#ClinicSpeak: do you have mental health issues?

Are you depressed or anxious? Don’t suffer in silence ask for help. #ClinicSpeak #MSResearch #MSBlog

When you last saw your neurologist, or nurse specialist, did they ask you about depression and/or anxiety? Have you ever brought up the issue of depression and/or anxiety with your HCPs? Are you someone who knows that you have mental health issues, but suffers in silence? 

The study below using administrative data confirms what we know already that MSers are much more likely to be depressed and have anxiety than matched control subjects. In addition, bipolar disorder was almost 3x more common in MSers. We know that hidden mental health issues affect quality of life. In addition, depressed and anxious people are much more likely  to have sleep disorders, misuse substances and alcohol, and suffer from fatigue. Fatigue is one of the core symptoms of depression. Another issue is social isolation. Depressed people don’t like going out and socialising; they withdraw and their social capital contracts. Reduced social capital is associated with poorer outcomes. Put simply when you are depressed or anxious it creates a downward spiral. 

It is important to realise that there is a lot that can be done to help you. Under the NHS we have CBT (cognitive behavioural therapy), mindfulness therapy, group therapy, exercise programmes and if all else fails pharmacological interventions that can help. It is also clear that depression and anxiety may be linked to ongoing inflammatory activity as part of ‘sickness behaviour’. Sickness behaviour occurs in response to inflammation and is evolutionary conserved behavioural response to inflammation. I have seen many patients with depression and/or anxiety improve from simply having the MS disease activity brought under control.

Another is financial issues. MS is associated with mass unemployment. If you have financial issues there are things that can be done to help. We have a socialist healthcare system and there safety nets in place for people with chronic disease. If you don’t ask you won’t know what is available. 

For HCPs it is important to manage MS holistically and to ask about hidden symptoms. Treating patients with MS holistically can make all the difference, it also shows you care. Knowing that someone cares about you, particularly your HCPs, can make the difference between having hope and hopelessness. It also important to remember that having MS is a risk factor for suicide; MSers are between 2-7x more likely to commit suicide. It is our jobs to screen for depression and treat it with the aim of reducing this risk.

Marrie et al. Physical comorbidities increase the risk of psychiatric comorbidity in multiple sclerosis.Brain Behav. 2016 Jun 29;6(9):e00493

BACKGROUND: Risk factors for psychiatric comorbidity in multiple sclerosis (MS) are poorly understood.

OBJECTIVE: We evaluated the association between physical comorbidity and incident depression, anxiety disorder, and bipolar disorder in a MS population relative to a matched general population cohort.

METHODS: Using population-based administrative data from Alberta, Canada we identified 9624 persons with MS, and 41,194 matches. Using validated case definitions, we estimated the incidence of depression, anxiety disorder, and bipolar disorder, and their association with physical comorbidities using Cox regression, adjusting for age, sex, socioeconomic status, and index year.

RESULTS: In both populations, men had a lower risk of depression and anxiety disorders than women, as did individuals who were ≥45 years versus <45 years at the index date. The risk of bipolar disorder declined with increasing age. The risks of incident depression (HR 1.92; 1.82-2.04), anxiety disorders (HR 1.52; 1.42-1.63), and bipolar disorder (HR 2.67; 2.29-3.11) were higher in the MS population than the matched population. These associations persisted essentially unchanged after adjustment for covariates including physical comorbidities. Multiple physical comorbidities were associated with psychiatric disorders in both populations.

CONCLUSION: Persons with MS are at increased risk of psychiatric comorbidity generally, and some physical comorbidities are associated with additional risk.

15 thoughts on “#ClinicSpeak: do you have mental health issues?”

  1. Prof G,You've always said that you say it as it is with this disease – you don't pull your puniches. I feel there same way. My view is that the MS research industry / neurologists have let us down. All we ever wanted from treatments was treatments which stopped there disease and then allowed some repair. As a young professional this disease couldn't have wrecked my life any more – job losses, relationship breakdown, dependent on family and friends. No more ski trips, no more half marathons, no comfortable retirement. No chance of a family, no grandchildren. If I feel somewhat down can I be blamed? Will antidepressants and CBT help me? I could start some drugs to turn me into a zombie and help me forget my predicament, but my life won'this change. One disease, one life wrecked. I wish I could get a rebate for the huge sums I paid in tax to a health service which could only offer antidepressants when what I needed was treatments to stop my brain and spinal cord being eaten away.

  2. The NHS and DWP compound hopelessness, anxiety and depression. The systems which in theory are supposed to help, don't, if it doesn't suit to do so. NHS England is rife with COI, hence the current Consultation.

    1. Sorry to hear about your predicament. Have you had any help from the MS Society or MS Trust's helplines?

  3. "Another is financial issues. MS is associated with mass unemployment. If you have financial issues there are things that can be done to help. We have a socialist healthcare system and there safety nets in place for people with chronic disease. If you don't ask you won't know what is available."I am not working due to very significant issues caused by PPMS, yet I am having to go through a tribunal to receive what I am eligible for – with full support from my medical team. I paid taxes all my working days and never thought I'd be in a situation where I could not work due to health issues. I also never thought that DWP would let me down the way that they have. This battle I am now forced to fight is such a negative, demoralising and depressing process. So no one can cheer me with talk of a "safety net". It's a malfunctioning system designed to fail as many people as possible, in my experience.

    1. Under austerity things are breaking down in Britain; I hear about every week in clinic from my patients. The problem with socialism is that it has eroded the extended family. In the past family members would help pick-up the burden of care. Once the state took over it killed the extended family and now we paying for the consequences of this policy. What makes the state better at doing things than your family and/or friends?I have a very sick sister living in South Africa, where there is a very limited safety net. It is quite amazing to see our family in action. There is simply no substitute for unconditional love that comes from being related. Have you asked your family for help?

    2. What does a person in a welfare state pay NI contributions for, I wonder? One reason people become homeless, are raised in care, run away, go missing etc. is because they have no family, or have an abusive family. Sharing genes doesn't bring people together into a loving family.Are people to absolve government of responsibility, allow them to squander billions on questionable projects such as Hinkley Point and set bonfires they cannot promise to keep under control, i.e. Brexit, and just turn to a possibly non-existent or incapable family for help? Despite having paid into the social security system all their working lives? I don't feel like just turning the other cheek.

    3. You are not alone Safety net, in my voluntary work I see case after case in a similar situation as yourself. In my own, the questions were deliberately vague and obviously set up for failure, though I have the added woe of inadequate and obstructive medical records which doesn't help.My family is not close at all, but thankfully I am blessed with my husband who works his arse off for me and our children.

    4. Well said, Safety Net. Must I really trust what's left of my diminished life to people I didn't trust when healthy?

    5. My daughter is a hospital doctor. A big problem is families bringing an aged relative into A&E with some problem or other. They are admitted and it's sorted out as much as possible. The hospital then lets the relatives know the patient can go home. The family refuses to accept them back, saying they can't cope any longer. The hospital is then left with the patient, no longer ill enough to be in hospital but with nowhere to go unless and until a care home is found. The enormous problem of bed blocking

    6. This is families abrogating there responsibilities because the state has taken over their role. This would not happen in Southern Europe, South America, China and Africa; my mother, my father, my brother, my sister are my responsibility. It is cultural, it's religious, it's just what happens. It is what makes us human!

    7. I didn't intend to engender undeserved sympathies for me in particular, as anonymous as I am on here, as I am one of the fortunate people with a loving support network, which makes up in part for the abdication of the state that I have recently experienced. I am just acutely aware that not everyone has someone, anyone, to turn to. And even when help from family is there, people can make their sense of obligation more apparent than any heartfelt caring; the dignity offered by a functioning welfare state is a noble thing. But I do realise that, in these times of an aging population, the rise of diabetes and more, a welfare state – with those who are working contributing, as I did – may become very difficult. But I don't think that it is impossible – far from it. Sadly, I do not believe that the situation is better due to culture and religion in China, Africa etc. And I certainly do not believe that the welfare state is responsible for the breakdown of family support. A rigorous examination of social history consigns that myth rapidly to the dustbin.

  4. Prof G, do you, other neurologists and HCP's in your team promote the NHS EPP (Expert Patient Programme)? A free self management programme for people with chronic disease. Many NHS trusts run this programme. There is a programme for carers too. No referral needed.I'm not saying this is the answer to this issue but the course covers some useful skills.

    1. Thanks for your reply. There's also a free NHS promoted online CBT course called Living Life To The Full: helping you help yourself. Written by a psychiatrist. Links to course on the NHS website.This could help patients as there can be long waiting lists for NHS one to one CBT therapy.

  5. All the local areas I've lived in have access to mental health support services, I did an online course on stress management and had a counsellor call in each week to talk through my answers. Knowing she would call made me do my homework. GPs can be really helpful, if you just get a pill pusher make an appointment with another at the practice, you can get really different advice in the same building. A lot of mental health issues require the individual putting in a lot of effort, our brains are complex beasts.

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