Mastering Multiple Sclerosis
A Guide To Management

Depression
Diagnosis & Management

ch7
p142

A death in the family, unpaid bills, the recent diagnosis of MS; these are universally depressing. Normal Depression is a response to a real situation.

It improves with time, as the person learns to cope. We all weep from time to time, but after a good cry, we pull ourselves together and go forward.

A sad event may trigger MS Depression, but instead of improving with time, it lingers. It destroys joy and interrupts the flow of life from within.

Irritability and querulous behavior disrupt family harmony. Both suffer and family may fail to recognize depression because there is no reason for it. Even after identifying it, they often cannot combat it.

p143

A Picture Of Depression

Socks dumped on the floor are an annoyance to anyone, but to the depressed person this become a symbol of the family's indifference, lack of love, or downright hatefulness.

Instead of the crisp command, "Pick up your socks!" there is an outburst of anger and recrimination.

During depressed outbreaks, MSers are sometimes so upset that they strike out violently against anyone or anything within reach. The little things that trigger the blow-up are real, but the response is out of proportion to the event.

Depressed weeping is different from normal weeping. When it finally stops, it leaves no comfort. Like Depressed anger, Depressed weeping begins with little or no cause.

Instead of stopping after a few minutes, Depressed weeping continues for half an hour or more and seems to have a life of its own.

Depressed MSers sometimes weep when they are not sad, and weeping continues long after they are ready to stop.

Sleep suffers. Depressed people fall asleep when they retire, but they wake in the night to spend many hours tossing and turning. They feel alone and uncared for.

They rehash unhappy events from the recent and distant past that are relevant only to the depression. Sleepless nights increase fatigue.

Dishes pile up in the sink. The house is cluttered. Office work remains unfinished. Extra activities are abandoned for lack of energy.

p144

Body posture changes. The shoulders sag. Gait is slowed and shuffling. The face and voice are sad even when the person smiles. The voice loses its normal quality. Its tone becomes flat and uninteresting.

Sad sighs punctuate waking hours. Even casual converersations are burdensome. Personal relationships at home and at work deteriorate. Reclusiveness becomes a way of life.

Terrible! These changes are difficult to describe, but once recognized, they are unmistakable.

The problem is, usually no one knows! We expect others to pull their weight at home and at work. We resent unjustified anger and irrational weeping.

When someone changes so completely because of unrecognized Depression, the angry reactions of friends and family only make things worse.

This kind of Depression is so common among MSers, that it is now recognized as a specific symptom of MS.

Although MS Depression can be terrible, it is ususlly not as severe as I have portrayed it. Fortunately, once recognized it is treatable.

p145

The insidious Depression of MS responds well to treatment. AntiDepressant medications should be given to the MSer whose life is disrupted by Depression and who is willing to take AntiDepressants.

All AntiDepressants have various side effects, some cause more sedation, others more dryness of the mouth. All are effective in treatment of people with Depression.

Elavil (Amitriptyline) causes more initial sleepiness than some of the others, but after a while this goes away. Elavil causes one lasting side effect: dry mouth. Not to worry, drink more water.

The major disadvantage of Elavil is its long biological half-life. Elavil accumulates in the body for two weeks before its concentration becomes stable.

If the first dose is too small to combat Depression, wait two weeks before increasing the dose, and perhaps two weeks more before Depression begins to clear.

This is a serious disadvantage when treating severe psychotic Depression. Fortunately, MSers do not usually have psychotic Depression, so they can afford the wait.

Other treatments for Depression are available but are usually unnecessary. They should be taken only under the close supervision of a Psychiatrist.

MonoAmine Oxidase Inhibitors fall into this category. Lithium Carbonate has great value underspecifically defined conditions.

Phenothiazines and other major tranquilizers are good for treatment of psychosis, but if yours is the usual MSer's Depression, you do not need tranquilizers. Electroshock therapy is used by psychiatrists.

Avoid using the minor tranquilizers like Valium (Diazepam) and Librium (Chlordiazepoxide), which may actually make Depression worse.

Since depressed MSers respond so well to Elavil, these other treatments are usually unnecessary.

p146

When compared to Elavil, the talking treatment and simple reassurance are ineffective. MS Depression is not caused by disordered life experiences.

It is primarily the result of MS plaques somewhere in the depths of the Brain. The biochemical pathology of Depression is becomming better understood.

AntiDepressant medications attack that pathology. If you are depressed, get medicinal treatment first. Once your thoughts have cleared, go for counseling if you like, with a Brain that's eager to learn new things.

Here are a few rules for use of AntiDepressants. They are determined by the biological half-life of the medications, by their effective dose and by the usual duration of Depression after treatment has begun.

p147

The First Few Weeks Of Treatment

1. Take the daily dose at bedtime. Because of their long biological half-life, AntiDepressants accumulate and disappear slowly in the body. A single dose per day is just as effective, and it is easier to remember.

   The major early side effect is sleepiness, so use the side effect to your advantage. Take your pills at bedtime and get some rest.

2. Begin with the standard starting dose, which rarely produces incapacitating sleepiness or other side effects. The standard starting dose of Elavil, 75mg. at bedtime, is usually inadequate to treat Depression.

   In practice nearly everyone with MS Depression requires 100 -125 mg of Elavil each day. Some people need 150 mg. A few MSers need more.

   Some people complain of uncomfortable sleepiness, even on the standard starting dose. If this happens, decrease the dose. Once your body has adjusted to the medication, go back to 75mg at bedtime.

   The effective dose is usually the same, despite early side effects. Plan to increase your total dose to 100 - 150mg per day, as other people do, but more slowly.

3. Once you reach any dose, remember the long biological half life and wait the required period of time before increasing the dose.

   Usually it takes two weeks for blood and tissue concentrations to stabilize, so do not decide about your clinical response for at least two weeks.

   Then ask the questions that tell whether this is the right dose: Is there a distinct change in mood?

   Have weeping spells and anger outbursts stopped? Are you back to normal slightly improved or unchanaged?

   p148

4. If there is no change, or only a slight change in mood after two weeks, raise the dose by one dosage increment. Do not make the mistake of accepting minimal improvement. Increase the dose deliberately till mood returns to normal.

   As you proceed, keep your doctor informed about your dose and your mood to get the best possible guidance in your search for the best dose.

5. Families often know before the MSer does, when the right dose has been reached. Behavior changes dramatically when blood and tissue concentrations reach a therapeutic level.

   But even after depressed behavior has ended, depressed thoughts linger. The MSer whose depressed thoughts still churn despite the improved mood, reports "no change." Thoughts are still depressed.

   The person may still be mulling over inconsequential events from the past but does not recognize that these thoughts are no longer accompanied by the temper tantrums of a few weeks ago.

   It often takes another two to six weeks before the MSer realizes that Depression has disappeared.

p149

It is important to remember the delay between improved behavior and improved thought. The family is the first to know when the dose is right. They are the only accurate barometer of future blue skies or storm clouds.

Conversely, when the MSer stops the pills, family notices immediately, the return of depressed voice and posture. These changes often occur before the MSer notices the return of depressed thoughts.

p150

Plan with your family for your future use of AntiDepressants. Most people need AntiDepressant medication for 6 to 15 months, and can then stop without immediate return of Depression.

Knowing the usual duration of treatment, the MSer can agree to stay on the AntiDepressant dose for at least six months. After that time the MSer will begin to reduce the dose by one increment each month.

If Depression still does not return, the MSer can continue to reduce the medication monthly over a period of several months. Most people begin to decrease the dose before their Depression is over so it returns.