What treatment options are available for depression?
Receiving a diagnosis of ALS—and the associated process of coming to terms with a progressive disease and the life-limiting nature of ALS—constitutes a psychologically stressful and exceptional situation. Psychological stress can also arise during the course of the disease, caused by physical symptoms, life changes, and social challenges. Low mood may be associated with other psychological and physical symptoms, which collectively are referred to as depression (or depressive syndrome).
Typical symptoms of depressive syndrome include (in addition to low mood) sleep disturbances, a loss of appetite, and a reduced motivation to carry out daily activities (lack of drive).
There are various options available for “managing” or treating depressive syndrome, which depend largely on the severity of the symptoms and the patient’s attitude toward the treatment options. If low mood or sadness is experienced as distressing, modern antidepressants—which can be understood as “mood stabilizers”—may be used. These medications reduce the “low mood” without negatively affecting mental abilities or other cognitive functions.
The following medications are the preferred treatments for depressive syndrome in ALS: citalopram, mirtazapine, and amitriptyline. The choice of antidepressants depends largely on the accompanying symptoms of depression. Citalopram is preferred when, in addition to low mood, there is also a lack of motivation or ALS-related motor disinhibition. Mirtazapine is a particularly suitable medication when sleep disturbances are present (the medication promotes sleep and is preferably taken at night). Amitriptyline is an older antidepressant that has the side effect of causing dry mouth. This side effect can be deliberately “exploited” if an ALS-related swallowing disorder has led to excessive salivation (sialorrhea). In this scenario, treating depression with amitriptyline would be beneficial.
Overall, the fundamental decision to treat depressive syndrome with medication is made through a dialogue between the doctor and the patient. The selection and dosage of the antidepressant are based on the doctor’s expertise, taking into account the patient’s individual circumstances and needs.
In addition to antidepressant medication, psychotherapy can be another treatment option. A survey of ALS patients at Charité has shown that 25% of all people with ALS require psychological support. Psychotherapy is provided by medical specialists or psychologists who have undergone psychotherapeutic training and are licensed to practice. Within psychotherapy, various approaches can be distinguished (supportive psychotherapy, behavioral therapy, psychoanalysis, etc.), the selection of which depends largely on the individual situation, the patient’s attitude, and clinical needs. In the case of ALS, supportive psychotherapy is most commonly used, as it serves to provide emotional stabilization and strengthen the patient’s own psychological resilience. In Germany, psychotherapy can be prescribed by primary care physicians and specialists. One challenge is the limited number of therapists who provide psychological support to ALS patients and have experience with this condition.
When considering medication and psychotherapy together, medication plays a significantly greater role. Because these medications—most of which are well tolerated—are readily available, they can effectively stabilize mood.