When Brain Injury and Mental Health Look the Same: The Diagnostic Challenge of Concussion Recovery

Concussions are classified as a form of mild traumatic brain injury (TBI) that are a growing concern in high school sports. While much attention is given to the immediate physical effects, a more complex and often overlooked issue is the strong overlap between concussion symptoms and mental health disorders. This overlap makes diagnosis difficult, delays treatment, and increases the risk of long-term harm for student-athletes.¹

Consider a 15-year-old football player who presents several weeks after a concussion. His headaches have improved, but he continues to struggle with poor concentration, irritability, sleep disruption, and anxiety about returning to school and sports. Are these lingering concussion symptoms? The onset of an anxiety disorder? Depression? Or all 3 simultaneously? For clinicians, parents, coaches, and athletes, distinguishing between these possibilities can be challenging, yet the answer has significant implications for treatment and recovery.

One of the most critical challenges in concussion care is that symptoms of a brain injury often mirror those of mental health conditions such as generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), and major depressive disorder (MDD).

After a concussion, student-athletes may experience:

• Irritability
• Fatigue
• Difficulty concentrating
• Sleep disturbances
• Anxiety
• Depressed mood

These same symptoms are also key indicators of GAD, PTSD, and MDD. As a result, it becomes extremely difficult to determine whether a student is struggling with the neurological effects of a concussion, a developing mental health disorder, or both simultaneously.^2,3 This diagnostic ambiguity can lead to misinterpretation. For example, a student experiencing depression after a concussion may be seen as simply dealing with “normal recovery symptoms,” while underlying mental health issues go untreated.

The relationship between concussions and mental health is not just overlapping; it is also reinforcing. Research has associated concussion with an increased risk of depression, anxiety, PTSD, and other mental health symptoms, while pre-existing mental health disorders can intensify concussion symptoms and contribute to prolonged recovery.^4,5

This creates a cycle:

• Student presents with a mental health disorder (eg, increased performance anxiety)
• A concussion leads to emotional and cognitive symptoms
• Those symptoms resemble or trigger mental health disorders
• The mental health condition worsens the overall recovery process

Because of this cycle, student-athletes may experience prolonged recovery times, more severe symptoms, and increased emotional distress.

The Psychiatrist's Perspective

From a psychiatric perspective, one of the greatest challenges in concussion care is determining whether symptoms are primarily neurologic, psychiatric, or a combination of both. The overlap is rarely straightforward. A student-athlete who appears anxious may be experiencing anxiety related to academic pressures, frustration from being sidelined, or emotional changes related to the injury itself.

Athletes may also underreport emotional symptoms because of concerns about appearing weak, losing playing time, or disappointing teammates and coaches. As a result, routine mental health screening should be considered an important component of concussion management rather than a separate issue addressed only when symptoms become severe.

Why Overlap, Delayed and Hidden Warning Signs Lead to Underdiagnosis

Mental health symptoms following a concussion are often delayed. Student-athletes may not show signs of depression, anxiety, or trauma-related distress until weeks or months after the injury.^2,6 This delay makes it harder to connect symptoms back to the original injury. Additionally, many athletes underreport both physical and emotional symptoms due to pressure to perform and return to play. This underreporting further obscures the distinction between concussion effects and mental health disorders.⁷ Research suggests that depression, PTSD, and other mental health symptoms may persist for months following mild TBI, with some studies demonstrating elevated symptom burden up to 1 year after injury.⁸

Emerging research has further highlighted the connection between mild TBI and subsequent mental health concerns. A National Institutes of Health-funded study found that children and adolescents who experience mild TBI may be at increased risk for developing mental health disorders in the months following injury.⁸ These findings reinforce the importance of viewing concussion recovery through both a neurological and psychiatric lens.

The similarity in symptoms often results in:

• Missed diagnoses: Mental health conditions are overlooked because symptoms are attributed solely to concussion recovery
• Delayed treatment: Students do not receive timely psychological support
• Inadequate care plans: Return-to-play decisions may ignore underlying mental health risks

Without careful monitoring, student-athletes may return to sports before fully recovering physically and mentally, putting them at risk for further injury and worsening psychological outcomes.

Rethinking Concussion Awareness

Experts emphasize that concussion recovery must include both physical and mental health evaluation over time. Since symptoms can persist for months, ongoing screening is essential to differentiate between injury-related effects and emerging mental health disorders.^6,8

A more effective approach includes:

• Regular mental health check-ins following a concussion
• Education for coaches, parents, and athletes about symptom overlap
• Encouraging honest reporting without stigma
• Coordinated care between medical providers and mental health professionals

Understanding concussions requires moving beyond the idea of a short-term physical injury. The overlap in symptoms with conditions like GAD, PTSD, and MDD highlights the need for a more comprehensive approach, one that treats brain injuries and mental health as deeply interconnected.

For psychiatrists and other clinicians working with student-athletes, recognizing this overlap is critical. Mental health symptoms that emerge following a concussion should not automatically be viewed as part of routine recovery, nor should concussion-related symptoms be mistaken for primary psychiatric illness without careful evaluation. Both possibilities deserve consideration.

Without this awareness, student-athletes risk falling through the cracks of a system that struggles to distinguish between the visible and invisible effects of injury. Recognizing and addressing this overlap is essential to ensuring accurate diagnosis, effective treatment, and long-term well-being.

Ms Grate-Perry is a licensed clinical social worker who focuses on sports.

Dr Mirhom is past president of the New York County Psychiatric Society, an assistant professor of psychiatry at Columbia University, a Forbes contributor, and chief wellbeing officer at Athletes for Hope.

References

1. Mental health among high schoolers. Concussion Alliance. 2022. Accessed July 23, 2026. https://www.concussionalliance.org/mental-health-among-high-schoolers#affect%20on%20mental%20health

2. Mental health. Concussion Alliance. 2021. Accessed July 23, 2026. https://www.concussionalliance.org/mental-health

3. Bains N, Abdijadid S. Major Depressive Disorder. StatPearls [Internet]. April 10, 2023. Accessed July 23, 2026. https://www.ncbi.nlm.nih.gov/books/NBK559078/

4. Concussions among adolescents. Concussion Alliance. 2019. Accessed July 23, 2026. https://www.concussionalliance.org/concussions-among-adolescents

5. Chrisman SPD, Richardson LP. Prevalence of diagnosed depression in adolescents with history of concussion. J Adolesc Health. 2014;54(5):582-586.

6. Little DM. Post-concussive depression – it's real, it's serious, and it happens a lot. May 16, 2023. Accessed July 23, 2026. https://med.uth.edu/psychiatry/2023/05/16/post-concussive-depression-its-real-its-serious-and-it-happens-a-lot/

7. Strength isn’t just physical: exploring athletes’ mental health. McLean Hospital. April 20, 2026. Accessed July 23, 2026. https://www.mcleanhospital.org/essential/athlete-mh

8. Mental health disorders common following mild head injury. National Institutes of Health. January 30, 2019. Accessed July 23, 2026. https://www.nih.gov/news-events/news-releases/mental-health-disorders-common-following-mild-head-injury