Concussions and depression: Yes, Virginia, there IS a connection.

Wade Belak, 1976-2011

 

It’s been a rough summer for hockey. The deaths of Derek Boogaard, Rick Rypien and Wade Belak have raised questions about the role of fighting in the NHL, and whether the NHL/NHLPA are doing enough to support players with mental health issues. I was astounded to find I was consistently finding people questioning the link between head injury and depression in the numerous news stories and blog posts on the subject.

The CBC recently published an interview with Dr. Robert Cantu, co-director of the Centre for the Study of Traumatic Encepholopathy at Boston University. Dr. Cantu (a neurosurgeon) explains that depression, anxiety and substance abuse are all common in athletes with CTE (chronic traumatic encephalopathy). He goes on to state something any rational person could have guessed – that NHL players have admitted to him that they’ve had concussive-type injuries far more frequently than they’ve actually reported to their coach or trainers.

 

In a truly spectacular show of idiocy, the CBC’s story received comments like these, questioning the head injury/depression link:

 

IMHO, hockey players kids are raised as prima donnas who are encouraged to win at atl costs. I find a lot of them to be incredibly immature. Scientists should be looking at their lifestyle first. I would think the depression came from excesses in lifestyle, and an immaturity with which they cannot cope with the stress related to that lifestyle.

- GordonRobertson

Nice try.
These tragedies likely have more to do with the moral conflict one would have to deal with after having been paid a large sum of money to inflict violence on others.
Once again nice try Dr. Cantu.
Obviously the NHL did a good shopping job. 

- Hihohum

 

Wow. So here we have the (apparently not uncommon) opinions that depression comes from lifestyle excess, immaturity, and moral conflict. No doubt GordonRobertson and Hihohum’s opinions are based on their extensive reading on traumatic brain injury.

 

Right?

 

Hell no, because they’re completely wrong. There are literally thousands of studies linking traumatic brain injury to depression, and not just in CTE (a condition so dramatic that it actually changes the gross appearance of the brain), but also in mild concussive injuries. Something that keeps coming up is the argument that correlation does not imply causation. Do the concussions actually result in depression, or do people who’ve had concussions just happen to also be depressed?

 

Yes, concussions can cause depression. 

 

Researchers at McGill’s Montreal Neurological Institute did a study using fMRI (functional MRI), a technology which looks at blood flow to specific areas of the brain as related to neural activity. Put simply, the more neural activity in an area, the more blood flow to that area. The McGill team examined athletes suffering from post-concussive syndrome both with and without depression, and compared them to athletes who had never been head injured.  None of the athletes studied had been diagnosed with depression prior to their injury.  The team found that the fMRI results on the depressed post-concussion athletes were very similar to those seen in people with major depressive disorder. Let’s make this crystal clear – after a concussion, athletes with no history of depression became depressed. Fancy brain imaging on these athletes looked like fancy brain imaging done on people with regular (non-head injury-related) depression. What’s truly scary is that the concussed athletes (both depressed and not depressed) were also found to have areas of grey matter loss in their brains. Let me say that again another way. The actual anatomy of their brains had changed.

 

Not convinced?

 

How about the 3rd International Conference on Concussion in Sport? In 2008 a group of neurologists, neurosurgeons and representatives from various hockey organizations sat down in Zurich and spent a long time discussing nothing but concussions. The idea was to produce a list of recommendations for the management of head-injured athletes that could be used by doctors, trainers, and other people involved in their care. The group encouraged evaluating head injured athletes for depression, as “Mental health issues (such as depression) have been reported as a long-term consequence of traumatic brain injury, including sports related concussion.” They also provide about 11 references for that statement, which you’re more than welcome to look up on your own.

 

The implications

 

It’s difficult to pin down an exact percentage of people with concussions who end up with depression as well. A review article published in 2001 suggests the number could be as high as 42%. Dr. Cantu’s experience, as well as that of anyone who is an athlete, who’s been around an athlete, or who’s ever spoken to an athlete tells us that a lot of concussions go unreported. The implication is also that there are a lot of athletes (in the NHL and elsewhere) who could be suffering from depression and other mental health problems.

The NHL/NHLPA Substance Abuse and Behavioural Health Program has come under fire in the wake of Boogaard, Rypien and Belak’s deaths. The suggestion is that not enough is being done to protect the well-being of NHL players and alumni. The NHL and NHLPA released a joint statement on September 1st addressing the deaths.

 

 

While the circumstances of each case are unique, these tragic events cannot be ignored. We are committed to examining, in detail, the factors that may have contributed to these events, and to determining whether concrete steps can be taken to enhance player welfare and minimize the likelihood of such events taking place. Our organizations are committed to a thorough evaluation of our existing assistance programs and practices and will make immediate modifications and improvements to the extent they are deemed warranted.

It is important to ensure that every reasonable step and precaution is taken to make NHL Players, and all members of the NHL family, aware of the vast resources available to them when they are in need of assistance. We want individuals to feel comfortable seeking help when they need help.

 

Obviously NHL players are either not “aware of the vast resources” or not “comfortable seeking help”. Whatever is currently being done can’t be enough if three players have (directly or indirectly, intentionally or not) killed themselves in under 5 months. Were Rypien and Belak’s depression issues linked to head injuries? Does it matter? Whether their depression was pre-existing or the result of an injury, it was real, and it killed them.

Having said that, knowing that depression is found in as many as 42% of people suffering head injuries, it behooves the NHL to find a way to reduce those injuries. Fighting has been named as a culprit, as has contact with the head, hits from behind, and I’d add poorly fitted helmets to the list. The NHL has made efforts to reduce injury with Rule 43 (checking from behind), but remains miles behind other hockey organizations. One of the few sane commenters on the CBC article noted that the most exciting hockey game they’d watched in recent memory was the 2010 USA-Canada Olympic gold medal game – a game played under IIHF rules, where hits to the head and fighting aren’t permitted.

 

Take-home points

 

Some concussions cause depression. Period. No, no, we don’t need to talk about it. The science is there.

Fighting for the sake of fighting (I’m looking at you, Matt Carkner and Colton Orr) has no place in an NHL interested in the well-being of its players. Rule changes need to be made to reduce the incidence of head injuries. Obviously the very nature of the game dictates that you can’t eliminate every injury. The point is to eliminate what you can. The IIHF, NCAA and Olympics all have more protective rules, and all have exciting hockey.

The NHL/NHLPA need to do more to ensure their players and alumni’s mental health and substance abuse needs are taken care of. Three deaths in less than five months should be an enormous wake up call – one that never should have happened.

 

The folks at puckscene are hosting the Wade Belak Memorial Charity Drive to benefit the Tourette Syndrome Clinic at Toronto Western Hospital, the charity he’d chosen to skate for on Battle of the Blades.

September 4-10 is National Suicide Prevention Week in the US. Your contribution can be as simple as educating yourself on the warning signs of depression and suicidality. Extensive resources can also be found at The Canadian Association for Suicide Prevention.

 

References: 

Jen-Kai Chen; Karen M. Johnston; Michael Petrides; Alain Ptito
Neural Substrates of Symptoms of Depression Following Concussion in Male Athletes With Persisting Postconcussion Symptoms
Arch Gen Psychiatry. 2008;65(1):81-89.

M Aubry; R Cantu; J Dvorak; K Johnston; P McCrory; W Meeuwisse; M Molloy
Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008
Br J Sports Med 2009;43:i76-i84.

Eugene Gourley; Jeffrey S. Kreutzer; Ronald T. Seel
The prevalence and symptom rates of depression after traumatic brain injury: a comprehensive examination
Brain Injury 2001; 15(7):563-576.

About Jo Innes
Who am I? I'm a paramedic turned ER doc with truly sub-par rec league hockey skills. And I have absolutely no problem sharing my opinion with you. You're welcome.

4 Responses to Concussions and depression: Yes, Virginia, there IS a connection.

  1. Aura says:

    Great article! I agree with you.

    I’ve had four concussions over the course of four or five years, and ever since that first concussion I have tumbled into a depression. I’ve had severe depression for years now, and white trying to recover, I realized perhaps the concussions were to blame in part.

    Thanks foe the article, very helpful!

  2. kidney tumor says:

    Very energetic post, I liked that a lot. Will there be a part 2?

  3. Cynthia Stewart says:

    Tragically, my 19 year old nephew recently took his own life. He had experienced 2 concussions. One he received when punched in the head from behind from another young man. The 2nd concussion was received in an automobile accident. Both of these happened within a 3 year period. As a family, we are trying to find answers and think this may have had something to do with it. He was a bright, happy young man always wearing a smile and we were not aware of this recent study/finding. If only we had known……..maybe we could have prevented his suicide. People, please take this seriously.

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