1. health and fitness
2. disorders
3. mental disorder
4. depression

Depression
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Depression
Date of issue: March 2015
This factsheet will be reviewed within three years
Contents
Introduction
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1. What is depression
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2. What are the symptoms of depression?
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3 . How does depression impact on daily life?
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4. What causes depression?
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5. What causes depression in MS?
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6. How is depression diagnosed?
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7. How is depression treated?
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7.1 Self-management
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7.2 Talking therapies
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7.2.1 Cognitive behavioural therapy (CBT)
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7.2.2 Counselling
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7.3 Drug treatment
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7.4 St John’s wort
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8. Severe complicated depression
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9. Recurrent depression
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10. How can friends and family help?
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11. Sources of support
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12. Useful organisations
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13. References
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1
Introduction
Depression is common in the general population but research suggests that
people living with long-term conditions, including MS, are at greater risk. It is
estimated that about half of all people with MS will experience an episode of
depression at some time regardless of the type of MS they have1.
Clinical depression can be difficult to identify and people with MS themselves
may not always recognise it. It can be hard to talk about feelings and the
stigma associated with mental health problems may also be a barrier to
discussion. Family and friends can play a key role in helping to identify or
recognise depression. Health professionals rely on descriptions of the
symptoms to make a diagnosis and identify the best approach to treatment.
Some facts about depression:

depression is common in MS

it is not unusual or a consequence of personal actions

help is available from your MS specialist nurse, MS specialist clinic or GP

depression is treatable, and can be managed successfully.
There are effective approaches to treating depression and the person
experiencing this should be fully involved in decision making at every point.
1. What is depression?
Everyone feels sad at times. Depression is different in that it is constant and
interferes with normal everyday activities. People with depression often lose
pleasure in things that were once enjoyable and may give up usual activities
such as hobbies and lose interest in seeing friends and family. Some people
even feel that life is no longer worth living and may have thoughts of ending it
all. Depression may be mild, moderate or severe and a person may
experience different levels of depression at different times2.
Mild depression is when a person has a small number of symptoms that
have a limited effect on their daily life.
Moderate depression is when a person has more symptoms that can make
their daily life much more difficult than usual.
Severe depression is when a person has many symptoms that can make
their daily life extremely difficult.
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2. What are the symptoms of depression?
The symptoms of depression are many and varied and recognising
depression when you have MS can be difficult. Many people may already
experience symptoms that are usually associated with depression such as
fatigue, constipation, poor concentration and sleep problems3.
The important thing to focus on are changes, and changes in outlook
including:

low mood all the time and in every situation for at least two weeks

negative thoughts about yourself and the future which might not be related
to the level of disability that you experience

not being able to take pleasure in routine things such as eating, watching
TV or talking to friends that you have previously enjoyed

thoughts of suicide.
It has also been suggested that in MS, depression causes increased
problems with thinking; and feeling irritable, frustrated and discouraged can
be part of depression. Worsening of MS symptoms that someone already has,
in the absence of infection or relapse, and deepening of fatigue could also be
flags for concern.
3. How does depression impact on daily life?
Describing the symptoms of depression cannot capture its enormous impact
on daily life. It affects many aspects: personal, social, and professional.
Without the right help depression can spiral out of control becoming a serious
threat. It is important to speak to a GP, other health professional or a trusted
person at the earliest opportunity.
Withdrawal from intimate or social relationships can be misunderstood by
others as rejection or disinterest. Friends, relatives and carers of people with
depression are not always able to recognise that this is due to the condition.
This might lead to a lack of empathy and sensitivity towards the person with
depression. This, in turn, can feed into the depression and social withdrawal.
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Depression can interfere with the ability to concentrate, which may affect work
performance. Without the understanding and insight of work colleagues, this
reduced performance may be perceived as laziness or incompetence.
Depression is often accompanied by feelings of despair, uselessness and lack
of self-worth which can result in self-neglect. People stop caring for
themselves in the way they usually would, and this can mean people stop
taking prescribed medication and following a healthy lifestyle. This can result
in deterioration of health and complications or a worsening, of MS symptoms.
Because of the impact that depression can have on an individual, and the
management of their MS, it is important to seek help.
4. What causes depression?
The causes of depression are not fully understood, but it is thought that an
imbalance in brain chemistry causes a drop off in mood. Anyone can develop
depression at any time in their lives without any apparent cause or reason. It
is not an inability to cope with life, nor is it a weakness or failure of any sort.
Some people are more at risk of developing depression. For example: people
living with a long-term condition; people who experience a stressful life event
such as a relationship break-down or bereavement; people with a family
history of depression; women who have recently given birth; people who are
socially isolated; and people with drug or alcohol addictions.
5. What causes depression in MS?
For people with MS, in addition to the factors for the general population, the
challenges of living with an unpredictable and potentially debilitating long-term
condition can also be a trigger factor for depression. Other contributing factors
might include symptoms such as chronic pain and overwhelming fatigue, or
the social isolation that disabilities can bring.
Depression can also be due to MS itself, where lesions in certain parts of the
brain directly alter mood and can therefore cause depression4. Drugs
prescribed for MS might, in some instances, contribute to depression. Cases
have been described with corticosteroids used in the treatment of MS relapse,
beta interferons (disease modifying drugs) and muscle relaxants.
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6. How is depression diagnosed?
Depression is often diagnosed by a GP, and a person may recognise it
themselves or their family or close friends may notice a change. Other health
professionals with whom they have contact, such as a neurologist, may also
make a diagnosis of clinical depression.
Depression is diagnosed from a person's own account of their feelings and
symptoms. There is no scan or blood test to help. Health professionals look
for certain key themes in what people say and start to think about depression
when people describe low mood on most days, for most of the day, over at
least two weeks.
Having MS may make diagnosing depression more difficult because many
common MS symptoms, such as fatigue and reduced concentration, are also
associated with depression. It is important to focus on changes in a person's
outlook, which is why it is important that health professionals also listen to
what friends and family tell them.
Two simple questions have been devised to establish if someone is
depressed5,6.

During the last month have you often been bothered by feeling down,
depressed or hopeless?

During the last month have you often been bothered by having little or no
pleasure in doing things?
If the answer is 'yes' to either of these questions, it is important that you speak
to your MS specialist team or GP. It is not usual to feel low all the time.
7. How is depression treated?
There are a number of approaches to treatment which depend on the severity
of depression and these are often used in combination. Other factors such as
an individual’s treatment preferences, sources of support, and past history of
depression are also taken into consideration.
Treatment for depression should be approached in the same way one might
approach treatment of a physical injury. A broken leg, would be given time to
heal. This approach should also be used to restore the mind and emotional
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wellbeing following an episode of depression and this can take many weeks
or months.
Referral may also be made to a neuropsychologist, where they are part of the
MS team, or to other members of the mental health team.
7.1 Self-management
In mild to moderate depression, self-management is the approach
recommended by the NICE guidelines2. This may include advice on
increasing levels of physical activity7, accessing self-help groups, adopting a
healthier lifestyle, minimising stress, practising sleep hygiene, relaxation
techniques or mindfulness6,8. This should be reviewed by the health
professional to ensure that mood is improving.
7.2 Talking therapies
Talking therapies or psychological approaches aim to help people identify and
overcome negative thought patterns associated with depression. These
include cognitive behavioural therapy (CBT) and would usually be
recommended in mild to moderate cases of depression. Access to
psychological therapies is currently limited on the NHS.
7.2.1 Cognitive behavioural therapy (CBT)
CBT is based on the idea that the way people think about a situation affects
how they act. In turn, actions can affect how people think and feel. It is
therefore necessary to change both the act of thinking (cognition) and
behaviour at the same time.
Cognitive behavioural therapy has proven effective in treating less severe
cases of depression in MS9. CBT emerged out of two types of psychotherapy:

cognitive therapy - designed to change people's thoughts, beliefs, attitudes
and expectations

behavioural therapy - designed to change how people act.
A course of CBT is typically comprised of 5-20 weekly sessions, with each
session lasting between 30-60 minutes. A programme of CBT can be given
individually, or as part of a group; and it may be delivered by a trained CBT
therapist or as a computer-based programme. CBT is available on the NHS
and a GP should be able to give further information about how to access it
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locally. There may be limited resources or a long waiting list in some areas,
but it can also be accessed through private CBT counsellors.
7.2.2 Counselling
Counselling is a form of therapy that helps people to think about the problems
they are experiencing in their lives and to identify ways of overcoming or
managing them. Counselling differs from other forms of therapy in that the
counsellor is more passive. Counsellors can often be accessed through local
MS Therapy Centres.
Other talking therapies include psychotherapy, family therapy, couples
therapy, and group therapy.
7.3 Drug treatment
In moderate to severe cases of depression, or where previous treatment
approaches have not been effective, antidepressant medication may be
recommended.
Health professionals will generally prescribe the lowest possible dose of a
particular drug that is expected to improve symptoms10. The effects of
antidepressants usually take around four weeks to take effect. It is important
not to give up too early, but to give the medication a chance to work. The
particular drug or dose prescribed in the first instance will be regularly
reviewed and possibly changed if it is not effective, or its side effects prove
intolerable.
Some people may start to feel better after a short period of time, but it is
important not to stop taking the antidepressants without talking to the GP.
Stopping a course of antidepressants before the recommended treatment
duration could result in the depression coming back.
Antidepressants
The drugs to manage depression vary in the way they work, but they all act by
increasing the levels of neurotransmitters in the brain. Neurotransmitters
transmit signals between brain cells and some, such as serotonin and
dopamine, are thought to boost mood.
The most commonly prescribed type of antidepressants are selective
serotonin re-uptake inhibitors (SSRIs) and include fluoxetine (Prozac) and
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paroxetine (Seroxat). Amitriptyline (Triptafen) and imipramine may be used to
treat moderate to severe depression and are also used in lower doses in MS
to treat neuropathic or nerve pain, even if there is no depression.
7.4 St John’s wort
St John's wort (hypericum perforatum) is an unlicenced herbal remedy that
has been shown to be effective in treating depression. However, the current
NICE guideline2 does not recommend its use because of ongoing concerns
about appropriate doses, duration of effect, variation in preparations and the
potential for serious drug interactions. It can also counteract the effects of
warfarin and oral contraceptives. It is important that the GP and MS nurse
know if St John's wort is being taken.
8. Severe complicated depression
Rarely, where a person has persistent and repeated episodes of severe
depression resulting in severe self-neglect, or is believed to constitute a major
risk to people close to them, standard treatments such as antidepressants or
talking therapy may prove ineffective. In such cases, people may be referred
to specialist mental health services and receive a tailored programme of
specialist medicines and treatments in either an inpatient or outpatient setting.
These often have a positive result and are managed in association with the
MS specialist team.
9. Recurrent depression
People who experience depression can find that it recurs and it is important to
continue taking prescribed antidepressants. It is also helpful to learn some
skills that can help in preventing relapse. Keeping a diary can be helpful for
monitoring sleeping patterns or other changes.
If a doctor feels that someone is at significant risk of a relapse of depression,
they may be referred for psychological therapy based on CBT. This could
consist of individual face to face CBT or mindfulness based CBT.
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10. How can friends and family help?
Friends, family and carers of people coping with depression can play an
important role in the diagnosis and management of the condition. The person
with depression may not always recognise changes in their mood or
behaviour until someone else points it out. If you are worried that a person
with MS you know might be depressed, it is important to approach the subject
with sensitivity and understanding. Being receptive towards any changes in
mood or behaviour and encouraging people to talk to their GP, MS nurse or
other health professional is an important way of supporting somebody who
has depression.
11. Sources of support
Depression can be very lonely and isolating, but it is a recognised and
treatable condition. There are support structures and services in place to help
people overcome it.
Sources of support available to people who are depressed include local selfhelp groups, telephone counselling services, online discussion forums and
mental health charities offering information and support.
12. Useful organisations
Depression Alliance
Provides information and support and co-ordinates a network of self-help
groups.
Website: www.depressionalliance.org
Depression UK
A self-help organisation made up of individuals and local groups.
Website: www.depressionuk.org
MIND
Provides confidential help and advice on a range of mental health issues.
Website: www.mind.org.uk/Information-support
Infoline: 0300 123 3393
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Rethink
Offers support to people affected by severe mental illness.
Website: www.rethink.org
Infoline: 0300 5000 927
Samaritans
Provides confidential emotional support, 24 hours a day for people who are
experiencing feelings of distress or despair.
Website: www.samaritans.org
Telephone: 08457 90 90 90
SANE
Provides emotional support and information for anyone affected by mental
illness.
Website: www.sane.org.uk
Helpline 0845 767 8000
Self-help websites:
Living life to the full
Living life to the full is a free online lifeskills course based on CBT. It has
modules that help people to understand why we get depressed or anxious,
and covers skills such as recognising and challenging unhelpful thoughts,
anxiety management, overcoming reduced activity. It can be done with the
support of your family or local practitioner.
www.llttf.com/
Get Self Help
A website that offers CBT self-help information and resources.
www.getselfhelp.co.uk
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13. References
1. Feinstein A. Multiple sclerosis and depression and multiple sclerosis. Multiple Sclerosis
2011;17(11):1276-1281.
2. National Institute for Health and Clinical Excellence. Depression in adults with a chronic
physical health problem. NICE Clinical Guideline 91. London: NICE; 2009.
3. Patten SB. Diagnosing depression in MS in the face of overlapping symptoms.
International MS Journal 2010;17(1):3-5.
4. Kiy G, et al. Decreased hippocampal volume, indirectly measured, is associated with
depressive symptoms and consolidations deficits in multiple sclerosis. Multiple Sclerosis
2011;17(9):1088-1097.
5. National Institute for Health and Clinical Excellence. Depression: the treatment and
management of depression in adults. NICE Clinical Guideline 90. London: NICE; 2009.
6. Minden SL, et al. Evidence-based guideline: assessment and management of psychiatric
disorders in individuals with MS: report of the Guideline Development Subcommittee of the
American Academy of Neurology. Neurology 2014;82(2):174-181.
7. Ensari I, et al. Exercise training improves depressive symptoms in people with multiple
sclerosis: results of a meta-analysis. Journal of Psychosomatic Medicine and Research
2014;76(6):465-471.
8. Simpson R, et al. Mindfulness based interventions in multiple sclerosis – a systematic
review. BMC Neurology 2014;14:15.
9. Askey-Jones S, et al. Cognitive behaviour therapy for common mental disorders in people
with multiple sclerosis: a bench marking study. Behaviour Research and Therapy.
2013;51(10):648-655.
10.Koch MW, et al. Pharmacologic treatment of depression in multiple sclerosis Cochrane
Database of Systematic Reviews 2011:Issue 2: CD007295.
Please contact the MS Trust Information Team if you would like any further information about
reference sources used in the production of this publication.
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