Depression

Trying to talk about depression in sports, or just depression for that matter is like saying I want to discuss "apples". Where would I begin?

Given the news of Rick Rypien's passing, and arguably that of Derek Boogard, mental illness has been in the NHL newswire a lot more recently than I can remember.

And rightfully so.

I think the most important conclusion I want to draw in this post is that depression is a medical disease. It may seem like a simple and obvious statement to some, but maybe a bit harder to accept for others. I'm not going to get into how it's diagnosed, treatment, etc. Today's post is just focusing on my argument that for most people it's not something trivial or an excuse.

First off, let's clarify - sadness is part of life. Duh. We get our sad days, mad days and happy days and everything in between -- those are just emotions. We're supposed to feel them. However, a major depressive disorder is not just being sad. It comes down to a chemical imbalance in the brain that causes someone to feel hopelessness, despair, or even numbness for extended periods of time. You wouldn't say to someone with diabetes, "Hey! Stop being so tired and just correct your sugars already!". Nor would you tell someone with half a foot to try to walk properly. That would be stupid.

Pathogenesis

If you grouped all the patients in the world with depression, you'd actually have a large group of people with similar symptoms but a wide variety of different reasons for being depressed. Let's list a few key causes:

• Genetics - Single gene causes haven't been identified yet, but there is a strong pattern of heritability of depression - 42% heritability in women, and 29% in men.
• Early life adversity - exposure to severe stress and trauma as a child can cause major changes in a child's brain to stress and negative stimuli. If you want to get technical, studies have shown overactivity of corticotropin-releasing cells in the hypothalamus - that basically means the cells in the brain that stimulate stress response in the brain become overly sensitive.
• Social factors - Strangely, proximity to someone who is depressed can make you more prone to get it too. Chew on this: you're 93% more likely to become depressed if you are directly connected to someone who is depressed. Other factors include poor sibling relationships, and persistent negative and critical comments.
• Psychological factors - pessimism, neuroticism, and certain personality types are more likely to lead to depression than others.
• Secondary depression - this can arise from a number of medical conditions like heart attacks, neurologic diseases, and metabolic problems.

On top of all these causes, research has shown physical changes in the brain in patients who are depressed. I'll admit that it's tough to determine whether or not these changes are present in people who will become depressed, or occur after people are depressed (i.e. cause/effect vs correlation).

Certain neurotransmitters, or chemicals that cause signal conduction in the nerves of the brain, have shown to be imbalanced or functioning abnormally. As mentioned above, overstimulation of the corticotropin-releasing cells in the hypothalamus, resulting in abnormally increased stress responses can play a role as well. Other physical changes seen are an abnormal density of glial cells in the frontal or occipital cortex of the brain, a smaller hippocampus, or altered brain activity.

Now don't go to your family physician tomorrow and ask for an MRI of your brain to assess the size of your hippocampus, or ask for certain hormone levels to see if you're depressed. That's not the point. What I'm trying to get at here is that many people who suffer from depression should not be dismissed.

A common but often misplaced argument is: "this person has no reason to be depressed. He/she is hot/has money/lives the life." (Exhibit A: list of famous people with depression, from Wikipedia) Such a scenario is actually common with people with depression. They could have a great spouse, supportive children, a stable job, and still find sadness and disparity... that's how their brain has been wired.

Sources: UpToDate

Dolphins Brandon Marshall - borderline personality disorder

This story came through the news a couple weeks ago but I feel it's worth addressing giving the relative lack of public knowledge regarding borderline personality disorder, or many psychiatric disorders for that matter. Many people view psychiatric diagnoses as scapegoats for people to act out, behave inappropriately, etc. so I think it's warranted to clear the air.

Of course, we don't know anything about Marshall's condition so I will write in generalities for borderline personality disorder (BPD).

Borderline personality disorder - From UpToDate: "[it is] characterized by instability of interpersonal relationships, self-image, and emotions and by impulsivity. The name of the disorder was originally based upon a concept that this syndrome constituted the boundary or borderline between neurosis (a pattern of maladaptive traits and coping mechanisms) and psychosis (a condition of grossly impaired reality testing)."

What causes it? The exact suspect isn't exactly known, but likely due to a combination of factors including genetic susceptibility (i.e. family history of mental health issues), previous traumatic life experiences including those in interpersonal relationships. A number of clinical trials cite high rates of childhood sexual and physical abuse in patients with BPD. Neglect has also been correlated. (**Note: Keep in mind that there is a difference between "correlation" and "cause-and-effect").

In terms of how it manifests itself in the brain, it is still difficult to understand, but some neurotransmitter dysfunction has been seen. Again, whether this is a correlation or cause/effect pattern is uncertain.

OK, but I still don't get how these people act? The disease usually manifests itself in a number of ways:

• Interpersonal difficulties - Patients with BPD tend to have unstable relationships with close friends or romantic partners. They often alternate between idealizing somebody to seeing them as betraying or cruel. These two extremes tend to happen when the person is present (i.e. seen as perfect), or absent (i.e. seen as awful). In essence, the partner or friend is viewed as completely good or bad; this phenomenon is called "splitting". During times of strong negative emotions, the patient often thinks this person is going to leave or abandon them, leading to anger, depression, hopelessness or suicide. They also tend to see minor or neutral facial expressions, words or events as overly negative - i.e. an imagined desire that the other party wants to leave or terminate a relationship.
• Affective instability - We all have mood swings or fluctuations throughout a day but people with BPD have these to an extreme. These changes can occur within minutes, usually from environmental factors. They can alternate from explosive outbursts to someone close (from dissatisfaction) to extreme bouts of shame, guilt and worthlessness.
• Impulsivity - Patients with BPD have trouble controlling impulses. These can include binge eating, irresponsible spending of money, unsafe sex, or ending a job or relationship.

How is it diagnosed? All psychiatric illnesses are diagnosed using the Diagnostic and Statistical Manual of Mental Disorders, and can only be made by a qualified health professional. A diagnosis of BPD requires five of the following:

1. Frantic efforts to avoid real or imagined abandonment
2. Unstable and intense relationships
3. Unstable sense of self
4. Impulsivity in two potentially harmful ways (drugs, sex, money)
5. Recurrent suicidal behaviour/self-harm
6. Unstable mood/affect
7. General feelings of emptiness
8. Difficulty controlling anger
9. Transient dissociative symptoms (i.e. temporary hiding of a memory, feeling or sensation) or paranoid ideation associated with stress

Treatment

In short, psychotherapy. Now, this isn't just your run-of-the-mill counselling or talking to somebody. It involves very deliberate direction and focus in order to be effective. UpToDate mentions a few goals or objectives that need to be reached:

• Teaching or helping with emotional regulation
• Targeting impulsivity - getting patients to observe emotions rather than feel them
• Targeting relationship difficulties - helping patients become cognizant of other people's emotions

Yeah, I know it looks pretty elementary like stuff you would see or learn about in primary school; I could try to go into details but that would require writing paragraphs of text. Basically, it's a lot more complicated than it sounds.

Drug therapy can be used in conjunction with psychotherapy - many patients receive mood stabilizers or antipsychotics. The use of drugs with BPD is a bit hazy though because patients often have other psychiatric issues like major depressive disorder, or post-traumatic stress disorder that also need treating.

So people with BPD have a rough time, I get it. But does all this diagnosing, treating, etc. really make a difference?

Yes. With proper treatment, remission of the disease was found to be anywhere from 45-54% within 2-4 years of follow-up. In one study, 93% of patients were in remission by 10 years. 86% of patients achieved remission that lasted for at least four years.

The proportion of patients with "good psychosocial functioning" (i.e. at least one close, emotionally sustaining relationship AND good work or school performance for at least 50% of the study period) increased throughout the years to up to 56% in year six.

Unfortunately, recurrence is relatively common. Loss of recovery has been in seen in 34% of people.

Sources:

Toronto Notes, 2010 edition

UpToDate

Philadelphia Eagles DT Mike Patterson - seizure from AV malformation

This week during training camp, defensive tackle Mike Patterson of the Philadelphia Eagles collapsed on the practice field, had a seizure and was taken to hospital. Given that the Minnesota Vikings recently remembered the 10 year anniversary of Korey Stringer dying from a heat stroke in training camp, needless to say it was a scary sight.

Since then, Patterson has being diagnosed with an arteriovenous malformation, or AVM, of the brain which likely caused his seizure. ESPN has an excellent article (and consequently does most of my work for me) here. I'll try not to repeat too much of what they say.

What is an AV malformation? Basically, it's a tangling of the arteries and veins in your head. Normally, your body's arteries carry oxygen-rich blood to tissue and organs to provide sustenance to your cells. The oxygen is delivered via tiny blood vessel beds, or capillaries. The blood vessels that carry blood with little oxygen left are the veins. So the sequence is artery --> capillary --> vein. With areas of AVM, you have some arteries feeding into veins, veins feeding into arteries, often no capillaries in between... it's just a giant mess. As a result, tissue that have these malformations don't get enough oxygen.

So then what happens? Smaller AVMs can cause hemorrhages (40-60%) because of the large pressure difference between arteries and veins (which should not be connected directly). Seizures, like in Patterson's case, are more common in larger AVMs (50%). Patients can also get localized headaches due to increased pressure in the brain, or other neurological symptoms like trouble with speech, eye movements, muscle weakness, etc.

Do I have it??? It's quite rare. 0.14% prevalence, more common in males than females, and it can only be inherited. The average age of diagnosis is ~33. People don't usually know they have it until they have some sort of event (i.e. seizure or intracranial bleed) that results in an MRI that picks it up.

Can it be fixed? The only definitive treatment is surgery, but this is only if the site of the AV malformation is accessible, if there has been a bleed, and if the benefits of the surgery outweigh the risks (think: a young strapping man like Patterson vs. a 95-year old man with severe heart and kidney failure). Many people who only experience seizures do well on anti-convulsant medication.

Surgery normally involves excision of the AVM. An alternative (which is what Patterson received) involves blocking the fistula (i.e. the direct pathway from artery-to-vein) which should normalize blood flow. There are other treatment options like endovascular embolization and stereotactic radiosurgery which kind of go above the scope of this blog and my interest level in the topic (haha).

Prognosis? Provided the doctors gave him a clean bill of health, Mike Patterson is a lucky guy. 10% of people die from each one of these bleeds, and 30-50% have some sort of neurological deficit as a result. Patients with AVM have a 2-4% chance of a major bleed each year.

Sources:

ESPN.com

Toronto Notes, 2010 edition

CURRENT Medical Diagnosis & Treatment, 2011

Ryan Kesler - "labrum repair" surgery

For my first post with actual content, let's go with some fresh hockey news despite the fact that I abhor the Canucks. Never liked Ryan Kesler's antics but he carried the Canucks on his back for portions of the playoffs when others didn't show up *cough* SedinsLuongo *cough* and I can admire that.

Anyways.

As per TSN.ca, Canucks forward Ryan Kesler just underwent "hip surgery" to repair his labrum.

The labrum of the hip, or the acetabular labrum, is a ring of cartilage that surrounds the hip joint and helps with stabilization. It deepens the "socket" portion of the joint making it more difficult for the femur to slip out (coincidentally this is pretty much Wikipedia says in its article). The hip, like the shoulder, is a joint with lots of flexibility and range of motion. With these types of joints, what you gain in flexibility you often lose in stability. The labrum helps counteract this instability. (the shoulder also has a labrum)

I am GUESSING that Kesler tore his labrum at some point in the playoffs (was it the end of the Nashville series where he pulled up lame after chasing the puck?).

Many fans are probably asking why he didn't go for surgery immediately after the playoffs. With labral tears, conservative treatment (i.e. physical therapy/rehab + rest) is used first to see if symptoms of the tear abate. Only if symptoms continue despite rehab is surgery offered. Surgery involves either the repair (sewing up of the labrum) or a resection, where the torn piece is removed.

Sources:

http://orthopedics.about.com/od/hipinjuries/qt/labrum.htm

UpToDate

Wikipedia (sketch of hip)

Inaugural post

I honestly have no idea how successful this blog will turn out to be, but it's something that's been on my mind for a while.

I'll admit, I'm an avid sports fan, sometimes moreso than I should be. If there's a big game on, odds are I'll choose that over reading about... hypothyroidism.

About me: I'm a medical student in my last year of training in one of Canada's fine medical schools (no, not the University of Phoenix or something) with hopes of becoming more of a "generalist" and some additional training in Sports Medicine.

Disclaimer: None of what I mention or say here should be taken as medical advice - I am merely writing about medicine in professional sports more for educational purposes so people can have a better idea when TSN or ESPN says somebody has a "labrum tear" or a "high ankle sprain". Although, if someone is listed as having a lower body injury or a bruised ego, I probably won't have much to say.

Anyways, let's see how this goes.