Management of depression in MS

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Management of depression in MS

• Dr Eli Silber
• Consultant neurologist,
• Kings College Queen Elizabeth Hospitals

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Background

• My limitations
• Taboos in MS

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Outline

• How much of a problem is depression in MS?
• What is depression/ how do we recognise it?
• What causes depression in MS?
• Management (medication therapy)
• Addressing needs in people with MS their carers

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MS A silent disease

• Silent patients
• Early Get on with it
• Delayed diagnosis
• Recovery from relapses
• Late
• Difficulty attending accessing services
• Limited by physical and cognitive ability

• Silent symptoms
• Fatigue
• Bowel, bladder, sexual
• Depression
• Cognitive dysfunction
• Pain

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How much of a problem is depression in MS?

• 50 of people with MS will have a period of
  depression at some time (v.s 15 of population)
• 15 - 30 will be depressed at any one time (v.s
  8 of population)
• Suicide twice average population

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What is depression?

• Depression is not
• Weakness of character
• Madness
• Something that will pass
• Incurable
• Inevitable

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What is depression? (DSM Criteria)

• Depressed mood (reports sad empty, appears
  tearful)
• Reduced interest/ pleasure in daily activities
• Increased/ decreased sleep
• Motor agitation / retardation
• Fatigue / loss of energy
• Feeling worthless / guilt
• Reduced ability to concentrate / indecisive
• Thoughts of death / suicidal thoughts or plans

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What is depression? (DSM Criteria)

• Last for two weeks, most days
• Cause significant distress or impairment of work,
  social functioning
• Minor episode less severe

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Symptoms of MS depression may overlap!

• Vegetative features
• Differentiating the two may be difficult!
• Sleep
• Fatigue
• Cognitive dysfunction, concentration/ memory
• Pain
• Appetite
• Sexual dysfunction
• Difference is anhedonia!

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What causes depression?

• Psychosocial
• Gender?
• Underlying personality
• Upbringing
• Way in which the
• world is perceived

Biology

• Precipitants
• Illness
• Relationships
• Work

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Depression is a brain disease!

• Gender (FM 21)
• Genetics
• Higher in 1st degree relatives
• Adoption studies
• Linked to specific genes
• Neurotransmitters
• Noradrenalin serotonin
• Can be brought on by medication

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Depression is a brain disease!

• Endocrine dysfunction
• Cortisol
• Steroids may precipitate
• Anatomical differences in brains
• Presence in other neurological diseases (e.g
  Parkinson's)

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What causes depression in MS?

• Reactive
• Correlates with degree of perceived stress
• Disability
• Motor and cognitive
• Pain (cycles!!)
• Effect on relationship / work / self esteem
• Practical concerns financial, housing
• Concerns (guilt) about the future / children

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What causes depression in MS?

• Biological
• Both are brain diseases!
• More common than in other medical conditions with
  similar disability
• Reports relate depression with
• Disability duration
• Cognitive dysfunction
• Lesions in frontal temporal areas

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Impact on family/ relationships

• Diad of person with MS and their family/ carers
• Caring is a stressful life event!
• Depends on disability and meaning of caring
• What are rates of depression in carers?

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Alcohol and other drugs

• Abuse is uncommon
• ? Poor tolerance, ? Less access
• Self medication
• Poor option
• May worsen depression
• Side effects

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Management of depression
Address precipitating problems (Social)
Medication
Psychological
One of the curable symptoms in MS!
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Drugs Basics

• Which neurotransmitters are involved?
• Noradrenalin
• Serotonin
• Other
• Tricyclic antidepressants (block reuptake of NA
  and serotonin)
• Selective serotonin reuptake inhibitors
• Other (e.g. venlafaxime)
• Dirty drugs

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Drugs Principles 1

• Try for long enough (usually 4 weeks minimum)
• Sufficient therapeutic dose
• Roughly equivalent efficacy (70)
• If fails try a different type

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Drugs Principles 2

• Choice often based on tolerability (adverse
  effects)
• Start low- go slow
• Non addictive

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Outcome after an episode

• Untreated episode of severe depression lasts 6-12
  months - treated usually 3 months
• Recurrence 30-50 in first year!
• Good prognosis
• Mild episode
• Good support, stable relationships
• Women
• No alcohol / severe anxiety disorder, abnormal
  personality

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How long should one stay on treatment?

• At least six months
• The more serious the longer
• As long as the precipitating stress (if any)
  persists?
• Taper slowly over 1-2 weeks
• ? Maintenance therapy- risk of relapse if stop
• No long term adverse effects

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Drug side effects Tricyclics

• amitriptaline, dothiapine
• Dry mouth, constipation, urinary retention,
  blurred vision
• Heart, drop in BP
• Sedation
• Pain control!!!!

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Drug side effects SSRIs 1

• fluoxetine (Prozac), paroxetine (Seroxat),
  citalopram (Cipramil)
• No molecular features thus different responses!
• Lower incidence of adverse effects v.s.
  tricyclics
• Useful for anxiety states (generalised panic
  attacks)

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Drug side effects SSRIs 2

• Sexual dysfunction
• Nausea, appetite, discomfort
• Anxiety (usually transient)
• Sleep disturbances
• Withdrawal syndrome

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Alternative therapies

• Drugs are drugs
• Do no harm
• St Johns Wart- mild antidepressant effects also
  has adverse effects
• Evening Primrose Oil

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The talking cures

• Psychodynamic therapy
• Behavioural therapy
• Cognitive therapy

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Psychodynamic therapy

• Daily lives influenced by an Unconscious
• Our childhood development influences personality
• Goals understanding and alteration of
  personality, address conflicts insight
  orientated
• Limitations evidence? Intensive resources
  (patient and health)

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Behavioural approach

• Black box interest in actions/ disease
  manifestations rather than underlying process
• Goals behaviour change, positive negative
  reinforcement
• Good for pain, anxiety, phobias, fatigue
• Limitations mechanistic inhuman

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Cognitive approach

• Cognitive distortions, learned negative views
• Goals Identify and alter self destructive
  thoughts, therapist is an active guide
• Advantages good evidence base
• Fixed duration, broadly useful, active client
• Works synergistically with medication

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Family therapy

• Addresses family as a unit
• Interactions between members
• Addresses roles and behaviour

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Addressing needs Background

• Current limitations
• Skill divide (neuro/ rehab psychiatric)
• Hospital based
• Developing a model
• Hospital vs. community based
• Within team
• Other agencies (social services)
• Patient empowering

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Addressing needs Assessment

• Assessment of
• Needs
• Community based
• Develop screening tools
• Educational needs
• Carers needs
• Resources
• Professional, community, individual

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Addressing needs Implementation

• CPN
• Individual cases
• Education
• Support groups
• Liaison
• Specialist clinic
• Guidelines for management referral
• Educational program (lay professional)

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Questions comments
? ?