What is a concussion?
A concussion is a type of mild traumatic brain injury. The CDC defines this as a disruption in the normal function of the brain caused by a bump, blow, or jolt to the head or body that causes the brain to move rapidly inside the skull. An estimated 1.6-3.8 million sports and recreation related concussions occur in the United States every year.
Just as the cause of a concussion is unique, so it the manifestation of symptoms. Typical signs and symptoms include headache, nausea, confusion, fatigue and sleep problems, and/or mood disturbance. Symptoms are often noticed immediately after an injury, but others can have a delayed or lingering presentation. Normal recovery time in adult athletes is 10days1; while children and adolescents appear to have a slower recovery2.
Reporting of Symptoms
In the adolescent population, injury to the brain is possible with even the slightest insult, which can affect recovery and predispose them to subsequent concussions3. One significant issue with identifying concussions is that a clinical diagnosis is based on the presence of signs and symptoms, which are self-reported by the patient. Despite the known adverse impact of concussion on various aspects of functioning, they still often go unreported. Less than half of high school athletes report their concussion4. McCrea et al (2004) identified several reasons why athletes “did not report a potential concussion as follows: the athletes did not think it was serious, did not understand the severity, did not want to let teammates down, and finally, they did not want to leave the game.”
Factors Impacting Recovery
There are numerous factors that impact the presentation of symptoms and recovery in an individual. These include location of the injury, co-morbid medical conditions, and psychological factors. The psychological factors may be pre-existing conditions or come about in reaction to the injury. An emotional reaction to an injury is normal and expected. However, this can be complicated by a pre-existing mental health condition or propensity. Nearly one in five adults in the United States lives with a mental illness and one in six youth experience a mental health disorder each year5. Injuries such as concussion can exacerbate mental health concerns. They can lead to and/or increase depression, anxiety, suicidal ideation, disorder eating, and substance use6.
Mental Health and Concussion
Numerous studies have found a significant link between concussion and depression, with concussion leading to an increased likelihood of experiencing depression symptoms7-8. Typical post-concussive depression symptoms include heightened emotionality, sadness, irritability, nervousness, and fatigue9. It has been found that individuals with depression showed poorer outcomes than those without10. Self-reported, sports-related concussion was also significantly associated with greater odds of experiencing suicidal ideations and suicide attempt11.
Seeking Counseling and Support
There is a stigma toward obtaining behavioral health intervention that perpetuates in our society. Approximately half of those experiencing mental health issues seek care5. This is often due to a self-imposed stigma against counseling. Athletes are less likely to seek treatment. According to Putukian (2016), athletes may view seeking counseling as a sign of weakness and may be afraid to reveal symptoms for a variety of reasons. However, it has been found that when athletes have encouragement from others and established relationships with providers that they are more likely to follow through with appropriate care12.
Concussion symptom management should be multipronged and include psychotherapy. These psychotherapy interventions could include psychoeducation regarding the course of the illness, supportive therapy, behavior therapy, and mindfulness training. Psychiatric medication management may also be a part of the treatment if appropriate. With awareness of the symptoms that an individual is facing, accommodations can be made in the school and work settings as well.
A team-based care approach is most beneficial for indivudals in their management and recovery post-injury. This is the approach that the UC Health Concussion Clinic and Peak Vista Community Health Centers take in whole-person healthcare. Together, recover better!
References
1. Riggio, S. & Jagoda, A. (2016). Concussion and its neurobiological sequelae. International Review of Psychiatry, 28(6), 579-586.
2. Thomas, D., Collins, M., Saladino, R., Frank, V., Raab, J., & Zuckerbraun, N. (2011). Identifying neurocognitive deficits in adolescents following concussion. Academic Emergency Medicine, 18, 246-254.
3. Kay, M., Welch, C., & Valovich McLeod, T. (2015). Positive and negative factors that influence concussion reporting among secondary-school athletes. Journal of Sport Rehabilitation, 24(2), 210-213.
4. McCrea, M., Hammeke, T., Olsen, G., Leo, P., & Guskiewicz, K. (2004). Unreported concussion in high school football players. Clinical Journal of Sports Medicine,14(1),13–17.
5. NAMI (2019). Mental health by the numbers, https://www.nami.org/mhstats.
6. Putukian, M. (2016). The psychological response to injury in student athletes: a narrative review with a focus on mental health. British Journal of Sports Medicine, 50, 145-148.
7. Gouttebarge, V. & Kerkhoffs, G.M. (2020). Sports career-related concussion and mental health symptoms in former elite athletes. Neurochirurgie, In press.
8. Harris, S.A., Chivers, P., McIntyre, F., Piggott, B., Bulsara, M., & Farringdon, F. (2020). Exploring the association between recent concussion, subconcussive impacts and depressive symptoms in male Australian Football players. BMJ Open Sport & Exercise Medicine, 6(1).
9. Ho, R., Hall, G., Noseworthy, M., & DeMAtteo, C. (2020) Post-concussive depression: evaluating depressive symptoms following concussion in adolescents and its effects on executive function. Brain Injury, 34(4) 520-527.
10. Rapoport, M. J., McCullagh, S., Streiner, D., & Feinstein, A. (2003). The clinical significance of major depression following mild traumatic brain injury. Psychosomatics, 44(1), 31–37.
11. Mantey, D., Omega-Njemnobi, O., Barroso, C., & Kelder, S. (2020). Self-reported history of concussions is associated with risk factors for suicide completion among high school students. Journal of Affective Disorders, 263, 684-691.
12. Gulliver, A., Griffiths, K., & Christensen, H. (2012). Barriers and facilitators to mental health help-seeking for young elite athletes: a qualitative study. BMC Psychiatry, 12(157).
