HealthyLiving
HIGHLIGHt
Connecting
the dots
Managing the combo of brain
fog, fatigue and depression
by Amy Paturel
A s a medically retired
special agent for the
Air Force and a deco-
rated veteran, Jeff Haugh,
34, of Maryland, started
his consulting business,
SilverStar, to offer services
to people with disabilities,
especially wounded soldiers.
But when he developed MS
symptoms of cognitive impair-
ment, fatigue and depression,
Haugh realized he couldn’t keep
up with daily demands.
“I was used to taking on
ambiguous challenges and
defeating the problems with
effort,” Haugh said. “But the
fatigue was so debilitating that
I could not will myself to get
things done, and I couldn’t reju-
venate myself with sleep.” That
led to poor performance and
depression.
Fatigue and depression
overlap
Experts say Haugh’s experience
is not uncommon. “Fatigue and
depression overlap,” said Dawn
Ehde, PhD, professor of rehabil-
itation medicine and investiga-
tor with the University of Wash-
ington Rehabilitation Medicine’s
nationalMSsociety.org/magazine
Multiple Sclerosis Rehabilitation
Research and Training Center
in Seattle. “Depression makes
fatigue worse, fatigue makes
depression worse, and both of
these make cognition worse.
So all of these things are really
interactive.”
Brain fogs
A person with MS
may not be physically
tired, but mentally, he
or she is spent. Studies
show that up to 50% of
people with MS experience
cognitive impairment, and for
10% of those people, the defi-
cits are severe. “These cognitive
effects don’t correlate at all with
physical impairment,” said
Dennis Bourdette, MD, chair
and Roy and Eulalia Swank
Family Research Professor in
the Department of Neu-
rology at Oregon Health
& Science University in
Portland.
So what does this
brain fog look like?
According to Dr. Ehde,
it can range from little or
no impairment to signifi-
cant disruptions in cognitive
processes, including memory,
word finding, and attention and
concentration. People with MS
often have difficulty multitask-
ing. They can be disorganized
and have trouble coming up
with words when they want to
use them. They might misplace
items, misperceive things, and
have trouble with executive
functioning skills, such as orga-
nizing information, planning
and strategizing.
The work-arounds
Unfortunately, there’s
no pill for cognitive
impairment. “The
drugs that are used
in Alzheimer’s disease
have shown no benefit,” Dr.
Bourdette said. Instead, people
with MS have to learn to work
around these difficulties. If
you’re having trouble remember-
ing what you need at the grocery
Momentum • Winter.2010–11 39
HealthyLiving
store, for example, make a list.
Trying to multitask? Turn off
the TV and eliminate outside
distractions. Find yourself fading
at 2 p.m.? Make sure to perform
cognitively demanding tasks
before noon. “There’s a host of
things patients can do to mini-
mize the impact of cognitive
difficulties,” said Dr. Bourdette.
“It just requires recognizing
and accepting that you have a
problem.”
He recommends a neuro-
psychological evaluation to
assess your cognitive status.
Working with a neuropsy-
chologist will help you identify
strengths and weaknesses and to
use strengths to overcome the
areas that aren’t working so well.
Hitting the wall
Ask people with MS what their
most disabling symptom is,
and many will say it’s fatigue.
It’s difficult to concentrate and
perform well when you’re tired.
So there’s certainly a connection
between fatigue and cognitive
function. The trick, say experts,
is learning how to work with the
exhaustion, not fight against it.
“The proven approaches to
improving fatigue are pacing
yourself, avoiding excessive heat,
exercising regularly, taking naps
and learning energy conservation
strategies,” said Dr. Bourdette.
“Unfortunately, many neurolo-
gists reach for their prescription
pad as the first option for
managing fatigue.” And while
a couple of medications show
40 Momentum • Winter.2010–11
some benefit for fatigue, there’s
evidence that exercise and energy
conservation are more effective
approaches to these issues.
Working smarter
After Haugh put himself in situ-
ations where he expected to do
well and realized he couldn’t, he
learned he had to work smarter,
not harder. “I have been forced
to assess where my energy is
during the day and how not to
waste it,” he says. “From 10
to 12, I can think pretty
clearly, but from 4 to 8,
I’m not that great. So
I do challenging tasks
earlier in the day.”
That pattern is com-
mon for people with MS,
said Adam Kaplin, MD, PhD,
assistant professor in the depart-
ment of psychiatry and neurol-
ogy and principal psychiatric
consultant to the MS sector at
Johns Hopkins University in
Baltimore. “With classic autoim-
mune fatigue, people have more
energy when they wake up,
but at 2 or 3 in the afternoon,
they hit a wall,” he said. “That’s
different than the kind of
fatigue where from the moment
you wake up to the moment
you go to bed at night, you’re
exhausted. That type of fatigue
is more likely to be depression
or a medication effect than auto-
immune fatigue.”
Beating back the blues
Given the unpredictable and
progressive nature of MS, it’s not
surprising that depression is a
hallmark of the disease. In fact,
the lifetime risk of major depres-
sive disorder among people with
MS is 50%. Compare that with
the lifetime prevalence of depres-
sion among people without MS:
7% to 12% among men and
20% to 25% among women.
“Depression is the third-
leading cause of death among
people with MS, and it’s the
number-one correlate of quality
of life for people with MS,”
Dr. Kaplin said. But
depression in people
with MS isn’t always
about pain or the loss
of cognitive or physical
ability. Depression in MS
is often a result of a chemi-
cal change in the brain.
“We don’t fully understand
the causes,” Dr. Ehde said.
“Certainly, not being able to do
what you want to do or what
you used to be able to do is one
big contributor. But there’s also
the underlying brain mecha-
nisms. Depression may be a
result of the MS disease process
itself. Neurologic and neuroim-
munologic changes in the brain
may contribute to depression in
MS.”
Depression is treatable
Fortunately, there are good treat-
ments for depression. Many
people with MS respond well
to selective serotonin reuptake
inhibitors (SSRIs). These drugs
are often the first line of defense
because they can be taken once a
day, and, unlike tricyclic antide-
pressants, they don’t exacerbate
the primary symptoms of MS,
including cognitive impairment.
In fact, taking SSRIs may actu-
ally protect your brain from the
MS attack. These meds act as a
sort of protective coating for the
brain.
“In terms of treating depres-
sion, you really want a multi-
modal approach,” said Dr. Ehde.
“There are medications, and
there’s also cognitive/behavioral
therapy where patients can learn
new ways of thinking, acting,
and coping with their disease
and the depression.”
There’s also some promis-
ing literature suggesting that
regular exercise among people
with MS may reduce depres-
sion. A 2005 study found that
exercising three times a week
for 45 minutes is as effective
as the prescription antide-
pressant Zoloft in reducing
symptoms of depression.
And exercise is
associated with a
lower depres-
sion relapse
rate com-
pared with
medication.
“Of the
three—
cognitive
impairment,
fatigue, and
depression—
depression is the easiest
to treat,” Dr. Bourdette said. “If
you correct the depression, you
nationalMSsociety.org/magazine
may also impact the cognitive
impairment and the fatigue.”
Where meds and symptoms
intersect
Medications to treat the MS
itself, not the symptoms, may
help keep your brain sharp and
focused. “As far as we know,
the disease-modifying therapies
(like interferon or glatiramer
acetate) don’t impair cogni-
tion,” said Dr. Bourdette. In
fact, these meds may reduce the
number of new brain lesions
forming, and that lowers the
risk of developing cognitive
impairment.
Unfortunately, that’s not
the case with medications used
to treat symptoms like fatigue,
spasticity or pain. In fact,
according to Dr. Kaplin, meds
are one of the top three causes
of cognitive impairment. People
with MS may get placed on anti-
epileptic drugs, for example, not
because they have epilepsy,
but because anti-
epileptic drugs
help manage
neuropathic
pain. Many
of the anti-
epileptic
drugs can
cause trouble
with memory,
information
processing, and
clear thinking.
Drugs used to fight
fatigue also negatively affect
brain function.
Do a drug review
“When people are experiencing
cognitive problems, it’s impor-
tant for them to do a careful
review of all of the medications
they’re taking (in conjunction
with their neurologist) and
make sure they need to be on
them,” said Dr. Bourdette. It’s
not uncommon for people with
MS to take a stimulant during
the day to manage their depres-
sion followed by a sleeping pill
at night to reverse the
stimulating effects of
their “day drug.”
“As you start
treating the side
effects of one med-
icine with another
medicine, soon you
get into a territory
where patients need
to be detoxed,” Dr. Kaplin
said. Once your system is clear
of medications, you’ll be better
equipped to determine which
symptoms are a result of MS
and which are related to your
prescription cocktail.
Strategize your defense
“Everyone gets older and deals
with physical and cognitive
decline,” said Haugh. “The silver
lining is that MS forces you to
address these tough issues sooner,
ask yourself tough questions, and
deal with the tough answers.”
For Haugh, that meant tak-
ing a more strategic approach
and reserving his energy for the
most important things in life. It
also meant eating a healthy diet,
Momentum • Winter.2010–11 41
HealthyLiving

taking a few choice supplements, you’re not going to with MS become their
like vitamin D and a pharmaceu- solve,” he said. own advocates,
tical-grade omega-3 fatty acid, do their own
being physically active and stay- Learn from research, go to
ing on top of MS research. “It’s others support groups,
like solving a puzzle, but always Dr. Kaplin try different
keeping in mind that it’s a puzzle suggests people treatments,
read articles,
and stay active
Tackling three symptoms at once in the world of
If you’re having problems with cognitive function, MS. “Doctors only
fatigue and depression, it’s critical to find ways to work have about 35% of the
around these issues. The first step is meeting with a quali- information patients need,”
fied health-care professional who can help you organize your he said. “We need to learn more
life more effectively. Then, try incorporating the following strate- about this illness, especially the
gies to maximize your energy and enhance your quality of life. underappreciated above-the-neck
1. Get support—Several studies show that people are happier effects that are woefully under-
and healthier when they’re emotionally engaged. Make time for studied. In the meantime, talk to
friends, attend support groups, play a sport. Social interaction can other people and ask what they’ve
lift your mood and reduce your symptoms. found that helps.”
2. Exercise—Exercise stimulates the growth of new neurons Experts agree that cogni-
in the brain, and it’s a proven mood booster. Swimming and yoga tive impairment, fatigue, and
are particularly useful because they are gentle forms of exercise depression can occur at any
that are easy on the joints. level of physical disability. But
3. Strategize—Take stock of when you’re at your best and there are treatment options
schedule tasks that require brainpower during that window. If you to help people manage the
think more clearly in the morning, set aside time from 8 a.m. to 10 symptoms and lead fuller lives.
a.m. to make important decisions. Things like exercise, nutrition,
4. Slow down—Control the speed of conversations by para- and cognitive behavioral ther-
phrasing what the person just said. So say things like, “Let me apy may not cure MS, but they
make sure I understand what you’re saying,” and then repeat what can enhance people’s quality of
they said. “People like that,” said Adam Kaplin, MD, PhD, assistant life. “I’m not in a war against
professor in the department of psychiatry and neurology and MS,” Haugh said. “It’s just as
principal psychiatric consultant to the MS sector at Johns Hopkins much a part of me as anything
University in Baltimore. “And it also serves the function of making else, and I’m learning to deal
sure you’re slowing the pace down to a manageable level so you with it the same way I deal with
don’t get derailed.” other things”—by taking it one
5. Take advantage of technology—BlackBerries, iPhones, day at a time.
computer programs, and other gadgets can help you stay on top For a list of references for this
of your schedule and manage tasks. Dr. Kaplin also recommends article, visit nationalMSsociety
a service he created called Mood 24/7 to help you track changes .org/dotref. n
in mood and identify what caused those changes. For details, visit
mood247.com. Amy Paturel, MS, MPH, is a freelance
health writer in Murrieta, Calif.

42 Momentum • Winter.2010–11 nationalMSsociety.org/magazine