This study explored the use of health services in people with MS, with and without depressive symptoms during a period of 30 months, with regard to disease severity. The results showed that people with EDSS mild and depressive symptoms used more hospital outpatient care and primary care, and spent more days in inpatient care compared to people with EDSS mild and no depressive symptoms. Furthermore, the results showed that those people with EDSS mild and depressive symptoms received more informal care and intense rehabilitation periods than did people with EDSS mild with no depressive symptoms.
The larger amount of contacts with welfare officers in hospital outpatient care and contacts with psychiatric departments among people with EDSS mild and depressive symptoms is not surprising, and may in fact reflect an adequate supply of healthcare in line with current recommendations of treatment for depression in people with MS . On the other hand, no clear pattern of healthcare use with regard to specific services was found, but instead, there was a noticeable general increase involving a number of different services. Similar results were found in a previous study of healthcare use among people with MS and fatigue based on the same cohort of people . However, in the present study, the types of services where an increased use were found differ from the previous study; two examples of this would be the larger number of contacts with nurses in outpatient hospital care, and more total days spent in inpatient care. There are several possible explanations for these results. It has been shown that patients rate the impact of mental health as more important than their physicians do , and that people with disability differ in their perception of rehabilitation needs compared with their nominated key professionals . Furthermore, depressive symptoms among people with MS have been found to be undertreated , and only a minority of those with depressive symptoms in the present study used antidepressant drugs. Thus, the increased use of health services may reflect that depressive symptoms were not noted or not adequately treated, therefore leading to repeated contacts with the healthcare system. Other possible explanations for the results could be that people with MS and depressive symptoms perceive their disability as being greater than their physicians' perception . Another possibility is that depressive symptoms are associated with secondary health conditions and so an increased use of healthcare follows, as shown in a previous study . Since people with MS and depressive symptoms have been shown to use less-effective coping strategies , it is also plausible that they are more dependent on the healthcare system in the absence of self-management strategies.
No differences in the use of health services were found among people with MS and EDSS moderate, while those with EDSS severe coupled with depressive symptoms had more contacts with several healthcare professionals compared to those with EDSS severe and no depressive symptoms. However, the differences in use of health services among people with EDSS severe were not as evident compared with people with EDSS mild. The differences in the use of health services with regard to disease severity may partly be attributed to the fact that the EDSS mild group was the largest, while the other groups of disease severity may have lacked statistical power to detect differences. Another plausible explanation might be that among people with EDSS moderate and EDSS severe, there are many other disabilities besides depressive symptoms that contribute to an increased need for use of health services.
Psychiatric symptoms, such as depressive symptoms, for example, in people with MS are associated with high levels of distress among caregivers . The finding in the present study that those with depressive symptoms also received more unsalaried informal care from partners and others adds further insights of the caregiver burden among caregivers to people with both MS and depressive symptoms. Caregiver burden is a very important issue with MS, since it is generally diagnosed in young adults, and many years of future caregiving are often involved. Recognition of caregiver burden is important in determining appropriate interventions for the families of people with MS .
The major strengths of the present study were the longitudinal design covering 30 months; the use of the BDI, a recommended screening measure for depressive symptoms in people with MS ; and the reliable data on healthcare use derived from the computerised register at the Stockholm County Council. However, data on the use of other healthcare services were collected by interview, and may thus be biased by the difficulties to recall information among the people with MS. Further, the groups of people with EDSS moderate and EDSS severe were quite small and may have lacked statistical power to detect differences in the use of healthcare services. The results should also be interpreted bearing in mind that the study was carried out within the Swedish healthcare system and differences in organisation and policies need to be considered before the results can be generalized to other healthcare systems.