Improving concussion care to combat anxiety and depression

Concussions are mild traumatic brain injuries (TBIs) accompanied by a change in brain functioning, ranging from temporary loss of consciousness to dizziness or memory loss. Once considered a mild inconvenience—as little as 2 decades ago, athletes were routinely sent back into play after a blow to the head—concussions are now recognized by medical professionals and the public alike as serious injuries.

What is less known, however, is that concussions are often marked by mental health issues, particularly anxiety and depression. And in situations where the injury was accompanied by a traumatic experience, as in intimate partner violence, the psychological consequences can be serious and difficult to untangle.

Regardless of the origin of the concussion, psychologists play a role in assessing symptoms and healing progress and can treat both emotional and cognitive symptoms during the recovery period. They can also educate individuals about the good news on concussions, said Anthony Kontos, PhD, a professor and research director of the University of Pittsburgh Medical Center Sports Medicine Concussion Program: that with assessment and targeted treatments in the first days after injury, most people recover fully within a few weeks, and that the subset of people who have persistent symptoms will also get better when treated appropriately.

“Psychologists in general are in a really good position to create better and more evidence-based awareness about the injury and its effects on patients,” Kontos said, “as well as debunking misinformation about the injury and its long-term effects.”

Each year, an estimated 1.6 million to 3.8 million people experience a blow to the head that causes a concussion (Langlois, J. A., et al., The Journal of Head Trauma Rehabilitation, Vol. 21, No. 5, 2006opens in new window). This commonly used estimate inadvertently reveals how challenging concussion can be to understand: The estimate is based on extrapolation from the number of emergency room visits involving only a partial subset of head injuries, and the figure does not consider updated epidemiology. The number of diagnosed concussions has been rising in recent years, likely at least partially because of improving diagnostic practices (Langer, L., et al., The Journal of Head Trauma Rehabilitation, Vol. 35, No. 1, 2020opens in new window). As of 2020, 6.8% of children age 17 or younger had experienced a concussion or other brain injury in their lifetimes ( Concussions and Brain Injuries in Children: United States , 2020, National Center for Health Statistics, 2021 opens in new window).

Though studies find different rates of recovery depending on context and the definition of recovery, an estimated 70% to 80% of people with concussion recover within a month, said William Barr, PhD, ABPP, a clinical neuropsychologist at the New York University Grossman School of Medicine. “The majority of people do recover within a few weeks, and that’s a pretty clear finding that is replicated in all contexts,” Barr said.

There are some demographic factors that influence recovery, Kontos said. Adolescents tend to recover more slowly than children or adults, he and his colleagues have found ( The Journal of Head Trauma Rehabilitation , Vol. 34, No. 6, 2019 opens in new window). And treatment is very important, with faster recovery seen in those who receive care within 7 days of the injury ( JAMA Neurology , Vol. 77, No. 4, 2020 opens in new window).

For those with longer-term symptoms, concussions can be a challenging experience. The most common complaints are memory and concentration struggles; physical symptoms such as dizziness, headache, and fatigue; and emotional and behavioral problems, particularly anxiety and depression (van der Vlegel, M., et al., Journal of Clinical Medicine, Vol. 10, No. 4, 2021opens in new window). The treatment for this anxiety and depression is no different from the treatment of anxiety and depression without a history of injury, but psychologists should know the person’s history.

“If a person who sustains a mild TBI is seeking care from a psychologist, it’s often because they’re having symptoms that haven’t gone away yet,” said Kristen Dams-O’Connor, PhD, a clinical neuropsychologist and director of the Brain Injury Research Center at the Icahn School of Medicine at Mount Sinai in New York, using “mild traumatic brain injury” as a term scientifically interchangeable with “concussion.” “The psychologist should be aware they’re seeing someone who is in the maybe 20% of people who sustain a concussion who don’t recover fully within the first days or couple of weeks.”

For these patients, said Dams-O’Connor, it is important to validate the symptoms with “an attitude of hope.”

“The research tells us that even though you aren’t recovering as quickly as you want to, you are very likely going to recover fully,” she said.

Sports-related concussions are the most thoroughly researched concussions, largely because these injuries are most easily recognized, and sports participation is conducive to longitudinal research studies. Much of the research and advice is centered around return to play.

People with concussion were once advised to go on full physical and mental rest, often in a darkened room, for days to weeks. Today, this treatment is recognized as both unnecessary and harmful, said Barr. Putting people with concussion in a dark room with instructions not to do anything leaves them vulnerable to increased anxiety and perseverating on their symptoms. “Complete rest is actually bad for you. It makes your symptoms worse,” Barr said. “But people are still recommending it, and I’m seeing this all the time.”

Kontos and his team have found that both physical activity and vestibular rehabilitation, including sets of exercises that integrate balance, bilateral motion, and eye gaze, speed concussion recovery ( The Journal of Pediatrics , Vol. 239, 2021 opens in new window).

According to the International Conference on Concussion in Sport, light exercise 24 to 48 hours after a concussion, as long as it does not exacerbate symptoms, is beneficial. Likewise, avoiding screens may help for the first 48 hours postinjury, but there is little evidence of benefit for reducing screen time after that. Clinicians should work with the concussed person to develop a plan for returning to regular activities, including work, school, or sports. These plans are based on the person’s symptoms during both rest and exertion. Neuropsychologists may be involved in this process by assessing symptoms and recovery rate, while clinical psychologists can help clients find ways to adapt their activities during recovery.

When people experience persistent symptoms, Barr said, the strategy is to treat those specific symptoms. “Focusing on the symptoms themselves, rather than any general ‘treatment of concussion’ is one direction that things are going,” he said.

Particularly relevant to psychologists’ role in this process is the prevalence of anxiety and depression as a persistent postconcussion symptom. A recent meta-analysis of 18 studies with 9,101 participants in all found that people with symptoms lasting longer than 4 weeks after injury were 4.5 times more likely than people who had recovered completely from their concussions to experience depressive symptoms (Lambert, M., et al., JAMA Network Open, Vol. 5, No. 12, 2022opens in new window). This could be a direct consequence of injury to the amygdala or other emotion-processing regions of the brain, the researchers wrote, or the symptoms might be the result of struggles wrought by other postconcussion symptoms, such as social isolation or academic difficulties.

Studies of athletes also suggest that depression and anxiety symptoms are common in the first days to weeks after a concussion (Hammer, E., et al., Sports Health, Vol. 13, No. 1, 2021opens in new window). Though the most common path is for these symptoms to resolve in the initial healing process, there are questions about whether a concussion history feeds into a risk profile for depression and suicide attempts in some subgroups of young people. A cross-sectional cohort study using national Youth Risk Behavior Surveillance System data found that while depression symptoms were most associated with suicide risk, there was a higher risk of suicide attempts in females of Black, Hispanic/Latino, or multiracial heritage who had a history of concussion (Eagle, S. R., et al., JAMA Network Open, Vol. 5, No. 7, 2022opens in new window). These findings were only correlational, the researchers wrote, and they did not probe into the prevalence of persistent concussion symptoms, but the numbers point to the need for more research into concussion impacts in underserved minority groups.

Anxiety and depression with concussion respond similarly to treatment as anxiety and depression without brain injury, Barr said. In particular, cognitive behavioral therapy can help people with a concussion history avoid catastrophizing their symptoms, he said.

The recent media attention on head injuries has raised awareness of concussion, Barr said, but also stoked many fears that concussion will lead to long-term damage or later dementia. This is because people often conflate concussion with chronic traumatic encephalopathy (CTE), a degenerative brain disorder observed in autopsies of some National Football League players. The link between CTE and repetitive head injury is still not entirely clear, but the condition is not linked to concussion, Barr emphasized.

“Concussions are discrete events,” he said. “What’s being reported in the football players is the cumulative effect of participating in the sport. You have a job where you go to work and you hit your head a hundred times a day, but none of those hits are concussions.”

Psychologists can play a role in keeping up to date with the literature around head injury and CTE and educating patients and families with accurate information, Barr said.

Concussion can be a very disruptive experience, especially when symptoms linger, said Robert Asarnow, PhD, a neuropsychologist and director of the University of California, Los Angeles Pediatric Traumatic Brain Injury Research Program. Asarnow said he has seen cases in which previously active athletes have their plans for future competition and education derailed by concussion symptoms that have not been properly treated. Clinical psychologists can help people with concussions cope with feelings of frustration and hopelessness, as well as help them manage symptoms.

“A lot of what we do with patients is based on good behavior regulation and management,” Kontos said. “Activity, sleep, stress management, hydration, and nutrition.”

Some of the somatic symptoms of concussion may also be manageable with psychological treatment. Spurred by a case involving a postconcussion complication, Asarnow now researches dysautonomia, or disruption of the automatic nervous system, postconcussion. He is currently an investigator on a multisite National Institute of Neurological Disorders and Stroke-funded grant that is looking to identify biomarkers for adolescents who experience complex, long-lasting symptoms from concussion. One possible measure under investigation, Asarnow said, is a test of pupil response that is a proxy for autonomic nervous system dysfunction. If the researchers can find evidence of autonomic nervous system dysfunction in people with persistent concussion symptoms, they may be able to treat the underlying problem.

“We’ve got very good treatments in psychology for anxiety and panic attacks, and many of those really are very helpful to dysautonomia, as well,” Asarnow said.

While athletic programs now have a framework for handling head injuries, concussions that take place outside of formalized sports may go unrecognized. Nowhere is this truer than in the case of intimate partner violence (IPV).

“Most of the physical injuries in this context are to the head, face, and neck,” said Angela Colantonio, PhD, OT, a professor at the University of Toronto who researches TBI in underserved populations. People in abusive relationships often experience multiple concussions alongside repeated lower-level blows to the head and strangulation injuries, all of which can damage the brain. Posttraumatic stress disorder symptoms can further overlap with brain injury symptoms. And the injuries occur in a context where identification and treatment are often a low priority: The IPV survivor may still be in danger from their abuser and may have immediate financial and legal concerns, such as ensuring they can keep custody of their children.

Despite the high frequency of head injury from IPV, experts know far less about concussion in that context compared with sports and recreation.

“There has been such an appalling gap in research here that we should all be furious and outraged and shouting from the rooftops,” Dams-O’Connor said. “The reality is, we just know far less, and what we have learned from the studies of male contact sport athletes, we should be extremely hesitant to apply to women in general. This is not the female equivalent of football.”

Regardless of the origin of a concussion, sex and gender differences may influence the outcome of the injury. The research on the impact of sex and gender in recovery from a concussion is mixed, but some evidence suggests women are at risk for a slower recovery. This finding may be driven in part by access to care, said Carrie Esopenko, PhD, an associate professor and research psychologist in the Brain Injury Research Center at the Icahn School of Medicine at Mount Sinai. Women are more likely than men to report feeling dismissed when they describe their concussion symptoms to professionals, Colantonio said.

There is also evidence that women’s recovery may be more affected by hormonal factors compared with men. Women who sustain a mild TBI in the luteal phase (between ovulation and the beginning of menstruation) display worse outcomes than women injured at other points in their cycle (Wunderle, K., et al., The Journal of Head Trauma Rehabilitation, Vol. 29, No. 5, 2014opens in new window). During the luteal phase of the menstrual cycle, the pituitary gland, which is tucked into the base of the brain, coordinates a higher concentration of progesterone in the blood. An impact to the pituitary may disrupt this progesterone spike, leading to progesterone withdrawal and thus a persistence of symptoms. However, Esopenko said, this is just a hypothesis.

“We truly need large, funded studies to be able to track cycles,” she said.

In a recent study using Concussion Assessment, Research, and Education Consortium data, Esopenko and her colleagues found similar recovery trajectories between male and female athletes when female athletes had the same access to care as males ( Sports Medicine , 2023 opens in new window). “For me, right now, that’s one of the biggest pushes we can make,” Esopenko said.

Access to care is extremely challenging in cases of IPV. “Women may not be aware that they’ve had a brain injury,” Colantonio said. “They may not be in a position to seek care. We have reports where care is sought out, but the perpetrator is present, and women are asked whether their partner did the injury in front of the partner.”

Often, women with a history of IPV do not see a psychologist until years later, said Dams-O’Connor. This may mean the psychologist has the opportunity to recognize a history of concussion and brain injury that has never been diagnosed before. Dams-O’Connor and her colleagues have developed a screening tool for IPV-related brain injury that asks specific questions: Instead of “Have you ever had a traumatic brain injury?” the screener uses context clues to remind people of events they might not have associated with head injury. For example, the screening tool asks if a sexual or intimate partner has ever shaken the person violently, hit them on the head with a fist or other object, strangled them, or hit their head into a surface such as the wall or floor. These detailed questions yield much higher reporting rates than more general screeners, Dams-O’Connor said.

“For a psychologist who is seeing someone who may have a history of IPV, whether or not they know about a potential head trauma history, asking these detailed questions is really important,” she said.

Colantonio and her colleagues have codeveloped a tool kit for front-line providers working at the intersection of IPV and TBI. Another organization focused on women and brain injury, PINK Concussions, also hosts and supports research and knowledge exchange on concussion in women.

Esopenko founded and leads a large research collaboration, the Enhancing Neuroimaging Genetics through Meta-Analysis (ENIGMA) Consortium Intimate Partner Violence Working Group, which includes Dams-O’Connor. The group has the goal of better understanding the consequences of IPV-related brain injury. Recently, Esopenko and her colleague Michael Ellis, MD, a neurosurgeon specializing in IPV brain injury care, launched an educational offshoot, the ENIGMA IPV Global Knowledge Exchange Network, which holds regular virtual fireside chat sessions; their May chat was about mental health symptoms associated with brain injury, which will be followed by an education session in late July. The goal is to facilitate front-line service providers and community partners in learning from one another, Esopenko said.

“In the IPV world, I just don’t know how we could do this without social workers and psychologists,” she said. “There is just so much to unpack in what these individuals have been through.”