This document discusses mood and sleep disorders that can occur after concussions. It notes that common sleep issues include insomnia, hypersomnia, and poor sleep quality. Poor sleep after concussions is associated with prolonged recovery times and worse outcomes. It also discusses the high rates of mood issues like anxiety and depression after concussions. Treatment options discussed include sleep hygiene, melatonin, CBT-I, and medications. The relationship between sleep, mood, and concussion recovery is bi-directional, so screening and treating both is important for optimal recovery.

1. Mood and Sleep Disorder in Concussion
Brett Dusenberry, MD

2. FINANCIAL DISCLOSURES

3. Objectives
• Identify common sleep disturbances after concussion
• Identify risk factors for development of mood symptoms after
concussion
• Recognize treatment strategies to reduce sleep and mood
symptoms after concussion

5. CONCUSSION
SLEEPMOOD

6. SLEEP DISORDERS IN CONCUSSION

7. Sleep Symptoms After Concussion
• Increased sleep latency
• Increased sleep disturbance
• Insomnia/Hypersomnia
• Increased daytime dysfunction
• Decreased sleep quality
• Increased fatigue

8. Consequences of Decreased Sleep
• Decreased endurance and sprint sport performance
• Decreased accuracy in sports
• Increased injury and illness risk
• Increased depression risk
Also found increase in accuracy, reaction time and sprint performance after increased
sleep duration (Watson 2017)

9. Frequency of Sleep Symptoms
• 34% of patients reported sleep disturbance (Bramley 2017, n- 367)
• 50% of patients had some form of sleep disturbance (Mathias 2012)
• 70% of patients experienced sleep disturbance (Paniak 2002, n- 118)

10. Concussion Leading to Sleep Problems
• Higher level of sleep related problems at 5 weeks in concussed patients
(Barlow 2020)
• Increased rate of sleep disturbances in individuals who have recovered
from concussion (Blake 2019)

11. Sleep Issues Prolong Concussion Symptoms
• Poor sleep vs good sleep
groups
– higher symptom scores at initial
visit and at 3 months post injury
in poor sleep
– Poor sleep group took 2 weeks
longer to recover (Chung 2019)
• Sleep disturbance associated
with almost 4 fold increase in
recovery time (Bramley 2017)

12. Is Poor Sleep A Risk Factor For Concussion?
Athletes with a history of moderate to severe insomnia
have a 2-3x higher risk of concussion (Raikes 2019)

13. Chicken Or The Egg

14. CONCUSSION
SLEEPMOOD

15. Ways To Treat Sleep Symptoms
• Sleep hygiene
• Melatonin
• Prescription medications
• CBT-I
• Blue light therapy?
• Active rehab

16. Sleep Hygiene
• Regular bedtime and wake
time
• Use bed for sleep only
• Cool, quiet, dark room
• No electronics before bed
• Avoid caffeine
• Daily exercise
• Avoid naps if not able to
sleep through the night

17. Melatonin
• Helps with sleep onset, some neuroprotective and antioxidant
properties (Zizhen 2017)
• Favorable safety profile
• AASM does not advocate for melatonin given weak evidence of
efficacy

18. Melatonin In Concussion
• RCT of melatonin vs placebo
showed improvement in sleep
onset time (Sletten 2018)
• 67% of concussed patients reported
improved sleep with melatonin
(Bramley 2017)
• RCT of melatonin vs placebo in
children with PPCS showed no
benefit (Barlow 2020)

19. Medications For Sleep
• Trazodone
• Zolpidem (Ambien)
• Amitriptyline
• Benzodiazepines and Diphenhydramine
are not recommended (Driver 2018)

20. Therapy For Sleep
• CBT-I (cognitive behavioral
therapy for insomnia)
• Has been shown to treat
insomnia in adults, limited
data in pediatrics
• RCT of CBT-I vs treatment as
usual in adolescents with
PPCS shows improvement
(Tomfohr-Madsen 2020)

21. Therapy For Sleep
• Blue light therapy
• RCT of blue vs amber light each morning
in patients with sleep problems after
mTBI showed improvement of
symptoms (Killgore 2020)
– Phase advanced sleep onset, but no
change in overall sleep duration
– Reduced daytime sleepiness
– Improved executive functioning
– Improved interconnectivity in brain
on DTI MRI

22. MOOD DISORDERS IN CONCUSSION

23. Mood Symptoms Seen In Concussion
• Anxiety
• Depression
• Irritability
• ADD/ADHD
• PTSD
• Personality changes
• Behavioral disorders

24. Frequency of Mood Symptoms With Concussion
• 23% of youth had psychological distress at 4 and 12
weeks post concussion (Brooks 2019)
• 22% of children recovering from concussion had
depression symptoms (Stazyk 2017)
• 49.4% of patients recovering from concussion had at
least 1 emotional symptom (Ellis 2015)

25. Mood Symptoms and Duration of Concussion
• Children with depressive symptoms had higher post
concussion symptom scores (Stayzk 2017, Ellis 2015)
• Pre concussion depression or anxiety disorder are
markers for prolonged concussion symptoms (Meares
2011)

26. Concussion Leading to Mood Issues
• Dose response relationship between amount of prior
concussions and risk for future diagnosis of depression
in retired NFL players (Kerr 2012)
• History of concussion was associated with a 3.3x greater
risk of diagnosis of depression in adolescents (Chrisman
2014)

27. Concussion and Elevated Anxiety
• Athletes may be worried about losing position on the
team, future scholarships and relationships with
teammates
• Adults may be worried about loss of income and
inability to support family
• Pandemics don’t help either

28. Concussion and ADHD
• Higher rate of concussion in adolescents with ADHD (Iverson 2016)
• Systematic review: Those with ADHD or LD do not appear to be at
substantially greater risk of concussion (Iverson 2017)
• Higher prevalence of prior concussion in adolescents with ADHD and/or LD
(Iverson 2020)
• 50% of adolescents with concussion had predating ADHD (Iaccarino 2018)
• Higher post concussion symptom score in patients with ADHD (Iaccarino 2018)

29. CONCUSSION
SLEEPMOOD

30. Ways to Treat Mood Symptoms With Concussion
• Reassurance, education, support
• Mindfulness and relaxation
• CBT
• Medication (SSRI etc.)
• Active rehab

31. Reassurance and Relaxation in Concussion
• Reassurance and education
– 10 randomized studies reviewed-
mixed results
• Relaxation and mindfulness-
– 2 randomized studies reviewed-
mixed results (Al Sayegh 2010)

32. Therapy for Mood Symptoms
• CBT
– 3 RCTs - all showing some benefit
• Reduced frequency, intensity and
duration of symptoms at 6 mo
• Improved anxiety and depression
symptoms at 1 mo
• Improvement in psychosocial
functioning (anxiety and depression)
– 7 non randomized studies- all showed
some benefit (Al Sayegh 2010)

33. Medication for Mood Symptoms
• SSRIs (Fluoxetine, Sertraline, etc)- first line
• SNRIs (Duloxetine, Venlafaxine, etc)- second line
– 2018 meta analysis shows no benefit for SSRI/SNRI vs placebo
– Included study with questionable mTBI
– Silverberg et al suggest treating mTBI with SSRIs (Silverberg 2019)

34. Relationship Between Sleep and Mood Symptoms
• In a cohort of pediatric patients with anxiety
disorder, 88% also had sleep related problems
(Chorney 2007)
• In a cohort of pediatric patients with depression
disorder, 74% also had significant insomnia
(Chorney 2007)
• Levels of anxiety and depression were found to
correlate with changes in sleep in TBI patients
(Parcell 2008)

35. CONCUSSION
SLEEPMOOD

36. Take Home Points
• There is a bi directional relationship between
– Concussion and sleep
– Concussion and mood
• Early recognition and treatment of sleep and mood
issues is important in concussion

37. References
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• Paniak C, Reynolds S, Phillips K, Toller-Lobe G, Melnyk A, Nagy J. Patient complaints within 1 month of mild traumatic brain injury: a controlled study. Arch Clin
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39. QUESTIONS???