Psychiatric  Treatment  of  the  Concussed  Athlete  

American  Osteopathic  Academy  of  Sports  Medicine  2015  Annual  Conference  

Alexander  S.  Strauss,  MD    Centra,  P.C.  Marlton,  NJ  

Clinical  Assistant  Professor,  Rutgers  RWJ  

E-­‐MAIL:  DRSTRAUSS@ALEXSTRAUSSMD.COM  

Disclosures  of  Poten7al  Conflicts  Source Research

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Today  •  My  interest  

•  Importance  

•  Epidemiology    

•  Defini7ons  •  Evalua7on  •  Neuropsychiatric  complica7ons  

•  Treatment  

My  Interest  Spring  Training  2005  

Concussions May Be More Severe in Girls and Young Athletes ... – May 10th, 2012

Evidence Mounts Linking Head Hits To Permanent Brain Injury -December 03, 2012

Concussions may cause lingering mental anguish – May 14th, 2014

Did multiple concussions lead to OSU football player’s suicide? – 12/1/2014

Post  Concussive  Symptoms  

•  CogniOve  Symptoms  • “Fogginess”  • Difficulty  concentra7ng  • Memory  deficits  • Cogni7ve  Fa7gue  

•  Sleep  AlteraOons  • Difficulty  falling  asleep  • Fragmented  sleep  • Too  much/too  liJle  sleep    

•  SomaOc  Symptoms  

• Headaches  (up  to  78%)  • Dizziness  (up  to  50%)  • Visual  changes    • Light/Sound  Sensi7vity  

•  Mood  DisrupOon  • Irritability  • Feeling  sad  • Anxiety  

Defined by the World Health Organization. ICD-10 Classification of Mental and Behavioral Disorders: Clinical Descriptions and Diagnositic Guidelines. 1992.

Defined by the Diagnositic and Statistical Manual of Mental Disorders (DSM-5) – Major or mild neurocognitive disorder due to traumatic brain injury.

Post  Concussive  Syndrome  

Postconcussive  Syndrome-­‐  ICD-­‐10  •  A.  History  of  head  trauma…  preceding  symptom  onset  by  a  maximum  of  4  weeks.    

•  B.  Symptoms  in  3  or  more  of  the  following  symptom  categories:    –  Headache,  dizziness,  malaise,  faOgue,  noise  intolerance;  

–  Irritability,  depression,  anxiety,  emoOonal  lability;  –  SubjecOve  concentraOon,  memory  or  intellectual  difficulOes  

without  neuropsychological  evidence  of  marked  impairment;  

–  Insomnia;  –  Reduced  alcohol  tolerance;  –  May  be  accompanied  by  a  preoccupaOon  with  above  symptoms,  

fear  of  brain  damage  with  hypochondriacal  concern  and  adopOon  of  sick  role  

ICD-10 .

Neuropsychiatric  Complica7ons  •  Cogni7ve  Deficits  (25-­‐70%)  •  Depression  (25-­‐50%)    •  Anxiety  (10-­‐77%)  •  Sleep  problems  (30-­‐70%)  •  Agita7on  &  Aggression  (~30%)    •  Suicide  (~3x  Incidence)  •  Substance  use  disorders    

•  Psychosis  

•  Obsessive  compulsive  disorder  

•  Personality  changes  •  Alzheimer’s  disease  

•  ADHD  •  Mania  (1-­‐10%)  

•  Stress  Disorders  •  Apathy  (10%)    

–  Mild  TBI  at  12  months  follow  up  22%  developed  a  psychiatric  disorder  that  they  had  never  experienced  before  

–  With  no  past  psychiatric  history  the  adjusted  rela7ve  risk  is  increased  compared  to  no  TBI  

•  Mild  TBI  ARR  =  2.8  (adults)  

•  Mild  TBI  ARR  =  2.03  (children)  

–  Past  psychiatric  history  is  a  significant  predictor  of  psychiatric  illness  

Fann, JR et al., 2004,Brant, RA et al., 2010, Vaishnavi et al., 2009 and Jorge, RE. 2005, Massagli, TL et al., 2004

Depression  

Suicide  

Clinical  Prac7ce  

1. Prior  mental  illness-­‐  exacerba7on    ADHD,  Anxiety,  Depression,  PTSD  

2.  Immediate  psychiatric  symptoms    Anxiety,  ADHD,  Depression  

3. Prolonged  recovery  –  adjustment      Depression,  Anxiety  

Risk  Factors  for  Protracted  Recovery  

•   Pre-­‐exis7ng  learning  disability  •   ADHD  •   Psychiatric  illness  •   Younger  age  •   Prior  concussive  injury  •   Amnesia  •   Chronic  headaches  or  migranes  •   Over-­‐exerters  

Reasons  for  Referral  to  Psych  

•  Exacerba7on  of  prior  mental  illness  •  Complaints  associated  with  mental  illness  

– Post  concussion  symptom  scale  a  score  2  to  3  or  above  (range  0-­‐6)  in  the  following  categories  •  Irritability  •  Sadness  •  Nervousness  •  More  emo7onal  

•  Fa7gue  or  sleep  problems  •  Difficulty  with  concentra7ng  or  remembering    

Less  Clear  Signs  and  Symptoms  

–  Symptoms  don’t  match  exam    •  Over  or  under  repor7ng  of  symptoms  

–  Changes  in  personality    •  Some  become  more  impulsive  others  more  reserved    

–  Low  mo7va7on    •  In  recovery,  in  school  or  outside  of  school  

–  Failures  in  effort    –  Drop  in  grades  –  Hopelessness  –  Avoidance    –  Isola7on  –  Crying  

Treatment  

Educa7on,  Support  &  Guidance  –  Over  10  studies  have  been  completed  

–  Mixed  results  with  regard  to  improvement  in  symptoms  and  func7oning  

–  Overall  support  and  educa7on  appear  to  benefit  pa7ents  –  Reassurance  and  educa7on  may  be  helpful  shortly  aner  

injury  

–  Group  educa7on  and  support  interven7on  and  group  CBT  decreased  postconcussive  symptoms  compared  to  wait  list  

Comper DP. et al., 2005 and Snell DL et al., 2009

Accommoda7ons  

•  Shortened  day  •  Adjusted  class  schedule  •  Breaks  •  Sea7ng  changes  •  Extra  7me  •  School  counseling  

•  Progress  reports  •  Quiet  areas  •  Excused  ac7vi7es  •  Academic  support  •  Etc…  

Academic- 504 plan in school can include:

Sleep  hygiene  and  other  techniques  

•  Only  go  to  bed  when  7red  •  Don’t  lie  in  bed  more  than  20  minutes  •  Relax  each  night  before  bed  •  Wake  up  at  the  same  7me  every  morning  

•  Avoid  taking  naps  •  Avoid  any  caffeine  aner  lunch  •  Etc…  

Relaxa7on  

•  Deep  breathing  •  Progressive  muscle  relaxa7on  

•  Calming  visualiza7on  

•  Medita7on  

•  Etc.  

Therapy  CogniOve  Behavioral  Therapy  

• Tiersky,  LA.  et  al.,  2005  –  20  people  with  mild  to  moderate  TBI  –  CBT  +  Cogni7ve  remedia7on  3x  per  week  x  11  weeks  v.  wait  list  controls    

–  Treatment  improved  emo7onal  func7on,  lessened  anxiety  &  depression  

• Trautmann,  et  al.,  2010  and  Powers,  et  al.,2013  –  Studies  looked  at  chronic  headaches    –  Cogni7ve  behavioral  therapy  led  to  improvement  in  headache    

Cogni7ve  Behavioral  Therapy  

http://www.ninjasdontsweat.com/blog/2014/4/23/triangles

Family  and  Family  Therapy  

•  “Group  differences  in  soma7c  symptoms  as  reported  by  parents  were  more  pronounced  among  children  from  families  that  were  higher  func7oning  and  had  more  environmental  resources.”  (Yeates,  K.  et  al.,  2012)  

•  “Mild  TBI  are  associated  with  family  burden  and  distress  more  than  mild  injuries  not  involving  the  head,  although  PCS  may  influence  post  injury  family  burden  and  distress  more  than  the  injury  per  se.”  (Ganesalingam,  K.  et  al.,  2008)  

Medica7ons  

•  No  medica7on  has  FDA  approval  for  the    treatment  of  neuropsychiatric  consequences  of  TBI  

•  Limited  quality  research  mostly  on  adults  

•  Many  different  medica7ons  have  been  used  

Arciniegas DB, et al., 2008

Cogni7ve  Deficits  

•  Methylphenidate  (Ritalin/Concerta)  increases  aJen7on  and  processing  speed,  possibly  mood  as  well  

–  First  line  for  aJen7on  difficul7es    –  Side  effect:  headache,  loss  of  appe7te,  sleep  problems  

•  Amantadine  (Symmetrel)    improving  cogni7on    –  Side  effects:  headache,  depression,  anxiety,  dizzy  

•  Donepezil  (Aricept)  increases  aJen7on  and  memory  –  First  line  for  memory  problems  in  adults  

–  Side  effects:  headache,  insomnia,  nausea  

Vaishnavi, et al, 2009, Lombardi, F. 2008, Leone, H. et al., 2005, Lee, et al., 2005 and Gualtieri et al., 1998

Depression  

•  SSRIs  –Sertraline  (Zolob),  FluoxeOne  (Prozac),  Escitalopram  (Lexapro)  –  Side  effects:  nausea,  headache,  insomnia,  suicidal  thinking  

•  SNRIs  –  Venlafaxine  (Effexor),  DuloxeOne    (Cymbalta)  –  Limited  data  at  this  7me  

•  Bupropion    (Wellbutrin)    –  Cau7on  due  to  increased  seizure  risk  

•  Tricyclic  anOdepressants  (TCAs)  –  Amitriptyline  (Elavil),  Nortriptyline      –  O"en  used  for  headaches  in  low  does.  Generally  for  depression  should  be  avoided  in  those  with  cogni:ve  dysfunc:on  due  to  an:cholinergic  effects  

Disordered  Sleep  •  Melatonin  –    3-­‐9mg  (Over  the  counter)  

–  Helps  with  ini7a7ng  sleep  •  Trazodone    

–  Helps  with  ini7a7ng  sleep  and  maintaining  sleep  –  Side  effects:  Dizzy,  headaches,  priapism  

•  Mirtazapine  (Remeron)    7.5mg  

–  Helps  with  depression  and  sleep  –  Side  effects:  weight  gain,  dry  mouth,  seda7on  

•  Prazosin  –  Helps  with  post-­‐trauma7c  nightmares  

•  Avoid  an7cholinergic  meds  (Benadryl,  ZzzQuil,  etc…)    as    well  as  benzodiazepines    

Vaishnavi et al., 2009

Case  Example  

–  15  year  old  male  freshman  in  high  school  

–  History  of  concussion  and  cleared  for  return  to  play  –  “Re-­‐injury”  with  bumpy  car  ride  

–  Fear  of  another  re-­‐injury  –  Significant  struggles  at  school  and  at  home  

–  Parents  divorced  –  Parent  with  substance  use    –  Not  engaging  with  friends  or  playing  basketball  

Case  Example  

–  14  year  old  female  8th  grader    

–  Soccer  goalie  with  head  injury  of  head  vs.  post  –  Client  with  intense  desire  to  return  to  sport  –  Headaches  won’t  resolve  despite  mul7ple  treatments  

–  Not  par7cipa7ng  in  eye  exercises  at  home  

–  Frustrated  with  lack  of  recovery  –  No  aJending  school  –  Not  seeing  friends  

Case  Example  

–  18  year  old  senior  in  high  school,  skiing  accident  –  Aner  period  of  rest  “unable”  to  return  to  school  –  Prescribed  physical  therapy  did  some    

–  Prescribed  medica7on  took  one  pill,  not  as  prescribed    

–  Con7nued  head  pain  aner  exer7on  and  fa7gue  –  Engaged  in  minimal  therapy  

–  Went  off  to  college  and  refused  an  accommoda7on  or  treatment  plan  

–  Called  in  crisis    a  month  into  school  

Case  Example  

–  19  year  old  college  sophomore,  rugby  injury  

–  Struggles  with  boyfriend  –  Partying  on  most  nights    

–  Failing  out  of  school    –  Success  at  community  college  

–  Returned  to  college  only  to  fail  out  again  –  Suicidal  leading  to  par7al  hospitaliza7on  –  Conflict  with  parents    –  Neuropsych  tes7ng  –  Treatment  for  cogni7ve  concerns  

–  Job  and  school  success    

Alexander  S.  Strauss,  MD    Centra,  P.C.    

E-­‐MAIL:  DRSTRAUSS@ALEXSTRAUSSMD.COM