied, but can include malnutrition, heredity, hormones, seasons, stress, illness, neurotransmitter malfunction, long-term exposure to dampness and mold and to aerosol exposure. There are also correlations between long-term sleep difficulties and depression. Up to 90% of patients with depression are found to have sleep difficulties.

Depression is often hard to distinguish from grief. Those with MS may experience losses; for example, the ability to work, to walk, or to engage in certain leisure activities. The process of mourning for these losses may resemble depression. However, grief is generally time-limited and resolves on its own. Moreover, a person experiencing grief may at times be able to enjoy some of life's activities. Clinical depression is more persistent and unremitting, with symptoms lasting at least two weeks and sometimes up to several months. It's important to distinguish between mild, everyday "blues" that we all experience from time to time, grief, and clinical depression. Clinical depression, which must be diagnosed by a mental health professional, is a serious condition that produces flare-ups known as major depressive episodes.

Major depression is a serious illness that affects a person's family, work or school life, sleeping and eating habits, and general health. Its impact on functioning and well-being has been equated to that of chronic medical conditions such as MS.

A person suffering a major depressive episode usually exhibits a very low mood pervading all aspects of life and an inability to experience pleasure in previously enjoyable activities. Depressed individuals may be preoccupied with, or ruminate over, thoughts and feelings of worthlessness, inappropriate guilt or regret, helplessness, hopelessness, and self hatred. Other symptoms include poor concentration and memory, withdrawal from social situations and activities, reduced sex drive, and thoughts of death or suicide. Insomnia is common with a typical pattern of waking very early and unable to get back to sleep.

With major depression, appetite often decreases, with resulting weight loss, although increased appetite and weight gain occasionally occur. The person may report multiple physical symptoms such as fatigue, headaches, or digestive problems. Family and friends may notice that the person's behavior is either agitated or lethargic. Older depressed persons may have cognitive symptoms of recent onset, such as forgetfulness, and a more noticeable slowing of movements. In severe cases, depressed people may have symptoms of psychosis such as delusions or, less commonly, hallucinations that are usually of an unpleasant nature.

For suicide prevention in the U.S. call 1-800-273-8255
National Suicide Prevention Lifeline or online at www.suicidepreventionlifeline.org