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).
Dr. Claudia L. Reardon
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.