Download Depression Suicide SRC VSCC Solomon 2016 06 10

Depression and Suicide in Athletes
with Sport-Related Concussions
Sports Concussion: State of the Science
June 10, 2016
Gary Solomon, Ph.D., FACPN
Associate Professor, Departments of
Neurological Surgery, Orthopaedic Surgery
& Rehabilitation, and Psychiatry,
Co-Director, Vanderbilt Sports Concussion Center
Vanderbilt University School of Medicine
Team Neuropsychologist, Nashville Predators
Consulting Neuropsychologist, Tennessee Titans
[email protected]
www.vanderbiltsportsconcussion.com

Full time employee, Vanderbilt University School of Medicine

Either Vanderbilt or I receive consulting fees, honoraria, and/or expense
reimbursements from: Nashville Predators, Tennessee Titans, Tennessee Tech Athletics,
University of Tennessee Athletics, ImPACT

12.58% of my annual income is derived from sports organizations

Grants: DoD: Restoration of standing and walking through Intra-spinal Microstimulation in
humans (Consultant to Peter Konrad, M.D., Ph.D.)

I do not see patients involved in litigation

This presentation is not endorsed by any organization with
which I am affiliated

This may not be a comprehensive assessment of the published
literature; my own biases in the selection of papers reviewed
and the opinions presented are acknowledged

Comments in blue represent my opinion

I express my appreciation to all authors whose work is discussed.
It is easy to criticize research, and difficult to do it well
1. To review the evidence on depression and anxiety disorders in
athletes with sport-related concussions
2. To review the evidence on suicide in athletes with sport-related
concussions
3. To discuss possible reasons for common beliefs related to the effects
of sport-related concussion and depression/suicide.
www.vanderbiltsportsconcussion.com
The effects of sport concussions and
Limbic System

Consensus statements

Epidemiology

Survey studies

Psychometric instruments
Practice Parameters/Consensus Guidelines/Position Statements
AAN
Mood disorder was not specifically
addressed in these guidelines
NAN
Practice Parameters/Consensus Guidelines/Position Statements
2011
ACSM
Practice Parameters/Consensus Guidelines/Position Statements
CISG4
AMSSM
Mental health issues may be multifactorial
and warrant consideration
Mood disorders complicate dx and management
Difficult to determine what precedes-causes-worsens
Practice Parameters/Consensus Guidelines/Position Statements
NATA

History of psychiatric illness should be
documented in pre-participation
evaluation

Athletes with psychiatric illness may
require referral to a neuropsychologist
for formal NPT

Depression may be a long-term
consequence of multiple SRCs
Evidence-based recommendations and empirical data related
to psychiatric illness have been limited in sports concussion
BJSM
Affective sxs (anxiety and depression) are
common immediately after a SRC, but are
typically subclinical and time-limited
Mental Health Epidemiology
Mental Health Epidemiology
2009: Average number “mentally unhealthy days” past month (Adults)
Average # “mentally unhealthy” days per month = 3 for men, 4 for women;
̴10% of the time life is crappy
Mental Health Epidemiology
National trends in mental health service utilization (USA)
Psychiatrist, Psychologist, Psychiatric NP, LCSW
Among insured people:
Overall, about 10%
Mental Health Epidemiology: PCP Visits
2012: In adults ≥18 years, >30% of PCP office visits
were related to mental health
Σ
crappy days (10%) + mental health (10%) + PCP (30+%) = >50%
Life is hard….(so be kind)
Lifetime Prevalence of Mood Disorders
14.4% for adolescents
21.4% for adults
Lifetime Prevalence of Anxiety Disorders
32.4% for adolescents
33.7% for adults
Mood Disorders in Collegiate Athletes
Brewer & Petrie, AAJ, 1995: 916 Division I football players;
33% with injury and 27% without injury were + for depressive sxs
Yang, et al. CJSM, 2007: 251 Division 1 athletes; 21% were + for sxs of depression
Armstrong & Oomen-Early, JACH, 2009: 227 collegiate students (104 athletes);
33.5% were + for “significant” depressive sxs
Proctor & Boan-Lenzo, JCSP, 2010: 61 Division I baseball players; 15.6% were + for depressive sxs
***Wolanin et al., BJSM, 2016: 465 D-1 athletes; Prevalence of clinically relevant level of depressive
sxs (CESD >16) = 23.7%, with 6.3% = moderate or severe; female gender RR=1.84
_______________________________________________________________________
Mood Disorders in Concussed Collegiate Athletes
Mainwaring et al., Br Inj, 2010: Athletes with ACL injuries had
greater severity and duration of depressive sxs vs. athletes
with concussion (Profile of Mood States-POMS)
Kontos et al., APMR, 2012: 75 h.s. and collegiate athletes had higher BDI-II
scores at days 2, 7, and 14 post-injury (“not clinically significant”)
Vargas et al., JAT, 2015: 84 collegiate athletes with concussions
vs. 42 controls; 20% of concussed athletes (vs. 5% controls)
showed a reliable increase in depressive sxs (BDI-Fast Screen)
Survey studies of depression
Retired NFL players
2007: When compared with retired athletes reporting no concussions--Retired athletes reporting 1-2 concussions were 1.5x more likely (prevalence ratio = 1.48,
95% CI = 1.08-2.02) to report a diagnosis of depression
Retired athletes reporting ≥3 or more concussions during professional football were 3x
more likely (prevalence ratio = 3.1, 95% CI = 2.3-4.1) to report a diagnosis of depression
_____________________________________________________________
2012: The 9-year risk of a depression diagnosis increased with an increasing number
of self-reported concussions, ranging from 3.0% in the ‘‘no concussions’’ group to
26.8% in the ‘’10+’’ group (linear trend: p<.001). A strong dose-response relationship
was observed even after controlling for confounders.
Beck Depression Inventory-II studies
Retired NFL players
Compared 30 retired NFL players with a history of concussion with 29 age- and
IQ-matched controls with no history of concussion
Found a significant correlation between the number of lifetime concussions and
depression symptom severity on the BDI-II
“…the number of self-reported concussions may be related to later
depressive symptomatology…”
__________________________________________________________
Beck, A.T., Steer, R.A., & Brown, G.K. (1996). Beck Depression Inventory: second edition
manual. San Antonio: The Psychological Corporation, 1996.
Norms
Minimal range = 0–13
Mild depression = 14–19
Moderate depression = 20–28
Severe depression = 29–63
The severity of depressive symptoms according
to BDI criteria is low in both groups
Retired NFL players
n = 26
Consistent with depression
5/26 positive; 19% rate of depression per BDI criteria
Retired NFL players
Distribution of scores
n
%
BDI-II score
30
66.67
0-13
9
20.00
14-19
3
6.67
20-28
3
6.67
>29
BDI ≥14= 33% rate of depression
BDI ≥20= 13.33% rate of depression
What is the
prevalence of
depression in
athletes?
15.6%-21%
 The prevalence of depression in athletes is equal to or may be slightly higher
than the general population, which is reported to be 13-16% (Gelenberg et al., APA, 2010),
but there is no clear evidence that this is due to concussions or even subconcussive
injury.
 Depression exists in athletes, and athletes commit suicide
In discussing depression and concussion we have to consider…
What is the table made of, where does the
table live, and who else sits at the table?
At baseline…
47 Division I football players, ages 17-19 (46 freshmen)
Concussion Resolution Index (CRI; a computerized neurocognitive test)
and Personality Assessment Inventory (PAI)
32-55% endorsed sxs of psych distress at baseline
Scores of athletes endorsing symptoms of anxiety, depression, substance misuse, or
suicidal ideas were correlated with CRI indexes (r²= 0.23-0.30)
Participants acknowledging suicidal thoughts (n=7) had significantly lower simple and
complex reaction time scores, with a trend also noted for Processing Speed (p=.10)
At baseline…
1616 athletes (837 collegiate and 779 high school)
athletes from 3 states participating in a variety of sports
At baseline, student-athletes with higher scores on Center for
Epidemiological Study-Depression (CES-D) had:
Greater symptom endorsement
Poorer Visual Memory scores (ImPACT)
At baseline…
Deidentified data base of athletes ages 13-24, matched, by sex, age, BMI, & concussion history
Athletes who report being prescribed psychostimulants displayed significantly lower visual motor
speed scores (32.8 vs 37.1, p=0.03) and slower reaction times (0.65 vs 0.60, p=0.04) than matched
(1:3 ratio) controls
Athletes who report being prescribed antidepressants displayed significantly faster reaction times
(0.58 vs 0.61, p=0.03) than matched (1:2 ratio) controls
Athletes with a self-reported history of depression/anxiety, not treated currently with
psychotropics, displayed significantly lower visual memory (70.4 vs 75.2, p=0.01) and higher
symptom scores (8.83 vs 4.72, p=0.005) than matched (1:2 ratio) controls
At baseline…
-31,958 high school athletes in Maine, baseline ImPACT from 2009-13
-19% of boys and 28% of girls endorsed a level of symptom burden consistent
with ICD-10 diagnosis of PCS
-Independent predictors of symptom endorsement:
For boys, prior psychiatric diagnosis and migraine HA
For girls, prior psychiatric dx, history of substance abuse, and ADHD
-Concussion history was the weakest predictor of symptom endorsement for both sexes
Post-Concussion
n=7 per group, assessed serially with CES-D
Groups: Concussion vs. Injured/Nonconcussed vs. Control
Week 1: Both groups + for depressive sxs > baseline
Week 4: Injured/Nonconcussed only > baseline
Post-Concussion
Prospective cohort study (n=67) at 2 Big Ten universities (9 sports teams)
2007-08 through 2011-12 seasons
CES-D & State-Trait Anxiety Inventory
Concussed athletes with + sxs depression at baseline were:

4.59x more likely (95% CI = 1.25-16.89) to experience depressive sxs

3.40x more likely (95% CI = 1.11-10.49) to experience state anxiety
Post-Concussion
40 PCS patients (defined as sxs > 3 months) matched by age at injury and
sex to controls on a 1:2 basis (control pts. had sx resolution within 3
weeks)
PCS was not predicted by race, insurance status, BMI, sport, helmet use,
medication use, or specific sx endorsement
PCS pts. were more likely than controls to have a concussion
history, premorbid mood disorder, other psychiatric
illness, or significant psychosocial stress
Other factors related to PCS were family history of mood
disorder, other psychiatric illness, and migraine
Genetic study in progress at VSCC
Post-Concussion
20/174 (11.5%) of the pediatric patients with a SRC qualified for a novel psychiatric diagnosis (based
on symptom checklist scores and clinical evaluation by a neurosurgeon)
- 10/20 (50%) had a pre-injury psychiatric history
- 8/20 (40%) had a family history of psychiatric illness
- 12/20 (60%) reported significant psychosocial stress
Risk factors: Female sex, higher baseline total symptom score, higher baseline emotional symptom
score (sadness, irritability, nervousness, more emotional), presence of pre-injury psychiatric illness,
and family history of psychiatric illness
One completed suicide (patient had a history of prior suicide attempt and psychiatric
hospitalization)
Synthesis: Limited research data suggests:
-
Athletes differ in the degree of depressive symptoms at baseline; gender may be relevant
- Athletes have at least the same rate of depressive symptoms as the general population
- Athletes may have biopsychosocially-influenced responses to concussion that may include
depressive symptoms
- Personal, contextual, and family genetic factors (including migraine, stress level, ADHD/LD,
and psychiatric illness) are relevant
Sports concussion and suicide
November, 2014
March, 2015
Suicide: Some Sobering Facts
Unfortunately, suicide is a very common occurrence
The suicide rate is nearly twice that of the homicide rate in the USA
CDC: In 2013, 41,149 suicides were reported, making suicide the 10th leading cause of
death for Americans (113 per day; the rate in Canada is slightly higher)
Suicide epidemiology
From 2000 through 2014, there was a statistically significant (p<0.05) increase in the
total suicide rate and the rates for each method, for both females and males.
QuickStats: Age-Adjusted Suicide Rates for Females
and Males, by Method — National Vital Statistics
System, United States, 2000 and 2014. MMWR
2016;65:503.
Suicide epidemiology
The rate of suicide is increasing in:
Civilians:
Sullivan EM, Annest JL, Luo F, et al. Suicide among adults aged 35–64 years—United
States, 1999–2010. MMWR. 2013;62:321–5.
Military:
Center AFHS. Deaths by suicide while on active duty, active and reserve components, US
Armed Forces, 1998–2011. Med Surveil Monthly Rep. 2012;19:7–10.
___________________________________________________________________________________
The rates of suicide in both men and women have increased
significantly from 1999-2010: Sullivan EM, Annest JL, Luo F, et al. Suicide among adults
aged 35–64 years— United States, 1999–2010. MMWR. 2013;62:321–5.
People in the US are now more likely to die from suicide than MVCs:
Rockett IR, Regier MD, Kapusta ND, et al. Leading causes of unintentional and intentional injury
mortality: United States, 2000–2009. Am J Public Health. 2012;102:e84–92.
www.vanderbiltsportsconcussion.com
What are the risk factors for suicide?
According to NIMH, risk factors for suicide include prior suicide attempt,
depression and other mental disorders, or a substance-abuse disorder
(often in combination with other mental disorders).
More than 90 percent of people who die by suicide have these risk factors.
www.vanderbiltsportsconcussion.com
Suicide in Athletes
In the recent past, at least 4 professional football players
(Dave Duerson, Ray Easterling, Junior Seau, Jovan Belcher)
have committed suicide. Duerson and Seau died via
GSW to the chest, apparently in an attempt to spare
their brains for postmortem study.
Other collegiate and professional athletes (football,
wrestling, hockey) have committed suicide and
have been later diagnosed with CTE.
Suicides have occurred among collegiate and high
school athletes, with sports-related concussions
claimed as the cause.
We know that athletes are not immune to mood disorders.
Do athletes abuse drugs?
 Telephone survey of 644 retired NFL players from the 2009 Retired
NFLPA directory conducted from March-August, 2010 (53.4% completion
rate)
 52% used opioids during their NFL career, and 71% admitted to misuse
 Prevalence of current opioid abuse was 7%, which is 3x rate of the
general population
_____________________________________________________
What is the suicide rate in retired NFL players?
NIOSH, American J Cardiology, 2012
Cohort: n= 3,439; 1959-1988
The rates of death due to suicide (and violence) in
NFL players were lower than the general population
“…12 suicide deaths observed compared
with 25.6 that would be expected in a comparable
sex/race/age sector of the US population
(SMR = 0.47)”.
College students and suicide
Suicide represents the third leading cause of death among
college-age individuals and the second leading cause of death
among college students.
What is the rate of suicide in NCAA student-athletes?
___________________________________________________________
Centers for Disease Control and Prevention. Leading causes of death reports, national and regional,
1999-2013.http://webappa.cdc.gov/sasweb/ncipc/leadcaus10_us.html.
McIntosh JL, Drapeau CW. U.S.A suicide 2011: official final data. http://www.
suicidology.org/Portals/14/docs/Resources/FactSheets/2011OverallData.pdf.
9 year study period of Divisions I, II, and III: 35 suicides out of 477 student-athlete deaths
Incidence of suicide was higher in males (82.9%) and in African-Americans
Highest suicide rate occurred in men’s football, with relative risk of suicide being 2.2 > vs. other male,
non-football athletes
After football, highest risk sports for suicide were soccer, track/cross-country, baseball, and swimming
Suicide rate of NCAA athletes was lower than the general and collegiate populations of similar age
Concussion history was not ascertained
3X higher risk
Adjusting for male sex, low SES, history of suicide
attempt, substance abuse, and prior psychiatric
diagnoses…
1.27x risk
Common beliefs about
the effects of sports
concussions and
mood disorder/suicide:
How did things
get this way?
1. The Popular Press
When a high profile
athlete commits suicide,
it is front page news…
When Joe or Jane Smith
commits suicide, it is
mentioned quietly in the
obits as a “sudden” or
“unexpected” death
2.
Concussion is the only sports medicine injury now
governed by law in all 50 states in the US
Plaintiff list in NCAA concussion lawsuit growing, schools bracing
September 13, 2013
Jeremy Fowler, College Football Insider
3.
Availability Cascades
and Risk Regulation
Timur Kuran and Cass R. Sunstein
“a self-reinforcing process of collective belief formation by which an expressed perception
triggers a chain reaction that gives the perception of increasing plausibility through its
rising availability in public discourse. The driving mechanism involves a combination of
informational and reputational motives: Individuals endorse the perception partly by
learning from the apparent beliefs of others and partly by distorting their public
responses in the interest of maintaining social acceptance.”
_______________________________________________________________
Availability cascade = repeat something long enough and it becomes true,
especially if it seems politically correct and appears socially acceptable
________________________________________________________________
Regarding the long term effects of concussion, the availability cascade involves the
neglect of empirical data in favor of highly publicized and emotional case findings, with
social psychological pressures leading individuals to believe, endorse, and perpetuate the
biased perception.
Summary
The current thinking among some clinicians and
researchers seems to be that sport-related
concussions and/or subconcussive impacts directly
cause psychiatric illness and suicide, and that the
presence of postmortem abnormal tau is causal proof
of the ante mortem cognitive, mood, impulse dyscontrol,
and neurobehavioral changes seen in athletes.
It is not certain that the presence of abnormal tau causes the neurobehavioral changes, nor is it
clear that the only reason for the presence of the abnormal tau is concussion or subconcussive
impacts. If hyperphosphorylated tau directly caused mood disorder and suicide, then there should
be a distinctly high prevalence of these conditions in patients with tauopathies, and this is not the
case*. If sport-related concussions directly caused psychiatric illness and suicide, then the
prevalence should be higher in athletes than in the general population, and this is not the case. For
purposes of cause and effect it is critical to account for genetic, medical, psychiatric, substance
abuse, and biopsychosocial variables that could well be relevant in the short- and long-term
neurobehavioral outcomes.
Epidemiological studies indicate that psychiatric illness and suicide are increasing in general, as are
diagnosed sport concussions. At present, the current evidence base indicates that attributing the
increases in psychiatric illness and suicide solely to sport-related concussions is unwarranted.
________________________________________________________________________________
*Haw, Camilla, Daniel Harwood, and Keith Hawton. "Dementia and suicidal behavior: a review of the literature."
International Psychogeriatrics 21.03 (2009): 440-453.
*Chesney, Edward, Guy M. Goodwin, and Seena Fazel. "Risks of all‐cause and suicide mortality in mental disorders:
a meta‐review." World Psychiatry 13.2 (2014): 153-160.
Summary
Psychiatric illness, suicide, and cognitive disorders are heterogeneous in nature
and multifactorial in etiology. We need controlled, prospective, longitudinal,
multi-modal assessment studies to determine the relationships among these
factors.
Granted, there is little doubt that some athletes may suffer from
adverse psychological effects from multiple sport-related
concussions. I favor access to mental health services for all.
At present, despite anecdotal and case series reports, it is my
opinion that there is no compelling empirical evidence to indicate
that sport-related concussion or subconcussive impacts are the
sole and direct cause of psychiatric illness or suicide.
Media reports, financial incentives, cognitive biases, and psychological
concerns appear to be primary factors in common beliefs related to the
presumed relationship between sport-related concussions and
psychiatric illness/suicide.
As sports medicine clinicians, it is incumbent on us to focus on the relevant,
multivariate factors in the outcome from sport-related concussion, and not
to reinforce the simplistic, linear thinking of concussions or subconcussive
impacts as the cause of all neuropsychiatric ills.
The brain remains gelatinous, and
although some of its structures are
fragile, it is still not made of spun glass.
Thanks to all of you for your time
and attention.