For those of us who have been watching the mental health space with bated breath, we have much to be encouraged about. In recent years, the COVID-19 pandemic has put a harsh spotlight on the issue of mental health, and how both health and economic factors can translate into poorer mental health. 

In the UK, members of the royal family have openly spoken about their own mental health struggles and have supported charities that encourage others to do so. In the United States, there has been a mushrooming of mental health apps, often led by licensed clinicians, that have put mental healthcare within touching distance of anyone who seeks it.

In the rare/chronic disease space, we are also watching as physicians begin to give greater weight to the mental health toll of contending with a disease with hardly any downtime. As a patient, it can be deeply uncomfortable as physicians talk about every clinical parameter except those that relate to mental health. 

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Instead, what we need to do is to recognize the indispensable value of sound mental health as it relates to a person’s well-being. For example, a patient with multiple sclerosis is not just (relatively) well when physical symptoms are well-controlled; instead, a patient can be said to be truly well only when he or she has a measure of self-confidence, is able to interact with others in a meaningful way, and possesses hope for the future. 

Invisible Disease Upon Invisible Disease 

The unique toll of multiple sclerosis on the well-being of patients is twofold: first, many of the symptoms experienced by patients with this disease are not necessarily obvious to those around them; second, the mental health cost of the disease is likewise invisible. 

Read more about multiple sclerosis prognosis  

Let’s quickly review what existing studies tell us about multiple sclerosis and mental illness. One perspective suggests that disease-modifying treatments can have an “unmasking” effect; in other words, underlying depressive symptoms rise to the surface once treatment is started. The alternative view is that existing depression is made worse by the commencement of disease-modifying therapy. 

In addition to mental health issues, patients with multiple sclerosis are also vulnerable to substance abuse, such as alcohol and drug abuse. In younger children, there have been reports of difficulties adjusting in school and interacting normally with peers. 

Sparaco and colleagues conducted a study into the psychiatric elements and disorders associated with multiple sclerosis. The study was published in the Journal of Neurology. 

In a number of the studies reviewed, researchers used varying questionnaires or scoring systems to assess the extent of mental illness. Significantly, the depressive scores attained by all the questionnaires showed similar characteristics and suggested that there is a high prevalence of mental illness among patients with multiple sclerosis. 

“Suicide is a relevant consequence of a depressive syndrome in [patients with multiple sclerosis],” the authors wrote. “The standardized mortality ratio (SMR) is the most correct method to analyze suicide in [multiple sclerosis]. In [patients with mutiple sclerosis], SMR for suicide is twice that of the general population.” 

Insights From Brain Imaging 

Is there more to depressive symptoms among patients with multiple sclerosis than difficulty coping with the diagnosis? As published in Neurological Sciences, Masuccio and colleagues conducted a study in which they proposed that brain damage peculiar to multiple sclerosis may be associated with worsening depression. 

“When considering the demyelinating brain injury, the possibility that depression and depressive symptoms in [patients with multiple sclerosis] might be in some way related to the structural brain alterations has been abundantly debated,” they wrote. 

The field of neurology is in a sense both ancient and young; ancient because physicians throughout the centuries have sought to understand the brain and how it relates to physiology, and young because new imaging modalities have helped us uncover the inner workings of the brain in stunning detail, often raising more questions than answers. 

Read more about multiple sclerosis diagnosis 

Brain atrophy that occurs in multiple sclerosis can be tracked by magnetic resonance imaging (MRI). In one study, patients with right temporal atrophy suffered from worse cases of depression. In another study, patients who were diagnosed with depression were found to have higher atrophy of the left anterior temporal region and less grey matter volume. 

“The brain lesions embody the expression of the inflammation and demyelination peculiar to a neuro-inflammatory disease such as [multiple sclerosis]. In turn, according to the studies considered, brain damage might represent one of the determinants of depressive status,” Masuccio and colleagues wrote. 

Hence, we can conclude that physical brain damage may predispose a patient to depression, and it may be made worse by the clinical limitations the disease causes. The million-dollar question that remains is “what we are going to do about it?”

Certainly, clinical research into how depression can be potentially addressed through the reversal of brain damage should be explored. However, on a more practical clinical perspective, physicians need to be better at picking up signs and symptoms of depression, offer a listening ear, and prescribe treatment and psychotherapies to help patients overcome the mental health aspects of their disease to the best of their ability. 


Masuccio FG, Gamberini G, Calabrese M, Solaro C. Imaging and depression in multiple sclerosis: a historical perspectiveNeurol Sci. 2021;42(3):835-845. doi:10.1007/s10072-020-04951-z

Sparaco M, Lavorgna L, Bonavita S. Psychiatric disorders in multiple sclerosisJ Neurol. 2021;268(1):45-60. doi:10.1007/s00415-019-09426-6