Cognitive Behavior Therapy for PCS

kouturesUp until a few years ago, I could readily admit that prolonged concussion recoveries were often influenced by mental health concerns, but had some difficulty in addressing those issues.

The glaring problem back then was a lack of coordinated resources and minimal professional collaboration between physicians and mental health professionals. My ability to confidently suggest and secure buy-in from my patients for mental health support was stifled by the available limited resources.

Within the past few years, I have had the good fortune of meeting dedicated mental health colleagues who share interest in helping concussed patients. Now I feel justified in offering a more comprehensive platform of necessary services to my patients and their families.

So I had to nod my head in a “this will help moment” when reading the findings of a recent research study in the journal of Pediatrics. The authors utilized Cognitive Behavior Therapy (CBT) to target post-concussive depression and anxiety symptoms in adolescents ages 11 to 17 who were experiencing persistent concussion symptoms for at least one month following a sports related concussion.

The researchers compared athletes who received CBT treatment for post-concussion and depression symptoms and those who did not received CBT treatment. At a 6 month follow-up, the patients who received CBT had fewer post-concussive and depression symptoms. However, there was no significant difference between the CBT and non-CBT group for changes in anxiety.

Given the reduction in post-concussive symptoms and co-occurring psychological symptoms, the researchers found that treatment involving collaboration between professionals in terms of mental health may be useful for slow-to-recover adolescents. Additionally, the athletes who underwent CBT treatment reported a significantly higher improvement in their quality of life.

I was somewhat surprised by the lack of improvement in anxiety symptoms using treatment involving CBT. In my practice, I have seen a fair amount of anxiety in post-concussion patients who

© Lauren Long (2013)

© Lauren Long (2013)have prolonged recoveries and benefit from coping skills learned through CBT.

I definitely endorse the role of collaborative care for mental health issues after concussion as the research has found it beneficial for patients with depressive symptoms. When applicable, patients should receive referrals to providers who utilize CBT as the tools patients learn not only help them recover, but serve as lifelong coping skills for adverse situations.

I would also like to share some other thoughts about how to best guide patients and families in making sure that mental health needs are aggressively met after a concussion:

  • Anticipate that any pre-existing mental health or school issues (anxiety, depression, dyslexia, ADD/ADHD) will flare after a concussion. Make certain that there are immediate and regular connections with established professional support personnel to help address these potential symptom spikes.
  • Don’t be hesitant to accept early referrals to professionals who can provide symptom-based support techniques such as CBT.
  • Later in recovery, be aware that around 4-6 weeks after a concussion, things such as feeling more emotional, sad, irritable, nervous, or anxiety flare up. I have no scientific rationale to explain this phenomenon, yet I see it so often in patients at the 4-6 week post-injury mark (both those with other symptoms and those who are otherwise recovered) that I make a point to mention this to patients, families, and colleagues.
  • Don’t underestimate the significance of irritability. As a post-concussive patient, if others are worried about your irritability, don’t take this lightly. Many patients will reluctantly agree that they tend to have periods of irritability and later report other emotional symptoms such as depression or anxiety. Thus, when I hear about irritability, I suspect that there are other issues lingering that need to be addressed.

I have found that emphasizing the role of mental health issues in concussion recovery during my initial visits helps with patient and family acceptance and makes finding mental health support a bit easier. Starting the referral process earlier can help overcome the challenges of insurance coverage limits, location, schedule coordination, patient-provider “fit,” and other issues.

I have found that building a team approach to treating concussions has been a rewarding process, so having research-based validation for collaborative care and especially mental health support is another positive step in providing optimal concussion treatment for patients and families.

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