Abstract
Sport-related concussions in youth and adolescent athletes most commonly resolve within one week without residual symptoms, with athletes resuming full participation following return to play guidelines. A small percentage of athletes have persistent symptoms that cause significant morbidity, some of whom are ultimately diagnosed with post-concussion syndrome. In these athletes, symptoms in the emotional domain can be more prolonged than other domains, with athletes reporting anxiety and depression months to years following injury. A prior personal or family history of pre-existing mood disorder or attention-deficit/hyperactivity disorder increases the risk of a prolonged duration of symptoms. In this case series, we discuss two cases of post-concussion syndrome in adolescent athletes with a past personal or family history of attention-deficit/hyperactivity disorder, anxiety, and depression treated by a combination of cognitive behavioral therapy and medication with ongoing persistent symptoms. There is increased need for mental health screening in all athletes to identify individuals at risk for post-concussion syndrome. Early identification of at-risk individuals allows the interdisciplinary care team to discuss expectations for the athlete and family regarding duration of symptoms.
Introduction
Sports-related concussions (SRCs) account for 8.9% of high school athletic injuries and 5.8% of college athletic injuries.1,2 A concussion is the biomechanically induced alteration in brain function following indirect or direct traumatic forces.3–5 Although over 90% of high school athletes with SRC return to baseline within one week following injury, many athletes experience persistent symptoms and are later diagnosed with post-concussion syndrome (PCS).6,7
PCS is defined as the abnormal persistence of ongoing concussion symptoms, with significant variation in diagnostic criteria. 8 When members of the American College of Sports Medicine were surveyed on the definition of PCS, the time frame of symptom duration required for diagnosis ranged from two weeks to greater than three months with further variability in the number of symptoms required for diagnosis. 8 Among members with greater than 10% of their clinic visits treating concussions and greater than 50% pediatric population, the most commonly reported time frame was greater than one month. 8
Symptoms of SRC and PCS have been grouped into four domains: somatic, cognitive, sleep, and emotional as shown in Table 1.6,7,9,10 Within the emotional domain, 49% of athletes endorsed at least one emotional symptom following SRC with 20% endorsing depression and 33% endorsing anxiety.11–13 Emotional symptoms often have a delayed presentation and greater persistence as compared with symptoms from other domains.4,14 In athletes referred to pediatric concussion programs, emotional symptoms are the most commonly reported with 72% of athletes endorsing at least one symptom in this domain. 13 Due to the significant morbidity of persistent emotional symptoms following SRC, these athletes may benefit from early mental health screening and treatment.
Domains of concussion symptoms.
Athletes with a past personal or family history of comorbid psychiatric diagnoses report increased symptoms within the emotional domain following SRC.6,7 In one study, athletes who endorsed baseline symptoms of depression were 4.6 times more likely to endorse symptoms of depression and 3.4 times more likely to report symptoms of anxiety following SRC.11,12 Those athletes who reported pre-injury symptoms of a comorbid psychiatric disorder were more likely to have a prolonged recovery time as compared to controls and more likely to be diagnosed with PCS.6,7,15–20 The mechanism of the increased severity of the symptoms is unknown; however, some have hypothesized that the SRC exacerbates underlying symptoms present prior to injury. 16 We present a case series below in two athletes who experienced a prolonged duration of symptoms in the emotional domain following SRC with personal or family history of psychiatric diagnosis.
Case reports
Case 1
In our first case, we present a 17-year-male athlete with the medical history of attention-deficit/hyperactivity disorder (ADHD) who sustained an SRC while participating in football practice. The SRC occurred while participating in a tackling drill in which this individual had a bouncing head injury with initial contact on the anterior aspect of his head. Immediately following the injury, he experienced retrograde amnesia, dizziness, and fogginess. He denied any previous history of concussion. Sideline sport concussion assessment tool (SCAT) was performed at the time of injury by the athletic trainer. The SCAT tool includes neurologic, cognitive, memory, balance, and symptom assessment following injury. The symptom evaluation includes symptoms in all four domains including the emotional domain and is the only component of the exam that addresses emotional symptoms. The SCAT additionally has a physical exam component that includes the Glasgow Coma Score and assessment of orientation, coordination, immediate memory, concentration, balance, and delayed recall. In this athlete, the initial SCAT was notable for deficits in memory, concentration, and balance. Symptoms reported included headache, psychomotor retardation, difficulty concentrating, fatigue, confusion, irritability, and anxiety. Symptoms were exacerbated by physical and mental activity. Following a period of physical and cognitive rest, he failed an attempt to return to usual activities due to headaches and difficulty concentrating. His transition back to school was exacerbated by bullying from his peers. The bullying was newly initiated upon his return to school and in the setting of concern that he was “faking his concussion.” In addition to headaches, he continued to endorse ongoing symptoms of irritability, anxiety, and insomnia. Amitriptyline 50 mg daily treatment was initiated for posttraumatic headaches and other associated symptoms. 21 He was transitioned to homebound education. Physical exam at the pediatric concussion clinic two months following SRC included difficulty with working memory, thought organization, language comprehension, and language retrieval. Ongoing nystagmus, saccadic eye movements, impaired motor development, and vestibular impairment were also observed. The patient endorsed symptoms of worsened anxiety and new onset panic attacks for which he was started on short-term lorazepam 1 mg as needed for panic attacks. Four months following initial injury, he reported mild improvement in symptoms but continued to endorse increased anxiety, irritability, and difficulty concentrating. He ultimately did not return to school due to persistence of symptoms and instead pursued his General Education Development and further employment in his family’s landscaping business. He follows with primary care, neurosurgery, psychiatry, and physical therapy to provide interdisciplinary care for his ongoing recovery.
Case 2
Our second case presents a 16-year-old male with the medical history of a simple febrile seizure during childhood. Family history is notable for depression and posttraumatic stress disorder with depression present in two first-degree relatives. He sustained his first concussion during a football scrimmage. He followed the return to play protocol progressing to full participation in both football practices and games. One month later, he sustained a second concussion following helmet to helmet contact during a game. He denies loss of consciousness. Family reports poor balance, slurred speech, and word finding difficulty immediately following injury. Symptoms reported in the first week following SRC include headache, photophobia, phonophobia, dizziness, nausea, confusion, balance difficulty, difficulty concentrating, sleep disturbance, and mood lability. Symptoms of benign paroxysmal positional vertigo predated both concussions. Return to school was unsuccessful due to ongoing headache, dizziness, and difficulty concentrating. Physical exam at the pediatric concussion clinic was notable for difficulty with balance and right eye nystagmus. He was transitioned to homebound education, started on amitriptyline, and parameters for ongoing physical and cognitive rest discussed. Following mild improvement in symptoms, he was unsuccessful at a second return to school attempt five months following injury. Headaches and dizziness did later improve, and he was able to return to school the following school year. However, he returned at his previous grade level. He endorsed ongoing symptoms of depression, for which he received counseling and was started on fluoxetine but required inpatient hospitalization in the setting of suicidal ideation and ongoing depression. He subsequently developed new onset grand mal seizures and was started on anti-epileptic medications. He continues to follow with primary care, psychiatry, and pediatric neurology for his ongoing care.
Discussion
We present two cases above in adolescent athletes with history of ADHD and family history of depression who were diagnosed with PCS with a prolonged duration of symptoms in the emotional domain. In both cases, the athletes experienced clinically significant symptoms in multiple domains affecting both school performance and home life. In case 1, the athlete was diagnosed with PCS following several months of persistent headaches, difficulty focusing, insomnia, and anxiety exacerbated by participation in previous activities requiring initial therapy with a tricyclic antidepressant and short-term benzodiazepines. His recovery was delayed due to bullying in the setting of his injury by his peers highlighting the impact of the environmental factors in duration of symptoms. In the second case, the athlete sustained two concussions in close proximity with PCS following his second concussion. He had persistent emotional symptoms of depression in addition to his ongoing balance and oculomotor deficits. Although he was trialed on multiple outpatient anti-depressant medications, he required inpatient treatment for his depressions. Due to the duration and severity of symptoms neither athlete had returned to baseline six months following injury and neither was able to return to grade-level participation in school or to return to participation in athletics. These cases demonstrate the significant impact of PCS in adolescents with a prolonged duration of symptoms in the setting of previous personal and family history of mood disorder.
Despite the increased awareness for the need for concussion screening and treatment, there has been limited awareness of the impact of mental health on concussion duration and severity. Further research would be beneficial in addressing the potential benefit of mental health screening in athletes and its impact on concussion treatment. Knowledge about an individual’s baseline psychological function and family history can assist in identifying individuals at risk for prolonged symptoms or increased severity of symptoms following SRC.6,7,16 Pre-participation sports physicals may, pending further research, benefit from evaluation of personal and family history of psychological disorder and depression screening through a PHQ-9 or similar validated screening tool. Any positive screening results should be further evaluated by a qualified professional with availability of mental health services as needed depending on clinical presentation. Mental health screening can identify individuals at risk for PCS and other athletic injuries and can assist in discussing expectations regarding symptom duration and recovery with athletes and their families following injury. 6 When discussing expectations and prognosis following SRC, it is important to take into consideration other risk factors for prolonged recovery including a previous history of SRC and younger age at time of injury.6,11,15,17,22,23
Symptoms of anxiety and depression are not limited to SRC and are common following sports-related injuries. Overall, athletes report lower baseline rates of depression compared with age-matched controls. 17 However, when athletes were evaluated for depressive symptoms following SRC or anterior cruciate ligament (ACL) injury, athletes with ACL injury endorsed more symptoms of depression following injury than those sustaining SRC.14,17 When division 1 collegiate athletes were evaluated for symptoms of depression following concussive and non-concussive injury, there was no difference in symptoms of depression between the two types of injury. 24 SRC can cause a variety of symptoms in the emotional domain including depression; however, it is important to note that any athlete is at risk for depression following significant injury. Proposed mechanisms of increased depression following athletic injury include the psychologic stress response to injury, sense of loss of athletic identity, and loss of avenue of stress release.25–28 Smaller studies have reported more symptoms of fatigue and loss of vigor following SRC, whereas anger is more commonly reported following non-concussive injury. 29 The social strain following SRC as compared to other sports-related injuries can also be increased as individuals do not often have visible physical manifestations that are able to be recognized by peers. Mental health support is an important component following SRC and other significant athletic injuries.
Treatment of emotional symptoms following SRC requires a multidisciplinary approach. Primary care providers familiar with concussion management can provide initial evaluation and treatment and benefit from greater familiarity with the athlete. Behavioral health referral should be available for individuals with significant, persistent symptoms in the emotional domain. Treatment can include behavioral and pharmacologic management. Cognitive behavioral therapy is the mainstay of behavioral therapy following SRC for individuals endorsing symptoms of anxiety, depression, or other symptoms within the emotional domain. 30 First-line medication therapy for depression includes selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, or tricyclic antidepressants based on the reported symptoms. Stimulant medications are also frequently used especially in individuals endorsing symptoms of inattention and difficulty concentrating. 30 For management of anxiety following SRCs, beta blockers, mood stabilizers, and short-term use of benzodiazepines can be considered. 31 Mental health support should be an essential component of the interdisciplinary care team in any concussion clinic. 32 Management of athletes with pre-injury mood disorders has to date been managed as discussed earlier depending on the clinical presentation.
Future research is needed to further understand to better treat individuals with pre-injury ADHD or mood disorders as the current literature is limited. Directions of further research include understanding the mechanism of interaction between pre-injury mood disorders and SRC, the potential benefit of early mental health screening for at-risk individuals, and best practices for treatment of the emotional symptoms of SRC for those with co-morbid mood disorder. Further research to better identify individuals at risk of a prolonged recovery is important to provide individuals and their family with expectations regarding prognosis and recovery. 33 Although the referenced studies have focused on children, adolescents, and collegiate athletes, similar findings are also seen in adults following SRC and traumatic brain injury, and information obtained from future studies may also benefit this population.34–36 Concussion protocols continue to evolve with ongoing research developments, and future protocols may consider the addition of mental health screening as part of routine evaluation.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.