Research Reports - Psychiatric outcomes after pediatric sports-related concussion

J Neurosurg Pediatr. 2015 Sep 11:1-10. [Epub ahead of print]

Ellis MJ(1,)(2,)(3,)(4,)(5,)(6), Ritchie LJ(7,)(4,)(6), Koltek M(8,)(4,)(6),
Hosain S(8,)(4,)(6), Cordingley D(4,)(6), Chu S(2,)(5,)(6), Selci E(2,)(5,)(6),
Leiter J(1,)(4,)(6), Russell K(2,)(5,)(6).

OBJECT The objectives of this study were twofold: 1) to examine the prevalence of
emotional symptoms among children and adolescents with a sports-related
concussion (SRC) who were referred to a multidisciplinary pediatric concussion
program and 2) to examine the prevalence, clinical features, risk factors, and
management of postinjury psychiatric outcomes among those in this clinical
population. METHODS The authors conducted a retrospective chart review of all
patients with SRC referred to a multidisciplinary pediatric concussion program
between September 2013 and October 2014. Clinical assessments carried out by a
single neurosurgeon included clinical history, physical examination, and
Post-Concussion Symptom Scale (PCSS) scoring. Postinjury psychiatric outcomes
were defined as a subjective worsening of symptoms of a preinjury psychiatric
disorder or new and isolated suicidal ideation or diagnosis of a novel
psychiatric disorder (NPD). An NPD was defined as a newly diagnosed psychiatric
disorder that occurred in a patient with or without a lifetime preinjury
psychiatric disorder after a concussion. Clinical resources, therapeutic
interventions, and clinical and return-to-play outcomes are summarized. RESULTS
One hundred seventy-four patients (mean age 14.2 years, 61.5% male) were included
in the study. At least 1 emotional symptom was reported in 49.4% of the patients,
and the median emotional PCSS subscore was 4 (interquartile range 1-8) among
those who reported at least 1 emotional symptom. Overall, 20 (11.5%) of the
patients met the study criteria for a postinjury psychiatric outcome, including
14 patients with an NPD, 2 patients with isolated suicidal ideation, and 4
patients with worsening symptoms of a preinjury psychiatric disorder. Female sex,
a higher initial PCSS score, a higher emotional PCSS subscore, presence of a
preinjury psychiatric history, and presence of a family history of psychiatric
illness were significantly associated with postinjury psychiatric outcomes.
Interventions for patients with postinjury psychiatric outcomes included
pharmacological therapy alone in 2 patients (10%), cognitive behavioral therapy
alone in 4 (20%), multimodal therapy in 9 (45%), and no treatment in 5 (25%).
Overall, 5 (25%) of the patients with postinjury psychiatric disorders were
medically cleared to return to full sports participation, whereas 5 (25%) were
lost to follow-up and 9 (45%) remained in treatment by the multidisciplinary
concussion program at the end of the study period. One patient who was
asymptomatic at the time of initial consultation committed suicide. CONCLUSIONS
Emotional symptoms were commonly reported among pediatric patients with SRC
referred to a multidisciplinary pediatric concussion program. In some cases,
these symptoms contributed to the development of an NPD, isolated suicidal
ideation, and worsening symptoms of a preexisting psychiatric disorder. Future
research is needed to clarify the prevalence, pathophysiology, risk factors, and
evidence-based management of postinjury psychiatric outcomes after pediatric SRC.
Successful management of these patients requires prompt recognition and
multidisciplinary care by experts with clinical training and experience in
concussion and psychiatry. 

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