Treatment Of Severe Depression
Following Head Injury
Martha M. Grout, MD
Curtis T. Cripe, PhD

ABSTRACT
Depression and other mental and psychological symptoms are frequent sequelae of mild traumatic brain injury. Two-thirds of patients recover 80% of their pre-injury functioning within 6 months of injury. Many of those who do not recover are left with severe cognitive and emotional impairment, refractory to treatment. The following case report describes treatment with multiple modalities including medical acupuncture, leading to complete recovery from a 6-year history of severe depression following head injury in a 22-year-old man.
KEY WORDS
Brain Injury, Head Trauma, Depression, Psychological Sequelae, Post-Concussion Syndrome, Acupuncture, Neurotherapy, Auditory Processing

INTRODUCTION
hysicians see approximately 300,000 people as a result of a blow to the head each year in the United States.¹ Of that number, between 50,000 and 100,000 have prolonged symptoms affecting their relationships and/or their ability to work. Approximately two-thirds of patients with mild traumatic brain injury will recover 80% of their pre-injury functioning within 6 months.² Most of these patients will fully recover within the subsequent 12-18 months.

 Initially, many people with mild traumatic brain injury experience confusion, agitation, and sometimes forgetfulness, even concerning personal hygiene. They may have debilitating mood swings or may deny that there is any problem, either because of emotional withdrawal or physical injury to the brain itself. Later, depression and anger often occur when patients fear that they may never function normally again.

Standard medical tests are often unremarkable, including neurologic exam, CT scan, MRI, and EEG. Even neuropsychologic testing may not be sensitive enough to detect the individual who functioned at a high level prior to injury. As many as 50% of subtle brain injuries remain undiagnosed, even after appropriate neuropsychologic testing.³ SPECT scan may be useful to detect subtle areas of increased or decreased cerebral blood flow often seen with traumatic head injury.⁴

Since the early 1990s, a diagnostic test, quantitative electroencephalogram (qEEG), has been used in the diagnosis of minimal traumatic brain injury.⁵ This test, based on work by Robert Thatcher, PhD, in the 1980s and supported by a grant from the National Institutes of Health (NIH), involves comparison of a patient's EEG signature with that of a database of normal EEG signatures.⁶ The difference in the signatures is expressed in terms of Z score or degree of deviation from normal. The signature is submitted to a multi-variant regression analysis that can discriminate for both mechanical head injury and diffuse axonal injury, as may occur with the twisting and shearing forces of traumatic head injury. The test has a sensitivity and specificity of over 95% for minimal traumatic brain injury^7-9 and is helpful in distinguishing subtle changes in both the anatomy and processing functions of the human brain.¹⁰

This article describes a patient with minimal traumatic brain injury, previously undiagnosed, presenting at our clinic with a 6-year history of severe depression and anxiety. The patient's therapy encompassed multiple modalities, medical acupuncture prominent among them.

CASE REPORT
A 22-year-old man presented for treatment of severe depression and anxiety of 3 years' duration following significant head injury. His initial head injury occurred at age 6 after a bicycle fall resulted in amnesia for the events of that day. He sustained a subsequent skateboarding injury at age 16 and suffered intermittent loss of consciousness for 2 hours. The patient stated that, in retrospect, he never felt normal after the skateboarding injury. He felt disconnected from and disinterested in life, although not diagnosed, with clinical depression. He sustained a 3rd injury at age 19 in a rollover car crash. His head struck the ground multiple times, but he had no prolonged loss of consciousness. A subsequent CT scan was negative. Within a few weeks of the car crash, the patient became depressed, irritable, and anxious. Schoolwork became impossible, personal relationships declined, he reported severe insomnia, and he attempted suicide 1 year after the car crash.

The patient's past medical history was significant for asthma and abdominal distress with bloating and pain under the ribs. He reported severe daily headaches. Hearing was normal, but telephone conversations were unclear in the left ear. Smoking included tobacco and marijuana.

Physical examination revealed a well-developed, well-nourished male, appearing extremely depressed with flat affect and slow movement. Examination was normal except for multiple tender points on the scalp, particularly in the frontal and temporal regions bilaterally; marked clamminess and coolness of hands and feet; pulses were deep and slow, diminished in all 3 positions on the left, with marked left/right imbalance; tongue was moist, somewhat pale, with multiple cracks in the midline, worse in rear position, and damp slightly yellowish coating in middle and rear positions; neurologic examination within normal limits; and neurodevelopmental and neuroprocessing evaluation (motor, tactile, auditory, and visual ) showed marked impairment of auditory discrimination (worse in the left ear), and marked disturbance of tactile discrimination, with relatively normal motor processing.

Diagnostic Assessments
Food allergy testing (using an immunoassay, the ALCAT test11) showed multiple foods to which the patient reacted strongly, which were subsequently eliminated from his diet (Table 1).

qEEG was analyzed to diagnose brain-processing issues.⁶ This specialized EEG, also referred to as a brain map, analyzes brain wave activity as measured using an electrode cap and standardized international 10/20 system of lead placement. The patient's brain wave activity (qEEG) was compared to that of other individuals of the same age using analyzing software developed by the NIH. (The analysis software received FDA approval as an objective diagnostic tool for conditions including learning disabilities, attention-deficit/hyperactivity disorder, depression, bipolar disease, and many others.)

The patient showed significantly increased power in the theta (associated with emotionality), alpha (associated with state of relaxed awareness), and beta (associated with focusing on task) bandwidths, despite his appearance of depression, with marked power asymmetry (i.e., left-right imbalance), worse in the temporal and central motor planning areas. He also had marked increase in coherence in the alpha, theta, and delta bandwidths, resulting in inflexibility, "squirrel cage phenomenon," and the inability to function normally. He showed loss of cortical function, consistent with post concussion syndrome; and incomplete communication between brainstem and cortex through the midbrain, resulting in marked brain-processing disorganization, which can lead to severe anxiety and emotional paralysis (Figure 1).

Traditional Chinese Medicine (TCM) Diagnosis Shao Yang Wood biopsychotype, Kidney Yang deficiency, Liver Qi stagnation with Liver Yang Rising, Spleen Qi deficiency, and food stagnation.

Table 1. ALCAT test for food allergies
RESULTS GUIDE
Reactive Foods			Non-Reactive Foods
Severe	Moderate	Mild	Dairy	Fruit	Vegetables	Grains	Meats	Beverages
Asparagus	Almond	Apricot		Cherry	Beet	Malt	Chicken	Coffee
Black currant	Apple	Avocado		Kiwi	Green pea	Rice	Lamb	Tea
Brewer's yeast	Bakers yeast	Banana		Olive	Lentil bean		Pork
Cashew	Black pepper	Basil		Orange	Mustard		Turkey
Chamomile	Blackberry	Beet sugar		Papaya	Okra
Cheddar cheese	Brazil nut	Blueberry		Peach	Pinto bean
Chick pea	Broccoli	Buckwheat		Pear	Red pepper
Cinnamon	Caraway	Cabbage		Plum	Soybean
Cumin	Cauliflower	Cantaloupe		Pumpkin	Spinach
Egg (whole)	Chicory	Carob		Watermelon	Squash
Eggplant	Chili pepper	Carrot			Sweet potato
Fig	Coconut	Celery			Turnip
Guava	Codfish	Cocoa
Grape	Cola	Coffee	Nuts & Oils	Salad	Herbs & Spices	Seafood	Yeasts
Green pepper	Cow's milk	Corriander
Honeydew melon	Cranberry	Corn	Olive	Cucumber	Mint	Clam
Hops	Duck	Cottonseed	Pecan	Lettuce	Turmeric	Crab
Kidney bean	Fennel	Ginger	Pistachio			Lobster
Leek	Goat's milk	Grapefruit	Sunflower		Misc.	Mussel
Mango	Halibut	Honey	Walnut		Food	Oyster
Mung bean	Hazelnut	Lemon			Cane sugar	Salmon
Mushroom	Herring	Lima bean			Cayenne pepper	Snapper
Navy bean	Liver (Beef)	Parsnip			Fructose	Sole
Onion	Millet	Radish			Garlic	Trout
Oregano	Nutmeg	Scallop			Safflower
Paprika	Parsley	String bean			Sesame
Peanut	Psyllium	Tomato			Vanilla
Pineapple	Raspberry	Veal
Rabbit	Strawberry
Shrimp	Tapioca
	Tuna
NOTES: Patient had no reaction to gluten. Patient had a medium reaction to casein. We recommended that the patient stay away from the following foods: goat's cheese. Further eliminations, if any: beef due to a reaction to liver (beef); goat cheese due to a reaction of goat's milk; oat, rye, and wheat due to a reaction to gliadin.
Items in the the 3 left hand columns showed reactivity: the 1st column being most severe; the 2nd column moderately severe; the 3rd column least severe. Items in the 4th through 9th columns showed no reactivity. The ALCAT test is an immunoassay, based on swelling of white blood cells when exposed to aliquots of food (or chemical) extract.

METHODS
Treatment Principles
Tonify the Kidney Yang (because the brain is under the charge of the Kidney), relieve stagnation of Liver Qi, and tonify Spleen Qi to relieve both food and mental stagnation, restore the energy balance of the system.

From the neurodevelopmental point of view, treatment was aimed at redeveloping and integrating the peripheral nervous system, retraining the central nervous system, dislodging neuroinhibitors, and exercising and training the brain to a more normal brain wave pattern.

TREATMENT
Acupuncture
Acupuncture was used in this patient to stimulate the Kidney Qi, thereby stimulating growth of neural pathways. Treatment was also aimed at moving the Liver Qi to help relieve severe anxiety. Treating the Spleen helped both the digestion and the left-brain functions of word retrieval and logical thinking by clearing Phlegm.

The patient consented to treatment. He rested on a massage table, listened to music (therapeutic music of the Dynamic Listening System, Native American flutes and drums, or piano music of the meditative variety). Needles were inserted to elicit De Qi or "needle grab," generally about 5 mm. Needles were tonified briefly, then left in neutral for 20 minutes. (Needles were manufactured by HwaTo, 32 gauge of varying lengths from 25 to 75 mm.) Both scalp and body treatments were used, either during the brain lab sessions or at separate times.

Initial treatments were 2 times weekly for 4 weeks, using the Shao Yin Tai Yang meridians. Points included: KI 3 Taixi, KI 7 Fuliu, HT 3 Shaohai or HT 7 Shenmen, BL 59 Fuyang, and BL 60 Kunlun for energetic movement. Multiple focus points were piqured in the scalp, especially on the Gallbladder meridian, in the frontal and temporal areas. Points were chosen based on the patient's tenderness to palpation, and the areas the brain map demonstrated to be out of balance. Scalp points included: GV 20 Baihui, GV 21 Qianding (to cover the central motor strip, and corpus callosum), GB 8 Shuaigu, GB 13 Benshen, GB 18 Chengling, and multiple sensitive points surrounding the ears. Multiple Mu points were used, tonifying Stomach CV 12 Zhongwan, Small Intestine CV 4 Guanyuan, Liver LR 14 Qimen, Gallbladder GB 24 Riyue, Kidney GB 25 Jingmen, and Large Intestine ST 25 Tianshu. Mu points were used mainly for their energetic and metaphorical attributes: Stomach to help the patient digest and process his experience, Small Intestine to help him distinguish the useful parts of his experiences from the emotionally toxic parts, Liver to help detoxify the emotional charge of the experience, Gallbladder to accumulate and remove from the circulation those toxic emotional wastes, Kidney to help him overcome the fear associated with those toxic experiences, and the Large Intestine to discharge from the body that which no longer served a useful purpose.

When the patient began to complain more of sweaty hands and feet and less of depression, treatments then focused (weekly for 3 weeks) on the Chong Mo (SP 4 Gongsun, KI 3 Taixi, MH 6 Neiguan), and Dai Mo meridians (GB 41 Zulinqi, TH 5 Waiguan) because of their influence on both the Tai Yin meridian (Spleen meridian, whose deficiency resulted in confusing thinking), and the Jue Yin Shao Yang meridians (Master of the Heart and Triple Heater meridians, corresponding to the autonomic nervous system). Mu points and focus points on the scalp were also used, as outlined above.

In the final 2 weeks, the patient was treated using the Tai Yin Yang- Ming meridians. Points included: SP 6 Zhigou, KI 3 Taizi, LU 7 Lieque, LI 4 Heku, ST 36 Susanli). Mu points and focus points on the scalp were also used, as outlined above. Kidney cerebral circulation,¹² both anterior and posterior pathways, was treated several times to stimulate both the auditory pathways and the brain itself. Points included: KI 27 Shufu, SI 19 Ting Gong, and BL 10 Tianzhu. Auricular acupuncture was used to stimulate specific areas of the brain via the gateway of the ear. In particular, we focused on the Corpus Callosum (to restore proper left brain-right brain communication),¹³ the Pineal (for overall regulation),¹⁴ and the frontal and pre-frontal areas (to stimulate integration of sensory input, both spatial and verbal, and executive functions).¹⁵

Figure 1. qEEG initial brain map. Note the hyperactivity in the frontal lobes, and the marked left/right imbalance, with hyperactivity in the left temporal-parietal areas, characteristic of anxiety and depression.

All 3 Nogier phases¹⁶ were used, depending on the activity of the points at any given treatment. Auricular points were stimulated with a NET-2000C Auri (STIM Medical, Inc, Denver, CO) device that delivers microcurrent at frequencies ranging from 5-80 Hz. All frequencies were delivered simultaneously. Each active point was treated for 30 seconds.

Neurotherapy
Neurotherapy, a form of EEG biofeedback, or brain wave training, which restores the pattern of cortical brain waves to within the normal range, was performed in our clinic "brain lab" 4 times weekly, 11/2 hours per session. The patient was treated for a total of 12 weeks. Each treatment included neurotherapy, auditory processing training, and memory exercises.

We used both the FLEYX system¹⁷ and the Brain Master¹⁸ training systems of neurotherapy, and the BrainBuilder¹⁹ system of memory exercises to recover memory function and emotional stability. Brain Master is a computer-based program that invokes volitional control of cortical brain waves; BrainBuilder is a computer-based program that provides numerous exercises to develop the memory.

We also used the Dynamic Listening System, which allowed us to focus on the auditory spectrum that was not responding within age-appropriate norms, as measured in the patient's listening test. Thus, in this patient, the cerebral cortex was activated via auditory stimuli, and we saw reduction in the hyperacoustic state that overwhelmed and irritated the cortex and emotional regulation systems, contributing heavily to anxiety and depression.

Memory Work
A significant part of the patient's ongoing therapy was memory work. We targeted especially the short-term and intermediate-term memory systems. When the intermediate memory was functioning well, the brain was no longer overwhelmed by auditory stimuli. Stress, anxiety, and depression were relieved, and transfer of information between frontal and temporal lobes was improved. We used many different exercises, including sequencing activities and digit spans (auditory and visual, forward and reverse, to cover both short-term and working memory).

Dietary Modification
Based on the results of food allergy testing using the ALCAT immunoassay (Table 1), the patient maintained this diet (minimally, for the major reactive foods, listed in the severe and moderate zones). He reported when not adhering to the diet, his memory systems were affected.

Figure 2. Follow-up brain map Note the clearing of hyperactivity in the frontal lobes, and the lessening of right/left imbalance. There is persistence of hyperactivity in the left temporal-parietal areas, suggestive of continued tendency to depression and anxiety. Within a month, the patient was asymptomatic.

Herbal Therapy
Herbal therapy consisted of Chinese herbal formulations to tonify the Kidney and stimulate growth of neural pathways. Since the Kidney supervises the brain, the marrow of the skull, we thought it logical to use Kidney-tonifying herbs to stimulate the brain in its development of new neural pathways. The formula used were: Strengthen the Root (East West Herbs) in the morning to stimulate Yang energy, and Nourish the Root (East West Herbs) in the evening to stimulate Kidney Yin and Essence.²⁰

RESULTS
Acupuncture was performed 2 times weekly, and neurotherapy and auditory processing rehabilitation 4 times weekly. Within the first 10 days of treatment, the patient reported experiencing clear thinking and feelings of normalcy for the first time in several years. During the course of therapy of 12 weeks' duration, he ceased drinking alcohol, stopped smoking tobacco and marijuana, and eliminated from his diet those foods to which he showed reactivity on the ALCAT test.

After 12 weeks of therapy, thebrain map had cleared almost completely (Figure 2), the patient no longer had symptoms of depression or anxiety, and his brain processing had returned to normal. Abdominal distress was no longer present, headaches were gone, and he could hear and comprehend with no difficulty using his left ear. He was discharged from our program and resumed college work.

The patient continued to do well as long as he avoided foods to which he is sensitive. He was instructed to continue the herbal formula to strengthen the brain for 18 months.

CONCLUSION
This case demonstrated how a combination of modalities could be helpful in treating a difficult condition. Our patient had been functioning abnormally for 6 years, and barely able to function for 3 years.

Using a combination of Chinese medicine, acupuncture, neurotherapy, and allergy clearing, the patient was restored to full health. The combination of medical acupuncture, neurotherapy, and dietary modification proved to be extremely valuable in the treatment of persistent post-concussion syndrome.

REFERENCES

1. Sports-related recurrent brain injuries – United States. MMWR Morb Mortal Wkly Rep. 1997;46:224-227.
2. Levin HS. Prediction of recovery from traumatic brain injury. J Neurotrauma. 1995;12:913-922.
3. Posthuma A, Wild U. Use of neuropsychological testing in mild traumatic head injuries. Cogn Rehabil. March/April 1988:22-24.
4. Ichise M, Chung DG, Wang P, et al. Technitium99-HMPAO SPECT, CT and MRI in the evaluation of patients with chronic traumatic brain injury: a correlation with neuropsychological performance. J Nucl Med. 1994;35: 217-226.
5. Thornton K. Exploratory investigation into mild brain injury and discriminate analysis with high frequency bands (32-64 Hz). Brain Inj. 1999;13:477-488.
6. Thatcher RW, et al. An EEG severity index of traumatic brain injury. J Neuropsychiatr Clin Neurosci. 2001;13:1.
7. Thatcher RW, Walker RA, Gerson I, Geisler F. EEG discriminant analyses of mild head trauma. Electroencephalogr Clin Neurophysiol. 1989;73:93-106.
8. Thatcher RW, Cantor DS, McAlaster R, Geisler F, Krause P. Comprehensive predictions of outcome in closed head injury: the development of prognostic equations. Ann N Y Acad Sci. 1991;620:82-104.
9. Trudeau DL, Anderson J, Hansen LM, et al. Findings of mild traumatic brain injury in combat veterans with PTSD and a history of blast concussion. J Neuropsychiatr Clin Neurosci. 1998;10:308-313.
10. Thatcher RW, North DM, Curtin RT, et al. An EEG severity index of traumatic brain injury. J Neuropsychiatr Clin Neurosci. 2001;13:1.
11. Solomon B. The ALCAT test – a guide and barometer in the therapy of environmental and food sensitivities. Environmental Med. 9(2):54-59.
12. Helms JM. Acupuncture Energetics: A Clinical Approach for Physicians. Berkeley, Calif: Medical Acupuncture Publishers; 1995.
13. Greenstein B, Greenstein A. Color Atlas of Neuroscience. Verlag; 2000.
14. Nelson C, Luciana M. Developmental Cognitive Neuroscience. Cambridge, Mass: MIT Press; 2001.
15. Frank B, Nader S. Atlas of Auricular Therapy and Auricular Medicine. 2001.
16. Available at: http://www.AuricularTherapy.com; IntegratedMedicine Seminars.com/products/index.html.
17. FLEYX system [currently available as the LENS system, low energy neural stimulation]. Link: http://www.futurehealth.org/nfcntral.htm. Verified November 13, 2003.
18. Brain Master (URL: http://www.brainmaster.com). Verified November
    13, 2003.
19. URL: http://www.advancedbrain.com. Verified November 13, 2003.
20. http://www.CraneHerb.com.

AUTHORS' INFORMATION
Dr Martha Grout is a Board-certified Emergency Physician, Board-certified in Medical Acupuncture, and President of the Arizona Chapter of the American Academy of Medical Acupuncture (AAMA). She has used acupuncture to treat large numbers of patients in the Emergency Department with severe chronic illness. Dr Grout was appointed to the Arizona State Board of Acupuncture in 2003.

Martha M. Grout, MD, MD (H)*
The CrossRoads Clinic
18404 N Tatum Blvd, Ste 207
Phoenix, AZ 85032
Phone: 602-787-8500 • Fax: 602-787-8503
E-mail: drmartha@worldnet.att.net

Curtis T. Cripe has a PhD in Psychology with emphasis in Neuropsychology, Neurodevelopment, and Psychophysiology, as well as Master's degrees in both Clinical Psychology and Aerospace Engineering. Dr Cripe is Board-certified in Neurodevelopment and Neurotherapy,and is a Diplomate in Peak Performance. Dr Cripe was formerly an Aerospace Engineer in NASA's Jet Propulsion Laboratory.

Curtis T. Cripe, PhD
The CrossRoads Clinic
18404 N Tatum Blvd, Ste 207
Phoenix, AZ 85032
Phone: 602-787-8500 • Fax: 602-787-8503

*Correspondence and reprint requests