Early psychological symptoms predict concussion recovery time in middle and high school athletes.

Wilmoth K, Tan A, Tarkenton T, Rossetti HC, Hynan LS, Didehbani N, Miller SM, Bell KR, Cullum CM. J Clin Exp Neuropsychol. 2022 May;44(4):251-257. doi: 10.1080/13803395.2022.2118676. Epub 2022 Sep 8. PMID: 36073744.

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Take-Home Message

Middle school and high school athletes who reported more concussion symptoms and sleep issues, as well as post-traumatic amnesia, had a greater chance of a prolonged recovery than peers without these concerns. Furthermore, depressive symptoms may help identify males at risk for a prolonged recovery.


Concussion recovery is quite variable. Hence, determining risk factors for prolonged recovery is vital to provide appropriate patient care to reduce this risk. Several post-injury risk factors for prolonged recovery have emerged (e.g., emotional symptoms, sleep disturbance). However, these factors have not been well-established in school-aged athletes. 

Study Goal

The authors analyzed clinical data from middle and high school athletes to examine if post-concussion psychological factors and sleep symptoms predict prolonged recovery.


The authors recruited 393 middle school and high school students (~15 years of age; 45% female) to complete 3 surveys within 14 days of injury (~6 days post injury), which is part of a larger study through Con Tex. Students completed the 3 questionnaires during their clinical evaluation: 1. Generalized Anxiety Disorder 7-item Scale (GAD-7), which screened for anxiety; 2. The Patient Questionnaire 8-item Depression Scale (PHQ-8) to assess for depression; and 3. The Pittsburg Sleep Quality Index (PSQI) to evaluate sleep quality. The authors found the provider-documented date of symptom resolution via a medical record review.


Overall, 17% (n=66) took more than 30 days to recover. The authors found that post-traumatic amnesia, worse concussion signs and symptoms scores, and worse sleep quality predicted longer concussion recovery. Among females, only more severe concussion symptoms predicted a prolonged recovery. In contrast, among males, greater depression and post-traumatic amnesia related to prolonged recovery.


Someone with more severe symptoms or poor sleep quality within the first 2 weeks after a concussion may be more likely to experience a prolonged concussion recovery. However, the authors found that when they considered sex, there were different predictors. Females with greater symptom severity were more likely to have a prolonged recovery. At the same time, males were more likely to have a prolonged recovery if they had worse depression symptoms or post-traumatic amnesia. It is worth noting that though sleep, anxiety, and depressive symptoms were predictors, the overall scores were low, indicating they probably were not experiencing high levels of anxiety, depression, or sleep disorders.

Clinical Implications

Medical professionals should screen patients after a concussion for signs of anxiety, depression, or sleep disorders because even subtle signs may increase the chance of a prolonged recovery. These assessments may help identify problems early and lead to a more targeted concussion management plan.

Questions for Discussion

Have you noted any specific predictors associated with your athlete’s recovery? How do you work concussion risk into your concussion education/management/baseline protocol?

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  3. Typical vs Prolonged Recovery Time and Predictors Following Concussion in High School and College Athletes
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Written by: Jane McDevitt
Reviewed by: Jeffrey Driban

Evidence-Based Assessment of Concussion Course - 5 EBP CEUs