High Prevalence of Depression and Anxiety With MS

[MUSIC PLAYING] Welcome, everyone. I'm Dr. John Whyte, the chief medical officer at WebMD. Today, we're going to talk about relapsing multiple sclerosis. And when you think about it, what's the relationship between anxiety, depression, and multiple sclerosis, particularly relapsing multiple sclerosis? And just to step back for a second, as you know, multiple sclerosis is a disease in which our immune system basically eats away at the protective covering of our nerves, and that creates a problem in terms of connecting our brain and our body.

Nearly a million people in the US are living with MS, and more than half of them experience bouts of depression. Depression, stress, anxiety, they're all common in people with multiple sclerosis. But does multiple sclerosis cause depression, or is it a reaction to the disease? To learn more about the causes, how it's diagnosed, and the treatment options, I'm joined by two experts.

Dr. James Sumowski, an associate professor of neurology at the Icahn School of Medicine at Mount Sinai, and Dr. Abbey Hughes is a rehabilitation psychologist and assistant professor of physical medicine and rehab at Johns Hopkins Medicine. Thanks for joining me.

Thanks for having us.

Thank you so much.

Well, let's start off, Dr. Hughes, with which comes first in relapsing multiple sclerosis. Is it depression, or is it the disease itself?

The answer is yes to both. It's a bit of a complicated question because MS itself can be a cause for depressive symptoms. And there are multiple ways that we can talk about that in terms of the neuropathology and the ways that MS lesions affect the brain. But also, by the time that people are diagnosed with MS, usually they're in their 20s, 30s, 40s or older, they've lived a number of years that may also have depression prior to the diagnosis of MS. And we know that in coping with MS, a prior mental health history that includes a depression diagnosis puts people at risk for another relapse or another episode of depression after MS diagnosis and throughout their disease course.

But which might come first?

Dr. Sumowski, I'm going to push you a little. What are you seeing more? Are you seeing people that have the disease have relapsed to multiple sclerosis? And let's be honest. There are a lot of challenges with that. They can become depressed. Or is it because, as Dr. Hughes talked about, this neurologic circuitry that potentially causes depression as a component of multiple sclerosis?

Right. So I would definitely agree with Dr. Hughes, what she said are points then. And I would add, in terms of the timeline, it seems new research is coming out on a prodrome of MS. And so the idea is to identify diagnoses that were present two, three, four, or five years before someone is diagnosed with MS, and then those people go on to develop MS. And one of those is depression that is there early. Now, the idea of a prodrome is difficult because the question is always going to be, is this a precursor to MS, or was this undiagnosed MS? But, in any event, it's there pretty early.

And is it undiagnosed typically in people with MS? Is there an issue there?

I think that that relates to the type of depression directly. And I think there are some people with MS who definitely say that they're sad, and that their life isn't going well, they're stressed out, and they're just feeling down emotionally. And I do think that those are the people that are more likely to get diagnosed.

I think we're missing a large group of patients that have anhedonia, which is a symptom of just not enjoying life as much as you used to, which could lead to your lower drive. And sometimes when people say "drive" or motivation, it takes on this sort of judgment or a character thing. But really, we're talking about is that the circuits of the brain responsible for reward-- reward responsiveness, may be less active or may be affected by MS. And therefore, things aren't as much fun anymore, and they're feeling unmotivated. And it's not a symptom that gets you to the doctor, because they don't know that they're depressed most of the time. That's our impression clinically, is that we see many report those symptoms.

So, Dr. Hughes, how do we diagnose depression, then, in patients with multiple sclerosis, particularly relapsing multiple sclerosis?

Sure. Well, diagnosis often begins with a conversation and a question of a provider, or, on the reverse, a patient bringing concerns to their provider around, as Dr. Sumowski said, lower mood or loss of interest or pleasure in activities. And that can come from a wide range of causes, but the diagnosis itself usually comes from a series of self-report questionnaires. And so asking patients and their family members, "What have you noticed about your changes in mood over the most recent weeks or months?"

And it includes a long list of symptoms regarding things like feeling down, depressed, or hopeless, that loss of interest in activities, but then also a lot of neurobehavioral symptoms that also tend to overlap with MS symptoms themselves, like the cognitive fog, or feeling slowed down, or, on the opposite end, keyed up, either cognitively or motor wise. Fatigue is a huge piece of this. Over 90% of people with MS do report fatigue, and the overlap of fatigue and depression symptoms is significant.

And there are different questionnaires, PHQ-9 and some others. But we have to be on the lookout, and we have to help patients understand that depression is not a normal part of the disease process in the sense that you don't have to suffer with it. Before we get to treatment, I want to talk about something that often goes hand in hand with depression is anxiety. So how does anxiety play a role? Kind of that same issue. I'll first go with Dr. Sumowski on this one.

So the issue of approaching people about their depression, screening for depression. And I think there are two takes on that. And I think one is, it's really important when you speak with patients about depression, that you normalize it. And sometimes it is actually helpful to discuss depression as a symptom of the disease itself.

So about anxiety, I think less is known about anxiety. It's harder to pinpoint how the disease may be affecting anxiety than depression, I think. But when we speak with patients-- and we've looked at the questionnaires on anxiety and we're analyzing these data now. But what we're finding is that the type of anxiety that patients are having relates mostly to worries. Worries about the future

and worries about, are they going to take care of their family? Are they going to be around in a few years to take care of their family? And whether or not they're being a burden. And these sorts of anxieties are worries about the future. It seems less to be symptoms that you would see in a generalized anxiety disorder like panic attacks, or this physiologic arousal that they're on edge and feel butterflies in their stomach. It's mostly, I think, unlike depression, which we can identify a disease-related biological driver.

Dr. Hughes, how do we treat depression and anxiety? Do we need to treat it differently in patients with MS?

Well, it's a good question, because if we target each symptom as its own disease, we would get overwhelmed with the amount of different treatments that a patient would need. And so I think depression and anxiety are often co-occurring and overlapping conditions that are often approached from a psychological standpoint with evidence-based therapies like cognitive behavioral therapy, which have been shown in MS to be effective.

Cognitive behavioral therapy is based on the idea that we all come into this world developing certain beliefs about ourselves and about the way that the world works. And some of those core beliefs are about ourselves like, I'm a worthwhile person. I can handle things and problems when they come my way. I can have flexibility of thinking and problem-solving.

And sometimes when those core beliefs or core thoughts become unhelpful over time, that can play a role in the development of depression and the development of anxiety. A core belief that the world is an unpredictable, scary, unsafe place is a common core belief for people who have generalized anxiety disorder or more trait-based anxiety symptoms.

In the context of MS, there's also the added piece about the uncertainty of the future. And there's some validity to this. You can't predict what's going to happen in the future. But when we start to focus on those symptoms or focus on those thoughts, then that starts to take away from our ability to function in daily life and not pursue enjoyable life-giving kinds of activities that we want people to continue to do which are antidepressant and anti-anxiety.

Well, doctors, I want to thank you both for addressing the role of anxiety, depression in patients with multiple sclerosis, particularly relapsing multiple sclerosis.

Thank you for having us.

Thank you very much.

If you have questions for us, drop us a line. You can email me at [email protected].

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