Skip main navigation

Military Health System

Clear Your Browser Cache

This website has recently undergone changes. Users finding unexpected concerns may care to clear their browser's cache to ensure a seamless experience.

Concussion Linked to Depression, Anxiety and PTSD, Studies Show

Image of Picture of blast waves during an explosion. Service members can suffer concussions when exposed to blast waves when explosions occur during training or operations (Photo by: U.S. Army, Sgt. M. Austin Parker).

Recent research shows mounting evidence of a link between mild traumatic brain injury and mental health conditions like depression, anxiety, and posttraumatic stress disorder.

For the first time, a study of post-mortem brains of service members who were diagnosed with blast-related concussions found visible evidence of damage to the brain.

Researchers believe the unique scarring that the study found could account for the mental health conditions that are diagnosed more frequently among service members who have suffered mild TBIs or been exposed to blast concussions.

In other words, the "invisible wounds" - as TBI is frequently called - might not be invisible anymore.

"The more we look, the more we're finding other subtleties and other kinds of changes in the brains of individuals who've been exposed to blast," said Dr. Daniel Perl, one of the study's researchers and a neuropathologist specializing in TBI and neurodegeneration at the Uniformed Services University (USU) of the Health Sciences in Bethesda, Maryland.

As a result, "we think there is a biology to this, that the exposure to blast can, in some people, produce damage to the brain, which leads to dysfunction and underlies some aspects of [mental health issues]," Perl said.

The Link

TBI is associated with an increased risk of psychological health conditions, such as anxiety, depression, and even post-traumatic stress, according to experts at the Defense Health Agency's Traumatic Brain Injury Center of Excellence (TBICoE), in Falls Church, Virginia.

A 2019 study of a Department of Veterans Affairs health care database found that "a history of TBI increased the risk for suicide and other psychiatric conditions by more than two-fold."

Veterans with a history of TBI also had a two-to-four times higher prevalence of psychiatric diagnoses compared with those who did not suffer a TBI, with PTSD being the most common, according to the TBICoE team.

The prevalence of depression in the mTBI group was 68.1 percent, the TBICoE team said.

David Riggs, a clinical psychologist and chair of the Department of Medical and Clinical Psychology at USU, explained how the exact reason for the neuropsychiatric symptoms service members experience following a blast-related concussion is not clear.

"We don't know exactly, particularly in the case of mild TBIs or concussions, what might be leading to these problems because it's very hard to identify the specific change in the way that the brain functions after a concussion," he said.

"If you have a penetrating head injury, where the skull is fractured or penetrated, you can actually identify the part of the brain that was injured and perhaps is no longer functioning at all," added Riggs.

"In the case of concussion, it's very hard to identify where the brain was injured."

Riggs explained that there might be a disruption in "the way that the neurons in the brain talk to one another."

What is known, is "that the way that a person processes information is related to mood and trauma symptoms on the psychological or psychiatric side," said Riggs. "So, it may be that there are disruptions at the neurological level that lead to these psychological and psychiatric issues."

"It's also possible that what leads to the depression or the trauma symptoms isn't about the injury, the concussion, or the idea that the brain is working differently, but rather the emotional and life-disrupting aspects of that," he added.

Seeing the 'Invisible Wounds'?

Mild TBI occurs when there's a sudden jolt to the head due to impact or blast, causing it and the brain to jerk abruptly back and forth. This results in the brain bouncing or twisting inside the skull, creating chemical changes that can stretch and harm the brain cells, thus affecting brain function, according to the Centers for Disease Control and Prevention.

While the USU study appears to have identified physical scars from blast damage in service members who are deceased, there are no visible damages to the brain when testing live patients diagnosed with blast-related concussion and other forms of TBI.

Picture of the brain Concussion, or mild traumatic brain injury, occurs when a service member experiences a bump, blow, or jolt to the head that causes the head and brain to move rapidly back and forth, causing the brain to bounce around or twist in the skull and creating chemical changes in the brain and sometimes stretching and damaging brain cells (Photo by: CDC).

"When you do an MRI on such a patient, you don't see anything consistently," said Perl. "The implication is that something's wrong with the brain, but you just can't see it."

Perl established a neuropathology lab at USU dedicated to researching the acute and long-term effects of TBI and PTSD among military personnel. In the study, they analyzed brain specimens of cases with chronic blast exposure, acute blast exposure, chronic impact TBI, exposure to opiates, and a control group with no known neurological disorders for comparison.

"The one thing that kept coming up in these cases [with blast exposure] was a pattern of scarring in the brain that seemed rather unique and had really not been described previously," he said.

"And the more we worked, the more it appeared to be related to blast exposure."

The type of unique scarring they observed is called interface astroglial scarring. From there, they learned that blast waves emerging from detonations of high explosives such as improvised explosive devices and suicide bombs carry pressure waves "that expand in all different directions, at about the speed of sound, and actually pass through the skull, and through the brain, the most delicate and complex organ in the body," he said.

This led to the assumption that it must produce some damage to the brain.

"Indeed, the places where we found the scarring were places where biophysicists had previously shown that the blast wave gives off its energy," he said. "Putting two and two together, we have indicated that we think that the blast wave is damaging the brain in these locations, and this is the brain's attempt to repair itself from that damage."

"Mental health issues may be superimposed to this," he said, attributing the symptoms of concussion to "a duality of both factors - biologic factors plus functional factors - that are interplaying, interacting."

Similar Symptoms

Concussion can result in a wide variety of symptoms that can also be attributed to other causes, including headaches, irritability, fatigue, balance difficulties, sleep disturbance, dizziness, ringing in the ears, blurred vision, concentration, or memory difficulties, and other problems. But these are believed to be temporary and usually heal on their own over time, as the brain resettles back to regular functioning.

Likewise, people who have had a TBI and people who are depressed can share similar symptoms. These include low activity levels, sleep problems, difficulty controlling emotions, loss of interest in pleasurable activities, decreased energy, changes in appetite, and lack of initiation.

Similarly, Riggs said, while some people with a concussion may also have PTSD, not everyone does. He said some experts believe some people may be more vulnerable to psychological health conditions after a concussion because they were having problems already, or because they may be genetically predisposed to psychological health issues, like depression or anxiety.

Either way, the psychological health conditions that arise from concussions may require longer-term treatment.

Common treatment options include counseling and medications. Most cases of PTSD respond well to treatment, according to TBICoE.

And some complementary or alternative medical approaches such as meditation have shown to be useful, as a second-line treatment for managing PTSD.

Perl's research findings have implications for the way TBI might be diagnosed and treated in the future as well as for spurring broader research on the ways service members can be better protected as they head into situations where they might be exposed to blasts.

"We're beginning to work on if there are means by which we can detect this in living individuals," said Perl. "Our work has stimulated a number of ongoing studies to look for unique ways in which newer imaging and even fluid biomarkers can be used to identify these changes in the living."

Service members experiencing depression, anxiety, and PTSD due to concussion are not alone. The TBICoE website provides ample resources to help service members, veterans, their families, and loved ones cope with mTBI.

If you notice changes in the behavior of a loved one after concussion or fear a loved one may try to hurt themselves, urge them to call their health care provider, the Suicide and Crisis Lifeline at 988, or the Military Crisis Line at 800-273-8255 as soon as possible.

You also may be interested in...

Fact Sheet
Mar 7, 2024

Medical Devices for Assessment of TBI Fact Sheet

.PDF | 698.53 KB

This fact sheet defines the different regulatory terms and pathways of medical devices, provides an overview on what devices are currently FDA approved for assessing TBI, and shares some considerations for clinicians and researchers before using a device.

Fact Sheet
Mar 6, 2024

Managing Headaches Following Concussion Fact Sheet

.PDF | 592.42 KB

This patient fact sheet on managing headache following concussion will help patients understand post-traumatic headache basics, triggers, and non-drug remedies. Post-traumatic headache is one of the most common and persistent symptoms of mild traumatic brain injury.

Fact Sheet
Dec 14, 2023

PTSD and Other Stress-Related Disorders Following Concussion/Mild TBI Fact Sheet

.PDF | 542.68 KB

Co-occurring concussion and stress-related disorders, including PTSD, are common among service members. This fact sheet defines concussion, also known as mild traumatic brain injury, and provides an overview of common stress-related disorders, the overlapping symptoms, and how to manage those symptoms.

Fact Sheet
Dec 13, 2023

Low-Level Blast: VA Provider Fact Sheet

.PDF | 820.18 KB

This fact sheet was developed specifically for VA medical providers. Low-level blast is defined as blast generated from firing heavy weapon systems or explosives in combat or training environments. Exposure to low-level blast does not typically result in a clinically diagnosable concussion, also known as mild traumatic brain injury.

Fact Sheet
Nov 6, 2023

Warfighter Brain Health After TBI: Guidance for Leaders

.PDF | 895.85 KB

This TBICoE fact sheet, Warfighter Brain Health After TBI: Guidance for Leaders, condenses the basics of recognizing, reporting, and preventing TBI in service members. It updates and supersedes the Line Leader Policy Guidance fact sheet and includes a list of what the DOD has defined as potentially concussive events and outlines leaders’ ...

Fact Sheet
Jul 18, 2023

Low-Level Blast: Fact Sheet for Service Members

.PDF | 867.41 KB

Low-level blast is defined as blast generated from firing heavy weapon systems or explosives in combat or training environments. Exposure to low-level blast does not typically result in a clinically diagnosable concussion, also known as mild traumatic brain injury. Both providers and service members should be aware of the potential effects of low ...

Fact Sheet
Jul 18, 2023

Low-Level Blast: Fact Sheet for Providers

.PDF | 1.26 MB

Low-level blast is defined as blast generated from firing heavy weapon systems or explosives in combat or training environments. Exposure to low-level blast does not typically result in a clinically diagnosable concussion, also known as mild traumatic brain injury. Both providers and service members should be aware of the potential effects of low ...

Fact Sheet
Jun 14, 2023

Leader Policy Guidance for Mild TBI/Concussion in the Deployed Setting Fact Sheet

.PDF | 723.27 KB

This document describes the line leader responsibilities for the Department of Defense mandated policy, DOD Instruction 6490.11, “DOD Policy Guidance for the Management of Mild Traumatic Brain Injury/Concussion in the Deployed Setting,” that applies to all service members involved in potentially concussive events in deployed settings.

Fact Sheet
May 22, 2023

Changes in Behavior, Personality or Mood Following Concussion/mTBI Fact Sheet

.PDF | 977.73 KB

This TBICoE fact sheet can be used by health care providers to educate patients with a concussion, or mild TBI, on how to manage changes in mood related to their injury. Patients and caregivers would also find this information useful.

Fact Sheet
Nov 16, 2022

Healthy Sleep Following Concussion/mTBI Fact Sheet

.PDF | 108.25 KB

Getting restful sleep is one of the most important things you can do for your health, and it often takes thoughtful preparation during the day. This fact sheet offers service members and veterans who experience sleep disturbances after a concussion with healthy sleep tips that can likely improve sleep.

Fact Sheet
Sep 14, 2022

Neuroendocrine Dysfunction Following Concussion/Mild TBI Provider Fact Sheet

.PDF | 168.72 KB

The Neuroendocrine Dysfunction Following Concussion/Mild TBI Provider Fact Sheet, developed by TBICoE, is a one page document that gives primary care managers (PCMs) an overview of neuroendocrine dysfunction (NED) that can occur after concussion, or mild TBI. It highlights conditions with overlapping symptoms, screening and treatment considerations, ...

Fact Sheet
Jun 8, 2022

Talking to Your Child about TBI: A Guide for Caregivers of Service Members and Veterans

.PDF | 246.77 KB

This TBICoE fact sheet includes age-appropriate strategies adults can use to speak with children about traumatic brain injury—or concussion. It also includes tips on how to help kids cope with changes that impact the family unit.

Skip subpage navigation
Refine your search
Last Updated: July 11, 2023
Follow us on Instagram Follow us on LinkedIn Follow us on Facebook Follow us on X Follow us on YouTube Sign up on GovDelivery