Adam Kaplin, MD, PhD

Treating and managing depression in people with multiple sclerosis (MS) is as important as treating and managing other symptoms of this central nervous system disease, such as weakness and numbness, says Adam Kaplin, MD, PhD, assistant professor of psychiatry and behavioral sciences in the departments of psychiatry and neurology at Johns Hopkins University School of Medicine in Baltimore. Dr. Kaplin is one of only a few neuropsychiatrists specializing in MS.

According to Kaplin, depression is “extremely common in MS,” occurring in 15 to 30 percent of people who have MS at any one time, and with a lifetime prevalence of 40 to 60 percent.

“The magnitude of this can't be underestimated,” he says. “We also know from studies that many neurologists don’t consider this a priority, and that it is 'the elephant in the room' for them. We can appreciate that short appointment times don't leave much room for asking a patient, 'How's your mood?' In fact, depression is a life-threatening component of MS.”

Calling depression “lethal,” he cites the following facts:

  • Thirty percent of people with MS will think about suicide.
  • Ten percent will attempt suicide.
  • Suicide is the third leading cause of death in people with MS, after cancer and pneumonia.
  • Fifty percent of people with MS have clinical depression.
  • One in four MS patients in the neurology waiting room will have clinical depression.
  • In people who have MS, depression occurs at 5 times the rate of the general population.

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Destructive to Work, Family, and MS Treatment

“Depression is the number one correlate of quality of life for the MS patient and for their family,” says Kaplin. Research shows it affects a person’s ability to maintain stable social support systems and is associated with increased time lost from work, disruption of social support, and decreased adherence to treatment.

“If you have MS and you're not going to treat depression for yourself, do it for your spouse and your children,” he says.

“What's going to make life harder for them than it [already] is? It's you, if you're depressed, maybe irritable, yelling, and not wanting to get out of bed. It also has a tremendous impact on patient mortality and morbidity, and yet it is rarely recognized and even more rarely, treated appropriately,” Kaplin says.

Still, there is light at the end of this tunnel. “With proper treatment, depression is reversible, and people can get back to leading purposeful lives, adjusting to life under altered circumstances,” says Kaplin.

Research shows treating depression may also improve cognitive functioning in many people with MS and may also reduce fatigue.

Antidepressants May Treat More Than Mood

Antidepressant treatments affect the central nervous system and the immune system. Kaplin cites the findings of the so-called FLAME study, published in the journal The Lancet Neurology, as evidence of the neuroprotective aspects of the antidepressant drug Prozac (fluoxetine), a selective serotonin reuptake inhibitor (SSRI). In people whose stroke resulted in one-side body weakness, recovery was significantly better if a person was on Prozac than if he or she wasn't.

A second, smaller study published in the Journal of Neurology, Neurosurgery & Psychiatry found that Prozac tended to reduce the formation of new enhancing lesions in people with MS.

“This medication is neuroprotective,” Kaplin says. “Depression is a neurotoxic event that over time leads to shrinkage of the hippocampus. It's no surprise that SSRIs are good for inflammatory depression. We have results showing that Tysabri (natalizumab) is also quite a good antidepressant for MS, presumably by impeding inflammation in the brain.”

Lifestyle behaviors can also play a role in improving mood.

“Once a patient's medication gets them past the point of being severely depressed, it's great if they can start exercising,” Kaplin says. “Exercise releases growth hormones, and research shows exercise really is a natural and effective treatment for depression.”

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Everyone With MS Should Be Screened for Depression

Dr. Kaplin believes everyone should be screened for depression, and that mood ought to be the “fifth vital sign,” along with heart and respiratory rates, temperature, and blood pressure.

Depression is diagnosed based on signs and symptoms, which may include sleep problems, decreased interest in activities that were once enjoyable, feelings of worthlessness, low energy, low mood, poor concentration, appetite changes, psychomotor retardation — slowed thoughts and reduced movement — and thoughts of death, as well as others.

Symptoms of MS can look like those of depression, which adds a layer of complexity to diagnosing depression in individuals with MS.

Kaplin says he hopes that people with MS don't blame themselves for their depression and that they understand there is a brain-based reason for their mood disorder. These two conditions are also connected in other major ways, he says.

“Not only does MS cause depression due to inflammation in the brain, but when you block inflammation of MS, you block depression,” he says. “Depression is a risk factor for getting MS, and it also may worsen MS and lead to worse outcomes.”

The inflammation causes the brain to cease producing new neurons, most notably in the hippocampus. “After a decade or so, the hippocampus may shrink by 20 percent in volume.”

With so much at stake for people with MS, Kaplin wants them and their clinicians to understand the critical importance of asking about depression, diagnosing it, and treating it promptly.

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