When you have a condition like multiple sclerosis, it’s vital to pay close attention to the physical symptoms and limitations of the condition. Things like difficulty walking, changes in vision, and increasing fatigue all have a significant impact on daily life and can provide signals of disease progress. Because patients and doctors alike can be so focused on the physical symptoms, it’s easy to forget about the mental and emotional implications of multiple sclerosis.
Mood changes, like depression and anxiety, are just as important as physical changes. Depression has been found to be more common in patients with MS compared to the general population. As a result, it can make other symptoms feel worse, impact relationships, and increase the risk of suicide.
What is Depression?
When dealing with symptoms of multiple sclerosis, it’s normal to feel extremely sad from time to time. You may feel especially down or even hopeless after experiencing an exacerbation or relapse. While it is normal to have these moments, there is a difference between feeling extremely sad and being depressed.
Depression is much more than being sad. It’s a serious mental illness marked by commons symptoms like:
- Depressed mood
- Loss of interested in activities
- Changes in appetite and weight
- Changes in sleep
- Feeling fatigued
- Thoughts of suicide
For sadness to cross over to clinical depression, patients must present with at least five symptoms that have persisted for at least two weeks. The longer someone goes without treatment for depression, the more severe it can get.
In patients with MS, it’s important to be aware of less common symptoms of depression like physical pain, headaches, and vision changes. Oftentimes, people experience these symptoms because of their MS so it’s natural to write off these symptoms as a part of the disease. However, they can also be a sign of depression. Research shows that about 25% of adults with multiple sclerosis also have depression.
How is Multiple Sclerosis Linked to Depression?
Depression impacts the way you feel, think, and manage daily activities. This means, that for people with MS, it can impact treatment adherence and may make the disease worse. One study found that 28% of MS patients with depression had a more difficult time accepting their disease and found it more challenging to adhere to treatment.
Identifying the connection between the two has been challenging since the etiology of the conditions varies from person to person. However, experts believe that people with MS are at a higher risk of depression because of changes to the brain and immune system.
Changes in Brain Structure
Imaging data has long established a between depression and structural brain changes. In one study, researchers found that people with major depressive disorder had abnormal patterns of excitement and inhibition at the dorsal lateral prefrontal cortex of the brain, which. This is the part of the brain that regulates the cognitive function and emotional expression. The MRI results of 66 adults with MDD compared to 66 matched health controls show that those with MDD had either abnormally low functionality in the amygdala or abnormally high activity in the thalamus, both of which play a primary role in emotional regulation.
Another researcher compared MRI scans in 21 MS patients with major depression to 19 carefully matched non-depressed MS patients. They used the DSM-IV, the gold standard for diagnosing mental disorders as set forth by the American Psychiatric Association, as the criteria for major depressive disorder. The study found that depressed MS patients had more hyperintense lesions in the left inferior medial frontal regions of the brain and greater atrophy in the left anterior temporal regions. Both of these areas also play a role in cognitive function.
Evidence shows that structural changes to the brain, including brain legions like those found in MS patients, can be a contributing factor in depression for MS patients. Other researchers looked to understand how the severity of depression was correlated to brain legions. They found that MS patients with moderately severe depression had greater legion involvement in areas of the brain that are connected to the amygdala.
While more research on a larger scale is needed to confirm preliminary findings, the evidence suggests that using MRIs in MS patients can help better predict depression in MS patients, evaluate treatment impact, and dictate management of the two conditions.
Changes in the Immune System
In addition to changes in the brain, changes to the immune system have been found in both depression and MS. The immune system is an intricate network of cells, tissues, and organs that help the body fight infections and diseases. When the body is under attack from an invader (infection or disease), different types of white blood cells are released to protect the body against the invader. While this defense process is natural and vital to protecting the body, if white blood cells are released when an invader isn’t present or too many at one time, it can increase inflammation and cause other illnesses.
Studies have shown that patients with major depressive disorder have increased levels of proinflammatory cytokine activity and inflammation throughout the body. Similarly, inflammation of the central nervous system (CNS) is a hallmark of multiple sclerosis.
Other studies found that patients with depression have lower T-cells compared to patients without depression. T-cells, also called T lymphocytes, are a type of white blood cell in the immune system that focuses on attacking specific antigens. They are responsible for maintaining immune homeostasis, but can also cause inflammatory or autoimmune diseases, like multiple sclerosis.
In patients with multiple sclerosis, T-cells accidentally attack the healthy myelin antigens. Myelin is the protective sheath around nerves in the CNS. It allows electric signals to transmit along the nerve cells. But, when T-cells attack and damage the myelin, it causes a delay in cell signaling. If damage is severe, it can lead to a complete disruption in communication.
One study investigated the effect of depression treatment on the immune system in MS patients. The small study included 14 relapse remitting multiple sclerosis patients with major depression as classified by the DSM-IV. They measured the production of interferon-gamma (IFN- γ), the main inflammatory cytokine produced by activated T-cells, and treated patients with either sertraline, group therapy, or individual cognitive-behavioral therapy. They found that by the end of the 16 weeks, levels of IFN- γ significantly decreased as did depression scores.
Is Depression a Side Effect of Multiple Sclerosis?
Many symptoms of depression and multiple sclerosis overlap, making it difficult to determine what is causing what. However, depression has been understood as a common feature of MS. Depression can even occur before neurological symptoms in some people. Some early, non-neurological symptoms between depression and multiple sclerosis are:
- Difficulty concentrating
- Chronic pain
- Sudden mood changes
In many cases, depression can still develop after an MS diagnosis. This may be because of the emotional burden of MS, structural changes to the brain, genetic factors, or medications used to treat the condition.
Depression is a known side effect of some medications used to treat and manage MS. Some of these include:
- Disease-modifying therapies (DMTs)
When to Seek Help for MS and Depression?
Whether you were diagnosed with depression prior to MS, or you start to notice the signs of depression as you move along your MS journey, it’s important to tell someone you trust. Living with either condition is isolating. When you combine the two together, it can be even more lonely.
The good news is that depression in MS is highly treatable.
Treatment for depression is most effective when started immediately after a diagnosis, which is why it’s important to seek help right away. It’s individualized based on the severity of your symptoms, how long you have had them, your physical and mental health history, and the state of your MS.
Many courses of treatment will include a combination of therapy and medication. There are many different kinds of therapies and medications to help manage and reduce depression, so it’s important to be open with your treatment providers about what you feel is helping you the most. Some experts also recommend regular exercise, an improved diet, and support groups to help with your recovery.
If you have depression and MS and are struggling to find a community, know you are not alone. There are thousands of members at PatientsLikeMe who understand what it’s like to live with one or both of these conditions. Join the community today to connect with others who can help support you through your MS and depression journey.