Multiple sclerosis and mental health

Living with a chronic illness such as multiple sclerosis (MS) can lead to mental health problems such as depression and anxiety. This is due to how MS damages the nervous system, as well as the challenges that come with navigating the world with a chronic illness.

MS is caused by the immune system mistakenly attacking myelin, resulting in axonal and neuronal injury in the brain and other parts of the nervous system. Because the brain is responsible for regulating and experiencing emotions, the nervous system damage that occurs in MS can result in mental health challenges or emotional changes for people.

People with MS may also face added stress as they adapt their daily routines to navigate life with a chronic condition. In fact, compared with the general population, both depression and anxiety are about three times more common in people living with MS.

Under the guidance of a doctor, an MS patient may be able to manage mental health issues through a variety of medications, such as antidepressants or anti-anxiety medications (anxiolytics), specialist care such as talk therapy, as well as lifestyle modifications such as a varied and well-balanced diet and physical activity.

MS and depression

Depression is a relatively common MS symptom, with as many as half of those with MS experiencing it at some point in their lives. It is characterized by profound fatigue, accompanied by feelings of sadness and a loss of interest or pleasure in activities.

Depression on its own can be disabling if the severity is high, says Michael Cossoy, MD, a neurologist with subspecialty expertise in MS and neuroimmunology, and an assistant professor at the University of Manitoba in Winnipeg, Canada.

He views depression as a magnifying glass that can amplify other health symptoms.

“People with depression often experience disrupted sleep, which can contribute to greater fatigue and cognitive difficulties, both of which are common in MS,” Cossoy says. “Neuropathic [nerve-related] pain is often worse in patients with depression, presumably in part due to alteration in how the brain processes pain.”

Depression may also make it more difficult for some people to adhere to their MS treatment plan, including taking disease-modifying therapies consistently. Reduced treatment adherence can increase the risk of disease activity and progression, potentially leading to worse long-term outcomes.

“Depression is clearly related to lower quality of life,” Cossoy says.

However, because it can overlap with other symptoms of MS, including fatigue and cognitive problems, depression can be difficult to diagnose in people with MS.

MS depression symptoms and contributing factors

Symptoms of depression may include:

sadness
feelings of emptiness
irritability
lack of interest or pleasure in activities
lack of energy
loss of appetite
concentration problems
feelings of worthlessness or guilt
suicidal thoughts

Contributing factors for depression in people with MS may include:

fatigue
insomnia
pain
sexual dysfunction
cognitive problems
spasticity resulting in stiffness
neurogenic bladder, or a lack of bladder control due to nerve problems

If you are experiencing feelings of depression, you can reach out to a healthcare professional. They will be able to provide you with support, advice, and treatment options for managing your symptoms.

If you are looking for online help, Mental Health America offers a short screening test for depression, looking at symptoms experienced over the prior two weeks.

In some cases, depression can lead to suicidal intent and must be taken seriously. If depression includes suicidal feelings, please call the National Suicide Prevention Line by dialing 988 or visit suicidepreventionlifeline.org.

What is pseudobulbar affect?

Pseudobulbar affect (PBA) is a neurological condition that can occur in some people with MS. It causes sudden, involuntary episodes of laughing or crying that are disproportionate to or inconsistent with the person’s underlying emotional state.

PBA is an under-recognized and under-treated symptom in those with MS, and it can be misinterpreted for symptoms of mood or personality disorders, such as depression or bipolar disorder.

Understanding anxiety in MS

Anxiety is defined by feelings of fear, dread, and uneasiness. More than 36% of people with MS are estimated to report clinically relevant anxiety.

MS anxiety can lead to:

elevated heart rate
inability to relax
lack of mental focus
trouble sleeping
trembling or shaking
muscle tension
gut issues

Anxiety also may be linked to:

reduced cognitive abilities, specifically slower processing speed
lower working memory performance

Nika’s story

Nika (who asked her last name not be used) says she experienced anxiety long before she was diagnosed with MS in January 2022. She had seen multiple doctors in the seven-plus years it took to pinpoint the cause of her unexplained health problems, which included pain, fatigue, and irritable bowel syndrome-like symptoms.

“I was finally diagnosed with MS after an episode where I experienced double vision and was admitted to the hospital for about one week while they ran tests,” Nika says, adding that doctors were initially unsure if the cause of her illness was a stroke or a brain tumor. “This experience was very traumatic and anxiety-provoking itself because I was by myself through this process and unable to have any family with me due to COVID.”

Is tingling related to MS or anxiety?

Symptoms of MS can include numbness and tingling. However, these body sensations can also be due to other conditions or circumstances, including anxiety.

MS tingling, caused by nerve damage in the spinal cord and/or brain, can be an early symptom of the disease and may also occur during a relapse. Also known as paresthesia, tingling is an altered sensation on the skin usually described as a pins-and-needles sensation. People with MS often report tingling and numbness in the face, arms, and legs, or the torso.

“It is presumably due to an altered signal getting to the sensory cortex, which is then perceived as tingling,” Cossoy says, adding that it can “fluctuate in location and severity. Like many MS symptoms, it can get worse when the body is overheated.”

Cossoy says that tingling can be present in the absence of any anxiety or other mood issues.

In contrast, anxiety-related tingling is not caused by nerve damage but is typically brought on by stress, particularly during episodes of rapid or deep breathing. Such stress may be a generalized feeling of anxiety from being overwhelmed by life or triggered by social situations. This type of tingling is often associated with hyperventilation, rapid or deep breathing caused by anxiety or panic, and usually affects the limbs or the area around the mouth.

Anxiety tingling usually resolves in a short period, once the source of anxiety is identified and addressed, while tingling associated with MS tends to last longer and potentially get worse over time.

Treatment for MS tingling or numbness typically is not needed, but may include anticonvulsants or antidepressants if symptoms become painful or disruptive. In severe cases, or when associated with a disease relapse, corticosteroids might be used as a treatment.

Medical treatments and professional counseling

If you are experiencing stress, anxiety, or depression, healthcare professionals may help to address these issues with medication or professional counseling.

Medication

Antidepressant medications can help treat a variety of mental health issues with MS, including depression, anxiety, and irritability.

Two common types of antidepressants that could help people with MS are:

selective serotonin reuptake inhibitors, such as fluoxetine, paroxetine, and citalopram
serotonin and norepinephrine reuptake inhibitors, such as venlafaxine, duloxetine, and desvenlafaxine

Nuedexta (dextromethorphan hydrobromide and quinidine sulfate) was approved in the U.S. in 2010 for PBA, and is the only approved medication specifically for this indication. Other antidepressants may also help manage this symptom.

Counseling and therapy

Counseling provides a safe, supportive space for patients and caregivers to discuss the impact of the disease and navigate uncertainties at home or work. Counselors can provide emotional support and discuss the importance of assistance from family, friends, and coworkers. They can also outline a strategy to help patients cope with the disease.

Therapy options available to help with mental health include:

cognitive behavioral therapy: This seeks to help identify thoughts and behaviors that can have a negative impact and to work on practical problem-solving techniques. It can take the form of talk therapy and may help ease the severity of insomnia, fatigue, and anxiety.
psychodynamic therapy: This can help those with emotional disorders and improve their mental health. It is considered a form of talk therapy and comprises several techniques grounded in specific concepts or models of human behavior.
mindfulness-based interventions: These interventions — focused on teaching to direct attention to the present moment and guiding toward becoming more aware of experiences without judgment (attention and acceptance) — can potentially alleviate stress, fatigue, anxiety, and depression.

Amy MB Sullivan, a psychologist with the Cleveland Clinic Mellen Center, spoke to Multiple Sclerosis News Today about how life with a chronic illness adds another layer of complexity to mental health.

“The process is going to look different for each patient, and we have to recognize each individual’s needs and the ways they process the stages of their disease,” Sullivan said.

Cossoy, a neurologist in Canada, says most MS clinics screen patients for mental health issues at every visit.

“Our clinic has a social worker who can provide some counseling, and we have an agreement with psychiatry to see some patients in consultation for guidance if their mental health issues are beyond the scope of primary care,” Cossoy says.

The Choosing Therapy Directory has a search function for therapists by specialty, experience, location, insurance, or price.

Nika, who is a licensed clinical social worker, says she works with a therapist specializing in supporting those who struggle with chronic health conditions.

She started therapy in 2020, ahead of her MS diagnosis, because she was dealing with health problems with no apparent cause, and she felt this was taking a toll on her relationships with others.

“I think it was helpful because I needed an ally and someone to help me make some big decisions at the time,” Nika says. “I still meet with my therapist, and she has helped me explore ways to advocate for myself when meeting with my doctor and make some major decisions regarding MS medications as well.”

Nika notes that talking about traumatic events can be difficult while feeling unwell physically and hard on the nervous system.

“Revisiting past traumas must be done delicately with someone who has MS and a compromised nervous system,” she says.

Daily self-care and coping strategies

MS patients can help support their mental health by adopting self-care strategies such as eating a varied, well-balanced diet, getting enough exercise, quitting smoking, reducing stress through meditation, and finding an enjoyable hobby.

The sooner a person with MS shifts to a healthier lifestyle, the better, Cossoy says.

“Unfortunately, patients with more severe physical impairment from their MS have more difficulty implementing these changes,” he notes.

Diet

While no single dietary plan fits everyone with MS, experts generally recommend a varied, well-balanced diet to help manage and control the disease.

Evidence shows that what people eat can influence their mood and vice versa. Eating a healthy diet that includes a balance of the following can give mental health a boost:

protein
nonprocessed carbohydrates
healthy fats
fiber
vitamins and minerals

Exercise

Exercise can be helpful in reducing stress, anxiety, and depression. Gentle exercises to try include:

swimming
pilates
yoga

Yoga practice can lead to a better connection between mind and body, useful when dealing with a chronic illness.

Individuals with MS can speak with a physiotherapist or other healthcare team members to discuss other options for exercise and ways to minimize the risk of falls. Some exercises can be done while sitting, with many available to view online.

Before starting any new physical activity or changing diet, patients would benefit from speaking with their doctors, who can provide advice on how to make changes.

Not smoking

Another lifestyle factor that can influence mental health in MS is smoking tobacco products. Smoking has been associated with a higher prevalence of depression and anxiety among people with MS.

Smoking-cessation programs are available through the Centers for Disease Control and Prevention, and smokefree.gov offers support, tips, tools, and expert advice.

Coping strategies

Coping strategies that might help with managing mental health on a day-to-day basis include:

talking with family and friends
writing feelings in a journal
relaxation activities, such as mindfulness and meditation
deep breathing exercises
listening to music, a podcast, or an audiobook
watching a favorite movie or TV show
petting or playing with a companion animal
watching birds at a feeder or fish in an aquarium

It’s also important caregivers take time to reset their own mental health. As they help people with MS to deal with disease-related physical and mental health, they too can experience anxiety and depression.

Taking regular breaks and using coping strategies to recharge can help caregivers feel their best and cope, which, in turn, will help them deliver better care.

‘I am proof that there is hope’

Nika has made a number of changes to her lifestyle, including:

practicing meditation
exercising
writing in a gratitude journal
adding healthy foods to her diet, which is now primarily plant-based
avoiding caffeine and alcohol
quitting smoking

“I pray, do yoga, walk, and get outside in nature as much as possible, deep breathing, positive self-talk: ‘You can do this’; ‘you are safe’; ‘you have health in you,’” she says. “I recently completed a seven-day medical medium stone meditation that was super helpful in letting go of fear, anxiety, and other difficult emotions.”

By making modifications to her lifestyle, plus working with a mental health therapist and the rest of her MS healthcare team, Nika says that she has made improvements to her mental health.

“I do want others to know that I am proof that there is hope, things can get better, and there are so many things we can do to empower ourselves and live our lives to the fullest (and perhaps an even fuller life than we did prior to having MS), even with a diagnosis like MS,” says Nika, a resident of Chicago.

Support groups for MS and mental health

Most organizations that provide information about multiple sclerosis also have MS support groups, which can be useful for people looking after their mental health.

The forums on Multiple Sclerosis News Today enable connection with fellow community members with MS, fostering social interaction and providing support through shared experiences.

In the U.S., organizations that offer support groups include the following:

In addition, most U.S. states have local support groups, and many other MS organizations worldwide offer in-person and online support.

Recognizing and managing a mental health crisis

A mental health crisis is when someone’s behavior and thoughts prevent them from functioning, or indicate they might harm themselves or others. This can happen when feelings of distress become overwhelming, and previous coping methods don’t work.

The American Psychological Association says the most common sign of a mental health crisis is “a clear and abrupt change in behavior.”

A mental health crisis can include:

intense changes in mood
inability to function in daily tasks or take care of hygiene
feeling increasingly agitated, angry, or violent
self-medication or self-harm
withdrawal from others
hallucinations or delusions
paranoia
suicidal thoughts
thoughts about causing harm to others

If anyone is experiencing these symptoms, please seek crisis intervention services, including walk-in psychiatric urgent care, a hospital emergency department, or by calling 911.

When calling 911, the caller should say there is a mental health crisis so that the appropriate service is contacted, such as a crisis intervention team.

Suicidal thoughts

Suicidal ideation is thinking about or making plans to end one’s life and can include thoughts and behaviors such as:

actively seeking ways to end life
self-destructive behavior
talking about suicide
feeling like there is no reason to live
feelings of guilt, shame, and failure
withdrawal from family and friends
excessive anger
giving away possessions

These are signs of an acute mental health emergency and should be taken seriously.

Anyone with suicidal thoughts should reach out for help. Counselors are available through these crisis lines:

In the U.S., call the 988 Suicide and Crisis Lifeline by dialing 988.
Military veterans can reach out to the Veterans Crisis Line by dialing 988 and pressing 1.
Send a text to the Crisis Text Line at 741741 in the U.S. and Canada.
Internationally, find country-specific crisis text lines.
Find country-specific crisis hotlines internationally at Suicide Stop or Befrienders Worldwide.

Multiple Sclerosis News Today is strictly a news and information website about the disease. It does not provide medical advice, diagnosis, or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.

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