Abstract
Multiple sclerosis (MS) is a chronic demyelinating disease of the central nervous system with a significant comorbidity with depressive disorders. Prevalence rates for major depressive disorder (MDD) range from 36% to 54% and the rate is around 22% for adjustment disorders. Selective serotonin reuptake inhibitors (SSRIs) are considered well-tolerated first-line treatment. Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) are generally reserved for second-line use after SSRIs, because of sedating or anticholinergic side effects. SNRIs, with the exception of duloxetine, and combinations of newer antidepressants have failed to treat depression due to their side effects profile and frequent interaction with other drugs. Among SSRIs, sertraline is usually the first option, starting at 25mg/day and increasing to 50mg/day; and waiting a few weeks to assess drug effects before increasing the dose. The maximum is generally 200mg/day in a single dose. Paroxetine is the second choice, starting at 10mg/day for the first 5days, and then at 20mg/day thereafter. The maximum dose is about 50mg/day in a single dose. Fluvoxamine is used at 100-200mg/day, starting with 25mg/day, and increasing 25mg/day every 5days until 200mg/day is reached. We should take into account increasing blood level amounts of MS treatments (corticosteroids and cyclophosphamide) with fluvoxamine. With duloxetine, doses will be at 60-120mg/day. The initial dose for depression is 40mg/day in two doses; it can increase to 60mg/day in one to two doses if necessary. The maximum dose is generally 120mg/day. Duloxetine may increase liver problems through interaction with these MS treatments: teriflunomide, interferon beta-1a, and interferon beta-1b. Considering psychotherapy, only cognitive behavior therapy and mindfulness-based interventions have shown efficacy in improving depression disorders in MS. A comprehensive treatment for depression should include pharmacotherapy and psychotherapy.
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