Concussions and Mental Health in Teens: What Most Providers Are Missing

In this eye-opening episode, Dr. Zimmerman uncovers the deep—and often ignored—connection between concussions and mental health struggles. Drawing from research, clinical insights, and real-world cases, he exposes why so many patients suffering from depression, anxiety, and ADHD may actually be battling the silent aftermath of an undiagnosed or improperly treated concussion.

💡 Key Takeaways:

• Concussions Aren’t Just a Sports Injury:
  While sports get the spotlight, concussions from car accidents, slips, and falls are even more common—and frequently overlooked, especially in non-athletes.
• Mental Health Diagnoses Often Miss the Mark:
  Research shows concussions drastically increase the risk of depression, anxiety, ADHD, and even suicide—yet many patients are misdiagnosed and mistreated because providers aren’t screening for brain injury.
• Outdated Beliefs Are Failing Patients:
  Coaches, parents, and even medical providers often rely on childhood-era concussion myths—leading to dangerous underdiagnosis and poor care.
• Proper Evaluation Requires More Than a Cognitive Test:
  A thorough concussion evaluation must include balance testing, oculomotor testing (like eye tracking), and metabolic lab work—not just symptom checklists or paper-based cognitive exams.
• There Is No One-Size-Fits-All Treatment:
  The best outcomes come from stacked, personalized treatment plans that combine neurological rehab, metabolic support, and advanced testing—not relying on a single therapy like neurofeedback or hyperbaric oxygen.

Transcript

Concussions and mental health. We're going to talk about this super important topic because even though concussions are becoming more and more common, There's also a lot of issues with how we really talk about and make sure these individuals who've suffered concussions are getting the proper care they need versus things being explained away kind of inappropriately. So what we're going to do is we're going to dig through the research. We're going to come at this from a very much evidence based perspective. What does the research show? We're going to talk about what should happen as far as with an evaluation. Now, it's really important to understand these first basic constructs, because the better we understand these constructs, then in future recordings for the podcast or for youtube you will understand what's happening with rehab and why we do different things but what I don't want is for people to get tied to a certain rehab type or a rehab tool without understanding why something should be selected and that's why it's going to be its own thing so let's dive right into concussion and mental health Every single year, millions upon millions of concussions occur. Many of these go undiagnosed. Now, a lot of people are thinking, oh, concussions happens in football and soccer and lacrosse and rugby, gymnastics. They think about all the sports. But you actually have more concussions occurring every single year in car accidents than you do with sports. You have more concussions from slip and falls. So while sports is definitely a big contributor, it is not the only contributor and unfortunately results in people not getting evaluated because like, oh, but I don't play sports. Next, as we're going to go through the research, you're going to figure out that many do not recover. they are going to be facing lingering symptoms. So brain fog, fatigue, headaches, neck pain, mood changes. So depression, anxiety, irritability, lack of patience, sleep disorders, dizziness, and much more. So Does everyone recover? How common are these symptoms that individuals are experiencing? We are going into that. And then lastly, many providers are using outdated information or even worse, they're using prior beliefs from their childhood about when they played sports, about the significance of a concussion on someone's life and how it may or may not impact someone. And unfortunately, this hurts people all the time. And it's not just providers. This goes for coaches, athletic trainers, and even parents who are going off of previous bias. So we've got to really get rid of this because concussions are a significant issue that will ruin people's lives. So what happens though, when we look at this, right? So childhood brain injury and mental health, what does the research show? Well, Higher likelihood of current depressive symptoms if they had a prior concussion or brain injury. Anxiety. Difficulty making friends. Use of medications for mental, social, behavioral issues. And mental health therapy counseling. So these are the people who turn to alcohol, marijuana, other drugs of abuse. They may be loners, right? They're more likely to end up in mental health places as we're going to keep going through this. So they have a higher rate of mental and social disturbances. Nearly one quarter of children with significant symptoms after head trauma are never checked for a concussion or brain injury. So twenty five percent. Now, there's other research that does show as high as fifty percent, but twenty five percent. And so imagine you have a teenager or maybe it's yourself and you're in your thirties. and you have depression or anxiety and you've had concussions, guess what? That may be a contributing factor. And if you don't do this right, you get the wrong treatment. When you do the wrong treatment, you get the wrong outcome. TBI and depression. Twenty nine point three percent of women and twenty one point nine percent of men develop depression after a traumatic brain injury with once again, remember, concussions are the most common type of traumatic brain injury. History of concussion. Three point three fold greater risk for depression and diagnosis in adolescence. So, right. We're seeing this. It is there experiencing concussion or mild TBI was associated with a two X higher risk of suicide. So, and then as they said, higher risk of suicide attempt and suicide ideation. So it's not just thinking about it, but it's actually going through and trying to make it happen. So depression, anxiety, suicide. Now, It's once believed, oh, you know, but kind of everyone recovers. There's not going to be many symptoms. Well, this was from a survey research study where they asked people, what were they still dealing with? And you see seventy percent of individuals still have headaches. Seventy percent difficulty concentrating. Over fifty percent fatigue. They don't feel right. They have brain fog. They have head pressure, sensitivity to light, memory is not as good, neck pain, noise sensitivity, depression, sleep issues, other mood changes, and the list goes on and on and on. And these are things that I have individuals who come to my clinic every day with this, where it all started ten, fifteen years ago after a concussion that unfortunately was not diagnosed or treated. For most, but for a few, they were diagnosed, but they just never got the proper treatment. And this is unfortunate because these are very common symptoms that people go to their primary care for. They go to functional medicine providers. And if you're trying to treat the symptoms versus the reason why the symptoms are there, the results are likely not going to be fantastic. What else do we know? Results indicate an increased risk of emotional and behavioral problems in children that experience possible MTBI, okay? So once again, they're gonna have emotional and behavioral problems. So maybe the kid doesn't have ADHD. Maybe the kid has a prior concussion. What else do we know? TBI with depression imaging. TBI associated with depressing that was independent of traumatic brain injury major depressive disorder, PTSD, depression, severity, and cohort. They found changes in communication between parts of the brain. So the dorsal attention network, the subgenual cingulate connectivity and increased attention network and default mode network connectivity. So there's, you get changes in this that actually occurs independent, right? So a concussion or TBI with depression behaves differently than depression on its own when you look at imaging. Unfortunately, this imaging is not routinely available though. So this is not something that if someone's being diagnosed that they're getting, this is stuff that's done as part of research study. Now, as we've talked a little bit about kids, we find that in the study based out of Israel, twenty five point three percent discharged from the emergency room after a head injury are misdiagnosed and continue to suffer symptoms for years. They're mistakenly diagnosed as suffering from ADHD, sleep disorders, depression. This misdiagnosis leads to a treatment that is not suited to the problem. thus causing the children prolonged suffering. For example, children who report difficulty concentrating and the doctor prescribes Ritalin. Unfortunately, these children continue to suffer for many years from various disorders. And instead of treating the real problem, which is the syndrome, they receive treatments that usually do not solve the problem. So this is a big thing which we're going to talk about more at the end. But When people have concussions, this can impact them for years. And the amount of kids and teenagers who are misdiagnosed with anxiety, depression, oppositional defiant disorder, ADHD, when it's really a concussion, it's staggering. It's really, really high. People don't think about, well, my kid rode their bike, they crashed. And then over the next couple of weeks, things kind of got worse. They don't think about that. Or my kid was playing soccer and got nailed. Or my kid was involved in a car accident when we were in a car accident. And because here's what happens. Kids are not the best at explaining things, right? I've got kids. They are not the best at explaining how they feel. So they often behave differently. But the behaving differently is a manifestation of something else. It is not the cause in and of itself in many instances. And it's why one of my most favorite things I've ever read in a research article, or maybe it was their opinion on it, right? It was this person out of, it was either UK or Ireland. And they basically said mental health diagnoses are scientifically meaningless as they do nothing to help us help the individual. Like you have depression due to what? Do you have depression due to abusive parents? Do you have it due to the food you're eating? Do you have it due to the fact that you can't sleep? Do you have it due to prior concussions? Like what is it due to versus, oh, well, you know, we just give everyone who's got depression, Prozac or escitalopram, or all these new medications that are coming out that doesn't do anything to serve or really help these people at the highest level possible. And unfortunately, even those who get diagnosed in the emergency room, fifty two percent reported having seen a medical practitioner by three months after diagnosis. So three or more moderate to severe symptoms. Basically, fifty percent saw a provider of any type within three months. And whenever I say provider of any type, this was used very, very loosely. This like included primary care doc, ophthalmologist, dermatologist, like it was anything. It wasn't someone who's trained and qualified to evaluate a concussion and treat it. It was anyone. And so. know that's we've got to do better than this and that's why I'm out here talking about this because this is ridiculous if they're not going they're usually not getting the education they need to on the importance of it and yes societal bias does not help but there are studies that show that Only twenty five percent of people of locations provided them with education on what they had. Now, the high end was seventy five percent. But when you average and it's not maybe fifty percent provides education, this is an issue. What else? Well, when we look at the military population. Service members with concussive blast TBI experience evolution. So evolution would be worsening or progression, not resolution of symptoms from the one to five year outcomes. But what if you have some preexisting stuff? Because this always gets claimed, but you know, they already had some depression. They already had some anxiety, you know? And what do we know? Nearly half of those, right? who experienced mild brain injury continue to experience persistent symptoms one year later. Okay, so nearly fifty percent. Individuals who have history of previous brain injuries use psychotropic medications. So these are your anti anxiety meds, your depressants, probably sleep meds, mood stabilizers, or with additional comorbidities are at increased risk of ongoing difficulties. So Yes, previous mental health does matter, but we should not explain away what is truly going on by trying to reduce it down to one thing. We are not helping people when we do that. What else? Children and youths age five to eighteen years. Concussion was associated with an increased risk of mental health issues, psychiatric hospitalization and self-harm. compared to those with any other type of injury. So an arm, a leg, right? Those would be orthopedic injuries. And once again, ages five to eighteen. The amount. especially when we look at teenagers, where it gets explained away on puberty and hormones and changing grades and making new friends in school. It is highly disturbing. The amount of these individuals who are not getting proper care, it ruins their life. It impacts what they can become. Many of them will not achieve in life what they should have. And it's only because they were not given the proper evaluation and care and things were being explained away on other things. And if they did achieve what they could have, they probably had to work exponentially harder. But a lot of them don't even realize what they lost. They just know they don't feel right. Next, persistent post-concussive changes in cerebral blood flow and white matter at return to plane up to one year later. So an absence of symptoms and even being medically cleared does not mean you have recovered. And this is why I've done a lot of personal injury work. And people ask me, have I completely recovered from my concussion? And because I do not have this imaging, I say no. Based upon what I can measure, your testing looks appropriate. But have you really recovered, as this says, cerebral blood flow? Have you recovered from an inflammatory state? Have you recovered from an electrical brainwave state? And the answer is we don't know. And most people will never know because they won't be able to get the testing they need. So that's why you want to make sure Don't ever get returned to play or just say you've recovered purely based off of symptoms alone. Let's make sure that you've had the best objective testing possible. And then maybe in the future, we will see some of these things being used in the research becomes more accessible. Next, we've talked about this, do most recover. So this was those who had a concussion. normal imaging and remember imaging is going to be normal with concussions okay ct scans regular MRIs will be normal. Twenty-seven percent had a functional recovery and seventy-three percent were not by two weeks okay so so if everyone's like oh yeah we're all better we're all better yeah you know what there's a lot of things being missed there they're probably not even being asked the right questions Now, six months down the road, forty four percent had functionally recovered and then fifty six percent still were at an incomplete recovery. So this still fits with basically that fifty percent mark are not recovering. Now, if you're like me, you grew up at a time when it was like, oh, everyone recovers. You know, you take a concussion one day, you probably even finish the game. But at the worst, you miss a day or two, and then you're back in. And this shows we made our medical system, because the research wasn't really there, was making horrible choices. Now, we have to accept evidence. We cannot live in the Stone Age because, oh, something was done in our childhood. Just because something was done in our childhood doesn't make it right. Next, another research study, more than fifty percent of the TBI sample, including fifty percent of both mild, moderate and severe. So it didn't matter. The severity continued to endorse three or more symptoms as worse than pre-injury through twelve months. So once again, we're still seeing this fifty percent. Fifty percent are just they're just not magically recovering. Now, what about imaging? Well, forty seven percent showed incomplete recovery six months post-injury. They found changes in thalamic hyper connectivity within those with mild traumatic brain injury. So let's say we're still basically at that fifty percent mark, whether it was done with symptoms, whether it was done based upon imaging. And this is why you have to have a provider who's really going to grill you on this because if they don't ask you the right questions you don't get the right solution so the question is what do we even do when we diagnose this so let's just get this right okay um you see here this is from the american congress of physical medicine and rehabilitation you have to have a proper right mechanism of injury car accident slip and fall whiplash injury Right. Rapid jolt hit to the head. You do not need to lose consciousness. You do not need to be vomiting. Now you should have two or more symptoms that appear within forty eight hours. And we've already covered those symptoms. And then you should have clinical examination findings and laboratory findings. So we're going to break these down now. It's important to remember at this point in time. Of this recording, elevated blood biomarkers indicative of intracranial injury do not currently exist. There's some thoughts on matrix MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP-MMP Here are the things listed in that cognitive impairment on acute clinical examination. Two, balance impairment on acute clinical examination. Three, oculomotor impairment or symptom provocation to response with vestibular oculomotor challenge on acute clinical examination. Now, guess what? When you look at criteria number four, it says one or more, okay? You do not have to have issues on all these. You don't. There's no criteria for this. And this is where I really get irked when I see reports from neuropsychologists. They will say someone couldn't have had something based upon a cognitive evaluation alone. A cognitive evaluation does not pass snuff test, right? Sniff test, right? It's like, hmm, doesn't smell right. It doesn't mean it can't be used to diagnose because it can. But it cannot make up for a balance assessment and an alkaline motor assessment. You need to do them all. That is where we best help people. So cognitive testing, not gonna go into this a ton, but ultimately there's different paper-based testing and then there's computerized testing. Personally, having done this for years, whenever I make clinical decisions, cognitive testing is the least important aspect that I'm using, okay? Some of the providers like it more. Once again, I'll do it, but it's not the best thing for me. Balance testing. Now it's important when we look at this. So this is from a research study. Results reveal that balance behaviors of participants with mild traumatic brain injury deteriorate more abruptly in the absence of visual inputs when compared to neurotypical controls. So when people lose their visual input, so they close their eyes, you're going to see a breakdown in their balance. So this is computerized balance testing that we do. So if you're listening to the podcast, I just want you to imagine basically you have someone who's standing there, hands on hips, looking straight ahead, feet fairly close together, and you're looking at how they sway. On our platform, it's measuring it. Then you do it again with eyes closed. Now you're naturally going to sway more when you close your eyes compared to eyes open, but it should be within a reasonable amount. Next, what happens when you do eyes open on a uneven surface? So a balance pad. And then lastly, what happens when you close your eyes on the balance pad? Okay, that's the one that really matters the most too. It's what happens when you're on a unsteady surface when you close your eyes. And as you see here, before this individual got treatment, they scored really high. After treatment, they're now in the sixty-third percentile compared to fourteen percent initially. So balance testing should be done. Now, can you do some of this where they observe you? Yes, but honestly, should be done computerized too I understand you can't do it all computerized but the parts that can be should be okay that gives us best before and afters because once you treat someone and you retest that becomes their new baseline in case something else happens now we look at oculomotor testing there are different types And the ones we're going to go over is vergence, gaze fixation, pursuits, and saccades. So when we look at vergence, vergence is the ability of moving your eyes in and out, right? So if a target comes close to you, your eyes come in together. If it goes out, they separate. Now, normal is when you come out in, right? So if you come in, you should not go double within ten centimeters. Some are more picky and they'll do five. But within ten centimeters, it should be single if it goes in. double out like thirteen fifteen that's not normal okay next gaze fixation which I'll show you some videos on same thing with pursuits but then saccades is your ability to shift your attention so if you're looking at stuff it's like okay how fast can you start that movement when you start movement how quick does it get there and then lastly what's the accuracy of this Now, once again, you can do some of this bedside, but it really is best to do it computerized as much as you can. It's going to be exponentially better data. So we use what's called video oculography or video nystagmography. So here's an example of gaze fixation. So someone's looking at a stationary target and you want to say, are their eyes still or are they shifting left and right? So you notice when you're looking at this, there's shifting left and right. Okay. They had some times where they were a little still. They had times where it definitely picked up. That's not a normal response. Next, pursuits. So pursuits is tracking a target. Now, when we do pursuits, we should track left and right. We should track up and down. So as you see here, they're following a target that's moving smooth like this. And you'll notice their eyes are not nice and smooth. The eyes are jerky. They're stuttering. Maybe you think it's glitchy. However you want to describe it, that's fine. But this is not normal. And most people, guess what? They think they do fine on this test. Maybe it creates symptoms, but outside of it, they think they do pretty good. So this is something that should be done as well. Next, we repeat it again. We go up and down. So are their eyes nice and smooth going up and down? Does it kind of zigzag? And that's what we see, right? We see lots of skipping up and down. We see zigzag. Now, we may still have some skipping by the time we finish treatment, but it should improve. Normally, as we see the testing improves, symptoms improve right along with it. And once again, this should just not be done bedside. They should have the technology to do this because no one is going to document this appropriately. No one is going to say, oh, well, you know, we saw this many psychotic pursuits and the pursuits were, you know, the saccades were of this distance and this freak, like no one's going to do that. And so the best way to do it is by having computer recordings where you can come back and truly compare it. now once we leave that right so that's the standardized part now there's something that is becoming more popular quantitative electroencephalogram this is brain mapping essentially and you see here brain waves okay you see goes up and down here we've got a good stretch of alpha shows us different parts of the brain so currently qeg brain mapping it is becoming popular okay it is becoming popular But we still have a lot more research that's needing to be done. So I like this test, but it's also lowered down on the things I make decisions based off of until I see the research gets a little bit clearer. And then here you just see an analysis of how excessive or deficient their brainwaves were in different parts of the brain. So here we had very excessive for most parts of the brain. After treatment, it pretty much normalized. Now, that's the neurological side of the evaluation. But remember, the brain doesn't live in isolation. The health of the body impacts the health of the brain. So does this person have anemia? Do they have blood sugar issues, insulin issues? What about their food they're eating? Are they fueling their brain appropriately? Do they struggle with sleep? What about their gut health? Do they have thyroid issues? Do they have autoimmunity? Do they have hormonal issues, poor testosterone, crazy menstrual cycles, heading through perimenopause and amenopause? Do they have chronic infections, Epstein-Barr virus, Parvo virus, herpes viruses, and more? What about how much stress do they have in their life, right? There's a lot of things that can sabotage what is happening. And this is why one of the things that I do with every patient who comes in is we're going to go through history pretty in depth and we're going to identify labs that we need to be done because there's nothing worse than trying to rehab a concussed brain where someone's severely anemic or they're diabetic or these things are off. just makes it harder and if they do get initial results the likelihood that they keep them down the road does go down substantially now treatment we're not going to go into what treatment looks like but we are going to talk about what it doesn't look like okay because we need way more time to get through treatment one is there isn't one treatment And I need to say that again, there is not one treatment for concussions. There's a lot of people who I talk to on a weekly basis who've been taken advantage of by other providers. And some of the things I'm going to say are going to irk those providers. Okay. But hyperbaric does not fix every single concussion. It doesn't. Neurofeedback does not fix every single concussion. IVs do not fix every single concussion. Chiropractic adjustments do not fix every single concussion. Acupuncture does not fix every single concussion. And the list goes on and on and on. The more someone tries to reduce things down to one treatment, the faster you should run away from them. Now, it doesn't mean they have to offer everything. Okay, let's be very clear. But they do need to have the ability to say, here's what I can do, but here's also where I need someone else who can help co-manage this and co-treat you at the same time. Because that's where you're going to get the best results. Unfortunately, far too many people, they try one thing and they put all their eggs in one basket and it fails miserably. Next, what do we look at treatment? Treatment should focus on treating the underlying mechanisms of why you have not recovered from a concussion. What is your neurological testing show? What's your labs? Why is that stuff there? Not only symptoms, because there's a lot of different reasons why you may have fatigue, why you may have brain fog, and why you may have headaches. The more treatment is focused on only alleviation of symptoms, the less likely you're truly going to recover. It's going to be more of a band-aid. When you're finding someone, it's important to realize that nuances absolutely matter. And unfortunately, the terms vestibular rehabilitation doesn't mean a lot to me at this point in time. The amount of patients I have who've said they've done vestibular rehabilitation and it was a super generic form that was not tailored at all to them. it's insanely high or the amount of people who said, oh, I did vision therapy. And once again, it was super generic or is overly biased. Only one thing, right? Nuances matter. You may do the same generic therapies as someone else, right? Like, oh, I did stuff with my eyes or, oh, I did stuff with my balance. But the way it's executed and the nuances about delivery, that should be different, right? If not, the results really suffer. And then lastly, as we've talked about, isolated approaches have a much lower success rate compared to when you stack things. So, right, I will stack vestibular rehabilitation with oculomotor-based therapies, with hand-eye coordination, with cognitive tasking, with low-level laser... therapy with mild hyperbaric with nutritional supplements or peptides, right? There's a lot of things that can be stacked together. And this is where things go off because people like, Ooh, hyperbaric, it didn't help me. You're right. It wasn't going to help you as a standalone, but maybe if it was done with something else, it would have allowed you to move forward in a better way. So I hope, You got a lot of good information out of this. What happens when we are looking at mental health issues with concussions? So just really quick synopsis on this side. Anyone who's dealing with mental health issues, depression, anxiety, PTSD, oppositional defiant disorder, ADHD, all that, right? If they have a concussion in their past, We need to make sure they are screened appropriately so that we're getting the right treatment. And an absence of a prior concussion does not mean anything if they had the appropriate mechanism of injury that would have explained it being there. So we don't want to say, oh, but they never got diagnosed because as we've already covered in the research, there's a lot of people with concussions who are not diagnosed when they should have been. Because once again, it's easy to blame everything on mental health But let's stop doing that. We're hurting people. So if your kids, teenagers, you, if you've got those issues, remote chance of a concussion or whiplash injury, make sure you're screened appropriately because if it's off, the treatment that you need is going to be different than what anyone would ever recommend to you. Because once again, we don't chase symptoms here. We identify what is truly causing the issue. And if you have requests on future podcasts and videos you'd like me to create, feel free to comment and let me know. Till next time, this is Dr. Z.