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A concussion from an impact while an athlete is playing hockey can result in life-threatening psychological and psychiatric damage, a Toronto psychiatrist says.

Depression, a form of mental illness, frequently occurs beyond the common hockey injuries of stitches and bruises, Shree Bhalerao said. "But no one's talking about it because there's a stigma attached to it."

Because of the stigma associated with mental illness, depression can drive a problematic injury even deeper, the doctor said. Players in a macho game don't want to be seen as "damaged goods" in the lineup, he said.

Often called an "invisible injury," depression and concussion are cited as conditions afflicting fist-fighting NHL enforcers in their careers. Sometimes they have been connected to untimely deaths and suicides of NHL players.

"I've spent 12 years doing this stuff in an acute setting, but what I haven't seen is articles from the psychiatric point of view," Bhalerao told a conference on Outcomes in Concussion cases, organized by neurosurgeon Michael Cusimano.

Cusimano of St. Michael's hospital here is a pioneer in brain injury management. He said there will be between 15,000 and 20,000 concussive brain injuries across Canada this year.

The conference heard more concussions happen in the first period, when players are charged up aggressively with adrenalin and by coaching pep talks about "owning" the rink. (This is contrary to the belief that injuries occur late in games when athletes are tired and let down their guard down.)

The psychiatrist said he sees depression frequently in concussion patients – 30 per cent of patients exhibit it. They suffer from diminished motivation, impaired sleep, are withdrawn, have anxiety and have unfounded fears.

"They don't want to return to the ice. They have a feeling of panic … the elements of an acute stress disorder," Bhalerao said. Concussion patients often exhibit personality changes. They are irritable, they have increased impulsivity and can lapse into substance abuse.

"Eighty-seven per cent have cognitive changes in short-term memory and problems in executive functions, encapsulated in the acronym SOAP: sequencing a series of events, organization, attention and planning."

"There's still an attitude out there that brain injury is like a broken arm," Cusimano said. "You can't take your brain for granted."

In the seminar, Michael Hutchison, the assistant coach of the men's University of Toronto Blues and a postdoctoral fellow in injury prevention at St. Mikes, said a videotape study of almost 200 concussions in the NHL from 2007 to 2010 showed most concussions are caused by head shots initiated by the shoulder, elbow or gloves. Only about one in 10 were the result of fights, he said.

The seminar also heard from Karolina Urban, captain of the University of Toronto women's Varsity Blues hockey team, who has had three concussions while playing – the first one from a direct hit to the head (although women's hockey is supposed to have no body checking) and two more which have not been direct head hits. In none of the cases was a penalty called, she said. Toronto's women's team had 11 concussions last winter.

Repeat concussions can happen if a player comes back when not fully healed from an initial concussion, Toronto neurosurgeon Charles Tator said. Kids who suffer concussions may be willing to take their time healing before coming back to play, but there's pressure from parents who are paying money for equipment, coaching, fees and ice time. Second impact syndrome can occur, Tator said, although it is rare. That rarity isn't a good thing: Sometimes players die because of second concussions or are severely disabled by them.

Education of coaches and trainers of what to look for in possible cases of concussion are the key, he said. About half the states in the United States have legislated more education of concussion symptoms for coaches and trainers. "For some reason, we're still thinking this through in Canada," he said. He said coaches and trainers, because they are on the spot at hockey games, should be trained as the first line of defence against serious brain injury.

Cusimano said that part of the problem has been the macho culture of hockey. A few years ago, he said, researchers tried to take the message to hockey coaches "and some of them wouldn't be part of it," he said. The reluctant coaches were fearful they might be urged to take a softer approach to a physical game.

Rob Zamuner, who played 13 years in the NHL and is now a divisional representative for the National Hockey League Players' Association, said NHL hockey was still making spots for enforcers, "who have five years to do it, make the money that is supposed to support the family for their whole lives." Some decide to make a difficult bargain with themselves: They take a high-paying job, but they risk a serious injury and have a short career. "It's what they've grown up to do [play the enforcer role]and they do it well." But he said it's wrong to chastise players who take a lucrative role pro hockey makes open to them as long as it's there.

Cusimano said about one in 4,000 hockey players has a pro career "but about 70 per cent of young mothers are thinking they don't want their young athletes playing hockey. There's an urgency to do something now, not 10 years from now."

The incidence of concussion is serious, he said, noting research that shows that the occurrence of concussion is seven times as common as breast cancer and 30 times as common as HIV.

"What's happening is, it's now possible to talk about TBI [traumatic brain injury]and it becomes more possible to talk about mental illness from injury in the brain," Bhalerao said. Some may have grown up being rewarded for tough behaviour, but some may have learned it.

"It would be interesting to talk to players and see their developmental histories and to see... are their certain enforcers or certain types of players who have a certain background? Do they have aggressive role models or have they had multiple head injuries that have made them that way even before they got to the NHL? Did the NHL create more of that problem?"