Depression and Pain in Retired Professional Football Players

Thomas L. Schwenk; Daniel W. Gorenflo; Richard R. Dopp; Eric Hipple

Disclosures

Med Sci Sports Exerc. 2007;39(4):599-605. 

In This Article

Discussion

These self-report survey data from a large sample of retired professional football players give a structured assessment of depression and pain symptoms experienced by professional athletes after retirement. Their problems are not necessarily worse than those experienced by the general population in retirement, nor are they necessarily better.[9,15] Although it is difficult to make comparisons of this population versus other retired populations because of the difference in age at retirement, most studies would suggest that older adults have roughly similar levels of depressive symptoms, in the range of 8-10% as measured by self-report questionnaires.[14,15] The high profile of many of these retired professional athletes, and the concomitant financial benefits and emotional support they experience, seems to neither increase nor decrease the likelihood that an athlete will experience significant difficulties in retirement, although we could not make direct correlations with income or retirement assets. The prevalence of moderate to severe depressive symptoms as measured by the PHQ-9 is also roughly similar to that found in the general population,[17] and seems to be higher than in younger, active athletic populations.[10,16] The association of certain problems (e.g., trouble sleeping, use of prescription medications, drugs, or alcohol, and loss of fitness) with higher depression symptom scores is also typical for patients in the general population, as are associations with a wide range of comorbid medical conditions, including diabetes, cardiovascular disease, cancer, and several neurological diseases.[7]

It is the cooccurrence of depressive symptoms and pain that puts retired players at the highest risk of significant difficulties in retirement. The relationship between depression and pain is important and complex. A recent systematic review of almost 60 studies of the comorbidity of pain and depression showed that roughly two thirds of patients with major depressive disorder had significant pain symptoms, and roughly half of patients seen in chronic pain clinics met criteria for major depressive disorder-proportions that are roughly similar to the cooccurrence found in these subjects.[2] For example, of 236 subjects in this study with high depression scores, 173 (73%) had high pain scores. Most patients eventually diagnosed as depressed in primary care settings present initially with somatic symptoms-most commonly, pain complaints, including back pain, chronic abdominal or pelvic pain, or headache.[19] The biological and psychological mechanisms underlying these highly comorbid conditions have been studied in depth[12] and suggest that depression more likely follows pain than vice versa, and that the risk of developing depression is correlated with the severity of the pain complaints.[6] Recent research has focused on approaches to screening and diagnosis of comorbid pain and depression (because there is considerable symptom overlap) and combined approaches to treatment using both medications and psychotherapeutic interventions such as cognitive behavioral therapy.[6] It also seems that the baseline level of pain in patients with both disorders detracts from the eventual response to treatments for depression.[3] These data can be linked with findings in a recent study in which vigorous physical activity was highly protective of the development of depression in older former athletes[1] to suggest that a hypothesis worth further exploration is that the high level of physical disability and chronic pain with which these athletes leave their football career causes them to have significant difficulty maintaining their activity and fitness levels, thus predisposing them to an increased risk of depression.[14]

Although pain and depression are commonly comorbid in the general population,[2,12] the frequency with which retired professional football players report difficulty with pain seems to put them at additional risk of both developing depression and experiencing associated difficulties with retirement. The high level of psychosocial dysfunction and significant barriers to receiving help put a small but important subgroup of all retired NFL players at significant risk of adverse life events and disability, almost certainly including an increased risk of suicide.[4] The respondents with high scores for either depression or pain endorsed a congruent set of programs for life assistance, including programs focusing on help with fitness and exercise, nutrition, financial assistance, and sleep, marital, and relationship problems. Given the significant barriers to effective treatment noted above, and the known difficulty in treating patients comorbid for both depression and pain,[6] future research should evaluate a range of clinical and educational outreach programs to serve this population, including ways to provide anticipatory guidance to active players as they plan for their future retirement. This is particularly true because retirement can occur suddenly, with little opportunity for planning, after a career-ending injury or being unexpectedly cut from the team. Possible approaches that deserve development and evaluation include educational interventions to make players aware of potential future problems, self-assessment instruments, educational resources, and a network of clinical services organized around NFLPA chapters, most of which are based in current NFL team cities.

The most obvious limitation to this study is the self-report nature of both the depression and pain data, as well as the respondents' perceptions of the life problems they are experiencing, barriers to receiving help, and the types of programs most needed. The PHQ-9 has fair concordance with longer diagnostic interviews conducted by trained health care professionals, but it is overly sensitive, with a significant rate of false positives based on self-report symptoms that may not reflect a deeper, more enduring clinical depression.[18,22] Most studies in the general population suggest that roughly 25-40% of those screening positive for depression on any of several self-report instruments will have a criterion-based diagnosis based on a structured clinical interview.[22] The single question asking about difficulty with pain is not likely to be as accurate as more detailed visual analog scales and other standardized questionnaires assessing pain, but it was adequate for our initial purposes in understanding the basic issues faced by retired professional football players. More detailed assessments and interviews on a smaller population, with more objective data concerning clinical diagnoses, financial status, or health insurance, for example, would be appropriate to characterize more fully the clinical and demographic characteristics of this study population.

The response rate of nearly 50% can be seen as literally either "half full" or "half empty" with regard to the generalizability of these results to the larger population of retired professional football players. Our inability to follow up with nonrespondents regarding their comparability with respondents is a significant weakness. Retired players who chose to not respond could be more depressed and have more life problems, making them less likely to take the time or have the energy to complete the survey. Or, they may be less depressed and have fewer life difficulties, leading them to believe that the survey does not apply to their life situation. A future study should explore methods to increase the response rate and make particular outreach to those who do not initially respond.

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