Researchers found that one in three former American football players believe they have CTE, which significantly increases the risk of suicidality and mental health problems – highlighting the urgent need for targeted support and further research.
Study: Observed chronic traumatic encephalopathy and suicidality in former professional football players. Image credits: Master1305 / Shutterstock
In a cross-sectional study published in the journal JAMA NeurologyResearchers in the United States of America examined the proportion, clinical correlates, and suicidality of living former professional American football (ASF) players with self-reported chronic traumatic encephalopathy (CTE). They found that 34% of players reported what they believed to be CTE, and this was significantly associated with several health problems, including a higher rate of suicidality compared to those with no perceived CTE.
Background
CTE neuropathological change (CTE-NC), posthumously identified by phosphorylated tau aggregates in the brain, is commonly found in deceased former AVP players. However, in living individuals, only ‘observed CTE’ is reported, influenced by symptoms and external factors such as media reporting. There is no diagnostic test for CTE-NC in living individuals, and the association with premortem neuropsychiatric problems remains unclear.
Traumatic encephalopathy syndrome (TES), the proposed clinical condition associated with CTE-NC, involves cognitive and neurobehavioral problems that cannot be explained by other conditions. Despite this uncertainty, CTE is often discussed as affecting living people, with associations with cognitive decline, mood disorders, and suicidality.
However, the relationship between perception of CTE, cognitive decline, mood disorders, and suicidality remains poorly understood, and the extent to which living former ASF players believe they have CTE remains unknown. Therefore, in the current study, researchers sought to determine the proportion of living former professional AVP players with observed CTE and identify clinically relevant correlates, including suicidality, by comparing the characteristics of those with and without observed CTE.
About the study
The Football Players Health Study recruited 4,180 former ASF players, of which 1,980 players provided follow-up data on perceived CTE and self-harm. Surveys collected data on demographics, football history and health conditions, including mental and physical problems. Demographic, football-related and health-related data were collected through surveys, including factors such as age, race and ethnicity. Football exposures include position, career length, and concussion history.
The average age of respondents was 57.7 years, with an average length of professional football career of seven years. Perceived CTE was measured by asking participants whether they thought they had CTE, without defining what CTE means, allowing for subjective interpretation. Clinical variables included assessments of cognitive problems, depression using the Patient Health Questionnaire-9 (PHQ-9), anxiety using the Generalized Anxiety Disorder-7 (GAD-7), pain intensity, emotional dyscontrol, and physical activity levels.
Suicidal ideation was taken from the PHQ-9 item on suicidal ideation. Cognitive and emotional dysfunction were assessed using the Quality of Life in Neurological Disorders (Neuro-QoL) measures, with scores reflecting the frequency of cognitive and emotional symptoms. The potential relationship between perceived CTE and these variables was analyzed, along with suicidality, depression, and other health problems often associated with cognitive impairment in former athletes. Statistical analysis included the use of Kruskal-Wallis rank sum and chi-square tests, logistic regression, multinomial logistic regression, and inverse probability weighting.
Results and discussion
A total of 681 former professional ASF players (34.4%) reported observed CTE. Those who diagnosed themselves with CTE were, on average, 5.4 years younger than those who did not. Players with observed CTE showed higher scores for concussion signs and symptoms, increased use of performance-enhancing drugs, and worse symptoms of depression and anxiety. Notably, subjective cognitive difficulties were the strongest predictor of perceived CTE, underscoring the role of self-rated cognitive decline in shaping perceptions. Emotional and behavioral dyscontrol also played an important role, in addition to low testosterone levels and CSS scores.
Suicidality was reported by 25.4% of participants with observed CTE, compared to 5% without. Factors independently associated with suicidality among people with perceived CTE included depressive symptoms, perceived CTE, anxiety, and emotional dyscontrol. Interestingly, physical activity and the presence of diabetes were associated with a reduced likelihood of suicidality. Participants with perceived CTE were found to be twice as likely to report suicidal ideation (odds ratio 2.06).
When predicting suicidality, factors differed depending on perceived CTE status. Among those with perceived CTE, depression, anxiety, and emotional dyscontrol significantly predicted suicidality, while diabetes and physical activity were associated with lower odds. In contrast, headache emerged as the most important predictor of suicidality in people without perceived CTE, alongside depressive symptoms.
The study provides insight into the complex interplay between perceived CTE and mental health outcomes in former AVP players. However, the study is limited by its reliance on self-reported data on comorbidities, potential bias in sample representation, the lack of independent verification for dementia diagnoses, and the inability to accurately categorize the extent of suicidality. Furthermore, the reliance on observed CTE, rather than confirmed diagnoses, introduces potential bias influenced by media portrayal of CTE in former athletes. Further research is needed to clarify the relationship between observed CTE and actual neuropathological evidence.
Conclusion
In conclusion, the study showed that one-third of former professional AVP players reported reported CTE, highlighting clear clinical correlations between those with and without this perception. Perceived CTE may indicate an increased risk for suicidality, suggesting that recognizing this perception could inform diagnostic and therapeutic strategies to better identify and address suicide risk in these athletes. However, the study underlines that observed CTE is not a confirmed diagnosis and that further research is needed to understand its true clinical implications.
Overall, the findings highlight the importance of addressing potential issues related to mental health and emotional well-being in this population, as this could improve overall health outcomes for former players.