Using the PHQ-9 to identify and manage depressive symptoms in patients with sport-related concussion

Cases

The 2 students were varsity athletes attended by a family physician with a focused practice in sport and exercise medicine (SEM). An 18-year-old female student athlete was taking 40 mg of fluoxetine daily for an anxiety disorder before her injury. During a preseason tryout she was struck in the jaw by a flying baseball bat. She was assessed at an emergency department, had normal findings on jaw x-ray scans, and was given a concussion diagnosis. She had no previous concussion history. Eight days after her concussion she consumed an excessive amount of alcohol and then felt so guilty and overwhelmed that she consumed a month’s worth of her fluoxetine at once. She was taken back to the hospital emergency department where her overdose was managed and a mandatory 72-hour psychiatric evaluation was ordered. If used early, the PHQ-9 might have helped anticipate this suicide attempt. Her SEM only became aware of her concussion 1 week after her hospital discharge for the overdose, and at that first meeting she answered PHQ-9 item F with “2,” indicating that she was feeling bad about herself more than half of the time. On item I, she responded “1,” indicating that for several days she had had thoughts that she would be better off dead or hurting herself in some way. Her PHQ-9 score was 18, which indicated moderately severe depression. However, as her anxiety and depression symptoms had abated considerably, we agreed with her strong request for no additional medication. We discussed her safety plan and the SEM showed her the Anxiety Canada website (https://anxietycanada.com),⁴ which has a link to the MindShift app and a very helpful section directed at youth. The SEM subsequently followed her biweekly. The use of the PHQ-9 at follow-up visits helped the SEM to manage her recovery. She learned cognitive-behavioural therapy techniques from the SEM at follow-up visits. Within 2 months she was symptom free and resumed her academic and athletic activities. However, 5 months later she had another concussion after hitting her head on a television upon entering the gym. This time the PHQ-9 was used by her SEM early in her clinical course and at follow-up visits, as her depression symptoms recurred. She was cautiously prescribed sertraline in 1- to 2-week amounts and was followed biweekly with demonstrable improvement.

Another 19-year-old female student athlete at the same college started taking anxiety medication prescribed by her own family physician 2 months before her concussion. She was playing soccer and in the last minute of the game she collided with an opponent and struck her occiput on the turf. She got up immediately and felt fine. However, 2 days later during a long team bus ride, she noticed her eyes were sensitive to her computer screen’s light and she could not focus. Her team therapist strongly suspected concussion and she indeed recognized several symptoms, as she had had 3 previous concussions. Her concussion was managed by her athletic therapy team with the appropriate protocols and she was not allowed to return to play. Two weeks after her injury, she became overwhelmed on the day of her team’s first provincial playoff game. She felt that she was letting her team down because of her injury and exclusion from play. This developed into a panic attack, which required several of her teammates and her student athletic therapist to support her. She told them she was fearful of being left alone, lest she do some considerable self-harm. Her SEM assessed her a few days after the panic attack and used the PHQ-9 (along with the Generalized Anxiety Disorder–7 scale⁵) to determine the severity of her mental health concerns. She scored low on both these measures and, with some counseling, she had an uneventful recovery aided by these clinical tools.