Frequency of Concussion Exposure Modulates Suicidal Ideation, Planning, and Attempts Among U.S. High School Students
Kay JJM, Coffman CA, Tavakoli AS, Torres-McGehee TM, Broglio SP, Moore RD. J Athl Training. 2022 doi: 10.10.4085/1062-6050-0117.22. Epub ahead of print.
Take-Home Message
High school students who reported a sport- and recreation-related concussion in the past 12 months were more likely to report depressive symptoms and suicidal ideation than those who did not. Students who reported multiple concussions in the past 12 months were about twice as likely to report attempting suicide than those who reported a single concussion.
Background
A history of repetitive concussions may increase the risk of adverse mental health outcomes, including suicidal ideation, the second leading cause of death in adolescents in the United States. However, we lack evidence to inform clinical practice about this risk in adolescents and whether the risk differs among males and females.
Study Goal
Kay and colleagues completed a retrospective cross-sectional study to examine the association between concussion frequency and suicidal ideation or behavior among biological males and females.
Methods
The researchers used data from the National Youth Risk Behavior Surveillance System to explore this question. The survey was administered in 2017 and 2019 to students in 9th through 12th grade in both private and public schools. The authors summarized the self-reported sports- or recreation-related concussion history responses as 1) no history, 2) a single concussion, or 3) multiple concussions. The survey included five yes/no questions regarding mental health: 1) feeling sadness/hopelessness, 2) suicidal ideation, 3) suicidal planning, 4) suicide attempts, and 5) injurious suicide attempts. The timeframe for all variables was “within the last 12 months.”
Results
Fifteen percent of respondents reported at least one concussion in the last 12 months. A larger proportion of female respondents reported yes to each mental health question. The authors observed an overall relationship between concussion history and the chance of reporting feelings of depression, suicidal ideation, and behaviors. Respondents who reported multiple concussions in the past 12 months were about twice as likely to report attempting suicide than those who reported a single concussion. While this finding occurred among males and females, this association was stronger in males.
Viewpoints
Interestingly, the authors found that a high school student who reports a history of concussion in the prior year could be more likely to report adverse mental health outcomes. However, they also observed that when a person sustains multiple concussions, they may be at even greater risk for attempting suicide. However, this data comes from a cross-sectional survey. Hence, it is impossible to know the timing of these adverse mental health outcomes. Could they precede the concussion and cause someone to take more risks and experience more concussions? Is this an acute or chronic outcome that develops after concussions, or a vicious cycle where a concussion causes adverse mental health outcomes that increases their risk for another concussion and worse outcomes that manifest as attempting suicide? This information will be essential to understand to help inform prevention strategies. Hopefully, this study encourages future longitudinal research that can assess the timing of events and the impact of multiple concussions. Future research could also explore the role of concussion severity concerning mental health outcomes.
Clinical Implications
Clinicians should recognize that even a single concussion could be related to negative mental health outcomes within 12 months. Clinicians should monitor mental health outcomes after a concussion and educate family members about recognizing changes to a patient’s mental health status.
Questions for Discussion
How do you currently discuss or monitor a patient’s mental health following a concussion? Is there anything you would consider changing in your clinical practice considering the findings of this study?
Written by Kyle Harris
Reviewed by Jeffrey Driban
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Should it be implemented in practice to screen athletes for suicidal thoughts and ideation in pre-participation physicals not only for general mental health concerns but also part of concussion screening?
Yes, ideally, someone would be screened during their pre-participation physical and after an injury.
If a clinician finds that a patient has a high concern for depression or already has the diagnosis, had previous concussions, and participates in a sport with a high risk of concussions, is there a line that needs to be drawn to mitigate the risk of suicidal attempts/ideation?
I think many people forget about the mental health aspect of health. Having more athletic trainers partake in these discussions with their athletes will normalize mental health conversation and make it more integral to the return to play protocol, so athletes feel physically, mentally, and psychologically fit to return to sport. A concussion can take a significant toll on a patient’s physical and mental health, as it removes a significant portion of their social and societal roles when healing. A concussion’s primary treatment is to essentially do nothing so your brain doesn’t get more stressed, which can also take a significant impact on individuals.
Using this information, I would take more care to monitor an athlete’s mental health while they are healing physically. Being able to monitor any suicidal ideation or increases in anxiety and depression can make the difference when these athletes are being put under high pressure environments constantly.
Mental health should be a more discussed topic when it comes to sport and injury in sport. In school we talk about depression and anxiety and what to look for, but we rarely talk about depression and anxiety when an athlete sustains an injury. Not only do athletes have to physically deal with a musculoskeletal injury, for example, but they also have to endure the mental aspect of the injury as well. They always wonder “Am I going to get better?” “Am I going to be as good as I was before?” “How am I going to get through this?”. This is the biggest consequence of an injury as the athlete feels as if they are alone and no one can relate to them. Mental health in sport should not be taboo to talk about. Mental health and physical health go hand in hand, and athletes should not feel afraid to talk about their feelings like they are not afraid to talk about their broken leg. Schools and sport clubs should have resources readily available for the players and their parents of what they should look for post-concussion and how they can help moving forward. If athletes, parents, and coaches are all educated on the mental health side of a concussion, they will all know what to look for, red flags, and how to assist their friend/family when they are in need. Mental health is not a burden and athletics should not make any athlete feel that way.
Mental health is such an important aspect of our wellness and it is often overlooked, especially in athletics. When it comes to concussions, the findings of this article were completely new to me and very alarming. Since I am not practicing in clinic, I have only observed bits and pieces of a concussion RTP protocol. In my limited observation, I have not seen mental health be a discussion or major consideration in this protocol. The primary way I have seen mental health addressed with any type of injury is through continued involvement with the team. Allowing the athlete to participate as much as they can in team activities is the only mental health-specific aspect of concussion RTP protocol that I have experienced.
I also personally have not previously thought of mental health when it comes specifically to concussions. However, after reading the findings from this article, it will be a major consideration for me as I get more clinical experience. In addition to involving the athletes with the team, I will make a point to check in with currently concussed athletes or those who have previously experienced a concussion and see how they are doing as far as their mental health. I also think that getting a mental health professional involved in these situations may be appropriate if the athlete is comfortable with that option. While I am not sure all the ways in which I will practically be able to implement these findings into my clinical practice, I will be sure to discuss this very important topic with my preceptors in the near future.
This is a very prevalent and growing topic that athletic trainers should address. As mentioned, it would be great to understand when these depressive and suicidal feelings are strongly present (after the initial concussion, weeks after the concussion, etc.). However, this information is not extremely surprising since it has been found that athletes typically experience depressive or suicidal episodes following a detrimental injury that takes them out. It would be interesting to see how concussions compare to other common sports injuries in regards to the level of depression/suicidal thoughts/ideation that an athlete may experience post-injury.
Regardless, this is something that should be addressed. Athletes should be monitored and assessed for their mental health upon their return to play to make sure their goals and intentions are understood and acknowledged properly.
I think mental health is often something that is forgotten or there is not a great enough emphasis placed on this. Throughout recent times, I think there has become a greater attention placed on this aspect of athlete’s health, however, it can always be greater. Athletes, especially those in high school, have many different stressors and causes of stress in their lives. I found this study’s results fascinating, however, not as surprising as I would have thought. Research has been looking into concussions and post-concussion care for a very long time. I would like to implement and look at more studies that involve a return to play protocol that has a greater emphasis on mental health. The questions that are often seen are “what symptoms are you experiencing” and there are many steps to get the athlete back symptom free, however, like I stated before I think it would be very beneficial to implement a better practice of a RTP guidelines that focus solely on the athlete’s mental health. Also, monitor and track the health of this athlete for longer that RTP protocols normally look at.
Mental health in relation to concussions is a topic I feel not enough people who interact with the athletes are aware of. The article discusses taking an interest not only in athletes with multiple SRRCs but the occurrence of different risk behaviors or thoughts amongst males vs females. This difference is important to note; multiple SRRCs will present different mental health concerns for different populations and to be aware of these differences. This is an important topic not only amongst the sports medicine staff but anyone who interacts with the athletes. Often times people involved in the sports medicine team such as athletic trainers, do not know the athlete well enough or see them enough, to be aware of altered behavior. Coaches and teammates should be made aware at the beginning of every season the dangers of concussions. Education about concussions should not stop at the physical effects but also should encompass mental and psychological concerns.
Mental health in relation to a concussion is a topic I feel not enough people who interact with athletes are aware of. The article discusses taking an interest not only in athletes with multiple concussions but the occurrence of different risk behaviors or thoughts amongst females vs males. This difference is important to note; multiple concussions will present different mental health concerns for different populations and to be aware of these differences. This is an important topic not only amongst the sports medicine team but anyone who interacts with the athlete. Often times people involved in the sports medicine team such as athletic trainers, do not interact with athletes enough to be aware of altered behavior. Coaches and teammates should be made aware at the beginning of every season the dangers of concussions. Education about concussion should not stop at physical effects but should also encompass mental and psychological concerns.