Wednesday, 4 April 2018

Brain damage and the Black Dog

MSers are often depressed. Depression leads to poor quality of life, the breakdown in relationships, a sense of hopelessness, social isolation, unemployment and suicide. It is important that MSers are regularly screened for depression and treated.



Are you interested in knowing more about depression in MS?



The study below suggests that depression in MS may occur as a result of damage to the temporal and frontal regions of the brain, which may lead to a disconnection between the frontal and limbic systems of the brain. If this is the case then depression, at least in some MSers, is due to end-organ or brain damage. Is this not another reason to treat MS early and effectively to prevent this damage from occurring in the first place? 

If you have MS and are depressed you should seek help from your family doctor, MS nurse or neurologist as soon as possible. If you are not sure that you are depressed you can use the Beck's Depression Inventory and score and self-diagnose yourself. 

Please note that depression rarely occurs in isolation and is usually accompanied by fatigue, anxiety and cognitive problems (difficulty concentrating, poor memory and inability to think clearly and efficiently). Depression may be associated with 'sickness behaviour', which in MS may be due to ongoing inflammation in the brain. Therefore if you are depressed your MS should be assessed to see if it is active. The latter would involve being seen by a neurologist and examined for new clinical signs and almost invariably include a new MRI scan to see if you have new or enlarging MS lesions. In some centres, such as Barts-MS, you may be offered a lumbar puncture to have your neurofilament levels measured in your spinal fluid. If the neurofilament levels are raised it indicates that your MS is active. If you are not on a disease-modifying therapy (DMT) and your MS is active you should be offered a DMT. The latter is not universal and will be determined by local and regional treatment guidelines and whether or not your neurologist accepts depression as a clinical marker of possible disease activity. If you are on a DMT already and have evidence of disease activity this may prompt a switch in your treatment.

In conclusion, depression like other hidden symptoms of MS should not be ignored. Depression, or the black-dog, is a red-flag and indicates that something is going on inside your brain.

van Geest et al. Fronto-limbic disconnection in patients with multiple sclerosis and depression. Mult Scler. 2018 Mar 1:1352458518767051.

BACKGROUND: The biological mechanism of depression in multiple sclerosis (MS) is not well understood. Based on work in major depressive disorder, fronto-limbic disconnection might be important.

OBJECTIVE: To investigate structural and functional fronto-limbic changes in depressed MS (DMS) and non-depressed MS (nDMS) patients.

METHODS: In this retrospective study, 22 moderate-to-severe DMS patients (disease duration 8.2 ± 7.7 years), 21 nDMS patients (disease duration 15.3 ± 8.3 years), and 12 healthy controls underwent neuropsychological testing and magnetic resonance imaging (MRI; 1.5 T). Brain volumes (white matter (WM), gray matter, amygdala, hippocampus, thalamus), lesion load, fractional anisotropy (FA) of fronto-limbic tracts, and resting-state functional connectivity (FC) between limbic and frontal areas were measured and compared between groups. Regression analysis was performed to relate MRI measures to the severity of depression.

RESULTS: Compared to nDMS patients, DMS patients (shorter disease duration) had lower WM volume ( p < 0.01), decreased FA of the uncinate fasciculus ( p < 0.05), and lower FC between the amygdala and frontal regions ( p < 0.05). Disease duration, FA of the uncinate fasciculus, and FC of the amygdala could explain 48% of variance in the severity of depression. No differences in cognition were found.

CONCLUSION: DMS patients showed more pronounced (MS) damage, that is, structural and functional changes in temporo-frontal regions, compared to nDMS patients, suggestive of fronto-limbic disconnection.

ProfG    

20 comments:

  1. Prof G,

    "Is this not another reason to treat MS early and effectively to prevent this damage from occurring in the first place?"

    Isn't this just a statement of the bl**dy obvious. I can't understand why you keep repeating it after every paper which shows how dreadful and damaging MS is. Who disagrees with the statement / approach? When you have a new patient are you robust enough in convincing them that this approach gives them the best chance etc.

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    Replies
    1. There are still a lot of people who think that because some people may turn out to have benign MS we need a wait and see approach initially. The latter is probably the norm in relation to CISers.

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    2. Sadly from my own experience I know that your repeated emphasis on early and effective treatment is still totally valid. As I've said before on the Blog, there was no rush to provide treatment and I was told by the neuro I initially saw that I'd be fine on the escalation approach, even though I presented as eligible for induction therapy. Do push for early and effective treatment if you ain't getting it!
      I'd like to add that with depression being so predominant with MS the potential benefit to working with it everyday - being proactive - resilience strategies, Mindfulness, CBT techniques etc. I find that if I leave off Mindfulness meditation for more than four days my mental processing is more stressy/negative.
      I'm really having to fight depression at the moment, because post second round of Alemtuzumab I'm now three weeks into living with Shingles and Boy! is it nasty!! Consequently, I know for sure right now the benefit of being proactive - yes I was crying when I did a Mindfulness on managing pain this morning, but it did help. Guess, I'd like to think of other PwMS out there being in a little bit of a better place looking after their minds as well as their bodies - as best they can!

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    3. Yes, too many people with MS dx's start on subpar drugs too like the CRAB drugs.

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  2. I came to the blog to type 'depression' into the search bar, timely post! Funny how things happen like that sometimes. Do you have anything to say about liver problems and ms?

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    Replies
    1. Re: "Do you have anything to say about liver problems and ms?"

      Not really. The liver should be normal in pwMS unless they are drinking too much, eating too much sugar/carbohydrates, in particular fructose, or the meds they are on are affecting liver function.

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    2. Some pwMS may have comorbid autoimmune hepatitis; this however is rare.

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  3. What is the problem with suicide in ms? We all know that advanced ms is worse than death, and most of msers will progress to that point. And there is no data to show this could be impacted somehow by any treatment... sooo isn’t suicide is favorable outcome in the course of ms?

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    Replies
    1. 'and most of msers will progress to that point.'

      Source? I find it hard to believe most pwMS progress to a state worse than death, esp with current dmts

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    2. What a reckless comment. Can you prove that 'most' of the untreated MSers with advanced disease have a quality of life worse than death? And can you then prove it for those on DMTs too?

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    3. This is from a paper in 2007 we are in a different place treatment wise.

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  4. I am not a depressed person I have a depressing disease. Cure the disease, no depression. Of course I am suicidal I am loosing my ability to walk.

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  5. I have a point of view, as you GG know, and would like to express it but strongly believe that comments here should be accompanied by numbers (Age 67, EDSS 8.5, Diagnosis age 43, 9HPT-N/A)

    This is a, round about, way of asking for a non-pen&paper version of the tool above.

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  6. "Depression leads to poor quality of life, the breakdown in relationships, a sense of hopelessness, social isolation, unemployment and suicide."

    Actually, I think you've got it the wrong way round. Replace "depression" with "MS" - it's living with MS and its attendant issues that's causing the depression, not a brain lesion.

    Treating early is fine and dandy for the newly diagnosed with RRMS. For those of us recently diagnosed (a mere 4 years ago!) with PPMS, there is still nothing available in the UK.

    I see a lot of the comments on this blog talk about how none of us are going to get that bad with effective DMTs. Well, for PPMS, there are NO effective DMTs in the UK.

    And that's 10% of those diagnosed - which is QUITE A LOT!

    ReplyDelete
    Replies
    1. Thank you JoH - you have expressed my feelings exactly! As a 62 year old, with less than 4 years since diagnosis of PPMS, my chance of ever receiving any DMT is very slim and therefore my future looks pretty grim.

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  7. I realise the following might not work for all cases in MS but exercise can be as effective as antidepressants for mild to moderate depression (according to research and the World Health O's video on Youtube named... I had a black dog and his name was depression).

    This makes me realise even more the 'Think Hand' campaign is so important. That I exercise my arms and hands often.

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    Replies
    1. I strongly recommend learning to play the piano to maintain finger dexterity, help concentration and relieve depression. Thankfully it doesn't have to cost a fortune either as self-teaching books are often available from local libraries.

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    2. All I have to say is - Jacqueline du Pre. She was a brilliant concert cello player, and had manual dexterity in abundance. She lost sensation in her fingers due to her MS and had to retire at the grand old age of 28.

      I'm failing to see how learning to play the piano leads to anything other than being able to play the piano.

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  8. It is hard to exercise when you can barely drag yourself out of bed.

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    Replies
    1. I know what you mean. I wonder if in-bed rehabilitation exercises for people with chronic illnesses would help me when I find it hard to get out of bed.
      https://www.youtube.com/watch?v=5oAa7BqI8_c
      In Bed exercises to aid with walking.
      Help balance and stop bed sores.

      Also hand exercise balls.

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