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. 2024 Sep 23;81(11):1130-1139.
doi: 10.1001/jamaneurol.2024.3083. Online ahead of print.

Perceived Chronic Traumatic Encephalopathy and Suicidality in Former Professional Football Players

Rachel Grashow  1   2 , Douglas P Terry  3 , Grant L Iverson  4   5   6   7 , Heather DiGregorio  1 , Inana Dairi  1 , Cheyenne Brown  1 , Paula S Atkeson  1 , Alicia J Whittington  1 , LeRoy Reese  8 , Jonathan H Kim  9 , Niki Konstantinides  1   2 , Herman A Taylor  1   10 , Frank E Speizer  1   2   11 , Daniel H Daneshvar  4 , Ross D Zafonte  1   4   5 , Marc G Weisskopf  1   2 , Aaron L Baggish  1   12   13
Affiliations

Perceived Chronic Traumatic Encephalopathy and Suicidality in Former Professional Football Players

Rachel Grashow et al. JAMA Neurol. .

Abstract

Importance: Participation in American-style football (ASF) has been linked to chronic traumatic encephalopathy neuropathological change (CTE-NC), a specific neuropathologic finding that can only be established at autopsy. Despite being a postmortem diagnosis, living former ASF players may perceive themselves to have CTE-NC. At present, the proportion and clinical correlates of living former professional ASF athletes with perceived CTE who report suicidality are unknown.

Objective: To determine the proportion, clinical correlates, and suicidality of living former professional ASF players with perceived CTE.

Design, setting, and participants: A cross-sectional study within the Football Players Health Study at Harvard University was conducted from 2017 to 2020. Using electronic and paper surveys, this population-based study included former ASF players who contracted with a professional league from 1960 to 2020 and volunteered to fill out a baseline survey. Data for this study were analyzed from June 2023 through March 2024.

Exposures: Data included demographics, football-related exposures (eg, position, career duration), and current health problems (anxiety, attention-deficit/hyperactivity disorder, depression, diabetes, emotional and behavioral dyscontrol symptoms, headache, hyperlipidemia, hypertension, low testosterone level, pain, sleep apnea, and subjective cognitive function).

Main outcomes and measures: The proportion of participants reporting perceived CTE. Univariable and multivariable models were used to determine clinical and suicidality correlates of perceived CTE.

Results: Among 4180 former professional ASF players who volunteered to fill out a baseline survey, 1980 (47.4%) provided follow-up data (mean [SD] age, 57.7 [13.9] years). A total of 681 participants (34.4%) reported perceived CTE. Subjective cognitive difficulties, low testosterone level, headache, concussion signs and symptoms accrued during playing years, depressive/emotional and behavioral dyscontrol symptoms, pain, and younger age were significantly associated with perceived CTE. Suicidality was reported by 171 of 681 participants with perceived CTE (25.4%) and 64 of 1299 without perceived CTE (5.0%). After adjusting for established suicidality predictors (eg, depression), men with perceived CTE remained twice as likely to report suicidality (odds ratio, 2.06; 95% CI, 1.36-3.12; P < .001).

Conclusions and relevance: This study found that approximately one-third of living former professional ASF players reported perceived CTE. Men with perceived CTE had an increased prevalence of suicidality and were more likely to have health problems associated with cognitive impairment compared with men without perceived CTE. Perceived CTE represents a novel risk factor for suicidality and, if present, should motivate the diagnostic assessment and treatment of medical and behavioral conditions that may be misattributed to CTE-NC.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Grashow reported grants from the National Football League Players Association (NFLPA) during the conduct of this study. Dr Terry reported grants from Amgen and Football Research, serving on the scientific advisory board for HitIQ, and previously consulting for REACT Neuro outside the submitted work. Dr Iverson reported grants from the NFLPA and Wounded Warrior Project during the conduct of the study; grants from the National Football League outside the submitted work; philanthropic support from the National Rugby League outside the submitted work; serving as a scientific advisor for Sway Medical, Highmark, NanoDX, NeuroHealth, and NeuroHealth Research and Rehabilitation outside the submitted work; having a clinical and consulting practice in forensic neuropsychology, including expert testimony, involving individuals who have sustained mild traumatic brain injuries (TBIs), including former athletes, and on the topic of suicide; past research support or funding from several test publishing companies, including ImPACT Applications, CNS Vital Signs, and Psychological Assessment Resources; royalties from the sales of 1 neuropsychological test (WCST-64); travel support and honorariums for presentations at conferences and meetings; subcontract grant funding as a collaborator from the Harvard Integrated Program to Protect and Improve the Health of National Football League Players Association Members; and unrestricted philanthropic support from ImPACT Applications, the Mooney-Reed Charitable Foundation, the National Rugby League, Boston Bolts, and the Schoen Adams Research Institute at Spaulding Rehabilitation. Dr DiGregorio reported grants from the NFLPA during the conduct of the study. Dr Dairi reported grants from the NFLPA during the conduct of the study. Dr Whittington reported that immediate family members are former NFL players. Dr Taylor reported grants from the NFLPA during the conduct of the study and serving as advisor and consultant for Apple, Google, and Microsoft. Dr Daneshvar reported personal fees from expert testimony related to TBIs and being a medical advisor and options holder for StataDx outside the submitted work. Dr Zafonte reported royalties from Springer/Demos Publishing for serving as co-editor of the text Brain Injury Medicine; serving on the scientific advisory board of Myomo, onecare.ai, Kisbee, and NanoDiagnostics; evaluating patients in the Massachusetts General Hospital Brain and Body-TRUST Program, which is funded by the NFLPA; being partially supported by the National Institute on Disability, Independent Living, and Rehabilitation Research; and funding from the Football Players Health Study at Harvard University, which is funded by the NFLPA. Dr. Baggish reported funding from the National Heart, Lung, and Blood Institute, NFLPA, and American Heart Association and compensation for his role as team cardiologist from the US Olympic Committee/US Olympic Training Centers, US Soccer, US Rowing, the New England Patriots, the Boston Bruins, the New England Revolution, and Harvard University. Dr Weisskopf reported personal fees from Spaulding Rehabilitation Hospital and grants from the NFLPA during the conduct of the study. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Demographic Variables, Football-Related Exposures, and Current Health Factors Associated With Perceived Chronic Traumatic Encephalopathy (CTE)
Odds ratios and 95% CIs from the model of the association between demographic factors, football exposures, and health-related factors and perceived CTE. Note that data for those who were assigned the race and ethnicity category Native Hawaiian/Pacific Islander/Asian/American Indian/Alaskan Native or missing were removed from the image but not the model. Concussion signs and symptoms (CSS) score, anxiety symptoms, depressive symptoms, body mass index (BMI), emotional and behavioral dyscontrol, and perceived cognitive function are shown in standard deviation units. ADHD indicates attention-deficit/hyperactivity disorder; PED, performance-enhancing drugs.
Figure 2.
Figure 2.. Demographic Factors, Football-Related Exposures, and Current Health Factors Associated With Suicidality
Odds ratios and 95% CIs from the model of the association between demographic factors, football exposures, and health-related factors and perceived chronic traumatic encephalopathy (CTE). Note that data for those who were assigned the race and ethnicity category Native Hawaiian/Pacific Islander/Asian/American Indian/Alaskan Native or missing were removed from the image but not the model. Concussion signs and symptoms (CSS) score, anxiety symptoms, depressive symptoms, body mass index (BMI), emotional and behavioral dyscontrol, and perceived cognitive function are shown in standard deviation units. ADHD indicates attention-deficit/hyperactivity disorder; PED, performance-enhancing drugs.
Figure 3.
Figure 3.. Demographic Factors, Football-Related Exposures, and Current Health Factors Associated With Suicidality and Stratified by Perceived Chronic Traumatic Encephalopathy (CTE)
Odds ratios and 95% CIs from the model of the association between demographic factors, football exposures, and health-related factors and perceived CTE. Note that data for those who were assigned the race and ethnicity category Native Hawaiian/Pacific Islander/Asian/American Indian/Alaskan Native or missing were removed from the image but not the model. Concussion signs and symptoms (CSS) score, anxiety symptoms, depressive symptoms, body mass index (BMI), emotional and behavioral dyscontrol, and perceived cognitive function are shown in standard deviation units. ADHD indicates attention-deficit/hyperactivity disorder; PED, performance-enhancing drugs.
See this image and copyright information in PMC

Comment in

  • doi: 10.1001/jamaneurol.2024.3078

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