Suicide represents a devastating event that has both immediate and long-term consequences. Surprise, grief, and a sense of preventable loss which follow these events leave an indelible mark on the affected community. Athlete populations are no different, and the impact of suicide is further magnified through media coverage of these high-profile, tragic events. Athletes are often seen as pillars of health and wellness, a perception that excludes the possibility of weakness or emotional frailty in the setting of success on the playing field. Further, some athletes consider mental distress as a sign of weakness and may be resistant to disclosing mental health concerns to family, friends, and medical providers (1,2).
Athletes face unique challenges to their health and wellness. Kate Fagan, a journalist who has detailed the life and death of Madison Holleran, a University of Pennsylvania athlete who famously revealed her tragic descent to suicide through social media, has described that “transitioning to life as a college athlete is like walking through an obstacle course wearing a blindfold” (3). Athletes may not recognize maladaptive behaviors that reflect underlying psychiatric illness, such as sleep disturbances, disordered eating, social withdrawal, substance use, mood lability, unexplained somatic symptoms, and overtraining (4). In addition, they may be unwilling to disclose a mental health issue for fear of stigmatization or losing financial support, regardless of the safety mechanisms in place to protect their privacy and participation. These issues are further compounded by physicians' reticence to discuss mental health concerns and limitations of team medical and coaching staffs in identifying signs of mental illness (5,6).
Does Athletic Participation Increase or Decrease Suicide Risk?
Suicide remains the third leading cause of death among adolescents and young adults and trails only accidents as a cause of death in college students (7,8). One of every four to five young people meets the criteria for a severe mental health disorder capable of causing severe impartment over a lifetime (9). When considering how athlete populations compare with the general population, research is beginning to reveal a protective impact of athletic participation. Data from the Youth Behavior Risk Survey suggest that high school athletes, particularly those described as “highly involved,” are less likely than their nonathletic peers to consider or plan suicide (7,10). In college athletes, suicide represents the fourth leading cause of death, trailing accidents, sudden cardiac death, and homicide (11). However, collegiate athletes appear to be substantially less likely to die from suicide (0.93/100,000) than either the general population of same age (11.6/100,000) or an age-matched nonathlete collegiate population (7.5/100,000). Data in current and retired professional athletes are scarce, though studies have indicated that retired NFL players are less likely to die by suicide than men in the general population (12). Theories for this protective effect revolve around the social support and structure provided by team and athletic participation, as well as prompt access to medical care through athletic training staff and team physicians (13,14). Physical fitness also has been discussed as a treatment for mental health disorders and may confer its own protective benefits. Thus, although suicide remains a problem in athletic communities, athletic participation may confer a protective effect.
Suicide and Chronic Traumatic Encephalopathy — Clarifying Causality
In recent years, much of the focus of suicide in athletes has centered on its purported association with chronic traumatic encephalopathy (CTE), a neuropathological diagnosis that has been recently redefined to include features of psychiatric illness and dementia (15). The media, in highlighting the stories of Aaron Hernandez, Junior Seau, Rashaan Salaam, and others, has promoted a compelling narrative that repetitive head impacts produce chronic brain changes that impart depression, irrational behavior, substance abuse, and suicidal behavior on former American football athletes. Such reports infer causality despite the lack of definitive scientific evidence, thus magnifying concerns related to the safety of football and other contact sports. As a result, participation in youth contact sports is falling, and athletes actively entertain early retirement due to concerns of concussion and the long-term impact on their health. Yet, studies that report a lower lifetime risk of depression and other adverse health outcomes in football athletes, using population data and an age-matched comparison group of nonathletes, have been largely ignored (12). In studies which look selectively at cases of CTE, a high prevalence of depressive symptoms, substance abuse, and chronic pain are attributed directly to CTE rather than being considered independently (16). This narrative also fails to embrace a larger concern that mental illness is a prevalent problem in athletic communities worthy of its own attention.
End of Career Concerns
It remains unclear how the end of a career due to performance decline, injury, or circumstance may impact an athlete’s mental well-being. For athletes who have achieved elite performance in the high school, college, or professional setting, accepting that their talents are no longer possible due to injury or that their position on a team is no longer valued can be immensely disruptive to their self-identity, self-confidence, and social fabric. In some instances, depression, anxiety, and suicidal thoughts can manifest. Not every athlete is prepared for life after sport, yet careers inevitably end. Athletes should not be criticized or misdirected away from mental health resources in confusing these symptoms for the purported signs of CTE. Certainly, brain injury provides a more tangible attribution for difficult emotions and feelings, rather than admission of a primary mental health disorder and its associated stigmas. This is not to contend that brain injury cannot contribute to the development of mental health disorders. However, what if this narrative is incorrect or incomplete? Causes of suicide are complex, multifactorial, and challenging to predict, and research to understand the causes and evolution of suicide in the athletic setting is still needed.
Many Questions — Future Directions
Suicide events raise challenging questions in both social and scientific circles, and clear answers are not always available. What signs and symptoms do athletes at risk of suicide present? Can at-risk athletes be identified early, leading to better preventative strategies? What resources, education, and interventions are most effective for athletes? Is there a stigma in the athletic community that prevents athletes from seeking care or disclosing mental health concerns? What truly is the role of traumatic brain injury on mental health outcomes? In the case of NFL athletes, why are we seeing a relative increase in suicide-related mortality in the past decade? To begin to answer some of these questions, team physicians and other athlete care providers can apply lessons learned from broader populations. For example, the United States Preventative Services Taskforce recommends that all adults be screened for depression, citing a 10% to 47% increase in detection and diagnosis (17). Given that 90% of individuals committing suicide are found to carry a DSM-IV categorized psychiatric illness, screening at key times (i.e., after major injury or the end of career transition) may promote early identification of athletes at risk of suicide or with other significant mental health disorders (14).
To move the discussion forward and to understand athlete-specific mental health factors, better empiric evidence is needed. The majority of peer-reviewed athlete mental health research has relied upon retrospective data using non-mandatory reporting systems. The methodology used to collect data, including survey-based research, reviews of media reports, and catastrophic injury claims, does not capture the entire scope of the problem, as cases may go undetected. Until we have more reliable data, we cannot confidently claim that athletes are at lower risk for suicide, though the current evidence does point us toward this conclusion. Without additional inquiry, we cannot claim that CTE is the sole cause of the psychiatric and cognitive disorders reported in deceased athletes harboring this neuropathological diagnosis. For the time being, it is our responsibility as care providers to regularly inquire about our athletes’ well-being and to create an environment where disclosure and treatment of sensitive mental health concerns is truly acceptable.
The author declares no conflict of interest and does not have any financial disclosures.
1. Lopez RL, Levy JJ. Student athletes’ perceived barriers to and preference for seeking counseling. J. Coll. Counsel
. 2013; 16:19–31.
2. Lipson SK, Speer N, Brunwasser S, et al. Gatekeeper training and access to mental health care at universities and colleges. J. Adolesc. Health
. 2014; 55:612–9.
3. Fagan K. What Made Maddy Run: The Secret Struggles and Tragic Death of an All-American Teen
. Boston, MA: Little, Brown and Company, 2017.
4. Neal TL, Diamond AB, Goldman S, et al. Inter-association recommendations for developing a plan to recognize and refer student-athletes with psychological concerns at the collegiate level: an executive summary of a consensus statement. J. Athl. Train
. 2013; 48:716–20.
5. Mann BJ, Grana WA, Indelicate PA, et al. A survey of sports medicine physicians regarding psychological issues in patient-athletes. Am. J. Sports Med
. 2007; 35:2140–7.
6. Mentink JW. Major depression in collegiate student-athletes: case study research. Dissert Abst Int Sect A. Humanties Soc. Sci
. 2002; 62:2697.
7. Sabo D, Miller KE, Melnick M, et al. High school athletic participation and adolescent suicide: a nationwide U.S. study. Int. Rev. Sociol Sport
. 2005; 40:5–23.
8. Centers for Disease Control and Prevention. Leading causes of death reports, national and regional, 1999–2013. [cited 2017 December 1.] Available from: http://webappa.cdc.gov/sasweb/ncipc/leadcause10_us.html
9. Merikangas KR, He JP, Burstein M, et al. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication — Adolescent Supplement (NCS-A). J. Am. Acad. Child Adolesc. Psychiatry
. 2010; 49:980–9.
10. Lester D. Participation in sports teams and suicidal behavior: an analysis of the 1995 National College Health Risk Behavior Survey. Percept. Mot. Skills
. 2014; 119:38–41.
11. Rao AL, Asif IM, Drezner JA, et al. Suicide in National Collegiate Athletic Association (NCAA) athletes: a 9-year analysis of the NCAA resolutions database. Sports Health
. 2015; 7:452–7.
12. Manley G, Gardner AJ, Guskiewicz KM, et al. A systematic review of potential long-term effects of sport-related concussion. Br. J. Sports Med
. 2017; 51:969–77.
13. Armstrong SA, Oomen-Early J. Social connectedness, self-esteem, and depression symptomatology among collegiate athletes versus nonathletes. J. Am. Coll. Health
. 2009; 57:521–6.
14. Rao AL, Hong ES. Understanding depression and suicide in college athletes: emerging concepts and future directions. Br. J. Sports Med
. 2016; 50:136–7.
15. Gardner A, Iverson GL, McCrory P. Chronic traumatic encephalopathy in sport: a systematic review. Br. J. Sports Med
. 2014; 48:84–90.
16. Mez J, Daneshvar DH, Kiernan V, et al. Clinicopathologic evaluation of chronic traumatic encephalopathy in players of American football. JAMA
. 2017; 318:360–70.
17. Siu AL; U.S. Preventive Services Task Force (USPSTF), Bibbins-Domingo K, et al. Screening for depression in adults: U.S. Preventive Services Task Force recommendation statement. JAMA
. 2016; 315:380–7.