Collaborative Care May Aid Kids’ Concussion Recovery

Multi-modal approach saw improved symptoms, less depression

Excerpted from Med Page Today | By Molly Walker

Collaborative care, including cognitive behavioral therapy (CBT), was linked with decreased reporting of post-concussive symptoms as well as fewer depressive symptoms among adolescents with persistent symptoms of concussion, a small randomized trial found.

Six months following treatment, a significantly smaller portion of the group that received collaborative care reported having post-concussive symptoms, and a larger portion of the collaborative care group reported a significant reduction in depressive symptoms compared with kids receiving usual care, reported Carolyn A. McCarty, PhD, of Seattle Children’s Hospital, and colleagues, writing in Pediatrics.

In an email to MedPage Today, McCarty said that there are no evidence-based treatments to address prolonged concussive symptoms, which can be particularly problematic for adolescents, who are learning and developing very rapidly.

“Based on our experience using collaborative care and cognitive behavioral therapies to address other health problems, we had reason to believe that these approaches would translate well to address post-concussive symptoms,” she said.

“We believe we have developed an effective alternative to watchful waiting that meaningfully impacts quality of life for patients with prolonged concussion.”

This was a small pilot study of 47 patients ages 11-17 years (mean 15.0 years, 65% girls, 75% white), who reported persistent symptoms more than a month after a sports-related concussion. The sample was comprised of 57.5% sports-related concussions and 42.5% recreation-related concussions (such as trampoline park injuries). There was a significantly larger portion of kids sustaining sports-related concussions in the collaborative care group versus those in usual care.

Overall, after the full 6 months of treatment, 13.0% of the collaborative care group continued to report post-concussive symptoms compared with 41.7% of the usual care group (P=0.03). Over three-quarters of the collaborative care group also reported a more than 50% reduction in depressive symptoms after 6 months of treatment compared with 45.8% of the usual care group (P=0.02). However, there were no significant differences between the two groups in anxiety symptoms.

McCarty added that 41% of the sample presented with symptoms of depression, a frequently co-occurring problem among youth with post-concussive symptoms.

“It is important to screen for depression among youth with persistent concussion symptoms,” she said. “Pediatricians should also consider partnering with a behavioral health provider when possible to manage these patients, particularly therapists with experience using cognitive behavioral approaches.”

In total, 23 patients completed the collaborative care model of treatment. Each patient received cognitive behavioral therapy to target symptoms of anxiety and depression. Care management involved coordinating with the patient’s school as the treatment progressed. Patients also had the opportunity to consult with an expert in pediatric psychopharmacology to address any symptoms that did not respond to behavioral therapy.

For the 24 patients who completed the usual care model, they received an initial visit to a sports medicine-trained physician, followed by a referral to an expert in pediatric rehabilitation if symptoms did not resolve in 4-6 weeks. Follow-up was conducted by the referring clinic concussion specialist.

Examining types of healthcare visits, 33% of the usual care group reported visits to a mental health professional, while 8% saw a psychiatrist. Nearly 60% of the usual care group saw their primary care physician, although 21% sought treatment from “another physician.”

A third of the collaborative care group received psycho-pharmacologic counseling, and completed a median number of eight CBT sessions over the 6-month treatment period. Outpatient concussion-related visits were similar between the intervention and control groups (average of 6.2 visits versus 5.8 visits, respectively).

Limitations to the study include the small sample size and demographic makeup, which may limit the generalizability of the findings, and that researchers used the PHQ-9 to evaluate depressive symptoms, which may overlap with concussion symptoms.

McCarty characterized the study as “a great launching point” for more research, such as whether boys recover differently from concussions than girls, as well as a longer follow-up period to observe the patients. She added that further collaboration is needed with schools in terms of managing students who have had a concussion.

“We found that there are often school-related needs and issues to consider in the treatment plan as well, such as determining whether accommodations are needed to promote academic learning in the context of post-concussive symptoms,” said McCarty.

“More guidance and education is needed around when and how to support patients as they ‘return to learn.' ”

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