Persistent postconcussion signs or symptoms (PPCS) are tied to a substantially amplified danger of producing subsequent depressive signs and symptoms, new research shows.
Success of a large meta-investigation that integrated 18 studies and more than 9000 individuals confirmed a fourfold higher chance of establishing depressive signs in these with PPCS versus individuals devoid of PPCS.
“In this meta-examination, suffering from PPCS was affiliated with a better danger of encountering depressive signs,” write the investigators, led by Maude Lambert, PhD, of the School of Psychology, University of Ottawa, Ontario, Canada, and Bloorview Exploration Institute, Toronto, Ontario, Canada.
“There are numerous essential scientific and overall health coverage implications of the results. Most notably, the development of techniques for helpful avoidance and earlier intervention to optimize psychological overall health restoration next a concussion must be supported,” they include.
The analyze was published on the net December 27 in JAMA Network Open.
“Crucial Minority”
An “crucial minority” of 15{fc1509ea675b3874d16a3203a98b9a1bd8da61315181db431b4a7ea1394b614e}-30{fc1509ea675b3874d16a3203a98b9a1bd8da61315181db431b4a7ea1394b614e} of individuals with concussion keep on to encounter signs for months, or even yrs, subsequent the injuries, the investigators be aware.
Indications fluctuate, but can include things like problems, tiredness, dizziness, cognitive issues, and psychological modifications, which can “significantly impression an individual’s daily functioning.”
The association amongst PPCS and mental health and fitness outcomes “has emerged as an region of interest” about the past ten years, with numerous experiments pointing to bidirectional associations concerning depressive signs and PPCS, the researchers note. Folks with PPCS are at considerably greater threat of enduring depressive signs and symptoms, and depressive signs or symptoms, in convert, forecast far more prolonged postconcussion recovery, they include.
The authors conducted a preceding scoping assessment that confirmed individuals with PPCS experienced “better psychological overall health troubles than men and women who recovered from concussion or healthy controls.”
But “quantitative summaries assessing the magnitude and character of the association among PPCS and psychological wellbeing outcomes were not conducted,” so they determined to carry out a follow-up meta-examination to corroborate the hypothesis that PPCS might be associated with depressive signs.
The researchers also desired to “look into potential moderators of that affiliation and figure out whether the association amongst depressive signs and symptoms and PPCS differed primarily based on age, intercourse, mental sickness, historical past of concussion, and time due to the fact the injuries.”
This could have “major general public health and fitness implications” as it signifies an “critical action” towards understanding the association amongst PPCS and psychological well being, paving the way for the “development of optimum postconcussion intervention approaches, focusing on helpful avoidance and earlier intervention to enhance recovery trajectories, enhance psychological well being, and endorse very well-remaining next concussion.”
To be integrated in the meta-examination, a study experienced to focus on contributors who had knowledgeable a concussion, diagnosed by a health care experienced, or as labeled by diagnostic actions, and who professional ≥ 1 concussion symptom lasting > 4 months.
There was no explicit higher limit on period, and men and women of all ages were eligible.
Depressive signs or symptoms ended up defined as “an result that should be calculated by a validated and standardized evaluate of melancholy.”
Biopsychosocial Design
Of 580 reports assessed for eligibility, 18 have been bundled in the meta-analysis, incorporating a overall of 9101 individuals, with a median (range) sample dimension of 154 (48 – 4462) members and a signify (SD) participant age of 33.7 (14.4) decades.
The signify length of time considering the fact that the concussion was 21.3 (18.7) weeks. Of the participants, a necessarily mean of 36.1{fc1509ea675b3874d16a3203a98b9a1bd8da61315181db431b4a7ea1394b614e} (11.1{fc1509ea675b3874d16a3203a98b9a1bd8da61315181db431b4a7ea1394b614e}) experienced a historical past of ≥ 2 concussions.
Near to 3 quarters of the reports (72{fc1509ea675b3874d16a3203a98b9a1bd8da61315181db431b4a7ea1394b614e}) utilised a cross-sectional design, with most scientific tests performed in North America, and the remaining conducted in Europe, China, and New Zealand.
The researchers found a “sizeable constructive affiliation” among PPCS and postinjury depressive signs and symptoms (OR, 4.87 95{fc1509ea675b3874d16a3203a98b9a1bd8da61315181db431b4a7ea1394b614e} CI, 3.01 – 7.90 P < .001), "representing a large effect size."
Funnel plot and Egger test analyses “suggested the presence of a publication bias.” However, even after accounting for publication bias, the effect size “of large magnitude” remained, the authors report (OR, 4.56 95{fc1509ea675b3874d16a3203a98b9a1bd8da61315181db431b4a7ea1394b614e} CI, 2.82 – 7.37 P < .001).
No significant moderators were identified, “likely due to the small number of studies included,” they speculate.
They note that the current study “does not allow inference about the causal directionality of the association” between PPCS and postinjury depressive symptoms, so the question remains: Do PPCS induce depressive symptoms, or do depressive symptoms induce PPCS?”
Despite this unanswered question, the findings still have important clinical and public health implications, highlighting “the need for a greater understanding of the mechanisms of development and etiology of depressive symptoms postconcussion” and emphasizing “the necessary emergence for timely and effective treatment interventions for depressive symptoms to optimize the long-term prognosis of concussion,” the authors note.
They add that several research teams “have aimed to gain more insight into the etiology and underlying mechanisms of development and course of mental health difficulties in individuals who experience a concussion” and have arrived at a biopsychosocial framework, in light of “the myriad of contributing physiological, biological, and psychosocial factors.”
They recommend the establishment of “specialized multidisciplinary or interdisciplinary concussion care programs should include healthcare professionals with strong clinical foundations and training in mental health conditions.”
Speedy Multidisciplinary Care
Commenting on the research for Medscape Medical News, Charles Tator, MD, PhD, professor of neurosurgery, University of Toronto, Division of Neurosurgery, Toronto Western Hospital, Ontario, Canada, said the researchers “performed a thorough systematic review” showing “emphatically that depression occurs in this population.”
Tator, the director of the Canadian Concussion Centre, who was not involved with the current study, continued: “Nowadays clinical discoveries are validated through a progression of case reports, single-center retrospective cohort studies like ours, referenced by Lambert et al, and then confirmatory systematic reviews, each adding important layers of evidence.”
“This evaluative process has now endorsed the importance of early treatment of mental health symptoms in patients with persisting symptoms, which can include depression, anxiety, and PTSD,” he said.
He recommended that treatment should start with family physicians and nurse practitioners, “but may require escalation to psychologists and social workers, and then to psychiatrists who are often more skilled in medication selection.”
He encouraged “speedy multidisciplinary care,” noting that the possibility of suicide is worrisome.
No source of study funding was listed. Scratch has reported receiving funds from the Holland Bloorview Kids Rehabilitation Hospital Foundation (via the Holland Family Professorship in Acquired Brain Injury) during the conduct of this study. No other disclosures were reported. Tator has reported no relevant financial relationships.
JAMA Netw Open. Published online December 27, 2022. Full text
Batya Swift Yasgur, MA, LSW, is a freelance writer with a counseling practice in Teaneck, New Jersey. She is a regular contributor to numerous medical publications, including Medscape and WebMD, and is the author of several consumer-oriented health books as well as Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom (the memoir of two brave Afghan sisters who told her their story).
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