Pre-injury psychological history or diagnosis of a psychiatric disorder is a predictor of persistent symptoms following mTBI/concussion.44, 45, 62, 64, 261 Additionally, people with high burden of adverse childhood experiences (ACE) (i.e. significant traumatic or stressful events) are more likely to experience mTBI/concussion and risk of mental health and mood problems which may effect recovery.262
People experiencing prolonged symptoms following mTBI/concussion are at an increased risk of developing new or worsening mental health symptoms. Psychological distress following mTBI/concussion can occur even without a premorbid psychological history. Psychological distress is associated with other complaints including subjective cognitive symptoms.263
The burden of mental health problems, whether caused by the mTBI/concussion or not, can be a barrier to recovery. Identification and treatment of mood and mental health problems (including patient education) facilitate recovery and return to work following a mTBI/concussion.264, 265 Identification of a high burden of adverse childhood experiences or presence of attachment disorders has important treatment implications that may require more specialized psychological interventions when symptoms persist.
Disturbances in mood, cognition, and behaviour are commonly experienced following injury and may signal the presence of a mental health disorder. Pre-existing mental health conditions and symptoms with post-injury onset are predictive of persisting post-concussive symptomatology.43, 44, 266, 267
Box F: Mental health disorders – Adjustment disorders
– Behavioural changes (e.g. lability, irritability)
– Anxiety disorders
– Mood disorders– Post-traumatic stress disorder and other trauma and stressor-related disorders
– Alcohol and substance use disorders
-Somatoform disordersSource: Adapted from Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023. EBR (conditional)43, 56, 58, 60, 62 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.
43. Cnossen MC, Winkler EA, Yue JK, Okonkwo DO, Valadka AB, Steyerberg EW, et al. Development of a Prediction Model for Post-Concussive Symptoms following Mild Traumatic Brain Injury: A TRACK-TBI Pilot Study. J Neurotrauma. 2017;34(16):2396-409. doi: 10.1089/neu.2016.4819.
56. Madhok DY, Yue JK, Sun X, Suen CG, Coss NA, Jain S, et al. Clinical predictors of 3- and 6-month outcome for mild traumatic brain injury patients with a negative head CT scan in the emergency department: A TRACK-TBI pilot study. Brain Sci. 2020;10(5). doi: 10.3390/brainsci10050269.
58. Ponsford J, Cameron P, Fitzgerald M, Grant M, Mikocka-Walus A, Schonberger M. Predictors of postconcussive symptoms 3 months after mild traumatic brain injury. Neuropsychology. 2012;26(3):304-13. doi: 10.1037/a0027888.
60. Silverberg ND, Gardner AJ, Brubacher JR, Panenka WJ, Li JJ, Iverson GL. Systematic review of multivariable prognostic models for mild traumatic brain injury. J Neurotrauma. 2015;32(8):517-26. doi: 10.1089/neu.2014.3600.
62. Yue JK, Cnossen MC, Winkler EA, Deng H, Phelps RRL, Coss NA, et al. Pre-injury Comorbidities Are Associated With Functional Impairment and Post-concussive Symptoms at 3- and 6-Months After Mild Traumatic Brain Injury: A TRACK-TBI Study. Front Neurol. 2019;10:343. doi: 10.3389/fneur.2019.00343.Adapted29 EBR (strong)45, 56, 62, 166, 167, 267-280 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.]
45. Campbell-Sills L, Jain S, Sun X, Fisher LB, Agtarap
SD, Dikmen S, et al. Risk factors for suicidal ideation following mild
traumatic brain injury: A TRACK-TBI study. J Head Trauma Rehabil.
2021;36(1):E30-E9. doi: 10.1097/HTR.0000000000000602.
56. Madhok DY, Yue JK, Sun X, Suen CG, Coss NA, Jain S, et al. Clinical predictors of 3- and 6-month outcome for mild traumatic brain injury patients with a negative head CT scan in the emergency department: A TRACK-TBI pilot study. Brain Sci. 2020;10(5). doi: 10.3390/brainsci10050269.
62. Yue JK, Cnossen MC, Winkler EA, Deng H, Phelps RRL, Coss NA, et al. Pre-injury Comorbidities Are Associated With Functional
166. Teymoori A, Gorbunova A, Haghish FE, Real R, Zeldovich M, Wu YJ, et al. Factorial Structure and Validity of Depression (PHQ-9) and Anxiety (GAD-7) Scales after Traumatic Brain Injury. J Clin Med. 2020;9(3). doi: 10.3390/jcm9030873.Impairment and Post-concussive Symptoms at 3- and 6-Months After Mild Traumatic Brain Injury: A TRACK-TBI Study. Front Neurol. 2019;10:343. doi: 10.3389/fneur.2019.00343.
167. Donders J, Pendery A. Clinical Utility of the Patient Health Questionnaire-9 in the Assessment of Major Depression After Broad-Spectrum Traumatic Brain Injury. Arch Phys Med Rehabil. 2017;98(12):2514-9. doi: 10.1016/j.apmr.2017.05.019.
267. Hellewell SC, Beaton CS, Welton T, Grieve SM. Characterizing the risk of depression following mild traumatic brain injury: a meta-analysis of the literature comparing chronic mTBI to non-mTBI populations. Front Neurol. 2020;11:350. doi: 10.3389/fneur.2020.00350.
268. Bryan CJ, Clemans TA, Hernandez AM, Rudd MD. Loss of consciousness, depression, posttraumatic stress disorder, and suicide risk among deployed military personnel with mild traumatic brain injury. J Head Trauma Rehabil. 2013;28(1):13-20. doi: 10.1097/HTR.0b013e31826c73cc.
269. Haarbauer-Krupa J, Taylor CA, Yue JK, Winkler EA, Pirracchio R, Cooper SR, et al. Screening for post-traumatic stress disorder in a civilian emergency department population with traumatic brain injury. J Neurotrauma. 2017;34(1):50-8. doi: 10.1089/neu.2015.4158.
270. Chang HK, Hsu JW, Wu JC, Huang KL, Chang HC, Bai YM, et al. Risk of attempted suicide among adolescents and young adults with traumatic brain injury: A nationwide longitudinal study. J Affect Disord. 2019;250:21-5. doi: 10.1016/j.jad.2019.02.059.
271. Donders J, Darland K. Psychometric properties and correlates of the PHQ-2 and PHQ-9 after traumatic brain injury. Brain Inj. 2017;31(13-14):1871-5. doi: 10.1080/02699052.2017.1334962.
272. Karr JE, Iverson GL, Huang SJ, Silverberg ND, Yang CC. Perceived Change in Physical, Cognitive, and Emotional Symptoms after Mild Traumatic Brain Injury in Patients with Pre-Injury Anxiety or Depression. J Neurotrauma. 2020;37(10):1183-9. doi: 10.1089/neu.2019.6834.
273. Langer LK, Alavinia SM, Lawrence DW, Munce SEP, Kam A, Tam A, et al. Prediction of risk of prolonged post-concussion symptoms: Derivation and validation of the TRICORDRR (Toronto Rehabilitation Institute Concussion Outcome Determination and Rehab Recommendations) score. PLoS Med. 2021;18(7):e1003652. doi: 10.1371/journal.pmed.1003652.
274. Brett BL, Kramer MD, Whyte J, McCrea MA, Stein MB, Giacino JT, et al. Latent profile analysis of neuropsychiatric symptoms and cognitive function of adults 2 weeks after traumatic brain injury: Findings from the TRACK-TBI Study. JAMA Netw Open. 2021;4(3):e213467. doi: 10.1001/jamanetworkopen.2021.3467.
275. Doroszkiewicz C, Gold D, Green R, Tartaglia MC, Ma J, Tator CH. Anxiety, depression, and quality of life: a long-term follow-up study of patients with persisting concussion symptoms. J Neurotrauma. 2021;38(4):493-505. doi: 10.1089/neu.2020.7313.
276. Moriarty H, Robinson KM, Winter L. The additional burden of PTSD on functioning and depression in veterans with traumatic brain injury. Nurs Outlook. 2021;69(2):167-81. doi: 10.1016/j.outlook.2020.11.003.
277. Popov N, Mercier LJ, King R, Fung T, Debert CT. Factors associated with quality of life in adults with persistent post-concussion symptoms. Can J Neurol Sci. 2022;49(1):109-17. doi: 10.1017/cjn.2021.53.
278. Ramanathan-Elion DM, Baydoun HA, Johnstone B. Psychological predictors of functional outcomes in service members with traumatic brain injury. Brain Inj. 2020;34(9):1183-92. doi: 10.1080/02699052.2020.1793387.
279. Vikane E, Froyland K, Naess HL, Assmus J, Skouen JS. Predictors for psychological distress 2 months after mild traumatic brain injury. Front Neurol. 2019;10:639. doi: 10.3389/fneur.2019.00639.
280. Zachar-Tirado CN, Donders J. Clinical utility of the GAD-7 in identifying anxiety disorders after traumatic brain injury. Brain Inj. 2021;35(6):655-60. doi: 10.1080/02699052.2021.1895315.Adapted29 Assessment tools include:
– Beck Depression Inventory
– Depression self-report questionnaire
– Hamilton Depression Rating Scale
– Health of the Nation Outcomes Scales
– Hospital Anxiety and Depression Scale
– Self report measure of anxiety
– GAD-7
– Kessler Psychological Distress Scale (K10)
– The PTSD checklist for DSM-5 (PCL-5)
– International trauma questionnaire for PTSD
– Bipolar self test
Tools for the assessment of children include:
– Post-Concussion Mental Health Considerations Algorithm
– Management of Prolonged Mental Health Disorders Algorithm
– Strength and difficulties questionnaire
– Self report measure of anxiety GAD-7
– Patient Health Questionnaire 9Clinical Practice Guidelines
– RANZCP Mood disorders
– RANZCP Anxiety disorders
– RANZCP Post-traumatic stress disorder
There is no current evidence to indicate that the mental health problems of individuals who have suffered a mTBI/concussion should be treated any differently than mental health problems of other aetiologies. mTBI/concussion diagnosis should not delay appropriate management and treatment. As such, pharmacological and nonpharmacological interventions including therapeutic interventions that have been found to be helpful in the general population should be considered for individuals who have developed mental health problems post-concussion.
Non-pharmacological treatments
Psychotherapeutic interventions are generally considered the first-line treatment for mood disorders of mild severity. Cognitive behavioural therapy (CBT) has well-established efficacy for the treatment of mood, anxiety, and trauma and stressor-related disorders.281-286 It has been shown to be efficacious in individuals with TBI when both depression and anxiety are addressed together.287 CBT has been shown to be effectively delivered across various modalities, such as telehealth virtual psychotherapy.288, 289 Remote delivery of CBT may promote retention due to its accessibility and flexibility. Related psychotherapeutic modalities such as cognitive processing therapy, trauma-focused therapy and mindfulness-based interventions may also promote positive outcomes among people with mTBI/concussion.290, 291
EBR (strong)281 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.]
281. Kennedy SH, Lam RW, McIntyre RS, Tourjman SV, Bhat V, Blier P, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 3. Pharmacological Treatments. Can J Psychiatry. 2016;61(9):540-60. doi: 10.1177/0706743716659417.Adapted29 EBR (conditional)187, 282, 283, 289, 291-296 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.]
187. Rytter HM, Graff HJ, Henriksen HK, Aaen N, Hartvigsen J, Hoegh M, et al. Nonpharmacological Treatment of Persistent Postconcussion Symptoms in Adults: A Systematic Review and Meta-analysis and Guideline Recommendation. JAMA Netw Open. 2021;4(11):e2132221. doi: 10.1001/jamanetworkopen.2021.32221.
282. Little A, Byrne C, Coetzer R. The effectiveness of cognitive behaviour therapy for reducing anxiety symptoms following traumatic brain injury: A meta-analysis and systematic review. NeuroRehabilitation. 2021;48(1):67-82. doi: 10.3233/NRE-201544.
283. Mikolic A, Polinder S, Retel Helmrich IRA, Haagsma JA, Cnossen MC. Treatment for posttraumatic stress disorder in patients with a history of traumatic brain injury: A systematic review. Clin Psychol Rev. 2019;73:101776. doi: 10.1016/j.cpr.2019.101776.
289. Jak AJ, Jurick S, Crocker LD, Sanderson-Cimino M, Aupperle R, Rodgers CS, et al. SMART-CPT for veterans with comorbid post-traumatic stress disorder and history of traumatic brain injury: a randomised controlled trial. J Neurol Neurosurg Psychiatry. 2019;90(3):333-41. doi: 10.1136/jnnp-2018-319315.
291. Ackland PE, Greer N, Sayer NA, Spoont MR, Taylor BC, MacDonald R, et al. Effectiveness and harms of mental health treatments in service members and veterans with deployment-related mild traumatic brain injury. J Affect Disord. 2019;252:493-501. doi: 10.1016/j.jad.2019.04.066.
292. Bedard M, Felteau M, Marshall S, Cullen N, Gibbons C, Dubois S, et al. Mindfulness-based cognitive therapy reduces symptoms of depression in people with a traumatic brain injury: results from a randomized controlled trial. J Head Trauma Rehabil. 2014;29(4):E13-22. doi: 10.1097/HTR.0b013e3182a615a0.
293. Kreutzer JS, Marwitz JH, Sima AP, Mills A, Hsu NH, Lukow HR, 2nd. Efficacy of the resilience and adjustment intervention after traumatic brain injury: a randomized controlled trial. Brain Inj. 2018;32(8):963-71. doi: 10.1080/02699052.2018.1468577.
294. Novakovic-Agopian T, Posecion L, Kornblith E, Abrams G, McQuaid JR, Neylan TC, et al. Goal-oriented attention self-regulation training improves executive functioning in veterans with post-traumatic stress disorder and mild traumatic brain injury. J Neurotrauma. 2021;38(5):582-92. doi: 10.1089/neu.2019.6806.
295. Thomas RE, Alves J, Vaska Mlis MM, Magalhaes R. Therapy and rehabilitation of mild brain injury/concussion: Systematic review. Restor Neurol Neurosci. 2017;35(6):643-66. doi: 10.3233/RNN-170761.
296. Silverberg ND, Cairncross M, Brasher PMA, Vranceanu AM, Snell DL, Yeates KO, et al. Feasibility of concussion rehabilitation approaches tailored to psychological coping styles: a Randomized Controlled Trial. Arch Phys Med Rehabil. 2022;103(8):1565-73 e2. doi: 10.1016/j.apmr.2021.12.005.Adapted29 EBR (conditional)290,297 29. Marshall S, Lithopoulos A, Curran D, Fischer L, Velikonja D, Bayley M. Living concussion guidelines: Guideline for concussion and prolonged symptoms for adults 18 years or older 2023 [Available from: https://concussionsontario.org.]
290. Acabchuk RL, Brisson JM, Park CL, Babbott-Bryan N, Parmelee OA, Johnson BT. Therapeutic effects of meditation, yoga, and mindfulness-based interventions for chronic symptoms of mild traumatic brain injury: A systematic review and meta-analysis. Appl Psychol Health Well Being. 2021;13(1):34-62. doi: 10.1111/aphw.12244.
297. Shirvani S, Davoudi M, Shirvani M, Koleini P, Hojat Panah S, Shoshtari F, et al. Comparison of the effects of transcranial direct current stimulation and mindfulness-based stress reduction on mental fatigue, quality of life and aggression in mild traumatic brain injury patients: a randomized clinical trial. Ann Gen Psychiatry. 2021;20(1):33. doi: 10.1186/s12991-021-00355-1.Adopted29
Pharmacological treatments
Pharmacological treatment should commence if symptoms are persisting, rather than in the acute phase as experiencing mental ill health may be reactionary following mTBI.
N/A New
Treatment of mental health conditions may be conducted in primary care or the person may be referred for more specialised mental health care if needed.
For children, referral to a local mental health professional with experience in the care of children or specialist with experience in paediatric mental health is a consideration if mental health symptoms are prolonged or urgent.
CBR 30. Zemek R, Reed N, Dawson J, Ledoux AA. Living guideline for pediatric concussion care 2023 [Available from: www.pedsconcussion.com; https://doi.org/10.17605/OSF.IO/3VWN9. Adapted30
Further Australian resources to aid the assessment and management of mental health conditions is available from beyondblue, the Black Dog Institute, Headspace and the RACGP. Links are also provided in Box F.