Mental Health, Concussion, and Integrated Health Systems
Observations of a former Student-Athlete and Current Doctoral Student
By Kait Simpson, MPH (@kait_simps), March 3rd 2021
Exhausted and out of focus during a difficult workout, instead of pushing off my flip turn a little towards the right to return down the opposite side of the pool, I pushed off my flip turn straight and right into my teammate who was coming into the wall behind me. We collided heads.
As a student majoring in public health and psychology, and as an NCAA Division 1 scholarship athlete, I knew what a concussion (TBI) meant. I knew what the long-term consequences and implications were. I had seen close friends and family suffer from TBI and post-concussive syndrome. I had even suffered a debilitating concussion playing water polo two years prior.
Yet, as the pressure in my brain made me see white light, I down-played my symptoms. I felt so much guilt that I had hurt my teammate and taken her out of action. I knew how frustrated and potentially demotivated the team and coaches might be if not just one, but the two of us were out of action. I knew enough to “out-smart” the system. And I did. …This made things worse in the end. Until that evening, when my best friend talked some sense into me, after immediately recognizing over the phone that I was not okay. I reported my true symptoms, but still made sure not to mention I had suffered a concussion within the last 2 years.
The following two weeks were literally and figuratively the darkest of my life. I left my dark room only for meals and to see my athletic trainer for a daily check-in. My coaches did not talk to me or acknowledge me when they saw me. I felt their disappointment and all the hours alone in a dark room with my thoughts was dangerous. I had never had such negative thoughts. I convinced myself that I was no longer a welcome member of my team or university, that my coaches were going to take my scholarship away, and that I was a terrible person and athlete. On the day I was finally cleared to return to practice, I had a panic attack when my morning alarm went off; I was so terrified of hurting another teammate, I could not practice. My athletic trainer brought me to the campus student counseling center. It was my first time meeting with a therapist. I told the therapist the situation, but she knew nothing about the demands or pressures of a student-athlete. I left the meeting feeling more isolated than when I arrived.
Fortunately, my mental health was otherwise resilient to the demands of being a Division 1 NCAA athlete with 35 hours of weekly athletic commitments and a full-time courseload. I had an incredible college athletic experience, was proud to represent my school and team, and the resources available to student athletes at my institution were advanced, plentiful, and some of the best in the country. Despite my athletic department being considered leaders in sport healthcare and athlete support in many ways, I was astutely aware that many student-athletes at both my own university and external universities were not as mentally resilient and were struggling with their mental health. Many other university teams and organizations did not have the same resources and ability to invest in healthcare, athletic trainers, and student-athlete support staff that my school did.
Key Takeaways:
Even those who are educated can sometimes make poor decisions around reporting concussion.
The culture, context, and pressures can dictate an athlete’s response to a concussion.
My mental health was not addressed as part of concussion protocol, but reactively, once I had a problem.
The mental health resources available were not adequate for my specific needs as a student-athlete.
The top organizations still have not figured it all out. Mental health and concussion are complex and relatively new issues. Multidisciplinary collaboration and commitment to improving systems of care are still in their early phases.
My Recommendations:
1. Marry Mental Healthcare with Concussion Treatment (Integrate Care and Education)
Concussion and mental health are close cousins in many ways. While they are indeed distinctly different morbidities (a concussion is induced by biomechanical forces, often has quick onset and results in short-term neuropathological changes, while a mental illness or disorder is typically multifaceted, may not be determined by an isolated event, and often affects an individual persistently and for a long period of time), we cannot deny their relationship. Concussion and depression are associated (Rice et al., 2018), and a dose-response relationship exists between multiple concussions and later life depression (Manley et al., 2017). Given this evidence, it is reasonable to recommend that mental healthcare be integrated with concussion treatment and that individuals who suffer a concussion be given resources to proactively maintain their psychological wellbeing.
In 2020, Krutsch et al. published a comprehensive guide to injury and health risk management in sports. The guide breaks down risks into levels of play, ages of athletes and offers in depth chapters on each sport and their specific risks. Although concussion is well addressed, mental health risks are not mentioned in any capacity (Krutsch et al., 2020). Given the emerging body of evidence, it would be pertinent for the next edition to include education around mental health and concussion in sport.
2. Pre-empt the Social Contagion of Mental Illness in Team Settings
Athletes are the bread and butter of sport organizations; revenue and outcomes for sport organizations from the grassroots to the pros depend on the performance of humans (athletes). We all have watched our team lose or struggle when a top player is completely out of action. In that scenario, an athlete is at 0% contribution level on the field of play. What about when a player is playing in the game, but not operating to their optimal capacity, say at 60% of their possible contribution and functioning level? What if, for instance, the players on a team are collectively operating at an overall average of 70% of their total contribution level? This means that the organization is effectively not seeing 30% of the returns that they are investing in (think paying for 10 apples, and only getting 7). What are the direct and indirect costs of a “sick” (or not completely healthy) player?
Mental illness and concussion have larger implications and externalities that differ from other injuries or illnesses. There is a social contagion aspect to mental illness that is not often discussed. For example, economists have found that for every one point increase in depression score for a student, the depression scores of five other people in their social network also increase as well (Golberstein et al., 2013). This is very relevant to sport, especially because the sport team often is an athlete’s social network. Thus, if one athlete on a team is struggling with mental ill-health, it would be my recommendation to consider proactively implementing strategies and resources to help maintain well-being amongst the entire team, and effectively mitigate the contagion effect.
3. Take a Public Health Approach to Optimize Economic and Health Returns
Public health is about prevention. Medicine is about reaction (treatment, therapy, medical care). The role of a health system is to create processes that optimize population health. The best systems do this while also cutting healthcare costs and put effective measures in place rather than inefficiently over regulating. Taking a stronger public health and health systems lens to sport can mitigate risk for illness, injury, and economic loss. A public health approach offers potential to save organizations time, money, and pain. Education about the clinical consequences and proper concussion protocol is incredibly important. The effectiveness of this education can be increased when integrated into the DNA of the larger health system.
COVID-response has opened a beautiful window of opportunity by exposing and magnifying clear systemic flaws and especially risks surrounding athlete mental health, that previously some claimed were difficult to distinguish. This is a great time to have open discussions, put new systems in place, collaborate and collaborate. It is my hope that when sport comes back full-go, it can be more fun and the psychological risks less than they were before the COVID-19 pandemic.
Kait Simpson, MPH, is a PhD student at the University of Edinburgh. Her doctoral work focuses on University Sport and Student-Athlete Mental Health.
References
Golberstein E, Whitlock JL, Downs MF. (2013). Social contagion of mental health: Evidence
from college roommates. Health economics. 2013;22(8):965-986. doi:10.1002/hec.2873.
Krutsch, W. (2020). Injury and health risk management in sports : A guide to decision making (1st ed. 2020.. ed.). Berlin, Germany: Springer : ESSKA : ESMA.
Manley, G., Gardner, A. J., Schneider, K. J., Guskiewicz, K. M., Bailes, J., Cantu, R. C., ... & Iverson, G. L. (2017). A systematic review of potential long-term effects of sport-related concussion. British journal of sports medicine, 51(12), 969-977.
Rice, S. M., Parker, A. G., Rosenbaum, S., Bailey, A., Mawren, D., & Purcell, R. (2018). Sport-related concussion and mental health outcomes in elite athletes: a systematic review. Sports medicine, 48(2), 447-465.