Anthony Feinstein, MD, professor of psychiatry at the University of Toronto and director of the neuropsychiatry program at Sunnybrook Research Institute and Women’s College Health Science Centre, also in Toronto, who has studied depression and fatigue in people with MS and is considered a pioneer in the field, summarized some of the latest findings during the recently held European Committee for Treatment and Research in Multiple Sclerosis (ECTRIMS) meeting in Berlin. “A number of studies that have looked at nonpharmacologic approaches for the treatment of depression and fatigue in MS have had more positive outcome results than those involving drugs commonly used to treat both conditions,” says Dr. Feinstein. That Feinstein was even invited to speak on the topic at ECTRIMS is a sign that clinicians who work with people with multiple sclerosis are becoming increasingly aware of the relationship between the conditions, as well as the preferred options for treating them. It was the first time he gave a presentation on both subjects combined at the annual meeting. As he notes, “The behavioral aspects of MS are at times overlooked because they have so-called ‘silent symptoms’; you don’t see them during a neurological examination.” RELATED: Depression: Common but Undertreated in People With MS, Expert Says
Many Possible Causes of Fatigue in People With Multiple Sclerosis
Feinstein’s talk, entitled “Depression and Fatigue: How to Break the Vicious Circle,” used as its starting point a diagram with three interlocking circles, with fatigue being the “common denominator” at the center. The diagram was designed to illustrate the potential causes of fatigue in MS, and how they intersect. The first circle symbolized fatigue as a direct result (or symptom) of MS, while the second circle described “secondary fatigue” caused by a side effect of an MS medication, or by depression or hypothyroidism. Finally, the third circle represented fatigue secondary to sleep problems, another common health condition associated with MS. The purpose of the diagram was to drive home the importance of adopting a sort of step-wise approach to treating fatigue in MS. “When you’re dealing with depression and fatigue it’s important you tease out what’s going on and what’s causing what,” Feinstein says. To that end, he advocates that physicians start by assessing whether or not a person with MS in their care who is experiencing fatigue is having trouble sleeping or is also dealing with another health condition, like depression or thyroid problems. If these underlying health issues are treated and the person with MS is still experiencing fatigue, then it follows that the fatigue is a direct result of their MS and should be “treated accordingly,” Feinstein says. Historically, it has been difficult to diagnose the causes of fatigue in MS because there’s “symptom overlap,” he adds. Indeed, symptoms like fatigue, appetite loss, and sleep problems are common to both depression and MS.
Nondrug Therapies for Depression and Fatigue Often More Effective Than Drugs
Notably, in most cases, a person with MS who has significant fatigue or depression will benefit most from treatments that aren’t medication-based — namely, cognitive behavioral therapy (CBT) or mindfulness-centered approaches. For evidence, Feinstein cites a study published in 2014 in the journal Behavior Neurology, which analyzed an online survey of 3,132 people with MS and found that those who meditated at least once a week had better overall health. These findings echoed those of a landmark study published in the journal Neurology, which also found a benefit for mindfulness-based approaches in the prevention or treatment of depression, fatigue, and anxiety in people with MS. “The underlying principle behind CBT and mindfulness approaches is that if you can change people’s thoughts, you can change how they feel,” Feinstein explains. “In essence, you are working to correct faulty thought processes that are making it difficult for them to overcome their fatigue.” “Unfortunately,” he continues, “It’s going to be hard for a person with MS to tease out for themselves what’s causing their fatigue and guide their physician toward the proper treatment. However, the more we educate physicians on these subjects, the better. And, of course, for people with MS, knowledge that depression and fatigue are common, and that there are treatments available that don’t involve the use of more medication, can be very empowering.” RELATED: How Mindfulness Can Reduce Stress and Improve Quality of Life for People With MS
Removing the Stigma Helps People Get Treatment for Depression
Rosalind Kalb, PhD, a clinical psychologist and consultant for the National Multiple Sclerosis Society, in New York City, agrees. “Our perception of depression and fatigue in MS has really changed over the past decade or so, and a lot of that shift has been down to the work by Dr. Feinstein and others,” she says. “A lot of the stigma has been removed from the equation, and when you take away the stigma and tell people, ‘depression is a common symptom of MS,’ people are more likely to talk to their physicians about it and their physicians are more likely to ask.” The National MS Society recommends that newly diagnosed people with MS get screened for depression, because it can make their MS symptoms — including fatigue, cognitive problems, and pain — worse. “Depression is depression no matter what the underlying cause is,” Dr. Kalb says. “And that’s important for people and healthcare providers to know. It’s very treatable, whether it’s with ‘talk therapy,’ medication, or a combination of the two.”
