Continuation of 02-01

Mastering Multiple Sclerosis
A Guide To Management

Diagnosis & Management


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.


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.


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.


Treatment Of Depression

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.


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.

Strategy For AntiDepressant Medications

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.


    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?


  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.


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.


Strategy For Stopping Treatment

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.


Standard TriCyclic AntiDepressants
Chemical Trade Therapeu- Increase Onset Of Wait Time Name Name tic Dose Amt Action For Increase ________________________________________________________________________ Imipramine Tofranil 75-300mg 25mg 7-14 days 2-3 wks Imavate Amitriptyline Elavil 75-200mg 25mg 7-14 days 2-3 wks Desipramine Norpramin 30-250mg 25mg 7-10 days 2-3 wks Pertofrane Doxepin Adapin 75-250mg 25mg 14-21 days 4 wks Sinequan Nortriptyline Aventyl 50-100mg 25mg 14-21 days 2-3 wks Protriptyline Vivactil 15- 60mg 5-10mg 7-14 days 2-3 wks ________________________________________________________________________
Newer AntiDepressants
Maprotiline Ludiomil 75-200mg 25mg 3-21 days 2-3 wks Amoxapine Asendin 100-300mg 50mg 4-21 days 2-3 wks Trazodone Desyrel 100-400mg 50g 4-21 days 2-3 wks ________________________________________________________________________

The standard group of AntiDepressants are TriCyclic compounds with similar chemical structures. The newer AntiDepressants are chemically diverse.

The possibility of a more rapid onset of action is an advantage, but all of them have delayed onset action in some people.

So the waiting time between dosage increments is unchanged to guard against too rapid increase of dose among persons whose response will appear, but not at the accelerated time.


Usually, depressed people do not accept first barometric reports that storm clouds loom on the horizon. After all, a temper tantrum may have occurred before depressed thoughts developed.

An emotional outburst that sounds inappropriately violent to the family may not seem so to the person coming off medications. The job of the family isn't to force the MSer back on pills but to inform.

Depressed people are not crazy. They are able to reason and think clearly, especially if they get feedback early in a depressed period.

If family members have made an accurate diagnosis, the return of depressed thoughts, reappearance of weeping spells and temper tantrums convince most depressed people that the medication is needed.

Once you make the decision, return to the proper dose, the same as it was before. Continue it for another four to six months and then try again.

Most Msers can finally stop treatment. Some stop periodically and go back again in six months or a year. Some must take Elavil for many years.

If a medication makes life worth living, why not take it? AntiDepressants are relatively safe for long term use, and are preferable to the disruptions caused by Depression.


Cautions About The Use Of AntiDepressants

Serious side effects are unusual, and the benefits of treatments are impressive. Most MSwes appreciate Elavil or a related compound despite irritations like dry mouth and some sedation.

Some MSers should investigate more serious complications, and talk with their doctor before they accept treatment. Glaucoma may flare up, causing pain and visual loss in one or both eyes.

This complaint could be mistaken for Optic Neuritis! MSers with Glaucoma must have their ocular pressures monitored as they use AntiDepressants.

MSers on AntiDepressants who develop new visual complaints, should remind the doctor of this possible complication and ask for prompt referral for Glaucoma testing.

Seizure disorder may become more difficult to control. Blood AntiConvulsant levels should be checked before starting treatment and again soon afterwards, to be certain they do not change.

Kidney and Liver Disease may also be aggravated by AntiDepressants. If you have Heart failure, Angina, disturbances of Heart rhythm or have had a recent Heart Attack, speak to your doctor first.

These complications are serious contraindications to the use of AntiDepressants. Perhaps ask for help from a Psychiatrist with experience in the use of these medications. Then decide if your Depression warrents the risk.


Emotional Incontinence Is Not Depression

Some MSers and many other Neurological patients have frequent brief episodes that are easily mistaken for Depression.

If someone unexpectedly walks into the room, if a brief sad remark is made, if the person laughs, a weeping spell may appear suddenly and without warning.

Indeed laughter may change directly into a silent wail that resembles the worst of grief. The spells are brief, usually less than half a minute.

Often there are no tears. There is no accompanying sad emotion. Crying just happens. People are never violent during these attacks, and between spells, emotional tone is normal.

This is called "PseudoBulbar Emotionality" or "Emotional Incontinence", (Emotional Lability).

It occurs most commonly in people who have had bilateral Stroke, but it can occur in anyone with lesions of any kind on both sides of the Brain. I think of it as an accentuation of normal emotional responsiveness.

When I listen to Puccini, for instance, I am not depressed. But his heartrending melodies always bring a catch to my breath and a lump to my throat that lasts throughout the performance.

After I have had a Stroke or whatever, connections from my thinking Brain to my feeling Brain will be weakened and I won't be able to control my emotions as easily as I do now.

Other people will see my Emotional Incontinence for the first time. I have been embarrassed by that response for years. The difference is, it never used to show.


Emotional Incontinence Is Often Treatable

Emotional Incontinence is sometimes controlled by Levodopa, a medication with powerful effects on Nerve Cells deep in the Brain. Levodopa is usually used against Parkinson's Disease.

Its effect on Emotional Incontinence was first noticed when emotional outbursts stopped for some Parkinson patients, even before there was improvement in their Parkinson symptoms. A recent report has confirmed those original observations.


If the description of easy laughter or crying in this section describes your situation, talk with your doctor about the use of Levodopa.

Begin with a small dose, 250mg three or four times per day, and increase the dose slowly at four to five day intervals to a maximum of 2000mg per day.

If your easy laughter or crying does not stop on 2000mg per day of Levodopa, it is ineffective for you and should be stopped.

Levodopa may cause nausea and sometimes vomiting. This can usually be controlled by taking it after meals or a snack.

MSers who cannot use Levodopa for some reason, should consider the use of Amantadine, 100mg once a day. Low dose Elavil may be useful in suppressing Emotional Incontinence.

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