Monday, 19 January 2015

ClinicSpeak: psychiatric problems in MS

Are you depressed? Don't ignore it ask for help. #ClinicSpeak #MSResearch #MSBlog

"The following meta-analysis (a study combining the results of individual studies) clearly shows that the elephant in the room is psychiatric co-morbidity in MS. MSers are at increased risk of all the major psychiatric diseases (anxiety, depression, including major depression, alcohol & substance abuse, psychosis). I am surprised the authors' didn't include cognitive impairment, dementia, fatigue and some of the sleep disorders on their list. Depending on how you define psychiatric some would argue the latter are diseases of the mind and therefore need to be included under the psychiatric rubric."

"Are you surprised by the high incidence of these disorders? I suspect not as so many of you can relate to this problem. Psychiatric manifestations are common in MSers because MS is a disease of the brain and the incidence of psychiatric co-morbidity in MS is not dissimilar to that seen in most other neurodegenerative diseases. A lot has been said on this blog about anxiety in MSers and its pernicious effect on quality of life. Targeting anxiety, particularly early in the course of the disease is critical to help MSers come to terms with their disease, engage with the disease and to aid them make a decision about the treatment of their disease. Once you able to control MS disease activity you give MSers some control over their lives and hence the confidence to tackle their anxiety and the future. Imagine, not being able to face the future with confidence?"

"Several weeks ago I was asked in a comment how I treat MS-related depression. I have reposted my response here as it is relevant to this post. Depression in MS is a massive clinical problem. In short there are many reasons why a person with MS may be depressed. In my experience MSers rarely complain of depression, but usually manifest with other, but related, symptoms. You often have to ask them specifically about symptoms of depression. MS-related depression is frequently associated with anxiety and/or stress; if you don't treat or manage the anxiety the depression won't respond to treatment. I have seen several patients who have had a major depression (unipolar or bipolar) and I have to had refer them to a psychiatrist for management of their depression. These patients tend to end up on antidepressants and mood-stabilizers. Depression can also be a manifestation of poor sleep, or sleep deprivation, a side effect of medication, a feature of alcohol or other substance misuse, seasonal affective disorder (SAD), associated medical problems (e.g. hypothyroidism), etc. We shouldn't forget that MSers have a higher risk of suicide than the general public; depression is one of the predictors of suicide. It is important to identify those at risk of suicide so they can be proactively managed. In short, the treatment of depression is complex and depends on the associated co-morbidities, the cause, the severity and whether or not there is a risk of suicide. There is no black-and-white answer about how you treat MS-related depression; rarely some patients need to be sectioned and admitted into a psychiatric unit, some need urgent outpatient or community psychiatric input (suicidal patients), other need to improve their sleep hygiene, some need anxiety or stress provoking triggers addressed, some need medications changed, some need to be referred to an addiction service, some may need light therapy (SAD) or medication, others may be choose exercise or CBT therapy."

"Please note that active inflammation in the brain triggers sickness behaviour; one of the manifestation of sickness behaviour is fatigue and low mood. Hence, if we want to practice holistic medicine, DMTs, and the response to DMTs, should also be included in the holistic approach to managing depression in MS."

Epub: Marrie et al. The incidence and prevalence of psychiatric disorders in multiple sclerosis: A systematic review. Mult Scler. 2015 Jan 12. pii: 1352458514564487.

BACKGROUND: Psychiatric comorbidity is associated with lower quality of life, more fatigue, and reduced adherence to disease-modifying therapy in multiple sclerosis (MS).

OBJECTIVES: The objectives of this review are to estimate the incidence and prevalence of selected comorbid psychiatric disorders in MS and evaluate the quality of included studies.

METHODS: We searched the PubMed, PsychInfo, SCOPUS, and Web of Knowledge databases and reference lists of retrieved articles. Abstracts were screened for relevance by two independent reviewers, followed by full-text review. Data were abstracted by one reviewer, and verified by a second reviewer. Study quality was evaluated using a standardized tool. For population-based studies we assessed heterogeneity quantitatively using the I2 statistic, and conducted meta-analyses.

RESULTS: We included 118 studies in this review. Among population-based studies, the prevalence of anxiety was 21.9% (95% CI: 8.76%-35.0%), while it was 14.8% for alcohol abuse, 5.83% for bipolar disorder, 23.7% (95% CI: 17.4%-30.0%) for depression, 2.5% for substance abuse, and 4.3% (95% CI: 0%-10.3%) for psychosis.

CONCLUSION: This review confirms that psychiatric comorbidity, particularly depression and anxiety, is common in MS. However, the incidence of psychiatric comorbidity remains understudied. Future comparisons across studies would be enhanced by developing a consistent approach to measuring psychiatric comorbidity, and reporting of age-, sex-, and ethnicity-specific estimates.

CoI: multiple


  1. Great post Prof G, thank you.

  2. Thank you very much for this post. It is very important that handling depression be a part of standard MS treatment. Happy thoughts lead to better disease course. My neurologist also suggests exercising to help manage depression.

  3. Depressing post. Is there any function that MS doesn't destroy? Could some research team out there work out what's causing / driving itt and come up with something to stop it? Prof G - please post ONE positive story. Your grim posts are giving me depression. The Marquis de Sade was less cruel than you.

  4. So, a person went from having a normal life to being disabled. Their entire lifestyle and support system is under attack. Their prognosis is grim from either the disease or the drug side effects (which include death). They are reasonably worried about having too little money, enjoyment, employment, or activity and your response is to treat them for depression?

    Doctors can be such idiots it's infuriating. Depression isn't the problem, they are sad for good reason: their life sucks. Putting them on more drugs or threatening to place them in a mental institution is not going to make them happier. Doctors are obsessed with preventing death even when it's the most logical option.

    So if you truly want to solve the co-morbidity problem, solve the root cause, make suicide not the most logical option. Fix the care system so that you can let them know that they will have enough money, activity, and enjoyment in spite of MS that there's no need to be sad to an extreme level. What if you prescribed money or housing instead of drugs? It would almost certainly work better. But you won't do anything to cure the real problem and, worse, you won't even admit that that it is the real problem.

    So drugs and mental institutions, that's your solution. Well, you suck. Fix the system, fix the doctors.

    1. "So, a person went from having a normal life to being disabled. Their entire lifestyle and support system is under attack. Their prognosis is grim from either the disease or the drug side effects (which include death). They are reasonably worried about having too little money, enjoyment, employment, or activity and your response is to treat them for depression"

      I do understand a little where anon is coming from here. A holistic view / response would be to consider the barriers many MSers face (social, economical, environmental etc) and address them. Where do you draw the line between realism and depression? After all much of the research posted (on here and elsewhere) indicates unfavorable outcomes for MSers in all areas of life, employment being one of them. Mood meds and CBT cant really help with that. I think feelings of depression and anxiety are a normal, reactive response to MS and I'd be more worried about my mental health if I didn't have those feelings. Please don't forget what we've lost.

  5. "Imagine, not being able to face the future with confidence?"

    This is how it is for me, possibly many people with MS. My future once full of dreams is now full of fear. Better DMT's potentially give hope but gaining access to them is another matter.

    I've forked out privately for counselling since diagnosis but what can be said to make things seem better really? MS is incurable, its progressive and going to get worse. Nothing is sacred with MS, it attacks the very core of who you are. The only thing no one can say with any certainty is how bad you are going to get and how quickly. No amount of CBT can change the reality of that.

    I remember a nurse once saying to me that its a very exciting time to be diagnosed with MS. Poor choice of words perhaps but I cant say I'm excited or positive about my future.

  6. Prof G,

    There's only one way you can lift my depression - give me your view of what treatments might be available in 3, 5, 7 years. I'm talking treatments to stop the disease, treatments which provide some repair, treatments which really impact on symptoms such as spasticity. I need hope, not more drugs or phycho- babble.. I need some sense that if i hang on that better times might come. This blog is killing my hope - shrivelled brains, depression..... You don't seem to understand what it's like to see your dreams and hopes slowly destroyed.

  7. I like the idea of prescribing practical things. I could see travel vouchers lifting the mood of an otherwise housebound MSer who has lost his DL! Probably more expensive than antidepressants but could be quite effective.

  8. MS is a hellacious beast. How is one supposed to not be anxious and depressed, at least at times, when confronted with "the dark at the end of the tunnel" that is the ultimate reality for so many struck with the disease, particularly those who are dealing with the progressive flavors of MS.

    To my fellow commenters, though, I would say let's not blame this blog for contributing to the depression. The folks who write this blog are doing a tremendous service to the MS community, and are only reporting on the reality of the situation. I personally find it quite heartening that people of such obvious intellect and passion are involved in the fight against this scourge, and do find rays of hope in much of the info posted here (the Charcot project, etc.).

    I will say, though, that much of the MS research infrastructure has been rotted to the core by the corrosive effects of big money. While the current crop of DMDs has improved the quality of life of many MSers, the fact that they have become blockbuster drugs has actually inhibited the search for the root cause of the disease, which is vital to finally curing this monster. Ultimately, suppressing and/or modulating the immune system is a sophisticated form of symptom management. An immune system gone wonky is a symptom of some much greater ill, and that much greater ill has remained hidden for far too long.

  9. Anxiety and depression is fairly common in healthy individuals too, when I think about my family and friends, I have three relatives that have all suffered from a period of depression. My friends I can think of two that get severe anxiety and a friend that got depression.
    A GP once said to me in some cases people who suffer from severe anxiety seem to go on to develop MS. Could it be the connection with anxiety and an the CNS being over active.

  10. There is a really interesting article in the Huffington Post about looking at addiction and considering how our current approach may be inefficient.

    It looks at some older studies done with rats and two water dispensers in their cage. One with regular water and one with cocaine water. The study shows that rats in this experiment would quickly get "addicted" to the cocaine water and eventually die of cocaine use.

    The new study noted that these rats were basically in prison and had nothing to do but drink cocaine water. So they did another experiment where they gave a number of rats a nice social environment with other rats where they had food, and activities, and a happy life. None of the rats died of cocaine use. They self moderated their use of cocaine.

    This has been replicated in humans in Portugal where they took a lot of their money use for "drug enforcement" and shifted it to give drug users a good life with housing and government subsidized jobs. More of the drug users were able to stop using drugs, and they were actually happy, than when they spent the same amount of money to place drug users in jail. At the end, the police chief who was originally against it changed his mind and said it was a good program.

    My suspicion is that this same method could be use to fight suicide in MS. Let people know that they will have food an housing and care no matter what happens to their body or their bank account. Give even the most disabled among us government subsidized jobs, some of which may be very simple, that give us something to accomplish and live for and a way to earn some money without the constant fear of being discriminated against and fired. For the less disabled give employers subsidies to cover sick leave to cover time away from work to deal with exacerbations or even doctors appointments. As soon as people are diagnosed let them know that all this exists for them. I suspect you would see a vast drop in the number of MS suicides without drugs or mental institutions.

    Doctors must learn to be able to deal with the cognitive dissonance that this is the right thing to do to cure MS suicide and lessen MS "depression", but that it's going to take expanding the definition of medicine outside its current boundaries to accomplish it. Doctors and support organizations must learn to treat the effects of MS on their patients lives, not just on their bodies and brains.

    1. Hi, I kind of agree with you to a large extent. Something along these lines would help with much of the external anxieties that come with an MS diagnosis and thereafter for evermore. Though a bit more tricky when depression/anxiety is actually cause be MS itself. Sadly in this world (at least in the West as I experience it) the only thing that seems to 'matters' is money, or rather the lack of it in terms of social care -practice and policy, etc etc. But a genuine more holistic approach in treating MS would be a good place to start.


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