The published literature regarding sport-related concussion has increased dramatically in the past two decades. In addition to thousands of original research studies, numerous guidelines and consensus and position statements1–11 have been published. These publications provide specific recommendations for the diagnosis, evaluation, treatment, and management of sport-related concussion to return patients to all activities of daily living, academics, and physical activity. Historically, these statements have focused primarily on safely returning a patient to athletic activity through the use of serial assessments, including a clinical examination and assessments of self-reported symptoms, postural control, and cognition. However, in the past several years, there has been a greater emphasis on assessing other aspects of health that may be affected by sport-related concussion, such as psychological issues and health-related quality of life.
The emphasis on mental health as it relates to sport-related concussion is an important aspect of providing whole-person health care, which is a patient-centered care approach in which health status is monitored across all aspects of disablement models,12 allowing clinicians to provide a more comprehensive care plan. In fact, this has been a focus of both the National Athletic Trainers' Association (NATA) and National Collegiate Athletic Association (NCAA) with the publication of the twin documents on recognition and referral of student-athletes with psychological concerns13,14 and the NCAA's mental health web site ( http://www.ncaa.org/sport-science-institute/mental-health) and handbook entitled Mind, Body and Sport: Understanding and Supporting Student-Athlete Mental Wellness.15 Although the purpose of the NATA's statements is to provide recommendations to clinicians regarding the development of plans to address psychological concerns, concussion is specifically identified as one special consideration or triggering event that may lead to a new mental or emotional health concern or exacerbate an existing condition.13 Thus, understanding the mental health implications of concussion and having a plan in place to assess and refer patients who present with mental health concerns is important.
Recommendations related to mental health from the numerous consensus and position statements have only been included in more recent statements and have generally provided broad recommendations that highlight the need to assess and monitor these domains of health (Table 1). Limited recommendations have been provided regarding how clinicians should assess and monitor mental health considerations following concussion. Although a prior review of concussion-related outcomes16 summarized that sport-related concussion can result in mood disturbances, emotional or affective symptoms, and sleep disturbances, the review noted the absence of a concussion-specific patient-reported outcomes measure. Therefore, it was recommended that clinicians should incorporate a generic health-related quality of life measure and specific scales selected to match the patient's clinical presentation and symptom complaints.
Sport-Related Concussion Recommendations Regarding Psychological and Mental Health
Although numerous studies have assessed the effect of mild traumatic brain injury on various domains of mental health, we aimed to limit our discussion to sport-related concussion, but did include evidence on combined sport-related concussion and non–sport-related concussion mechanisms. In reviewing the literature, we used the recognized definition and associated features of concussion from the international consensus statement11 and included studies in which the mechanism was from participation in sport or physical activity.
In this review, mental health can be thought of as an umbrella term that encompasses a spectrum of characteristics, with resilience and thriving at one end and mental health disorders at the other end.15 The specific outcomes discussed were determined based on the literature identified and included symptoms or clinical diagnoses of depression, anxiety, mood disorders, and quality of life. It is important to also understand that many studies of sport-related concussion have investigated self-reported symptoms. Although these are important to the assessment and management of the patient after concussion, it should be noted that the presence of symptoms does not equal the diagnosis of a clinical disorder and that symptoms may also be separate risk factors for clinical disorders.
The purpose of this review was to outline existing evidence regarding concussion and mental health to provide health care providers with the best evidence recommendations for clinical practice (Figure 1). Specifically, we aimed to describe the importance of screening for mental health issues during the examination before sport participation, discuss the effect of concussion on mental health outcomes, describe risk factors for psychological issues following concussion, and provide recommendations for clinicians regarding assessment of and referral for mental health issues that arise following a sport-related concussion.
Recommendations for clincians regarding mental health concerns following concussion. SRC = sport-related concussion
Mental Health Screening before Sport Participation
Because concussion is often evaluated using assessment tools that include symptom scales and neurocognitive tests, understanding the prevalence of mental health issues and their influence on these assessments is important for subsequent interpretation. Bailey et al.17 found that anxiety, depression, substance abuse, and suicidal ideation were all significantly correlated to baseline neurocognitive test scores, with those athletes who endorsed more symptoms associated with mental health conditions performing worse on neurocognitive scores. It was also noted that 32% of otherwise healthy collegiate athletes endorsed symptoms of psychological distress.
Several investigations have attempted to characterize the rates of mental health concerns among otherwise healthy student-athletes. In a study of high school and collegiate athletes during a preseason screening, Covassin et al.18 noted that, although most (91.3% to 99%) participants were categorized with minimal depression (Beck Depression Inventory II score of 0 to 13), percentages for mild (Beck Depression Inventory II = 14 to 19) (0% to 6.2%), moderate (Beck Depression Inventory II = 20 to 28) (0% to 2.6%), and severe (Beck Depression Inventory II = 29 to 63) (.39% to 1.2%) depression demonstrated the need to assess these important outcomes. Additionally, several studies have attempted to determine the relationship between athletes with and without a previous concussion and measures of psychological health or quality of life.19–22 In a study of youth ice hockey athletes, athletes with a history of at least one prior concussion or combined concussion and musculoskeletal injury had higher perceived ratings of psychological difficulties than those without. Specifically, somatic or bodily symptoms, atypical behaviors, locus of control, anxiety, symptoms of depression, sense of inadequacy, and attention issues were noted to be higher in athletes with a history of concussion.19 Interestingly, no differences between athletes with and without a history of concussion were noted for attitudes toward teachers or school, or stress with interpersonal relationships, with both areas noted as concerns following concussion in other studies.23
Similarly, two studies evaluating health-related quality of life outcomes between athletes with and without a history of concussion noted adverse effects for numerous domains. Specifically, collegiate athletes reported higher bodily pain and headaches and lower vitality and social functioning,20 whereas adolescents with a history of concussion reported worse scores for bodily pain, general health, vitality, and mental health.21 In a retrospective cohort study using a national database, a history of concussion was associated with a 3.3 times increased risk for a diagnosis of depression among adolescents.22 Additionally, baseline self-reported symptoms of depression were the strongest predictor of depression and anxiety following concussion.24 These findings demonstrate the usefulness of the examination before participation in sport and an expanded baseline test battery in detecting psychological distress among athletes that can be used in the management of any subsequent concussions.
Concussion can lead to physical, emotional, and psychological distress25 in patients with and without a history of mental health conditions,26 and can potentially affect reporting on symptom scales and performance on neuropsychological tests. To best manage mental health aspects following sport-related concussion, these areas of health need to be included and evaluated in all examinations, including before participation in sport and at baseline through any follow-up examinations after concussion. Both the NCAA and NATA have recommended incorporating questions pertaining to psychological history in the physical examination before participation in sport as a means to capture this important patient information.13,14,27,28 When a patient with a preexisting mental health condition is identified, obtaining a baseline score on an outcome measure specific to the diagnosed condition(s) would be beneficial.28 Following concussion, serial assessments for preexisting diagnoses and any new psychological symptoms should be performed because newly diagnosed psychiatric disorders may result following a concussion.26 Numerous condition-generic and -specific patient-reported outcome measures may be valuable for obtaining a more in-depth understanding of the patient's mental health concerns. A list of outcome measures for specific mental health conditions and risk factors that clinicians may consider using is included in Table A (available in the online version of this article).
Suggested measures to assess psychological and mental health domains.12,13,68,69
Effect of Concussion on Mental Health Outcomes
As with other sport-related injuries, sustaining a concussion can lead to not only physical impairments, but also emotional and psychological distress that may affect the patient's recovery and be even more pronounced in patients following concussion.13,14 Unlike musculoskeletal injuries that may have outward signs of injury such as swelling, crutch use, and braces, patients who have sustained a neurologic injury or have psychological impairments often appear normal. Furthermore, traditional concussion management dictates a period of physical and cognitive rest7 that may elicit concerns regarding losing a spot on the team, decreased levels of fitness, and falling behind in academic coursework.29,30 When added to the patient's concussion-related symptoms and cognitive impairments, the addition of emotional stressors may serve to hinder recovery.25
Symptoms of sport-related concussion have been investigated in a multitude of studies to determine their prediction value for injury risk and recovery.31–34 Most of these studies use a graded symptom scale that includes affective symptoms of sadness, irritability, nervousness, and feeling more emotional35; however, these scales only allow endorsement of a symptom and do not provide sufficient follow-up questioning to further evaluate mental health concerns following concussion. Interestingly, Custer et al.36 found that high school and collegiate athletes who reported no symptoms at baseline experienced a significant increase in total symptom scores 2 to 7 days following the sport-related concussion (19.6 ± 16.4), whereas athletes who reported a high level of baseline symptoms (26.7 ± 10.3) reported fairly stable symptom scores after sustaining a sport-related concussion (27.1 ± 19.6). This suggests that athletes who report fewer symptoms at baseline may have worse initial symptom-related outcomes compared to those who experience high baseline symptoms, which is important when interpreting symptom scores following concussion. Moreover, these findings indicate that collecting symptom reports via checklists alone may not capture important information to guide patient care, thereby supporting the need for a multimodal approach to concussion evaluations and management that includes more sensitive mental health measures.
To conduct a thorough evaluation at baseline and following an injury, clinicians must use assessments that delve deeper into the mental health concerns that may follow a sport-related concussion. Mental health outcomes related to concussion have been investigated in numerous ways, including studies of preseason or baseline psychological health,17–22,24 acute effect of concussion on mental health outcomes,23,24,26,37–44 and long-term studies of mental health among retired athletes.45–51 The sections below review the literature for specific symptoms or conditions related to mental health with respect to our understanding of the short-and long-term effects of concussion.
Of all mental health concerns, depressive symptoms have been studied the most with respect to concussion.24,26,40,42,43 Kontos et al.40 investigated depression following sport-related concussion among high school and collegiate athletes and found a significant increase in scores on the Beck Depression Inventory II scale at 2, 7, and 14 days following the injury when compared to baseline. Although depression scores were higher than baseline, no patients in the study met the criteria for clinical depression. In contrast, no significant differences in the Beck Depression Inventory–Fast Scale scores between baseline and within 5 days following concussion were noted in another study of collegiate athletes following sport-related concussion.41 Of note, a higher prevalence of clinically important symptoms of depression (sadness, hopelessness, feeling like a failure, anhedonia, self-esteem, self-blame, and suicidality) were reported after concussion compared to baseline (23% vs 11%) and these rates were more than those of the control participants (10% vs 7%), who were measured at two time points with intervals similar to those of the athletes with concussion.41
Using the Center for Epidemiologic Studies Depression scale, Roiger et al.42 assessed depressive symptoms between NCAA Division I student-athletes with concussion, other sport-related injuries, and healthy controls at baseline and then at 1 week and 1 and 3 months following injury. Patients in both injured groups had higher depressive symptom scores at 1 week following injury when compared to baseline and the other two follow-up time points, but there were no differences between those with concussion or other sport-related injuries, suggesting that the nature of the injury may not alter the risk of depressive symptoms.42 Another study using the Center for Epidemiologic Studies Depression Scale noted that more than one-fifth of collegiate athletes reported symptoms of depression and those with baseline depressive symptoms were 4.59 and 3.40 times more likely to experience symptoms of depression and anxiety, respectively, following injury.24
In one of the first studies to assess the long-term mental health outcomes of retired National Football League (NFL) athletes, 11.1% of respondents reported a prior diagnosis of clinical depression, with the prevalence of depression higher in those with a greater number of prior self-reported concussions when compared to retired players who had never sustained a concussion.45 Furthermore, retired athletes diagnosed as having depression had significantly lower scores on the Short Form-36 (a generic health-related quality of life measure) mental component scale compared to those without depression, suggesting perceived deficits in mental health-related quality of life. A follow-up survey of the same retired NFL cohort46 noted that 10.2% of the sample had a clinical diagnosis of depression, with 64.2% of those players reporting that they still suffered from depression and 34% indicating they were currently taking an anti-depressant medication. Additionally, the number of prior self-reported concussions continued to be associated with the 9-year risk of depression in a dose–response manner, ranging from 3.0% in those with no previous concussions to 26.8% in athletes who reported 10 or more prior concussions.46 Similarly, in a small cohort of retired football athletes, 24% of participants were diagnosed as having depression, a rate slightly higher than those expected for individuals of the same age (15%).51 Another study of concussion history and depressive symptoms among the same cohort of retired professional football players noted higher depression scores compared to healthy matched controls and a moderate positive correlation between total lifetime concussions and depression score, even when other factors such as cardiovascular risk, arthritis, and headache were taken into account.52 Interestingly, half of the included retired players endorsed mild to moderate symptoms of depression, with most not having been diagnosed previously as having clinical depression.
It is not surprising that athletes, especially those who are high level, who are withheld from participation due to an injury would report elevated levels of depression. Most athletes self-identify with their sport and may feel a loss of identity, thereby resulting in an increased depression following their injury that is similar to newly retired athletes.53 It is also possible that depression may lengthen recovery and require different management strategies. In a prospective cohort study of youth seeking care in a specialty clinic, a diagnosis of depression was associated with a significantly higher persistent (> 3 months) reporting of concussion symptoms and decreased academic standing that would warrant a multimodal treatment approach, including referral to mental health professionals and the involvement of school personnel.43 These findings further support the effects that baseline depression may have on athletes after a concussive injury and the need for baseline depression screening. Sports medicine professionals could use baseline depression screenings to determine which athletes are at a higher risk for developing depressive symptoms following concussion and to identify those who develop new symptoms.
Whereas many studies have focused solely on depression, Yang et al.24 investigated symptoms of depression (Center for Epidemiological Studies Depression scale) and anxiety (State-Trait Anxiety Inventory) among 71 collegiate athletes following concussion. They noted that 14 participants reported symptoms of depression, 24 participants reported symptoms of anxiety, and 10 participants reported symptoms of both. Whereas athletes who reported baseline depression were more likely to experience symptoms of depression and state anxiety following concussion, athletes who reported baseline symptoms of anxiety did not report increased symptoms of either depression or anxiety following injury.
A study investigating the effects of social support on anxiety following concussion and orthopedic injures in collegiate athletes found no differences between state anxiety and trait anxiety scores on the State-Trait Anxiety Inventory between groups at baseline or 1 week following the injury (average return to play: approximately 8.9 days for both groups).44 When they investigated the effect of group on state anxiety scores following injury when controlling for baseline anxiety and social support, they found no differences between groups. The authors reported that satisfaction with social support was a significantly better predictor for the concussion group compared to the orthopedic group.44 This is interesting because the concussion group reported lower satisfaction overall with their social support following injury and, on average, their teammates, coaches, and physicians were ranked below their family, friends, and athletic trainers for all six social support questions. These findings suggest that a stronger social support system can reduce state anxiety during recovery and return to play. These findings also indicate that teammates and coaches may not interact the same with teammates who sustain concussions versus orthopedic injuries. Unlike depression, the effect of sport-related concussion on anxiety-related outcomes is less studied. Regardless, clinicians should be aware of the potential for anxiety to increase following injury, especially when symptoms persist and require the athlete to be away from school and sports for a prolonged period of time.
Mood States and Quality of Life
In one of the first studies to evaluate emotional responses following concussion, Mainwaring et al.39 noted a significant increase in the Profile of Mood States depression, confusion, and total mood disturbance scores that resolved 3 weeks after the injury. Subsequent studies37,38 have reported that emotional functioning before the injury was not related to responses following concussion; however, following concussion, patients demonstrated increased fatigue, decreased vigor, and increased total mood disturbance when compared to healthy controls and patients with musculoskeletal injuries during the 2 weeks following injury.38 In contrast, patients who had sustained a concussion reported fewer emotional disturbances when compared to patients who had sustained season-ending anterior cruciate ligament injuries, but had higher levels of depression and total mood disturbance than healthy controls.37 Similarly, a qualitative study of health-related quality of life following concussion reported that overall symptom reports and a high symptom burden play a significant role in the patient's perception of health-related quality of life and lead to a feeling of frustration, with patients describing anger, emotions, irritability, and anxiety as a result of the concussion.23 Many of these patients had symptoms lasting at least 3 months and noted that the symptoms also influenced their school attendance and activities and the nature of their interpersonal and team relationships.23
In contrast to studies that have focused on one psychological concern, Ellis et al.26 retrospectively reviewed patient charts from a multidisciplinary specialty clinic and found that 49% of patients reported at least one emotional symptom following concussion and that 11.5% of patients met the criteria for a psychiatric disorder following the injury. Such disorders included newly diagnosed psychiatric disorders following concussion (depressive disorders, anxiety disorders, major depression with secondary anxiety, attention deficit hyperactivity disorder, bipolar disorder, and substance abuse), novel and isolated suicidal ideation, and worsening of a preexisting psychiatric disorder.26 Collectively, these studies demonstrate an increase in mental health concerns following concussion that typically resolves within the first month. However, it is important that these areas of mental health are addressed and referrals are made to the appropriate health care providers as dictated by the patient's clinical presentation and outcome measure scores.
With respect to long-term mood states, a comparison of professional ice hockey players and age-matched controls noted significant group differences for self-reported, informant-reported, and endorsement of psychiatric symptoms, with the retired athletes having higher endorsements of psychosocial impairments such as depression, anxiety, impulsivity, and general symptoms.49 These findings were also in line with those from a cross-sectional study of retired college athletes that used several mental health outcomes, including depression, impulsivity, and aggression.47 Nearly 5% of respondents had moderate to severe depression and associations were noted between recurrent concussions and depression and between higher levels of impulsivity and aggression.
Although the number of prior concussions has been an interest in many studies of long-term player health, research has also begun to assess the length of a playing career and number of subconcussive hits an individual takes during the course of that career on several important variables. Specifically related to mental health concerns, a study of retired NFL athletes that investigated the influence of football participation before high school noted that self-reported depression, anxiety, alcohol, eating, and somatoform symptoms were not associated with exposure to beginning football participation at the youth level. These findings suggest that starting the sport at a young age does not contribute to long-term behavioral issues.54 Furthermore, with concerns regarding chronic traumatic encephalopathy and its associated mental health issues such as aggression, depression, and suicidal ideations, understanding whether retired athletes have increased rates of suicide is important. To date, only one study has addressed the suicide mortality rates of retired NFL players, with rates found to be approximately one-half that of the general United States population when controlling for sex, race, and age (12 vs 25.6 deaths),50 thus suggesting that other factors may be involved in many of the high-profile cases of player death.
Mental Health Conditions and Behavioral Traits as Contributing Factors for Concussion
As described above, several studies have investigated the effects of sport-related concussion on mental health. Conversely, there has been little research on how preexisting mental health and behavioral traits may modify the risks of sport-related concussion. There is evidence that sex is associated with altered emotion and behavioral scores.55 In addition, contact56,57 and power sports58 may modify behavioral traits such as aggression and anger. Finally, athletes with higher risk-taking thresholds may be more inclined to participate in sports that are associated with higher risks of sport-related concussion.59–63
Fraser et al.55 reported baseline sex and contact level (high, low, and no) mental health differences in high school athletes. Males reported significantly higher aggression and impulsivity scores and lower depression and anxiety scores when compared to females. In addition, high contact sports reported significantly higher impulsivity and lower anxiety and depression scores when compared to low and no contact sports. Finally, athletes with a history of sport-related concussion reported significantly higher aggression and depression scores when compared to athletes with no history of sport-related concussion. This study indicates that important sex- and sport-related mental health differences may exist at baseline in high school athletes. Broshek et al.64 believed that the sex-based differences in their study may have also been related to differences in playing style or levels of aggressiveness in female and male sports, noting that more male sports allow contact and require body protection than female sports. Youth and adult male athletes report lower perceived risk59 and precautionary behaviors60 and greater deliberate risk taking59,60 when compared to female athletes, indicating sex-related differences in thought processes and actions in situations that may lead to injury.
In support of these findings, aggression has been found to be significantly higher in athletes in contact (football and basketball)56 and power (boxing, martial arts, weight-lifting, and wrestling)65 sports, with participation in these sports leading to an enhancement of aggression outside of sport over time. A cross-sectional study of men 30 to 74 years of age reported maladaptive behavioral differences and structural and functional brain alterations related to increased aggression and impulsivity in retired professional football players with histories of multiple concussions when compared to healthy, non-athlete controls.58 This study was retrospective in nature and lacked a control group of retired football players without a history of concussion, so it is impossible to determine whether these group differences were caused by their exposure to football, subconcussive repeated head impacts, sport-related concussion, traumatic brain injuries, or other unknown factors. It is possible that these differences were preexisting and were, in fact, what led these individuals to suffer multiple concussions. Although these metrics have not been investigated thoroughly with respect to sport-related concussion, a plethora of data does exist in the research on traumatic brain injuries.
A complication in diagnosing aggression in athletes is the positive implication it holds in certain sports. Robazza et al.57 found that male rugby, wrestling, and judo athletes frequently found their competitive anger to facilitate their performance. They also found that higher-level athletes tended to report higher levels of anger when compared to low-skill athletes. Interestingly, rugby athletes (team sport) interpreted their anger as more of a facilitator of their athletic abilities compared to the two individual sports (wrestling and judo). Similarly, Huang et al.56 reported that male high school contact sport athletes (football and basketball) reported significantly higher aggressive scores when compared to classmates participating in low contact sports (track and baseball). These findings indicate that anger and aggression are coveted traits in athletic arenas, particularly in contact sports.
Risk taking, also referred to as sensation seeking, is another factor that may help predict which athletes are at greater risk for sport-related concussion. Although risk taking has primarily been used to determine associations with alcohol and drug use risk,66 gambling,61 and risky sexual behaviors,67 some researchers have investigated its association with risk taking in sport. Several measures59–62 have been used to assess risk taking/sensation seeking in athletes. These metrics could be of great value to sports medicine professionals when attempting to determine preseason risk for injuries and placement into intervention groups to improve techniques that reduce injury risk like-lihood. Studies have noted that males are more likely to report taking deliberate risks or score higher in sensation seeking and disinhibition compared to females.62,63 Other studies found significant correlations between alexithymia (difficulty in differentiating one's feelings and expressing them in words), deliberate risk taking, life-threatening close calls (eg, nearly being hit by a loose rock when climbing a mountain), and accidents (eg, getting hit by the falling rock).60,62 The addition of risk taking and alexithymia measures to baseline concussion testing could help athletic trainers and coaches identify athletes who are at an increased risk for both concussions and orthopedic injuries. Due to the dearth of mental health studies on sport-related concussion and the fact that symptom checklists may not be sensitive enough to detect these negative mental health outcomes of sport-related concussion, further research is warranted to determine whether aggression, impulsivity, and risk taking can help predict the risks and outcomes of sport-related concussion.
Accessibility and Referral to Mental Health Professionals
Athletic participation can account for a large portion of a student-athlete's identity and way to deal with emotional stress.53 When illness or injury occurs, it can result in not only pain and issues with physical functioning, but also emotional, social, and psychological concerns.6,21,68 Negative emotional responses to injuries and illnesses in athletes are expected; however, these often resolve as the patient recovers and returns to sport participation.69,70 In some patients, a delayed recovery, injury complications, prior mental health concern, or risk factor(s) for mental health issues following injury may exacerbate any mental health concerns to a level that requires professional care.68 Referral may be necessary when emotional symptoms worsen or persist beyond the expected duration of concussion symptom recovery, when symptoms evolve to the point that a clinical diagnosis of a condition is suspected or in patients with pre-existing mental health conditions.11,68 A multidisciplinary approach to concussion management should be followed and the treating clinician should seek out professionals with an expertise in these areas.11,28 Athletic trainers should refer a patient with prolonged emotional symptoms or suspected mental health conditions to the appropriate providers as described in Table 2.71 Ideally, the mental health professional has knowledge and experience working with athletes and sport-related concussion11,28,68 and may include a combination of on-campus, community-based, and private professionals.72–74 In addition to face-to-face sessions, the option of telemedicine, in which patients interact with specialists through video conferencing, is gaining interest in an attempt to provide behavioral medicine services for patients with limited access to these professionals in their geographic area.75,76
Referral Sources for Mental Health Services10,11,77,80
School-based health care providers such as athletic trainers and school nurses often serve as the primary access point to health care, especially in the secondary school setting.77 These providers are most accessible to student-athletes in secondary schools and often manage the day-to-day aspects of concussion recovery. Access to school-based providers may assist with identifying mental health concerns because it is reported that students are more likely to use in-school services compared to community-based services78 and follow through with treatment when using school-based services.72 In the secondary school setting, common health care provider referrals within the school may include the school counselor,72,77,78 school psychologist or therapist, and school-based health centers, depending on the specific health concern with the patients as they recover from the sport-related concussion.74,79
When referring patients to mental health care services, it is important to consider the availability and confidence of the individual in providing mental health care to patients following concussion. Some providers may not have the proper experience or time available to provide appropriate care72,78,80,81; in this case, referrals should be made to appropriate individuals outside of the school. In the college setting, student-athletes have improved access to mental health services, especially with the emphasis on this topic within the NCAA. Additionally, outside of athletics, many colleges and universities provide free or affordable on-campus mental health services, although many college students are unaware of the services available to them on campus.82 Ideally, providers who have experience working with athletes and sport-related concussion should be identified and used with patients who require mental health care following a sport-related concussion.11,28 The list should be available to all health care professionals working within the sports medicine team.28
Implications for Clinical Practice
The management of concussion is a challenge for all health care providers and requires a multifactorial assessment and management plan that takes into account the physical, psychological, and emotional aspects of health. Therefore, it warrants a whole-person health care approach that includes age-appropriate screening tools and assessments for mental health concerns. Clinicians should follow best practices10,11 regarding the evaluation and treatment of patients following concussion and use a multimodal approach when assessing symptoms, cognition, balance, and oculomotor function. Specific to symptom assessment, it is imperative that a more in-depth clinical interview be included when patients self-report high severity scores on a symptom, especially those that are related to affect or emotions. Additionally, complementary assessments such as patient-reported outcome measures should be integrated into the concussion assessment battery to capture detailed information about mental health conditions such as anxiety, depression, or mood disturbances. As described by Neal et al.,13 clinicians should have heightened awareness and monitor for changes in behavior or psychological issues following sport-related concussion. Importantly, athletic trainers and other providers should understand the mental health implications of sport-related concussion, acknowledge the limitations of their education and scope of practice in these areas, and have access to other health care providers with an expertise in psychological concerns to which they can refer. Only when providers are working together to assess and treat the physical and psychological manifestations of concussion can a comprehensive concussion management plan be truly implemented.
- Aubry M, Cantu RC, Dvorak J, et al. Summary and agreement statement of the first International Conference on Concussion in Sport, Vienna, 2001. Phys Sportsmed. 2002;30:57–63. doi:10.3810/psm.2002.02.176 [CrossRef]
- Guskiewicz KM, Bruce SL, Cantu RC, et al. National Athletic Trainers' Association position statement: management of sport-related concussion. J Athl Train. 2004;39:280–297.
- McCrory P, Johnston KM, Meeuwisse W, et al. International Symposium on Concussion in Sport. Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Clin J Sport Med. 2005;15:48–55. doi:10.1097/01.jsm.0000159931.77191.29 [CrossRef]
- Moser RS, Iverson GL, Echemendia RJ, et al. Neuropsychological evaluation in the diagnosis and management of sports-related concussion. Arch Clin Neuropsychol. 2007;22:909–916. doi:10.1016/j.acn.2007.09.004 [CrossRef]
- McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. J Sci Med Sport. 2009;12:340–351. doi:10.1016/j.jsams.2009.02.004 [CrossRef]
- Echemendia RJ, Iverson GL, McCrea M, et al. Role of neuropsychologists in the evaluation and management of sport-related concussion: an inter-organization position statement. Arch Clin Neuropsychol. 2012;27:119–122. doi:10.1093/arclin/acr077 [CrossRef]
- McCrory P, Meeuwisse W, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Clin J Sport Med. 2013;23:89–117. doi:10.1097/JSM.0b013e31828b67cf [CrossRef]
- Giza CC, Kutcher JS, Ashwal S, et al. Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013;80:2250–2257. doi:10.1212/WNL.0b013e31828d57dd [CrossRef]
- Harmon KG, Drezner JA, Gammons M, et al. American medical society for sports medicine position statement: concussion in sport. Br J Sports Med. 2013;47:15–26. doi:10.1136/bjsports-2012-091941 [CrossRef]
- Broglio SP, Cantu RC, Gioia GA, et al. National Athletic Trainers' Association. National Athletic Trainers' Association position statement: management of sport concussion. J Athl Train. 2014;49:245–265. doi:10.4085/1062-6050-49.1.07 [CrossRef]
- McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport: the 5th International Conference on Concussion in Sport held in Berlin, October 2016 [published online ahead of print April 26, 2017. Br J Sports Med.
- Snyder AR, Parsons JT, Valovich McLeod TC, Curtis Bay R, Michener LA, Sauers EL. Using disablement models and clinical outcomes assessment to enable evidence-based athletic training practice: Part I. Disablement models. J Athl Train. 2008;43:428–436. doi:10.4085/1062-6050-43.4.428 [CrossRef]
- Neal TL, Diamond AB, Goldman S, et al. Interassociation recommendations for developing a plan to recognize and refer student-athletes with psychological concerns at the secondary school level: a consensus statement. J Athl Train. 2015;50:231–249. doi:10.4085/1062-6050-50.3.03 [CrossRef]
- Neal TL, Diamond AB, Goldman S, et al. Inter-association recommendations for developing a plan to recognize and refer student-athletes with psychological concerns at the collegiate level: an executive summary of a consensus statement. J Athl Train. 2013;48:716–720. doi:10.4085/1062-6050-48.4.13 [CrossRef]
- National Collegiate Athletic Association. Mind, Body and Sport: Understanding and Supporting Student-Athlete Mental Wellness. Indianapolis: National Collegiate Athletic Association; 2014.
- Valovich McLeod TC, Register-Mihalik JK. Clinical outcomes assessment for the management of sport-related concussion. J Sport Rehabil. 2011;20:46–60. doi:10.1123/jsr.20.1.46 [CrossRef]
- Bailey CM, Samples HL, Broshek DK, Freeman JR, Barth JT. The relationship between psychological distress and baseline sports-related concussion testing. Clin J Sport Med. 2010;20:272–277. doi:10.1097/JSM.0b013e3181e8f8d8 [CrossRef]
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Sport-Related Concussion Recommendations Regarding Psychological and Mental Health
|First International Consensus Meeting1 (2001)||– No specific recommendations provided|
|NATA Position Statement2 (2004)||– No specific recommendations provided|
|Second International Consensus Meeting3 (2004)|
A sports psychology approach may have application, specifically in cases where recovery takes longer than 10 days (complex concussion)
The assessment should include affective symptoms such as depression
|National Academy of Neuropsychology4 (2007)||– Neuropsychologists are uniquely qualified to assess the neurocognitive and psychological effects of concussion|
|Third International Consensus Meeting5 (2008)|
A sports psychology approach may have application, specifically in cases where recovery takes longer than 10 days
The assessment should include affective symptoms such as depression
|American Medical Society for Sports Medicine9 (2012)|
Preexisting or newly diagnosed mood disorders may complicate the diagnosis and management of the concussion
Depression, anxiety, and other psychological impairments may influence neurocognitive test scores at baseline or post-injury and should be accounted for in interpreting test results
Having a measure of preinjury mood status may be beneficial to clinicians for subsequent post-concussion assessments
|Fourth International Consensus Meeting7 (2012)|
Psychological approaches may be useful, specifically in patients with concussion modifiers, such as migraine, depression or other mental health disorders, attention deficit hyperactivity disorder, learning disabilities, and sleep disorders
The evaluation should include affective symptoms such as depression and anxiety that are common in all forms of traumatic brain injury
|Neuropsychology Inter-association Position Statement6 (2012)|
Concussion assessment should include both neurological and psychological factors, which neuropsychologists are uniquely qualified to assess
Neuropsychologists can provide early intervention and treat emotional problems that might arise during recovery
|NATA Position Statement10 (2014)||– Factors that modify risk of concussion and duration of recovery may include migraine, depression, or other mental health disorders; attention-deficit hyperactivity disorder; learning disabilities; sleep disorders|
|Fifth International Consensus Meeting11 (2016)|
Patients with a pre-injury history of mental health problems or migraine headaches appear to be at some-what greater risk of having symptoms for more than 1 month
Psychological factors may play a significant role in symptom recovery and contribute to risk of persistent symptoms
Although the literature on neurobehavioral sequelae and long-term consequences of exposure to recurrent head trauma is inconsistent, clinicians need to be mindful of the potential for long-term problems such as cognitive impairment, depression, and other disorders in the treatment of all athletes
Referral Sources for Mental Health Services10,11,77,80
|Psychologist||Mental health examinations|
|Emergency evaluation and triage|
|Diagnostic evaluation and assessment|
|School Psychologist||Direct support and intervention to students at the school|
|Psychological and academic assessments|
|Evaluations for emotional or behavioral problems|
|Individual and group counseling sessions|
|Collect and analyze data on factors related to student outcomes|
|Make referrals and help coordinate community services provided in schools|
|Sport Psychologist||Cognitive and behavioral skills training for performance enhancement|
|Counseling and clinical interventions for both general mental health issues and those specific to sport and sports culture|
|Consultation and training for athletes, parents, and coaches|
|Cognitive behavioral therapy|
|Assist in return to normal activities|
|Other forms of medical treatments such as electroconvulsive therapy, deep brain stimulation, transcranial magnetic stimulation, and light therapy|
|School Counselor||Short-term interventions for students|
|Evaluations for emotional or behavioral problems|
|Individual counseling sessions|
Suggested measures to assess psychological and mental health domains.12,13,68,69
|Scale||Subscales / Domains||Items||Age Range (years)||Reliability||License/User Agreement Requirements||Notes|
|Short Form 36 (SF-36)||Physical Functioning
Role Limitations due to Physical Problems
General Health Perceptions
Role Limitations due to Emotional Problems
General Mental Health
Mental composite||36||14+||α=.78–.93||Yes||Commonly used
Can compare across different conditions
Scoring can be difficult
Items not specific to athletes
Each one point difference/change in scores equals an effect size of .10|
|Pediatric Quality of Life Inventory (PedsQL)||Physical Functioning
Total Score||23||5–25||α=.68–88||Yes (for funded research and clinical use)||Numerous modules that can be added for specific conditions
Specific to adolescents and young adults
Items not specific to athletes|
| Beck Depression Inventory-II (BDI-II)||None||21||13–80||α=.92||Yes||Frequently used scale with extensive psychometric publications|
|Center for Epidemiologic Studies Depression Scale||Sadness(Dysphoria)
Loss of Interest(Anhedonia)
Thinking / concentration
Suicidal ideation||20||13+||α=.85–.95||No public domain||Four response options per question: 0) rarely or none, 1) some or little of the time, 2) occasionally or a moderate amount, 3) most or all of the time
Range of scores is between 0 and 60
Score classifications: 0 no depression exists; 1– 16 little or no depression and not clinically significant; 17–49 mild depression; 50–60 major depression
Questions can be asked context of how the participant felt in the days and weeks after a concussive event|
|Patient Health Questionnaire (PHQ) Depression Module||None||9||12+||α = .85||No||Scored from “0” (not at all) to “3” (nearly every day)
Score classifications: Minimal depression 0–4, Mild depression 5–9, Moderate depression 10–14, Moderately severe depression 15–19, Severe depression 20–27
Short and well validated|
||40||18+||α=.66–.95||Yes||Administrator can ask about the “past week, including today” or “right now”
Used in numerous studies of healthy and injured athletes
Includes mainly negative emotions|
|Generalized Anxiety Disorder -7 (GAD-7)||None||7||18+||α=.92
Test-retest = .83||No||Scores of 0, 1, 2, and 3, assigned to the response categories of ‘not at all’, ‘several days’, ‘more than half the days’, and ‘nearly every day’,
Total score is sum of 7 questions
Scores of 5, 10, and 15 are cut-off points for mild, moderate and severe anxiety
Score of >10 should indicate referral|
|Beck Anxiety Inventory (BAI)||Subjective
Panic-related||21||17–80||α=.92||Yes||Scale ranging from 0 (not at all) to 3 (severely, I could barely stand it)
Total score ranges from 0 – 63|
|Sport Anxiety Scale-2 (SAS-2)||Somatic anxiety
Concentration disruption||15||9+||α=.91 (95% CI = .90 .92)
Test-retest =.87 (total)
Subscales = .76–.90||No||Widely used in sports psychology
Assesses competitive trait anxiety|
|State-Trait Anxiety Inventory (STAI)||State anxiety (20 items)
Trait anxiety (20 items)||40||18+||α=.86–.95
Test-retest: state scale, r=.76; trait scale, r=.86||Yes||Scores range from 20 to 80
Higher scores reflects a greater level of anxiety
Widely used in sports contexts|
|Anxiety Sensitivity Index (ASI)||None||36||12+||α=.95||Yes||Questions scored as ‘very little’ (0) to ‘very much’ (4)
Total scores range from 0 to 144|
|Barrett Impulsiveness Scale 11 (BIS-11)||Attentional: Attention, Cognitive Instability; Motor: Motor, Perseverance; Nonplanning: Self-control, Cognitive Complexity||30||12+||α =.79–.83||No||Scores range from 30 to 120
Higher scores reflects a greater level of impulsivity
Widely used in clinical and research psychology|
|Buss Perry Aggression Questionnaire (BPAQ)||Physical aggression
Hostility||29||13+||α = .72–.85||No||Scores range from 29 to 145
Higher scores reflects a greater level of aggression
Widely used in clinical and research psychology|