Symptom Management

“Why have I felt so down lately?”

Living with MS can be stressful. Feeling sad or irritable, wanting to be left alone, and difficulty concentrating or sleeping are common reactions to stress. But what if you notice that these experiences occur more often or worsen over time? Might you be suffering from depression?

Because stress, MS, and depression have overlapping symptoms (e.g., sleep difficulties and poor concentration), trying to uncover the source of your feelings can be tough. A useful first step is to document the ways in which you are feeling, thinking, or behaving differently, particularly those changes most noticeable or distressing. The people around you (e.g., spouse, children, friends, and coworkers) can provide additional insight. They may be the first to note changes in you and express concerns like, “You haven’t seemed yourself lately.”

Seeking out a healthcare provider to evaluate your physical and emotional wellness is a crucial next step. Regardless of whether you are experiencing depression, MS relapse, stress, or something else, it is essential to trust your instincts, advocate for yourself, and take action. Without intervention, depression can worsen and may affect MS by interfering with your ability to adhere to MS treatments.

“How does a doctor evaluate me for depression?”

During your visit, your physician may start by listening to your specific concerns, asking questions related to your symptoms, including duration and effect on daily life. The doctor may also do a physical exam or order additional tests, especially if MS relapse is a concern. It is important to be honest and forthcoming when reporting on symptoms. The stigma of mental illness may tempt you to minimize depressive symptoms by denying the presence or severity of symptoms or the need for treatment. Having a caregiver present to provide support and confirm information is frequently a good idea.

If your symptoms are consistent with depression, your provider will collaborate with you on deciding the best interventions for your individual circumstances. Your provider may consider:
 
Intervening in Depression With Therapy

Therapy with a mental health provider (sometimes called psychotherapy, counseling, or “talk therapy”) is one available avenue for learning effective ways to gain relief during a depressive episode. Therapists come from a variety of educational backgrounds such as psychology, psychiatry, social work, counseling, or marriage and family therapy; will have a master or doctoral degree; and are licensed by their state of practice. Therapy can be done in individual, family, and group formats. Although many people initially prefer individual therapy, group therapy can be essential for relieving isolation experienced during depression, receiving support from others experiencing similar circumstances, and learning additional depression management strategies that others are utilizing successfully.

An effective and widely-practiced type of therapy is cognitive-behavioral therapy (CBT). Research has found CBT is beneficial for a variety of MS-related concerns, including depression, anxiety, grief, and pain. The basic premise of CBT is that emotions are influenced by “cognitions” or thoughts. When individuals have negative thoughts, such as “It is my fault that I am depressed,” or “No one can love me because of MS,” they tend to experience greater despair than individuals with fewer of these thoughts. When people learn ways to balance their perspective, they often feel happier, more hopeful, and less depressed, even when their situation remains unchanged.

Similarly, CBT teaches that emotions are also influenced by “behaviors.” Engaging in behaviors that make us feel good (such as exercising, socializing with friends, or enjoying a hobby) decreases negative thinking and increases participation in positive activities, which can alleviate depressive symptoms. Similarly, we feel better when we reduce behaviors that make us feel poorly (such as overeating, being inactive, or taking medications incorrectly). Working as a team with your therapist to challenge and change problematic thinking and to try out new behaviors allows you to feel better and accomplish new goals for yourself.

CBT is a relatively time-limited treatment (often 12 sessions or less), augmented by homework assignments that allow you to practice the skills learned in sessions. Once learned, you can apply these techniques whenever you are facing emotionally challenging situations.

Intervening in Depression With Medication

Your MS physician, primary care doctor, or psychiatrist can prescribe and monitor medication to treat depression. Factors including convenience, visit frequency, and severity of depression may be considerations for determining the most appropriate provider for offering depression care. Sometimes referral to another provider with expertise in addressing your unique needs is needed.

Numerous medications are effective for treating depression; in fact, there are so many, it is impossible to review them all here. In general, medications for depression may be especially helpful for regulating physical aspects of depression, such as sleep, energy, and appetite changes. For severe depression, medications may be essential to increase your ability to engage in additional depression treatments, like therapy.

Some people worry about medication side effects (such as weight gain, sexual dysfunction, and drowsiness) or about adding new medication to already complex MS treatment regimens. These concerns are legitimate and should be discussed explicitly during healthcare visits. Of note, some medications used for depression can actually help manage MS symptoms. For example, some medications are effective at decreasing nerve pain common in MS. And while some depression medications facilitate sleep in those suffering insomnia, others can assist in promoting wakefulness and stamina. Again, honest communication with your provider can help with identifying the best medication(s) for you.

As with MS medications, always take depression medication(s) as prescribed and inform a healthcare provider if problems develop. It typically takes several weeks or longer to determine a medication’s effectiveness; dose adjustments and changes in medication may be needed to provide the most symptom relief.

Patience can be difficult when you want desperately to feel better. Because depression is complex – made up of physical, psychological, and environmental factors (like distressing life events) – treatment (medication, therapy, or a combination of both) can take time to work. Practicing self-management techniques, including good nutrition, physical activity, relaxation, recreation, engagement in social activities, and spiritual involvement, may more quickly and enjoyably maximize effectiveness of these treatments.

A Final Word on Depression Treatment

Although some people improve without treatment, it is usually not the simple passing of time that brings healing, but rather changes in circumstance that come with time’s passing. You can await these changes, realizing that changes may take considerable time in occurring or turn out to be negative. Alternatively, you can overcome depression by being active. Depression treatment can be a humbling, rewarding, and life-altering experience. It can be challenging, even frustrating – most journeys are, if they lead to lasting change. Not everyone receiving treatment fully recovers, but most people who adhere to treatment will get significantly better. If you have good healthcare providers assisting you, maintain treatment even when it is tough, practice the skills you learn at every opportunity, and take medications as prescribed, you may find yourself feeling less depressed and more content with yourself, your relationships, and your life.

Rebecca Floyd, PhD is a postdoctoral health psychology fellow. Floyd serves as the Clinic Coordinator for the MS Center, where she also facilitates a monthly MS support group and supervises psychology residents in the provision of MS clinical services.
  Kimberly Lewis specializes in providing psychological services to individuals with chronic health concerns, including MS. She provides clinical services in the MS Center at GRU.