Premorbid anxiety and depression and baseline neurocognitive, ocular-motor and vestibular performance: A retrospective cohort study

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Highlights

  • Athletes reporting premorbid anxiety and/or depression perform worse on visual motor speed components of neurocognitive testing

  • No differences were found between matched controls and athletes reporting premorbid anxiety and/or depression on baseline Vestibular/Ocular Motor Screening and King-Devick assessments

  • Athletes reporting premorbid anxiety and/or depression report higher symptom severity scores than matched controls

  • Poorer visual motor speed performance and higher symptom severity scores are not unusual for athletes with premorbid psychological conditions

Abstract

Concussion has become a growing concern among sport and healthcare practitioners. Experts continue to investigate ways to advance the quality of concussion evaluation, diagnosis and management. Psychological conditions have been reported to influence concussion assessment outcomes at baseline and post-concussion; however, little evidence has examined psychological conditions and their effect on multifaceted measures of concussion. A retrospective cohort design was employed to examine differences between those with and without a premorbid psychological condition for high school and collegiate athletes who completed a preseason baseline battery, consisting of symptom reporting, computerized neurocognitive assessment, Vestibular-Ocular Motor Screening (VOMS), and the King-Devick (KD) test. Forty athletes within the sample self-reported a diagnosed psychological risk factor, consisting of depression and/or anxiety, and each were matched with a discordant control. Controls were matched on sex, age, sport, concussion history and ocular history. Athletes with psychological conditions reported higher symptom severity and had worse visual motor speed than controls. There were no differences between groups on other neurocognitive domains, VOMS, or KD. These results suggest that vestibular-ocular tools may be more consistent or less likely to vary between those with and without a premorbid psychological diagnosis, adding value to tools such as the KD and VOMS.

Introduction

Concussion is a heterogeneous injury [1] and current literature is encouraging individualized and multimodal management. [2,3] Further, individual differences between athletes at baseline and during the pathophysiologic recovery, account for the incongruent outcomes seen in real life. [4] Differences in testing at baseline and during recovery could be influenced by an athlete's past concussion history, personal and family medical history, and concurrent diagnoses. Specifically, neurocognitive assessments utilized for concussion evaluation and treatment can be affected pre- or post-injury by what consensus statements and professional organizations delineate as ‘modifying factors.’ [5,6] These include, but are not limited to, pre- and co-morbidities such as depression [7] and anxiety [8], sex [9,10], history of migraines/headaches [11,12], attention deficit hyperactivity disorder (ADHD) [[13], [14], [15]], learning disability (LD) [14,15] and sleep disorders. [16] Empirical evidence prospectively exploring modifying factors associated with performance on multifaceted concussion measures at baseline is lacking.

In the United States, 46.6 million adults experience symptoms associated with mental illness representing 18.9% of the population, while prevalence among adolescents was as high as 49.5%. [17] Each year, approximately 20% of adults and 32% of adolescents experience symptoms related to anxiety [18], while 7.1% of adults and 13.3% of adolescents experience episodes of major depression. [19] A lack of clinical diagnosis(es) does not negate the presence of depressive or anxiety-related symptoms, as research indicates 32–55% of the athletic population endorses symptoms of psychological distress, and 24% of healthy controls report a symptom score of 6+ on the Post-Concussion Symptom Scale (PCSS). [20,21] Premorbid depression and anxiety have been shown to increase overall symptom severity at baseline [22] and can lengthen recovery after concussion. [23] Moreover, concussed athletes who reported symptoms of depression at baseline were 4.59 times more likely to experience depression symptoms post-concussion and 3.40 times more likely to experience anxiety [24].

Premorbid psychological conditions have shown to influence performance on computerized neurocognitive testing. Individuals reporting symptoms of severe depression at baseline demonstrate slower reaction time and visual motor speed, and poorer verbal and visual memory scores on computerized neurocognitive assessments [25]. Further, among collegiate athletes, verbal memory impairments have been weakly correlated with psychological conditions of anxiety and depression [22]. Psychological symptoms can be transient in nature, but have the potential to have moderate to large effects on baseline concussion testing, providing an additional challenge to clinicians who must balance pre- and co-existing morbidities with concussion management post-injury.

Numerous concussion assessment tools are receiving growing implementation to help clinicians evaluate and manage concussions, such as the King-Devick (KD) and the Vestibular Ocular-Motor Screening (VOMS). The KD test was originally developed as a reading tool to assess the relationship between poor oculomotor function and LD [26], and the VOMS is a valid and consistent assessment tool requiring minimal equipment to assesses vestibular and ocular motor impairments via patient-reported symptom provocation. [27] Researchers have begun to examine risk factors on baseline KD and VOMS performance. Specifically, a study investigating sex differences reported that females performed better than males at baseline on the KD, yet sex did not influence baseline performance on the VOMS. [28] Further, Vartiainen et al. [29] reported that professional ice hockey players with a history of concussion did not differ at baseline on the KD from those without a history of concussion. Within the literature, other modifying risk factors of age [28], motion sensitivity [30,31], history of migraine [11], ADHD [14], and LD [14] have been studied and some have shown to elicit differences in performance on vestibular and ocular-motor measures at baseline; however, no research to-date has investigated if pre-existing psychological conditions affect baseline scores on the KD or VOMS.

It is imperative for clinicians and researchers to consider premorbid and comorbid psychological conditions at baseline, especially when using these assessments to make clinical return-to-play decisions. While previous research has reported athletes with a history of psychological disorders performed worse on some baseline measures of neurocognitive function and self-reported symptoms [20,22], research to-date has yet to examine psychological conditions on vestibular/ocular motor assessments. Therefore, the current study examined differences between individuals with and without a diagnosis of premorbid psychological conditions (depression and/or anxiety) and baseline measures on symptom reporting, neurocognitive assessment, and vestibular-ocular motor assessments.

Section snippets

Methods

Research Design and Participants.

This study employed a retrospective cohort design. Collegiate athletes from a Division I university and athletes from nine different high schools were recruited for this study. Prior to the start of the athletic season, any athlete who self-reported a history of being diagnosed by a medical professional with one of the following psychological conditions on pre-participation health history materials was identified for final analyses: depression and/or anxiety. A

Results

A total of 80 participants from a larger sample of 261 total subjects (age = 17.74 ± 2.7 years) completed a baseline ImPACT computerized neurocognitive assessment, KD and VOMS assessment, consisting of 40 individuals diagnosed with a psychological condition, defined as a self-report history of anxiety alone (12/40, 30%), depression alone (2/40, 5%) or both anxiety and depression (26/40, 65%), cases (age = 17.73 ± 2.8 years) and 40 match controls (age = 17.75 ± 2.7 years). Of the 80, 36 (45%)

Discussion

The current study examined the influence of psychological conditions of diagnosed anxiety and depression and their effect on baseline concussion outcomes, specifically cognitive, vestibular and ocular-motor function, and symptom severity scores. The primary findings from this study suggest that at baseline those with a premorbid diagnosis of anxiety and/or depression, report higher overall symptom severity scores, and have worse visual motor speed compared to matched controls. At baseline,

Conclusion

While previous literature has investigated psychological conditions as a result of concussion, there still remains a lack of evidence prospectively investigating pre-existing psychological conditions on baseline measures. Congruent with other studies, a self-reported premorbid psychological condition diagnosis appears to elicit a greater difference in baseline symptom severities and visual motor speed compared to those without a diagnosis. Despite the inability to demonstrate a difference on

Funding

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

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