Rushing to find a connection

Experts caution against linking player suicides with concussions from football

Updated: November 27, 2012, 2:34 PM ET
By Mike Fish | ESPN.com

When former NFL star Junior Seau put a .357 magnum to his chest last May, the media nearly immediately jumped on the possibility that concussions suffered by the hard-hitting linebacker contributed to his death. The same had earlier been suggested after the suicides of NFL retirees Dave Duerson, Andre Waters and Ray Easterling -- heightened by brain studies revealing the trio had each suffered from chronic traumatic encephalopathy, a condition thought to be triggered by repetitive head trauma or multiple concussions.

The prevailing narrative regarding Seau, whose brain remains under study for signs of CTE, as well as other aging athletes who have killed themselves in recent years is that head injuries sustained long ago on playing fields laid the groundwork for a downward spiral of depression and suicide. While in some cases that may be true, researchers and medical experts, including leaders in the study of CTE, cautioned against rushing to judgment in interviews with "Outside the Lines."

Chicago-based neurosurgeon Julian Bailes says it is "absolutely not true" that an automatic connection can be made between NFL players who commit suicide and CTE. "I think there are many reasons" why a player might choose to commit suicide. Bailes, a one-time physician for the Pittsburgh Steelers and founder of the Brain Injury Research Institute, remains careful about jumping to conclusions, particularly when asked about Seau, a future Hall of Famer.

"That is the ultimate irrational decision, to commit suicide, so you don't know," says Bailes, who partners with forensic neuropathologist Bennet Omalu, the first to identify chronic brain damage as a factor in the deaths of some NFL players. "You could have CTE changes in your brain, and that didn't necessarily make you commit suicide. ... The distribution of injury in the brain [with CTE] is around the emotional circuitry of the brain, so that explains why suicide is frequent. But it doesn't mean that CTE caused every suicide. It just means it is a trend."

Seemingly lost in the media and public conversation amid the flurry of suicides by high-profile athletes is an examination of the roles failed relationships, tattered financial portfolios and flawed transitions from the NFL regiment could play in the states of mind of ex-players. Were they depressed and suicidal because they'd lost their athletic mojo?

Or how many suffered chronic pain, a known cause of depression? Were they short on cash, with no distinguishable job skills? Did recreational drugs or painkillers play a role? Had their minds simply been short circuited by repeated knocks to the head? Or did a handful of variables, including traumatic brain injury, create a deadly domino-effect?

"What you are dealing with, in my mind, is an incredible spiral of coexistent situations, all making the situation worse," says Dr. Robert Cantu, co-director of Boston University's Center for the Study of Traumatic Encephalopathy. "In other words, there is no question that if you have advanced CTE that you do have commonly as part of the symptoms of it decreased impulse control, decreased ability to handle problems that are irritative, and flying off the handle type behavior as a result of it. But if in addition to that you undergo life changes that are incredibly depressive, it is like throwing kerosene on smoldering ashes. And each of the things -- between the divorce, the alcohol and drug abuse -- it is just making the situation much more volatile and much more likely that somebody is going to have an outcome that is really very tragic.

"There is no question that when you put a gun to your heart that you meant to do it. But when you are a Derek Boogaard, or several of the other NHL enforcers that died in the last year, and start mixing alcohol and cocaine or alcohol and narcotics, which was the case with [Tom] McHale, the football player -- they probably didn't mean to kill themselves. Nobody can tread that line consistently and walk away."

As for Seau, it's beyond comprehension he could have played as ferociously as he did from the outside linebacker position for 20 NFL seasons and not gotten his bell rung more than a few times, even if confirmation never surfaced in an official injury report. So experts say it wouldn't be shocking if ultimately the microscopic analysis of his brain reveals signs of CTE, often described as a close relative of Alzheimer's disease.

"There were countless times when Junior would come back to the huddle [after a tackle] and you knew something was going on, but that whole bravado that we were raised with is 'Line up for the next play,'" says law clerk Orlando Ruff, who lined up alongside Seau at middle linebacker for the San Diego Chargers during the 2000-02 seasons and was his training camp roommate. "It is just one of those things where, if you look in an individual's eyes, you can see that something is not right. I'm sure it has happened with me as well. It has happened with all of my teammates, not just him."

Seau, though, 43 at the time of his death, may have dealt with multiple potential suicide risk factors, regardless of the state of his brain. His parents were immigrants from Samoa, which has one of the world's highest per-capita suicide rates. He suffered through a divorce and a fledgling restaurant business that would be promptly shuttered after his death. He signed a one-day contract in 2006 with the Chargers and offered a fiery retirement speech, only to four days later trek east to sign with the New England Patriots -- and twice more returning from inactivity before retiring for good after the 2009 season.

Perhaps in what should have been a warning sign, he was arrested a few months after his final NFL retirement on suspicion of domestic violence against a former girlfriend, who was 25 at the time. Hours later, after his release, Seau survived after his SUV plunged off a coastal road in Carlsbad, not far from his Oceanside, Calif., home.

So a lot of stuff may have been going on, perhaps even some traced to earlier head blows. The same can be said for many athletes who have been diagnosed postmortem with CTE.

"What we feel is that there is credibility to joining the dots from repeated concussions to depression to suicide," says Charles Tator, a neurosurgeon heading up the Toronto-based Canadian Sports Concussion Project. "That people who have repetitive concussions do become depressed. Not because they are sad that they can't go back and play, but they are depressed because of the brain injury. Brain injury produces the depression. Depression is part of the picture of brain injury. And suicide can happen in anyone who is depressed. Now exactly the role of CTE in joining those dots, we don't know. I think there is a connection, but it is going to be a while before we can say for sure that CTE causes suicide.

Seau Memorial
Jake Roth/US PresswireMany in the media and public immediately linked Junior Seau's suicide with head injuries he suffered as a player.

"We recognize that there is a range of mitigating factors that could enhance the development of this CTE. I think alcohol, drugs, smoking, genes are all important. And that needs to be dissected out. And the only way we are going to get at that is with much more intensive research."

Not every former NFL player who is depressed or suicidal suffers from CTE. Nor is the players' rate of depression appreciably different from the general population, particularly as football retirees age.

According to a recent study of former NFL players conducted by the University of North Carolina's Center for the Study of Retired Athletes, the rate of depression among those 35 to 44 years of age was 14 percent; the rate for the general population is 8 percent.

"That disparity begins to shrink as they age up," says Kevin Guskiewicz, a UNC research professor and head of the center. "I think the reason we see the disparity there during that earlier window of time has a lot to do with players transitioning out of the game. And I am not saying that some of it may not be due to repetitive concussions or repetitive sub-concussive impacts, but I know a part of it has to be from transitioning out of the game."

George Koonce is a case in point. As a contemporary linebacker of Seau's, Koonce never experienced serious head or concussion issues playing for Green Bay and later Seattle. But after leaving the game, he talks now of having felt like a part of him had died. He'd lost his identity. Surprisingly, he missed the game's structure, what he calls being "institutionalized." He was depressed ... and ultimately suicidal.

In 2003, he got behind the wheel of his Chevy Suburban and tried to end it all. "I went around a curve a little bit faster than what I should have been going," he said. "I survived what was, in retrospect, a suicide attempt."

Had he been successful, the top research teams would have followed the script of aggressively recruiting his family in hopes that they'd donate his brain for study. And, if signs of CTE had been discovered, linkage would almost certainly have been made to his demise. Guskiewicz blames this CTE hysteria not on the researchers, but the media coverage.

"I have seen [CTE research teams] present their data at meetings and they talk about the limitations of it," says Guskiewicz, director of UNC's highly regarded Department of Exercise and Sports Science. "But sometimes when the media grabs onto it they -- I'll just be honest with you, they sensationalize it. And it is all about 'Every former player that plays for more than five seasons must have this. And the minute they start to get depressed they must think they have it.' So that is the scary part of this. I am not willing to connect all these dots yet.

[+] EnlargeKevin Guskiewicz
Courtesy of University of North CarolinaKevin Guskiewicz leads the University of North Carolina's Center for the Study of Retired Athletes.

"We have been moving a little bit too quickly. We need to get more prospectus studies that are going to really identify whether there is a cause-and-effect relationship. Because right now all we are doing is looking at a cross section of a relatively small group of former players that are based on case reports and not scientific studies. I say that all, but I also commend the group at Boston for doing some early work on this. And it is not just them. It is Julian Bailes and Bennet Omalu who have done some of this and others."

At its full-blown worst, CTE is known to wreck its victims' control over emotions and impulses and cause memory loss, depression and, eventually, progressive dementia. CTE has been associated with boxers since the 1920s, but only in the last decade has it been confirmed in retired professional football players and other athletes who have histories of repetitive brain trauma. This trauma triggers progressive degeneration of the brain tissue, including the build-up of an abnormal protein called tau. What makes the diagnosis tricky is these changes in the brain can begin months, years or even decades after the last brain trauma or end of an athletic career.

So far, scientists generally believe the cause of CTE to be multiple traumatic injuries or concussions and not a single blow or concussion. It previously had been speculated that anabolic steroid usage coupled with a concussion experience might dramatically exacerbate the problem, but that was disproved by Bailes in a recent study using laboratory rats.

But to study the long-term effects of head shots in sports, researchers have to get their hands on the brains of dead athletes. Unfortunately, scientists can definitively diagnose CTE postmortem only at this point.

That in itself possibly fuels some of the hysteria tied to the high percentages of CTE reported in deceased athletes. Researchers at Boston University, for instance, have identified CTE in 68 of the more than 80 brains of athletes studied to date, but officials caution that the brains are almost exclusively from those who committed suicide or suffered horrendous cognitive and emotional difficulties at the end of their lives. Their brains and spinal cords are often turned over by families desperate to find answers. What researchers don't get are the brains of those who played pro football or hockey and died peacefully of old age.

What researchers also don't yet have in their databases are matched, controlled subjects for every athlete pathologically studied for CTE -- for example, someone of the same age, who either grew up in the same approximate area or lived in the same town later in life. Some in the sports science community question if there aren't other factors for the tau deposits found on the brain. They mention the possibility of environmental toxicity playing a role. They question the theory of CTE being caused solely by repetitive head trauma, presumably over lengthy careers, when tau protein was reportedly found in the brains of former Penn defensive end Owen Thomas and an 18-year-old high school football player.

"It is a very skewed sample of brains that we look at," says Cantu, a leading sports concussion specialist. "So the fact we have found such high incidences of chronic traumatic encephalopathy is partly explained by the fact that these were very symptomatic people. It tells us there is a problem, but it doesn't give us any good idea of what is the incidence or prevalence of it because we are not able to examine all comers, so to speak.

[+] EnlargeRobert Cantu
Scott J. Ferrell/Congressional Quarterly/Getty ImagesDr. Robert Cantu during the House Judiciary hearing on head injuries among NFL players.

"There is a lot to be learned about CTE. Yes, it is being overly hyped right now. It is not the answer to all the post-concussion symptoms -- the emotional, cognitive troubles that people have, at least in the beginning."

So the search for answers continues.

At North Carolina, Guskiewicz and Robert Turner, a former pro football player and a postdoctoral fellow in UNC's Department of Exercise and Sports Science, have submitted a grant with the NFL to study depression among retirees, those suffering from past sports concussions as well as those who suffer chronic pain from an assortment of old injuries. Earlier studies, according to Turner, indicate an alarming 65 percent of retired NFL athletes are suffering some form of chronic pain, which can often be a catalyst to depression.

"The incidents of depression tied to chronic pain are just as high as it is to concussions," says Turner, who is in the midst of penning a manuscript titled "Not For Long: The Life and Career of the NFL Athlete." "So we need to pull out those differences between the two. And we also need to find out, is there a multiplier effect from those who have had concussion and chronic pain? The other thing, and this would speak very directly to the Junior Seau situation -- with athletes who are suffering from multiple concussions, from depression and/or chronic pain, we don't know what their behaviors are to manage or deal with those issues.

"So someone may be feeling depressed and they may self-medicate through finding ways to do Vicodin and those kinds of things. Or we may find that they smoke a lot of marijuana. They may wind up going to professional counselors and they may manage it. And they may have high levels or incidence of CTE as well. There are a number of different things we don't know about people's behavior, so to start automatically saying this is what happens and these links are directed to that -- there is no medical evidence, there is no social science behind it to say right now we know what is going on and this is going to lead to this."

As the researchers and neurosurgeons go about the business of debating and finding answers to the game's most vexing issue, another football season has kicked off. And whether aging players with CTE killing themselves is a short-lived trend or an epidemic that speaks to the brutal long-term consequences of concussions remains to be determined.