Researchers found that one in three former American football players believe they have CTE, significantly increasing their risk of suicidality and mental health challenges—highlighting the urgent need for targeted support and further study.

Study: Perceived Chronic Traumatic Encephalopathy and Suicidality in Former Professional Football Players. Image Credit: Master1305 / Shutterstock

In a cross-sectional study published in the journal JAMA Neurology, researchers in the United States of America investigated the proportion, clinical correlates, and suicidality of living former professional players of American-style football (ASF) with self-reported chronic traumatic encephalopathy (CTE). They found that 34% of the players reported what they believed to be CTE, and this was significantly associated with various health problems, including a higher rate of suicidality compared to those without perceived CTE.

Background

CTE neuropathological change (CTE-NC), identified posthumously by phosphorylated tau aggregates in the brain, is commonly found in deceased former ASF players. However, in living individuals, only “perceived CTE” is reported, influenced by symptoms and external factors such as media coverage. There is no diagnostic test for CTE-NC in living individuals, and its link to premortem neuropsychiatric issues remains unclear.

Traumatic encephalopathy syndrome (TES), the proposed clinical disorder tied to CTE-NC, includes cognitive and neurobehavioral problems not explained by other conditions. Despite this uncertainty, CTE is often discussed as affecting living people, with associations to cognitive decline, mood disorders, and suicidality.

However, the relationship between the 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, researchers in the present study aimed to determine the fraction of living former professional ASF players with perceived CTE and identify clinically relevant correlates, including suicidality, by comparing the characteristics of those with and without perceived CTE.

About the study

The Football Players Health Study recruited 4,180 former ASF players, out 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 health and physical issues. Demographic, football-related, and health-related data were collected through surveys, including factors such as age, race, and ethnicity. Football exposures included position, career duration, and concussion history.

The mean age of respondents was 57.7 years, with an average professional football career duration of seven years. Perceived CTE was measured by asking participants whether they believed they had CTE without defining what CTE means, allowing for subjective interpretation. Clinical variables included assessments for cognitive difficulties, 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 captured from the PHQ-9 item on suicidal thoughts. 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 conditions commonly associated with cognitive impairment in former athletes. Statistical analysis involved 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 perceived CTE. Those who perceived having CTE were 5.4 years younger on average than those who did not. Players with perceived CTE showed higher concussion signs and symptoms (CSS) scores, increased use of performance-enhancing drugs, and worse symptoms of depression and anxiety. In particular, subjective cognitive difficulties were the strongest predictor of perceived CTE, underscoring the role of self-assessed cognitive decline in shaping perceptions. Emotional and behavioral dyscontrol also played a significant role, alongside low testosterone levels and CSS scores.

Suicidality was reported by 25.4% of participants with perceived CTE compared to 5% without. Factors independently associated with suicidality among those with perceived CTE included depressive symptoms, perceived CTE, anxiety, and emotional dyscontrol. Interestingly, physical activity and the presence of diabetes were linked to reduced odds of suicidality. Participants with perceived CTE were found to be twice as likely to report suicidal thoughts (odds ratio 2.06).

When predicting suicidality, factors differed by 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, headaches emerged as the most significant predictor of suicidality for those without perceived CTE, alongside depressive symptoms.

The study provides insights into the complex interplay between perceived CTE and mental health outcomes among former ASF players. However, the study is limited by its reliance on self-reported data for comorbidities, potential biases in sample representation, lack of independent verification for dementia diagnoses, and the inability to accurately categorize the extent of suicidality. Moreover, the reliance on perceived CTE, rather than confirmed diagnoses, introduces potential bias influenced by the media portrayal of CTE in former athletes. Further research is needed to clarify the relationship between perceived CTE and actual neuropathological evidence.

Conclusion

In conclusion, the study showed that one-third of former professional ASF players reported perceived CTE, highlighting distinct clinical correlates between those with and without this perception. Perceived CTE may indicate an elevated risk of suicidality, suggesting that recognizing this perception could inform diagnostic and therapeutic strategies to better identify and address suicide risk among these athletes. However, the study underscores that perceived CTE is not a confirmed diagnosis, and further research is needed to understand its true clinical implications.

Overall, the findings emphasize the importance of addressing potential issues related to mental health and emotional well-being in this population, as it could improve overall health outcomes among former players.