Claudia L. Reardon, MD Associate Professor Department of Psychiatry University of Wisconsin School of Medicine and Public Health Madison, Wisconsin
Disclosure The author reports no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
For patients with SRC who experience insomnia, clinicians should focus on sleep hygiene and, if needed, cognitive-behavioral therapy for insomnia (CBT-I).31 If medication is needed, melatonin may be a first-line agent.31,35,36 Trazodone may be a second option.32 Benzodiazepines typically are avoided because of their negative impact on cognition.31
For patients with SRC who have depression, selective serotonin reuptake inhibitors (SSRIs) may simultaneously improve depressed mood31 and cognition.37 Tricyclic antidepressants (TCAs) are sometimes used to treat headaches, depression, anxiety, and/or insomnia after SRC,32 but adverse effects such as sedation and weight gain may limit their use in athletes. Theoretically, serotonin-norepinephrine reuptake inhibitors might have some of the same benefits as TCAs with fewer adverse effects, but they have not been well studied in patients with SRC.
For patients with SRC who have cognitive dysfunction (eg, deficits in attention and processing speed), there is some evidence for treatment with stimulants.31,37 However, these medications are prohibited by many athletic governing organizations, including professional sports leagues, the National Collegiate Athletic Association (NCAA), and the World Anti-Doping Agency.4 If an athlete was receiving stimulants for ADHD before sustaining an SRC, there is no evidence that these medications should be stopped.
Consider interdisciplinary collaboration
Throughout the course of management, psychiatrists should consider if and when it is necessary to consult with other specialties such as primary care, sports medicine, neurology, and neuropsychology. As with many psychiatric symptoms and disorders, collaboration with an interdisciplinary team is recommended. Primary care, sports medicine, or neurology should be involved in the management of patients with SRC. Choice of which of those 3 specialties in particular will depend on comfort level and experience with managing SRC of the individual providers in question as well as availability of each provider type in a given community.
Additionally, psychiatrists may wonder if and when they should refer patients with SRC for neuroimaging. Because SRC is a functional, rather than structural, brain disturbance, neuroimaging is not typically pursued because results would be expected to be normal.3 However, when in doubt, consultation with the interdisciplinary team can guide this decision. Factors that may lead to a decision to obtain neuroimaging include:
an abnormal neurologic examination
prolonged loss of consciousness
unexpected persistence of symptoms (eg, 6 to 12 weeks)
