Multiple Sclerosis and Mental Health: 4 Common Conditions
You probably know that when you have multiple sclerosis (MS), it's important to take care of your physical health. But caring for your mental health is important, too. In fact, the more researchers study the mind-body connection, the more it has become clear that we should aim to address both at the same time.
Among people with MS, rates of mental health issues, including depression and anxiety, are high. And there’s increasing evidence to suggest that these conditions are caused by the immune-mediated attacks to the brain that happen with MS.
“It's a little bit of chicken and egg—but I think most people would agree there’s a combination of biologic and/or structural changes due to MS, plus the psychological demands that any chronic disease may pose,” says Barbara Giesser, M.D., a board-certified neurologist and MS specialist at Pacific Neuroscience Institute at Providence Saint John’s Health Center in Santa Monica, California.
In other words, living with MS is stressful. And on top of that, certain aspects of the disease (like attacks on the nervous system) may increase the risk of developing mental health issues, too. Depression and anxiety may be considered symptoms of MS the same way that pain, weakness, and vision loss are.
Plus, some medications used to treat MS can cause mood change and/or anxiety.
If you’re living with MS, it’s important to be aware of other health issues you may be at risk for, including mental health issues, so you can act preventively or manage any symptoms you’re already experiencing.
If you recognize that you’re experiencing any of the symptoms mentioned below, or even if you’re just feeling emotionally off, you shouldn’t keep it to yourself. “The first thing [to do] is to notify your healthcare provider. There are a wide variety of treatments available,” Giesser says.
You can talk to either your neurologist or your primary care provider. You can also chat with an MS Navigator through the National Multiple Sclerosis Society, for support and suggestions on other resources and wellness strategies that can help you better care for your mental health.
Depression and MS
Depression is the most common mental health issue for people with MS. “Estimates are that at some point after the onset of their MS, 50% of people with MS will experience depression,” Giesser says. About 25% of people with MS carry a diagnosis of depression at any one given time—that’s about five times the rate of the general population.
A large number of studies suggest that the inflammation that affects the brain in MS causes depression. Since MS involves inflammation that directly affects the brain, it’s not surprising that the rate of depression in MS is so high. The rates of depression are highest during times of MS exacerbation (relapses). High-dose steroid treatments can also trigger or exacerbate depression in some people, or even cause hypomanic symptoms.
The effects of depression can be devastating if left untreated, lowering quality of life for the person with MS as well as their family members. Depression can worsen over the course of MS progression and prevent people from being able to recover from relapses and function. Severe cases of depression may even lead to suicide.
What to look for: Depression is characterized by low mood that goes beyond sadness. People with depression may no longer enjoy or take interest in their typical activities. Depression can also be characterized by feelings of guilt or worthlessness, significant weight loss or weight gain, lack of energy, lack of ability to concentrate, oversleeping or insomnia, and/or repeated thoughts of death or suicide, according to the American Psychological Association.
For some people with MS, it may be difficult to identify that they have depression, since things like lack of energy, concentration problems, and fatigue are all symptoms of MS, says Diane Solomon, Ph.D., a board-certified psychiatric nurse practitioner in Portland, Oregon.
What to do: If these symptoms are making it hard for you to function and/or to manage life with MS, it’s important to seek treatment. Fortunately, there are effective, evidence-based treatments for depression.
Talking to a mental health professional is a good place to start. Treatment may also include antidepressants, and they're very well tolerated in MS, Solomon says, noting that therapy and medication work well together for some people.
Exercise is both good for MS and has antidepressant effects on its own. Regular sleep and a balanced diet are important, as well. Saying yes to allowing people to help or doing things socially, if possible, is also likely to be therapeutic and enjoyable—even if you’re reluctant to participate in these activities.
Anxiety and MS
Anxiety is also more common in people with multiple sclerosis. In a small April 2020 study published in BMC Psychiatry, 39% of people with MS had moderate anxiety, which is about double the rate of anxiety in the general population.
Risk factors for anxiety can include having MS and other physical conditions, such as thyroid problems or a heart arrhythmia. A family history of the condition and trauma or stressful events in childhood or later may also increase the risk of anxiety. Sometimes, anxiety can be a symptom of depression, in which case the two will keep company with each other—as your mood goes up, your anxiety goes down, and vice versa.
What to look for: According to Solomon, symptoms of anxiety can include:
- Excessive worry
- Muscle tension
- Difficulty concentrating
- Feeling on edge or irritable
- Apprehension or dread
- Difficulty falling asleep
- Waking up during the night or too early in the morning
What to do: As with any unpredictable or debilitating illness, it's understandable that you may feel anxious living with MS. But if the symptoms of anxiety are making it tough for you to function, it’s a sign you may benefit from treatment. Your doctor may recommend psychotherapy and/or medication, Solomon says.
Bipolar Disorder and MS
While statistics vary, a May 2021 review in the journal Evidence-Based Mental Health suggests that the lifetime prevalence of bipolar disorder in people with MS could be as high as 8%. In contrast, the lifetime prevalence in the general population is half that, according to the National Institute of Mental Health.
Some of this increased risk may be due to shared genetic factors between MS and bipolar disorder, some research suggests. But the role of inflammation of the brain in exacerbating bipolar disorder has been studied similar to its role in depression.
Genetics and brain structure are recognized as the leading causes of bipolar disorder. There’s also evidence that drug or alcohol misuse, childhood trauma, or other high-stress situations may be risk factors.
What to look for: According to the American Psychiatric Association, the following are the types of episodes you may experience with bipolar disorder and their corresponding symptoms:
- Manic episode. This is a period of a week or more where the person has much higher energy, extremely high spirits, or irritability. The person may be restless or very distractible or have racing thoughts, need less sleep, and/or act impulsively. "That can mean suddenly doing something that is uncharacteristic, like dressing very flamboyantly, being hypersexual, and grandiosity—feeling like suddenly you can do things that you wouldn’t have normally thought, like, 'I'm going to run for mayor,'" Solomon says.
- Hypomanic episode. This is a period of time where the person has less-severe manic symptoms, or those that last less than a week.
- Major depressive episode. This is a period that lasts two-weeks or more where the person experiences at least five symptoms of depression. Symptoms of depression in bipolar disorder often appear similar, if not identical, to those seen in clinical depression.
What to do: Treatments for bipolar disorder include mood stabilizer medications and psychotherapy. It’s also important to practice good sleep habits when you’re not experiencing an episode—not staying up late and preventing disruptions in regular sleep cycles—to maintain a stable mood and prevent switches into mania or depression.
Pseudobulbar Affect and MS
Pseudobulbar affect (PBA) is a neurological challenge to be aware of with MS. Although different studies have found a wide range of rates of PBA, it has been suggested that roughly 10% of people with multiple sclerosis are affected by it. “Patients with damage in parts of the brain, such as some areas of the frontal lobes, are more at risk for pseudobulbar affect,” Giesser says.
What to look for: PBA is characterized by uncontrollable episodes of crying or laughing. These bouts may seem extreme for the situation, or there may seem to be no reason for them at all. The laughing or crying or emotional outbursts can last from a few seconds to several minutes at a time.
What to do: Treatment for pseudobulbar affect typically includes a medication called dextromethorphan hydrobromide/quinidine sulfate (brand name: Nuedexta), which may help reduce the emotional episodes of PBA. Some doctors opt to prescribe low-dose antidepressants (such as SSRIs or SNRIs) to reduce the frequency and severity of emotional outbursts.
Therapy can be helpful to support someone with this type of emotional lability, as well, says Solomon. Unlike medication, therapy won’t address the symptoms of PBA, but it may help you cope with stress, embarrassment, or other tough feelings you may experience living with pseudobulbar affect.
Help Is Available
Remember that with multiple sclerosis, your mental health is just as important as your physical health. “The bottom line is that mental health issues can affect function and quality of life for people with MS as much as physical impairments,” Giesser says.
If you’re not feeling like yourself—whether from MS or otherwise—talk to your doctor for their recommendations on what you can do. Help is available for any mental health issue.
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