Depression and MS.

A teenager describes the mood-of-the-moment: "I'm so depressed because my friend hasn't called." An adult says, "You'd be depressed, too, if the boss screamed at you for being late and you lost your credit cards all in the same morning."

The words depressed and depression are used so casually in everyday conversation that their meaning has become murky. True depression is a disorder that will affect from 5 to 20 percent of Americans during their lifetime. Depression is not a fleeting emotion. It is a persistent disturbance of mood with complex roots in an individual's physiology and psychology, and it has marked symptoms.

"There's a strange feeling in this country that depression is a character flaw. It is not. There is treatment for depression, and it is curable," said Dr. Randolph B. Schiffer, at the University of Rochester, a neurologist and psychiatrist who has done research on the psychological aspects of MS.

People with MS and other chronic illnesses experience depression more than the general population, although research is inconclusive about an exact rate and about why this is so. When "depression" and "MS" are mentioned in the same breath, some people say, "Of course you'd be depressed if you've been diagnosed with MS," or "How would you feel if your mobility just suffered a major setback?" Such reactions assume that depression is a direct psychological response to a diagnosis or an exacerbation of MS. That may be one explanation, but researchers are looking at possible physiological causes of depression in people with MS.

Cause of effect?

Dr. David Michelson, a staff psychiatrist in the neuroendocrinology branch of the National Institute of Mental Health, is studying the interaction between the body's hormone system, immune system, and central nervous system in people who have both depression and MS. "There is some evidence to suggest that the physiology of MS may predispose people to depression," he said. "At the same time, these people carry the burden of MS -- the changes in daily life, the loss of function. We don't know the answer4 definitively yet. But wether one becomes depressed in reaction to illness, or the depression is a part of the biology of MS, the fact to remember is there are effective interventions."

Overlapping symptoms

The first step is to acknowledge the symptoms and seek help, specialists agree. But recognizing depression in someone with MS is not always easy because some symptoms are common to both conditions.

"It can be hard to sort out signs and symptoms like fatigue and loss of energy, which are signs of depression and also signs of MS," Dr. Schiffer said. "Sometimes there is a slowness to recognize depression by patients, families, and doctors because it may appear so gradually. One thing I'm sure of is that depression symptoms tend to be at their worst when MS symptoms are exacerbated."

To find help, he advises asking your neurologist or general medical doctor, "the one with whom you're best connected." Dr. Andrew H. Miller, a psychiatrist at Mt. Sinai School of Medicine in New York City, agreed that people with the depression shouldn't wait for it to go away. "The quality-of-life issues are serious. Treatment can optimize your daily functioning."

Drug therapy

"If you're severely depressed, with major impairment in function at home or work, it is best to try antidepressant medication," Dr. Miller said. For those with mild to moderate symptoms, there is "a choice among psychoterapies and the possibility of medication."

Many types of antidepressants are available, but none are magic bullets. Most work gradually. The patient's mood may show some improvement after several days, but the drug's full effect may not appear for several weeks. Generally, if there is no improvement after six weeks, the doctor will prescribe a different type.

"It's very important to target selected symptoms and to follow them to see if the medication is helping," Dr. Mililer said. He pointed out that a person is likely to respond to the same antidepressant drug that has been used effectively to treat a family member. Biochemistry runs in families.

Antidepressant medications can have some side effects. Dry mouth, urinary hesitancy, constipation, blurred vision, fatigue, drowsiness, dizziness, light-headedness, and weight gain or loss are among them. The newer agents cause far fewer of these complications. All side effects should be discussed with your doctor. Often, the type or the dosage can be changed to provide the best effect with the fewest problems.

Talking it through

Very few physicians believe that medication alone cures depression. "Most combine drug therapy with some form of counseling," said Dr. Sarah L. Minden, a psychiatrist who treats patients with MS at Brigham and Women's Hospital and Harvard Medical School.

Psychiatrists, who are MD's, can prescribe medication as well as provide counseling. Therapy can be obtained from social workers, psychologists, psychiatric nurses, or other qualified non-physicians, who will seek evaluations by a psychiatrist regarding the slection and monitoring of medication if it is indicated. Therapy can be supplemented by participating in an MS support group at your NMSS chapter.

"Talk therapy" takes several forms. It may be time-limited and address a current crisis; it may be supportive and focus on finding ways to cope; or it may involve in-depth exploration with the goal of greater self-awareness. The form depends on the individual's needs, and these many change over time or with the stage of illness.

Disability and depression

"Some patients who are profoundly disabled are not depressed--while others are very depressed but not physically disabled," Dr. Minden said. Reserch lhas shown no correlation between depression and an individual's degree of disability.

"What makes a person depressed seems to relate to a host of intersecting factors," she explained. "Disability may contribute but it's but an either/or issue. The factors include genetics, individuals coping styles, past and present experiences, what sorts of social supports a person has. But while we don't yet know how depression originates, we do know how to treat it."

A good relationship

"No matter what from talk therapy takes, a good 'fit' between you and your therapist is essential. You should feel that you can bring up any topic," advised Dr. Michelson.

"Treatment is very relationship-sensitive," Dr. Schiffer explained. "What's important is that you see somebody who believes in what he or she is doing, someone with whom you can have a good relationship." This may mean a period of shopping around -- obviously, not every qualified therapist is the right one for you. "Don't give up on the concept of treatment," Dr. Schiffer said. "When that relationship is developed, it can help you understand your emotions and gain more control over your life."