Persistent Postconcussion Symptoms Lead to Higher Risk of Depression

Among individuals who experienced PPCS, the likelihood for symptoms of depression is increased.

Higher risk of experiencing depressive symptoms is associated with experiencing persistent postconcussion symptoms (PPCS), according to a systematic review and meta-analysis published in the JAMA Network Open.

Symptoms of PPCS include cognitive difficulties, dizziness, fatigue, headaches, and emotional changes, any of which may lead to psychologic distress, higher levels of disability, and reduced quality of life. Investigators sought to assess the association between depressive symptoms and PPCS, hypothesizing more PPCS would be associated with more depressive symptoms. Secondary outcomes included an examination of potential association moderators to determine whether an association between depressive symptoms and PPCS differed by age, sex, concussive history, mental illness, and time since injury.

This systematic review and meta-analysis included 18 cohort studies (N=9101) culled from the Embase, PsycInfo, CINAHL, and Ovid Medline databases from 1995 to January 2022 and screened independently by 2 study authors. Included studies involved participants who experienced PPCS and quantified depressive symptoms.

PPCS was defined by physician-diagnosed or self-reported concussion, and symptoms lasted at least 4 weeks postinjury. Inclusion criteria included peer-reviewed studies in English only or translated into English, participant Glasgow Coma Scale scores between 13 and 15, loss of consciousness 30 minutes or less, and/or posttraumatic amnesia of less than 24 hours. Investigators sought to examine anxiety, depression, irritability, and aggression.

These findings suggest that individuals with PPCS are at risk of experiencing symptoms of depression; postinjury support and interventions targeting mental health are necessary for optimal outcomes.

There were no age restrictions. Studies with participants with moderate-to-severe traumatic brain injury, in the acute stage of concussion (<4 weeks postinjury), or with unrelated head injuries were excluded, as were opinion articles, dissertations, editorials, and reviews.

Among the included studies, 13 consisted of adult participants. Median sample size was 154 (range 48-4462). Mean time since concussive injury was 21.3±18.7 weeks. Investigators noted a mean of 36.1% of participants had a history of 2 or more concussions.

They found 13 of the studies used a cross-sectional design. Studies were conducted in the US (8), Canada (5), Europe (3), China (1), New Zealand (1). PPCS was most frequently assessed with the Rivermead Post-Concussion Symptoms Questionnaire (6 studies). Depressive symptoms were most frequently assessed with the Patient Health Questionnaire (5 studies), the Beck Depression Inventory-II (4), and the Hospital Anxiety and Depression Scale (2).

Investigators noted random-effects meta-analysis revealed significant positive association between PPCS and depressive symptoms postinjury (odds ratio [OR], 4.87; 95% CI, 3.01-7.90; P < .001) with similar results after accounting for potential publication bias (OR, 4.56; 95% CI, 2.82-7.37; P <.001). They found no significant moderators despite high heterogeneity between studies (I2=95.74%; Q=508.03; P <.001).

Review and meta-analysis limitations include the design nature of this study, heterogeneity in PPCS study methods, use of self-reported measures, lack of randomized controlled trials, operationalization bias, and the inability to make any causal inference.

“These findings suggest that individuals with PPCS are at risk of experiencing symptoms of depression; postinjury support and interventions targeting mental health are necessary for optimal outcomes,” investigators concluded. They believe their findings lead to important health policy and clinical implications, the most significant of which is “the development of strategies for effective prevention and earlier intervention to optimize mental health recovery following a concussion should be supported.”


Lambert M, Sheldrake E, Deneault AA, Wheeler A, Burke M, Scratch S. Depressive symptoms in individuals with persistent postconcussion symptoms: a systematic review and meta-analysis. JAMA Netw Open. Published online December 27, 2022. doi:10.1001/jamanetworkopen.2022.48453