An Interview with Dr. Chris Bojrab ’89
With recent discoveries comparing the physical
effects of untreated depression to “the brain on fire,” the question isn’t “Should you seek treatment?” but rather “How soon can you get there?”.
WM: How have recent advances in brain science changed our understanding of depression?
When I first got into practice, I would tell my patients, “Depression is a brain disease, but it’s not like having MS. It’s not like having a stroke. It’s not structural on a macro level.”
It turns out I was wrong: Depression is not just a neuro-chemical, a neuro-physiologic disorder; this is a large-brain–structure disorder.
Patients who have chronic depression and patients who have trauma experiences have really significant structural changes in their brains.
Changes you can see?
Changes you can see.
In studies looking at people who have long histories of untreated or unsuccessfully treated depression versus patients without a history of depression, you see up to 20 or 30 percent difference in the size of the hippocampus. This is an area of the brain that's involved in memory storage and formation. It also is involved in emotional processing.
So, at least one new good reason to get this treated.
We actually now know that in parts of the brain, you continue to grow new brain cells throughout most of your life. However, the rate of growth is under the influence of a number of factors. Some of those are subject to change, based on the presence or absence of depression or different treatments for depression.
If you were to look at an electron micrograph of brain cells from patients who have chronic severe depression versus the same area of the brain in people who don’t have depression, it’s like the difference in looking at the College’s arboretum in the summer versus winter. In the brains of people with depression, you see more brain cell loss, more dead trees. You see the loss of synaptic connection, so fewer branches and leaves. Whereas in people without depression or in people who have been treated successfully, your arboretum is filled with more healthy trees that have more branches and more leaves.
These are actually structural differences we’re talking about now.
Is this science out there in the public—how are people responding?
People should have a sense of urgency about getting this treated.
It also turns out that depression is bad for your brain in another very concerning way.
Depression is an inflammatory process. People with depression are at increased risk for certain cancers, for stroke, and for heart attack.
People with depression light up the inflammatory system in their bodies. When you do that, you activate platelets, and you activate chemistry in your body that makes your platelets more sticky. You become at greater risk for having a stroke or a heart attack.
Only if your depression is untreated?
Untreated or unsuccessfully treated. In fact, there was a study done years ago that looked at the histories of patients coming into the hospital after having a first heart attack. They were asked, “Do you have high cholesterol and triglycerides? Are you a smoker? Do you have diabetes? Do you have high blood pressure? Do you have an arrhythmia?”
They were also asked to fill out a Beck Depression Inventory.
Researchers tracked the patients for years and found that the chance that they would be dead in the next five years after having a first heart attack was more highly correlated with their Beck Depression Inventory than it was with the presence of diabetes, smoking, high lipids, or arrhythmia—all things that we think of as being the very highest risk factors for death.
Untreated depression is actually a better predictor of someone’s demise from cardiac reasons, not suicide events.
Whether we’re talking depression, a psychotic illness, or bipolar disorder, when you have a mental illness like this, your brain is on fire.
What are the symptoms that we can see?
The classic symptoms are depressed mood, anxiety, guilt, hopelessness, physical changes either with changes in appetite, changes in sleep patterns, problems with concentration, suicidality.
I always tell people if there was just one symptom or one question that I could ask to try to determine if somebody had a clinically relevant depression, it would be anhedonia, the inability to experience joy or pleasure.
If I have a grandparent in the room and if I ask them about their grandkids and I don’t get a smile, I’m like, “Shit, this is bad.”
Dr. Keith Baird ’56 used to tell me that his patients with depression often felt ashamed of it, that they thought they were weak, that they ought to be able to just pull themselves out of this.
There’s still a stigma about the illness, but just in the 20 years I’ve been in practice, it’s gotten better than it was. I think our understanding has changed a lot.
I treat a lot of physicians, and especially older physicians will say, “I never really understood this until it happened to me.”
The word depression gets thrown around a lot, so I think everybody believes that they’ve had the experience of depression. Now, I think everybody has been sad, everybody has been down, everybody has been through grief, everybody has had disappointment, but not everybody has been what we mean by depressed when we talk about depression.
It’s so hard to understand unless you’ve been there.
One of things I find really rewarding about this field of medicine is that, boy, if you can help a patient with depression, if you can help a patient with a significant anxiety disorder, you’re not just fixing this specific symptom, you’re really changing how they feel, how they relate to others; you change how they are as a friend, a spouse, a child, a teacher, an employer, a clergy member, a member of a congregation. I think that’s something that people don’t understand—just how totally depression affects a person.
That lack of understanding feeds into this, “Well, why don’t you just snap out of it if you could just change the way you were feeling?” because from the outside, it looks that way, right? It looks like something you should be able to change.
But depression has very little of that sort of outward stigmata.
It’s hard for people to understand. They hear the word and they think, “Well, gosh. I remember when I didn’t get the promotion I was hoping for and I was really down, but I wasn’t like that. Come on, come on…
Just get over it…
Yeah. Well-meaning people. These are not insensitive clods. I think it’s hard to understand just how pervasive it is through every part of your life. It not only makes you feel terrible, it makes you feel like things are always going to be terrible. There’s a hopelessness to it that is just so debilitating.
How do you encourage people with that sense of hopelessness to get help?
Help them understand that they’re not alone. I think most people vastly underestimate the prevalence of this. Roughly 20 percent of women will have at least one major depressive episode over the course of their lives. About 12 to 13 percent of men will have at least one major depressive episode over the course of their lives.
This is not a character flaw. This is not a weakness. Three hundred people walk into these offices every day, and a lot of them
are people that anybody in this state (and
in some cases, most people in this country) would recognize. This is not a disease of the uneducated, the unintelligent, the weak, or people who have brought disaster emotionally on themselves.
Depression doesn’t discriminate. When they realize how common this is and understand that we now have a better concept of what’s going on that drives this, they usually feel better about seeking treatment.
I understand that you use genetic testing in your practice to help better match patients to their medications.
Pharmacogenomic testing really appealed to me because I see it as a way of bringing more science to the treatment decisions we’re making for patients. Usually the patients I get are people who have tried four, five, six medicines that didn’t work for them.
This testing breaks down into two general areas—pharmacokinetic and pharmacodynamic. The pharmacokinetic side refers to the genes which affect the way in which your body works on a medicine when you take it. This largely has to do with a family of enzymes called the cytochrome P450 enzymes. Pharmacodynamic refers to what the drugs do to your body. These are genes that speak to enzymes that metabolize neurotransmitters.
This is not magic. This does not spit out capital “T” Truth that promises, “This is the medicine that’s going to work for you.” This is probability management. It increases the likelihood of making a good decision. What we can do is we can categorize medicines and say, “Listen, if you take these medicines, we know that, to the best of our ability to discern it, you should have the cellular wherewithal to be able to respond to this type of medicine.”
Any examples where the testing provided a real breakthrough for a patient?
There was a young man who was referred to me—a really bright, sensitive, very articulate high school student with terrible chronic depression who had tried a ton of medicines. He came in and said, “Listen, I’m just tired of this. Nothing works. I keep trying things. They give me bad side effects. I just don’t know if I’ve got it in me to do this.”
“Listen, I completely understand. The way you’re feeling is very rational.” I said. “Would you consider doing this testing if it points us in a different direction where something might be better?”
He said, “Yeah.”
The testing helped to explain why certain things he tried likely hadn’t worked and pointed us in a direction of medicines
that work better. We went to one of those medicines. Lo and behold, it worked.
What would you say to our readers—alumni, family members, or students— who either suffer from depression or other disorders, or who have friends and family who do?
This is treatable. This is a medical issue. It’s not a flaw or a character weakness. There’s an urgency to treatment, because the longer you go untreated, the worse this is. The longer you go without treatment, the harder it is to treat. The longer you go without treatment, the more likely you are to have more episodes of depression over the course of your life.
Second, don’t settle. If you’re getting treatment, whatever kind of treatment, whether you’re talking about therapy, whether you're talking about medicines, don’t stop because things are better, because better doesn’t cut it. Statistics show that even getting people most-of-the-way well only affords them maybe 20 percent of the protection from future episodes that getting people all-the-way well does.
I have a fraternity brother who’s a firefighter, and not once has he ever told me, “Hey, I had a really great day today, Chris. There was this house on fire, and we put it almost all the way out.” Not once has he said that to me. Treat depression the same way.
Finally, Wabash is such an unusual, unique place. In some ways it’s a very demanding, challenging, and stressful place, but you’re there with like-minded men, by and large, with a much different sense of community than you have on a lot of other college campuses. It affords people the wonderful opportunity to take care of each other, because you’re much in the type of environment where you can pick up on changes, realize that Hey, something is not right here.
If you have a concern, say something. Sometimes, people get so worried about offending somebody—“I don't want to hurt their feelings,” or, “I don't want to make them feel ashamed.”
Almost every patient I’ve had has said, in one form or another, “When somebody recognized I was hurting and reached out to me, that’s what made it easier for me to get help.”
Wabash is a place where there are more opportunities than at many other places for that to happen.
DR. CHRIS BOJRAB is president of Indiana Health Group, the largest multidisciplinary behavioral health private practice in Indiana. A board certified psychiatrist and Distinguished Fellow of the American Psychiatric Association, he is also the team psychiatrist for the Indiana Pacers.