As my readers know, I am a diehard football fan. Although I watch more college football than NFL games (they just seem more unpredictable and exciting somehow), I like it all (even Arena football). Unfortunately, the game is not without its risks, and the risk of repeated concussions is pretty high on the list.

We used to think that if a concussion did not involve bleeding, that it was not too serious an injury. However, with improved imaging, we can see that even these mild injuries cause permanent damage. Repeated concussions may result in chronic traumatic brain injury (CTBI), which can produce slurred speech, memory impairments, personality changes, lack of coordination, and symptoms similar to Parkinson’s disease.

Now a report by forensic pathologist Bennet Omalu of the University of Pittsburgh has linked the suicide of former NFL player Andre Waters to the repeated concussions Waters sustained during his 12 year playing career. According to Omalu, Waters’ brain resembled that of an 85 year old man, in spite of his age of 44 at the time of his death. Omalu had participated in a previous analysis of football-related head injury. Omalu seems to be interested in cause-of-death cases that are a bit different. He has also published about death by python.

It occurred to me that I really didn’t know much about the relationship between TBI, mood disorder, and suicidal ideation, so I did a quicky search. Harrison-Felix and colleagues (2006), in an extensive review of cause of death data for people with traumatic brain injury (TBI) list seizures, septicemia, pneumonia, and other respiratory conditions as the most likely causes of death following TBI, but suicide is not on the list. Simpson and Tate (2005) conclude that patients with TBI who also experienced substance abuse and “psychiatric/emotional disturbance” were 21 times more likely to attempt suicide than TBI patients without these complications. Anstey et al. (2004), using a large population sample in Australia, concluded that “History of TBI was associated with increased symptoms of depression, anxiety, negative affect, and suicidal ideation.” These findings suggest that a prudent course of action would be to regularly evaluate people with a history of TBI for possible mood disorders.

According to the Philadelphia Eagles’ website, Waters seemed to recognize the risks of his position. “Playing strong safety in the NFL, it’s either kill or be killed like ‘Survivor,'” Waters said. Unfortunately, the risks may have caught up with Waters.

NFL spokesman Greg Aiello was quoted as saying that the NFL is “devoting substantial resources to independent medical research of current and retired players, strict enforcement of enhanced player safety rules, development and testing of better equipment, and comprehensive medical management of this injury.”

To complicate the situation, a person’s genetics might influence his or her recovery from repeated concussions. Boxers with the E4 variant of the APOE gene implicated in Alzheimer’s disease appear to be more vulnerable to CBTI than boxers with other variants [1].

We might envision a time when athletes are advised to continue or drop their chosen sport on the basis of their genetic profile. It is relatively unlikely many would voluntarily follow this advice. In many surveys of high school athletes, the vast majority indicate a willingness to trade life expectancy for success in their sport. Not too surprisingly, many young athletes are already heavily engaged in risky behavior, such as the use of steroids and other drugs, in an effort to win. It is doubtful that the risk of brain damage would deter them any more than the risks of using performance enhancing drugs.

[1] Jordan, B.D., Relkin, N.R., Ravdin, L.D., Jacobs, A.R., Bennett, A., & Gandy, S. (1997). Apolipoprotein E epsilon4 associated with chronic traumatic brain injury in boxing. Journal of the American Medical Association, 278, 136-140.