In combat sports, we place enormous emphasis on concussions, and rightfully so. Outside of a clear knockout, it’s important to be able to spot a concussion when it happens and stop the fight in time, so that the fighter is not exposed to more concussions and other injuries. It’s the reason for the standing eight-count in boxing, and it’s why an athlete’s corner can “throw in the towel” when they feel their fighter has become too vulnerable to continue. Clearly, we need to protect the brain as much as we can in such brutal sports as boxing and MMA. But there’s a piece of the conversation that often gets left out: mental health. As a sports psychiatrist, I would argue that mental health is one of the most practical indicators we have of brain health. In combat sports, the two are tightly linked.

 

Why are combat sports risky to mental health?

Every sport carries psychological risks, but several features of combat sports amplify them:

• Head trauma is part of the goal. Repetitive blows to the head aren’t an accident, they are meant to injure and are part of the goals of competition.

• Training camp can be stressful, and weight cutting makes it much worse. Not only is fight preparation already incredibly tough mentally and physically, but the process of making weight (particularly the dehydration that comes right before weigh-ins) makes it significantly more risky. The physical and psychological stress of cutting weight repeatedly over an athlete’s career weighs heavily on mental health in many ways (more on this very important and mostly unappreciated aspect of combat sports in our next post).

• There’s no off-season. Most combat athletes have no defined season and must stay ready to compete, sometimes on short notice.

• Fights can fall through. Bouts can be canceled close to fight night due to injury or a missed weight, erasing months of preparation and expected income.

• It’s an individual sport. Even though a fighter depends on their corner people and training team, it’s only the athlete that actually competes. Thus, combat sports can feel like a solo pursuit, and athletes may feel personally responsible for every outcome.

• Toughness is the point. Combat sports are visual displays of grit and hypermasculinity — qualities known to feed the stigma against seeking mental health help. 

 

How much head trauma are we talking about?

A lot. An analysis of more than 2,000 UFC bouts found that fighters absorbed an average of 6.3 head strikes per minute, 2.4 of them significant. In a study of the losing fighters in professional boxing bouts, fighters who lost absorbed 2 to 5.6 head strikes per minute in men, and 2.9 to 8.4 among women, depending on weight class. Meanwhile, a systematic review found concussion rates in boxing ranging from 14 to 41.5 per 100 participants.

In a combined study of professional boxing and MMA fights by video review, recognizable concussions occurred in 47 out of 60 fights — which translated to roughly one concussion every 12.5 minutes of fight time. The physician reviewers judged that 24 of those fights were not stopped soon enough – on average 44.5 seconds too late in MMA, and 220 seconds too late in boxing.

With this much head trauma in combat sports, why are we still not asking about mental health symptoms regularly?

 

Mental health and concussion have a complex relationship

Concussions can affect mental health, and mental health factors can affect concussion risk and outcomes.

Sustaining a concussion can lead to poor mental health, at least in the short term. It can cause mood changes, depression, anxiety, irritability, emotional dysregulation, and insomnia during the recovery period, and in fact doctors watch out for these symptoms when monitoring the athlete who just suffered a concussion.

But mental health issues themselves can increase the risk of sustaining a concussion. Collegiate athletes with depression and anxiety on baseline were found to be more likely to sustain a sport-related concussion, even after they factored out the type of sport played. Having certain baseline traits such as aggression, are also associated with higher concussion risk.

Studies have also found that having pre-existing depression, anxiety, irritability, and a family history of psychiatric illness is linked to more severe concussion symptoms, longer recovery, and persistent symptoms.

 

A closer look at ADHD

ADHD deserves special attention in combat sports because athletes with ADHD may be almost two times more likely to sustain a concussion, and may take longer to recover.

When we think of what it means to have a brain with ADHD, this actually makes sense. The brain with ADHD has altered brain signaling (in terms of chemical messengers like dopamine and norepinephrine), thinner prefrontal lobes (the part of the brain that manages attention and impulse control), and impaired functioning of the cerebellum (the part of the brain that coordinates movement and timing). These can translate to lapses in attention, difficulty stopping an action that needs to be stopped (reduced inhibitory response), and less precise motor control. The white matter (the long fibers that act as the brain’s highway for passing signals) of a brain with ADHD also tends to not be as robustly structured, and theoretically this may make the brain less able to withstand the forces of a concussion.

We should also note that it can be more difficult to assess how severe a concussion is in an athlete with ADHD, because they can already have mild but detectable cognitive impairments even without a concussion. All of these are reasons why it is important to know during pre-fight evaluations if a fighter has ADHD, because they will need individualized evaluation and care should they sustain a concussion.

 

The takeaway

If we care about protecting fighters’ brains, then we have to care about and follow their mental health as well. This includes asking about mental health history and symptoms even before the fight, and asking about mental health symptoms that may develop after a fight. Brain health manifests as mental well-being — assessing mental health is one of the clearest windows we have to understanding a person’s brain health.