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Sports concussions leave sneaky side effects

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.