When asked, athletes tend to describe themselves in terms related to the sport of which they play. This is known as athletic identity. When an athlete becomes injured and can no longer participate, a part of that identity is lost.
Losing part of this identity can lead to depression amongst athletes and in conjunction with recovering from a sport-related concussion (SCR), it can lengthen the road to recovery and make it more difficult. Any injury can be challenging for an athlete to deal with; imagine it being “invisible” and leading to isolation. Neurological testing can be done at baseline and post-concussion to aid in rehabilitation or determine predictors. Based on literature reviewed there is a significant decrease in neurophysiological testing in athletes who suffer from depression. Thus, this could indicate a longer return to sport. Clinical implications of prolonged recovery following a SRC and future research suggest a need for more baseline testing for psychological disorders so the rehabilitation can be handled more adequately.
College can already be a stressful enough time for some, let alone adding an injury on top of that. Put yourself in an athletes shoes, having an injury that no one can see or understand, one that affects your activities of daily living, the ability to go to class and participate with your team. Sport-related concussions (SRC) are serious injuries that have no definitive timeline for healing. Not all concussions are reported and it is estimated that 3.8 million concussions occur each year from sports or recreation (Broglio et al., 2014). A concussion occurs when the brain strikes the inside of the skull from rapid head movement. Head contact does not have to occur for this to happen; for example, whiplash can result in a concussion. This injury to the brain results in changes at the cellular level causing neurocognitive disruptions and signs and symptoms such as headaches, dizziness, and memory loss (Broglio et al., 2014). Baseline screening for concussion is vital for returning to sport and can also play an important role in predicting an athlete’s psychological post-concussion symptoms (Vargas, Rabinowitz, Meyer, & Arnett, 2015; Yang, Peek-Asa, Covassin, & Torner, 2015). With a better understanding of the psychological response to a SCR there can be improved management and a potential for a quicker recovery time.
When examining neurocognitive performance depression becomes more evident in comparison to concussion symptoms (Kontos, Covassin, & Parker, 2012). Concussions are a neurological disruption to normal brain activity and psychological symptoms are not a requirement for a diagnosis (Broglio et al., 2014). However, collegiate athletes who have suffered a concussion and were also depressed had decreased memory composite testing in comparison to athletes who were not depressed. A Beck Depression Inventory-Fast Screen can be used as a baseline for depression and is ideal for testing large groups of athletes (Riegler, Guty, & Arnett, 2020). Athletes who have previous history of concussions have reported recurrent anxiety and depression after being deemed medically cleared of a SRC (Weber et al., 2015).
Though depression prior to a concussion can be a predisposing factor to suffering from depression post-concussion, a study performed by Riegler et al. (2020) noted a handful of athletes that were not depressed prior to sustaining a SRC but still reported depression symptoms following the injury (Riegler et al., 2020; Yang et al., 2015). Some predicting factors of suffering from depression after a SRC include, but are not limited to, quality of life and the recovery process (Vargas et al., 2015). It is imperative that psychological symptoms and mood assessments be monitored following a SRC to help recovery so that the symptoms are not being treated by the cause (Kontos et al., 2012; Yang et al., 2015). There is a significant overlap in concussion symptoms and depression. Due to this, following a concussion, it can be difficult to differentiate if an athlete is suffering from post-concussion depression or prolonged concussion symptoms. Ho, Hall, Noseworthy, and DeMatteo (2020) tested two groups of concussed participants, depressed and not depressed adolescents. When looking at ImPACT scores, it could not be distinguished which group the individual was in. Both groups demonstrated sadness and fatigue along with neurocognitive deficits. The distinguishing factors for those with depression were more irritability, increased nervousness, and greater emotionality (Ho et al., 2020). It is important when looking at these results as well to know the athlete’s concussion history because this can influence their results. Athletes with an extensive history of concussions have reported greater anxiety and depression levels (Weber et al., 2018).
A study done by Xie, Tao, Zhang, Tao, and Wu (2019) focused on insufficient physical activity and its effects on depressive symptoms. It did not solely focus on athletes, but it can be paralleled with someone who used to be active and is no longer able to be due to injury. The study revealed that insufficient physical activity had a significant association with depression symptoms (Xie et al., 2019). If this is the effect physical activity has on someone who is not regularly participating with a team, think of how it can affect someone who is. Parallels can also be drawn to military members’ depression after a mild-traumatic brain injury (mTBI). Military service members who had suffered a mTBI, which is similarly to a SRC but with a different method of injury (MOI), had shown significant increases in post-traumatic stress disorder and depression. Many military service members have suffered from mTBI and it is a significant risk factor for cognitive and behavioral disorders to develop later. (Kennedy, Lu, Reid, Leal, & Cooper, 2019). Due to this, the military also performs baseline depression tests. Being physically active alone does not decrease depression symptoms to stand alone, when not having have suffered a SRC. Uglesic et al. (2014) performed a study that established that physically active collegiate males and females had no statistically significant change in depression symptoms following sport activity. (Uglesic et al., 2014).
After suffering from a SRC, athletes who are depressed have significantly decreased neurocognitive test results compared to those who are not depressed (Kontos et al., 2012). It is important to be able to distinguish between symptoms of depression and those of a concussion. Looking at the individual symptoms reported by individuals, there is potential to differentiate between the two diagnoses (Ho et al., 2020)
If athletes are having difficulty with neurocognitive testing it can be hypothesized that there will be a complicated and prolonged return to sport. Neurocognitive testing plays an extremely important role when knowing when to return an athlete to play. As more research is done, it is found that depression plays as large of a role on neurocognitive performance as a concussion alone does (Ho et al., 2020). When considering predisposing factors, it can be predicted which athletes will suffer from greater symptoms post-concussion (Weber et al., 2018).
Athletic trainers, coaches, and athletes should all be aware of what to look for regarding depression symptoms. This can include but is not limited to, anxiety, loss of interest or pleasure in usual activities, mood swings, sleeping more or less than usual, loss of appetite, thoughts of suicide, or even significant weight gain or weight loss. A lot of these symptoms can overlap with symptoms of a concussion as well. It would be beneficial for signs and symptoms check lists to be broadened. This can aide in a correct diagnosis. The sports medicine or athletic team should be aware of the big picture to properly identify a potential issue. This way, when an athlete suffers a concussion or any other injury they can be handled more adequately and help with the rehabilitation process.
Lindsay Scuoteguazza
Head Athletic Trainer
Stoughton High School
References
Broglio, S. P., Cantu, R. C., Gioia, G. A., Guskiewicz, K. M., Kutcher, J., Palm, M., & McLeod, T.C.V. (2014). National Athletic Trainers’ Association position statement: Management of sport concussion. Journal of Athletic Training, 49(2), 245-265. doi: 10.4085/1062-6050-49.1.07
Ho, R. A., Hall, G. B., Noseworthy, M. D., & DeMatteo, C. (2020). Post-concussive depression: Evaluating depressive symptoms following concussion in adolescents and its effects on executive function. Brain Injury, 34(4), 520-527. http://dx.doi.org/10.1080/02699052.2020.1725841
Kennedy, J. E., Lu, L. H., Reid, M. W., Leal, F. O., & Cooper, D. B. (2019). Correlates of depression in U.S. military service members with a history of mild traumatic brain injury. Military Medicine, 184, 148-154. http://dx.doi.org/10.1093/milmed/usy321
Kontos, A. P., Covassin, T., & Parker, T. (2012). Depression and neurocognitive performance after concussion among male and female high school and collegiate athletes. Physical Medicine and Rehabilitation, 93(10), 1751-1756. https://doi.org/10.1016/j.apmr.2012.03.032
Riegler, K. E., Guty, E. T., & Arnett, P. A. (2020). Neuropsychological test performance in depressed and nondepressed college athletes following a concussion. Neuropsychology, 34(1), 63-76. doi: 10.1037/neu0000582
Uglesic, B., Lasic, D., Zuljan-Cvitanovic, M., Bukovic, D., Karelovic, D., Delic-Brkljacic, D., … Radan, M. (2014). Prevalence of depressive symptoms among college students and the influence of sport activity. Collegium Antropologicum, 38(1), 235-239. Retrieved from https://www.collantropol.hr/antropo
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