Diagnosing and Treating Depression in Multiple Sclerosis

Seeing a Psychiatrist and Undergoing Therapy for Your Depression in MS

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Depression is nothing to be ashamed of and is not your fault. In people with MS, depression 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, the most specialized mental health professional is a psychiatrist.

The treatment of depression requires careful monitoring and individualized treatment plans so it's ideal if you find a doctor who treats other patients with MS.

Depression in MS is complex. For instance, many of the symptoms of MS such as fatigue, cognitive problems, physical slowness and problems sleeping mimic the symptoms of depression and vice versa.

In addition, some of the disease-modifying therapies for MS, such as the interferon therapies 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 for a referral. You can also contact the main office or your local chapter of the National Multiple Sclerosis Society for the names of doctors experienced with both depression and MS in your area.

How is Depression Diagnosed?

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. That being said, doctor do commonly check your blood work to rule out health conditions that can mimic depression like thyroid disease or anemia.

 

In addition, you will probably be asked about a list of your specific symptoms such as sadness, tiredness, pessimism, problems sleeping, and feelings of guilt or hopelessness. Your doctor will also inquire about how long you have had each symptom, and how severe your symptoms are. The doctor will also ask you about any history of depression and treatment, any drug and alcohol use, current medications, relatives with a 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's important that you answer honestly.

Medications for Depression

There are several classes of medications for depression. Those most commonly used today are:

  • Selective Serotonin Reuptake Inhibiters (SSRIs): SSRIs are the most widely prescribed antidepressants and include Prozac (fluoxetine), Zoloft (sertraline), Celexa (citalopram), Paxil (paroxetine), and Lexapro (escitalopram).
  • Selective Serotonin and Norepinephrine Reuptake Inhibitors (SSNRIs): Effexor (venlafaxine) and Cymbalta (duloxetine hydrochloride) are two SSNRIs sometimes used to treat depression. Cymbalta is also used to treat neuropathic pain so may be a good option for people with pain and depression.
  • Tricyclic Antidepressants: The tricyclic antidepressants, such as Elavil® (amitriptyline) and Pamelor® (nortriptyline), tend to have side effects like drowsiness, constipation or difficulty passing urine. This can make your MS symptoms feel worse.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.

How your doctor chooses your antidepressant is based on a number of factors like side effects of the medication, how often it's taken, your most notable or bothersome depressive symptoms, cost, and your preference as a patient.

What You Should About Your Depression Treatment

It's 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 determine if dosage adjustments need to be made. Remember, it's 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.

Also, 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 Group. The Goldman Consensus statement on depression in multiple sclerosis. Mult Scler. 2005 Jun;11(3):328-37.

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