Depression
Multiple sclerosis brings many variable and unpredictable challenges and can be a source of distress. Often these challenges occur with the onset of new disease milestones, such as the diagnosis or an increased disability. Given the physical, cognitive, and social stresses, it is not surprising that depression is extremely common, appearing in about half of patients with MS over their lifetime. 5 During the course of ordinary MS care, the majority of patients with depression can be identified by a brief screening and referred for additional assessment and treatment.
Fortunately, there are many available treatment options. Antidepressant medications have shown some efficacy. 6 Cognitive behavioral therapy (CBT), a counseling strategy that helps individuals become more active, connects them with rewarding activities, and challenges maladaptive thought patterns, has been shown to be effective in individual and group counseling settings via in-person or telephone-based delivery. 7,8 Anxiety is also common experience among patients with MS and is treated with many of the same types of psychotherapy intervention. 9
Focusing on the psychological and social needs of patients with MS has obvious implications for holistic care and QOL, but in some instances, MS may also contribute to safety concerns. Nearly one-third of veterans with MS admit to suicidal ideation, and the ultimate risk of suicide is about twice that of similar individuals without MS. 10,11 For this reason, screening for risk of self-harm should be routinely incorporated into MS care.
A quick look at William’s Computerized Patient Record System (CPRS) record revealed that he had called the VA suicide prevention hotline. During the conversation he had noted that although he originally thought he would be able to deal with MS on his own, he realized he couldn’t. When the psychologist asked William about life at home, he disclosed that some days he never left his bed except to go to the bathroom. He stated he had given up on dating, and asked “who would want me?” He reported little appetite or interest in sex.
William was anxious about the problems he faced from day to day and grieving about the future that he no longer believed was possible. His distress was generally related to the MS diagnosis, and he spent a significant amount of time minimizing his disability, avoiding his family for this reason.
The psychologist diagnosed William with adjustment disorder with mixed anxiety and depressed mood and initiated individual CBT. The psychologist suggested that William attend the MS social work support group and the MS education group to get to know other veterans with MS and learn about managing symptoms. William agreed to attend the groups and admitted it would be good to have a reason to leave the house.
Health Behavior
Recognizing that MS is a chronic illness that requires coordinated efforts, the MS team helped William manage his disease and maintain his health. The psychological and social components of this process were considerable. For most newly diagnosed patients with MS, diseasemodifying therapies (DMTs) are important tools to decrease relapses and short-term disability. Although the benefits of these medications are well known, many patients are nonadherent. Contributing to poor adherence are adverse effects, cognitive challenges, anxiety, depression, and lack of belief in their efficacy. 12,13 Brief
counseling, problem solving, and clinical monitoring have all been shown to reduce missed doses and improve DMT use. 13 Both the MS Assessment Tool and the pharmacy database within CPRS are helpful for tracking patient adherence over time.