Ask an athlete who is struggling after a concussion how they feel and you’ll often hear “not myself” before you hear “dizzy”. Feeling off-balance in a busy supermarket. A racing heart when turning quickly. Avoiding the gym because the treadmill feels wrong. These are vestibular symptoms, but they are also emotional ones.
That overlap is not a coincidence. The vestibular nuclei connect directly to the structures that regulate emotion, and those connections are well described. What is less settled is what follows clinically when a concussion disrupts them.
With World Mental Health Day on 10 October, this piece looks at the pathways the two systems share, what the evidence suggests about their relationship after concussion and mild traumatic brain injury (mTBI), and what clinicians can reasonably take from it.
The vestibular apparatus in the inner ear is usually described as a balance organ. Its central connections go much further. A review by Rajagopalan and colleagues sets out how the vestibular nuclei project to structures central to emotional processing:
The vestibular system also feeds directly into autonomic control, adjusting heart rate and blood pressure as we change position. Balaban and Thayer described these shared pathways two decades ago as a neurological basis for balance and anxiety links. Put simply, the circuits that tell us where we are in space overlap with the circuits that tell us whether we are safe.
If those pathways are shared, you would expect vestibular problems and emotional problems to travel together. The clinical data support that.
A 2026 systematic review and meta-analysis in The Laryngoscope (Kim et al., 85 studies, over 760,000 participants) found pooled anxiety prevalence of 31.4% in adults with vestibular disorders against 8.3% in controls. Depression prevalence was 28.3% against 4.7%.
Large cohort data point the same way. A UK Biobank analysis of more than 450,000 people (Chen et al., BMC Medicine) found that people hospitalised with peripheral vertigo had roughly double the risk of subsequent depression and anxiety, with risk highest in the first two years after diagnosis.
The link also works in reverse. Anxiety and low mood measurably change how people control their balance, even in healthy participants (Bolmont et al., 2002). This loop is one way to understand persistent postural-perceptual dizziness (PPPD), where an initial vestibular insult sets off heightened vigilance and altered postural control, and those changes keep the dizziness going long after the original injury has settled.
Before going further, it is worth being clear about what is established and what is not. The anatomical connections described above are well documented, as is the fact that vestibular and emotional symptoms frequently co-occur. Whether vestibular disruption after concussion directly drives those emotional symptoms is not settled. The evidence that follows is largely observational, and it shows association rather than cause.
That said, concussion is one of the most common ways an otherwise healthy, active person ends up with vestibular dysfunction and emotional symptoms at the same time.
Vestibular problems after concussion are common, and they track with slower recovery:
There is evidence of measurable injury behind these symptoms in athletes. Gard and colleagues (2022) found that post-concussive vestibular dysfunction was related to injury of the inferior vestibular nerve, and the same group later identified widespread white matter abnormalities in concussed athletes using 7T diffusion MRI. Depressive and anxiety symptoms after concussion have themselves been linked to white matter changes and specific qEEG patterns, which points to a biological basis rather than a purely psychological reaction to being injured.
Mental health problems after mTBI are also more common than many people expect. In the US TRACK-TBI study of 1,155 patients seen in emergency departments, 21.2% reported PTSD and/or major depression six months after mild TBI, compared with 12.1% of patients with orthopaedic injuries (Stein et al., 2019). Markers of injury severity, such as loss of consciousness, did not predict who developed these problems. A “mild” injury is not always mild in its effects.
A recent scoping review of adult athletes with persisting symptoms after concussion (Lumb et al., 2026), a term now preferred over post-concussion syndrome because it frames the symptoms as injury-related and treatable, found that most of the included studies reported a link between persisting symptoms and symptoms of depression or anxiety. Persisting symptoms are thought to affect roughly 10% to 35% of athletes, depending on the cohort and how “persisting” is defined.
The relationship also runs in the other direction before any injury occurs. Athletes with pre-existing depressive and anxiety symptoms are more than twice as likely to go on to sustain a concussion (Thomas et al., 2024). Emotional symptoms are a risk factor to screen for, not only an outcome to monitor afterwards.
It is worth noting that not all of this is neurobiology. Sport-related concussion carries pressures that other head injuries do not: expectations to return to play, stigma around head injury, fear of re-injury, and the gap between how an athlete saw themselves before the injury and how they feel now. That gap alone has been associated with depressive symptoms and apathy.
Symptoms overlap, so assess both domains. Dizziness, light-headedness, a racing heart, poor concentration and feeling “foggy” appear on concussion symptom scales, and they are also features of anxiety. A symptom score on its own cannot tell you which is driving what. Objective vestibular and oculomotor assessment alongside structured mental health screening gives a clearer picture than either alone.
A concussion symptom scale is not a mental health screen. This is one of the clearest messages from the Lumb review. Across the studies included, positive associations between persisting symptoms and depression or anxiety were found most often where dedicated psychological screening had been used. Studies that relied on the emotional items embedded within a general concussion symptom scale were more likely to report inconclusive or negative associations. The emotional questions on a symptom scale flag that something is wrong. They are not built to characterise it.
The same review identified the flip side of that problem. Across just 14 studies, 13 different screening instruments were used, and most were generic tools not developed for athletes. That inconsistency limits what research can tell us and leaves clinicians without a clear pathway. It is precisely the gap the IOC set out to close with a sport-specific, standardised tool (more on that below).
Watch for avoidance. Athletes who feel dizzy in busy or visually complex environments often start avoiding them. That is understandable, but avoidance can reinforce both vestibular sensitivity and anxiety. Graded exposure is a core principle of vestibular rehabilitation, and it overlaps with approaches used in psychological therapy.
Don’t assume the exercise protocol covers it. Several studies in the Lumb review found that structured exercise improved physical symptoms but did not significantly reduce depression or anxiety symptoms. Graded return to activity is well supported for concussion recovery, but emotional symptoms appear to need their own targeted input rather than resolving alongside the physical ones.
Screen early and routinely, not only when recovery stalls. The review argues that psychological screening and management should be an integral part of concussion care rather than something triggered when symptoms fail to settle. The vestibular cohort data point the same way, with the highest risk window for anxiety and depression falling soon after onset.
For clinicians working in sport, the IOC has updated its athlete mental health screening tool. The IOC Sport Mental Health Assessment Tool 2 (SMHAT-2), developed by Gouttebarge and colleagues, was created specifically to address the feasibility, reliability and validity gaps identified in SMHAT-1. It uses a three-step approach:
It is designed for athletes aged 16 and over and covers areas including anxiety, depression, substance use and disordered eating. Two features make it the sensible default for this population. It was built for athletes rather than borrowed from general practice, and it is a stepped pathway rather than a single questionnaire, so a positive screen leads somewhere specific rather than leaving a clinician holding a score.
SMHAT-2 is now available free on ScreenIT, alongside SCAT6 and the vestibular assessments, so mental health and vestibular findings sit on the same athlete timeline and can be tracked across a recovery.
Much of the anatomical evidence for vestibular and limbic connections comes from animal tracing studies, and the human data are largely observational. In the athlete literature specifically, almost all the evidence is cross-sectional, only one of the 14 studies in the Lumb review was rated high confidence, and time since injury across those studies ranged from 28 days to 55 years. Depression and anxiety were also nearly always assessed together, so we cannot yet say which predominates after concussion. Vestibular stimulation as a direct treatment for mood is an interesting idea, but the evidence is early. The shared pathways are well described. How best to use that knowledge clinically is still being worked out.
This year’s World Mental Health Day theme is Lived Experiences Heard: Real Voices, Real Change. After a concussion, part of listening well is recognising that “I feel dizzy” and “I feel anxious” may be two descriptions of the same experience. The brain does not keep balance and emotion in separate boxes, and our assessments should not either.
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