What do I need to do to feel better and be happy again?

Question: I'm feeling really down and am on my 5th week on Cymbalta (60mg). I think it is changing my mood but it is not helping my pain. I feel no one cares or wants to listen and even i notice my husband is sick of it. I try my best but with leg pain, headaches and feeling drained it is hard to be happy. I am just surprised how downhill my MS is going and wonder is it my meds or because my meds are not working??

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Answer: Thank you very much for your question.  The first thing to keep in mind to help frame how you approach this is to recognize that mood symptoms, and depression and anxiety in particular, are very commonly experienced in MS and are much more prevalent than in the general population.  The second thing to keep in mind is that they are very treatable using medications counseling, and/or behavioral medicine (non medication approaches that can have a medication like effect) treatments.  Sometimes these symptoms represent a form a depressive or anxiety disorder, and other times they are secondary to other things, like adjusting to a new MS diagnosis, a new life event (positive or negative), other symptoms (like pain, headaches, cognitive problems, or new MS symptoms, etc.).  In your case it sounds like you are dealing with pain, headaches and fatigue in addition to the mood symptoms and that the medication you are currently taking, duloxetine (cymbalta) 60mg daily, is not helping after 5 weeks on treatment.  I have a few recommendations which I hope will help and give you some additional options to think about.

1) Duloxetine (cymbalta): Antidepressants reach full effect within 4-6 weeks of starting treatment.  Lack of effect at 5 weeks is a good signal to congtact your prescriber and discuss options.  It could be that further adjustment of the dose is needed (higher doses of duloxetine are often used in psychiatry and also for headache and pain management even though the usual maximum dose is 60mg daily), or that a different antidepressant is needed (it is not uncommon to need to try 2 or more antidepressant trials to find the "right" one).  It will also be helpful (I think) for you to further assess the type of headaches and pain that is present.  Duloxetine can help with certain types of pain (especially neurogenic pain) but less so with others and often needs to be supplemented (or replaced) with other treatments.  Same thing with the headaches. Duloxetine helps more with certain types of headaches and less so with others, and may also need to be supplemented (or replaced) with other treatments.  Finally, ruling out that your treatment resistant symptoms are due to a MS exacerbation is also important.  All of these considerations suggest that you talk with your providers for further assessment, guidance, and treatment planning at this time.  Depending on your situation, referrals to a pain specialist, a headache specialist, or both may be needed (but not always, often can be managed by your PCP and neurology specialists).

2) Effects of Fatigue: Fatigue can be a product of pain and also of MS, and can likewise reduce the pain threshold (how much pain you can tolerate) and worsen mood symptoms.  In the warmer summer months, heat (if you are heat sensitive) can exacerbate fatigue as well.  Practicing energy conservation and heat management techniques (including using cooling equipment when outdoors if needed) can help you keep the energy you have in the tank and to use it most effectively.  Doing so can minimize the effect fatigue has on other symptoms.  Self-monitor a bit to see if you notice worsening of pain and headaches and mood symptoms when you are more tired and if there is a daily pattern of this.  If so, there may be a fatigue effect involved.  A review of your medication list with your provider can also help to see if other medications you are on may be contributing to fatigue, headaches, or both (duloxetine is not know to commonly cause either).

3) Self-Monitoring for Depression: Feeling down is never much fun but it could be worse, and it is important to watch for signs that it may be worsening.  Losing interest in things you used to like to do (decreased motivation), decreased ability to enjoy pleasurable activities (anhedonia), increased isolation, decreased appetite for food or intimacy, difficulty with concentration (more than usual), difficulty sleeping, and thoughts of self-harm are all indicators that depressive symptoms are worsening and suggest that you should contact your provider for follow up immediately.  From your message I cannot tell if you are experiencing any of these things or just feeling down.  That being said, in mental health care, as well as in general health care, prevention and early treatment is often better than waiting for things to get worse.  Best to try and get your current symptoms better treated so they will not worsen.  But while you are working on that, keep these other things in mind to watch for as they can indicate worsening.

4) Non-medication options: Medicines are just one of many options that can help with treating mood symptoms and pain.  Non-medication options can often be used instead of medicines and are commonly used in combination with medicines for mental health and pain management.  Counseling can be very effective (especially if working with a counselor with experience helping people with chronic illness, I recommend cognitive-behavioral-therapy or CBT based approaches), especially in situations where difficult life situations are involved, relationships are involved, and/or if you are wrestling with difficult decisions or trying hard to adapt to a chronic health condition (like MS).  Oftentimes, counseling can have a faster onset of action than medication, especially if you have weekly counseling sessions.  Behavioral medicine approaches such as meditation, yoga, tai chi, progressive muscle relaxation, guided imagery, exercise (yes, general exercise), sleep hygiene, and others can also help.  A basic exercise plan (even getting outdoors and walking daily is a good start) will do wonders.  Add a daily pleasurable activity such as a hobby, etc. (even if just for 30 minutes) can also have a good effect (do it even if you don't feel like it, over time it will have a countering effect to the depressive symptoms).  Talk about these options with your providers to see which ones might be best for you.  Sometimes there can be a wait to start counseling (if you choose that option), but the good news is that there are many self-help options available that are actually quite effective and can be combined with traditional counseling approaches.  Two sources that have been really helpful for the people I have treated as a MS mental health specialist include The Relaxation and Stress Reduction Workbook and The Stress and Mood Management Program for Individuals With Multiple Sclerosis: Workbook.  Both of them are very user friendly, less than $20, and do not take a pile of reading to get results.  

I hope that this is helpful.  I think you are right on target to be concerned about your current symptoms and that your instinct is good to want to think about other options.  I hope the above is helpful for you as you think on your options and also for your discussions with your providers.  Best wishes :)

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BRANT J. OLIVER, PhD, MS, MPH, APRN-BC

Assistant Professor, School of Nursing, MGH Institute of Health Professions, Boston, MA
Adjunct Assistant Professor, The Dartmouth Institute and Departments of Community & Family Medicine and Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH
Faculty Senior Scholar, Dept. of Veterans Affairs National Quality Scholars (VAQS) Fellowship Program, White River Junction, VT
Faculty Nurse Scientist, Yvonne L. Munn Center for Nursing Research, Massachusetts General Hospital, Boston, MA
Neurobehavioral Specialist, Multiple Sclerosis Specialty Care Program, Concord Hospital, Concord, NH
Board Certified Nurse Practitioner (APRN-BC): Family Practice (FNP-BC) and Psychiatry (PMHNP-BC)

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