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. 2025 May-Jun;17(3):498-511.
doi: 10.1177/19417381241255308. Epub 2024 Jun 4.

Association of Premorbid Anxiety and Depression Symptoms in Concussion Recovery in Collegiate Student-Athletes

Sabrina P Sawlani  1 , Joshua T Goldman  1 , Talin Babikian  2 , David L McArthur  3 , Douglas Polster  2 , Michael McCrea  4 , Thomas McAllister  5 , Christopher C Giza  6 ; CARE Consortium; CARE Consortium Investigators; Justus D Ortega  7 , Nicholas Port  8 , Margot Putukian  9 , Jane McDevitt  10 , Christopher C Giza, Joshua T Goldman  11 , Holly J Benjamin  12 , Thomas Buckley, Thomas W Kaminski  13 , James R Clugston  14 , Luis A Feigenbaum  15 , James T Eckner  16 , Jason P Mihalik  17 , Scott Anderson  18 , Christina L Master  19 , Anthony P Kontos  20 , Sara P O Chrisman  21 , Kenneth Cameron  22 , Stefan Duma  23 , Christopher M Miles  24
Affiliations

Association of Premorbid Anxiety and Depression Symptoms in Concussion Recovery in Collegiate Student-Athletes

Sabrina P Sawlani et al. Sports Health. 2025 May-Jun.

Abstract

Background: Mental health disorders are linked to prolonged concussion symptoms. However, the association of premorbid anxiety/depression symptoms with postconcussion return-to-play timelines and total symptom burden is unclear.

Objective: To examine the association of self-reported premorbid anxiety/depression symptoms in collegiate student-athletes with (1) recovery times until asymptomatic, (2) return-to-play, and (3) postconcussion symptom burden.

Study design: Athletes in the Concussion Assessment, Research and Education Consortium completed baseline concussion assessments (Sport Concussion Assessment Tool [SCAT3] and Brief Symptom Inventory-18 [BSI-18]). Athletes were tested postinjury at <6 hours, 24 to 48 hours, time of asymptomatic and start of return-to-play protocol, unrestricted return-to-play, and 6 months after injury. Injured athletes were categorized into 4 groups based on BSI-18 scores: (1) B-ANX, elevated anxiety symptoms only; (2) B-DEP, elevated depression symptoms only; (3) B-ANX&DEP, elevated anxiety and depression symptoms; and (4) B-NEITHER, no elevated anxiety or depression symptoms. Relationship between age, sex, BSI-18 group, SCAT3 total symptom and severity scores, and time to asymptomatic status and return-to-play was assessed with Pearson's chi-squared test and robust analysis of variance.

Level of evidence: Level 3.

Results: Among 1329 athletes with 1352 concussions, no respondents had a self-reported premorbid diagnosis of anxiety/depression. There was no difference in time until asymptomatic or time until return-to-play between BSI-18 groups (P = 0.15 and P = 0.11, respectively). B-ANX, B-DEP, and B-ANX&DEP groups did not have higher total symptom or severity scores postinjury compared with the B-NEITHER group.

Conclusion: Baseline anxiety/depression symptoms in collegiate student-athletes without a mental health diagnosis are not associated with longer recovery times until asymptomatic, longer time to return-to-play, or higher postconcussion total symptom and severity scores compared with athletes without baseline symptoms.

Clinical relevance: Anxiety and depression symptoms without a clear mental health diagnosis should be considered differently from other comorbidities when discussing prolonged recovery in collegiate student-athletes.

Keywords: anxiety; concussion; depression; mental health.

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Conflict of interest statement

The following authors declared potential conflicts of interest: T.W.K. has received royalties from American Psychiatric Association Publishing and honoraria from Harvard Medical School. C.C.G. has received royalties from Blackwell/Wiley, consulting fees from the National Basketball Association (NBA), National Football League (NFL), National Hockey League/National Hockey League Players Association (NHL/NHLPA), and Highmark Interactive, honoraria from Harvard and New York University (NYU), speaker hospitality from Concussion in Sport Group, the National Collegiate Athletic Association (NCAA), the National Acquired Brain Injury Society (NABIS), and Neuro Grand Rounds, and stock options from Highmark Interactive. M.M. has received royalties from Oxford University Press and consulting fees from Neurotrauma Sciences and the Green Bay Packers. C.C.G. holds stock options with Highmark Interactive, and has received funding from National Institutes of Health-National Institute of Neurological Disorders and Stroke (NIH-NINDS) and University of California Los Angeles (UCLA) unrelated to the current work, consulting fees from the NBA, NFL, NHL/NHLPA, and the Los Angeles (LA) Lakers. A.P.K. has received royalties from APA Books, funding from the University of Pittsburgh/Centers for Disease Control and Prevention (CDC), Chuck Noll Foundation for Brain Injury Research, Department of Defense (DoD), NFL, and NIH. J.T.E. has a device patent to the University of Michigan. J.M. has received funding from the CDC, NIH, DoD, National Operating Committee on Standards for Athletic Equipment (NOCSAE), NFL, and Football Research unrelated to the present study.This publication was made possible, in part, with support from the Grand Alliance Concussion Assessment, Research, and Education (CARE) Consortium, funded, in part by the NCAA and the DoD. The United States Army Medical Research Acquisition Activity, 820 Chandler Street, Fort Detrick MD 21702-5014 is the awarding and administering acquisition office. This work was supported by the Office of the Assistant Secretary of Defense for Health Affairs, through the Combat Casualty Care Research Program, endorsed by the DOD, through the Joint Program Committee 6/Combat Casualty Care Research Program - Psychological Health and Traumatic Brain Injury Program under Award No. W81XWH1420151. Opinions, interpretations, conclusions and recommendations are those of the author and are not necessarily endorsed by the DoD.

Figures

Figure 1.
Figure 1.
Consort diagram detailing participant and case inclusion and exclusion criteria. B-ANX, elevated anxiety symptoms only on BSI-18; B-ANX&DEP, elevated anxiety and depression symptoms on BSI-18; B-DEP, elevated depression symptoms only on BSI-18; B-NEITHER, no elevation of anxiety or depression symptoms on baseline BSI-18; BSI-18, Brief Symptom Inventory 18.
Figure 2.
Figure 2.
Sorted proportion of athletes in the 12 most popular sports in the target group, along with proportion of athletes in the excluded group for the same sports (n = 47,397 reports from 34,487 athletes).
Figure 3.
Figure 3.
Time until asymptomatic per BSI group. Violin plots are shown with colored lines connecting the medians (dark gray), averages (blue) and Huber’s robust estimates of the distribution centers (crimson), along with deciles connected by thin gray lines. ANX, anxiety; BSI, Brief Symptom Inventory; DEP, depression.
Figure 4.
Figure 4.
Time to return-to-play per BSI group. ANX, anxiety; BSI, Brief Symptom Inventory; DEP, depression.
Figure 5.
Figure 5.
SCAT3 total symptom score per BSI group at 24 hours postinjury. ANX, anxiety; BSI, Brief Symptom Inventory; DEP, depression; SCAT3, Sport Concussion Assessment Tool.
Figure 6.
Figure 6.
SCAT3 total symptom score per BSI group at 6 months postinjury. ANX, anxiety; BSI, Brief Symptom Inventory; DEP, depression; SCAT3, Sport Concussion Assessment Tool.
Figure 7.
Figure 7.
SCAT3 symptom severity score per BSI group at 24 hours postinjury. ANX, anxiety; BSI, Brief Symptom Inventory; DEP, depression; SCAT3, Sport Concussion Assessment Tool.
Figure 8.
Figure 8.
SCAT3 Symptom Severity Score per BSI Group at 6 months postinjury. ANX, anxiety; BSI, Brief Symptom Inventory; DEP, depression; SCAT3, Sport Concussion Assessment Tool.
See this image and copyright information in PMC

References

    1. Armstrong S, Oomen-Early J. Social connectedness, self-esteem, and depression symptomatology among collegiate athletes versus nonathletes. J Am Coll Health. 2009;57(5):521-526. - PubMed
    1. Asken BM, McCrea MA, Clugston JR, Snyder AR, Houck ZM, Bauer RM. “Playing through it”: delayed reporting and removal from athletic activity after concussion predicts prolonged recovery. J Athl Train. 2016;51(4):329-335. - PMC - PubMed
    1. Baker JG, Leddy JJ, Darling SR, Shucard J, Makdissi M, Willer BS. Gender differences in recovery from sports-related concussion in adolescents. Clin Pediatr (Phila). 2016;55(8):771-775. - PubMed
    1. Barlow KM, Crawford S, Stevenson A, Sandhu SS, Belanger F, Dewey D. Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury. Pediatrics. 2010;126(2):e374-e381. - PubMed
    1. Benton SA, Robertson JM, Tseng WC, Newton FB, Benton SL. Changes in counseling center client problems across 13 years. Prof Psychol Res Pract. 2003:24(1):66-72.