Concussions Raise Risk of PTSD, Depression and Anger in Returning Military Personnel

James L . Spira, PhD, MPH, ABPP Professor, Department of Psychiatry, John A Burns School of Medicine, University of Hawaii Director, National Center for PTSD, Department of Veterans Affairs, Pacific Islands Interview with:
James L . Spira, PhD, MPH, ABPP
Professor, Department of Psychiatry, John A Burns School of Medicine, University of Hawaii
Director, National Center for PTSD, Department of Veterans Affairs, Pacific Islands Division

Medical Research
: What is the background for this study?

Dr. Spira:  Approximately 1.5 million Americans survive a traumatic brain injury (TBI) from traffic accidents, assaults, sports, and work injuries, with the vast majority of these being primarily mild (mTBI), otherwise known as concussion.1 Concussion, however, is uniquely problematic in the military given the new strategies of war encountered by service members when fighting an insurgency using improvised explosive devices. The rate of concussion experienced by United States (U.S.) service members engaging in combat during the wars in Afghanistan and Iraq has been estimated at between 15% and 22%.2–4There has been controversy in the area of neurotrauma as to whether persistent postconcussive symptoms (PPCSx) are due to neurological causes or solely due to the psychological sequelae of having been exposed to a traumatic event.  The recent wars in Iraq and Afghanistan have afforded an opportunity to examine these factors, although teasing them apart has proven difficult.  The most influential study of persistent effects of concussion in service members is that of Hoge and colleagues,5 in which they failed to find an independent effect of prior concussion on PPCSx, once depression and posttraumatic stress (PTSD) was taken into account.  They went so far as to recommend that assessment for concussion following deployment is unnecessary.  Others, however, have reported persistent cognitive, emotional, and physical symptoms following concussion.

Medical Research: What are the main findings?

Dr. Spira: In order to better understand the reasons for this disparity, we assessed concussion history, cognitive functioning, emotional distress, and somatic symptoms in 685 US Marines, most of whom recently returned from combat deployment.  Our findings supported Hoge’s findings that a prior concussion did not influence PPCSx, once combat exposure, PTSD, and depression were separated out through covariate analysis.  However, we found that having had three or more lifetime concussions did predict PPCSx across all domains, independent of PTSD and Depression or combat exposure.  Further, analysis of those who were recently deployed versus those where never deployed suggests that having had even one concussion increases the likelihood of developing PTSD, depression, and anger.

Medical Research: What should clinicians and patients take away from your report?

Dr. Spira: Concussion can have lasting effects on emotional health. Multiple lifetime concussions can be especially debilitating, with 2 to 4 times the likelihood of having persistent symptoms than having had none or one prior concussion.  Clinicians should take a complete concussion history, asking if patients have ever had a head injury that resulted in even temporary confusion, disorientation, or dizziness, or loss of memory for a time surrounding the event, or loss of consciousness even for a second or two.  Recency of concussion is also an important factor to consider, since re-injury even up to a month after symptoms subside can result in much worse symptoms than a single concussion.  However, it is also important to determine if symptoms attributed to concussion might in fact be caused, at least in part, by emotional factors associated with the traumatic event.  In either case, a referral to a mental health professional such as a neuropsychologist or a health psychologist is warranted.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Spira:  Research is underway to track athletes and military personnel longitudinally to determine the course of concussion and recovery from concussion – and it is critical to assess for lifetime concussions to determine the relative impact of number of concussions on severity and duration of persistent postconcussive symptoms.  Further research is also planned to examine the ability of postconcussive neurocognitive functioning, balance, and eye-tracking to help ER clinicians determine if a CT is warranted.


  1. National Center for Injury Prevention and Control (2003). Report to Congress on Mild Traumatic Brain Injury in the United States: Steps to Prevent a Serious Public Health Problem. Centers for Disease Control and Prevention: Atlanta, GA.
  2. M.A. Polusny, S.M. Kehle, N.W. Nelson, C.R. Erbes, P.A. Arbisi, and P. Thuras (2011). Longitudinal effects of mild traumatic brain injury and posttraumatic stress disorder comorbidity on postdeployment outcomes in national guard soldiers deployed to Iraq. Arch. Gen. Psychiatry 68, 79–89.
  3. T.C. Smith, M.A.K. Ryan, D.L. Wingard, D.J. Slymen, J.F. Sallis, D. Kritz-Silverstein, and T. Millennium Cohort Study (2008). New onset and persistent symptoms of post-traumatic stress disorder self reported after deployment and combat exposures: prospective population based US military cohort study. BMJ 336, 366–371.
  4. T. Tanelian, and L.H. Jaycox (2008). Invisible Wounds of War: Psychological and Cognitive Injuries, their Consequences, and Services to Assist Recovery. RAND Corporation: Santa Monica, CA.
  5. C.W. Hoge, C.A. Castro, S.C. Messer, D. McGurk, D.I. Cotting and R.L. Koffman (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. N. Engl. J. Med. 351, 13–22.


The Impact of Multiple Concussions on Emotional Distress, Post-Concussive Symptoms, and Neurocognitive Functioning in Active Duty United States Marines Independent of Combat Exposure or Emotional Distress

James L. Spira, Corinna E. Lathan, Joseph Bleiberg, and Jack W. Tsao
J Neurotrauma. Nov 15, 2014; 31(22): 1823–1834.

doi:  10.1089/neu.2014.3363

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