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• Reply to: Mental health and suicide in former professional soccer players
  Emma R Russell, Thomas McCabe, Daniel F Mackay, Katy Stewart, John A MacLean, Jill P Pell and William Stewart
  Published on: 16 November 2020
• Response to: Mental health and suicide in former professional soccer players
  Adam J White, Alan Pearce, Jo Batey, Keith D Parry, Gary Turner and Eric Anderson
  Published on: 16 November 2020

• Published on: 16 November 2020

  Reply to: Mental health and suicide in former professional soccer players

  • Emma R Russell, Postgraduate Student University of Glasgow
  • Other Contributors:
    • Thomas McCabe, Specialty Trainee in Psychiatry
    • Daniel F Mackay, Professor of Public Health Informatics
    • Katy Stewart, Sports Scientist
    • John A MacLean, Medical Director
    • Jill P Pell, Director of Institute of Health and Wellbeing
    • William Stewart, Consultant Neuropathologist

  We thank White and colleagues for their correspondence on our article(1) and note many of the observations raised are already addressed by our robust study design and discussed in the original manuscript text. Importantly, we are quite clear throughout that this is a study designed to investigate whether there is higher risk of common mental health disorder in former professional soccer players than anticipated from general population controls.

  Undoubtedly, there will be physically active individuals in our general population control group, including a number who might have participated in some form of contact sport. However, we would suggest this does not define our over 23,000 matched general population controls as a cohort of ‘non-elite’ athletes, as proposed by White et al. Instead, we would assert this merely underlines their legitimacy as a general population control cohort for comparison with our cohort of almost 8000 former professional soccer players.

  Potential study limitations regarding healthy worker effect, illness behavior in former professional soccer players and use of hospitalization datasets are addressed in detail in our manuscript text. Regarding data on duration of hospital stay and therapy, while these might indeed be of interest in follow-on studies regarding illness severity, we would suggest that they are not immediately relevant to a study designed to address risk of common mental health disorder.

  As White et al observe, wh...

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  We thank White and colleagues for their correspondence on our article(1) and note many of the observations raised are already addressed by our robust study design and discussed in the original manuscript text. Importantly, we are quite clear throughout that this is a study designed to investigate whether there is higher risk of common mental health disorder in former professional soccer players than anticipated from general population controls.

  Undoubtedly, there will be physically active individuals in our general population control group, including a number who might have participated in some form of contact sport. However, we would suggest this does not define our over 23,000 matched general population controls as a cohort of ‘non-elite’ athletes, as proposed by White et al. Instead, we would assert this merely underlines their legitimacy as a general population control cohort for comparison with our cohort of almost 8000 former professional soccer players.

  Potential study limitations regarding healthy worker effect, illness behavior in former professional soccer players and use of hospitalization datasets are addressed in detail in our manuscript text. Regarding data on duration of hospital stay and therapy, while these might indeed be of interest in follow-on studies regarding illness severity, we would suggest that they are not immediately relevant to a study designed to address risk of common mental health disorder.

  As White et al observe, while our data reporting lower risk of hospitalization for common mental health disorder in former professional soccer players might appear ‘surprising’, this is perhaps a reflection of methodological limitations and biases in previous reporting in this issue, as discussed in our text. As such, as a robust study specifically designed to address many previous limitations and minimize biases, we would disagree with White et al’s suggestion that our ‘surprising’ observations are ‘not necessarily a significant contribution’ to this field.

  1 Russell ER, McCabe T, Mackay DF, et al Mental health and suicide in former professional soccer players Journal of Neurology, Neurosurgery & Psychiatry Published Online First: 21 July 2020. doi: 10.1136/jnnp-2020-323315

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  Conflict of Interest:
  None declared.

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• Published on: 16 November 2020

  Response to: Mental health and suicide in former professional soccer players

  • Adam J White, Lecturer Oxford Brookes University
  • Other Contributors:
    • Alan Pearce, Associate Professor
    • Jo Batey, Senior Fellow
    • Keith D Parry, Senior Lecturer
    • Gary Turner, PhD Student
    • Eric Anderson, Professor

  Russell et al. (1) published a retrospective cohort study with a population of former professional soccer players with known high neurodegenerative mortality. Findings showed that they are at lower risk of common mental health disorders and have lower rates of suicide than a matched general population. These findings are surprising and different from previous studies, which have used first-hand clinical accounts of ex-athletes who have lived with neurodegeneration (1). We suggest there may be reasons for this disparity and welcome critical dialogue with the authors of this research.

  Cohort Comparison
  Russell et al. has compared their soccer cohort with a matched population cohort. However, the matched cohort may also include those who have experienced repetitive head impacts, such as amateur soccer players, rugby players or boxers. Therefore, the study represents differences of elite versus non-elite rather than sport versus non-sport. While Russell recognises the healthy worker effect (2), it may have a greater influence in this study than presented.

  Soccer Stoicism
  Men’s engagement in health-seeking behaviours has been a long-standing concern in health care and is often attributed to factors such as stigma, hypermasculinity and stoicism (3). Furthermore, working-class sports such as soccer, require the acceptance of pain, suffering, and physical risk, so these players are more likely to ‘suffer in silence’ than the general population (4). Give...

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  Russell et al. (1) published a retrospective cohort study with a population of former professional soccer players with known high neurodegenerative mortality. Findings showed that they are at lower risk of common mental health disorders and have lower rates of suicide than a matched general population. These findings are surprising and different from previous studies, which have used first-hand clinical accounts of ex-athletes who have lived with neurodegeneration (1). We suggest there may be reasons for this disparity and welcome critical dialogue with the authors of this research.

  Cohort Comparison
  Russell et al. has compared their soccer cohort with a matched population cohort. However, the matched cohort may also include those who have experienced repetitive head impacts, such as amateur soccer players, rugby players or boxers. Therefore, the study represents differences of elite versus non-elite rather than sport versus non-sport. While Russell recognises the healthy worker effect (2), it may have a greater influence in this study than presented.

  Soccer Stoicism
  Men’s engagement in health-seeking behaviours has been a long-standing concern in health care and is often attributed to factors such as stigma, hypermasculinity and stoicism (3). Furthermore, working-class sports such as soccer, require the acceptance of pain, suffering, and physical risk, so these players are more likely to ‘suffer in silence’ than the general population (4). Given the effectiveness of masculine socialisation through sport participation, the absence of elevated medical reporting between male athletes and non-athletes does not indicate an actual absence of a larger disease profile. The lack of ex-elite athletes engaging with mental health support at a hospital may rather be indicative of health-avoidance behaviours.

  Mental Health Concerns Defined by Hospital Admission
  Using hospital admission records as the primary definition for mental health concerns is problematic. Hospital admission is reserved for the most severe acute psychiatric concerns. Therefore, such records miss many mental health concerns that are better managed in primary and community care settings. This may be particularly pertinent for this study, given that many of the sample have diagnosed dementia, and may be fully supported with their neuro-psychiatric needs by health care professionals outside the hospital context.

  The Bigger Picture
  It appears that only a selective subsection of data, or part of the picture, has been reported. No information on the length of visit to hospital, extent and nature of medical interventions, public health burden, number or frequency of visits by an individual and any further care has been provided. This information may illuminate other explanations for why there is a difference in common mental health disorders for soccer and match control samples.

  Concluding thoughts
  Russell et al assert research, “… has placed greater emphasis on psychiatric symptomatology in CTE. Nevertheless, data supporting this association are weak”. This study does little to support or contest this position. While the results presented are novel, they are not necessarily a significant contribution to the debate on the relationship between soccer participation, common mental health disorders and other neurological

  References

  (1) Russell, E. R., McCabe, T., Mackay, D. F., Stewart, K., MacLean, J. A., Pell, J. P., & Stewart, W. (2020). Mental health and suicide in former professional soccer players. Journal of Neurology, Neurosurgery and Psychiatry.

  (2) Li CY, Sung FC. A review of the healthy worker effect in occupational epidemiology. Occup Med 1999;49:225–9.

  (3) Wang Y, Hunt K, Nazareth I, Freemantle N, Petersen I. Do men consult less than women? An analysis of routinely collected UK general practice data. BMJ Open. 2013;3(8):e003320

  (4) Anderson, E., & White, A. (2017). Sport, theory and social problems: A critical introduction. Routledge.

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  Conflict of Interest:
  None declared.

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