DIDACTIC SESSION:

CHRONIC SEQUELAE
DEPRESSION AND SUICIDE IN
ATHLETES
PROGRAM SYLLABUS

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2015 AAN Sports Concussion Conference

July 24-26, 2015
Didactic Session: Chronic Sequelae
Sunday, July 26, 2015
8:00 a.m. 11:30 a.m.
General Information:
Attendees must be registered and badged to attend the individual programs.
CME Category 1 Credit is awarded to persons registering for and participating in the AAN Regional
Programs and submitting an evaluation form. Program evaluations are online and a link to access
them will be emailed to you at the end of each day. Evaluations are due within two weeks of the
program.
An email will be sent to all attendees on how to access your CME credits earned approximately six
weeks after the conference.
Program Directors
Jeffrey S. Kutcher, MD, FAAN Ann Arbor, MI
Christopher Giza, MD Los Angeles, CA
Program Schedule and Faculty
8:00 AM 8:15 AM
Welcome and Introduction
8:15 AM 8:55 AM

Epidemiology/Risk Factors for Long-term

Sequelae

Barry D. Jordan, MD
White Plains, NY

8:55 AM 9:35 AM

Depression and Suicide in Athletes

Gary Solomon, PhD, FACPN

Nashville, TN

9:35 AM 9:50 AM

Break

9:50 AM 10:30 AM

Chronic Traumatic Encephalopathy Pathology

vs. Presentation

Samuel E. Gandy, MD, PhD

New York, NY

10:30 AM - 11:10 AM

Putting it all Together: The Landscape of

Dementing Illnesses
Panel Q&A

Steven T. Dekosky, MD, FAAN

Charlottesville, VA

11:10 AM 11:30 AM

Program Description:
This three-day conference will focus on the science behind concussion. The conference will follow a new
programming model to include five half-day sessions, each with its own general theme, faculty presentations, and
a panel discussion. Poster presentations will occur on the first two days of the conference. The five half-day topics
are: concussion, concussion research (epidemiology, biomechanics, and imaging), post-concussive syndrome,
research (mTBI), and chronic Sequelae. In addition, there will be lunchtime breakout sessions targeted to the
following audiences: professional sports, collegiate sports, high school sports, and youth sports.
Learning Objectives:
Participants should be able to accurately and appropriately diagnose concussion; institute appropriate and
clinically useful diagnostic tests when indicated; provide state-of-the-art management of concussed athletes and
individuals; make safe and appropriate return to play, school, work, and life decisions; and educate athletes, nonhealth care professionals, and other health care practitioners on key issues related to concussion.
Recommended Audience:
Neurologists, Athletic Trainers, Primary Care Physicians, Neuropsychologists, and Sports Medicine Professionals.

Accreditation
The American Academy of Neurology is accredited by the Accreditation Council for Continuing Medical Education
(ACCME) to provide continuing medical education for physicians.
AMA PRA Credit
The AAN designates these educational activities for a maximum number of hours in category 1 credit toward the
AMA Physician's Recognition Award. The number of credits assigned to each individual program is outlined in the
program's description. Each physician should only claim those hours of credit that he/she actually spent in the
activity.
Certificates for Non-Physicians
Non-physician participating in the programs will receive a certificate of attendance indicating attendance at an
activity designated for AMA PRA category 1 credit.
Education/Posters Disclaimer
The primary purpose of the AAN Sports Concussion Conference is to provide educational programs and
information. Information presented, as well as publications, posters, technologies, products and/or services
discussed, are intended to inform attendees about the knowledge, techniques, and experiences of physicians and
other professionals who are willing to share such information with colleagues. A diversity of opinions exists in the
medical field, and the view of the conferences faculty and other presenters is offered solely for educational
purposes. Faculty members' and presenters views represent neither those of the AAN nor constitute
endorsement by the AAN. The AAN disclaims any and all liability for all claims which may result from the use of
information, posters, publications, products, and/or services discussed at the AAN Sports Concussion
Conference.
Faculty's Disclosure of Commercial Relationships
Consistent with the AAN and ACCME policies, faculty must disclose any significant financial or other relationship
with the manufacture(s) of any commercial product(s) or service(s) discussed in their course. This policy is
intended to make participants aware of all speakers' financial or other relationship(s), so that attendees may form
their own judgments about material discussed during the educational activity. Full disclosure of faculty's
commercial relationships will appear in the individual program materials. All faculty must sign a letter of
agreement stating explicitly that they understand and will adhere to AAN and ACCME guidelines that require full
disclosure of commercial relationships, unlabeled use of products, and identification of data sources.
Faculty Commercial Relationship Disclosures
Jeffrey S. Kutcher, MD Dr. Kutcher has received personal compensation for activities with the National
Basketball Association Concussion Program as a director, with National Hockey League Players
Association and ElMindA, Ltd. As a consultant. Dr. Kutcher has received research support from ElMindA,
Ltd. For a research grant.
Christopher Giza, MD Dr. Giza has received personal compensation for activities with the Medical
Education Speakers Bureau and for medicolegal consultation with Alcobra and Pearson TLC.
Barry D. Jordan, MD Dr. Jordan has nothing to disclose.
Gary Solomon, PhD, FACPN Dr. Solomon has received personal compensation from Vanderbilt
University Medical Center as an employee, from the Nashville Predators, Tennessee Titans, University of
Tennessee Athletics, and Tennessee Tech Athletics as a consulting neurophsychologist, and from
IMPACT as a consultant. Dr. Solomon has received royalty payments from Human Kinetics Publishers,
Inc. Dr. Solomon has received research support from Rawlings Sporting Goods for an unrestricted
educational grant for sports concussion community education and from the Department of Defense as a
consultant on a grant.
Samuel E. Gandy, MD, PhD Dr. Gandy has received research support from Baxter and Polymeidlin.
Steven T. Dekosky, MD, FAAN - Dr. Dekosky has received personal compensation from Roche, Novartis,
Cowen Group, Trinity Partners and Interactive Forums, Inc. as a consultant. Dr. Dekosky has received
personal compensation for serving on the editorial boards of Up to Date and JAMA Neurology.

Unlabeled Use of Product Disclosure

The AAN, as an ACCME accredited provider, requires all faculty members to disclose if a product is not labeled
for the use being discussed or that the product is still investigational.
Faculty Unlabeled Use of Product Disclosures
Dr. Jordan will not include any information on unlabeled use of products or investigational uses during the
presentation.
Dr. Solomon will not include any information on unlabeled use of products or investigational uses during
the presentation.
Dr. Gandy will discuss the new unapproved diagnostic ligands and unapproved uses for existing ligands.
Dr. DeKosky will not include any information on unlabeled use of products or investigational uses during
the presentation.

DEPRESSION AND SUICIDE IN ATHLETES WITH SPORTS-RELATED

CONCUSSIONS
Gary Solomon, Ph.D.
Vanderbilt University School of Medicine
Nashville, TN
The objectives of this course are:
1. To review the evidence on depression and anxiety disorders in athletes with sports-related concussions.
2. To review the evidence on suicide in athletes with sports-related concussions.
3. To discuss possible reasons for common beliefs related to the effects of sports-related concussion and
depression/suicide.
Epidemiological data on depression, anxiety, and suicide in athletes (and in the general population) will be
reviewed, compared, and contrasted, with a focus on athletes with sport-related concussions. Studies assessing
the relevance of pre-injury biopsychosocial factors on post-injury outcome in sports-related concussion will be
discussed. Finally, possible explanatory mechanisms for popular beliefs about the relationship between sportsrelated concussions and depression/suicide will be addressed.
References:
Guskiewicz, Kevin M., et al. "Recurrent concussion and risk of depression in retired professional football players."
Medicine and science in sports and exercise 39.6 (2007): 903.
Kerr, Zachary Y., et al. "Nine-year risk of depression diagnosis increases with increasing self-reported
concussions in retired professional football players." The American journal of sports medicine (2012):
0363546512456193.
Didehbani, Nyaz, et al. "Depressive symptoms and concussions in aging retired NFL players." Archives of clinical
neuropsychology 28.5 (2013): 418-424.
Strain, Jeremy, et al. "Depressive symptoms and white matter dysfunction in retired NFL players with concussion
history." Neurology 81.1 (2013): 25-32.
Casson, Ira R., et al. "Is there chronic brain damage in retired NFL players? Neuroradiology, neuropsychology,
and neurology examinations of 45 retired players." Sports Health: A Multidisciplinary Approach 6.5
(2014): 384-395.
Wolanin, Andrew, Michael Gross, and Eugene Hong. "Depression in Athletes: Prevalence and Risk Factors."
Current sports medicine reports 14.1 (2015): 56-60.
Covassin, Tracey, et al. "The role of age and sex in symptoms, neurocognitive performance, and postural stability
in athletes after concussion." The American journal of sports medicine 40.6 (2012): 1303-1312.
Roiger, Trevor, Lee Weidauer, and Bryce Kern. "A longitudinal pilot study of depressive symptoms in concussed
and injured/nonconcussed National Collegiate Athletic Association Division I student-athletes." Journal of
athletic training (2015).
Yang, Jingzhen, et al. "Post-Concussion Symptoms of Depression and Anxiety in Division I Collegiate Athletes."
Developmental neuropsychology 40.1 (2015): 18-23.
Morgan, Clinton D., et al. "Predictors of postconcussion syndrome after sports-related concussion in young
athletes: a matched case-control study." Journal of Neurosurgery: Pediatrics (2015): 1-10.
Cottler, Linda B., et al. "Injury, pain, and prescription opioid use among former National Football League (NFL)
players." Drug and alcohol dependence 116.1 (2011): 188-194.
Lehman, Everett J., et al. "Neurodegenerative causes of death among retired National Football League players."
Neurology 79.19 (2012): 1970-1974.
Iverson, Grant L. "Chronic traumatic encephalopathy and risk of suicide in former athletes." British journal of
sports medicine 48.2 (2014): 162-164.
Kuran, Timur, and Cass R. Sunstein. "Availability cascades and risk regulation." Stanford Law Review (1999):
683-768.
Wortzel, Hal S., Robert D. Shura, and Lisa A. Brenner. "Chronic traumatic encephalopathy and suicide: A
systematic review." BioMed research international 2013 (2013).

7/10/2015

Depression and Suicide in Athletes

with Sports-Related Concussions

2015 AAN Sports Concussion Conference

Denver, CO
July 26, 2015
Gary Solomon, Ph.D., FACPN
Associate Professor, Departments of
Neurological Surgery, Orthopaedic Surgery
& Rehabilitation, and Psychiatry,
Co-Director, Vanderbilt Sports Concussion Center
Vanderbilt University School of Medicine
Team Neuropsychologist, Nashville Predators
Consulting Neuropsychologist, Tennessee Titans
gary.solomon@vanderbilt.edu

Disclosures and Disclaimers

Full time employee, Vanderbilt University School of Medicine

Book sale royalties, Human Kinetics

Either Vanderbilt or I receive consulting fees, honoraria, and/or expense

reimbursements from: Nashville Predators, Tennessee Titans, Tennessee Tech Athletics,
University of Tennessee Athletics, ImPACT, National Steeplechase Association

Grants: Rawlings Sporting Goods: Unrestricted Educational for community education

on sports concussion
DoD: Restoration of standing and walking through Intraspinal Microstimulation in humans (Peter Konrad, M.D.)

This presentation is not endorsed by any organization with

which I am affiliated.
This is not a comprehensive assessment of the published
literature; my own biases in the selection of papers reviewed
and the opinions presented are acknowledged.

Comments in blue represent my opinion

I express my appreciation to all authors whose work is discussed.

It is easy to criticize research, and difficult to do it well

Objectives
1. To review the evidence on depression and anxiety disorders in
athletes with sports-related concussions
2. To review the evidence on suicide in athletes with sports-related
concussions
3. To discuss possible reasons for common beliefs related to the effects
of sports-related concussion and depression/suicide.

7/10/2015

Practice Parameters/Consensus Guidelines/Position Statements

Mood disorder was not specifically

addressed in any of these guidelines

Practice Parameters/Consensus Guidelines/Position Statements

Mental health issues may be multifactorial

Mood disorders complicate dx and management
Difficult to determine what precedes-causes-worsens

Recommendations and empirical data are limited in sports concussion

Epidemiology
National trends in mental health service utilization (USA)

Among insured people:

Overall, about 40%
Ages 18-34, about 33%
Ages 35-49, nearly 40%
Over age 50, about 50%

7/10/2015

Lifetime Prevalence of Mood Disorders

Twelve-month and Lifetime Prevalence and Lifetime Morbid Risk of Anxiety and
Mood Disorders in the United States
Kessler, Petukhova, Sampson, et al.

International Journal of Methods in Psychiatric Research, 2012

DSM-IV TR/CIDI Mood and Anxiety Disorders

National Comorbidity Survey Replication (NCS-R) and Adolescent Supplement
(NCS-A)

Mood Disorders

Anxiety Disorders

38.3% for adolescents

33.7% for adults

18.2% for adolescents

21.4% for adults

Mood Disorders in Collegiate Athletes

Yang, et al. CJSM, 2007: 251 Division 1 athletes;
21% were + for sxs of depression
Armstrong & Oomen-Early, JACH, 2009: 227 collegiate
students (104 athletes); 33.5% were + for significant depressive sxs
Proctor & Boan-Lenzo, JCSP, 2010: 61 Division 1 baseball players;
15.6% were + for depressive sxs
Brewer & Petrie, AAJ, 1995: 916 Division 1 football players;
33% with injury and 27% without injury were + for depressive sxs

_______________________________________________________________________

Mood Disorders in Concussed Collegiate Athletes

Mainwaring et al., Br Inj, 2010: Athletes with ACL injuries had
greater severity and duration of depressive sxs vs. athletes
with concussion (Profile of Mood States-POMS)
Vargas et al., JAT, 2015: 84 collegiate athletes with concussions
vs. 42 controls; 20% of concussed athletes showed a reliable
increase in depressive sxs (BDI-Fast Screen)

Survey studies of depression

(retired NFL players)

Recurrent Concussion and Risk of Depression in Retired Professional Football

Players
Guskiewicz, Marshall, Bailes, McCrea, et al.

Medicine and Science in Sports and Exercise, 2007

Nine-Year Risk of Depression Diagnosis Increases with Increasing SelfReported Concussions in Retired Professional Football Players
Kerr, Marshall, Harding, & Guskiewicz

American Journal of Sports Medicine, 2012

7/10/2015

Depression

Concussion

Have you ever been told by a physician or health professional

that you have/had any of the following medical conditions?
2007: When compared with retired athletes reporting no concussions--Retired athletes reporting 1-2 concussions were 1.5x more likely (prevalence ratio =
1.48, 95% CI = 1.08-2.02) to report a diagnosis of depression
Retired athletes reporting 3 or more concussions during professional football were
3x more likely (prevalence ratio = 3.1, 95% CI = 2.3-4.1) to report a diagnosis of
depression
_____________________________________________________________
2012: The 9-year risk of a depression diagnosis increased with an increasing
number of self-reported concussions, ranging from 3.0% in the no concussions
group to 26.8% in the 10+ group (linear trend: p<.001). A strong dose-response
relationship was observed even after controlling for confounders.

Beck Depression Inventory-II studies

Depressive Symptoms and Concussions in Aging Retired NFL Players

Didehbani, Cullum, Mansinghani, et al.

Archives of Clinical Neuropsychology, 2013

Compared 30 retired NFL players with a history of concussion with 29 age- and IQmatched controls with no history of concussion
Found a significant correlation between the number of lifetime concussions and
depression symptom severity on the BDI-II
the number of self-reported concussions may be related to later depressive
symptomatology

Didehbani et al., ACN, 2013

BDI-II Scores

Athletes (n=30)

Controls (n=29)

8.80 (8.83)

2.83 (3.95)

__________________________________________________________
Beck, A.T., Steer, R.A., & Brown, G.K. (1996). Beck Depression Inventory: second edition
manual. San Antonio: The Psychological Corporation, 1996.

Norms:
Minimal range = 013
Mild depression = 1419
Moderate depression = 2028
Severe depression = 2963

The severity of depressive symptoms according

to BDI criteria is low in both groups

7/10/2015

Depressive symptoms and white matter dysfunction in retired NFL players

with concussion history
Strain, Didehbani, Cullum, et al.

Neurology, 2013

Asymptomatic athletes (n=21)

Symptomatic athletes (n=5)

0-11, x=4.29 (3.72)

18-28, x=23.6 (4.28)

BDI-II Score

5/26 positive; 19% rate of depression per BDI criteria

Is There Chronic Brain Damage in Retired NFL Players? Neuroradiology,

Neuropsychology, and Neurology Examinations of 45 Retired Players
Casson, Viano, Haake, et al.

Sports Health, 2014

Distribution of scores

30

66.67

BDI-II score
0-13

20.00

14-19

6.67

20-28

6.67

>29

Using the BDI criteria, the 15 subjects with any

severity of depression is higher than the
reported prevalence of depression in the general
population (15-20%). The 6 subjects with
moderate or severe depression (13.33%) are
more in line with the overall population
numbersThe evidence in this study does not
support the contention that a career in the NFL
is causally related to later-life depression.

BDI 14= 33% rate of depression

BDI 20= 13.33% rate of depression

Neuroinflammation and Brain Atrophy in Former NFL Players: An in vivo

multimodal imaging pilot study.
Coughlin, Wang, Munro et al.

Neurobiology of Disease, 2015

All eleven former NFL players were without moderate or severe

depression defined as a score >13 on the HAMD, though two
players had a HAMD score between 8 and 13, indicating mild
depression.

n = 11

Controls were not assessed via HAM-D

HAM-D: 18% rate of depression

7/10/2015

Depression in Athletes: Prevalence and Risk Factors

What is the
prevalence of
depression in
athletes?

15.6%-21%

Wolanin, Gross, & Hong

Current Sports Medicine Reports, 2015

Depression does occur in athletes

In certain subpopulations of athletes, there may be a higher
rate of depression than nonathletes.
Suicide in athletes, a tragic outcome that can be associated
with depression, exists.

The prevalence of depression in athletes may be slightly higher vs. the general
population, which is reported to be 13-16% (Gelenberg et al., APA, 2010),
but there is no clear evidence that this is due to concussions or subconcussive
injury.
Depression exists in athletes, and athletes commit suicide

Depression in Athletes or Increased Depressive Symptoms in Athletes?

Schuch

Current Sports Medicine Reports, 2015

Depression or depressive sxs?

No psychiatric diagnosis made in these studies
No attention paid to bipolar illness
_________________________________________________________
Relying on Beck, POMS, or CES-D scores is not ideal
Highest scores on these instruments are
not always obtained by pts. with depression

At baseline
Sex and Age Differences in Depression and Baseline Sport-Related Concussion
Neurocognitive Performance and Symptoms
Covassin, Elbin, Larson, Kontos

Clinical Journal of Sport Medicine, 2012

1616 athletes (837 collegiate and 779 high school) athletes from 3
states participating in a variety of sports
At baseline, student-athletes with higher scores on CES-D had:
Greater sx endorsement
Poorer Visual Memory scores (ImPACT)

7/10/2015

At baseline

The Relationship Between Psychological Distress and Baseline Sports-Related

Concussion Testing
Bailey, Samples, Broshek, et al. CJSM, 2010

47 Division I football players, ages 17-19 (46 freshmen)

Concussion Resolution Index (CRI) and Personality Assessment Inventory (PAI)
32-55% endorsed sxs of psych distress at baseline
Scores of athletes endorsing sxs of anxiety, depression, substance misuse, or suicidal
ideas were correlated with CRI indexes (r= 0.23-0.30)
Participants acknowledging suicidal thoughts (n=7) had significantly lower simple and
complex reaction time scores, with a trend also noted for Processing Speed (p=.10)

At baseline
Are Prescribed Psychotropic Medications Associated with Differences on
Baseline Neurocognitive Assessment Performance? A Pilot Study
Yengo-Kahn & Solomon

The Physician and Sportsmedicine, in press

Deidentified data base of athletes ages 13-24

Athletes who report being prescribed psychostimulants displayed significantly lower visual motor
speed scores (32.8 vs 37.1, p=0.03) and slower reaction times (0.65 vs 0.60, p=0.04) than matched
non-users (1:3 ratio)
Athletes who report being prescribed antidepressants displayed significantly faster reaction times
(0.58 vs 0.61, p=0.03) than matched (1:2 ratio) controls
Athletes with a self-reported history of depression/anxiety, not treated with psychotropics,
displayed significantly lower visual memory (70.4 vs 75.2, p=0.01) and higher symptom scores (8.83
vs 4.72, p=0.005) than matched (1:2 ratio) controls

Post-Concussion

n=7 per group, assessed serially with CES-D

Groups: Concussion vs. Injured/Nonconcussed
Week 1: Both groups + for depressive sxs > baseline
Week 4: Injured/Nonconcussed only > baseline

7/10/2015

Post-Concussion

Post-Concussion Symptoms of Depression and Anxiety in

Division 1 Collegiate Athletes
Yang, Peek-Asa, Covassin, Torner

Developmental Neuropsychology, 2014

Prospective cohort study at 2 Big Ten universities (9 sports teams) 2007-08 through 2011-12
seasons
CES-D & State-Trait Anxiety Inventory
67 concussed athletes with + sxs depression at baseline were:

4.59x more likely (95% CI = 1.25-16.89) to experience depressive sxs

3.40x more likely (95% CI = 1.11-10.49) to experience state anxiety

Post-Concussion

Importance of baseline biopsychosocial factors

Synthesis: Limited research data suggests:

Athletes differ in the degree of depressive symptoms at baseline; gender is relevant

- Athletes may have a higher rate of depressive symptoms (but not necessarily major
depressive disorder) than the general population
- Athletes may have biopsychosocially-influenced responses to concussion that may
include depressive symptoms
- Personal and family genetic factors (including migraine and psychiatric illness) are
relevant
_______________________________________________________________________
- We need prospective studies with matched controls, utilizing valid psychometric
instruments and clinical psychiatric diagnostic criteria, to assess empirically the
relationships between sports-related concussion and mood disorders

7/10/2015

Sports concussion and suicide

November, 2014

March, 2015

Suicide: Some Facts

Unfortunately, suicide is a very common occurrence

The suicide rate is nearly twice that of the homicide rate in the USA
CDC: In 2013, 41,149 suicides were reported, making suicide the 10th leading cause of
death for Americans (113 per day, about one every 13 minutes; the rate in Canada is
slightly higher)

The rate of suicide is increasing in:

Civilians: Sullivan EM, Annest JL, Luo F, et al. Suicide among adults aged 3564 yearsUnited
States, 19992010. MMWR. 2013;62:3215.
Military:

Center AFHS. Deaths by suicide while on active duty, active and reserve components, US
Armed Forces, 19982011. Med Surveil Monthly Rep. 2012;19:710.
___________________________________________________________________________________

The rates of suicide in both men and women have increased

significantly from 1999-2010: Sullivan EM, Annest JL, Luo F, et al. Suicide among adults
aged 3564 years United States, 19992010. MMWR. 2013;62:3215.

People in the US are now more likely to die from suicide than MVCs:
Rockett IR, Regier MD, Kapusta ND, et al. Leading causes of unintentional and intentional injury
mortality: United States, 20002009. Am J Public Health. 2012;102:e8492.

7/10/2015

What are the risk factors for suicide?

According to NIMH, risk factors for suicide include depression and other
mental disorders, or a substance-abuse disorder (often in combination
with other mental disorders).
More than 90 percent of people who die by suicide have these risk factors.

In 2012, Ages 10-24=

5,178 deaths

The Risk of Adolescent Suicide across Patterns of Drug Use: A Nationally

Representative Study of High School Students in the United States from
1999 to 2009.
Wong, Zhou, Goebert, et al.

Social Psychiatry and Psychiatric Epidemiology, 2013

Suicide risk escalates as a function of the number of drugs used

0 categories: 2.4% of attempts
1 category: 4.0% of attempts
3 categories: 7.8% of attempts
5 categories: 18.0% of attempts
7 categories: 23.3% of attempts
10 categories: 69.6% of attempts

10

7/10/2015

In the recent past, 3 professional football players

(Dave Duerson, Ray Easterling, and Junior Seau)
have committed suicide. Duerson and Seau died via
GSW to the chest, apparently in an attempt to spare
their brains for postmortem study.
Other collegiate and professional athletes (football,
wrestling, hockey) have committed suicide and
have been later diagnosed with CTE.
Suicides have occurred among collegiate and high
school athletes, with sports-related concussions
claimed as the cause.
We know that athletes are not immune to mood disorders.
Do athletes abuse drugs?

Injury, Pain, and Prescription Opioid Use Among Former National Football
League (NFL) Players.
Cotler, Abdallah, Cummings, et al.

Drug and Alcohol Dependence, 2011

Telephone survey of 644 retired NFL players from the 2009 Retired
NFLPA directory conducted from March-August, 2010 (53.4% completion
rate)
52% used opioids during their NFL career, and 71% admitted to misuse
(opiate abuse is a cause of hyperphosphorylated tau)

Prevalence of current opioid abuse was 7%, which is 3x rate of the

general population
_____________________________________________________________
What is the suicide rate in retired NFL players?

11

7/10/2015

Body Mass Index, Playing Position, Race, and the Cardiovascular Mortality
of Retired Professional Football Players.
Baron, Hein, Lehman, et al.

American Journal of Cardiology, 2011

Cohort: 1960-2007

The rates of death due to suicide (and violence) in

NFL players were lower than the general population

Chronic Effects of Mild Neurotrauma: Putting the Cart Before the Horse?
Castellani, Perry, Iverson

J Neuropathology and Experimental Neurology, 2015

Virtually all articles on CTE since 2010 have asserted

that suicide is a core feature of this disease
Suicide was not considered a feature of CTE prior to 2010
A random sample of 250 boxers reported by
Roberts (1969) revealed one case of CO
poisoning but no confirmed cases of suicide

College students and suicide

Suicide represents the third leading cause of death among

college-age individuals and the second leading cause of death
among college students.
What is the rate of suicide in NCAA student-athletes?
___________________________________________________________
Centers for Disease Control and Prevention. Leading causes of death reports, national and regional,
1999-2013.http://webappa.cdc.gov/sasweb/ncipc/leadcaus10_us.html.
McIntosh JL, Drapeau CW. U.S.A suicide 2011: official final data. http://www.
suicidology.org/Portals/14/docs/Resources/FactSheets/2011OverallData.pdf.

12

7/10/2015

Suicide in National Collegiate Athletic Association (NCAA) Athletes: A

9-Year Analysis of the NCAA Resolutions Database
Rao, Asif, Drezner, et al.

Sports Health, 2015

9 year study period of Divisions I, II, and III: 35 suicides out of 477 student-athlete deaths
Incidence of suicide was higher in males (82.9%) and in African-Americans
Highest suicide rate occurred in mens football, with relative risk of suicide being 2.2 > vs. other male,
non-football athletes
After football, highest risk sports for suicide were soccer, track/cross-country, baseball, and swimming
Suicide rate of NCAA athletes was lower than the general and collegiate populations
of similar age
Concussion history was not ascertained

Review papers
Chronic Traumatic Encephalopathy and Risk of
Suicide in Former Athletes
Grant Iverson

Br J Sports Med, 2014

There are no published cross-sectional, epidemiological, or prospective

studies showing a relation between contact sports and risk of suicide.
Chronic Traumatic Encephalopathy and Suicide: A Systematic Review
Wortzel, Shura, Brenner
BioMed Research International, 2013

Overall quality of evidence regarding a relationship between CTE and suicide

was rated as very low using Grading of Recommendations Assessment,
Development, and Evaluation Working Group (GRADE) criteria.

NFL and NCAA athletes have a lower risk of suicide

There is no clear evidence that concussions cause suicide

Media bias?
_______________________________________________________________

13

7/10/2015

Availability Cascades
and Risk Regulation
Timur Kuran and Cass R. Sunstein

a self-reinforcing process of collective belief formation by which an expressed perception

triggers a chain reaction that gives the perception of increasing plausibility through its
rising availability in public discourse. The driving mechanism involves a combination of
informational and reputational motives: Individuals endorse the perception partly by
learning from the apparent beliefs of others and partly by distorting their public
responses in the interest of maintaining social acceptance.

_______________________________________________________________
Availability cascade = repeat something long enough and it becomes true
________________________________________________________________
Regarding the long term effects of concussion, the availability cascade involves the
neglect of empirical data in favor of highly publicized and emotional case findings, with
social psychological pressures leading individuals to believe, endorse, and perpetuate the
biased perception.

Summary
The current thinking among some clinicians and
researchers seems to be that sports-related
concussions and/or subconcussive impacts directly
cause psychiatric illness and suicide, and that the
presence of postmortem abnormal tau is causal proof
of the ante mortem cognitive, mood, impulse dyscontrol,
and neurobehavioral changes seen in athletes.
It is not certain that the presence of abnormal tau causes these aberrations, nor is it clear that the
only reason for the presence of the abnormal tau is concussion or subconcussive impacts. If
hyperphosphorylated tau directly caused mood disorder and suicide, then there should be a
distinctly high prevalence of these conditions in patients with tauopathies, and this is not the
case*. If sports concussions directly caused psychiatric illness and suicide, then the prevalence
should be higher in athletes than in the general population, and this is not the case. For purposes
of cause and effect it is critical to account for genetic, medical, psychiatric, substance abuse, and
biopsychosocial variables that could well be relevant in the short- and long-term neurobehavioral
outcomes.
________________________________________________________________________________
*Haw, Camilla, Daniel Harwood, and Keith Hawton. "Dementia and suicidal behavior:
a review of the literature." International Psychogeriatrics 21.03 (2009): 440-453.

*Chesney, Edward, Guy M. Goodwin, and Seena Fazel. "Risks of allcause and suicide
mortality in mental disorders: a metareview." World Psychiatry 13.2 (2014): 153-160.

Summary
Psychiatric illness, suicide, and cognitive disorders are heterogeneous in nature
and multifactorial in etiology. We need controlled, prospective, longitudinal,
multi-modal assessment studies to determine the relationships among these
factors.

The brain remains gelatinous, and

There is little doubt that some athletes may suffer from

adverse psychological effects from multiple sports-related
concussions.

although some of its structures are

fragile, it is still not made of spun glass.

At present, despite anecdotal and case series reports, it is my

opinion that there is no compelling empirical evidence to indicate
that sports-related concussion or subconcussive impacts are the
sole and direct cause of psychiatric illness or suicide.
Media reports, financial incentives, and cognitive biases appear to
be primary factors (among others) in common beliefs related to the
presumed relationship between sports-related concussions and
psychiatric illness/suicide.
As sports medicine clinicians, it is incumbent on us to focus on the relevant,
multivariate factors in the outcome from sports-related concussion, and not
to reinforce the simplistic, linear thinking of concussions or subconcussive
impacts as the cause of all neuropsychiatric ills.

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