Attention Turns to Concussions' Psychiatric Effects in Athletes

HONOLULU – Concussions in athletes often produce acute and chronic psychiatric symptoms, but there are few data on the epidemiology and treatment of these problems.

That’s beginning to change.

Physicians increasingly are recognizing chronic traumatic encephalopathy and psychiatric symptoms in athletes after traumatic brain injury (TBI). Unfortunately, little is known about the use of psychotropic medications in athletes with or without TBI, eating disorders, depression, anxiety, or other disorders, several speakers said at the annual meeting of the American Psychiatric Association.

Psychiatric sequelae from TBI in particular "is a timely topic, but that doesn’t mean it hasn’t been around a long time," said Dr. Antonia L. Baum, moderator of the session and a sports psychiatrist in Chevy Chase, Md.

Dr. Claudia L. Reardon of the University of Wisconsin, Madison, recently published a review article summarizing the medical literature on the diagnosis and treatment of mental illness in athletes, which she was able to describe in a single presentation at the meeting (Sports Med. 2010;40:961-80).

Psychiatric symptoms can arise in an athlete after TBI for a variety of reasons. Symptoms of attention-deficit/hyperactivity disorder (ADHD), for example, may worsen after a concussion, or the TBI’s damage to specific brain areas might cause psychiatric symptoms. Reaction to the stress of TBI or to stressful life events after the TBI, might lead to psychiatric symptoms, Dr. Reardon said.

Between 20% and 30% of people who suffer concussions develop acute major depressive disorder, and subacute depression or mood liability is seen in others. Insomnia troubles 36%-70% of patients after TBI. Other acute and subacute symptoms after TBI include anxiety, posttraumatic stress disorder, irritability, apathy, personality changes, impulsivity, somatization, and ADHD-like symptoms. In patients with preexisting disorders, concussion may exacerbate symptoms and make them more difficult to treat.

Chronic traumatic encephalopathy (CTE), a neurodegenerative disease, can develop years after recovery from the acute effects of TBI, especially if the brain has insufficient time to recover between serial concussions.

Clinical symptoms of CTE emerge 8 years after serial concussions, around age 43 years on average; but the timing varies widely, Dr. Reardon said. Symptom onset usually is insidious, with slow and steady progression over an average of 18 years, though somewhat faster in football players than in other athletes.

Irritability, anger, apathy, a "punchy" personality, and a so-called "shorter fuse" typify early symptoms of CTE. "Rarely, cognitive difficulties are the first signs to emerge, but usually psychiatric symptoms are what we see first," she said.

People with CTE are more likely to be suicidal, to have an early accidental death, or to overdose on drugs, compared with people without CTE. In later stages of CTE, the neurologic abnormalities appear, such as parkinsonism or speech and gait abnormalities.

Children may be at greater risk than adults for long-term sequelae of TBI, because their brains are still developing, and serious sequelae may be more likely in female than in male athletes, the literature suggests.

Concussions are common not just in "contact" sports such as football and soccer, but in many other sports, even when there’s not a blow to the head. Athletes may have hard contact with floors (gymnastics or wrestling), walls (racquetball), or other objects or people (golf or basketball), she said.

"Traumatic brain injury does set people up for even higher rates of psychiatric conditions, so it’s important to know the baseline rates of these conditions in athletes," Dr. Reardon said.

Eating disorders can be found in up to 60% of female athletes in such sports as running and gymnastics. In male athletes, eating disorders increasingly are being recognized in rowing, wrestling, and other sports, but male bodies tend to recover once the season is over, while females do not.

Abuse of alcohol, stimulants, steroids, and other substances is fairly common in athletes, and TBI can reduce tolerance to alcohol, she noted.

The incidence of major depressive disorder in athletes is probably similar to that in nonathletes, but athletes are at high risk for depression after injury, overtraining, poor performance, or retirement. A few athletes may develop compulsive disorders, but superstitious rituals usually are normal, so "don’t become overly concerned about obsessive-compulsive disorder," she advised.

More Research Data Coming

Physicians, athletes, and sports leagues are beginning to gather sorely needed data on TBI and sequelae in athletes.

"We need to know baseline function to assess any changes" after TBI, said Dr. David A. Baron, professor of psychiatry and director of the Global Center for Exercise, Psychiatry and Sports at the University of Southern California, Los Angeles.

The Glasgow Coma Score may not be sensitive or specific enough to detect many of the problems that sports psychiatrists see, such as early cognitive symptoms, he asserted. "We might be missing some very early clinical findings" by using this most common system for classifying TBI severity, Dr. Baron said.

In 2007, under pressure from politicians and the media, the National Football League for the first time acknowledged that concussions lead to long-term problems and put independent neurologists in charge of return-to-play decisions after TBI, Dr. Baron said. The league started a database to log every concussion for every player. There’s also a new interest in studying the long-term effects of TBI in retired athletes.

William Tsushima, Ph.D. and his son Vincent G. Tsushima, Ph.D., both neuropsychologists in Honolulu, reported that 4 million high school and college athletes have undergone computer-based neuropsychological assessments before sports participation. Each year, 300,000 athletes suffer mild TBI, including 60,000 high school athletes with cognitive and emotional symptoms of TBI. Every player in the National Hockey League now is required to undergo testing before playing.

A study by the Tsushimas in 639 high school athletes found that younger teens recover more slowly than older athletes after concussion, suggesting that more time is needed before allowing younger athletes to return to play.

They used the ImPACT neurocognitive assessment tool, which now comes in a handheld version for use on the field that includes a brief mental status evaluation, Dr. Vincent G. Tsushima said. The device’s makers are working on versions for use with younger ages (5-11 years) and in different languages, he said.

Weigh Rx Choices for Concussion in Athletes

Consider three questions before starting an athlete on a psychiatric medication: Is it safe, especially if the athlete exercises to exhaustion and sweats a lot? Will it affect performance? Is it allowed under antidoping guidelines?

Results of studies of psychiatric medications in athletes may not be generalizable, cautioned Dr. Reardon. They typically involve only one or two doses rather than long-term use.

One of the most common measures of effects on performance is grip strength. "How readily can you extrapolate that to the athlete who is an Olympic 400-meter dasher?" asked Dr. Reardon, who previously was a 400-meter runner in track and field competitions.

The selective serotonin reuptake inhibitor drugs generally are considered first-line therapy for behavioral and cognitive symptoms of traumatic brain injury (TBI) that do not start resolving within a few weeks of TBI, including anxiety, depression, irritability, poor tolerance of frustration, and even cognitive difficulties in athletes who suffered concussion.

Preliminary data suggest that fluoxetine does not affect athletic performance and has no safety concerns. One study reported that paroxetine inhibited athletic performance, but another found no effects.

Very preliminary data from one study on bupropion suggests it may be performance enhancing if used acutely in hot temperatures, but "we should take very seriously that we should avoid this medication in athletes who suffered recent head injury, given the epileptogenic potential of the drug," she said.

In athletes with TBI, preliminary data suggest avoiding anticholinergics and other anxiolytics or sedative-hypnotic drugs that may cause cognitive slowing, fatigue, or drowsiness. Beta-blockers are banned in archery and probably inhibit performance in endurance sports. Melatonin, used as a sleep aid, seems safe and does not seem to inhibit performance. Avoid benzodiazepines, especially longer-acting ones, which affect performance.

A relatively new area in the treatment of deficits in memory or attention after TBI is "cognitive enhancers, commonly stimulants. This is "a potential recipe for disaster" for athletes who exercise to exhaustion in hot climates, Dr. Reardon warned, because stimulants allow the athlete to exercise harder, to a higher core body temperature without perceiving greater effort. "There are reports of some who dropped dead," she cautioned.

Amantadine, bromocriptine, and to a lesser extent levodopa also increasingly are being used after TBI, but there is little research in athletes. Preliminary interest is growing in using cholinergic augmentation (donepezil, for instance) to treat attention or memory deficits after TBI, Dr. Reardon noted, but not yet in athletes.

Dr. Reardon, Dr. W. Tsushima, and Dr. V. Tsushima said they have no relevant conflicts of interest. Dr. Baron has received financial support from Eli Lilly.

HONOLULU – Concussions in athletes often produce acute and chronic psychiatric symptoms, but there are few data on the epidemiology and treatment of these problems.

That’s beginning to change.

Physicians increasingly are recognizing chronic traumatic encephalopathy and psychiatric symptoms in athletes after traumatic brain injury (TBI). Unfortunately, little is known about the use of psychotropic medications in athletes with or without TBI, eating disorders, depression, anxiety, or other disorders, several speakers said at the annual meeting of the American Psychiatric Association.

Psychiatric sequelae from TBI in particular "is a timely topic, but that doesn’t mean it hasn’t been around a long time," said Dr. Antonia L. Baum, moderator of the session and a sports psychiatrist in Chevy Chase, Md.

Dr. Claudia L. Reardon of the University of Wisconsin, Madison, recently published a review article summarizing the medical literature on the diagnosis and treatment of mental illness in athletes, which she was able to describe in a single presentation at the meeting (Sports Med. 2010;40:961-80).

Psychiatric symptoms can arise in an athlete after TBI for a variety of reasons. Symptoms of attention-deficit/hyperactivity disorder (ADHD), for example, may worsen after a concussion, or the TBI’s damage to specific brain areas might cause psychiatric symptoms. Reaction to the stress of TBI or to stressful life events after the TBI, might lead to psychiatric symptoms, Dr. Reardon said.

Between 20% and 30% of people who suffer concussions develop acute major depressive disorder, and subacute depression or mood liability is seen in others. Insomnia troubles 36%-70% of patients after TBI. Other acute and subacute symptoms after TBI include anxiety, posttraumatic stress disorder, irritability, apathy, personality changes, impulsivity, somatization, and ADHD-like symptoms. In patients with preexisting disorders, concussion may exacerbate symptoms and make them more difficult to treat.

Chronic traumatic encephalopathy (CTE), a neurodegenerative disease, can develop years after recovery from the acute effects of TBI, especially if the brain has insufficient time to recover between serial concussions.

Clinical symptoms of CTE emerge 8 years after serial concussions, around age 43 years on average; but the timing varies widely, Dr. Reardon said. Symptom onset usually is insidious, with slow and steady progression over an average of 18 years, though somewhat faster in football players than in other athletes.

Irritability, anger, apathy, a "punchy" personality, and a so-called "shorter fuse" typify early symptoms of CTE. "Rarely, cognitive difficulties are the first signs to emerge, but usually psychiatric symptoms are what we see first," she said.

People with CTE are more likely to be suicidal, to have an early accidental death, or to overdose on drugs, compared with people without CTE. In later stages of CTE, the neurologic abnormalities appear, such as parkinsonism or speech and gait abnormalities.

Children may be at greater risk than adults for long-term sequelae of TBI, because their brains are still developing, and serious sequelae may be more likely in female than in male athletes, the literature suggests.

Concussions are common not just in "contact" sports such as football and soccer, but in many other sports, even when there’s not a blow to the head. Athletes may have hard contact with floors (gymnastics or wrestling), walls (racquetball), or other objects or people (golf or basketball), she said.

"Traumatic brain injury does set people up for even higher rates of psychiatric conditions, so it’s important to know the baseline rates of these conditions in athletes," Dr. Reardon said.

Eating disorders can be found in up to 60% of female athletes in such sports as running and gymnastics. In male athletes, eating disorders increasingly are being recognized in rowing, wrestling, and other sports, but male bodies tend to recover once the season is over, while females do not.

Abuse of alcohol, stimulants, steroids, and other substances is fairly common in athletes, and TBI can reduce tolerance to alcohol, she noted.

The incidence of major depressive disorder in athletes is probably similar to that in nonathletes, but athletes are at high risk for depression after injury, overtraining, poor performance, or retirement. A few athletes may develop compulsive disorders, but superstitious rituals usually are normal, so "don’t become overly concerned about obsessive-compulsive disorder," she advised.

More Research Data Coming

Physicians, athletes, and sports leagues are beginning to gather sorely needed data on TBI and sequelae in athletes.

"We need to know baseline function to assess any changes" after TBI, said Dr. David A. Baron, professor of psychiatry and director of the Global Center for Exercise, Psychiatry and Sports at the University of Southern California, Los Angeles.

The Glasgow Coma Score may not be sensitive or specific enough to detect many of the problems that sports psychiatrists see, such as early cognitive symptoms, he asserted. "We might be missing some very early clinical findings" by using this most common system for classifying TBI severity, Dr. Baron said.

In 2007, under pressure from politicians and the media, the National Football League for the first time acknowledged that concussions lead to long-term problems and put independent neurologists in charge of return-to-play decisions after TBI, Dr. Baron said. The league started a database to log every concussion for every player. There’s also a new interest in studying the long-term effects of TBI in retired athletes.

William Tsushima, Ph.D. and his son Vincent G. Tsushima, Ph.D., both neuropsychologists in Honolulu, reported that 4 million high school and college athletes have undergone computer-based neuropsychological assessments before sports participation. Each year, 300,000 athletes suffer mild TBI, including 60,000 high school athletes with cognitive and emotional symptoms of TBI. Every player in the National Hockey League now is required to undergo testing before playing.

A study by the Tsushimas in 639 high school athletes found that younger teens recover more slowly than older athletes after concussion, suggesting that more time is needed before allowing younger athletes to return to play.

They used the ImPACT neurocognitive assessment tool, which now comes in a handheld version for use on the field that includes a brief mental status evaluation, Dr. Vincent G. Tsushima said. The device’s makers are working on versions for use with younger ages (5-11 years) and in different languages, he said.

Weigh Rx Choices for Concussion in Athletes

Consider three questions before starting an athlete on a psychiatric medication: Is it safe, especially if the athlete exercises to exhaustion and sweats a lot? Will it affect performance? Is it allowed under antidoping guidelines?

Results of studies of psychiatric medications in athletes may not be generalizable, cautioned Dr. Reardon. They typically involve only one or two doses rather than long-term use.

One of the most common measures of effects on performance is grip strength. "How readily can you extrapolate that to the athlete who is an Olympic 400-meter dasher?" asked Dr. Reardon, who previously was a 400-meter runner in track and field competitions.

The selective serotonin reuptake inhibitor drugs generally are considered first-line therapy for behavioral and cognitive symptoms of traumatic brain injury (TBI) that do not start resolving within a few weeks of TBI, including anxiety, depression, irritability, poor tolerance of frustration, and even cognitive difficulties in athletes who suffered concussion.

Preliminary data suggest that fluoxetine does not affect athletic performance and has no safety concerns. One study reported that paroxetine inhibited athletic performance, but another found no effects.

Very preliminary data from one study on bupropion suggests it may be performance enhancing if used acutely in hot temperatures, but "we should take very seriously that we should avoid this medication in athletes who suffered recent head injury, given the epileptogenic potential of the drug," she said.

In athletes with TBI, preliminary data suggest avoiding anticholinergics and other anxiolytics or sedative-hypnotic drugs that may cause cognitive slowing, fatigue, or drowsiness. Beta-blockers are banned in archery and probably inhibit performance in endurance sports. Melatonin, used as a sleep aid, seems safe and does not seem to inhibit performance. Avoid benzodiazepines, especially longer-acting ones, which affect performance.

A relatively new area in the treatment of deficits in memory or attention after TBI is "cognitive enhancers, commonly stimulants. This is "a potential recipe for disaster" for athletes who exercise to exhaustion in hot climates, Dr. Reardon warned, because stimulants allow the athlete to exercise harder, to a higher core body temperature without perceiving greater effort. "There are reports of some who dropped dead," she cautioned.

Amantadine, bromocriptine, and to a lesser extent levodopa also increasingly are being used after TBI, but there is little research in athletes. Preliminary interest is growing in using cholinergic augmentation (donepezil, for instance) to treat attention or memory deficits after TBI, Dr. Reardon noted, but not yet in athletes.

Dr. Reardon, Dr. W. Tsushima, and Dr. V. Tsushima said they have no relevant conflicts of interest. Dr. Baron has received financial support from Eli Lilly.

HONOLULU – Concussions in athletes often produce acute and chronic psychiatric symptoms, but there are few data on the epidemiology and treatment of these problems.

That’s beginning to change.

Physicians increasingly are recognizing chronic traumatic encephalopathy and psychiatric symptoms in athletes after traumatic brain injury (TBI). Unfortunately, little is known about the use of psychotropic medications in athletes with or without TBI, eating disorders, depression, anxiety, or other disorders, several speakers said at the annual meeting of the American Psychiatric Association.

Psychiatric sequelae from TBI in particular "is a timely topic, but that doesn’t mean it hasn’t been around a long time," said Dr. Antonia L. Baum, moderator of the session and a sports psychiatrist in Chevy Chase, Md.

Dr. Claudia L. Reardon of the University of Wisconsin, Madison, recently published a review article summarizing the medical literature on the diagnosis and treatment of mental illness in athletes, which she was able to describe in a single presentation at the meeting (Sports Med. 2010;40:961-80).

Psychiatric symptoms can arise in an athlete after TBI for a variety of reasons. Symptoms of attention-deficit/hyperactivity disorder (ADHD), for example, may worsen after a concussion, or the TBI’s damage to specific brain areas might cause psychiatric symptoms. Reaction to the stress of TBI or to stressful life events after the TBI, might lead to psychiatric symptoms, Dr. Reardon said.

Between 20% and 30% of people who suffer concussions develop acute major depressive disorder, and subacute depression or mood liability is seen in others. Insomnia troubles 36%-70% of patients after TBI. Other acute and subacute symptoms after TBI include anxiety, posttraumatic stress disorder, irritability, apathy, personality changes, impulsivity, somatization, and ADHD-like symptoms. In patients with preexisting disorders, concussion may exacerbate symptoms and make them more difficult to treat.

Chronic traumatic encephalopathy (CTE), a neurodegenerative disease, can develop years after recovery from the acute effects of TBI, especially if the brain has insufficient time to recover between serial concussions.

Clinical symptoms of CTE emerge 8 years after serial concussions, around age 43 years on average; but the timing varies widely, Dr. Reardon said. Symptom onset usually is insidious, with slow and steady progression over an average of 18 years, though somewhat faster in football players than in other athletes.

Irritability, anger, apathy, a "punchy" personality, and a so-called "shorter fuse" typify early symptoms of CTE. "Rarely, cognitive difficulties are the first signs to emerge, but usually psychiatric symptoms are what we see first," she said.

People with CTE are more likely to be suicidal, to have an early accidental death, or to overdose on drugs, compared with people without CTE. In later stages of CTE, the neurologic abnormalities appear, such as parkinsonism or speech and gait abnormalities.

Children may be at greater risk than adults for long-term sequelae of TBI, because their brains are still developing, and serious sequelae may be more likely in female than in male athletes, the literature suggests.

Concussions are common not just in "contact" sports such as football and soccer, but in many other sports, even when there’s not a blow to the head. Athletes may have hard contact with floors (gymnastics or wrestling), walls (racquetball), or other objects or people (golf or basketball), she said.

"Traumatic brain injury does set people up for even higher rates of psychiatric conditions, so it’s important to know the baseline rates of these conditions in athletes," Dr. Reardon said.

Eating disorders can be found in up to 60% of female athletes in such sports as running and gymnastics. In male athletes, eating disorders increasingly are being recognized in rowing, wrestling, and other sports, but male bodies tend to recover once the season is over, while females do not.

Abuse of alcohol, stimulants, steroids, and other substances is fairly common in athletes, and TBI can reduce tolerance to alcohol, she noted.

The incidence of major depressive disorder in athletes is probably similar to that in nonathletes, but athletes are at high risk for depression after injury, overtraining, poor performance, or retirement. A few athletes may develop compulsive disorders, but superstitious rituals usually are normal, so "don’t become overly concerned about obsessive-compulsive disorder," she advised.

More Research Data Coming

Physicians, athletes, and sports leagues are beginning to gather sorely needed data on TBI and sequelae in athletes.

"We need to know baseline function to assess any changes" after TBI, said Dr. David A. Baron, professor of psychiatry and director of the Global Center for Exercise, Psychiatry and Sports at the University of Southern California, Los Angeles.

The Glasgow Coma Score may not be sensitive or specific enough to detect many of the problems that sports psychiatrists see, such as early cognitive symptoms, he asserted. "We might be missing some very early clinical findings" by using this most common system for classifying TBI severity, Dr. Baron said.

In 2007, under pressure from politicians and the media, the National Football League for the first time acknowledged that concussions lead to long-term problems and put independent neurologists in charge of return-to-play decisions after TBI, Dr. Baron said. The league started a database to log every concussion for every player. There’s also a new interest in studying the long-term effects of TBI in retired athletes.

William Tsushima, Ph.D. and his son Vincent G. Tsushima, Ph.D., both neuropsychologists in Honolulu, reported that 4 million high school and college athletes have undergone computer-based neuropsychological assessments before sports participation. Each year, 300,000 athletes suffer mild TBI, including 60,000 high school athletes with cognitive and emotional symptoms of TBI. Every player in the National Hockey League now is required to undergo testing before playing.

A study by the Tsushimas in 639 high school athletes found that younger teens recover more slowly than older athletes after concussion, suggesting that more time is needed before allowing younger athletes to return to play.

They used the ImPACT neurocognitive assessment tool, which now comes in a handheld version for use on the field that includes a brief mental status evaluation, Dr. Vincent G. Tsushima said. The device’s makers are working on versions for use with younger ages (5-11 years) and in different languages, he said.

Weigh Rx Choices for Concussion in Athletes

Consider three questions before starting an athlete on a psychiatric medication: Is it safe, especially if the athlete exercises to exhaustion and sweats a lot? Will it affect performance? Is it allowed under antidoping guidelines?

Results of studies of psychiatric medications in athletes may not be generalizable, cautioned Dr. Reardon. They typically involve only one or two doses rather than long-term use.

One of the most common measures of effects on performance is grip strength. "How readily can you extrapolate that to the athlete who is an Olympic 400-meter dasher?" asked Dr. Reardon, who previously was a 400-meter runner in track and field competitions.

The selective serotonin reuptake inhibitor drugs generally are considered first-line therapy for behavioral and cognitive symptoms of traumatic brain injury (TBI) that do not start resolving within a few weeks of TBI, including anxiety, depression, irritability, poor tolerance of frustration, and even cognitive difficulties in athletes who suffered concussion.

Preliminary data suggest that fluoxetine does not affect athletic performance and has no safety concerns. One study reported that paroxetine inhibited athletic performance, but another found no effects.

Very preliminary data from one study on bupropion suggests it may be performance enhancing if used acutely in hot temperatures, but "we should take very seriously that we should avoid this medication in athletes who suffered recent head injury, given the epileptogenic potential of the drug," she said.

In athletes with TBI, preliminary data suggest avoiding anticholinergics and other anxiolytics or sedative-hypnotic drugs that may cause cognitive slowing, fatigue, or drowsiness. Beta-blockers are banned in archery and probably inhibit performance in endurance sports. Melatonin, used as a sleep aid, seems safe and does not seem to inhibit performance. Avoid benzodiazepines, especially longer-acting ones, which affect performance.

A relatively new area in the treatment of deficits in memory or attention after TBI is "cognitive enhancers, commonly stimulants. This is "a potential recipe for disaster" for athletes who exercise to exhaustion in hot climates, Dr. Reardon warned, because stimulants allow the athlete to exercise harder, to a higher core body temperature without perceiving greater effort. "There are reports of some who dropped dead," she cautioned.

Amantadine, bromocriptine, and to a lesser extent levodopa also increasingly are being used after TBI, but there is little research in athletes. Preliminary interest is growing in using cholinergic augmentation (donepezil, for instance) to treat attention or memory deficits after TBI, Dr. Reardon noted, but not yet in athletes.

Dr. Reardon, Dr. W. Tsushima, and Dr. V. Tsushima said they have no relevant conflicts of interest. Dr. Baron has received financial support from Eli Lilly.