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MS and Your Emotions (Transcript)

March 7, 2007 Teleconference with Dr. Robert Godsall

Operator: Good afternoon, ladies and gentlemen. My name is (Gerald) and I will be your conference operator.

At this time, I would like to welcome everyone to the MSF conference call. All lines have been placed on mute to prevent any background noise. After the speakers’ remarks, there will be a question and answer session. If you would like to ask a question during this time, please press star-1 on your telephone keypad. Again, if you would like to ask a question, please press star-1 on your telephone keypad. If you wish to withdraw your question, press the pound key.

Thank you.

It is now my pleasure to turn the conference over to your host, Ms. Christine Ratliff, Editor of the MSFocus, the national magazine of the Multiple Sclerosis Foundation.

Ms. Ratliff, please go ahead

Christine Ratliff: Thank you, (Gerald).

Good evening, everyone. Welcome. I’m so glad that you joined us.

As you know, the Multiple Sclerosis Foundation has designated the month of March as National MS Education and Awareness Month. So we are delighted to welcome you. And this is our National MS Education and Awareness Month teleconference series.

Tonight we’ll be speaking about MS and your emotions with Dr. Robert Godsall. Robert Godsall, Ph.D., is a clinical neuropsychologist at the MS Institute of Shepherd Center. Dr. Rob performs patient assessments to determine the impact of MS on cognitive functioning and emotions and provides counseling services to MS patients of the Shepherd Center.

Last year, Dr. Rob presented onboard the MSF Cruise for a Cause, educating us about depression, fear, anxiety, emotional lability and ways to recognize and manage these emotional challenges.

Dr. Rob also answers questions on emotional issues on our Ask the Doctor forum.

Let’s begin. Dr. Rob, could you provide a brief overview of the ways in which MS impacts a person emotionally?

Robert Godsall: Sure, Chris, I’ll be glad to do that.

First I want to say good evening, everyone, and welcome to the conference. I hope that this’ll be a very educational experience for you and hopefully will provide some information that can help you in regards to managing the emotional impact of MS.

This emotional impact is highly varied, much like MS itself. The ways that MS can affect emotions are – there are quite a number of them. The most common is depression, although anxiety and certainly other forms of emotional lability are also present.

Depression as I mentioned is probably the most common reaction to MS. You might say depression is the common cold of mental illness. Approximately 20 million to 30 million people experience some form of depression on a daily basis.

And there are many different kinds of depression. One is just kind of what we call the blues, which people kind of wake up with and just kind of feel off balance emotionally.

Another form of depression is bereavement, which is grief over the loss of a loved one. There are also dysthymic disorders in which people’s mood may fluctuate, primarily in a downward direction, but generally comes back up after a short period of time.

And then there are the major depressive disorders where people experience prolonged depression for quite a period of time and there doesn’t seem to be much relief from it.

Depression in MS is related in large part to the unpredictability and the chronicity that MS often imposes on the person’s life. And due to these factors, the core issue is often a perceived loss of control that can result in changes in a person’s belief about their personal efficacy. By efficacy, I mean the person’s ability to manage their lives and be successful.

The loss of personal efficacy is often reflected in three different areas. One is about the self, as I mentioned, in which the person, their belief about their ability to manage themselves in life and in their world is challenged.

Another factor in depression is what we call the future orientation. And in this situation, people become very focused on the future and what it’s going to be like and how their life is going to look due to the MS.

And finally, the world, which has to do with how people in their lives are going to respond to their MS and how that will affect their ability to just successfully live in the world around them.

Depression is – as I said, the most common reaction for people with MS. And frankly, the people with MS are at greater risk for depression than the general population, as well as other chronic disorders, such as diabetes.

And it’s so prevalent that it can happen at any time in the course of the disorder. As a matter of fact, research indicates that approximately 50% of people with MS will experience a major depressive disorder at some point in the course of the illness.

And as I mentioned earlier, depression in MS is very different from normal grieving in that generally with normal grieving in the person works through the loss, the depression resolves.

Unfortunately in MS, because of relapses and the chronic nature of MS, people may re-experience their depressive episodes.

Generally speaking, depression is treatable. It is very responsive to quite a number of medications that are now available, but it’s also treatable with psychotherapy and counseling to address the adjustment issues that occur when one is experiencing living with MS.

That about covers what I’d like to present at this point, Chris. Perhaps people have questions at this point?

Christine Ratliff: Sure.

Does anyone have any questions now, (Gerald)?

Operator: Ladies and gentlemen, if you would like to ask a question at this time, please press star then the number 1 on your telephone keypad. Again, if you’d like to ask a question, press star then the number 1.

And your first question comes from (Jeanette) in Montana.

Christine Ratliff: Hi (Jeanette).

(Jeanette): Hi Doctor.

Robert Godsall: Hi (Jeanette).

(Jeanette): Hi. Thank you for putting this on. I really appreciate it.

My question with depression, is – have you ever seen patients who just absolutely don’t respond to the therapies that are out there, the different medications and things?

Robert Godsall: There are a subset of patients who have difficulties, persistent difficulties and do not seem to respond well to the more I guess traditional or more commonly used treatments, particularly in regards to medication.

My experience is that then what needs to happen is they need to go to a psychiatrist and have their depression evaluated. Most of the time, the depression in MS is managed by the MS specialist or the neurologist, but for persistent depression, there may be other factors that are going on besides the MS, which may simply have exposed a vulnerability for the person, which they may have been just like I said, vulnerable to a depression.

Sometimes what we see are people who have an extensive family history of depression, so there may be some other biological bases for their depression. And as I said, at that point, probably seeing a psychiatrist to have an evaluation to determine maybe a different medication regimen can be considered.

(Jeanette): Thank you. Thank you.

Christine Ratliff: Thanks for the call.

Operator: And your next question comes from (Janine) in Maine.

(Janine): Hi. I can’t believe I’m actually asking a question.

Well, it’s not really a question per – (oh), wait, am I on or no?

Christine Ratliff: You are.

Robert Godsall: You are. Welcome (Janine).

(Janine): Okay.

What you described in the beginning about the (phases) of depression and stuff like that, it was totally me. From the time I learned about it in 1992, I’ve had it like since I was 18 and I (unintelligible)…

Robert Godsall: Your depression or the MS?

(Janine): The MS. But I think…

Robert Godsall: (Okay).

(Janine): …the depression as well. But I don’t think I’ve ever really acknowledged that all of this time that I was harboring all of my depression like deep down. But I got to do things, I got to get through college and blah, blah, blah.

But I – now I’m on actually long-term disability through my previous company. But anyway, so I’ve had a lot of time to think. And now I go to a psychiatrist and a therapist. And sure, there are lots of things that are not good right now. I just can’t believe that I still have that depression from 14 years ago.

And I think I’m going to shut up because I think I’ve talked too long.

Christine Ratliff: (That’s) an excellent point. What do you have to say about that, Dr. Rob?

Robert Godsall: Well, first of all, I’d like to know, are you on any medication for your depression?

(Janine): Yes.

Robert Godsall: Okay.

(Janine): Yes.

Robert Godsall: Have you been in any kind of counseling?

(Janine): Yeah, I’ve gone through a number of therapists until I found the one I liked. And…

Robert Godsall: Okay.

(Janine): …she’s absolutely wonderful. And I – and actually she was recommended to me by my psychotherapist because he is just incredible and helped me a lot.

But, you know, (it was) the insurance company wouldn’t pay for a lot of the, you know, a lot of sessions. So I just decided I could see him for medications and then go to my therapist. So that worked out well, thankfully.

Robert Godsall: Okay, good. Well, I’m glad that you’re finding that to be helpful.

As I mentioned earlier, you know, because of the chronic nature of MS and certainly relapses and other episodes that occur with MS, people often experience recurrent episodes of depression.

(Janine): I really don’t think mine’s ever gone away, though. That’s the thing. And I’ve been that kind of person my whole life anyway.

Robert Godsall: (Ah) okay, so…

(Janine): But…

Robert Godsall: So it was there before the MS was present? Was it before – it was there before you were diagnosed?

(Janine): No, I was very happy at that point and…

Robert Godsall: (Oh) okay.

(Janine): …because I was in college.

But this is like really bad this time. I mean, I know when I’ve had other episodes of this before. But, you know, I don’t share it with anybody. And – but this has been continuous since I’ve had MS. And I’m finally starting to talk about to my therapist.

And I’m saying the same things that I was saying in 1992 to myself still.

Robert Godsall: (Mm-hm).

(Janine): And that’s what worries me. Is my whole life just going to be a big ball of depression and just reliving the same moment over and over, you know?

Robert Godsall: (Mm-hm).

Well, I would say likely no, I don’t think it has to be that way.

(Janine): (Okay).

Robert Godsall: I would encourage you to keep working in the psychotherapy. How long have you been with this – the psychotherapist now who’s been so wonderful for you?

(Janine): I think (it’s) about a year and a half.

Robert Godsall: Okay.

(Janine): And my therapist I just started with I think in September perhaps, last September, or August.

Robert Godsall: Okay, so you have two psychotherapists?

(Janine): No.

I have a psychotherapist who prescribes (unintelligible)…

Robert Godsall: Okay, so you have a psychiatrist who prescribes your medication?

(Janine): Yes.

Robert Godsall: Okay.

(Janine): And then I have a therapist who just is an LCSW. And I talk to her every Monday at 1:00.

Robert Godsall: Okay, good. Good.

And this LCSW professional, this is the one that you’re finding to – that you really enjoy?

(Janine): (Oh) yeah. I love both of them. But she’s really – she really just gets me somehow where the other ones I never felt – besides my psychiatrist…

Robert Godsall: Okay.

(Janine): …(I never) felt that comfortable.

Robert Godsall: Good.

Because a therapeutic relationship is like any other relationship.

(Janine): (Mm-hm).

Robert Godsall: Some work, some don’t. And some it just takes time for a relationship to develop.

And you have been seeing this LCSW professional now for about, what, four or five months?

(Janine): Yeah.

And I feel like I’ve been with her forever, like she really does make me after sessions think about – like things will come up in my head that she said and I’m like (oh) my God, she’s right. Why do I do that, you know?

Robert Godsall: (Mm-hm). Okay, good.

Because I think that you have found the person with whom you can work and it’s going to be most effective for you.

Keep working with that person.

(Janine): Okay, I will.

Robert Godsall: Okay?

Because having a good relationship within the therapeutic relationship is probably the single most important aspect of the therapy.

(Janine): (Oh) definitely.

Robert Godsall: And it sounds like you’ve connected with this person very well.

(Janine): Very well, yeah.

Robert Godsall: Okay? So I…

(Janine): Thank you so much for the call.

Robert Godsall: Okay.

Christine Ratliff: Do we have any more questions right now?

Operator: We certainly do. And our next question is going to come from (Jennifer) in Arizona.

(Jennifer): Hi.

Robert Godsall: Hi (Jennifer). How are you?

(Jennifer): I’m fine, thanks.

Robert Godsall: Good. What can we help you with?

(Jennifer): My question has to do with depression and its relationship to the MS therapy that I’m taking or that anybody’s taking in terms of I’ve noticed that I’ve had probably continual depression since I switched from one medication to a different medication.

And I’m wondering if it’s possible that I need to switch medications again or if the antidepressant medication that I’m taking might eventually work? Or if it hasn’t shown that it’s worked in the past, I don’t know, two years, do I need to try something else?

Robert Godsall: When you say medication, are you talking about the antidepressant medication or the therapy for your MS?

(Jennifer): I’m talking about the therapy for my MS.

Robert Godsall: Okay.

Certainly the therapies for MS can have an effect on your emotions. I would, you know, if that medication is – has stabilized your MS, I would be very cautious about – certainly about changing that. Okay?

(Jennifer): Okay.

Well, I’m secondary progressive, so it’s kind of – I – the depression has gotten worse probably since I became secondary progressive. So it’s probably a combination of the fact that I don’t really have relapses. I just have sort of a continual slow increasing of my level of disability…

Robert Godsall: (Okay).

(Jennifer): …which I assume is contributing to more depression.

Robert Godsall: And that may very well be.

But any of the therapies for your MS, I mean, certainly the – you know, the primary concern for those – or the hope for impact by those therapies is that it slows the progression.

So while you may continue to progress, the therapy should certainly slow that progression down such that you can maintain, you know, a better quality of life in spite of the progression.

And so (when) I was saying about it that, you know, if it manages your MS, then I would not change it. Certainly if you want to discuss that with your MS specialist or your neurologist, you know, go ahead and do that.

Now you do mention, though, that you’ve been on an antidepressant for several years?

(Jennifer): Yes I have.

Robert Godsall: And you don’t feel like you’re getting any benefit from it?

(Jennifer): Well, I’ve been on different ones.

Robert Godsall: Okay.

Over that two year period? Or are you still on the same one?

(Jennifer): No, over that two-year period I’ve been on different ones.

Robert Godsall: Okay.

People have differential responses to all the medication, to the antidepressant medications. And, you know, generally speaking, most of them take anywhere from two weeks to four to six weeks before you feel a consistent effect and things are stable.

If you haven’t had that response, then I would go back to your neurologist or your MS specialist and discuss it with him or her and see about trying something different.

(Jennifer): Okay.

Yeah, I’m in the process of doing that. I just wondered if there was a relationship between the type of MS therapy and a worsening of depression, if there are some that are worse than others in terms of contributing to the depression.

Robert Godsall: Again, I think that’s a very individual response.

(Jennifer): Okay.

Robert Godsall: I don’t think you can necessarily say, you know, that a certain kind of person is going to respond to, you know, one of the therapies differently or consistently across all different kinds of people.

(Jennifer): Okay.

Robert Godsall: That’s why I’m saying I think your best bet is going to be to work with your MS specialist on this until you find the therapy combination, the medication combination that works best for you.

I’m also wondering, again, are you in any kind of counseling?

(Jennifer): I am actually. I see a psychiatrist. But I know that I do need to find a therapist that I can see on a more regular basis. I see a psychiatrist for medication management and have been for about a year. But I do not see a psychologist if you will. And I know that I need to see somebody in that capacity just to talk to on a more regular basis.

Robert Godsall: Okay.

I would encourage that you do that. You know, most of the research that evaluates treatment of depression usually looks at some combination of medication alone, psychotherapy alone, or a combination of medication and psychotherapy. And the research is very consistent in showing that the best combination is the medication and the psychotherapy together.

(Jennifer): Okay.

Robert Godsall: So I’m glad that you’re going to see your psychiatrist for the medication management. On the other hand, yes, I think you’re in the right track. I would very much encourage you to find a psychotherapist with whom you feel most comfortable and begin to address some of the adjustment issues associated with your MS.

(Jennifer): Thank you, Doctor. That’s exactly what I was wondering.

Robert Godsall: Okay?

(Jennifer): Thank you.

Robert Godsall: Okay. Have a good evening.

(Jennifer): Thank you, you too.

Robert Godsall: (Mm-hm).

Operator: And our next question comes from (David) in California.

(David): Hi.

Robert Godsall: Hey (David).

(David): Hey.

Robert Godsall: How are you?

(David): I’m actually wonderful.

Robert Godsall: Well good.

(David): Yeah.

I’ve had MS for 25 years and I guess I’ve been progressive since about 1999. And I haven’t really had much problem with depression, but I wanted to stress a couple of points that I haven’t heard yet.

And the first one, the most important one to me is the importance of physical activity.

Robert Godsall: (Mm-hm).

(David): You know, people call it exercise. I mean, exercise has the two wonderful effects of lifting your mood immediately just by some kind of chemical response that I don’t understand…

Robert Godsall: (Mm-hm).

(David): …and also by making you feel better about yourself, you know, like (the fact) that you’re doing it. And if you, you know, if you – especially things like lifting weights, you know, when you feel hopeless, like I can’t do anything, I can’t make any changes, and then you actually feel like you can – well, I actually can get a little bit strong here – that makes a big difference.

And when I don’t exercise, I’m in a lot worse shape mentally. So I really – and I know that for people with MS and people who are depressed, it’s not that easy necessarily to get moving, to get to, you know, to go out and move your body (and get it).

But usually there’s ways that we can do it, like in a swimming pool or in a chair or something. So I really wanted to recommend that because it’s made so much difference for me.

Robert Godsall: Good.

I think you have brought up an excellent, excellent point and I’m glad you did so.

The only reason why I hadn’t spoken to it is because it just hadn’t come up in the questions. But I am a firm believer in getting people who are experiencing depression doing some form of exercise, even if it’s just a brief walk daily to start out and then slowly extend the walk.

And the reason is exactly what you said. I think when people can go and do something and they can succeed at it, it begins to shift their beliefs about their personal efficacy. Because that’s what personal efficacy does is it just gives us a sense that we have some control over what’s going on with us.

And if we can succeed in achieving that, then that begins to form the foundation for as you put it for feeling better. So I fully agree with you in your recommendation that any kind of exercise people can do is just one of the best treatments for depression.

(David): Yes.

Robert Godsall: It’s not the be-all, end-all. I think you need to be involved with the medication and the psychotherapy as well. But, you know, you can do exercise every day whereas the – with psychotherapy, it tends to be once a week or once every couple of weeks. But the exercise can be done daily.

(David): (Yeah).

And I think there were some studies actually that show that. (Now) maybe not in MS, but in other conditions, that exercise is really valuable for depression.

And the trouble is things like walking, I mean, there’s a lot of – I can’t walk for exercise. You know, I…

Robert Godsall: (Mm-hm).

(David): …for me, walking is walking practice. It’s not exercise.

Robert Godsall: (Mm-hm).

(David): You know, but if I can get in the swimming pool…

Robert Godsall: (Right, right).

(David): …and put on a floatation belt or something and, you know, then you can do stuff or…

Robert Godsall: Right.

(David): So…

Robert Godsall: (Well, and) I realize that for folks with MS that walking may not be an appropriate thing to do. On the other hand, the reason why I say walking is that the exercise doesn’t have to be anything fancy.

(David): (Mm-hm).

Robert Godsall: It does not have to be extravagant. And certainly getting into a pool and just engaging in that kind of exercise, you’re absolutely right on that.

(David): Can I say one other thing?

Robert Godsall: Sure.

(David): I – you know, I’m the facilitator, one of the facilitators of the support group here in San Francisco…

Robert Godsall: (Mm-hm).

(David): …for many years. And we’ve had a number of members of our group who have told me that they were really depressed when they were taking one of the interferon therapies and that they didn’t realize it, (you know), sometimes until they came off the therapy. And they would say things like I never knew I was depressed until I stopped Avonex or whatever it was.

So I do think there is some – you might – like you said for her, the person who talked about that before to talk with her doctor. I would really encourage that because there may very well be another drug that isn’t going to have the same effect.

Robert Godsall: Absolutely.

And (what) we see here at the MS Institute of Shepherd Center is that it is a very individual response to the various therapies. Some people seem to do fine.

You mentioned Avonex. Some people seem to do fine on it. They do not have a depressive reaction. But if you were to put them on Copaxone or Betaseron or one of the others, then they have that difficulty.

That’s why I think, you know, get with the MS specialist that you work with and evaluate, you know, the choice of medication, the therapy that you’re on. So sometimes you just have to work until you find the right balance.

(David): (Right, right).

Christine Ratliff: (David), thank you so much for the call.

Operator: And our next question is going to come from (Isabelle) in Pennsylvania.

(Isabelle): Hi.

Robert Godsall: Hi (Isabelle).

(Isabelle): The caller that just called, that was a great call because exercise did help me.

But now the diagnosis was secondary progressive. And I believe that I am depressed.

Robert Godsall: Okay.

(Isabelle): I’m taking something called Aleve I think? Not Aleve.

Robert Godsall: Elavil?

(Isabelle): Yeah, Elavil.

But when I was given that, it was for pain.

Robert Godsall: Really?

(Isabelle): Yeah.

I take it because I also suffer with insomnia. And I take it at night to help me get to sleep.

Robert Godsall: Okay.

And Elavil is commonly used for sleep, to help people get to sleep. So, I mean, that makes sense.

How is this doing…

(Isabelle): (But)…

Robert Godsall: …for other things?

(Isabelle): …(unintelligible) I really don’t know where I’m at in the depression because I’m not sure, but I’ve been doing a whole lot of crying lately. And I went to the doctor, the one that told me I had secondary – had progressive. And the assistant said to me that that’s a symptom of MS, the crying all the time. That could be MS.

Robert Godsall: There is such a thing in MS. It’s – I mean, it’s certainly emotional ability. But typically with – what I think this assistant may be referring to is what we call the pseudobulbar affect.

And sometimes that gets confusing for people. Pseudobulbar affect as a manifestation of MS is typically when people burst into tears and there has been no trigger for the tearfulness.

And on top of that, in addition to that, the feelings they have inside, when you ask people with pseudobulbar affect about their feelings inside, they don’t feel sad. They don’t have the feeling that goes along with the tearfulness, or the other extreme is laughing. And it just seems to be uncontrollable.

On the other hand, if you are, you know, just having constant crying spells, that to me sounds more like depression. And I would encourage you to see a psychologist or a licensed clinical social worker and get that evaluated.

Because the Elavil certainly – can help stabilize mood and it will help you get to sleep at night, but…

(Isabelle): (Okay).

Robert Godsall: …you may need an antidepressant medication such as one of the what they call SSRIs or selective serotonin reuptake inhibitors that may be helpful in stabilizing your mood during the day, giving you some energy so that you can return to the activities you were doing earlier.

(Isabelle): Yeah.

Because when I first – when I got this diagnosis, it seemed like I was depleted down, down, down, down and…

Robert Godsall: (Mm-hm).

(Isabelle): Okay, Doc. Thank you for your help.

Robert Godsall: Okay. Have a good evening.

Operator: And our next question comes from (Deborah) in Arizona.

(Deborah): Hello?

Robert Godsall: Hello (Deborah)?

Robert Godsall: Hi.. What can I do for you?

(Deborah): My question is if you – the program is talking about the roller coaster of MS. And I’m thinking about the emotional roller coaster. I don’t feel like I need to be on an antidepressant, even though I feel depressed. But most of the time, it’s because I feel bad physically.

If I’m having a bad day because my MS symptoms are acting up or I didn’t get a good night’s sleep, then I’ll feel depressed. But if I have a good day and I got enough sleep and I feel emotionally like it’s a good day, then I don’t feel depressed.

And so I don’t feel like I need to be on a depression medicine. I’m seeing a therapist, but I’m not on medicine for depression because I feel like it’s, you know, like a roller coaster, like I’ll have a good day, then not good day. And so what do you think is the best for that?

Robert Godsall: Well, I certainly understand your reluctance to get on a medication, particularly if you have periods of, you know, where you feel good and, you know, you sleep well, everything is okay.

(Deborah): (Yeah).

Robert Godsall: You don’t have the negative physical experiences.

(Deborah): (Uh-huh).

Robert Godsall: What the medication would do, though, is just kind of help stabilize the roller coaster. It’ll smooth it out.

(Deborah): (Oh).

Robert Godsall: Okay? So that you don’t have the highs and lows.

(Deborah): (Uh-huh).

Robert Godsall: Okay?

And what that can help with is the bad days, the valleys on the bad days, don’t have to be so steep or deep. Then it allows you to move more rapidly or more quickly into – and transition into, you know, the more stable emotional period as opposed to the roller coaster.

So, you know, I might encourage you to think about your decision regarding the medication. And you might discuss it with your therapist also and see what he or she thinks.

(Deborah): Okay. All right, thank you.

Robert Godsall: Okay.

(Deborah): Okay.

Operator: Our next question comes from (Wendy) in Michigan.

(Wendy): Yes, thank you.

One thing that I’ve noticed with myself is I’ve been clinically depressed since 1990 and I started noticing my physical disabilities in 2004 and was diagnosed with MS in 2006.

And looking back since the early 90s, I was experiencing more of the depression in the cognitive parts of MS and then the physical part started showing up.

Is there any relationship to where the lesions are on the brain and with depression? And would those lesions cause like the chemical imbalance in our brain, Doctor?

Robert Godsall: Well, I’m not a physician, so when you ask about lesions in the brain, that’s something you might want to discuss with your physician.

I will say this – until recently, depression was considered kind of a response to the changes imposed by MS on the person’s life. And, I mean, it was considered just to be a normal reaction to those kinds of changes simply because as I talked about earlier, with depression, particularly grief, you know, was a response to loss or the interpretation of loss of abilities.

Over the last maybe year or two, people, professionals and researchers in MS have begun to wonder exactly what you’re asking. Is it possible that MS is more a symptom of – I’m sorry, depression is more a symptom of MS than a reaction to it, largely because of also what you indicate, that the – you know, the possibility that the lesions disrupt the – I guess the transmission, the neurotransmitters…

(Wendy): (Yeah).

Robert Godsall: …and creating depletions of neurotransmitters in the brain, and the same neurotransmitters that if they get depleted result in depression, particularly something like serotonin.

The research is far from complete on this, but it is something that is being considered. So, I mean, the jury is out on it at this point.

So I don’t think I can give you a – you know, a conclusive answer on your question. But I think that’s something that we’re, you know, that we’re going to be finding out over the next several years.

(Wendy): (Because) I know since the early 90s, I had been on several different types of antidepressant medications.

Robert Godsall: (Mm-hm).

(Wendy): And I know you kind of have to find the one that works with your own chemistry.

Robert Godsall: (Mm-hm).

(Wendy): And like I said, I found my cognitive problems and my depression were showing up first before my physical problems were.

Robert Godsall: (Mm-hm), (mm-hm).

(Wendy): So…

Robert Godsall: May I ask what kind of cognitive problems were you showing?

(Wendy): Like short-term memory…

Robert Godsall: (Mm-hm).

(Wendy): …and sometimes when somebody would explain something to me, (I’m able to) comprehend right away. They would have – and I’m a fairly intelligent woman. And they would have to explain it again to me.

Robert Godsall: (Mm-hm).

(Wendy): So there were – and my poor husband always repeating – asking him the same question in a matter of a few minutes…

Robert Godsall: (Mm-hm).

(Wendy): …those kind of things now that I look back, you know, over, you know, the past, you know, ten years or so. And I know my neurologist did do some cognitive studies on me when I saw her last fall.

Robert Godsall: (Mm-hm).

And what did she find? Do you remember?

(Wendy): Do I remember? Something very interesting that they found with the test that when I was listening to the sounds, whether my eyes were open and closed, even when my eyes were closed that my brain was just moving all over the place.

So I guess…

Robert Godsall: You were having trouble focusing?

(Wendy): Yeah.

Robert Godsall: Yeah.

And, I mean, depression does not exist in a vacuum as far as cognitive impact goes. I mean, when people are depressed, their fundamental neurocognitive processes, such as attention and concentration, as well as processing speed can be greatly affected.

(Wendy): Okay.

Robert Godsall: And if we’re having trouble attending to things…

(Wendy): Yes.

Robert Godsall: …then we are going to have trouble in kind of taking that information in and encoding it in a way that we can then recall it for later use, even if it’s just several, you know, minutes later, ten minutes later, what have you.

So people will often experience these kinds of difficulties as memory problems. So I’m not surprised to hear that you were having cognitive difficulties associated with your depression.

Now were these cognitive difficulties also maybe a symptom, kind of an early prodromal sign of your MS? We don’t know. But it certainly is possible.

And what you’re – I’m not familiar with the test that you’ve described that your neurologist used. But it certainly sounds like, again, that you were having a lot of difficulty concentrating and maintaining a focus.

(Wendy): Okay.

Robert Godsall: So, you know, I would certainly, you know, stay with – continue to work with your neurologist.

And did you mention if you were on medication?

(Wendy): Yes I am.

Robert Godsall: Okay.

Have you found the one that does work for you?

(Wendy): Yes.

Robert Godsall: Okay.

(Wendy): I’ve been on it for several years. It’s a serotonin reuptake medicine.

Robert Godsall: (It’s an) inhibitor, (yeah).

(Wendy): Yeah, (mm-hm).

Robert Godsall: Okay, good. Good.

(Wendy): (Yeah).

Robert Godsall: Well, I hope it continues to work well for you then.

(Wendy): And actually when they gave me the diagnosis of MS…

Robert Godsall: (Mm-hm).

(Wendy): …it didn’t put me into any whirlwind depression or anything. I just kind of, you know, I’ve accepted it and keep on keeping on.

Robert Godsall: Okay, good.

(Wendy): (Yeah).

Robert Godsall: Good.

Christine Ratliff: Thank you for the call. Take care.

Robert Godsall: Before we – okay, we – before we go to the next question, (Gerald)?

Operator: Yes sir?

Robert Godsall: Can I ask Chris something?

Christine Ratliff: Sure, go ahead.

Operator: (Certainly). Go ahead.

Robert Godsall: Okay.

Chris, is this going okay?

Christine Ratliff: Absolutely.

Robert Godsall: Okay.

Christine Ratliff: Absolutely.

I would like to interject for a moment, though, and give you a breather.

I just want to recommend three books for all of the listeners that are excellent on all of these things that we’re talking about. They’re all available through the MSF lending library. And they can also be found at your local bookstore or online. And all three of them are written by people with MS.

The first one is called, “MS and Your Feelings.” It’s by Allison Shadday. And she is a licensed clinical social worker who has MS.

The second one is, “Facing the Cognitive Challenges of MS.” That’s by Jeffrey Gingold.

And the third one is, “The Art of Getting Well – Five Steps to Maximizing Health When You Have a Chronic Condition.” And that is written by David Spero, who has MS and is also a registered nurse.

So if you want to borrow any of those books, just give us a call at 1-888-673-6287. They’re excellent and I think you’ll all find them helpful.

(Gerald), do we have some more calls?

Operator: We certainly do.

And our next question is going to come from (Hanitha) in Illinois.

(Haneefa): I’ve – there is a couple of things that you said. One was there was the mention of the exercise. I find that also because of the losses, you know, the feeling of loss of identity and status in the community and the whole thing as we lose, you know, abilities, gradually with picking up some of the things that I used to do, I do have a computer and that too and I’ve picked up some of my artwork.

The others, I mean, in terms of building self-esteem and self-confidence, I also have a therapist. And I went to her because of the pressure put on me by my family to – they’ll keep pushing and be the super person or whatever.

But I have found , I’ve had a couple of therapists. And they have been really good. But they both have a hard time actually talking about the replications of MS, like if something comes up because say the MS has affected my digestion or this or that or I lose – I’m worried about something else happening with my body, then there’s the cognitive therapy, which I think at times that can be overdone.

Christine Ratliff: Do you have a specific question that you want to ask Dr. Rob?

(Haneefa): I – well, I guess I’m saying that I think problem-solving for this situation, I think it can be – can it be there instead of the medications? Or not always medication? Medication – at – on – medication and then maybe off and like live life?

Christine Ratliff: Dr. Rob, can you help?

(Haneefa): Because there’s always going to be something coming up.

Robert Godsall: Kind of like Chris, I’m not clear what your question is. Are you…

(Haneefa): …by now, since this is the end of the show, I’m commenting.

Robert Godsall: Okay.

So you don’t have a question per se.

(Haneefa): Yeah.

I’m just – I’m saying as you kept putting the emphasis on the medicine, but there’s other ways too to help…

Christine Ratliff: Okay.

I think I know what you’re saying…

(Haneefa): …I’m saying for people to feel better.

Christine Ratliff: Right, right, like taking up hobbies and learning behavioral strategies that they can do to make things easier and pick up old hobbies that they had forgotten that they had and those kinds of things?

(Haneefa): Right.

Robert Godsall: (Sure).

Christine Ratliff: Right, right.

Robert Godsall: Yeah, no, I would agree with you.

(Haneefa): (The) medicine by itself isn’t going to make people necessarily feel better because what they want is their life back, one way or another.

Robert Godsall: You know, and a little while ago, I talked about research that evaluated the effects of, you know, various treatments, for example, for depression. And I talked about, you know, most of the studies look at medication alone or therapy alone or a combination. And that’s why I spoke to the combination of medication and the psychotherapy, as well as, you know, initiating activities on your own.

Most of the time when people are in psychotherapy, they go see somebody for an hour and then they leave. And psychotherapy, that hour alone, that – I mean, that’s going to be very productive for that hour, but you should be taking something home from that hour that you can do over the rest of the time between sessions, you know.

And I think what you’re saying is is that activities such as hobbies and what you do, for example, what you learn to do with the computer, absolutely, people need to do that, okay?

I mean, you can’t spend all of your, you know, hours in a week in psychotherapy. There has to be, I mean, life exists outside of that particular hour. And it’s up to you to initiate those activities (then).


Christine Ratliff: That was a great point. Thanks for calling.

Dr. Rob, I have a question.

Robert Godsall: Okay.

Christine Ratliff: All of these calls, except for I believe one, have been from women. And I’m wondering, does that mean that men don’t experience depression as often as women?

Robert Godsall: Well, I think most men would like to believe they don’t experience depression. But unfortunately they do. Men have a tendency to rather than talk about their feelings, they have a tendency to minimize those feelings and then take action on those feelings in the belief that, you know, whatever is going on with them emotionally will be discharged and they’ll be fine.

And to some degree that’s true. I mean, when we talk about the function of exercise and how it helps people feel better, (I mean), absolutely that’s true.

On the other hand, there’s a limit to how much benefit that you can accrue and maintain from activity because typically once you begin to stop the activity, then the feelings begin to build back up.

Men do a lot of times have difficulty talking about their feelings, so they tend to not show up on therapist’s office. And this is true across a variety of psychiatric disorders and probably across a variety of chronic illnesses.

Men do have a lot of difficulty with the adjustment issues because in our society and in our culture, I mean, we are groomed to be active and to do things rather than to think necessarily or feel about things.

So we tend to not access, you know, the resources to address the emotional issues associated with MS. And I think your point’s well taken. I don’t believe we’ve had an – well, we’ve had one call I think…

Christine Ratliff: (Yeah).

Robert Godsall: …from a male. And that was (David) in California.

Christine Ratliff: Right.

And also, a lot of the MS publications, MSFocus included I think, we feature a lot of people who are doing well with MS. And I…

Robert Godsall: (Mm-hm).

Christine Ratliff: …I wonder sometimes if that makes people who aren’t doing so well, you know, not want to admit that.

But I think it takes a lot of courage to admit that you’re depressed. Just to be on the phone listening is a big step.

Robert Godsall: Yes, yes.

I mean, it’s unfortunate, but I think even today, there is still a stigma that is, you know, attached to depression. People feel that, you know, it’s a – it is a very serious form of mental illness. And I’m not trying to minimize depression because it certainly is problematic.

But people tend to look at depression and develop, you know, ideas about well, you know, if I let myself feel depressed, you know, what are people going to think of me? What’s going to happen to my life? Am I going to kind of enter into this dark world from which I will never return?

And the answer to that is no. You will not enter into a dark world from which you will never return. Depression does tend to fluctuate. And I think the caller who talked about good days and bad days, I think that’s true.

But with psychotherapy and again medications and as well as the other things that people have talked about in terms of activities and exercise, the impact of depression can be minimized and can be reduced.

So, you know, I think there are other avenues. We just have to challenge people’s thinking about it.

Christine Ratliff: (Gerald), do we have a few more questions?

Operator: We certainly do. And our next question comes from (Claudette) in Georgia…

Robert Godsall: Hello Claudette?

(Claudette): Hello?

Robert Godsall: (Claudette)?

(Claudette): Yes.

Robert Godsall: This is Dr. Godsall. How are you this evening?

(Claudette): (Oh), doing great.

Robert Godsall: Good. What can we do for you?

(Claudette): I wanted to say since I’ve developed MS, I have these illusions that somebody’s coming through my door. And I also have this bubble that pops in my head. Sounds like a bubble, but (unintelligible).

Robert Godsall: Okay.

I think when you said illusion, maybe you mean a delusion?

(Claudette): Yes.

Robert Godsall: You – do you – I mean, do you recognize that somebody really isn’t coming through the door, but is – this is maybe a fear that you have?

(Claudette): Sometimes. And sometimes I call my family and tell them check the door, somebody’s at the door.

Robert Godsall: And…

(Claudette): And then my husband’ll come up and say see, the door is locked. And he’ll open it and he says see, nobody’s out there.

Robert Godsall: (Uh-huh).

And does that help?

(Claudette): Yes.

Robert Godsall: Okay, good. You know, then keep doing it. Ask him to check.

On the other hand, you know, I would talk with my MS specialist if I were you and let your MS specialist know about the delusions. There is medication that can help with those delusions…

(Claudette): (Unintelligible)…

Robert Godsall: …and reduce the fear of that.

(Claudette): (It seems) like I had something called Risperdal.

Robert Godsall: (Oh), (Risperadal). Okay.

(And) do you take the (Risperadal) regularly?

(Claudette): No. I haven’t taken it regularly.

Robert Godsall: Well, that’s probably going to be something that you need to do because if you take the (Risperadal) regularly, then it will help reduce those delusions. And your family won’t have to go open the door so often.

(Claudette): Okay.

Robert Godsall: All right.

Now may I ask why do you not take the (Risperadal) regularly?

(Claudette): It – I thought it seemed to make me weak. But I’ve really grown weaker. I’ve been in the bed for about five years. And the only time I get out of the bed is when I’m going to the doctor’s office.

Robert Godsall: (Mm-hm).

Yeah, that doesn’t sound like an effect of the (Risperadal) though.

(Claudette): Okay.

Robert Godsall: So, you know, you might want to just talk with your doctor. And I would encourage you to take the (Risperadal) on a regular basis. It may actually kind of help you get some strength in different ways.

(Claudette): Okay.

Robert Godsall: Okay?

(Claudette): (Mm-hm).

But I also told you I have this in my head, seems like a bubble’s bursting. And it’s always on the left side of my head. I don’t know why.

Robert Godsall: Are there any other symptoms that go along with that bubble bursting?

(Claudette): No.

Robert Godsall: Okay.

(Claudette): We went to Augusta one time and it – that trip took us 16 hours to get back home because somebody else went with us that had to go to another doctor. And then when I got home, it started. And I don’t know whether it lasts a day or two, but I have to be on oxygen when I go to bed. And I thought maybe that had something to do with it.

Robert Godsall: I have to be honest with you. I don’t have a clue. I’ve never heard of anything like that.

(Claudette): (Uh-huh).

Robert Godsall: That doesn’t mean it doesn’t happen for other people.

(Claudette): Yeah.

Robert Godsall: Does your physician know about these bubbles?

(Claudette): No. I don’t think I told him.

Robert Godsall: Well, I would…

(Claudette): (Unintelligible) next month.

Robert Godsall: Well, I would encourage you to tell your physician about the bubbles bursting.

(Claudette): Okay.

Robert Godsall: Okay?

(Claudette): (Uh-huh).

Robert Godsall: All righty. Good luck.

(Claudette): (Unintelligible).

Christine Ratliff: Thank you, (Claudette).

Operator: And your next question comes from Christian in Maryland.

Christian: Yes sir, thanks for taking my call.

I have depression pretty bad and I have had MS since they believe 1992. And the depression gets so bad – I’m on mediation for it, but it gets so bad at times that I get sort of like really I shouldn’t say violent, but like angered really easy.

Robert Godsall: (Mm-hm).

Christian: And I just wondered, I’m already on some type of – I’m on two different types of antidepressants. And some days I’ll feel really good. Everything depends on how much sleep I get at night.

Robert Godsall: (Mm-hm).

(Christian): If I don’t get enough sleep, then I’m pretty much shot the next day.

Robert Godsall: (Mm-hm).

(Christian): And I wondered, is there any medication that would keep you on, you know, one keel instead of (feeling) good one day and bad the other?

Robert Godsall: Do you take medication for sleep?

(Christian): I was taking Ativan for – to get to sleep. And then my psychiatrist said that I should try – this was something else that I wondered too – was melatonin. And I read on the bottle that it may cause depression. If you have any type of depression symptoms at all, that it might cause depression.

Robert Godsall: (Mm-hm).

(Christian): So I wasn’t sure if that was good to take at night or not.

Robert Godsall: Well, I was thinking more along the lines of, you know, a sleep medication such as trazedone…

(Christian): (Unintelligible).

Robert Godsall: …or Lunesta.

(Christian): (And that)…

Robert Godsall: …you know, that will really help you to sleep. Because it sounds like, you know, your anger outbursts have a lot to do with whether or not you get enough rest.

(Christian): Right, exactly.

Robert Godsall: So I think the key here is to make sure you sleep.

(Christian): Yes.

Robert Godsall: And it may be that one of the sleep medications will help with that.

Ativan is – and again, I’m not a physician, so I think this is something you need to discuss with your physician.

(Christian): (Okay).

Robert Godsall: But Ativan is what we call an anxiolytic. It’s a medication that’s designed to help reduce anxiety.

(Christian): (Yeah).

Robert Godsall: And it’s often given at night because when people get ready to go to bed, they may become anxious, which then interferes with their ability to go to sleep, because they can get agitated.

(Christian): Like a sedative, in other words.

Robert Godsall: I’m sorry?

(Christian): Like a sedative, in other words?

Robert Godsall: Exactly.

(Christian): Okay.

Robert Godsall: You know, so if the Ativan isn’t working, then you may consider again, you know, one of the other sleep medications.

I’m not familiar with the use of melatonin for that.

(Christian): (Mm-hm).

Robert Godsall: But – and I’d be reluctant, you know, to comment on that.

(Christian): I’m taking (unintelligible)…

Robert Godsall: (But if it’s) not working or you’re concerned about it, then again, go back to your physician, your psychiatrist, and let him or her know about that.

(Christian): This depression gets so bad that even the thought of doing something, like usually my joints’ll move real good, my limbs real well. But whenever I start thinking about something I have to do, it’s almost as if the depression takes over and it’s like (oh), I hate the thought of doing that. And my limbs don’t want to move, you know, the way that they basically should.

Robert Godsall: (Mm-hm).

(Christian): So I don’t know if that’s typical with the depression and MS. Is it the MS doing that or the depression? Is there any actual depression that bad that would cause a person not to be able to move their limbs like that? Or would it just be affecting the MS?

Robert Godsall: It could be one or the other. I mean, what you’re describing, where people have difficulty initiating activity…

(Christian): Right.

Robert Godsall: …with depression is what we call apathy. But apathy can also be, you know, a condition associated with MS depending on the location of the lesions.

(Christian): (Oh), okay.

Robert Godsall: Okay?

(Christian): (Mm-hm).

Robert Godsall: And there have been studies that looked at the use of central nervous stimulants such as Provigil to kind of help with that initiation.

(Christian): (Mm-hm).

Robert Godsall: So one of the things I would encourage you to do, again, is to do this with your psychiatrist or with your MS specialist and talk about one of the central nervous stimulants such as a Cylert or Ritalin, one of the CNS stimulants that’s become more widely accepted as Provigil. But a lot of times…

(Christian): My…

Robert Godsall: …that it’ll help with the initiation.

(Christian): My psychiatrist actually did give me a prescription for (provigil).

Robert Godsall: Okay.

(Christian): But I’m so allergic to like caffeine, if I even drink a cup of tea in the morning, I can’t sleep at night. It’s that bad, the stimulant, any type…

Christine Ratliff: (Christian), I’m sorry.

(Christian): That’s okay.

Christine Ratliff: I’m going to have to cut you short here because we’re out of time.

(Christian): Okay.

Christine Ratliff: I – I’m so glad…

(Christian): Thanks for taking my call.

Christine Ratliff: …that you called.

Robert Godsall: Thank you, (Christian).

(Christian): Okay, thank you, sir.

Robert Godsall: (Mm-hm).

(Christian): I appreciate it.

Robert Godsall: (Mm-hm).

Christine Ratliff: (Okay).

And (Christian) and anyone else out there who didn’t get all of your questions answered, please email me at chris – C-H-R-I-S – at msfocus.O-R-G. And I will do whatever I can to get the information to you.

And if you don’t have email, you can call me at 1-800-225-6495.

And Dr. Rob, you’ve been phenomenal.

Robert Godsall: Thank you.

Christine Ratliff: Thank you so much for sharing your expertise. We’d like to thank everyone for joining us.

Dr. Rob, do you have anything, any closing comment that you’d like to say really quickly to the listeners?

Robert Godsall: I’m talked out.

Christine Ratliff: Okay.

Robert Godsall: But I just want to thank everyone for joining us tonight. And I hope you will follow through with – for those of you who didn’t get your questions answered, please follow Chris’ suggestion. A lot of times, she and I will discuss people’s questions and we will try to address everybody’s question through other means.

Christine Ratliff: Thank you, Dr. Rob. And thank you to everyone who called in. Thank you, (Gerald). You did a great job. And also thank you to Berlex for providing the educational grant for National MS Education & Awareness Month.

Goodnight everyone.

Robert Godsall: Goodnight.

Operator: So ladies and gentlemen, we do appreciate your participation this evening. You may now disconnect your lines.



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