Post-Concussive Depression – It’s real, it’s serious, and it happens a lot.

May 16, 2023

Written by: Deborah M. Little, PhD

Scope of the problem:

In the United States alone, there are an estimated 2.5 million new brain injuries each year. This number continues to increase as our surveillance of injuries continues to improve.

Background:

While ~80% of people who suffer from a concussion will recover from the major post-concussive symptoms such as nausea, vomiting, photophobia, post-traumatic headache, ataxia, dizziness, confusion and/or memory problems, and alterations in sleep within days of the injury; depression and the risk of depression increases with time.

It’s critical to re-educate both providers, members of the community and our patients that the long-held beliefs that concussion “isn’t a big deal” and that patients who don’t recover from concussion fully are “malingering” or “exaggerating” are false. Further, we must pay attention to patients with a single concussion and not just those who present with a history of multiple concussion. The facts are:

  • For otherwise healthy adults, those with no depression prior to the injury had rates of depression following the injury acutely at 10% which increased to 40% at 1 year.1
  • A history of depression prior to the head injury has a major impact on risk for depression following the head injury. Patients with a history of depression prior to the injury but not depressed at the time of injury demonstrated rates of depression of 20% in the acute phase which increased to almost 60% at 1 year. Patients with depression at the time of injury also had rates of depression that started at 20% right after the injury which increased to 70% at 1 year.1
  • Risk of depression remains high (3-fold higher than uninjured) decades after the injury2
  • These rates of depression increased 4-fold in patients who did not recovery fully from the concussion (sustained post-concussive symptoms)3
  • In children and adolescents with a history of depression, a concussion increases risk of a suicide attempts by 31%.Current recommendations:

The American Academy of Neurology (AAN) has published recommendations for management of concussion in sport but these can be applied across the board. First, if a concussion is suspected that the child/adolescent/adult should immediately STOP activity. If there are no symptoms of concussion after 30 minutes activity can be re-started gradually and increased as long as no symptoms present themselves.

If any symptoms of concussion are observed, the patient should immediately begin a period of rest and not return to activity until cleared by a physician or other healthcare provider unless (1) there is a loss of consciousness after the injury or (2) symptoms get worse over 30 minutes in which case the patient should be evaluated in the emergency room. If asked to provide a return to activity letter, all post-concussive symptoms should be evaluated with a specific focus on continued alterations in sleep and headache.

We also recommend that all patients be screened for a history of concussion or TBI as these are risk factors for depression, anxiety, learning disabilities, and anger management. In the case of a history of multiple TBI, risk for early onset neurodegenerative disease. Patients with a history of TBI can and in many cases do respond differently to both behavioral and medication interventions.

Conclusions:

  • Concussion, or mild traumatic brain injury, is not a static event. The pathophysiologic cascade occurs over time even in patients with a concussion that fully resolves. It is because of this that most professional societies have adopted a “wait and watch’ approach to monitoring for symptoms and this continues to become more conservative.
  • Management of mild brain injury or concussion in the acute stage is exceptionally important to help reduce poor outcomes. Rest, rest, rest. Reduction of screen time is critical.
  • Treatment of depression in patients with a history of depression may require alternative approaches due to alterations in the biochemistry in the brain. However, SSRI’s are still considered the first line approach to depression post-concussion.
  • Patients presenting with symptoms of depression are also likely to present with chronic sleep problems confounding treatment of depression. The recommendations are to avoid pharmacologic interventions if possible and instead focus on non-pharmacologic interventions for sleep including sleep hygiene and CBT.

1 Bombardier CH, Fann JR, Temkin NR, Esselman PC, Barber J, Dikmen SS. Rates of major depressive disorder and clinical outcomes following traumatic brain injury. JAMA. (2010) 303:1938–45. doi: 10.1001/jama.2010.599

2 Hellewell SC, Beaton CS, Welton T, Grieve SM. Characterizing the Risk of Depression Following Mild Traumatic Brain Injury: A Meta-Analysis of the Literature Comparing Chronic mTBI to Non-mTBI Populations. Front Neurol. 2020 May 19;11:350. doi: 10.3389/fneur.2020.00350.

3 Lambert M, Sheldrake E, Deneault A-A, Wheeler A, Burke M, Scratch S. Depressive symptoms in individuals with persistent postconcussive symptoms: A systematic review and meta analysis. JAMA Network Open. (2002) 5(12):e2248453. Doi:10.1001jamanetworkopen.2022.48453.