* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Depression Suicide SRC VSCC Solomon 2016 06 10
Mental health professional wikipedia , lookup
Anti-psychiatry wikipedia , lookup
Bipolar II disorder wikipedia , lookup
Mental status examination wikipedia , lookup
Deinstitutionalisation wikipedia , lookup
Mental disorder wikipedia , lookup
Psychiatric and mental health nursing wikipedia , lookup
Psychiatric rehabilitation wikipedia , lookup
Political abuse of psychiatry wikipedia , lookup
Child psychopathology wikipedia , lookup
Cases of political abuse of psychiatry in the Soviet Union wikipedia , lookup
History of psychiatric institutions wikipedia , lookup
Diagnostic and Statistical Manual of Mental Disorders wikipedia , lookup
Postpartum depression wikipedia , lookup
Abnormal psychology wikipedia , lookup
Classification of mental disorders wikipedia , lookup
Political abuse of psychiatry in Russia wikipedia , lookup
History of psychiatry wikipedia , lookup
Major depressive disorder wikipedia , lookup
Causes of mental disorders wikipedia , lookup
Pyotr Gannushkin wikipedia , lookup
Controversy surrounding psychiatry wikipedia , lookup
History of mental disorders wikipedia , lookup
Depression and Suicide in Athletes with Sport-Related Concussions Sports Concussion: State of the Science June 10, 2016 Gary Solomon, Ph.D., FACPN Associate Professor, Departments of Neurological Surgery, Orthopaedic Surgery & Rehabilitation, and Psychiatry, Co-Director, Vanderbilt Sports Concussion Center Vanderbilt University School of Medicine Team Neuropsychologist, Nashville Predators Consulting Neuropsychologist, Tennessee Titans [email protected] www.vanderbiltsportsconcussion.com Full time employee, Vanderbilt University School of Medicine Either Vanderbilt or I receive consulting fees, honoraria, and/or expense reimbursements from: Nashville Predators, Tennessee Titans, Tennessee Tech Athletics, University of Tennessee Athletics, ImPACT 12.58% of my annual income is derived from sports organizations Grants: DoD: Restoration of standing and walking through Intra-spinal Microstimulation in humans (Consultant to Peter Konrad, M.D., Ph.D.) I do not see patients involved in litigation This presentation is not endorsed by any organization with which I am affiliated This may not be a comprehensive assessment of the published literature; my own biases in the selection of papers reviewed and the opinions presented are acknowledged Comments in blue represent my opinion I express my appreciation to all authors whose work is discussed. It is easy to criticize research, and difficult to do it well 1. To review the evidence on depression and anxiety disorders in athletes with sport-related concussions 2. To review the evidence on suicide in athletes with sport-related concussions 3. To discuss possible reasons for common beliefs related to the effects of sport-related concussion and depression/suicide. www.vanderbiltsportsconcussion.com The effects of sport concussions and Limbic System Consensus statements Epidemiology Survey studies Psychometric instruments Practice Parameters/Consensus Guidelines/Position Statements AAN Mood disorder was not specifically addressed in these guidelines NAN Practice Parameters/Consensus Guidelines/Position Statements 2011 ACSM Practice Parameters/Consensus Guidelines/Position Statements CISG4 AMSSM Mental health issues may be multifactorial and warrant consideration Mood disorders complicate dx and management Difficult to determine what precedes-causes-worsens Practice Parameters/Consensus Guidelines/Position Statements NATA History of psychiatric illness should be documented in pre-participation evaluation Athletes with psychiatric illness may require referral to a neuropsychologist for formal NPT Depression may be a long-term consequence of multiple SRCs Evidence-based recommendations and empirical data related to psychiatric illness have been limited in sports concussion BJSM Affective sxs (anxiety and depression) are common immediately after a SRC, but are typically subclinical and time-limited Mental Health Epidemiology Mental Health Epidemiology 2009: Average number “mentally unhealthy days” past month (Adults) Average # “mentally unhealthy” days per month = 3 for men, 4 for women; ̴10% of the time life is crappy Mental Health Epidemiology National trends in mental health service utilization (USA) Psychiatrist, Psychologist, Psychiatric NP, LCSW Among insured people: Overall, about 10% Mental Health Epidemiology: PCP Visits 2012: In adults ≥18 years, >30% of PCP office visits were related to mental health Σ crappy days (10%) + mental health (10%) + PCP (30+%) = >50% Life is hard….(so be kind) Lifetime Prevalence of Mood Disorders 14.4% for adolescents 21.4% for adults Lifetime Prevalence of Anxiety Disorders 32.4% for adolescents 33.7% for adults Mood Disorders in Collegiate Athletes Brewer & Petrie, AAJ, 1995: 916 Division I football players; 33% with injury and 27% without injury were + for depressive sxs Yang, et al. CJSM, 2007: 251 Division 1 athletes; 21% were + for sxs of depression Armstrong & Oomen-Early, JACH, 2009: 227 collegiate students (104 athletes); 33.5% were + for “significant” depressive sxs Proctor & Boan-Lenzo, JCSP, 2010: 61 Division I baseball players; 15.6% were + for depressive sxs ***Wolanin et al., BJSM, 2016: 465 D-1 athletes; Prevalence of clinically relevant level of depressive sxs (CESD >16) = 23.7%, with 6.3% = moderate or severe; female gender RR=1.84 _______________________________________________________________________ Mood Disorders in Concussed Collegiate Athletes Mainwaring et al., Br Inj, 2010: Athletes with ACL injuries had greater severity and duration of depressive sxs vs. athletes with concussion (Profile of Mood States-POMS) Kontos et al., APMR, 2012: 75 h.s. and collegiate athletes had higher BDI-II scores at days 2, 7, and 14 post-injury (“not clinically significant”) Vargas et al., JAT, 2015: 84 collegiate athletes with concussions vs. 42 controls; 20% of concussed athletes (vs. 5% controls) showed a reliable increase in depressive sxs (BDI-Fast Screen) Survey studies of depression Retired NFL players 2007: When compared with retired athletes reporting no concussions--Retired athletes reporting 1-2 concussions were 1.5x more likely (prevalence ratio = 1.48, 95% CI = 1.08-2.02) to report a diagnosis of depression Retired athletes reporting ≥3 or more concussions during professional football were 3x more likely (prevalence ratio = 3.1, 95% CI = 2.3-4.1) to report a diagnosis of depression _____________________________________________________________ 2012: The 9-year risk of a depression diagnosis increased with an increasing number of self-reported concussions, ranging from 3.0% in the ‘‘no concussions’’ group to 26.8% in the ‘’10+’’ group (linear trend: p<.001). A strong dose-response relationship was observed even after controlling for confounders. Beck Depression Inventory-II studies Retired NFL players Compared 30 retired NFL players with a history of concussion with 29 age- and IQ-matched controls with no history of concussion Found a significant correlation between the number of lifetime concussions and depression symptom severity on the BDI-II “…the number of self-reported concussions may be related to later depressive symptomatology…” __________________________________________________________ Beck, A.T., Steer, R.A., & Brown, G.K. (1996). Beck Depression Inventory: second edition manual. San Antonio: The Psychological Corporation, 1996. Norms Minimal range = 0–13 Mild depression = 14–19 Moderate depression = 20–28 Severe depression = 29–63 The severity of depressive symptoms according to BDI criteria is low in both groups Retired NFL players n = 26 Consistent with depression 5/26 positive; 19% rate of depression per BDI criteria Retired NFL players Distribution of scores n % BDI-II score 30 66.67 0-13 9 20.00 14-19 3 6.67 20-28 3 6.67 >29 BDI ≥14= 33% rate of depression BDI ≥20= 13.33% rate of depression What is the prevalence of depression in athletes? 15.6%-21% The prevalence of depression in athletes is equal to or may be slightly higher than the general population, which is reported to be 13-16% (Gelenberg et al., APA, 2010), but there is no clear evidence that this is due to concussions or even subconcussive injury. Depression exists in athletes, and athletes commit suicide In discussing depression and concussion we have to consider… What is the table made of, where does the table live, and who else sits at the table? At baseline… 47 Division I football players, ages 17-19 (46 freshmen) Concussion Resolution Index (CRI; a computerized neurocognitive test) and Personality Assessment Inventory (PAI) 32-55% endorsed sxs of psych distress at baseline Scores of athletes endorsing symptoms of anxiety, depression, substance misuse, or suicidal ideas were correlated with CRI indexes (r²= 0.23-0.30) Participants acknowledging suicidal thoughts (n=7) had significantly lower simple and complex reaction time scores, with a trend also noted for Processing Speed (p=.10) At baseline… 1616 athletes (837 collegiate and 779 high school) athletes from 3 states participating in a variety of sports At baseline, student-athletes with higher scores on Center for Epidemiological Study-Depression (CES-D) had: Greater symptom endorsement Poorer Visual Memory scores (ImPACT) At baseline… Deidentified data base of athletes ages 13-24, matched, by sex, age, BMI, & concussion history Athletes who report being prescribed psychostimulants displayed significantly lower visual motor speed scores (32.8 vs 37.1, p=0.03) and slower reaction times (0.65 vs 0.60, p=0.04) than matched (1:3 ratio) controls Athletes who report being prescribed antidepressants displayed significantly faster reaction times (0.58 vs 0.61, p=0.03) than matched (1:2 ratio) controls Athletes with a self-reported history of depression/anxiety, not treated currently with psychotropics, displayed significantly lower visual memory (70.4 vs 75.2, p=0.01) and higher symptom scores (8.83 vs 4.72, p=0.005) than matched (1:2 ratio) controls At baseline… -31,958 high school athletes in Maine, baseline ImPACT from 2009-13 -19% of boys and 28% of girls endorsed a level of symptom burden consistent with ICD-10 diagnosis of PCS -Independent predictors of symptom endorsement: For boys, prior psychiatric diagnosis and migraine HA For girls, prior psychiatric dx, history of substance abuse, and ADHD -Concussion history was the weakest predictor of symptom endorsement for both sexes Post-Concussion n=7 per group, assessed serially with CES-D Groups: Concussion vs. Injured/Nonconcussed vs. Control Week 1: Both groups + for depressive sxs > baseline Week 4: Injured/Nonconcussed only > baseline Post-Concussion Prospective cohort study (n=67) at 2 Big Ten universities (9 sports teams) 2007-08 through 2011-12 seasons CES-D & State-Trait Anxiety Inventory Concussed athletes with + sxs depression at baseline were: 4.59x more likely (95% CI = 1.25-16.89) to experience depressive sxs 3.40x more likely (95% CI = 1.11-10.49) to experience state anxiety Post-Concussion 40 PCS patients (defined as sxs > 3 months) matched by age at injury and sex to controls on a 1:2 basis (control pts. had sx resolution within 3 weeks) PCS was not predicted by race, insurance status, BMI, sport, helmet use, medication use, or specific sx endorsement PCS pts. were more likely than controls to have a concussion history, premorbid mood disorder, other psychiatric illness, or significant psychosocial stress Other factors related to PCS were family history of mood disorder, other psychiatric illness, and migraine Genetic study in progress at VSCC Post-Concussion 20/174 (11.5%) of the pediatric patients with a SRC qualified for a novel psychiatric diagnosis (based on symptom checklist scores and clinical evaluation by a neurosurgeon) - 10/20 (50%) had a pre-injury psychiatric history - 8/20 (40%) had a family history of psychiatric illness - 12/20 (60%) reported significant psychosocial stress Risk factors: Female sex, higher baseline total symptom score, higher baseline emotional symptom score (sadness, irritability, nervousness, more emotional), presence of pre-injury psychiatric illness, and family history of psychiatric illness One completed suicide (patient had a history of prior suicide attempt and psychiatric hospitalization) Synthesis: Limited research data suggests: - Athletes differ in the degree of depressive symptoms at baseline; gender may be relevant - Athletes have at least the same rate of depressive symptoms as the general population - Athletes may have biopsychosocially-influenced responses to concussion that may include depressive symptoms - Personal, contextual, and family genetic factors (including migraine, stress level, ADHD/LD, and psychiatric illness) are relevant Sports concussion and suicide November, 2014 March, 2015 Suicide: Some Sobering Facts Unfortunately, suicide is a very common occurrence The suicide rate is nearly twice that of the homicide rate in the USA CDC: In 2013, 41,149 suicides were reported, making suicide the 10th leading cause of death for Americans (113 per day; the rate in Canada is slightly higher) Suicide epidemiology From 2000 through 2014, there was a statistically significant (p<0.05) increase in the total suicide rate and the rates for each method, for both females and males. QuickStats: Age-Adjusted Suicide Rates for Females and Males, by Method — National Vital Statistics System, United States, 2000 and 2014. MMWR 2016;65:503. Suicide epidemiology The rate of suicide is increasing in: Civilians: Sullivan EM, Annest JL, Luo F, et al. Suicide among adults aged 35–64 years—United States, 1999–2010. MMWR. 2013;62:321–5. Military: Center AFHS. Deaths by suicide while on active duty, active and reserve components, US Armed Forces, 1998–2011. Med Surveil Monthly Rep. 2012;19:7–10. ___________________________________________________________________________________ The rates of suicide in both men and women have increased significantly from 1999-2010: Sullivan EM, Annest JL, Luo F, et al. Suicide among adults aged 35–64 years— United States, 1999–2010. MMWR. 2013;62:321–5. People in the US are now more likely to die from suicide than MVCs: Rockett IR, Regier MD, Kapusta ND, et al. Leading causes of unintentional and intentional injury mortality: United States, 2000–2009. Am J Public Health. 2012;102:e84–92. www.vanderbiltsportsconcussion.com What are the risk factors for suicide? According to NIMH, risk factors for suicide include prior suicide attempt, depression and other mental disorders, or a substance-abuse disorder (often in combination with other mental disorders). More than 90 percent of people who die by suicide have these risk factors. www.vanderbiltsportsconcussion.com Suicide in Athletes In the recent past, at least 4 professional football players (Dave Duerson, Ray Easterling, Junior Seau, Jovan Belcher) have committed suicide. Duerson and Seau died via GSW to the chest, apparently in an attempt to spare their brains for postmortem study. Other collegiate and professional athletes (football, wrestling, hockey) have committed suicide and have been later diagnosed with CTE. Suicides have occurred among collegiate and high school athletes, with sports-related concussions claimed as the cause. We know that athletes are not immune to mood disorders. Do athletes abuse drugs? Telephone survey of 644 retired NFL players from the 2009 Retired NFLPA directory conducted from March-August, 2010 (53.4% completion rate) 52% used opioids during their NFL career, and 71% admitted to misuse Prevalence of current opioid abuse was 7%, which is 3x rate of the general population _____________________________________________________ What is the suicide rate in retired NFL players? NIOSH, American J Cardiology, 2012 Cohort: n= 3,439; 1959-1988 The rates of death due to suicide (and violence) in NFL players were lower than the general population “…12 suicide deaths observed compared with 25.6 that would be expected in a comparable sex/race/age sector of the US population (SMR = 0.47)”. College students and suicide Suicide represents the third leading cause of death among college-age individuals and the second leading cause of death among college students. What is the rate of suicide in NCAA student-athletes? ___________________________________________________________ Centers for Disease Control and Prevention. Leading causes of death reports, national and regional, 1999-2013.http://webappa.cdc.gov/sasweb/ncipc/leadcaus10_us.html. McIntosh JL, Drapeau CW. U.S.A suicide 2011: official final data. http://www. suicidology.org/Portals/14/docs/Resources/FactSheets/2011OverallData.pdf. 9 year study period of Divisions I, II, and III: 35 suicides out of 477 student-athlete deaths Incidence of suicide was higher in males (82.9%) and in African-Americans Highest suicide rate occurred in men’s football, with relative risk of suicide being 2.2 > vs. other male, non-football athletes After football, highest risk sports for suicide were soccer, track/cross-country, baseball, and swimming Suicide rate of NCAA athletes was lower than the general and collegiate populations of similar age Concussion history was not ascertained 3X higher risk Adjusting for male sex, low SES, history of suicide attempt, substance abuse, and prior psychiatric diagnoses… 1.27x risk Common beliefs about the effects of sports concussions and mood disorder/suicide: How did things get this way? 1. The Popular Press When a high profile athlete commits suicide, it is front page news… When Joe or Jane Smith commits suicide, it is mentioned quietly in the obits as a “sudden” or “unexpected” death 2. Concussion is the only sports medicine injury now governed by law in all 50 states in the US Plaintiff list in NCAA concussion lawsuit growing, schools bracing September 13, 2013 Jeremy Fowler, College Football Insider 3. Availability Cascades and Risk Regulation Timur Kuran and Cass R. Sunstein “a self-reinforcing process of collective belief formation by which an expressed perception triggers a chain reaction that gives the perception of increasing plausibility through its rising availability in public discourse. The driving mechanism involves a combination of informational and reputational motives: Individuals endorse the perception partly by learning from the apparent beliefs of others and partly by distorting their public responses in the interest of maintaining social acceptance.” _______________________________________________________________ Availability cascade = repeat something long enough and it becomes true, especially if it seems politically correct and appears socially acceptable ________________________________________________________________ Regarding the long term effects of concussion, the availability cascade involves the neglect of empirical data in favor of highly publicized and emotional case findings, with social psychological pressures leading individuals to believe, endorse, and perpetuate the biased perception. Summary The current thinking among some clinicians and researchers seems to be that sport-related concussions and/or subconcussive impacts directly cause psychiatric illness and suicide, and that the presence of postmortem abnormal tau is causal proof of the ante mortem cognitive, mood, impulse dyscontrol, and neurobehavioral changes seen in athletes. It is not certain that the presence of abnormal tau causes the neurobehavioral changes, nor is it clear that the only reason for the presence of the abnormal tau is concussion or subconcussive impacts. If hyperphosphorylated tau directly caused mood disorder and suicide, then there should be a distinctly high prevalence of these conditions in patients with tauopathies, and this is not the case*. If sport-related concussions directly caused psychiatric illness and suicide, then the prevalence should be higher in athletes than in the general population, and this is not the case. For purposes of cause and effect it is critical to account for genetic, medical, psychiatric, substance abuse, and biopsychosocial variables that could well be relevant in the short- and long-term neurobehavioral outcomes. Epidemiological studies indicate that psychiatric illness and suicide are increasing in general, as are diagnosed sport concussions. At present, the current evidence base indicates that attributing the increases in psychiatric illness and suicide solely to sport-related concussions is unwarranted. ________________________________________________________________________________ *Haw, Camilla, Daniel Harwood, and Keith Hawton. "Dementia and suicidal behavior: a review of the literature." International Psychogeriatrics 21.03 (2009): 440-453. *Chesney, Edward, Guy M. Goodwin, and Seena Fazel. "Risks of all‐cause and suicide mortality in mental disorders: a meta‐review." World Psychiatry 13.2 (2014): 153-160. Summary Psychiatric illness, suicide, and cognitive disorders are heterogeneous in nature and multifactorial in etiology. We need controlled, prospective, longitudinal, multi-modal assessment studies to determine the relationships among these factors. Granted, there is little doubt that some athletes may suffer from adverse psychological effects from multiple sport-related concussions. I favor access to mental health services for all. At present, despite anecdotal and case series reports, it is my opinion that there is no compelling empirical evidence to indicate that sport-related concussion or subconcussive impacts are the sole and direct cause of psychiatric illness or suicide. Media reports, financial incentives, cognitive biases, and psychological concerns appear to be primary factors in common beliefs related to the presumed relationship between sport-related concussions and psychiatric illness/suicide. As sports medicine clinicians, it is incumbent on us to focus on the relevant, multivariate factors in the outcome from sport-related concussion, and not to reinforce the simplistic, linear thinking of concussions or subconcussive impacts as the cause of all neuropsychiatric ills. The brain remains gelatinous, and although some of its structures are fragile, it is still not made of spun glass. Thanks to all of you for your time and attention.