This week, our lead article, Concussion significantly increases the risk of severe mental health illness post-childbirth, is in the Women’s Health category.

In this newsletter: Opportunities, Education, Self-Care, Mental Health, Youth, Women’s Health, and CTE & Neurodegeneration Issues.

We appreciate the Concussion Alliance volunteers and staff who created this edition:
Writers: Ella Webster, Sravya Valiveti, Chelsea Ryan, Runa Katayama, and Malayka Gormally.

Editors: Malayka Gormally and Conor Gormally

Do you find the Concussion Update helpful? If so, forward this to a friend and suggest they subscribe.

Opportunities

A man sits on the floor in front of his couch studying his laptop that is on the coffee table; he is taking notes

Fridays, January 3, 10, 17, 24, 12:30 - 1:00 pm PST: A free series of short webinars, Understanding Cognition; A Workshop Series, presented by Miranda Gendreau, SLP, and hosted by the Brain Injury Alliance of Washington State. Register in advance.

Wednesday, January 8, 4:00 pm PST: A free Weekly Meditation Class led by Diana Winston, Director of UCLA Mindful, and guests. The program is every Wednesday, 4:00 - 5:30 pm PT, except during the holidays. The Zoom link is here; no advance registration is required.

Tuesday, January 14, 6 pm EST: A free webinar, Introduction to the Treatment of Concussions, presented by Dr. Charles Tator (Neurosurgeon), hosted by the Canadian Concussion Centre. Register in advance.

Thursday, January 16, 11 am PST: A free webinar, Navigating SSDI (Social Security Disability Insurance) & SSI (Supplemental Security Income): Understanding Disability Benefits, presented by Aliza Hauser, MA, CRC, PHR and hosted by the Brain Injury Alliance of Washington State. Register in advance.

Last call for enrollment (courses are almost full) for two kinds of free, interactive, online 6-week programs from Love Your Brain. Join a Zoom call for either Group Discussions (45 min classes with group discussion) or Yoga and Discussion (75 min classes with gentle yoga & group discussion.) Each program comes with weekly emails with four mindfulness tools, as well as specialized programs for BIPOC, Veterans, LGBTQIA+, and more. The programs begin in January.

Call for study participants: military veterans who have had concussions and/or a traumatic brain injury, including any injury to your head or neck that caused you to lose consciousness or feel dazed/confused/experience a gap in memory. This includes brain injury resulting from exposure to blasts. Read our blog post for more information on the Late Effects of TBI (LETBI) study. If you are interested, please contact Julia Kirschenbaum at julia.kirschenbaum@mountsinai.org, call us at 212-241-5152, or sign up online.

Education

New tools from CATT and PedsConcussion for screening, diagnosis, and management of brain injury due to intimate partner violence

A woman with headphones on takes notes with a pencil and paper while watching an online courese

An NBC News article, Brain injuries often go unrecognized among domestic violence victims, explains that nearly 25% of all women have experienced domestic violence, and up to 90% of these women have sustained at least one brain injury–including concussion. Most of these women do not get screened for brain injury, including when they go to the emergency department. “Anywhere a domestic violence survivor goes, there should be some sort of screening for a concussion and brain injury,” according to Dr. Javier Cárdenas, director and founder of the West Virginia Brain Injury Center.

Two new tools are available to meet this need. PedsConcussion, the Living Guideline for Pediatric Concussion, has published a Supplement: Intimate Partner Violence-Related Head and Neck Trauma. The supplement is for healthcare providers working with adolescents and provides a trauma-informed approach to initial medical assessment, medical follow-up, different types of medical sub-specialists to refer to for various injuries, and links to further resources. The supplement, created in collaboration with SOAR and researchers from Icahn School of Medicine at Mount Sinai, notes that “Teen dating is a common cause of physical and sexual violence.”

The Concussion Awareness Training Tool (CATT) for Women’s Support Workers is a second tool to address this need. This free online course “is a program designed for people who support survivors of intimate partner violence. It provides the information needed to take an evidence-based approach in recognizing, responding to, and managing concussion.” The course is 45 minutes long, includes five learning checks, and awards a certificate upon completion. In addition to the course, you can read several CATT posts about concussions in the context of intimate partner violence.

Self-Care

Download a free, high-quality mindfulness app

A mental health professional alerted us to a free, high-quality mindfulness app from the UCLA Mindfulness Education Center (also in a Spanish language version). It is good timing to share information about this app since our previous newsletter covered meditation, particularly mindfulness, for at-risk populations. We also discuss mindfulness in our Yoga and Meditation resource. Information about the UCLA Mindful App is here; download the UCLA Mindful App on the Apple Store or Google Play.

The UCLA Mindful App includes eight different Basic Meditations (available in multiple languages), a series of six Health and Wellness Meditations, recordings of Weekly Meditations and Talks led by the UCLA team, a meditation timer, and a link to many of these same resources (including videos) in Spanish.

Check out their video gallery on their website, which includes pre-recorded talks about meditation and mindfulness.

You can also join their free Weekly Meditation Class, led by Diana Winston, Director of UCLA Mindful. The program is every Wednesday, 4:00 - 5:30 pm PST, but there is no class on December 25 or January 1. The live programs explore topics such as "self-compassion, working with judgments, obstacles to meditation, dealing with difficult emotions, mindfulness in challenging times, and the spectrum of awareness.”

Mental Health

Psychiatric symptoms caused by multiple concussions may be due to the kynurenine pathway and structural changes in the brain in collegiate-aged athletes

In a study published in Brain, Behavior, and Immunity, Timothy B. Meier et al. investigated the link between concussion history, changes in limbic brain structure (the emotional processing system), and psychiatric symptoms, focusing on the kynurenine pathway (KP) as a potential mechanism. The KP is a metabolic pathway connected to inflammation, the immune system, and neurological conditions.

While prior studies have identified correlations between a higher incidence of concussions and mood disorders, this study suggests that inflammation-induced activation of the KP may underlie the association between cumulative concussions, psychiatric symptoms, and brain structure changes. The authors believe that the changes in the KP could explain these connections, noting that this pathway is associated with the development of mood disorders.

The study suggests that inflammation from repeated concussions activates the KP, diverting tryptophan (an essential amino acid) metabolism away from kynurenic acid (a neuroprotective metabolite) and toward Quinolinic Acid (QuinA), which is a potentially neurotoxic byproduct. These findings highlight the KP’s role in concussion-related psychiatric outcomes, particularly in female athletes. The study describes the association between changes in the KP pathway, reduction in hippocampal volume and white matter changes in the brain, and psychiatric outcomes.

The researchers analyzed 212 healthy collegiate athletes (male and female), collecting data on concussion history, psychiatric symptoms, serum biomarkers, and MRI scans. They found that a history of concussions was linked to greater depression, anxiety, and anhedonia symptoms (inability to experience joy or pleasure) in females and increased depression symptoms in males. More concussions were associated with MRI results revealing structural changes in the hippocampus (primarily associated with memory and learning), including hippocampal volume reduction and white matter microstructure changes, which were associated with “more severe anxiety and depression symptoms.”

These structural brain changes were also associated with blood serum level indicators of changes in the kynurenine pathway and with psychiatric symptoms in both sexes. In the KP, females with more concussions showed elevated levels of QuinA in the blood, while males exhibited reduced tryptophan levels. Elevated QuinA was associated with worse anxiety symptoms in females, while hippocampal volume reduction and white matter microstructure changes correlated with psychiatric symptoms. In males, lower tryptophan levels and smaller hippocampal volumes were associated with “more severe anxiety and depression symptoms.”

While the initial findings of this study are promising, the study emphasizes the need for further research to confirm the KP’s involvement and explore sex-specific effects in concussion recovery.

Youth

Sleep problems, depression, are risk factors for lower quality-of-life scores after concussion

A recent study published in the Journal of Pediatrics by researchers Jamie Shoop et al. studied health-related quality of life (HRQL) metrics and other psychological factors post-concussion in youth over a 12-month period. They found that psychological risk factors such as anxiety and depression negatively impact health-related quality of life in the initial 6-month phase of pediatric concussion, followed by steady improvement over the following six months. The study authors urged that healthcare providers should not overlook negative psychological changes immediately following a concussion, as they could serve as indicators of the risk for poor recovery outcomes.

A Children’s Hospital of Philadelphia (CHOP) press release emphasized that sleep disturbance and depressive symptoms, in particular, are two key risk factors linked to significantly lower HQRL following concussion, “demonstrating how concussion can have a ripple effect, impacting not only how a child feels physically and emotionally but also how they perform at school and in their relationships with friends and family.” Dr. Sloop emphasized that while the HRQL changes are transitory, it’s essential for healthcare providers to provide support for “cognitive and social-emotional symptoms following injury.”

The study evaluated 49 concussed patients who were receiving care at a specialty concussion program (the Minds Matter Concussion Program at CHOP). The concussed patients (median age 15.4 years) were followed to monitor health-related quality of life changes and completed self-reported HRQL questionnaires regularly across the 12-month period. The data was compared to that of non-concussed control patients who also completed these assessments. Health-related quality of life was found to be significantly lower in the 6 months post-injury in concussed adolescents, followed by gradual improvement over the next 6 months after the initial clinical assessment. Some of the key factors that the authors considered were mental health history prior to concussion, presence of pre-injury or current symptoms of anxiety and depression, sleep disturbance, and poorer results on the Short Grit Scale (which measures perseverance)––all of which negatively impacted HRQL in the initial phase.

Examining these quality-of-life measures and psychological changes in youth can help inform better quality of care in the acute phase post-concussion and provide comprehensive support that takes adolescent concussion patients’ physical, cognitive, and socio-emotional well-being into account.

Women’s Health

Concussion significantly increases the risk of severe mental health illness post-childbirth

A study in the Journal of Clinical Psychiatry has found evidence to suggest a link between concussion history and a 25% increased risk of severe mental health challenges in the 14 years after childbirth in comparison to those who have no history of concussion. Krueger et al. note that the risk was even higher for those with no pre-existing mental health conditions––increasing the risk of severe mental health illness in the years after childbirth to 33% higher than those who have not sustained a concussion. In a University of Toronto press release, Kruger notes that “concussion may be an important but overlooked risk factor during pregnancy and postpartum care.”

This study tracked over 750,000 individuals in Ontario, Canada over 10 years (2007-2017). Severe mental health outcomes noted in the study included self-harm or suicide, psychiatric emergency department visits, and psychiatric hospitalization. All these outcomes occurred significantly more frequently among the population with a history of concussion.

Study author Dr. Hilary Brown suggests that the “physical and emotional challenges of parenting,” including sleep deprivation, may worsen any existing concussion symptoms. She notes that “Sleep is critical to recovery after a head injury, but sleep deprivation is a reality for many new parents.” Additionally, Brown states that “Cognitive impairments, sensitivities to light and noise, and the stress of caring for a newborn can all intensify concussion symptoms, which in turn may raise the risk of mental health issues over time.”

These findings underscore the importance of early identification and tailored care for women with a concussion history. Routine screening during maternal care could help healthcare providers implement interventions to mitigate mental health risks. Potential support measures include programs targeted to address sleep, stress management, and emotional well-being.

Integrating concussion history screening into maternal care policies worldwide could safeguard the mental health of many new parents and foster healthier mental health outcomes for families.

CTE & Neurodegeneration Issues

Retired rugby players with concussion history have biomarkers that indicate risk of neurodegenerative diseases

In a new study published in the International Journal of Molecular Sciences, researchers involved in the UK Rugby Health Project found that retired rugby players who have a history of concussion have altered levels of specific proteins in their blood, indicating greater neural damage than their uninjured peers. These proteins include t-tau and p-tau 181, which are associated with neurodegeneration. A University of Durham press release suggests, “If athletes’ blood can be tested and monitored for these specific proteins, it may be possible to diagnose them early for neurodegenerative diseases and provide early interventions. ”

Norah Alanazi et al. evaluated 30 randomly selected retired male rugby players with a significant history of concussion. They compared the retired players with 26 non-contact sport athletes to “assess differences in specific biomarkers…focusing on biomarkers associated with Alzheimer’s, ALS, and CTE.” Serum biomarkers, plasma cytokines, and biomarkers associated with exosomes were analyzed with ELISA assays.

The study authors identified that biomarkers of total tau (t-tau) and phosphorylated tau (p-tau181) were elevated in the group of rugby players with previous concussion history. Elevated T-tau in the cerebrospinal fluid has been “associated with neuronal and axonal degeneration,” and p-tau 181 has been “suggested as a promising blood-based biomarker” that anticipates Alzheimer’s. Additionally, these retired rugby players with a concussion history “had lower levels of a different so-called retinoid transport protein which is important for the development and functioning of the brain.”

The differences in levels of biomarkers in athletes with concussion history show that these biomarkers could be an early indicator for future neurodegenerative diseases. The press release mentions that this study serves as a “beginnings of a biomarker toolbox to periodically monitor brain health” for retired athletes with concussion history. Further clinical trials to test the efficacy of interventions and a longitudinal follow-up with the study subjects are needed to validate current levels of proteins and reduce the risk of neurodegenerative diseases.