Online Health Chat with Amy Sullivan, Psych. D.
August 18, 2010
Do you have Multiple Sclerosis and find yourself depressed because of the challenges it presents? You are not alone. Up to half of all people who suffer from Multiple Sclerosis also show signs of being depressed, or having psychological problems, at some point during their illness. MS is a chronic and disabling disease which attacks the central nervous system, or CNS, which is made up of the brain, optic nerves and spinal cord. Symptoms have a wide range, from numbness in limbs to paralysis, to mood changes, or loss of vision. The drugs used to treat it, such as steroids and interferon, are powerful and can have side effects.
The combined effect of the stress related to the disease and possible medication side-effects, often leads to psychological problems, such as depression. The signs that someone may be depressed are sadness, loss of energy, feeling worthless/hopeless, loss of interest in activities they previously enjoyed, irritability, increased need to sleep, change in appetite causing weight loss or gain, decreased sex drive, thoughts of suicide and more. When these symptoms begin to interfere with your or a family members normal life, or if thoughts of suicide occur, help should be sought.
If you or someone you know have been, or may be suffering from psychological problems as a result of Multiple Sclerosis, it should not be ignored. Amy Sullivan, Psych. D is an associate staff member at the Cleveland Clinic Mellen Center for Multiple Sclerosis. She completed her undergraduate degree at St. Bonaventure University in St Bonaventure, NY, held an internship at the University of Cincinnati Medical Center/ University Hospital, and received her doctorate from Argosy University in Atlanta, GA. She then completed her fellowship at the Cleveland Clinic in health psychology and pain management.
To make an appointment with Amy Sullivan, Psych. D or any of the other specialists in our Mellen Center at Cleveland Clinic, please call 216.636.5860 or call toll-free at 866.588.2264. You can also visit us online at www.clevelandclinic.org/mellen
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Amy Sullivan. We are thrilled to have her here today for this chat. Thank you for joining us Dr. Sullivan, let’s begin with the questions.
Multiple Sclerosis and Depression: What are the Causes?
grandgesture: Is depression treated differently for multiple sclerosis patients?
Speaker_-_Dr__Amy_Sullivan: Managing depression in MS patients requires knowledge of both depression and the MS disease itself. Research has shown that depression is prevalent in up to 50% of patients with MS (although my personal bias says it is more).
What we do know about depression in MS is that it is one of the most treatable symptoms of MS. So, specifically to treat MS related depression, we use a multifaceted approach including managing mood, improving functioning, working with challenges of the disease, family issues, adjustment to the disease issues, fears about the future, and many more. If you are concerned about depression in you or a loved one, you should schedule an initial psychological evaluation and the behavioral medicine team will evaluate and provide an individualized treatment approach specifically for your case and what concerns you might have or life challenges you might be dealing with.
branding: Does every MS patient have or get depression?
Speaker_-_Dr__Amy_Sullivan: No, the research suggests that approximately 50% of MS patients experience depression; however in my experience, it seems higher. I am planning on doing research on this in the future, but right now we are going with the 50% rule of our patients.
Chronic Pain and Depression
sylvia927: I have chronic pain that never goes away, even with meds. This causes depression at times, and I'd like to know if there is anything I can do to feel better physically and mentally.
Speaker_-_Dr__Amy_Sullivan: Hi Sylvia927, this is a great question and tells me that you are in the right frame of mind regarding chronic pain. Just some general knowledge regarding chronic pain is that pain is the chief complaint in nearly 40% of patients seeking help from general practitioners; half of these patients have chronic pain. Health care utilization is 5 times that of those without chronic pain. Chronic pain is debilitating in many ways, as it contributes to decreases in quality of life through physical, social, and psychological losses. Moreover, nearly half of individuals with chronic pain acknowledge coexisting symptoms of anxiety and depression, further complicating the treatment of this disorder.
Regarding your question in general, I am going to direct you to a recent study published in Pain Medicine by Sullivan, Covington and Scheman (Pain Medicine 2010; 11: 524–529). In this study, 28 subjects who were admitted to the Cleveland Clinic Chronic Pain Rehabilitation Program were administered a 10-minute pre-established exercise protocol to determine the effect of exercise on physical conditioning, pain, and mood. We did this because previous studies only showed successes with 30 minute research protocols, and we know that nowadays, people are short on time, and so wanted to see what benefits we could find with 10 minutes of aerobic exercise. The results were astounding, in that we found significant immediate benefits of a 10 minute exercise protocol on mood (improvements in anxiety and depression) and over the long-term (3 week program) found improvements in pain.
Therefore, I think the moral of this study is that exercise helps improve mood and pain. A recent lit review by Sullivan (The Pain Clinic 2007 Vol 19 No 6 1) also shows the benefits of exercise. In addition to exercise, a wellness approach is well documented to show success as well, so working on all aspects of life; such as relationships, mental health, purpose/meaning through either job, volunteer work or family, social activities, recreational activities and sexual activities are all important aspects to mitigating chronic pain. Hope this helps.
sqscan: Recently diagnosed. Three days of inter. steroids, now on prednisone. Is it the medication or the illness that's making my thoughts 'numb'? I'm not dreaming, and thoughts are just 'grey'.
Speaker_-_Dr__Amy_Sullivan: That is probably a better question for your neurologist, I hope they can answer. Let me know if you have any questions related to mood or adjustment to MS and I would be happy to answer. Good luck.
sqscan: I just recently had my 'second' bout with my now newly diagnosed MS. Is it the meds or the MS that's making thinking a challenge?
Speaker_-_Dr__Amy_Sullivan: Unfortunately, MS is a disease that touches patients on so many different levels. Many things could be contributing to your cognitive challenges, including what you have said above.
Yes, we find that both the meds and the condition itself contribute to cognitive problems; in addition, depression and anxiety related to the diagnosis can contribute to cognitive difficulties. It is often difficult to determine what the root cause of the problem is. However, by working within a multidisciplinary team, such as Cleveland Clinic's Mellen Center, which has neurology, PT, OT, psychology, psychiatry and neuropsychology working together for each patient, we are generally able to provide suggestions for how to best manage the disorder and related symptoms. I hope this helps!
Signs & Symptoms
plunkett: What are the symptoms that I would experience that can differentiate between the symptoms of MS and symptoms of depression?
Speaker_-_Dr__Amy_Sullivan: Great question. Important to know is that many of the symptoms of MS and Depression overlap and so it is often difficult to distinguish. In fact, depression can be a symptom of MS. At the Mellen Center, when a neurologist or Advanced Practice Clinician suspects depression, they send the patient to me in the behavioral medicine clinic to determine the best approach to treatment. I would strongly recommend that if you feel that your personality has changed, if you find your self withdrawing and not able to complete tasks that you were once able to complete, you feel blue, helpless, hopeless, have lost interest in things that you once enjoyed, that you get scheduled for a psychological evaluation.
If at any time you feel hopeless or have thoughts of suicide, harm to self, or harm to others, please call the National Suicide Hotline Number, which is a nationwide 24 hour crisis hotline number at 1-800-273- TALK (8255).
nikkiforshort: I have been reading a lot about AD/HD and find many of the things I am having trouble with very to this disorder. I know that Ritalin and other drugs are sometimes prescribed for MS fatigue, but is it also used because of the possible cognitive help it may offer?
Speaker_-_Dr__Amy_Sullivan: Ritalin is not something that I see used frequently in our behavioral health clinic. Therefore, I am not sure of what research you are referring to.
nikkiforshort: I feel that my cognitive issues are much like ADHD, but doctors keep calling it "dementia." Is there an actual name for the whole group of psychological changes we go through with MS?
Speaker_-_Dr__Amy_Sullivan: Yes, you are correct. In some instances they may mirror some symptoms of ADHD. The cognitive changes are generally called Dementia related to your general medical condition/MS. Regarding the psychological changes, I generally see 2 prevalent conditions:
- Mood disorder related to a general medical condition/MS; and
- Adjustment Disorder with anxiety and depression.
cobebu8: What if, because the MS keeps progressing, medicines for depression and ADHD, if they work at all, only work a short period of time (e.g., 3months). Any other ways to help myself with the depression and ADHD other than meds? Recommendations please. Thanks!
Speaker_-_Dr__Amy_Sullivan: What a great question. This tells me that you are willing to take on personal responsibility and not rely solely on medications. Yes, in fact, the best way to treat depression and ADHD are through an interdisciplinary approach, meaning working with your neurologist and APC, your psychiatrist and psychologist.
Let me tell you a little about how behavioral medicine/psychology can help. Behavioral Medicine is an interdisciplinary field of medicine devoted to the understanding and management of health and illness through: disease prevention, health promotion, diagnosis, treatment and rehabilitation. At the Mellen Center for Multiple Sclerosis, the Behavioral Medicine or Health Psychology (titles are used interchangeably) Clinic is intended to help MS patients and their families with MS related psychological conditions, adjustment to the disease and disease management issues. Behavioral medicine is often an important and necessary component in the interdisciplinary treatment of MS patients. Patients and family members might find the disease difficult to fathom, as they may feel that hopes, dreams, and goals for the future will drastically change.
Individuals and family members may react in a number of different ways, including, but not limited to: grief, anxiety, anger, depression, fear, numbness, denial, hopelessness, and in the worst case suicidal ideation or intent. Through behavioral medicine, we can help you with the above through: exploring fears, adjusting expectations and setting appropriate life goals; achieving the benefits of maximum health by taking personal responsibility; exploring thoughts related to your fears of the disease, reducing frequency of relapse, prolonging disability; teaching relaxation skills; and most importantly teaching you how to manage your disease and live a more functional well rounded life.
cobebu8: Are you aware of assisted living "homes" where people set up the home for people with MS only, get their own room in the house and share? It is not an institution or nursing home. I found one in Atlanta, GA.
Speaker_-_Dr__Amy_Sullivan: I am not aware of any. That is more of a social work question. Let me direct you to the National MS Society who has a variety of resources and would be more than happy to assist with your question. Their contact information is as follows: 1-800-Fight-MS (344-4867) or www.nationalmssociety.org. Thanks for writing in and good luck
cobebu8: IS ECT recommended for people who have MS, with a lot of damage to the brain already?
Speaker_-_Dr__Amy_Sullivan: No, not that I am aware of.
cobebu8: Your answer: Not aware that there is anything I can do without medication for depression and ADHD or not aware about the ECT question?
Speaker_-_Dr__Amy_Sullivan: I am not aware about ECT being an effective therapy for depression in MS patients. We do not generally recommend it at Mellen Center.
cobebu8: Thank you for your answer.
Speaker_-_Dr__Amy_Sullivan: You are welcome.
Treatment Options: Behavioral Medicine
wilderland: I have some trouble with depression. I have tried just about every type of antidepressant but either they don't help or have side effects that are unacceptable. Does that mean my depression is not physical in nature?
Speaker_-_Dr__Amy_Sullivan: What a great question. The one thing that we must remember in the management of depression is that depression is multifaceted. With that being said, it is important to treat all aspects of depression: the physical/medical is only part of the equation.
Depression responds beautifully to combination therapy, and so having an excellent psychiatrist who specializes in MS and depression is important because that person will understand the physical aspects and emotional aspects, as well as having a psychologist who can help you through other aspects of your life.
Let me tell you a little about how behavioral medicine/psychology can help. Behavioral Medicine is an interdisciplinary field of medicine devoted to the understanding and management of health and illness through: disease prevention, health promotion, diagnosis, treatment and rehabilitation. At the Mellen Center for Multiple Sclerosis, the Behavioral Medicine or Health Psychology (titles are used interchangeably) Clinic is intended to help MS patients and their families with MS related psychological conditions, adjustment to the disease and disease management issues. Behavioral medicine is often an important and necessary component in the interdisciplinary treatment of MS patients. Patients and family members might find the disease difficult to fathom, as they may feel that hopes, dreams, and goals for the future will drastically change. We can help in a number of different ways. For example: exploring fears, adjusting expectations and setting appropriate life goals; achieving the benefits of maximum health by taking personal responsibility; working you through any fears that might be related to MS and your future; building a fear hierarchy and teaching CBT skills; and most importantly to help you increase your function and improve your mood.
mikealex: What is the risk of taking Tysabri and getting PML?
Speaker_-_Dr__Amy_Sullivan: I understand your fear, as many patients have this concern. Because I am a psychologist, I would like to direct you to your neurologist for specifics.
mikealex: I am sorry I did not phrase my question correctly about the PML. I have been told yoga and holistics can help with my apprehension about taking the Tysabri in the next few weeks. I don't no if I am more depressed the other drugs did not work or more scared that people have died taking it. I am not a believer in taking meds for mental issues. Any suggestions?
Speaker_-_Dr__Amy_Sullivan: Thank you for clarifying. You are correct in reading that a holistic approach can help tremendously with your anxiety related to possible PML with Tysabri. Many of our patients have found great successes with the combined approach to treating anxiety and depression. Psychotherapy to help you work through your fears is the best place to start and then with the help of your psychologist you can develop a treatment plan to include many of the holistic approaches such as Reiki, massage, acupuncture, yoga, exercise, etc. Many people respond differently to different approaches which is why we can not just treat everyone as a gingerbread cookie (or the same person). Each person deserves to be evaluated and then a personalized treatment plan directed to them.
Choosing a Therapist
bananas: Will my MS physician be able to treat my depression or is it better to see another professional?
Speaker_-_Dr__Amy_Sullivan: Luckily, at the Mellen Center our neurologist are extremely keen on picking up depression and starting patients on medications should they see this fit. However, in the event that a depression is found, neurologists refer to me in the behavioral medicine clinic because of our interdisciplinary approach. We believe that treating depression is never solely medication, it is a combined effort with behavioral approaches and if needed medication.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Amy Sullivan is now over. As previously mentioned, Dr. Sullivan will continue to answer some questions offline and these will be available in the transcript.
Thank you again Dr. Sullivan for taking the time to answer our questions about The Psychological Impact of Multiple Sclerosis.
Speaker_-_Dr__Amy_Sullivan: Thank you very much for your questions. There have been wonderful and insightful questions. Please let us know if we can help in the future.
- To make an appointment with Amy Sullivan, Psych. D or any of the other specialists in our Mellen Center at Cleveland Clinic, please call 216.636.5860 or call toll-free at 866.588.2264. You can also visit us online at www.clevelandclinic.org/mellen
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