How Sports Concussions and CTE can Impact an Athlete’s Mental Health

With events like the Winter Olympics and Superbowl LVI recently taking place, it’s no surprise that many of us are fixated on sports more than usual. These marquee events highlighted impressive feats of athleticism, provide hours of entertainment, and create a point of connection for people worldwide.

One issue that continues to cast a shadow over these athletic events, however, is the fallout from the intense gameplay that can lead to short-term and long-term injuries for many athletes. In particular, chronic traumatic encephalopathy (CTE) caused by concussions has been gaining increasing prominence as a troubling, long-term side effect of contact sports like football, hockey, rugby, and soccer.

What is Chronic Traumatic Encephalopathy?

Chronic traumatic encephalopathy (CTE) is a complex progressive neurodegenerative disorder that is believed to be caused by repeated head trauma, including concussions. It is primarily diagnosed at autopsy, and it’s difficult for doctors to conclusively offer a diagnosis except in unique circumstances where high-risk exposures make the conclusion obvious. As a result of this ambiguity, many living patients with potential cases of CTE are left confused and unsure of their path forward.

Currently, it’s not fully understood how the severity of concussions and other head traumas affect CTE. Researchers have determined that in general terms, athletes who experienced head traumas for a more extended period of time were more likely to develop CTE, even if those traumas were less violent than a concussion.  

The Four Stages of CTE

There are four recognized stages of CTE. 

Stage I is often marked by mild symptoms like a loss of concentration, memory problems, and headaches. Individuals may feel aggressive, angry, and explosive. 

Stage II can bring on some more troubling symptoms, such as depression, mood swings, and suicidal thoughts. Some individuals may also experience executive dysfunction and have problems with their short-term memory. 

Stage III individuals typically experience mood swings, depression, difficulty concentrating, visuospatial difficulties and aggression. This is the first phase of CTE where apathy first appears, and 75% of individuals within this stage are considered cognitively impaired.

Stage IV is when many people with CTE develop dementia, and experience issues with their cognition, gait, visual and spatial awareness, and language processing. Some develop the physical symptoms associated with Parkinson’s Disease, and may also be depressed, paranoid, and explosively angry. 

How CTE Affects an Individual’s Mental Health

CTE can have an outsized impact on an athlete’s mental health because the symptoms are mainly cognitive or behavioral. Changes to the brain chemistry caused by CTE can cause impairments like:

  • Depression
  • Anxiety
  • Memory loss
  • Poor executive function
  • Difficulty reasoning or thinking
  • Impulsive behavior
  • Aggressive behavior
  • Emotional instability
  • Suicidal thoughts

In addition to contributing to long-term CTE, even mild concussions have been seen to have troubling effects on an athlete’s mental health. Approximately 1 in every 5 individuals who experience even a mild traumatic brain injury (TBI) displays mental health symptoms up to 6 months after the incident. These mental health symptoms include PTSD, depression, and anxiety. Without healthy coping skills learned from a therapist or clinician, it’s difficult for these athletes to understand their condition and move forward in a positive way.

Athletes and CTE

Hall of Famer, “Iron” Mike Webster, a former offensive lineman for the Pittsburgh Steelers and Kansas City Chiefs suffered the adverse effects of CTE for years prior to his death. His behavior was explosive and erratic. He lost all of his money, got divorced, forgot how to eat, and was sleeping in his car prior to his death. His CTE symptoms were likened to “punch-drunk syndrome”– a disorder characterized by severe dementia including delusion, paranoia, explosive behavior, and loss of memory — all caused by repeated blows to the head. It has been speculated that Webster’s ailments were due to wear and tear sustained over his playing career, with some doctors estimating that he had been in the equivalent of “25,000 automobile crashes” in over 25 years of playing football at the high school, college and professional levels.  

But Mike Webster was not an anomaly when it comes to the mental health challenges that  athletes with concussions and CTE face. The list of current and former athletes with CTE is heartbreaking and disquieting. In recent years, we’ve seen several high profile NFL football players like Aaron Hernandez, Frank Gifford, Junior Seau, Ken Stabler, and Andre Waters succumb to the effects of CTE. The results of their post-mortem brain studies tell the tale of the tape, and are both shocking and unsettling. Former Atlanta Falcons safety Ray Easterling, who died by suicide, had CTE, as confirmed by his autopsy report. Other players like Vincent Jackson and Philip Adams were diagnosed with CTE post-mortem. During the lead-up to their deaths, both experienced progressive memory loss, paranoia, and headaches. 

How Mental Health Clinicians Can Help Clients with Concussions

Regardless of whether you have athletes in your practice or not, most clinicians are already aware of the mental health risks posed by concussions and CTE. While symptoms like depression and anxiety can be treated using traditional treatment methods like talk therapy and cognitive behavioral therapy, handling the physical condition as a whole may be more complex.

Here are some suggestions for ways to help the athletes in your practice deal with the mental health conditions that may be linked to concussions or CTE.

Identify at-risk clients. As you start working with new clients, it’s essential to collect as much biographical information as possible to provide more personalized care and treatment. It is even more important to collect this information when it comes to athletes. Identifying the types of sports they have participated in and how often they have had concussions can help determine whether they are at risk for related mental health symptoms. Documenting all of this information in a behavioral health EHR is critical for maintaining good client records that can also be shared with other healthcare providers.

Encourage athletes to connect with their feelings and emotions. In many cases, athletes are encouraged to put aside their feelings and emotions in favor of a better physical performance. If they have been doing this for an extended period of time, it can be difficult for them to re-learn how to experience these feelings in a healthy way. As a clinician, you are uniquely placed to help them learn how to understand and discuss their emotions and mental health positively and productively. By working with them to build a more substantial vocabulary to express their feelings, you can help them begin the work of reconnecting with their emotions.  

Work on healthy coping skills. Many athletes know how to cope with performance pressures on the track, at the rink, or on field, but don’t know how to regulate their emotions or cope with symptoms of anxiety or depression outside of their sport. To help them learn how to deal with their mental health challenges in their day-to-day life, work with them to create a personal set of healthy coping skills. These can include deep breathing exercises, a daily mindfulness practice, or even recall skills if they are experiencing memory loss.

Make the pressure to perform a part of the conversation. Athletes who are often under pressure to perform may normalize this stress and fail to realize how much it impacts their mental health. By making this part of the conversation, clinicians can help the athletes in their care understand how this stress has affected not just their mental health but also their overall well-being. It can also help athletes start to break down any stigmas they have about needing to be tough–both physically and emotionally–to perform at their best.

Help them round out their care team. If an athlete in your care is suffering from a mental health condition like depression, anxiety, or suicidality and you suspect it may be related to a concussion or CTE, you should always refer them to a neurologist. A behavioral health clinician can help treat the mental health symptoms of this condition, but they cannot treat the condition itself. Having a holistic healthcare team offers the client the best possible outcome.  

Resources for Clinicians Treating Athletes Affected by Concussions and CTE

When treating athletes who may be affected by concussions and CTE, clinicians need to approach their care holistically. Here are some resources that can help.

Concussion Alliance Mental Health Resources

Barrow Neurological Institute

Concussion Legacy Foundation Information on Post-Concussion Syndrome

Concussion Legacy Foundation Treatment Resources

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