Behind the game

How sports-related concussions affect mental health

Clinicians will anxiously be awaiting a new set of suggested diagnostic and treatment guidelines that most likely will need to be implemented before the next NFL season.


Sports-related concussions (SRC) continue to be one of the most complicated and challenging conditions that we treat in sports medicine. One only needs to look at this year’s NFL season to understand the controversy and complexity of the condition. As I sit down to write this article at the end of week 17 of the NFL season, there have already been 135 reported SRC’s.

The controversy surrounding the case of Miami Dolphins quarterback Tua Tagovailoa and the fact that this case preceded the meeting of the Concussion in Sport Group’s sixth International Consensus Conference on Concussion in Sport in Amsterdam at the end of October guarantees that clinicians will anxiously be awaiting a new set of suggested diagnostic and treatment guidelines this spring/summer that most likely will need to be implemented before the next NFL season and academic year.

Dividing treatment between mental and physical health

I want to be clear. This article is not to “call out” the NFL. Rather, I find referencing current events helps give a point of context. In addition, I have treated professional, collegiate, high school and Olympic athletes for over 20 years and have served on more than one national consensus document concerning the diagnosis and treatment of SRC, and have found that the story reported by the media and the actual medical decisions are often two entirely divergent entities as to how a particular case evolves.

I hope to give perspective as to the challenges of treating a condition that has no true diagnostic test or universally agreed upon treatment plan.

As complicated as it is to treat the physical signs and symptoms of SRC, the treatment of the mental health issues secondary to SRC can be even more challenging. We tend to classify SRC signs and symptoms into categories with no consensus as to the definitive designation of those categories. These categories grossly would be cervical spine pain, cognitive/fatigue, mental health issues (anxiety/mood), headache/migraine, sleep disturbance and vestibular/oculomotor.

All these symptom categories are challenging to manage; however, the additional stressors put on our athletes secondary to the pandemic and its fallout have made management of mental health issues secondary to SRC even more challenging.

Studies vary, but typically demonstrate that anxiety/mood signs and symptoms are present in as low as 5% or as high as 50% of those who suffer SRC. A 2021 study of 198 Canadian Football League and University of Alberta varsity football players demonstrated that as quickly as 24-48 hours after injury, concussed players can show an increase in anxiety or depression symptoms.

Watching the signs

Unfortunately, these symptoms are often not reported at the time of the initial office visit by the concussed athlete, nor asked about by physicians. They are also the symptoms that are often least acknowledged by the athlete, their caregivers or individuals in support roles. If they are reported, they are often relegated to a second phase of treatment with treatments for headache, balance and visual issues most often taking priority in treatment. 

Anxiety and mood signs and symptoms may coexist with other symptoms or exist in isolation. Concussed athletes with mood symptoms often report a large symptom inventory. In addition, they exhibit the following:

  • The inability of stop renumerating about their concussed state.
  • The recorded scale of their symptoms is heightened with increased thoughts about their concussion.
  • Concussed athletes often refuse to attend social activities.
  • In a youth athlete, there is often continued parental questioning about the symptoms to the concussed athlete, further increasing symptoms.
  • Sleep issues can also occur.

Anxiety/mood symptoms require a comprehensive evaluation and review of health history. If symptoms exist in isolation, the athlete’s physical examination and computerized neurocognitive testing are often normal; however, they will still exhibit a large symptom inventory. If baseline computerized neurocognitive testing has been performed on these athletes, there may be anxiety symptoms checked off on the symptom inventory which may increase the chance of an athlete having these symptoms if concussed, or increase the severity if they are present on post-injury testing.

The evaluation of the concussed athlete might include the following testing where appropriate:

  • Beck Depression Inventory II
  • Beck Anxiety Inventory
  • Patient Health Questionnaire 9
  • Generalized Anxiety Disorder 7
  • Pediatric Symptom Checklist

In addition, neuropsychological testing performed by a licensed neuropsychologist can assist in confirmatory diagnosis secondary to anxiety/mood signs, as these are not evaluated in computerized neurocognitive testing.

Dr. Ralph Franks, DO, FAOASM

The connection between anxiety and SRC

Anxiety symptoms in SRC can be attributed to many different factors and can be pre-existing, co-existing with the SRC, post-concussive or any combination of the three. As such, a multi-specialty team should be available to treat all concussed athletes that include psychiatry, psychology and/or neuropsychology. Identification of the exact ideology of anxiety/mood signs can be challenging and there often is not one isolated diagnosis.

Anxiety, depression and post-traumatic stress disorder are often the most common diagnoses and may exist alone or in combination. As timely access to mental health services can be difficult, mental health providers with experience in SRC should be part of the multi-specialty team and ready to provide immediate access for the concussed athlete.

Treatments that have been successful concerning anxiety in SRC include cognitive behavioral therapy (CBT), counseling, academic accommodations, lifestyle changes to maximize nutrition, hydration, sleep and exercise to decrease stress and rarely, medications. Use of medication in treatment of anxiety/mood symptoms is often temporary.

Expeditious identification, diagnosis and treatment of symptoms is critical as these are one of the two leading reasons for Persistent Symptoms After Sports-Related Concussion (PSaSRC) with a high initial symptom inventory after injury being the other. PSaSRC are concussion symptoms that last longer than 14 days in adults and longer than 4 weeks in children.

PSaSRC are believed to be the result of pre-existing, coexisting or post-concussive biopsychosocial factors. Many of the risk factors for PSaSRC can be traced back to previous issues, and might include:

  • Prolonged cognitive and/or physical rest greater than 24-48 hours.
  • SRC that is not recognized, treated or treated completely.
  • Sustaining another concussive blow to the head or radiated force from the body before a first SRC has resolved.
  • Athlete or family history of migraine.
  • Athlete or family history of mood disorder.
  • Pre-existing learning disorder.
  • Family or social stress.
  • High symptom inventory of baseline SRC before an actual SRC.

PSaSRC that involve symptoms of anxiety/mood should be approached similarly to that of the actual SRC phase itself. Treatment should be tailored to the individual athlete and can include cognitive behavioral therapy, counseling, academic accommodations and medications.

Getting back to the game

Issues with anxiety/mood must also be considered in making return to play decisions. Generally, return to play can be considered once the athlete is symptom-free, has discontinued the use of all medications to control symptoms, has returned to baseline on all neurocognitive testing, returned to normal activities (including Return to Learn if a student athlete) and completes a Return to Play protocol.

If athletes are not psychologically ready to return to play, either due to anxiety, depression or post-traumatic stress, they should continue to be held until a mental health specialist can help the athlete become psychologically ready. If psychological readiness cannot be achieved or if there is a permanent change on neuropsychological testing, a conversation should occur between the athlete, parents/guardians and the multi-specialty team to discuss risks and benefits of continuing in this particular sport.

As long-term studies in children, adolescent and adult athletes concerning the short- and long-term effects of SRC on the mental health of athletes continue to be published, it is up to the clinician to remain current on integrating this information into practice. Early intervention when signs of anxiety are suspected in SRC leads to more rapid recovery and prevention of PSaSRC.

Editor’s note: The views expressed in this article are the author’s own and do not necessarily represent the views of The DO or the AOA.

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One comment

  1. Elizabeth Wheeler

    My son suffered 2 concussions very close in time one year ago, and he has been showing signs of distress and depression since the onset of the concussions. He is a freshman at Indiana University and he has been having a tough time acclimating to being away from home, which has heightened his anxiety and brought on some depression. I do believe that his stress/depression is partly from his current situation but also the concussions, and he may have had some mental health anxiety pre-concussion. He is going to start talking to a therapist and also has a CT scan scheduled. And if needed, an MRI after that. Any other suggestions for testing or approaches we should take? Thank you for your commitment and research to this.

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