Brought to you by the Depression Is Real Coalition, The Down &
Up Show is dedicated to the reality of depression. Our
hosts will talk with some of the world's top experts on depression, as
well as people who have been impacted by this illness. The reality
of depression is that it is a debilitating and potentially deadly
medical condition that affects more than 15 million Americans every
year. The other reality of depression is that there is hope.
Down & Up Show #42: Brain Trauma and Depression
DR. REEF KARIM:
Welcome to the Down and Up Show on depressionisreal.org. I'm your
host Dr. Reef Karim, psychiatrist, addiction specialist and relationship
therapy. Today we'll be speaking to Dr. Alan Ptito from the Montreal
Neurological Institute.
Dr. Alan Ptito received his Ph.D. in neuro psychology in 1986
from the University of Montreal. He has been a staff neuro psychologist
in a cognitive neuroscience unit at the Montreal Neurological Institute
and Hospital since 1983. Dr. Ptito and other researchers at McGill
University Hospital recently published a study in the Archives of
General Psychiatry which examines symptoms of depression in patients
who had suffered concussions. Dr. Ptito thanks for taking the time
to speak to us today.
DR. ALAIN PTITO:
It's a pleasure.
DR. REEF KARIM:
Alright so let's talk about depression and concussions. That's very
interesting. When we talk about neurological dysfunction, either
a concussion or some type of brain trauma people don't generally
think one of the effects of this trauma is not only possibly loss
of consciousness or other factors associated with a trauma itself,
but something long lasting like depression.
DR. ALAIN PTITO:
Right. We were interested in looking at post concussion symptoms.
You know early, the acute symptoms right after a trauma are confusion
and disorientation, amnesia of the event, headache, nausea and vomiting.
But in a good number of people, in a significant I would think about
15 to 20 percent of people there are later persisting symptoms that
may last weeks to even months, you know.
And the somatic systems are the kind that are well known like
headaches, dizziness, vertigo, fatigue and there are also cognitive
deficits like slow thinking, poor attention and concentration and
also impaired memory. But the other aspect is the mood. And quite
often when we encountered people that had been concussed they were
complaining of anxiety, irritability and depression.
So we were, so we got interested in that because it was something
that was occurring often, this long lasting depression following
concussion. And our question was is there a pathological basis to
this depression, is something going on in the brain that is causing
the person to feel depressed or is it just a reaction to having
had an injury? So this was the impetus for doing the study and looking
at that aspect.
DR. REEF KARIM:
Can you explain how the brain is affected by a concussion? Like
let's go over the symptoms (ph.) of concussion and then how that
relates to depression.
DR. ALAIN PTITO:
Several things needs to be said before I get into this question.
First of all when a person has a concussion we're talking a very
mild head injury. So there may or may not be a loss of consciousness.
And this is important to realize because for many years people considered
that if there was no loss of consciousness then there was no concussion
essentially and the person was okay.
But this is not the case because it looks like even if the person
is stunned or dinged there may be persisting symptoms. So this is
the first thing that I'd like to mention. The second aspect that
suggests that something is going on in the brain is from a neuro
psychological standpoint. So there are, after a concussion, subtle
cognitive impairments in the subject.
And usually the deficits involve the functioning of the frontal
lobes that is the frontal lobes are involved in planning and mental
flexibility, in working memory, and also in attention. And these
are the kinds of deficits we see following a concussion.
The other aspect is if you look at the electro physiological studies
like changes in EEG recordings you see that the amplitude is lower
in mild head injury subjects. So usually there is something going
on electrically in the brain.
DR. REEF KARIM:
After a concussion?
DR. ALAIN PTITO:
After a concussion. And this has been shown with athletes, with
concussed athletes in looking at what we call event related potentials,
which a little more subtle than looking at just the regular EEG.
And the other aspect is that we now know that there are neuro chemical
changes going on in the brain that are very subtle.
And so at the level of the cells and the neuro chemistry the neuro
transmitters are affected after a concussion.
DR. REEF KARIM:
Can you talk a little bit more about that?
DR. ALAIN PTITO:
Pardon?
DR. REEF KARIM:
Can you talk a little more about that? Which neurotransmitters and
how are they changed?
DR. ALAIN PTITO:
Well, what seems to be happening after a concussion is that there
is a neurotransmitter released. So there is an influx of potassium
and there is an efflux É sorry, there is an influx of calcium and
an efflux of potassium. And so there is a lower oxygen metabolism
and there is also lower glucose supplied.
And so when you put these things together there is a cerebral
hypo metabolism and a metabolic crisis. And this may take time to
recover. And this is why we see that it takes several days for the
neuro chemical changes to subside and the person to come back to
a regular state. But this may last more than several days.
DR. REEF KARIM:
So when you say hypo metabolism you're talking about the brain not
being able to communicate neuronally with the same level of functioning
that it would without the concussion.
DR. ALAIN PTITO:
Right.
DR. REEF KARIM:
Because you said lower glucose metabolism, lower O2. And so if that's
happening when we communicate, when we memorize things, when we
plan things amongst all the other cognitive functions that we have
good communication neuronally.
DR. ALAIN PTITO:
Right. So this may be translated into being slower, reacting more
slowly or just thinking process is slow, things of that nature.
But if you look at a regular MRI if you were to take this person
that is showing these kinds of symptoms and put them in a regular
conventional MRI machine you'll see nothing and everything will
be normal.
And this has been the problem is the conventional neuro imaging
studies haven't shown anything that was obvious to explain these
symptoms. So many people have claimed that in fact it was only a
psychological reaction to an injury and therefore that since the
conventional neuro imaging is normal then this person will go into
therapy and will be fine.
So we with functional magnetic resonance imaging we're looking
at the function of the brain, so we're looking at oxygen uptake
of certain regions.
DR. REEF KARIM:
And so you said, what were you using, what's the instrument that
you use?
DR. ALAIN PTITO:
So we're using functional magnetic resonance imaging. So what we're
doing is we know for instance that a particular task that we developed,
a working memory task is recruiting specific regions in the brain
to carry out the task. And for this particular working memory task
we were looking to recruit the frontal part of the brain, it's called
the dorsal lateral prefrontal cortex.
So when we know that, when we put the person in the machine doing
that task those regions of the brain that are involved in doing
the task in that region there is an increased blood flow and there
is also greater oxygen demand from that region. And this is what
the magnetic field picks up, this demand for more oxygen in that
specific region.
And looking into that region we can measure the change in activation
within that region and then compare it to other individuals that
didn't have a concussion let's say. And then we can establish whether
there is less activation in that region for a particular individual.
DR. REEF KARIM:
And you said neurotransmitters change. When we think of neurotransmitters
we think of dopamine, we think of serotonin, we think of É did you
have some kind of measuring device for the specific neurotransmitter?
DR. ALAIN PTITO:
No, we haven't gotten into that aspect. We were more interested
in looking at the oxygen, metabolism. To look at the neurotransmitter
we would have to do some probably pat scanning and then inject a
radio active substance to be able to do the tracing. So with FMRI
we're more interested in being able to tap recovery because we can
repeat the same test with the same individual at several time points
and then establish whether there is a change for instance after
a particular treatment.
DR. REEF KARIM:
Now you mentioned the front lobe changed, right, changes to the
frontal lobe. Personality is often derived, there's lots and lots
of support that people who have injuries from hundreds of years
ago in the Phinnius (ph.) stage thing and on about brain trauma
in some aspects of the frontal lobe changing personality.
Have there been any reports or have you guys in your research
seen that happening as well? And how would you quantify that from
a neurological standpoint?
DR. ALAIN PTITO:
Well, the front lobe aspect is typical. First of all by the mechanics
of the injury, especially in athletes or in car accidents which
are very common usually the frontal lobes are the region of the
brain that are affected, and also the limbic frontal loop, which
is involved in emotions and orbital frontal cortex. So all this
region that is in the front of the brain is affected.
Now if you talk to the subjects themselves they'll tell you that
they feel like they may be depressed or they're irritable. And if
you talk to the families usually the families will tell you that
you know their personality has changed somehow, he gets upset very
quickly or she used to be one way and now she's like another person,
etc.
So there are definitely changes that are not as dramatic as Phinnius
Gage of course, because the injury is not as severe. But they're
definitely there, and much more subtle. But if you speak to the
family then you'll see that there are in fact some personality changes.
DR. REEF KARIM:
Okay. And just for our listening audience, Phinnius Gage was a guy
a long time ago that had a brain trauma in England.
DR. ALAIN PTITO:
Yeah, and you had this huge nail that, more than a nail, I think
it was one of those rods, iron rods that he was placing dynamite
into rocks and stuffing them with an iron rod and then there was
an explosion and the iron rod went through his front lobes. And
the change in his personality was dramatic, so this was reported
you know extensively.
And this was one of the first studies of frontal lobe function
and the possibility that they were involved in personality more
than anything else, because people that have frontal lobe dysfunctions
usually don't have lower intelligence.
DR. REEF KARIM:
Right, right. And according to what I've read about the case the
family members felt that he was a completely different person, right?
DR. ALAIN PTITO:
Right, exactly. So there can be a complete switch. You see that
in severe head injuries as well, you know. Most of the time it's
for the negative, but often it can happen that people say that oh,
you know, this person was so introverted and they were so quiet
and after this accident all of a sudden she's talkative and an extrovert
and everybody loves the way she's acting, etc.
So this may happen. Most of the time though, in my experience,
what happens is the opposite, the person becomes introverted and
becomes depressed, etc.
DR. REEF KARIM:
And brain injury. Can you tell us a little bit about gray matter
and how it was used in the study?
DR. ALAIN PTITO:
Well, if we take a certain region of the brain and we measure the
gray matter density of that region we can compare the density of
the gray matter to a normal population and establish whether this
gray matter density is significantly different. So when we looked
at depression we were interested in looking at the regions that
were involved in depression and we were also interested in looking
at those same regions and evaluate the density of those regions.
And what we found is that the gray matter density of the regions
that are involved in major depression, not necessary concussions,
in those regions the athletes showed less gray matter density. Now
what does this mean? And this is a question that we were looking
into into the future. Does the gray matter density mean loss of
neurons or does it mean just that there is less transfer of information
going on there.
We don't know what it really means. So what we would like to do
is to measure gray matter density for instance after treatment to
see if after the symptoms resolve whether we can see, document a
change there.
DR. REEF KARIM:
Yeah, because I guess one of the interesting things about this is
É well, maybe you could touch on this a little bit É is how flexible,
what kind of fluctuations are there in gray matter in any of us?
If somebody has acute loss, let's say they lost their significant
other or they encountered some kind of major trauma, and then they
really went into a deep, dark depression, would there be a change
in gray matter based on that?
And then through years of therapy and medications and whatever
else to get better would they then have a different level of gray
matter based on that?
DR. ALAIN PTITO:
Yeah, it's a great question. You know my feeling is that this is
the kind of thing we would see just like you said. We would say,
and we intend to try and look at that. You're referring in fact
to symptoms of a post traumatic stress disorder for instance and
comparing to mild traumatic brain injury and making the comparison
looking at what happens with a trauma that affects the brain and
if the trauma is resolved do we see a change in the brain.
And I believe we do. More and more we're beginning É when the
technology is allowing us to look, like in this case gray matter
density. So definitely I think we can begin to try to answer these
kinds of questions. But at the moment I don't think we can answer
them. My feeling is that the brain is quite plastic and even in
adults, you know it used to be thought that children's brains were
so plastic, etc., but I think the adult brain is also plastic and
we just need the means to measure these plastic changes.
And I think now we're getting more and more sophisticated with
the technology and this will allow us to do it. But my feeling to
answer your question in a speculative way, is that, yes, we will
see changes after the trauma is treated.
DR. REEF KARIM:
Because there are studies out there that are looking at not only
neuro chemical, neurotransmitter changes associated with taking
antidepressants and how the brain will look different after antidepressant
treatment, but there are also studies that look at therapy and look
at the affects of therapy on the brain and how there are brain changes
associated with having you know gone through the process of therapy
and really kind of collecting one self during that process.
DR. ALAIN PTITO:
Absolutely. And I believe strongly in that. I think in fact for
depression, from our conclusion in our study my feeling is that
for the treatment of depression in those concussed individuals is
a combination of medication and psycho therapy. I think one or the
other wouldn't be enough, you know. So there are definitely affects
of psych therapy that may reflect on the changes in the brain.
DR. REEF KARIM:
Okay. Let's keep talking. How does your study counter the idea that
depression is part of a patient's emotional reaction to their injury?
You got some people that are going to say, well, depression here,
you had a major trauma, of course you're going to be depressed as
opposed to this is really something that's part of the brain network.
DR. ALAIN PTITO:
Right. Yeah. So what we did is we looked at athletes that had no
depression, we looked at athletes that had symptoms of concussion
and no depression, we had athletes that had symptoms of concussion
with mild depression and we looked at athletes that had symptoms,
post concussion symptoms with moderate depression.
So we were able to compare in fact four groups. Two groups with
no depression, one of them had still symptoms and the other two
had symptoms and depression was one of them. And what we saw was
that definitely only those that had symptoms of depression showed
the same pattern that we see in major depression.
So those that had symptoms of concussion but no depression were
similar in their activation patterns as the control subjects, which
tells us that what is going on here is not simply a reaction to
the fact that they had a concussion, but more that there may be
a pathology underlying these symptoms of depression.
DR. REEF KARIM:
Does your study provide any suggestions then for physicians, if
you're lecturing a couple of physicians who are treating patients
with brain traumas that experience depression what would you say
to them?
DR. ALAIN PTITO:
Well, I think first of all that the symptoms of depression should
not be taken lightly, when somebody after a concussion complains
of depression they should be taken very seriously that it may be
that those symptoms of depression are, there's an underlying pathology
or a consequence of the concussion, that's for one.
Second of all, the physician should consider pharmacological treatment
along with psycho therapy if the symptoms of depression are pronounced.
And this should be done relatively early so as not to make these
symptoms chronic.
DR. REEF KARIM:
Okay. And is there anything athletes, as you studied athletes, and
those who are high risk for brain traumas, I think boxers, should
do to prevent depressive symptoms during their recovery? Obviously
don't engage in anything that's going to invite trauma.
DR. ALAIN PTITO:
Obviously. But what is more important and what people should realize
is it should always be a gradual return to whatever they were doing
previously, whether it be returning to work after a car accident
or returning to play after a concussion, it should always be a gradual
return, stepwise, and making sure that whatever you do when you
increase the activity symptoms don't come back. And if symptoms
do come back then stop and go back one step.
DR. REEF KARIM:
At what point does one suggest to somebody who had a concussion,
okay, you can drive now, you can go do physical activities that
require dexterity or at what point do you say to somebody, is there
a concussion measuring system?
DR. ALAIN PTITO:
Well, it's very simple actually. The answer is you have to be completely
symptom free. So that's why if you make a stepwise return to your
occupation and symptoms recur then you have to go back one step
and not take on your occupation full on. And this is, what we see
is if people return to their occupation too early and they're still
symptomatic they're inefficient and this may in fact make them even
more depressed.
DR. REEF KARIM:
Yeah.
DR. ALAIN PTITO:
So it's very important to make sure that if you return to whatever
you were doing you're going to have 100 percent success in taking
it on. So the reason for doing it stepwise is to make sure that
when you take on whatever you take on you're 100 percent sure that
you're going to do it well. And if you don't then you take one step
back.
DR. REEF KARIM:
And can you mention one more time, you had four groups in the study
and could you highlight those groups again and what the findings
were?
DR. ALAIN PTITO:
Yes. In the study we had a group of athletes that had, that were
a normal control group with a normal, no depression. We had also
a group of concussed athletes that had symptoms, but they didn't
have symptoms of depression. And then we had two groups of athletes
that had symptoms, post concussion symptoms but among those symptoms
were symptoms of depression. And those were either minimal or moderate.
And what we saw is that in the groups that had the depression
those patterns of activation that we saw were very similar than
what we see in major depression. The group in fact that suggested
to us that there was a pathology underlying it is the group that
had post concussive symptoms but no depression and that did not
show this pattern.
DR. REEF KARIM:
Okay. Good, good, good. So any last findings, any last thoughts
about the study or about anything related to depression that you
found?
DR. ALAIN PTITO:
Well, I think I've said what I, the message that I wanted to be
clear about was especially the return to occupation, which is extremely
important you know for everybody to reintegrate whatever they were
doing before and to do it you know at their full potential. And
I think it's better before a player for instance to make sure that
the symptoms have completely dissipated before they go back to play
or to someone before going back to work, because if they don't do
that their careers could be shortened.
So one has to make sure that all the symptoms are resolved before
going back to what they were doing, this will ensure that their
career will be prolonged.
DR. REEF KARIM:
Right. Well, thank you so much for speaking with us today Dr. ...
DR. ALAIN PTITO:
My pleasure.
DR. REEF KARIM:
Your research examines a very interesting aspect of brain health.
So join us next time for another segment of the Down and Up Show
on depressionisreal.org. I'm Dr. Reef Karim.
