Introduction
Sports-related concussion (SRC) has been an important topic of research as many studies have shown that concussions and mild traumatic brain injury (mTBI) can lead to cognitive, somatic, and psychological symptoms. This article reviewed the most recent literature with aims to review the effects of concussions such as anxiety, depression, and other related symptoms; as well as risk factors that increase the propensity of these athletes to exhibit some level of psychological dysfunction and potential strategies to treat them.
Sports related concussions represent a significant percentage of total annual concussion rates, and the risk of sustaining a SRC further increases based on the sport played, age, and sex. Girls and high-contact sports, such as football, hockey, and lacrosse, have the highest incidence rates of concussions annually (1). However, regardless of the sport-related cause, all concussions put the athlete at an increased risk for psychological sequelae. These patients may exhibit various signs and symptoms, in addition to possible worsening of known psychiatric diagnoses. For example, a patient with no known psychiatric diagnoses may exhibit signs and symptoms of increased sadness, anxiety, isolation, and aggression. In an athlete with a history of a psychiatric disorder, the associated symptoms may become worse, and ultimately be refractory to conservative management now requiring more aggressive treatment. A recent 2022 study involving 266 young athletes (133 in the concussion group and 133 in the control group) aimed to identify differences in depressive symptoms between athletes who suffered a SRC versus aged-matched controls who did not (2). Depressive symptoms were measured using the Patient Health Questionnaire (PHQ-9). The study found that athletes who suffered from a concussion had significantly increased PHQ-9 scores at enrollment and 1 month postconcussion.
Furthermore, the next question that arises is how long do these symptoms last? Previous studies on sports related concussions in adolescents suggest the effect of depression to be temporary, but anxiety associated with other causes of mTBI to be more long lasting (3,4). More recently, a study involving 2160 high school athletes (125 suffered concussion) supported depression to be temporary (5). Patient's PHQ-9 scores were evaluated at baseline, 24 to 72 h, 7 d, upon return to play, at 3, 6, and 12 months after the concussion injury. PHQ-9 scores were higher at 24 to 72 h and 7 d after concussion, but back to baseline upon return to play, and continued to be at baseline at 3, 6, and 12 months after concussion (6). Therefore, the length of symptoms do seem to be short-term, however, other factors including repetitive concussions, preexisting psychiatric disorders, and severity of symptoms may all play a role in the total duration of psychological effects (7).
Moreover, now that there is unequivocal evidence showing a clear association between concussions and psychological symptoms, clinicians and researchers must ask: what is the pathophysiology behind concussions leading to these effects? Although the resultant brain injury from a concussion cannot be seen on a standard CT or structural magnetic resonance imaging (MRI), research has now found changes in the biochemical and structural levels of the brain (8). The changes are visualized using techniques, such as functional MRI, diffuse tensor imaging, positron emission tomography, or brain metabolite imaging spectroscopy. Each modality has found evidence of various consequences including damaged fiber tracks and impaired neuron activation, particularly in the frontal lobe. These imaging techniques also indicate decreased metabolism and reduced blood oxygenation levels. Currently, there is ongoing research on cerebrospinal fluid biomarkers that can help predict long term consequences of TBI, but all studies have looked at moderate to severe cases, so there is an opportunity for future research on these biomarkers (microtubule-associated protein tau, glial fibrillary acidic protein, S100 calcium binding protein B, etc.) in patients with mild traumatic brain injuries and sports related concussions.
Methods
We searched the following databases for published and non-published studies in the English language from 2017–2022: PubMed and Ovid. The keywords and phrases of “sport-related concussion,” “concussion,” “mood,” “depression,” “suicide,” and “mental health” were used to generate a search. A total of 118 studies were found. Of the 118, 44 studies were included based on the inclusion and exclusion criteria. The inclusion criteria being sports related concussions, adolescent and young adult populations, and literature primarily from the last 5 to 7 years. Additional studies from no later than 2008 were used as reference on past discussions. Exclusion criteria included older adults and geriatric patient populations, mTBI from other causes not related to sports, and studies that focused on moderate to severe traumatic brain injuries.
Results
After a comprehensive review, sports related concussions in adolescents and young adults are associated with an increased risk of suicidal ideation, suicide attempt, and overall increased risk-taking behaviors. Research also has found an increasing association between concussions and other comorbidities, including post-traumatic stress disorder, attention-deficit/hyperactivity disorder, and other mood and anxiety disorders.
Concussions and Suicide
Concussions are associated with increased risk of suicide attempts. Fralick et al., conducted meta-analysis of 17 studies that included more than 700,000 children and adults with concussions and/or traumatic brain injury, and 6.2 million unaffected individuals, which showed that the risk of suicide was twofold higher for people diagnosed with concussion (9). A study using analyzed data from the Youth Risk Behavior Survey (YRBS) from 2017 also supported this finding. The YRBS is a local school-based survey conducted every 2 years that consists of questions regarding behaviors that contribute to death, disability, and social problems among youths and adults in the United States. The study data was collected from 144 private and public schools, from 9 to 12 graders, with a sample size of 13,353. Overall, teenagers with a self-reported history of sports-related concussions in the past 12 months had slightly higher odds of feeling sad or hopeless, suicidal ideations, and suicide attempt. Subgroup analysis in male and female teenagers showed that girls with concussions, compared with gender- and age-matched controls, had slightly increased odds of feeling sad or hopeless, suicidal ideations, planned suicide attempt, and actual suicide attempt. On the contrary, boys with concussions had moderately increased odds of suicide attempt, but no increased association with psychosocial or behavioral risk factors, such as sad or hopeless, suicidal ideations, or planned suicide, compared with the control group (10). A similar study using 2017 YRBS data from 19,254 middle school students (ages 11–14) also found mild to moderate increased odds of suicidal ideation, planned suicide, and history of suicide attempt (11). In summary, regardless of age or sex, those athletes who had recently suffered from a concussion were more likely to experience suicidal ideation or attempt suicide than those who did not.
Concussions and Increased Risk-Taking Behaviors
In addition, risk taking behaviors also have been associated with concussions among adolescents. In a cross-sectional study using the data from the 2017 Youth Risk Behavior Survey from 13,268 participants, found a moderate association with concussions and being in a physical fight in both boys and girls, tobacco/e-cigarette use in boys, binge drinking in boys, and riding in a vehicle with a driver who has been drinking (7). Potential reasons for risk taking behavior may be attributed to the disturbance or damage of fiber tracks in the frontal and prefrontal cortices of the brain in regulating emotions and behaviors, as stated in the introduction of this article. However, it also may be a way for individuals to deal with the direct psychological effects of the concussion. A survey study of 4849 college students examined the relationship between concussion and substance abuse. Researchers used the Patient Health Questionnaire (PHQ-9), Alcohol Use Disorders Identification Test, and Cannabis Use Disorders Identification Test-Revised to assess the mental health of participants and compared the scores between those who have had a history of concussion and those with no history of concussion. They used a regression model to examine the relationship between concussion, depression and anxiety, and drug use. Their analysis showed that concussion and substance use may have both a direct and indirect association via depression and anxiety with alcohol and cannabis use. This suggests that patients may be self-medicating with alcohol and cannabis to alleviate depression and anxiety symptoms associated with the concussion itself (12).
Concussions and Mood/Anxiety Disorders
Symptoms of depression often overlap with symptoms of concussion. Patients suffering from the effects of concussions present with various symptoms of varying degree of severity. Kontos and Collins (13) classified various symptoms of concussion into clinical profiles, including cognitive/fatigue, vestibular, ocular, posttraumatic migraine, and anxiety/mood, with sleep and cervical as modifiers of the clinical profiles. The anxiety/mood profile includes symptoms of depression, anxiety, feeling more emotional, moodiness, and irritability. Other indirect symptoms include sleep dysregulation, exaggerated or inconsistent somatic symptoms, physiological alterations of the autonomic nervous system, and psychological behaviors such as avoidance, rumination, and hypervigilance. Other researchers also have found similar overlap between patients with chronic traumatic encephalopathy and depression (14).
Multiple factors have been associated with the development of anxiety and depression among individuals who had an mTBI. These include the number of concussions, concussion symptoms at the time of a recurrent concussion, loss of consciousness, and sex.
The number of concussions appear to be correlated with the development of anxiety and depression in individuals. Previous studies involving high performance athletes, ages 17 years and older, found a threefold increased risk of developing depression in athletes with three or more concussions (15). A study examining 3506 former National Football League players through a questionnaire found that each five seasons of professional play was associated with a 9% increased risk of depression symptoms (16). Players who played positions that were considered a high concussion risk (running backs, offensive linemen, defensive linemen, and linebackers) were more likely to develop depression. In addition, those who suffered another concussion while having concussion symptoms were found to be two to six times more likely to develop depression (depending on severity of concussion symptoms suffered during a secondary injury) (17).
In addition, there are mixed studies between the severity of concussion and the development of anxiety and depression. The aforementioned study involving NFL players found that players who lost consciousness from a concussion were 5.9 times more likely to develop depression and 6.1 times more likely to develop anxiety (17). In contrast, other studies examining the severity of concussions and the development of psychological complications suggests that there is no association. A study of 291 patients in Taipei compared the neuropsychological symptom scores of emergency department patients who had a concussion. The patients were separated into complicated (Glasgow Coma Scale [GCS] scores of 13–15 with intracranial abnormalities on CT), and uncomplicated (GCS scores of 13–15 without intracranial abnormalities on CT), and patients who did not undergo CT (mild symptoms). Patients were asked for their recall of their symptoms prior to the injury using the Checklist of Post-Concussion Symptoms (CPCS), and their symptoms after injury from the Beck Depression Inventory and the Beck Anxiety Inventory. On average, there were no significant differences between the groups on the recall. Researchers found no significant difference in the frequency of anxiety, depression, attention difficulties, and headaches between the three groups. It was noted that the study had a much shorter interval between the concussion and the surveys (average of 11 days in the complicated group, 8.6 days in the uncomplicated group, and 6.6 days in the no CT group) (18). A prospective cohort study by Roy et al., involving mild traumatic brain injury of 407 emergency department patients, found that altered mental status, but not loss of consciousness, was associated with depression at one month (OR 1.59, P = 0.38) but not at six months (OR 1.6, P = 0.6) (19). This also has been demonstrated in prior studies (20–23). The differences may be explained by study method and potential confounding factors, as the study involving NFL players examined players’ depression symptoms months to years after their concussion based on the recall of their symptoms of that injury, compared to the ED studies, at 1 week to 6 months.
Previous literature has found an increase in neurocognitive symptoms and recovery time in girls after concussion (24). A similar trend also is found with depression. A prospective study of 491 adolescents (229 girls, 262 boys), ages 12–18 found that girls reported higher severity of anxiety and depression. Girls reported an average GAD-7 score of 4.05 (SD = 4.74) versus boys 2.44 (SD = 3.59), P < 0.01. Their PHQ-8 score was 4.73 (SD = 5.05) versus boys 3.09 (SD = 3.36, P < 0.01). Girls also reported a higher symptom level of headache, dizziness, light sensitivity, sound sensitivity, head pressure, feelings of fatigue, drowsiness, and feeling of being slowed down (25).
Concussion and Preexisting Psychological Traits
Previous literature has revealed different preexisting emotional and personality traits that predict worse recovery from concussion. These include baseline irritability, sadness, nervousness, and anger. Other things such as life stressors, personal and family history of psychiatric disorders (anxiety, depression) also predict poorer outcomes on recovery (26,27). Postconcussion symptoms may be a continuation of preexisting mental health issues rather than an increase in severity after concussion (28). A study of 297 patients in the emergency department evaluated postconcussion symptoms in patients with mTBI using the CPCS that included physical symptoms (headache, dizziness, fatigue, nausea, energy loss, vomiting, blurred vision, insomnia, tinnitus), cognitive symptoms (attention difficulty, memory loss, slowed processing), and emotional symptoms (anxiety, depression, irritability). Results found that participants who experienced preinjury anxiety or depression reported all symptoms at a greater frequency before and after the injury (29).
More recently, Brett, et al. derived four distinct neurobehavioral “latent profiles,” to predict recovery from concussion. The profiles are based on patient symptoms 2 wk after mTBI using self-reported measures, including 18-item Brief Symptom Inventory (for symptoms of psychological distress), Posttraumatic Stress Disorder Checklist for DSM-5 (for posttraumatic stress symptoms), Patient Health Questionnaire-9 (for depression), Insomnia Severity Index (for sleep disturbance), and the PROMIS Pain Intensity scale (for pain intensity). The four latent profiles include emotionally resilient, cognitive impaired, cognitively resilient, and neuropsychiatrically distressed. They found that patients in the neuropsychiatrically distressed group had the worst outcome of the four groups in all four measures of quality of life and neurocognitive symptoms 6 months after their concussion (30).
Treatment
Because psychological symptoms of concussions vary between individuals, treatment plans are different for each patient. In general, there has been an increased push for a more active recovery process after concussions. Cognitive and physical rest during the acute phase (24–48 h) including increased sleep is still recommended. However, beyond this point, patients are encouraged to gradually return to some degree of daily activity. There is concern for deconditioning from prolonged inactivity, as well as concerns for social isolation that can exacerbate anxiety and depression. Researchers suggest a regulated behavior plan that addresses positive lifestyle changes, including adequate diet/hydration, sleep, noncontact daily activity, stress management, rather than strict rest (13). Hunt et al., engaged children and adolescents (N = 40) with persistent postconcussion symptoms in a 6-wk active rehabilitation program. The rehabilitation consisted of low-intensity aerobic exercise, sports drills, relaxation exercises, concussion education, and support. Results show an improvement in scores relating to anxiety and anger reported by participants and lower complaints reported by parents regarding anxiety, depression, and somatic complaints (31).
An expose–recover model also is suggested. In this model, patients engage in activities, situations, and environments that provoke postconcussive symptoms for short durations with subsequent periods for recovery symptoms to subside. Repeated exposures to provocative stimuli will gradually lessen severity and duration of symptoms. For emotional and behavioral changes, psychotherapy has been noted to be effective in addressing symptoms of anxiety and depression (13).
Cognitive behavioral therapy (CBT) also has been used to treat anxiety symptoms related to concussions. CBT helps to educate and identify maladaptive thoughts and beliefs such as overgeneralization and catastrophizing that either result from the injury or prolong recovery by maintaining symptoms. This involves discussion of goals and expectations, and gradual resumption of daily activities and exposure to anxiety-causing stimuli (32,33).
Another therapy modality is based on psychoeducation, with focus on motivational interviewing, self-directed exercises to reinforce self-efficacy, awareness, and disengaging from problematic situations to make changes in their behavior. Education about concussions is important as it teaches players, parents, and coaches to recognize and manage concussions appropriately.
Biofeedback also has been suggested as a therapy modality. This technique involves identifying and measuring the behavior through a person's physiological response, such as EEG, MRI, heart rate, temperature, muscle contractions, or sweating through a device. If the response is detected, it is then sent back to the patient via a visual (e.g., flashing light), auditory, or tactile (e.g., vibration) cue for the person to correct their behavior. For instance, a patient's stress and anxiety can be measured using heart rate and muscle tension, this can be conveyed to the patient via vibration device, alerting the patient to use their learned techniques to relax (33). There has not been research on biofeedback specifically for concussion-related depression symptoms.
A systematic review on biofeedback therapy showed some improvement in the treatment of major depression, ranging from −7% to 52% improvement between groups. However, it was noted that the quality of the studies did not meet strict randomization, blinding, and control conditions, nor did they mention the duration, prior treatments, or treatment resistance of the subjects in the studies (34). A systematic review of cognitive and psychological interventions for reduction of postconcussion symptoms, evaluated the efficacy of various modalities including psychoeducation, psychotherapy, and cognitive training. The overall analysis found a small improvement in functional outcomes at 6 months, but no effect on symptom reduction. When looking at individual types of treatment modalities, the analysis found no significant difference in symptoms at 1, 3, 6 months, and 1 year follow-up in patients who underwent psychoeducation treatment versus the control group. On the other hand, psychotherapies including problem-solving treatment and cognitive behavioral therapy found a reduction in postconcussive symptoms at the end of the research period at 3 to 6 months in studies involving civilians (n = 4), but not on veterans (n = 3) (35).
There has not been any recent literature regarding pharmacological treatments for postconcussion neuropsychiatric symptoms. Prior research using medications in the treatment of postconcussion symptoms included methylphenidate and antidepressants. There was a small, randomized placebo-controlled trial (N = 32) using methylphenidate that showed improvement in cognitive symptoms such as fatigue, processing speed, and attention (36). However, one can argue that anyone given methylphenidate would show improvement in cognitive abilities, regardless of their history of concussion.
With regard to neuropsychiatric symptoms, there have been older studies that show the use of selective serotonin reuptake inhibitors is helpful in improving depression, processing speed, flexible thinking, and recent memory ability (37). A retrospective study of 277 patients has shown evidence of gabapentin in short-term improvement in headache (headache score decreased from 4.5 to 3.2 [P = 0.004]) in the gabapentin group, headache improvement over time with tricyclic antidepressants (TCA) (headache score decreased from 4.4 to 0.9 P = 0.006), and improvement in postconcussion symptom score with TCA (symptom score of 64 to 33, P = 0.005), although not specifically in depression and anxiety. However, at 1 year, there does not appear to be any difference in headache or symptom scores between the TCA, gabapentin, and the control groups (2). There have not been many studies regarding the efficacy and tolerability of other antidepressants, including serotonin and norepinephrine reuptake inhibitors, bupropion, MAO inhibitors (8).
Conclusion
Symptoms of anxiety, depression, difficulty with attention, and concentration are common for those suffering from concussion and may overlap with other directly related cognitive impairments. Early diagnosis of psychological symptoms may help in predicting long-term outcomes, as well as determine the likelihood that additional treatment modalities may be needed. Concussion may increase risk of mental health problems in particularly in the short term, but also possibly in the long term. Adolescents with concussions are associated with increased risk-taking behaviors. Repeated head injuries may increase risk of long-term mood problems. It is uncertain whether the risk of psychological symptoms correlates with the severity of concussion. Patients with psychological traits of anxiety and depression are more likely to have prolonged recovery. Although girls are more likely to have worse depression symptoms, male teenagers may need close monitoring as suicidal attempts are more likely, despite showing no increased mood scores. Psychoeducation, although may not be helpful in treatment of symptoms, may aid family and friends to identify concerning behaviors that necessitate additional treatment from health providers. Treatment of anxiety and depression should focus on cognitive behavioral therapy to eliminate counterproductive thought processes such as pain catastrophizing and limiting behaviors. Other treatments, such as biofeedback, may be helpful, although time and cost may limit access to these therapies. Medications should be considered if symptoms are severe and resistant to psychotherapy.
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