Concussion and Psychiatric Outcome in Adults and Children

I accepted the invitation to write this editorial on the traumatic brain injury (TBI) manuscripts in this edition of the Journal because of my career focus on psychiatric aspects of TBI. I disclose that I am also privileged to be a contributing author on both of the TBI articles. ^1,2

The 2 articles that focus on TBI in this edition are review articles of conditions of high public health concern. Public awareness of adult sports-related TBI has risen in the past few years, especially in the arena of football. Therefore, a review of adult sports-related TBI is timely. Similarly, there has been a marked increase in concern regarding mild TBI (mTBI) in children and adolescents, especially in sports (e.g., Institute of Medicine report). ³ Sports capture the imagination of a large segment of society. Adult sports stars tend to become role models for people of all ages, and professional sports are associated with substantial financial implications for players, franchise owners, media, fans, city coffers, and vendors. Thus, when our stars appear to be stricken with psychiatric disorders allegedly from multiple concussions, the sport itself has to respond to investigate the extent and nature of the problem for the safety of participants and the perpetuation of the sport. Concussion in youth has similarly become more prominent in societal discourse. ³ Although pediatric TBI encompasses a much broader problem than sports-related concussion, such is the ubiquity and passion for youth sports in our society that sports have become the driver for public attention to youth TBI. The role of youth sports in society is a positive force for socialization and physical health of our children. Youth sports also involve parents encouraging their children and potentially enhancing parent-child relationships. In addition, parents find that their social networks are extended by socializing with fellow parents of youth team members. The timely question asked is that if adult sport is associated with psychiatric complications from concussion, “how likely is it that our children who participate in sports face similar risks?”

The review of psychiatric sequelae of concussion related to adult sports ¹ suggested that there is a developing body of evidence supporting the existence of long-term psychiatric and psychological complications. Specifically, in most studies, depressive symptoms were linked to concussion. The studies with regard to anxiety and also substance abuse were few, and findings were mixed with regard to a connection with concussion. Studies that focused on behavioural changes typically identified behaviour and/or cognitive changes after sports concussion, and a link was suggested in 2 studies. Chronic traumatic encephalopathy, a degenerative neurological disease that occurs years after concussion or repetitive head trauma, was included in this review. This broad syndrome is associated with mood, behavior, cognitive, and substance use problems. Clear subtypes and aetiologies have not yet emerged, but there is some evidence of symptom patterns of initial onset of cognitive problems followed by psychiatric complications or early psychiatric problems followed by cognitive decline.

The systematic review of psychiatric, psychological, and behavioural outcomes after mTBI in children and adolescents ² found that problems were more prevalent earlier in the recovery period, when the injury was of sufficient severity to result in hospitalization, where there was preinjury psychiatric disorder, when assessment relied on retrospective recall, and when the comparison group consisted of noninjured healthy children rather than an injured child (e.g., orthopedic fracture) comparison group.

There is a clear common characteristic that both these reviews expose. There is a surprising paucity of data on topics that have such a high public health cost and that have generated such public interest and concern. The gold-standard psychiatric assessment, ⁴ which uses a structured or semistructured psychiatric interview complemented by report from a knowledgeable significant other (e.g., parent or spouse) and valid and reliable behavioural and emotional questionnaires, has yet to be published with regard to the investigation of adult sports or mTBI in children and adolescents.

We are attempting to address the scientific knowledge gaps identified regarding psychiatric outcome after mTBI in children and adolescents. Specifically, we are nearing completion of a large cohort of consecutively treated children with mTBI (n > 200) or orthopedic injury (n > 100) prospectively followed within 2 weeks of injury up until 12 months postinjury. The study design includes use of a semistructured psychiatric interview of parent and child assessing preinjury status at the first assessment and then tracking psychiatric outcome after 3, 6, and 12 months. Comprehensive family, child, and demographic measures as well as structural and functional brain imaging measures are conducted to shed light on risk factors and mechanisms involved in the development of psychiatric symptoms and disorders.

There is a clear need for prospective longitudinal studies to investigate psychiatric outcome related to adult sports concussion. This is by no means an easy task because it requires a large cohort; assessment of baseline psychiatric status, including substance use; cataloging of previous TBI; psychosocial factors assessment; structural and functional brain imaging measures; and neuropsychological function. Research efforts should also target education, prevention, and treatment.