Is multiple sclerosis patient depressed, stressed, or both?
How to sort through overlapping symptoms and provide appropriate treatment.
Psychosocial interventions
CBT is an effective treatment for depression in MS patients24 and is preferred for most patients with mild depression. CBT focuses on improving coping through behavioral activation and cognitive restructuring.35 CBT can incorporate teaching patients skills for managing MS-related problems such as fatigue, mild cognitive impairment, pain, stress, communication, sexual dysfunction, intimacy, and social difficulties secondary to MS.
Behavioral activation strategies focus on the relationship between activity and mood. They target a common pattern of avoidance and withdrawal from social, occupational, and physical demands that relieves MS patients’ anxiety in the short term but leads to problems associated with inactivity.35 Behavioral activation strategies—including exercise—have a strong evidence base supporting their use alone to manage depression and as a component of CBT.36
Active coping strategies. In early MS, patients often use avoidance and denial to cope with their disease. As symptoms become more intrusive, however, patients usually need to learn active coping strategies. These often begin with symptom management and evolve to include individually meaningful tasks such as reevaluating personal goals, values, and priorities.
Other psychotherapy modalities. In one study, patients randomized to an insight-oriented treatment group improved more than those in a placebo intervention based on discussing current events.37 Although not formally assessed in the literature, psychoeducation can help the patient maintain a sense of control over his or her treatment. Interpersonal therapy can help patients deal with role transitions caused by their illness and subsequent disabilities, although its use in this population has not been studied.
Although the literature does not favor supportive psychotherapy for treating depression in MS patients,24 this modality can help alleviate feelings of grief and loss that can emerge when MS symptoms worsen. Patients often appreciate having an opportunity to articulate their feelings and fears in a professional therapeutic relationship. MS patients often value validation and normalization of their emotional responses, and many therapists choose to integrate supportive strategies with CBT’s more “action oriented” elements.
Exercise is an effective treatment for fatigue in MS38 and also helps combat loss of physical fitness. MS patients who use energy conservation strategies to manage fatigue can participate in suitably paced physical exercise. Aquatic exercise is a popular option because it often does not cause overheating.
CASE CONTINUED: Energy surge
At the second follow-up appointment, Mrs. S notes that her energy level is better early in the day but decreases by late afternoon. An additional dose of modafinil, 50 mg, is added at noon, which increases her overall energy level.
CBT helps Mrs. S to develop reasonable expectations of herself and others and addresses the possibility that she could try part-time work. Including exercise as behavioral activation also lessens her fatigue. Reconnecting with family and friends helps relieve feelings of isolation resulting from her daughter moving away.
Related resources
- National Multiple Sclerosis Society. www.nationalmssociety.org.
- The Goldman Consensus Group. The Goldman Consensus statement on depression in multiple sclerosis. Mult Scler 2005;11:328-37.
- Feinstein A. The clinical neuropsychiatry of multiple sclerosis. Cambridge, UK: Cambridge University Press; 2007.
Drug brand names
- Amantadine • Symmetrel
- Amitriptyline • Elavil
- Carbamazepine • Tegretol
- Citalopram • Celexa
- Desipramine • Norpramin
- Fluoxetine • Prozac
- Fluvoxamine • Luvox
- Interferon beta-1a • Avonex, Rebif
- Interferon beta-1b • Betaseron
- Lithium • Eskalith, Lithobid
- Mirtazapine • Remeron
- Modafinil • Provigil
- Olanzapine • Zyprexa
- Paroxetine • Paxil
- Pemoline • Cylert
- Quetiapine • Seroquel
- Risperidone • Risperdal
- Sertraline • Zoloft
- Valproate • Depacon
- Zopiclone • Imovane, Zimovane
Disclosure
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
