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Caitlin Whyte: Sports are a major part of our lives. We enjoy seeing elite athletes compete for our favorite teams. However, research has shown that injuries incurred during sports can impact an athlete's mental health. To learn more, we are joined by Dr. Shea Fontana, a physician in psychiatry and behavioral medicine, as well as a Clinical Assistant Professor at the University of South Carolina School of Medicine Greenville; and Dr. Jacob Kay, a certified brain injury specialist and rehabilitation scientist at the Prisma Health Pediatric Concussion Clinic.

Caitlin Whyte: this is Flourish, a podcast brought to you by Prisma Health. I'm Caitlin Whyte. So, Dr. Fontana, start us off today. How do sports injuries affect mental health?

Dr. Shea Fontana: Yeah. Awesome. Thank you for the question and thank you for having us here this morning. So, sports injuries can impact mental health in a number of ways and, honestly, how athletes respond to those injuries are going to be different as well. And so when an athlete becomes injured, it's really taking them out of something they love, which is their sport, and this can threaten their athletic identity. And so, it's not unusual or even atypical to kind of see an emotional reaction after an injury. It's pretty common actually. And so, a lot of times this pretty much happens around the time that the athlete needs to maybe process the medical information that they were just given about the injury itself and kind of looking at just, you know, "How am I adjusting or coping emotionally now with this. And kind of with this information, how do I sit with this?" And so, looking at how this is going to impact their participation in sports, those emotional responses can kind of range from sadness, social withdrawal, irritability, maybe even anger or frustration at times. It can change their sleep patterns, their appetite patterns, potentially even lead to some disengagement, whether that's in or outside of sports.

And so, we know that athletes who sustain an injury are definitely at an increased risk for depression, especially within that first week from the injury. But we see actually that the depression scales can even stay pretty elevated within that first month out from injury. And so, you know, if it's not caught early on or if we're not asking our athletes how they're doing, how they're coping after injury, there is risk for that potentially progressing or leading to a mental health condition such as depression, maybe even substance use as a way of kind of coping with that injury, potentially eating disorders. You know, we have to think, hey, these athletes were once extremely active and now that they're kind of in this recovery phase doing the exact opposite of what they love to do and not being as physically active, there's a lot of risk for varying things to happen.

And then even just kind of in that midst or in the process of returning back to sport, sometimes we can see this increase in maybe fear of re-injury or even just performance-based anxiety about, "How am I going to perform? Am I even going to return back to that pre-injury status or pre-injury level of performance?" And so, I guess you can see that it's rather complex. It's not so simple. We know emotional responses are going to vary from athlete to athlete, and so it's just really important for them and the support network around them just to check in with one another during that post-injury phase.

Caitlin Whyte: It's so important to remember this other aspect of the injury, like you're saying. And Dr. Kay, let's talk about the different types of injuries. I mean, is it worse if the injury sustained is to the head?

Dr. Jacob Kay: This is a really great question, though I'm not really sure I can suggest that they're worse, maybe not the best term, so maybe just different. So, all sport injuries really come with unique challenges for the athletes and even their providers that are treating them. So, comparing a brain injury like a concussion to other orthopedic injuries is a little bit like comparing apples to oranges. But that said, there's been some recent studies that have shown increased mental health issues in psychiatric hospitalizations and self-harm among children and youth with concussion when compared to other orthopedic controls.

So, our group here, even in the Midlands, wanted to kind of explore this a little bit further. So, we used the National Youth Risk Behavior Surveillance System, which is a survey system that goes out every couple years to local high schools all across the country and gets thousands of responders. And we wanted to look at this idea of concussion frequency, the relationship between concussion frequency and suicidality, which is a term that really encompasses suicidal ideation, planning and attempts.

And so, our study, which is soon to be published in the Athlete of Mental Health Special Issue of the Journal of Athletic Training, demonstrated that students that reported two or more concussions were at significantly greater odds of reporting suicidal attempts and twofold actually when compared to students reporting just a single concussive event during the past 12-month timeframe. So, keep in mind, this is kind of a single snapshot in time and we're looking across 12 months, and folks that are reporting both suicidal behavior and concussion in looking at the association between the two.

In another paper we've recently had accepted, by the psychology of sport and exercise, we aim to investigate the combined influence of concussion history and attention deficit hyperactivity disorder or adhd, on mental health outcomes. And in this study we included over 300 collegiate athletes whose self-reported on their concussion history, ADHD diagnoses.

And then among them, we surveyed anxiety and depress. What we found was that both history of concussion and D H D were independently associated with elevated levels of state anxiety. However, the odds of reporting increased state anxiety were significantly higher among athletes with combined history of concussion and D H D.

And our analysis actually produced some similar results with respect to depression, such that the odds of reporting symptoms more than quadrupled in the presence of those with both history of concussion and ADHD relative to those with just ADHD or concussion history alone. So there appears to be this negative synergy between concussion and ADHD that may further complicate mental health among athlete.

So both of these studies really highlight the importance of screening mental health conditions among young athletes, as well as other neurodevelopmental challenges that may further complicate overall brain health.

Caitlin Whyte: Gotcha. Thank you for that. And Dr. Fontana, anything to add?

Dr. Shea Fontana: Yeah, no, absolutely. And I mean, I'm in complete agreement with Dr. Kay there in terms of, you know, it's really hard to say, "Is it worse?" I think you can't really compare injury to concussion, just because it's a head injury. Sure, it's going to be probably different, but all injuries are going to be different from one another, especially when we kind of look at that emotional response from the athlete. And so, you know, I think it's just super important, I can't stress enough, you know, we know psychological symptoms secondary to concussion are relatively common in the recovery phase. And so, it's just really important that we as clinicians are just monitoring those emotional responses as athletes are returning back to sport, back to education, and making sure that those responses are improving kind of in a similar fashion or similar timeline to the neurological or physical responses.

You know, another thing too that I always just kind of like to point out is that aspect of sustaining a concussion is kind of this mark of, you know, "this invisible injury," which is a little bit unique to a concussion compared to other injuries. You know, if an athlete injures an ACL or maybe gets an ankle sprain, you're typically going to see them maybe on crutches, maybe they're going to have a knee brace or a boot on. They might even need a potential surgery. And so, that physical kind of component of seeing the injury sometimes can provide the athlete with just more external support, kind of validation about their experience. Likely times, it's a shared experience, so other athletes are really able to understand what they're going through.

But that's not always the case or what we see with concussion. Even though sure many athletes have had probably a concussion, it's so hard because it's not like people are just walking around with an ACE bandage around their head. So, it's kind of like, "Hmm, unless we're not asking about it, are we really knowing about it?" And so, I think that just that physicality alone can really play a role in addition to the timeline for concussion just being unpredictable in and of itself. You know, everybody kind of responds or recovers from concussion on a different timeline, and also they don't have shared symptoms. Even the same person, if they sustain one concussion, another concussion might look very different in that recovery phase. And so, it can get really hard of looking at, okay, what are these athletes kind of experiencing, what does the timeline look like, how are they responding to that timeline, and kind of checking in from an emotional backing there. And I think they ask themselves, you know, "Hey, is this really what I'm experiencing?" I think there's sometimes like self-questioning or self-doubt of, "Is this concussion actually what just happened? Am I amplifying these symptoms? Am I actually maybe like not feeling as much as I can be? Or am I not disclosing those symptoms because I'm afraid of being benched?" So, I think there's just a lot of things internally that are happening with the athlete around that time of injury from a concussion, but also externally and kind of how is that holding environment or how is their external environment reacting and responding to the injury itself as well.

Caitlin Whyte: Thank you, yes. And I would love to talk about some other differences, Dr. Kay. Are there any differences between how children are affected versus adults in these scenarios?

Dr. Jacob Kay: Sure. It is another great question. There's this really common misconception actually that children are more resilient and bounce back quicker. When we're talking about concussions, this just isn't the case. So adolescents, even through young adulthood up until about the age of 25, the brain is still developing. And this timeframe kind of really marks a period of robust neurodevelopment. So, there's a lot of really fine tuning going on in the brain, if you will. And it can be a really challenging time to experience a concussion and throw that into the mix. In fact, age is one of the most consistent predictors of outcome following concussion, with adolescents in particular taking longer to recover from injury than their adults, about twice as long actually. So, typical for, you know, an adolescent is about two to four weeks, which is about twice as long as adults.

More specifically to mental health, there's been some really good systematic reviews and meta-analysis that have been published in this area in in the last year or two. And some of the findings are really actually quite alarming, suggesting as high as one in every three youth will report elevated mental health symptoms after concussion. So, these are feelings of anxiety, depression, or post-traumatic stress. And only about half of these are going to report concern for these issues prior to the injury. So, not only are concussions potentially exacerbating existing mental health issues, but they may also lead to the onset of new symptoms as well.

Caitlin Whyte: Thank you for that. Now, thinking about getting back on the field or the court or back to the sport,

Dr. Fontana, can a mental health issue lead to another injury?

Dr. Shea Fontana: I say it's hard to know, but I think absolutely. I mean, I actually look at mental health conditions and injury as a two-way street. They're not separate really from one another. So, just like what we were talking about earlier, we know injury can contribute to mental health symptoms and kind of similar to the ones we discussed, depression, fear of re-injury, anxiety, lack of motivation, et cetera. But I think it's just as important to note that there is maybe some evidence. So, a recent consensus statement in 2016 showed that there's kind of one psychological factor that kept coming up that potentially can increase the injury risk for an athlete, and that was actually stress.

And so, stress can look very different from one person to the next. We can experience stress typically emotionally, physically, maybe even behaviorally, maybe a combination of the two or even all three. And so, some examples of what that could potentially look like is, you know, maybe the athlete is holding a lot of their stress in their body. They're physically tense, their muscles are tight. Maybe somebody is experiencing just difficulty with concentration or feeling as though their mind is racing and they kind of just can't keep up with it. And that leads to kind of self-doubt or negative self-talk, both in and out of sport. Maybe they're just not sleeping as well or it's very disrupted and so you're kind of noticing some irritability or some anger, frustration levels kind of coming out on the field.

And so, I think those are just all really important kind of pieces because, again, it's kind of this bimodal pathway. It's a two-way street of, yes, I think, you know, an injury absolutely can lead to some mental health signs and symptoms that we've talked about, but also those mental health symptoms and particularly stress being the one that we've looked at can increase risk for injury. I think here recently we've seen, you know, a few elite athletes or professional athletes who have recently withdrawn from a major competition or sporting event kind of citing mental health reasons, right, as a driving factor for making that decision. And I think a big portion of that came from just them recognizing that if they're not in their what they consider, you know, their normal head space, because everybody's normal is different prior to and during competition that that absolutely could have had potential, you know, negative outcomes, not only maybe related to their performance during that competition, but potentially even leading to an injury. And so I think they were just pretty self-aware, which is great to see and, you know, I applaud that and I think it's just a really important measure to be able to look at how are we talking to our athletes about stress management, what type of skills are they utilizing and kind of how can we build those up to help build that resilience?

Caitlin Whyte: Absolutely. And Dr. Kay, anything to add?

Dr. Jacob Kay: Not a whole lot. I just want, you know, just to echo some of the things that Dr. Fontana said, that it really is kind of an area that is a hot topic in research right now, and there's not a lot of, you know, firm evidence on whether or not something like anxiety or depression is leading to increased risk of concussion. And a lot of that's really just based on the data that we have available and the way that we're able to analyze that today, being more association-based or cross-sectional type studies where we really can't establish that temporal sequence of which one came first. So, a little bit of that chicken or the egg problem, kind of like I mentioned a few moments ago with that YRBSS paper that we are working to publish now.

That said, the researchers have shown that certain behaviors such as, you know, higher tendency for on-field aggression, as well as other major risk behaviors among youth, like alcohol consumption, drug use, or physical violence have all been linked with greater risk of concussion among teens. And though, you know, often these behaviors are present among youth with, you know, overlapping diagnosis and mental health issues, we really do need some more research in this area before we can really draw some strong conclusions on this.

Caitlin Whyte: Well, thank you for that. And wrapping up here, I'll

go back to you, Dr. Fontana. What can athletes do?

Caitlin Whyte: to prevent or overcome mental health issues after an injury?

Dr. Shea Fontana: So, this is a great question and I think it really kind of boils down to communication. You know, I think that the athlete really needs to have someone to talk to and not just even talk to, but I think someone that they can really relate to and trust. It's not uncommon for athletes really at any level in sport to have probably some reservations about seeking out mental health treatment. I think that probably stems from, gosh, a myriad of things that are going to go far beyond the examples I'm about to list. But, you know, I think there's probably just even a fear of revealing symptoms that there's something wrong, maybe fear of that privacy being breached, so "Are my coaches going to find out? Am I going to be benched at all because I'm talking to somebody about some of these mental health concerns that are coming up for me?" I think, you know, there's still kind of this perception that, you know, even some may view seeking counseling as a sign of weakness, which is only kind of feeding into that stigma that athletes are somehow invincible, which we know is actually not true. They carry similar rates of depression and anxiety to our general public. So, they're not really separating out from, the prevalence of mental health conditions per se. And so, I think that when we look at how can we kind of bridge that gap and make sure that we're offering those resources, that's really important. And we want athletes to kind of feel supported in that, one, you're not alone; two, you're no different, right? And kind of being able to treat them just as that and as a person. And so, I think talking to an athlete through the entire recovery phase is not only just going to help address those emotions as they come up, but will hopefully help the athlete return to sport kind of at a pre-injury level of performance, which is the ideal, if they're able to even just understand or be aware of what warning signs or symptoms to kind of look for that we've talked about today or maybe even ones that are more particular to just how they're coping with the injury in general, so things like they're maybe in denial about the severity of the injury or if they just feel like they're generally impatient about the entire recovery process, just kind of checking in with them to make sure that they're not having any additional emotional responses kind of coming up in the context of that injury.

If I could have it my way, I would say that everybody post-injury should just check in with a licensed mental health provider, but that's in an ideal world, And so, whether that would be with a therapist, a sports psychologist, sports psychiatrist, just someone that has that knowledge to be able to share, but also kind of the resources to be able to provide that athlete would be great. And it gives them that resource and point of contact right after the initial point of injury. So, essentially we're kind of creating this framework that they can work within a team to be able to kind of get them through this recovery process, not only physically but mentally as well.

Caitlin Whyte: Great. And any final thoughts from you, Dr. Kay?

Dr. Jacob Kay: Just a few really. And I think Dr. Fontana did a really wonderful job highlighting, you know, all of the psychosocial factors and stigmas around mental health that present these barriers and just kind of speaking to student athletes. Yes, we do see increased rates, you know, particularly among this age group of adolescents where they're at greater risk of concussion and potentially at greater risk of prolonged outcomes, but they're also in this unique position where they have a lot of resources available to them, school counselors, nurses, and even, you know, athletic trainers, which are perhaps most relatable to them and closest proximity with sport teams.

So, you know, I would say to an athlete, if they feel like they're mentally struggling with an injury, particularly after a head injury, know, for one, this isn't uncommon and you're not alone and, two, just speak up and reach out to that athletic trainer or whomever that you need to and seek that help if you need it. This can be really tough, you know, for teens especially, for all the reasons that Dr. Fontana highlighted. So again, just kind of emphasized even to parents, you know, if you notice that something's going on with your child, ask questions. If you suspect something's going on or, you know, suspect a head injury, refer to your healthcare team. That's really for guidance. That's really what they're all there for. And I understand what I'm saying, it's probably a little bit easier said than done at most times, but I really can't emphasize the importance of communication enough, especially when we're talking about conditions where folks tend to withdraw a bit or even, you know, like the injuries, like concussion that are invisible, you know, like Dr. Fontana said, they can be really difficult to navigate.

Caitlin Whyte: Well, thank you both so much for joining me today and for all the work that you do. For more information and other podcasts just like this, head on over to prismahealth.org/flourish. And this has been Flourish, a podcast brought to you by Prisma Health. I'm Caitlin Whyte. Stay well.