Psychological approaches for the management of persistent postconcussion symptoms after mild traumatic brain injury: a systematic review.

Background: To evaluate the evidence for psychological treatments for persistent postconcussion symptoms following mild traumatic brain injury. There is scant evidence from limited clinical trials to direct the psychological management of persistent symptoms.Method: Databases were searched for studies that: (1) included adults (≥ aged 16 years) following injury (from any cause); (2) tested interventions for postconcussion symptoms after the acute injury period (e.g., after hospital discharge), but prior to established chronicity (e.g., not more than 12 months post-injury), and; (3) applied one of five broadly-defined psychological interventions (cognitive behavioural therapy, counselling, psychoeducation, education/reassurance, or mindfulness). All controlled trials were eligible for inclusion.Results: Of the 20,945 articles identified, 10 underwent risk-of-bias analysis by two independent reviewers. Nine were retained for data extraction. They used: cognitive behaviour therapy (n = 2), counselling (n = 2), psychoeducation (n = 2), education/reassurance (n = 2), or compared cognitive behaviour therapy to counselling (n = 1).Conclusion: Counselling or cognitive behaviour therapy have the most support but the evidence remains limited. We encourage further randomized controlled trials of early interventions in samples at risk for persistent symptoms, including closer study of psychological risk-factors and the 'active' ingredient. To advance the field, future trials must include additional methodological controls and improved reporting.Implications for rehabilitationPersistent symptoms following mild traumatic brain injury can be disabling and psychological management for rehabilitation may be proposed.However, Controlled trials show that while some psychological approaches hold promise for this purpose, there are significant gaps in the underpinning evidence.The best results are seen when postconcussion programs use counselling or cognitive behaviour therapy and are targetted for people with an increased risk of persistent symptoms.