Subclinical, long-term psychological symptoms following sport-related concussion: are athletes more depressed than we think?

INTRODUCTION: In adolescent and collegiate athletes with sport-related concussion (SRC), we sought to evaluate the prevalence and predictors of long-term psychological symptoms. METHODS: A cohort study was conducted of athletes 12-24-year-old diagnosed with SRC between November 2017 and April 2022. Athletes/proxies were interviewed on psychological symptoms (i.e. anger, anxiety, depression, and stress). Participants who scored ≥75th percentile on one or more PROMIS (Patient-Reported Outcomes Measurement System) measures were operationalized to have subclinical, long-term psychological symptoms. Uni/multivariable regressions were used. RESULTS: Of 96 participants (60.4% male), the average age was 16.6 ± 2.6 years. The median time from concussion to interview was 286 days (IQR: 247-420). A total of 36.5% athletes demonstrated subclinical, long-term psychological symptoms. Univariate logistic regression revealed significant predictors of these symptoms: history of psychiatric disorder (OR = 7.42 95% CI 1.37,40.09), substance use (OR = 4.65 95% CI 1.15,18.81), new medical diagnosis since concussion (OR = 3.43 95% CI 1.27,9.26), amnesia (OR = 3.42 95% CI 1.02,11.41), other orthopedic injuries since concussion (OR = 3.11 95% CI 1.18,8.21), age (OR = 1.24 95% CI 1.03,1.48), days to return-to-play (OR = 1.02 95% CI 1.00,1.03), and psychiatric medication use (OR = 0.19 95% CI 0.05,0.74). Multivariable model revealed significant predictors: orthopedic injuries (OR = 5.17 95% CI 1.12,24.00) and return-to-play (OR = 1.02 95% CI 1.00,1.04). CONCLUSIONS: Approximately one in three athletes endorsed long-term psychological symptoms. Predictors of these symptoms included orthopedic injuries and delayed RTP.

Acute psychological symptom profiles in high school football players following sport-related concussion.

OBJECTIVE: In a cohort of high school football athletes, the authors sought to 1) describe the proportion of those with acute psychological symptoms postconcussion, 2) determine predictors of more acute psychological symptoms postconcussion, and 3) determine if acute psychological symptoms impact recovery. METHODS: A retrospective cohort study of high school football athletes (14-18 years of age) who sustained a sport-related concussion between November 2017 and April 2022 and presented to a multidisciplinary concussion center was performed. Based on their Post-Concussion Symptom Scale (PCSS) scores at the initial clinic visit, their total psychological symptom cluster score was calculated by summing their scores for the four affective symptoms (irritability, sadness, nervousness, and feeling more emotional). The psychological symptom ratio was defined as the ratio of the psychological symptom cluster score to the total initial PCSS score. Primary outcomes included time to return to learn (RTL), symptom resolution, and return to play (RTP). Uni- and multivariable regression analyses were performed controlling for demographic factors, learning disabilities, attention-deficit/hyperactivity disorder, and personal and/or family history of psychological diagnoses and migraine. RESULTS: A total of 195 male football players (mean age 16.2 ± 1.2 years) were included in the study. About one-third of the sample (n = 70, 35.9%) reported at least one psychological symptom. Of these 70 athletes, their psychological symptom scores were 1 (10.3%), 2 (7.7%), and ≥ 3 (17.9%). Irritability was the most endorsed psychological symptom (25.1%), followed by nervousness (15.9%), feeling more emotional (12.8%), and sadness (11.8%). The multivariable regression model showed that a positive psychological history (B = 2.66, 95% CI 0.74-4.58, p = 0.007) and family psychological history (B = 2.43, 95% CI 0.98-3.88, p = 0.001) were significant predictors of a higher psychological symptom cluster score. Multivariable linear regression analysis showed that a higher psychological symptom cluster score was associated with a longer time to RTP (B = 1.22, 95% CI 0.17-2.264, p = 0.023) but not with time to symptom resolution or RTL. The psychological symptom ratio was not a significant predictor. CONCLUSIONS: In a cohort of male football players, 36% reported at least one psychological symptom, with irritability being most commonly reported. Athletes with a personal and/or family history of psychological disorders experienced more acute psychological symptoms following a sport-related concussion. A higher psychological symptom cluster score was associated with delayed time to RTP but not time to RTL or symptom resolution.

Do Sport-Related Concussions Later in the Season Take Longer to Recover From?

OBJECTIVE: In a cohort of high-school football athletes with sport-related concussion (SRC), we sought to investigate the role of seasonality, defined as time of injury during a season, on recovery. DESIGN: Retrospective cohort study. SETTING: Regional sport concussion center. PARTICIPANTS: High-school football athletes ages 14 to 19 -years old who sustained an SRC from 11, 2017 to 04, 2022. INTERVENTION: Athletes were divided into 3 groups based on seasonality: early, middle, and late season. MAIN OUTCOME MEASURES: The primary outcomes were initial Post-Concussion Symptom Scale score and recovery, as defined by time to return-to-learn (RTL), symptom resolution, and return-to-play (RTP). Descriptive statistics, analysis-of-variance, t tests, and multivariable regressions were performed. RESULTS: Of our cohort of 273 high-school football players who sustained an SRC, 97 (35.5%) sustained an SRC during early season, 107 (39.2%) during middle season, and 69 (25.3%) during late season. Compared with late-season concussions, early-season concussions took less days to symptom resolution (early = 11.5 ± 12.9 vs late = 25.5 ± 27.0, P = 0.03), but no differences were found in days to RTL (early = 5.3 ± 4.8 vs late = 7.2 ± 15.8, P = 0.51) and RTP (early = 13.5 ± 11.8 vs late = 23.0 ± 22.8, P = 0.08). Seasonality was not a significant predictor for any recovery metric in multivariable regressions. CONCLUSION: Sport-related concussions occurring in the early third of the season took significantly less time to symptom resolution than those occurring in the later third of the season; however, this was not statistically significant in multivariable analyses. No association was observed between seasonality and time to RTL and RTP. A trend of worse recovery with concussions later in the season may be present.

Sex Differences in Resource Allocation and Access to Care After Sport-Related Concussion.

CONTEXT: Following sport-related concussions (SRC), immediate access to a certified athletic trainer (ATC) is important to ensure proper treatment. However, resource allocation and coverage may differ between male/female youth sports. OBJECTIVE: We sought to compare resource allocation between male/female sports in the following areas: 1) rates of immediate on-field evaluation by an ATC at the time of injury, 2) time to general healthcare presentation, and 3) time to SRC clinic presentation. DESIGN: A retrospective cohort study. SETTING: Regional sports concussion center. PATIENTS: Athletes ages 14-19 who presented to a regional sports concussion center from 11/2017-04/2022 was conducted. MAIN OUTCOME MEASURES: The primary exposure of interest was sex (male/female). The primary outcome was immediate on-field evaluation by an ATC (yes/no). Secondary outcomes included time to general healthcare and SRC clinic presentation. Descriptive statistics, chisquared analyses, and linear regressions were performed. Covariates included age, history of prior concussions, and statistically significant demographics. RESULTS: A total of 832 patients with SRC were included (age 16.2±1.2, 66.5% male). Female athletes had lower rates of ADHD (X2=10.404, p=.001) and higher rates of anxiety/depression (X2=12.891, p< 0.001) compared to male athletes. Average time to presentation to general healthcare and SRC clinic did not differ between males/females, but ATC on-field evaluation occurred more in male (40.3%) than female (32.3%) athletes (X2=8.677, p=.013). Multivariable linear regression foun 24 d that ATC on-field evaluation was a significant predictor of time to general healthcare presentation (ß=-0.085, p=.015) but not SRC clinic presentation (ß=-0.055, p=.099). History of prior concussions was a significant predictor of time to initial healthcare contact (ß=0.083, p=.018). History of anxiety/depression (ß=0.136, p<.001) and initial evaluation by emergency department (ED)/urgent care (ß= 0.305, p<.001) were significant predictors of delayed time to SRC clinic presentation. CONCLUSIONS: Among 832 concussed youth athletes, female athletes were evaluated less frequently by an ATC immediately after injury. Furthermore, not being evaluated by an ATC on field was significantly associated with longer time to healthcare presentation. Future investigations should elucidate resource equity among male and female athletes.

Does earlier vestibular therapy after sport-related concussion lead to faster recovery?

OBJECTIVE: Many patients experience vestibular dysfunction following a sport-related concussion (SRC). Vestibular rehabilitation therapy has recently become more well established. In a cohort of athletes with SRC, the authors sought to 1) assess the relationship between symptoms at the initial clinic visit and time to referral for vestibular therapy, and 2) evaluate whether earlier referral to vestibular therapy was associated with faster recovery, as defined as days to return to learn (RTL), symptom resolution (SR), and return to play (RTP). METHODS: A retrospective cohort study was conducted using a regional multidisciplinary concussion center's database. Patients aged 12-23 years diagnosed with SRC who received vestibular rehabilitation therapy between October 2017 and October 2021 were included. Demographics and Post-Concussion Symptom Scale (PCSS) scores were extracted. The independent variable of interest was time to vestibular therapy referral. The three outcome variables were RTL, SR, and RTP. Spearman's rho correlation (rho) was used to evaluate the relationship between total PCSS score and individual symptoms (balance problems, blurred vision, and dizziness) and time to referral for vestibular therapy. Multivariable linear regression was performed to determine the impact of time to vestibular therapy on the three outcomes of RTL, SR, and RTP. Covariates included initial symptom burden, age, and prior concussions. RESULTS: Forty-two concussed athletes were referred for vestibular therapy (mean age 16.8 ± 2.7 years; 54.8% female). The mean time from concussion to the initial clinic visit was 22.4 ± 20.2 days, and the mean time from the initial clinic visit to vestibular therapy referral was 4.9 ± 11.3 days. Initial total PCSS scores (rho[37] = 0.05, p = 0.78) and individual symptoms, including balance problems (rho[33] = -0.004, p = 0.98), blurred vision (rho[34] = -0.17, p = 0.33), and dizziness (rho[33] = 0.07, p = 0.67), were not correlated with time to referral for vestibular therapy. Multivariable linear regression analysis found that earlier vestibular therapy referral was predictive of shorter days to SR (p = 0.002) and RTP (p = 0.02) but not RTL (p = 0.59). CONCLUSIONS: In athletes with SRC referred for vestibular therapy, earlier vestibular therapy referral was significantly associated with faster time to RTP and SR. Future investigations should focus on identifying common postconcussive signs and symptoms that serve as indications for referral to vestibular therapy.

Return-to-learn after sport-related concussion: does school level matter?

OBJECTIVE: Return-to-learn (RTL) after sport-related concussion (SRC) is an important yet understudied topic. The authors sought to do the following: 1) describe patterns of RTL among athletes by school level (i.e., middle school, high school, college); and 2) evaluate the predictive value of school level on RTL duration. METHODS: A retrospective, single-institution cohort study of adolescent and young adult athletes 12-23 years old who sustained an SRC between November 2017 and April 2022 and who presented to a multidisciplinary specialty concussion clinic was conducted. The independent variable was school level, trichotomized into middle school, high school, and college. Time to RTL was the primary outcome and was defined as days from SRC to return to any academic activities. ANOVA was used to compare RTL duration across school levels. A multivariable linear regression was performed to evaluate for predictive value of school level on RTL duration. Covariates included the following: sex, race/ethnicity, learning disorder, psychiatric conditions, migraines, family history of psychiatric conditions/migraines, initial Post-Concussion Symptom Scale score, and number of prior concussions. RESULTS: Of 1007 total athletes, 116 (11.5%) were in middle school, 835 (83.0%) were in high school, and 56 (5.6%) were in college. The mean RTL times (in days) were as follows: 8.0 ± 13.1 (middle school), 8.5 ± 13.7 (high school), and 15.6 ± 22.3 (college). One-way ANOVA showed a statistically significant difference between groups (F[2, 1007] = 6.93, p = 0.001). A Tukey post hoc test revealed a longer RTL duration in collegiate athletes when compared to middle school (p = 0.003) and high school (p < 0.001) athletes. Collegiate athletes had longer RTL duration compared to other school levels (ß = 0.14, p < 0.001). There was no difference between middle school and high school athletes (p = 0.935). The subanalysis revealed a longer RTL duration in high school freshmen/sophomores (9.5 ± 14.9 days) when compared to juniors/seniors (7.6 ± 12.6 days; t = 2.05, p = 0.041), and being an older (junior/senior) high school athlete was predictive of shorter RTL duration (ß = -0.11, p = 0.011). CONCLUSIONS: When examining patients who presented to a multidisciplinary sport concussion center, RTL duration was longer in collegiate athletes when compared to middle and high school athletes. Younger high school athletes had longer time to RTL compared to their older counterparts. This study provides insight into how varying scholastic environments may contribute to RTL.

A psychosocial pathway to paranoia: The interplay between social connectedness and self-esteem.

The quantity and quality of social contacts have been related to self-esteem, and both social relationships and self-esteem have been implicated in the pathways to paranoia. However, how social relationships interplay with self-esteem to trigger paranoia is not well understood. This study aims to investigate whether different measures of social connectedness (social support, loneliness, and desired friendship), as well as the frequency of social contact, impact paranoia and other positive and negative psychotic-like experiences (PLE) through the indirect effect of self-esteem. Data from a sample of 169 nonclinically ascertained participants oversampled for schizotypy scores were analyzed using two different approaches: retrospective trait-like and ecological momentary measures of social connectedness. Results showed that self-esteem mediates the pathways from poor social support and social longing, but not from loneliness, to paranoia and other cognitive PLE. In contrast, pathways from social connectedness to perceptual PLE and negative PLE were not mediated by self-esteem. Results were consistent across trait-like and momentary measures. Finally, self-esteem was not implicated in the pathways from the frequency of social contact and paranoia or other forms of PLE. These results provide a comprehensive picture of how social connectedness drives specific symptoms of psychosis through self-esteem. Findings underscore the need to explore separately the quality and quantity of social relationships and suggest that the subjective experience of meaningful social bonds is key social determinants of mental health. Therefore, addressing inadequacies of social connectedness could substantially improve symptomatic and functional outcomes of psychosis.

Interoceptive functioning in schizophrenia and schizotypy.

Though bodily self-disturbances are well documented in schizophrenia, interoceptive functioning (i.e., the perception of the internal state of the body) remains poorly understood in this population. In fact, only two studies to date have empirically measured interoceptive ability in schizophrenia. Both studies documented a deficit in interoceptive accuracy (i.e., the objective performance on a heartbeat detection task), and one noted differences in interoceptive sensibility (i.e., the subjective experience of interoception) in this population. To our knowledge, interoceptive awareness (i.e., the metacognitive awareness of one's interoceptive ability) has never been measured in schizophrenia and the link between interoceptive functioning and schizotypy remains unexplored. The present study addresses this gap by investigating the three dimensions of interoception in individuals with schizophrenia and matched controls (Experiment 1, N = 58) and in relation to schizotypal traits (Experiment 2, N = 109). Consistent with the literature, Experiment 1 documented a deficit in interoceptive accuracy and differences in interoceptive sensibility in individuals with schizophrenia. For the first time, our study revealed intact interoceptive awareness in individuals with schizophrenia. Against our expectations, we found no link between schizotypy and interoceptive functioning in Experiment 2. Our novel findings bear important clinical implications as insight into one's interoceptive limitations (i.e., intact interoceptive awareness) might promote treatment seeking behavior in schizophrenia. The lack of association between interoceptive ability and schizotypy in non-help-seeking youths suggests that changes in interoception may only arise with the onset of psychosis.