Suicide, Chronic Encephalopathy Link Questioned
Whether former football players’ deaths by suicide are linked to the chronic effects of head injuries during their playing careers needs more research.
The deaths by suicide of several prominent former National Football League (NFL) players have been linked, in the popular press at least, to the repeated blows to the head that they experienced during their playing careers. That connection may be too simplistic, however, and deserves a closer look, said several speakers at the annual meeting of the American Academy of Psychiatry and the Law in Chicago in October.
Hal Worztel, M.D.: “The notion that NFL players are facing some lethal epidemic is not supported by epidemiological data.”
Aaron Levin
Blaming head trauma alone for a suicide is “overly reductionist,” said Hal Wortzel, M.D., director of neuropsychiatric consultation services at the Denver VA Medical Center and the Veterans Integrated Service Network (VISN) 19 Mental Illness Research, Education, and Clinical Center (MIRECC). “The notion that NFL players are facing some lethal epidemic is not supported by epidemiological data.”
Chronic traumatic encephalopathy (CTE), the brain condition blamed by some neuropathologists for those suicides, is an ill-defined entity, said Wortzel. To proponents, it is a neuropsychiatric condition caused by one or many traumatic brain injuries or even by smaller but repeated blows to the head. However, literature on the subject indicates inconsistent patterns of gross pathology and histomorphology, said Wortzel.
That sparse evidence base concerns Wortzel. “Perhaps 100 brains with CTE have been studied, compared with thousands of those reported from TBI research,” he said. “Claims about CTE are dramatically ahead of the science now.”
A systematic review of CTE literature included just seven articles, six of them by a single neuropathologist and covering mainly case studies or series, said fellow panelist Lisa Brenner, Ph.D., director of the VISN 19 MIRECC and a professor of psychiatry, neurology, and physical medicine and rehabilitation at the University of Colorado School of Medicine.
“There are no prospective studies with control groups,” said Brenner. “So the quality is rated low, and there is a high risk of bias in these studies.”
Wortzel cites several problems in evaluating the connection between head injury and suicide.
First, selection bias of a few prominent cases may skew results, he said.
Second, the literature does not account for other causes of comorbidity such as depression, steroid or drug use, posttraumatic stress disorder, or cardiovascular disease.
Third, motivation for some has moved from medical necessity to litigation. The NFL agreed to settle one class-action lawsuit filed by 5,000 players for about $900 million, but that proposal still awaits final approval.
In any case, physicians should proceed cautiously before drawing a direct line from playing a sport to suicide.
“Suicide is a behavior, not a disease, and so it is multifactorial,” said panelist Morton Silverman, M.D., a clinical assistant professor of psychiatry at the University of Colorado Denver. The public may see just the tip of the iceberg, but biological, psychological, medical, and social factors must be included in any evaluation of an individual’s death by suicide.
Worzel is concerned that the media attention paid to the suicides will overpathologize the far more common experience of single concussions. Those may be stressful injuries, but most people recover within three to 12 months, he said. “We should enhance expectations of recovery and not propagate anxiety about the likelihood of CTE.”
Repeated concussions can’t possibly be a good thing, he said. “But we should try to better understand that phenomenon and then develop protocols for returning to play that enhance player safety and minimize these risks.” ■
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Published in print: December 2014
Published online: 18 December 2014
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