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7 Ways to Break the Cycle of Low Mood and Chronic Pain in MS

Managing MS

September 21, 2023

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Photography by MirageC/Getty Images

Photography by MirageC/Getty Images

by Stephanie Orford


Medically Reviewed by:

Susan W. Lee, DO


by Stephanie Orford


Medically Reviewed by:

Susan W. Lee, DO


Pain and low mood are intertwined in multiple sclerosis (MS). Pain can lead to depression, and depression may cause increased sensitivity to pain. To break the pain-depression cycle, treat both together.

The negative feedback loop of low mood and chronic pain can be a major challenge if you have multiple sclerosis (MS).

Some 50–75% of people with MS live with pain versus just one-fifth of people with chronic pain in the general population.

Research has found that people with chronic pain are also more likely to have significant depression. And when you have MS, you may be at greater risk for both. But medical and at-home treatments can help you break the cycle and improve both.

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The chronic pain-low mood link in MS

Chronic pain and low mood have a two-way relationship in MS, explains Dr. Anthony Feinstein, professor of neuropsychiatry at the University of Toronto and author of the book “Mind, Mood and Memory in Multiple Sclerosis.”

“Pain is obviously a very difficult symptom to live with. It can be disabling, and that can trigger depression,” he says.

“You can’t do things you want to do,” he explains. “And of course when you’re living with constant discomfort, that can wear you down. So it’s easy to understand how people who have pain that’s intractable, that doesn’t respond as you’d hoped to treatment, can lead to depression.”

On the other hand, people who are depressed are more sensitive to pain, Feinstein explains. “Your emotional distress, in a way, increases your sensitivity or your awareness of physical problems, so that a physical problem can take on a magnitude that it normally would not have.”

When you’re depressed, you can perceive the pain as being more intense or lasting longer, he says.

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Unraveling the connection

Scientists don’t fully understand how chronic pain and depression are interrelated neurologically. Some researchers believe that the inflammation in the brain that happens in MS can impair neurological functions like reward processing.

Inflammation and its associated compounds in the central nervous system have also been shown to be linked with both pain and depression.

Putting these possibilities together, some experts believe that the reduced ability to experience reward in MS may lead people to experience low mood. However, the connection isn’t fully clear and more research is needed.

In addition, evidence suggests that pain and depression occur in overlapping regions of the brain and share many of the same signaling pathways and neurotransmitters, such as serotonin and dopamine.

And when your pain or mood gets worse, it can cause the other to worsen along with it.

“You get trapped in this pathological loop of the two symptoms feeding off one another. And that’s very often what takes place in someone with MS who’s got pain,” Feinstein says.

That’s why if you have both chronic pain and depression, it’s critical to treat both conditions at the same time — ideally from the same team of specialists working together toward the same goal, Feinstein says.

7 ways to reduce depression and chronic pain when you have MS

Treating both chronic pain and depression at the same time seems to be the best way to reduce both. You can’t treat one and expect the other to go away along with it. The following are some of the best ways to treat both.

1. Cognitive behavioral therapy

Depression can set in when you feel powerless at the whims of your symptoms, Feinstein says. “Pain is a particular symptom that can dominate your life. Depression, too.”

Cognitive behavioral therapy (CBT), a type of talk therapy, is “the treatment of choice” for people with MS who have pain and depression, says Feinstein.

“Ultimately [with CBT], you want to come to a point where you control your symptom and the symptom doesn’t control you. So, how can I live with the symptom without the symptom taking over my life,” he says.

CBT can help reduce neuropathic pain specifically, according to the National Multiple Sclerosis Society.

2. Medication for depression

If you have depression, taking an antidepressant medication alongside therapy can help.

Feinstein recommends speaking with your doctor to find an antidepressant that matches your particular symptoms.

For instance, the drugs duloxetine and venlafaxine are often used for neuropathic pain in MS, but they also have antidepressant effects, so one of these may be a good option if you’re experiencing both pain and low mood, he says.

3. Practice mindfulness

Mindfulness and meditation practices can help improve your mood and may also help reduce neuropathic pain in people with MS, according to the National Multiple Sclerosis Society.

In a study from 2015, people with chronic pain experienced “noticeable improvement” in their chronic pain, as well as in depression and anxiety when they practiced mindfulness meditation 3 days a week and performed other mindfulness practices at home daily — including mindful eating, walking, breathing, body scans, and mindful inquiry — for 8 weeks.

4. Exercise

Getting active in ways you enjoy can help manage symptoms of MS.

Exercise can help improve your mood, cognitive function, and many other physical issues associated with MS, such as muscle strength throughout your body.

Research has shown that doing low to moderate intensity aerobic exercise regularly for as little as 4 weeks can have significant benefits on mood and longer-term quality of life in people with MS because it can help improve mobility and balance and reduce fatigue.

Many people with MS enjoy at-home exercises and water aerobics, and there are many more options.

And don’t forget to stretch. Stretching helps relieve the pain that happens with stiffness when you’re experiencing spasticity.

A physical therapist can provide personalized exercise recommendations.

5. Consider taking medication to relieve pain

Taking the right pain relief medication can go a long way toward pulling you out of the spiral of low mood and chronic pain. It’s important to ask your healthcare professional to recommend the right one.

The type(s) you take will depend on what’s worked for you in the past and what types of pain you have.

Here are three main types of pain in MS and the types of medication people often take for them:

  • Neuropathic pain: Anti-seizure medications and sometimes anti-depressants work for this type of pain. On the other hand, this type of pain usually doesn’t respond well to opioids or over-the-counter pain relievers like acetaminophen.
  • Musculoskeletal pain: This is when you experience physical strain or injury as a result of MS muscle weakness — such as falls or repetitive strain injuries. For this, it helps to take pain relief medications, including nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen.
  • Spasticity: Reducing stiffness is the goal with pain related to spasticity. Muscle relaxant medications can help.

Opioid pain relief medications can have a potent effect on some types of chronic pain, though they’re less effective for neuropathic pain and carry a risk of dependency, so they’re typically not recommended for MS pain. Still, they are sometimes used as second- or third-line treatments, or for pain that can’t be resolved with other treatments.

A 2017 study suggests some of these drugs may also help treat depression.

If you’re interested in taking or switching your pain relief medication, speak with your doctor.

It’s critical to note that some pain medications may not work well in people with depression because of their side effects. For example, a common drug called pregabalin that’s sometimes used off-label for neuropathic pain in MS has side effects including sedation, which may feed into the cycle of low mood, says Feinstein.

That’s why it’s important to tell your doctor about your low mood when they’re treating your pain — so they can make sure to give you the right prescription for your symptoms as a whole.

6. Endorphin-boosting activities

Your body produces feel-good chemicals on its own — compounds including endorphins, enkephalins, and other “endogenous opioids” — in response to particular activities or events, such as:

7. Get a massage

Massage can help if you’re experiencing musculoskeletal pain, which can occur due to falls, or strain or discomfort due to changes in gait, says the National MS Society.

Though more studies are needed, some research suggests that receiving massage therapy may help with depression in other chronic conditions, including rheumatoid arthritis, fibromyalgia, and breast cancer.

Studies have suggested that moderate pressure massage decreases adrenocorticotropic hormone (ACTH), a precursor of the stress hormone cortisol. And it increases oxytocin, a hormone related to feeling calm and bonding with others.

Even though the research on massage for depression in MS isn’t strong, massage doesn’t have many risks, and it may help your pain, so it may be a good therapy option to consider.

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The takeaway

Chronic pain and low mood can perpetuate each other and this harmful feedback loop is a common issue in people with MS.

Treating them together is your best bet. Make sure to tell your doctor you’re experiencing both since that will likely affect the approaches they’ll recommend for you.

CBT seems to be particularly effective. In addition, you can take steps on your own, such as exercising or practicing mindfulness.

“This is potentially treatable, so don’t lose hope,” says Feinstein. “Go to see a pain specialist, or go to see a psychiatrist … who has experience dealing with people who have multiple sclerosis.”

“There are good treatments for mood, and if you can successfully treat the depression, you may find an improvement in your pain,” he adds. “Conversely, help with your pain can lead to an improvement in your mood.”

Medically reviewed on September 21, 2023

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