Mental health & Suicide in Professional Soccer Players
Article in review: Russell, E.R., McCabe, T., Mackay, D.F., Stewart, K., MacLean, J.A., Pell, J.P. & Stewart, W. (2020). Mental Health and suicide in former professional soccer players. Journal of Neurosurgery Psychiatry, doi: 10.1136/jnnp-2020-323315
Soccer is the world’s most popular participation sport, and it is commonly associated with an increased risk of neurodegenerative disease such as Alzheimer’s and chronic traumatic encephalopathy (CTE). Until now, it has been unclear as to the link between participating in a contact sport such as soccer, and the presentation of mental health conditions. This is the first known study to access diagnostic datasets to investigate the association between playing a contact sport at an elite level, and the risk of common mental health conditions in retirement.
Chronic Traumatic encephalopathy
We have heard of an increase in the number of elite sportspeople exposed to traumatic brain injury and CTE of the brain as a result of their participation in the sport. Historically this condition was referred to as a punch-drunk syndrome because of its comparative frequency in boxers, and then later was described as dementia pugilista, noted for emotional liability, personality change, cognitive impairment, and dementia. Mental health conditions and suicidality were not typically associated.
Now known as CTE, this neurodegenerative disorder has been found amongst boxers and football and NFL players. Among former football players, the rate of neurodegenerative disease is 3.5 times higher than expected, with a doubling of deaths with Parkinson’s disease and a fivefold increase in death with Alzheimer’s disease. Autopsies performed on players of contact sports show CTE in a majority either as the primary dementia-associated pathology or as comorbid pathology in the context of other neurodegenerative diseases.
Today CTE is commonly thought to be associated with depression, impulsivity, aggression, and suicide. And the rates of reports of mental health conditions in people with CTE range from ‘higher than expected’ to no different from the general population. Yet these indicators have not been robustly studied in people who are known to have CTE. The study also considers if the retired footballer was a goalkeeper or a field player, as field players are exposed to more risk due to the nature of their position.
Study participants and approach
A total of 7676 former professional footballers were matched 1:3 with general population control groups from the Scottish population. Hospital admission and death data was accessed, and the data were interrogated to examine hospital admissions for one of the five most common mental health conditions affecting Scottish males. The study did not include review of localised or primary health data, which could be considered a limitation as this may be where more common mental health conditions are diagnosed and treated. However, it is assumed the level of provision of these services could be considered comparable in the two groups. The outcomes for past professional footballers were compared to those of the control group were matched by age, sex, and degree of social deprivation (income, employment, health, education, housing, crime).
When compared to the control group, with results fulfilling the assumption of proportional hazards, professional soccer players showed a lower risk of:
• Hospital admission for anxiety and stress-related disorders
• Drug use disorders
• Alcohol use disorders
• Bipolar and affective mood disorders
Further findings include:
• There was no significant risk of hospitalistion for mental health conditions between field players and goalkeepers.
• The age of onset of depression was slightly higher in football players (14.7 years compared to 13.6 years)
• There was no significant difference in the rate of death by suicide between soccer players and controls.
The number of suicides recorded was 19 of the 7,676 soccer players and 93 of the control group, rates of 0.25% and 0.40%, respectively. There was no significant difference in suicide risk or age at suicide between the footballers and the control group.
These findings were in keeping with a study of NFL players who were confirmed to have CTE at autopsy- suicide deaths were lower amongst those with CTE. The research suggests that some review and reappraisal of proposed diagnostic clinical criteria for CTE should be undertaken, particularly in relation to mental health outcomes.