Research News

UB psychiatry resident explores link between brain injuries, suicide

Comparison of a "normal" brain with an advanced CTE brain.

The image depicts the gross pathologic findings in Chronic Traumatic Encephalopathy (CTE). Compared to a normal brain, brains of those inflicted with CTE show evidence of severe atrophy and ventricular enlargement. Image: Boston University’s Chronic Traumatic Encephalopathy (CTE) Center

By BARBARA BRANNING

Published March 24, 2020

Erik Radick.
“Over the course of a 25-year football career, these athletes are estimated to have experienced the equivalent of 25,000 motor vehicle accidents, none of which result in any acute clinical symptoms.”
Erik Radick, fourth-year resident
Department of Psychiatry

It’s difficult to watch a professional football player take a hard hit to the head without immediately thinking about what that impact might be doing to his brain. And when he’s had multiple bad blows during his playing career, it becomes even more concerning. Dozens of National Football League players who have sustained repeated brain injuries while active have taken their own lives years after their careers have ended.

During a Psychiatry Grand Rounds in February at the Buffalo Psychiatric Center, Erik Radick, a fourth-year resident in the Department of Psychiatry in the Jacobs School of Medicine and Biomedical Sciences, discussed his research into the link between repeated brain injuries and suicide.

In his 90-minute presentation — “From Super Bowls to Suicide: A Systematic Review of the Neuropsychiatric Manifestations of Chronic Traumatic Encephalopathy (CTE)” — Radick presented a comprehensive overview of the existing scientific literature on mild traumatic brain injury (mTBI) and the neuropsychiatric manifestations of CTE. He cited data published by the National Football League, the National Hockey League and numerous pioneers in the field of neuropsychiatry and neuropathology.

In an interview with UBNow, Radick noted that research targeted at identifying the neurologic and psychiatric deficits of persistent exposure to neurotrauma is not new. Medical professionals first recognized CTE, which was formerly known as Dementia Puglistica and “Punch Dunk” Syndrome, more than 75 years ago.

“Researchers initially believed this neurodegenerative process was restricted to retired boxers,” he said. “It was not until 2002, following the death of former NFL player Mike Webster, that awareness of the long-term ramifications of repetitive, concussive and subconcussive head injuries became more mainstream.”

Although the professional sports organizations have repeatedly downplayed the effects, he said, since 2003, a disturbing number of contact-sport athletes have committed suicide.

Stages of CTE progression.

This image depicts the four stages of Chronic Traumatic Encephalopathy (CTE). As further neurodegeneration occurs, behavioral changes, mood disorders, confusion and memory loss manifest. Image: PBS "Frontline" article https://www.pbs.org/wgbh/frontline/article/the-four-stages-of-cte/

Radick has first-hand experience with traumatic brain injury. A self-described avid sports fan and high school athlete, he experienced three concussions in his teen years in the Philadelphia area — two while playing basketball and one during an automobile accident.

“I found that each concussion was transiently more debilitating than the previous one,” he said. The second basketball-related concussion was “far more deleterious,” he said. He suffered with fleeting amnesia, frequent headaches, brain fog, irritability and changes in concentration before gradually returning to baseline.

Radick’s interest in concussions and their aftermath was further piqued when he read a Journal of the American Medical Association publication that detailed the association of concussion with the risk of suicide.

DTI in normal and abnormal brain.

This image is an example of Diffusion Tensor Imagining (DTI), which enables brain connectivity patterns to be analyzed. The changes in connectivity after a traumatic brain injury can be detected and visualized through this imaging modality and are depicted in the photo. Image: Brain Injury Help

“This meta-analysis revealed a two-fold higher risk of subsequent suicide among more than 700,000 patients diagnosed with concussion and/or mild TBI, compared with more than 6.2 million individuals who had not been diagnosed,” he said. “This finding was disconcerting, given my history of concussions, and served as the catalyst for my research.”

The first part of Radick’s presentation focused on mTBI, which is synonymous with the term “concussion.” “The medical literature suggests that mood disorders, such as intermittent depression, dysphoria and anxiety are most common following a concussion,” he said, while psychotic symptoms, such as hallucinations, delusions and disorganized thought are atypical, as are mania and hypomania. Treatment following an mTBI usually does not include psychotropic medication, and most athletes recover from a single concussion within a week to 10 days without long-term consequences, he said.

For many years, research into CTE focused on concussions, Radick said. But now research focuses on identifying the importance of subconcussive head trauma, called the “invisible illness.” These injuries “result in the disruption of neuronal functioning that is below the threshold to elicit any clinically identifiable symptoms of concussion, he said. Radick calls these injuries the “everyday hits” that hockey or football players endure.

Evidence of CTE deterioation in Aaron Hernandez's brain.

Former NFL player, Aaron Hernandez’s brain, which shows evidence of severe atrophy and ventricular enlargement from CTE. Image: Boston University’s Chronic Traumatic Encephalopathy (CTE) Center

“My systematic review of the literature found that contact-sport athletes, particularly football players, endure 1,000 or more subconcussive injuries per season,” he said. “Each subconcussive injury is approximately 20 to 30 G-forces. “To put this in perspective, the G-forces exerted on the body during the descending portion of a roller coaster ride is four to six Gs,” while a car accident at 30 mph is approximately 30Gs.

“Over the course of a 25-year football career, these athletes are estimated to have experienced the equivalent of 25,000 motor vehicle accidents, none of which result in any acute clinical symptoms.”

Radick also examined research about changes in brain functioning in high school athletes who sustain as little as one season’s worth of repetitive, subconcussive neurotrauma. These athletes manifested cognitive, physiological and structural brain changes, he said. There were also changes in brain connectivity patterns, especially in regions of the brain involved in self-reflection and social cognition. “Hyper-connectivity caused by long-term, subconcussive head injury was found to be associated with psychiatric disturbances, such as major depressive disorder,” he said.

Radick concluded his presentation with a discussion of CTE, which is defined as a neurodegenerative disease, similar to Alzheimer’s disease. Unlike Alzheimer’s, CTE is not diagnosable until autopsy, and is not a disease of old age. Recently, an 18-year-old high school football player was diagnosed with CTE after his suicide.

“CTE symptoms include memory impairment, poor judgement and planning, gait abnormalities and confusion. Psychiatric manifestations include emotional and behavior dysfunction — impulsivity and irritability and poor frustration tolerance,” he said. “Most athletes with CTE develop depression, anxiety or even psychotic symptoms, like paranoia or hallucinations. An alarming number of retired athletes diagnosed after death died as a result of suicide.”

Chart of the number of concussions in the NFL during the 2019 season.

The number of concussions in the NFL during the 2019 season. Graph: NFL

Radick said a 2015 study reviewed the cause of death of every NFL player over 95 years. A total of 26,702 athletes were identified, and their death certificates reviewed. Of this number, 26 had committed suicide. This compares to a national rate of suicide the same year of 12.6 per 100,000. In other words, football players had a two-fold higher suicide rate in 25 percent of the patient population.

“CTE is a polarizing topic, as many individuals form strong attachments to both sports teams and athletes,” he said. “People become emotional and impassioned when discussing the deleterious effects of contact sports.”

Still, the presentation was well-received for the most part, he said, noting that many of the approximately 85 attendees commented on the unsettling association between brain injury and neurologic/psychiatric symptomology.

“Many parents were thankful, as this presentation provided evidence-based research that will allow them to make informed decisions about whether or not they will allow their children to play football or hockey,” he said.

When he completes his residency in June, Radick will return to Philadelphia to work in a physicians’ group practicing neuropsychiatry and general adult psychiatry.