Depression in MS

1. Depression in MS

2. What is depression ? • ‘Depression’ – term loosely used to describe a wide spectrum of low mood, ranging from temporarily feeling ‘down’ or ‘blue’ to severe, clinical depression lasting weeks or months • Depression is 2-3 times more common in those with chronic physical health problem (NICE 2009) NICE 2009 Depression in adults with a chronic physical health problem, London

3. Defining clinical or major depression • For a diagnosis of clinical depression or ‘major depressive disorder’ (MDD), these criteria must be met: • 5 (or more) of the following symptoms, present on most days during the same 2-week period (must include one of the first two symptoms listed) • Depressed mood • Loss of interest or pleasure • Significant weight loss (or gain) • Insomnia (or hypersomnia) • Psychomotor retardation (or agitation) • Fatigue or loss of energy • Feelings of worthlessness or guilt • Loss of concentration, indecisiveness • Suicidal ideation, recurrent thoughts of death (not fear of dying) American Psychiatric Assoc., DSM-IV,1994

4. Severities of depression • Mild depression – few, if any, symptoms in excess of the 5 required to make the diagnosis, and symptoms result in only minor functional impairment • Moderate depression – symptoms or functional impairment are between mild and severe • Severe depression – most symptoms, and the symptoms markedly interfere with functioning. Can occur with or without psychotic symptoms Taken from DSM-IV (see www.nice.org.uk/CG91niceguideline)

5. Is it depression ? • Distinguish from grief – a time-limited reaction to loss e.g. loss of physical ability, capacity to work, social life, family status. (NB An exaggerated or extended grief reaction may lead to clinical depression) • Consider if low mood could be as a result of fatigue • How much is cognition issues and how much is depression? • Some symptoms of depression and MS overlap e.g. sleep problems, fatigue and other somatic symptoms, (such as aches and pains) are common to both disorders

6. Depression in MS • Lifetime prevalence of major depression in MS is around 50% : half will have depressive symptoms severe enough for medical intervention at some point in their illness • Compare to prevalence of depression in : • general population = 3-9% • primary care setting = 10-15% • other chronic illness e.g. HIV = 21% • Similar rate to that seen in Parkinson’s disease, which is regarded as most common CNS disease with co-morbid depression Feinstein A. Canadian J Psychiatry,2004;49:157 Chwastiak L et al. American J Psychiatry,2002;159:1862

7. Causes of depression in MS • Depression in MS may be due to: • emotional and physical difficulties and stresses of having a chronic, degenerative disease • Lack of hope, feeling hopeless • underlying pathological changes in the CNS, and effects on neural structures and functions that may be involved in mood balance • Ineffective control of pain • disturbance of thyroid or other endocrine function • Side effects of drug treatment e.g. interferon, steroids Mc Donald WI & Ron MA. Philosophical Transactions Royal Soc Lond B,1999;354:1615

8. Suicide risk in MS • People with MS have: • higher rate of suicide (7-fold increase) : suicide accounted for 15% of all deaths in an MS clinic population • thoughts of self-harm - suicidal intent occurs in around 30% • Presence of depression, alcohol abuse and social isolation have an 85% predictive accuracy for suicidal intent in MS patients Sadovnik A et al. Neurology,1991;41:1193 Feinstein A. Neurology,2002;59:674

9. Those with MS who are at particularly high risk of suicide are • Males • Those who have severe disability • Those who feel hopeless • People who are unable to ask for help • Those who live alone or who have little family support Those who's depression is not treated or responding to treatment • People who also have financial issues • Also have alcohol or substance abuse

10. What can be done to assess for MS-related depression?

11. Screen for depression “…screening for depression should be integral to the regular evaluation of MS patients…” Chwastiak L et al. American J Psychiatry,2002;159:1862

12. Screening for depression in MS • Most cases of depression can be detected by asking patients two simple questions: • “During the past month… • …have you often been bothered by feeling down, depressed, or hopeless? • …have you often been bothered by little interest or pleasure in doing things?” • If answer is yes to either question; either refer to appropriate professional or carry out a mental health assessment (see Depression in Adults with a Chronic Physical Health Problem NICE 2009)

13. Other assessment tools that can be used • Commonly-used scales include: • Hamilton Rating Scale (HAMD) • Montgomery Åsberg Depression Rating Scale (MADRS) • Becks Depression Inventory • Clinical Global Inventory • Hospital Anxiety and Depression Rating Scale (HAD-S)

14. Management of depression

15. Management of depression in MS • Whilst mild depression can respond to a psychotherapeutic approach, optimum therapy in most other cases would be a combination of : • ‘talking’ treatment aimed at managing negative thoughts and improving coping skills, particularly cognitive behavioural therapy, which can be effectively administered by telephone to MS patients who are immobile and cannot attend clinics often • antidepressant drugs Mohr DC et al. J Consulting & Clinical Psychology,2000;68:356

16. Management options • Lifestyle advice e.g. sleep hygiene, exercise, diet, smoking, alcohol intake • Active monitoring with regular appointments • Education/information about depression • Peer support programme or cognitive behavioural therapy

17. Drug treatment principles Consider drug treatments for those with; • past history of moderate or severe depression • Mild depression that impacts on MS symptoms • Sub threshold depressive symptoms present for >2yrs • Sub threshold depressive symptoms/mild depression that persist despite other interventions • St John’s Wort is not recommended

18. Management of depression in MS • Few studies of antidepressants specifically in people with MS • Most commonly-used antidepressants are SSRIs e.g. fluoxetine, paroxetine, escitalopram. Selectively target neurotransmitter, serotonin (5-HT). Sertraline & fluvoxamine have been studied in MS patients. SSRIs are generally well-tolerated, but can increase spasticity in MS • Newer, dual-acting antidepressants e.g SNRIs – venlafaxine, duloxetine, and NaSSA – mirtazapine, target noradrenaline as well. Dual action may confer added benefit on physical symptoms of depression e.g. aches & pains, fatigue Benedetti F et al. J Neuropsychiatry & Clinical Neuroscience,2004;16:364 Scott TE et al. Neurological Research,1995;17:421

19. Management of depression in MS • Monoamine oxidase inhibitors MAOIs e.g. moclobemide. Not widely used, but studied with success in MS • Use of older tricylic antidepressants TCAs e.g. amitriptyline, imipramine has declined because of poorer tolerability (but are successfully used in MS, in lower doses, for their effects on neuropathic pain) Barak Y. J Neuropsychiatry & Clinical Neuroscience,1999;11:271

20. Summary • Depression represents considerable source of morbidity and mortality in MS • Where clinical depression or major depressive disorder has been diagnosed, prompt & effective treatment is mandatory – patients can rapidly deteriorate, with increased risk of suicide • In the majority of patients it can be successfully treated Feinstein, A (1999) The clinical neuropsychiatry of multiple sclerosis. Cambridge University Press