Psychiatric Treatment of the Concussed Athlete

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1 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:

2 Disclosures of Poten7al Conflicts Source Research Funding Advisor/ Consultant Employee Speaker Bureau Books, Intellect. Property In-kind Services (example: travel) Stock or Equity > $10,000 Honorarium or expenses for this presentation or meeting None

3 Today My interest Importance Epidemiology Defini7ons Evalua7on Neuropsychiatric complica7ons Treatment

4 My Interest Spring Training 2005

5 Evidence Mounts Linking Head Hits To Permanent Brain Injury -December 03, 2012 Concussions May Be More Severe in Girls and Young Athletes... May 10 th, 2012 Concussions may cause lingering mental anguish May 14 th, 2014 Did multiple concussions lead to OSU football player s suicide? 12/1/2014

6 Post Concussive Symptoms CogniOve Symptoms Fogginess Difficulty concentra7ng Memory deficits Cogni7ve Fa7gue Sleep AlteraOons Difficulty falling asleep Fragmented sleep Too much/too lijle sleep Headaches (up to 78%) Dizziness (up to 50%) Visual changes Light/Sound Sensi7vity Mood DisrupOon Irritability Feeling sad Anxiety SomaOc Symptoms

7 Post Concussive Syndrome Defined by the World Health Organization. ICD-10 Classification of Mental and Behavioral Disorders: Clinical Descriptions and Diagnositic Guidelines Defined by the Diagnositic and Statistical Manual of Mental Disorders (DSM-5) Major or mild neurocognitive disorder due to traumatic brain injury.

8 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.

9 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 Obsessive compulsive disorder Personality changes Alzheimer s disease ADHD Mania (1-10%) Stress Disorders Apathy (10%) Psychosis

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

11 Depression

12 Suicide

13 Clinical Prac7ce 1. Prior mental illness- exacerba7on ADHD, Anxiety, Depression, PTSD 2. Immediate psychiatric symptoms Anxiety, ADHD, Depression 3. Prolonged recovery adjustment Depression, Anxiety

14 Risk Factors for Protracted Recovery Pre- exis7ng learning disability ADHD Psychiatric illness Younger age Prior concussive injury Amnesia Chronic headaches or migranes Over- exerters

15 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

16 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

17 Treatment

18 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

19 Accommoda7ons Academic- 504 plan in school can include: Shortened day Adjusted class schedule Breaks Sea7ng changes Extra 7me School counseling Progress reports Quiet areas Excused ac7vi7es Academic support Etc

20 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

21 Relaxa7on Deep breathing Progressive muscle relaxa7on Calming visualiza7on Medita7on Etc.

22 CogniOve Behavioral Therapy Tiersky, LA. et al., 2005 Therapy 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

23 Cogni7ve Behavioral Therapy

24 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)

25 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

26 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

27 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

28 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

29 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

30 Case Example 14 year old female 8 th 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

31 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

32 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

33 Alexander S. Strauss, MD Centra, P.C. E- MAIL:

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