Psychological Distress Differs Between Female and Male College Athletes During Baseline Concussion Assessment
2021; Volume: 13; Issue: 5 Linguagem: Inglês
10.3928/19425864-20210228-02
ISSN1942-5872
AutoresPatricia R. Roby, Cassie B. Ford, Erin B. Wasserman, Corey J. Rodrigo, J.D. DeFreese, Michael McCrea, Jason P. Mihalik,
Tópico(s)Cardiac Arrest and Resuscitation
ResumoOriginal Research freePsychological Distress Differs Between Female and Male College Athletes During Baseline Concussion Assessment Patricia R. Roby, PhD, ATC, ; , PhD, ATC Cassie B. Ford, PhD, ; , PhD Erin B. Wasserman, PhD, ; , PhD Corey J. Rodrigo, ATC, ; , ATC J. D. DeFreese, PhD, ; , PhD Michael McCrea, PhD, ABPP, ; , PhD, ABPP Jason P. Mihalik, PhD, CAT(C), ATC, , PhD, CAT(C), ATC Patricia R. Roby, PhD, ATC , Cassie B. Ford, PhD , Erin B. Wasserman, PhD , Corey J. Rodrigo, ATC , J. D. DeFreese, PhD , Michael McCrea, PhD, ABPP , and Jason P. Mihalik, PhD, CAT(C), ATC Athletic Training & Sports Health Care, 2021;13(5):e317–e322Published Online:June 11, 2021https://doi.org/10.3928/19425864-20210228-02AbstractPDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinkedInRedditEmail SectionsMoreAbstractPurpose:To examine how preseason psychological distress measures (ie, depression, anxiety, and somatization) in college athletes are affected by sex and concussion history.Methods:Division I college athletes (N = 414; 262 [63.3%] men; 152 [36.7%] women; age = 20.6 ± 1.4 years) with a self-reported concussion history (n = 128; 52 [41%] women; 76 [59%] men) and with no self-reported concussion history (n = 286; 100 (35%) women; 186 [65%] men) completed demographics, concussion history, and Brief Symptom Inventory 18 (BSI-18) (somatization, anxiety, depression subscales) measures during preseason testing.Results:A significant sex-by-concussion history interaction was found for the anxiety subscale (chi-square = −0.98, P < .01) such that female student-athletes with a concussion history reported a higher anxiety symptom frequency. Men were more likely than women to endorse no symptoms using total BSI-18 score and all subscales.Conclusions:Men were significantly more likely to endorse zero symptoms than women, whereas women with a concussion history reported the highest anxiety subscale scores. Results suggest more sensitive metrics are needed when screening for psychological distress in athletes.[Athletic Training & Sports Health Care. 2021;13(5):e317–e322.]IntroductionIt is estimated that 6.2% of all injuries sustained by National Collegiate Athletic Association varsity athletes are sport-related concussions.1 Although the overall incidence rates remain unchanged, national estimates of reported sport-related concussions demonstrated statistically significant linear trends in specific sports such as men's football, women's ice hockey, and men's lacrosse.1 In reality, this incidence rate may be higher because underreporting remains an issue in collegiate sports.2 Current guidelines recommend that sport-related concussion assessment include self-reported symptoms, motor control testing, and neurocognitive assessment to complement the clinical examination.2 Although the most common concussion-related symptomology includes headache, dizziness, and neurocognitive deficits, recent consensus reports have advocated for research focusing on mood state changes and psychological distress following injury.3 A deeper understanding of athlete psychological distress with variables relevant to holistic athlete health care (ie, sex and concussion history) represents a unique opportunity to better understand and promote college athlete mental health within the concussion research-to-practice literature.Psychological distress is a clinically relevant issue on college campuses because students are at a higher risk for depressive symptoms due to adaptation to a new collegiate environment and changes in familial support.4 With additional stressors brought on by competition and injury risk, collegiate student-athletes may also be at an increased risk for depression, anxiety, and emotional dysregulation.5 The importance of psychological distress to concussion is well known; however, the connection of these psychological maladies to sex is also of empirical and practice interest. Psychological distress may be heightened in healthy female student-athletes who report higher levels of depression5,6 and social anxiety6 than both male student-athletes and non-athletes. Because women tend to be at a higher risk for concussion7 and concussion history has been linked to an increased risk in late-life depression,8 female athletes may be at an increased risk for psychological distress following concussion. To our knowledge, no studies have investigated sex differences in late-life depression among athletes. Female student-athletes tend to endorse more total symptoms and more severe symptoms after injury than men.7,9 This suggests that female student-athletes may experience concussive symptoms, particularly psychological symptoms, differently than men. Current literature has shown that college-aged men are less willing to endorse any mental health–related symptomology.10 These inherent factors may also influence common measure of psychological distress used within baseline concussion assessment protocols, namely the Brief Symptom Inventory 18 (BSI-18).Although college students seem to be at risk for psychological distress, current research on psychological distress, mood disturbance, and concussion history in athletic populations has been primarily focused on adult or retired populations. In retired populations, recurrent concussions have been associated with later life neurodegenerative deficits, cognitive impairments, and depression.8,11,12 More recently in collegiate athletics, Weber et al13 reported a higher self-reported concussion history of four or more injuries indicated greater anxiety, depression, and somatization at baseline. However, this study did not explore sex specifically or the important intersection between concussion history and sex, an important future direction with implications for research and practice. Sex differences have been reported in psychological measures in healthy populations. Understanding the influence sex differences have on these psychological outcomes in collegiate athletes with a concussion history is warranted. Therefore, the purpose of this study was to examine potential sex differences in psychological distress, including anxiety, depression, and somatization, in healthy college athletes. A secondary purpose of this study was to build on the Weber et al13 study by assessing how sex might influence the association of concussion history with psychological symptom endorsement.MethodsThe Office of Human Research Ethics at the University of North Carolina at Chapel Hill approved this research study and all participants provided informed consent prior to participating in the study. Participants included 414 collegiate athletes from a Division I institution (152 women, 262 men, age = 20.6 ± 1.4 years; age range = 18 to 25 years). The athletes selected for this study were practicing and competing in 18 varsity sports (baseball, crew, football, field hockey, fencing, gymnastics, softball, swimming and diving, track and field, volleyball, wrestling, men's basketball, men's and women's lacrosse, men's and women's soccer, and men's and women's tennis) during the 2014–2016 academic seasons. Additional descriptive statistics are reported in Table 1.Table 1 Descriptive Sample Data Categorized by SexParameterSexTotal (N = 414)Female (n = 152)Male (n = 262)Concussion history Yes5276128 No100186286Age, years (mean ± SD)20.5 ± 1.320.7 ± 1.420.6 ± 1.4Sport Contacta (%)31 (18)140 (82)171 Non-contactb (%)121 (50)122 (50)243Previous concussion frequency (range)0.41 (0 to 3)0.36 (0 to 3)1.2 (0 to 3)SD = standard deviationaContact sports included football, men's and women's soccer, and men's and women's lacrosse.bNon-contact sports included baseball, crew, field hockey, fencing, gymnastics, softball, swimming and diving, track and field, volleyball, wrestling, men's basketball, and men's and women's tennis.InstrumentationThe BSI-1814 is an 18-item screening tool that asks participants to report how much certain problems have distressed or bothered them during the past 7 days on a 5-point Likert scale (0 = not at all; 4 = extremely). The BSI-18 provides a total score (Global Severity Index; max = 72) and separate subscale scores for somatization, anxiety, and depression (max = 24 each), with six questions contributing to each subscale. Somatization included items related to feeling weak, nausea, numbness, faintness, trouble getting breath, and chest pains. Anxiety items included feeling tense, nervousness, feeling fearful, panic spells, suddenly scared, and feeling restless. Depression items included feeling blue, feeling no interest in things, feeling lonely, feeling hopeless about the future, feeling worthless, and suicidal thoughts. The BSI-18 has been used to assess psychological distress in healthy collegiate athlete populations and patients with traumatic brain injury and has exhibited good reliability and validity (Cronbach's alpha ranging from 0.83 to 0.91).14,15ProceduresOnce participants provided informed consent, they completed a series of demographic data collection forms where they identified personal information to obtain information related to sex and self-reported concussion history. For the purpose of this study, student-athletes were asked to identify any concussion resulting in "a change in brain function following a force to the head, which may be accompanied by temporary loss of consciousness, but is identified in awake individuals with measures of neurologic and cognitive dysfunction." Participants were also given examples of potential symptoms, including headache, difficulty concentrating or focusing, and feeling slowed down. It was also noted that a concussion can occur without being "knocked out" or rendering an athlete to be unconscious, and that getting your "bell rung" and "clearing the cobwebs" is a concussion.16 Using these guidelines, participants completed a self-report concussion history frequency. Participants also completed the BSI-18 as a part of this baseline data collection session.Statistical AnalysisOur study sample (N = 414 participants) was stratified into two groups to address our primary aim: women (n = 152; n = 52 [34.2%]) with self-reported concussion history and men (n = 262; n = 76 [29.0%]) with self-reported concussion history. Descriptive statistics were calculated for demographic variables and BSI-18 total and subscale scores. Due to the presence of zeros and extreme skewness in our dependent measures, zero-inflated Poisson regression models (employing Wald chi-square statistics) were used to assess the effects of sex (primary aim) and concussion history (secondary aim) on the various BSI-18 measures. Alpha (α) levels were set to 0.05 a priori.ResultsA significant sex-by-concussion history interaction was found for the anxiety subscale (chi-square = −0.98, P < .01) such that women with a concussion history reported significantly higher anxiety scores than men (Table 2). When examining the probability of a student-athlete reporting zero symptoms versus any symptoms, men were more likely to endorse zeros relative to women for BSI-18 total score (chi-square = 1.41, P < .01), depression (chi-square = 0.84, P < .01), anxiety (chi-square = 1.43, P < .01), and somatization (chi-square = 1.55, P < .01). Men were 2.3 times more likely to endorse zero depression symptoms, 4.2 times more likely to endorse zero anxiety symptoms, 4.7 times more likely to endorse zero somatization symptoms, and 4.1 times more likely to endorse zero as a total score on the BSI-18.Table 2 Summary of Results From Both Portions of the Zero-Inflated Poisson ModelsOutcomeSexaConcussion HistorybSex*Concussion HistoryEstimateWald chi-squarePEstimateWald chi-squarePEstimateWald chi-squarePCount modelc Anxiety subscale0.231.99.160.384.89.03−0.9810.28< .01 Depression subscale0.030.03.87−1.000.13.720.361.72.19 Somatization subscale−0.262.02.15−0.231.39.240.250.68.41 BSI-18 Total−0.12−0.29.140.06−0.13.560.10−0.18.47Zero-inflated modeld Anxiety subscale1.432.03< .010.340.82.36−1.003.49.06 Depression subscale0.848.21< .010.270.47.49−0.320.39.53 Somatization subscale1.5524.67< .01−0.090.05.82−0.731.81.18 BSI-18 Total1.410.89< .010.32−0.38.37−0.500.39.27BSI-18 = Brief Symptom Inventory 18aThe effect of sex reflects the difference for men versus women (ie, negative estimate indicates lower scores for men).bThe estimate for concussion history reflects the average difference in the outcome for those with a concussion history versus those without (ie, positive estimate indicates higher scores for those with concussion history).cThe count model tests the effect of each predictor on the number of symptoms reported for each outcome.dThe zero-inflated model tests the effect of the predictors on the presence of excess zeros in each outcome, thought to be driven by reasons other than the true absence of symptoms.DiscussionA primary finding showcased female student-athletes with a concussion history reported higher anxiety symptom frequencies, indicating a need for sex-specific symptom evaluation and increased post-injury psychological tracking. Critically, we also found that men were significantly more likely to endorse zero symptoms than women for BSI-18 total score and all subscales. For clinicians, this may underscore the need for a metric able to differentiate general psychological distress beyond depression, anxiety, and somatization, especially in male student-athletes. Overall, we demonstrate more specific psychometrics are needed to assess the long-term health of student-athletes following concussion.The association between sex and baseline anxiety measures depended significantly on the athlete's concussion history, such that female student-athletes with a self-reported concussion history demonstrated higher anxiety scores than female student-athletes without a concussion history. A variety of factors could explain this finding. First, it is generally well-established that women are more likely to endorse psychological symptoms and to develop affective disorders than men.17–19 Current literature theorizes that higher symptom endorsement in women may be due to several factors, including hormonal systems,20 selective attention to bodily cues,21 and more willingness to endorse symptoms.21 These findings may also translate to athletic populations and be particularly relevant to clinical care for concussive injuries. For example, otherwise healthy female athletes typically reported greater psychological symptom burden (frequency and severity) during baseline concussion assessments than male athletes.14 Additionally, women tend to have poorer outcomes following concussion, including symptom burden,9,22,23 neurocognitive function,7,20 and recovery rate9; however, women still typically recover within 14 days of injury.2,22 Our results suggest women with a self-reported concussion history may have lingering anxiety symptoms worthy of reporting during a baseline test session. This suggests athletes, and women in particular, may benefit from continued anxiety monitoring following injury. Additionally, anxiety was the only BSI-18 measure influenced by self-reported concussion history. These findings represent mixed evidence relative to current literature on the effect of concussion history on psychological distress, which found increases in depression, anxiety, and somatization in otherwise healthy collegiate student-athletes with a concussion history.13,14,24 These differences may be attributed to our use of a single college site for data collection and/or social desirability bias, particularly of male athlete participants.When testing the likelihood of reporting no symptoms as opposed to reporting any symptoms at all, men were significantly more likely to report zeros than women on total BSI-18 score and all three subscales. This is an important extension of earlier reports in distinguishing general concussion physical symptoms reporting behaviors between the two sexes.21 Additionally, greater male gender role conflict (ie, the stress from not conforming to socialized gender roles)25,26 is associated with lower mental health symptom disclosure and greater self-stigmatization.10 Martin et al27 suggested that the perception and experience of depression symptoms may also differ between men and women. Men are more likely than women to express feelings of sadness or emotional vulnerability through substance abuse or externalization of their problems, including anger, aggression, or lower impulse control.27,28 Men were more likely to endorse these symptoms over traditional depression symptoms after adding "male-type"28 depression symptoms (eg, agitation) to traditional depression scales. Traditional psychological distress scales may not be sensitive to specific male experiences as a result. Alternatively, men may have greater difficulty identifying traditional symptoms used to diagnose depression and thus may not recognize what they are experiencing as depression.28 It is important to note that when looking at male student-athletes who did endorse psychological distress symptoms in our study, there was no difference between those with and without a concussion history for total BSI-18 score or any subscale score. This suggests that among male student-athletes who endorse any symptoms, concussion history is not associated with psychological distress severity. Overall, our study suggests that both sexes endorse and experience psychological distress differently at the collegiate level.Our study has limitations worth transparently discussing in more detail. We relied on self-reported concussion history, which can present issues with memory error by the participants. This limitation is pervasive throughout the concussion literature and not unique to our study.29 Similarly, the BSI-18 requires participants to self-report symptoms, which leads to inherent subjectivity. We found that more than half of our participants reported 0 for BSI-18 Total Score. This raises an important clinical question: are these student-athletes truly experiencing no depression, anxiety, or somatization symptoms, or is this metric unable to sensitively differentiate between specific types of psychological distress in seemingly healthy college student-athletes? This may underscore the need to develop more sensitive questionnaires to assess psychological distress among otherwise healthy young adults. There are also limited data on BSI-18 utility in this study population; however, recent evidence shows that the BSI-18 has good internal consistency and validity in young, healthy athletes.14Implications for Clinical PracticeConcussion history was associated with an increase in anxiety scores for female collegiate athletes. Differences could be attributed to overall poorer clinical outcomes for female athletes following concussion.7,9,20,22 We also found men were more likely to endorse no symptoms in total BSI-18 or subscale scores. Broadly, men are less willing to endorse mental health symptomology, but they may also experience depression differently. This may underscore a need for more sensitive, population-specific measures of psychological distress.1.Zuckerman SL, Kerr ZY, Yengo-Kahn A, Wasserman E, Covassin T, Solomon GS. Epidemiology of sports-related concussion in NCAA athletes from 2009–2010 to 2013–2014: incidence, recurrence, and mechanisms. 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Reliability of concussion history in former professional football players. Med Sci Sports Exerc. 2012; 44(3):377–382. doi:10.1249/MSS.0b013e31823240f2 CrossrefGoogle Scholar Previous article Next article FiguresReferencesRelatedDetails Request Permissions InformationCopyright 2021, SLACK IncorporatedThe authors thank Drs. Thomas McAllister and Steven Broglio, who serve as Dr. McCrea's co-Principal Investigators on the NCAA-DOD CARE Consortium.PDF download • 167.1 KBCorrespondence: Jason P. Mihalik, PhD, CAT(C), ATC, Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, 2201 Stallings Evans Sports Medicine Complex, Campus Box 8700, Chapel Hill, NC 27599. Email: [email protected]unc.eduFrom Children's Hospital of Philadelphia, Philadelphia, Pennsylvania (PRR); the Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina (CBF); Real World Solutions, IQVIA, Durham, North Carolina (EBW); the Division of Physical Therapy, Emory University, Atlanta, Georgia (CJR); Center for Neurotrauma Research, Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin (MM); and the Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center, Department of Exercise and Sport Science, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (JDD, JPM).Supported in part by the Grand Alliance Concussion Assessment, Research, and Education (CARE) Consortium, funded in part by the National Collegiate Athletic Association (NCAA) and the Department of Defense (DOD). The U.S. Army Medical Research Acquisition Activity, 820 Chandler Street, Fort Detrick MD 21702-5014 is the awarding and administering acquisition office. This work was supported by the Office of the Assistant Secretary of Defense for Health Affairs, through the Combat Casualty Care Research Program, endorsed by the Department of Defense, through the Joint Program Committee 6/Combat Casualty Care Research Program–Psychological Health and Traumatic Brain Injury Program under Award No. W81XWH1420151. The opinions, interpretations, conclusions and recommendations are those of the authors and are not necessarily endorsed by the Department of Defense.Disclosure: Drs. McCrea and Mihalik report grants from the Department of Defense, National Institutes of Health, Centers for Disease Control and Prevention, and National Football League outside the submitted work. The remaining authors have no financial or proprietary interest in the materials presented herein. Received9/08/20Accepted12/17/20
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