Background Depression is the most common co-morbidity for people with Multiple Sclerosis (MS); irrespective of disease severity, depression has the greatest impact on quality of life. An emerging paradigm in the treatment of depression is lifestyle medicine. There is significant potential to prevent and treat depression through modification of lifestyle risk factors for people with MS. This study sought to understand the association between lifestyle risk factors, medication and depression risk through the analysis of self-reported data from a large international sample of people with MS.
Methods This cross-sectional analysis recruited a total of 2459 participants via Web 2.0 platforms. Survey data included socio-demographics; a range of lifestyle risk factors; medication; disease variables and depression risk using the Patient Health Questionnaire-2 (PHQ-2).
Results In total approximately one fifth (19.3%) of our sample screened positive for depression (PHQ-2 score ≥3). Several demographic factors were significantly associated with this depression risk in bivariate analysis. Regression analyses showed that poor diet, low levels of exercise, obesity, smoking, marked social isolation and taking interferon were associated with greater depression risk. Participants who supplemented with omega 3s, particularly flaxseed oil, had frequent fish consumption, supplemented with vitamin D, meditated, and had moderate alcohol consumption had significantly reduced depression risk.
Conclusions This study demonstrates a significant association between modifiable lifestyle factors and depression risk. Planned longitudinal follow up may clarify causality. Clinicians and people with MS should be aware of the wide range of modifiable lifestyle factors that may reduce depression risk as part of a comprehensive secondary and tertiary preventive medical approach to managing MS.
Multiple sclerosis (MS) is a chronic autoimmune, inflammatory and demyelinating disease of the central nervous system. Symptoms can include motor and sensory deficits, ataxia, visual impairment, bladder and bowel incontinence, cognitive impairment, pain and fatigue. However for people with MS it is depression, irrespective of disease severity that has the greatest impact on quality of life.
Depression is the most common psychiatric illness and co-morbidity for people with MS, who are also at higher risk of suicide and self-harm than others in the population. Severity of depression is a risk factor associated with suicide risk. For people with MS, the lifetime prevalence of a major depressive disorder is 50%, although an Australian study estimated an even higher rate of 67%. The annual incidence is estimated to be 20%.
Although the high prevalence of depression in people with MS is widely acknowledged, depression is under-recognised and poorly treated. People with MS who are depressed have increased use of outpatient and inpatient services, require comprehensive rehabilitative periods, and require more unsalaried care than those without depression. The timely and effective treatment of depression for people with MS is vital. Treatment should be provided by mental health professionals in collaboration with general MS care.
A recent Cochrane review of pharmaceutical treatment of depression in MS failed to find any antidepressant medication that was significantly effective in treating depression in this patient group. In fact a recent review of MS literature concluded there are no evidence based guidelines for either pharmacological or psychological treatments for people with MS and depression.
An emerging paradigm in the treatment of depression is lifestyle medicine. There is clear evidence that lifestyle factors are linked to the pathogenesis of mood disorders. Many lifestyle factors are modifiable yet there is often little consideration of this treatment strategy, and pharmacological and psychological therapies remain the first line treatment choices. A recent randomized controlled trial showed that modification of lifestyle factors (diet, sunlight exposure, exercise and sleep patterns) was an effective treatment strategy for depression. Evidence-based recommendations can also be made for the use of mindfulness-based meditation as a treatment intervention for depression in people with MS. There is strong evidence that smoking and lack of social support are risk factors for depression.[14,15] The evidence for lifestyle medicine encourages an integrative approach whereby lifestyle modification is a routine part of prevention and treatment for depression. Lifestyle medicine for depression brings additional benefits to general health, particularly in reducing the likelihood of other high prevalence chronic western lifestyle related diseases such as cardiovascular disease and diabetes.[10,13,16]
There appears to be significant potential to prevent and treat depression through modification of lifestyle risk factors for people with MS, although data are currently limited. In the Health Outcomes and Lifestyle Interventions in a Sample of People with Multiple Sclerosis (HOLISM) Study, we sought to understand the association between lifestyle risk factors amenable to modification and disease outcomes in general, through the analysis of self-reported data from a large international sample of people with MS. In this current study, part of the wider HOLISM research, we examined depression in particular, and its association with modifiable lifestyle risk factors and medication use, in order to better understand the potential for a secondary and tertiary preventive medical approach to managing depression in MS.[17–20]