Pain Compounds Depression’s Impact for Retired NFL Players

Retired professional football players have about the same severity of depression as does the general public—unless they also suffer from chronic pain. Thomas L. Schwenk, MD, and colleagues conducted a study that quantified the levels of pain and depression felt by retired National Football League (NFL) players. The findings were reported in the April Medicine & Science in Sports & Exercise. According to Dr. Schwenk, nearly half of the participants in the study reported chronic pain and depression, indicating a significant risk for postretirement medical and social problems.

Dr. Schwenk is the George A. Dean, MD, Chairman and Professor of Family Medicine at the University of Michigan Health System and Associate Director of the University of Michigan Depression Center. One of the coauthors on the study was former Detroit Lions quarterback Eric Hipple, who is the outreach coordinator for the University of Michigan Depression Center.

Dr. Schwenk and colleagues surveyed 3,377 retired members of the National Football League Players Association (NFLPA) and received responses from 1,617 (mean age 53). The respondents were asked about employment, marital and financial problems, the barriers for receiving help for these problems, and the types of programs that might be helpful for retired players. The survey included a structured depression questionnaire, a single question regarding chronic pain, and demographic questions.

Depression symptoms were measured using the Patient Health Questionnaire 9 (PHQ-9), a validated screening questionnaire based on standardized diagnostic criteria, including an assessment of the impact of depressive symptoms on personal and work roles. A self-rating of health status was made on a 5-point scale and was followed by assessments of past or current difficulties with nutrition, exercise, alcohol use, smoking, and depression. The respondents were asked additional questions about problems with alcohol and the impact of chronic pain on normal work.

LIFE AFTER THE GRIDIRON

The prevalence of moderate to severe depression was 14.7%, similar to that in the general population. However, nearly half of the players reported difficulty with pain, and many reported trouble sleeping, financial difficulties, marital or relationship problems, and problems with fitness, exercise and aging. All of these issues were strongly correlated with the presence of moderate to severe depression and with frequent difficulty with pain.

Dr. Schwenk said that his group’s most important finding was that the intersection of moderate to severe depression plus chronic pain seems to set up many retired NFL players for additional problems. He said this finding can also be applied to patients from the general population who have similar levels of depression and pain, but it’s more often seen in NFL players. “We have images of retired players as being wealthy, getting jobs as TV broadcasters, and spending a lot of time playing in pro-am golf tournaments, but many players have short careers, many injuries, and lots of residual pain that affects their future quality of life.”

About 11% of the subjects had high scores for both pain and depression, 37% had high pain scores and low depression scores, and 4% had low pain scores with high depression scores. Those with high depression scores were nearly eight times more likely than those with low depression scores to report a loss of fitness and lack of exercise, and they were seven times more likely to report financial difficulties. They were significantly more likely to have more problems with lack of social support; to use prescription medication, alcohol, or other drugs; and to have experienced trouble with the transition to life after football. “It is the co-occurrence of depressive symptoms and pain that puts retired players at the highest risk of significant difficulties in retirement,” said Dr. Schwenk.

The former NFL players reported a number of barriers to seeking help—most notably, failure to recognize these issues as important, and thinking they were just “a part of life” (66%). The respondents also said they felt embarrassment at what friends or family would think (52%) and feared that they would appear “weak” if they sought help (56%). Fifty-six percent also reported a lack of insurance coverage. The researchers suggested that future research should include ways to provide anticipatory guidance to active players before 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,” the authors wrote.

The elite athlete’s life is organized around performance and includes support personnel and logistic and financial resources. “On retirement, athletes have reported jarring transitions to a life in which the focus of such intense commitment is unclear, the resources and personnel that organized and managed their lives away from the competition venue are lost, and the rewards, both emotional and financial, are diminished,” Dr. Schwenk said. Indeed, 45% of players reported difficulty finding employment and 55% reported difficulty in finding satisfaction in work.

A PROACTIVE APPROACH

Dr. Schwenk said that his group is working with the NFLPA to develop a DVD to be given to all retiring players that will include educational information, questionnaires, stories about players, and resources for more information or help. They hope to have it available next year. They are also starting a longitudinal study that will track retired players in an effort to gather data on changes over time, including information on when depression develops.

In addition to its potential benefits for professional athletes, the results of this study also have implications for clinicians treating patients who are not former football stars. “The key issue is to be aware of the high likelihood that there is underlying depression in any patient with severe chronic pain and to dig into it on an aggressive basis with appropriate questionnaires or interviewing. Even simple questions, such as ‘Over the last two weeks, how many days have you had low mood or low energy?’ or ‘How many bad days have you had in the last week?’ or ‘Have you ever thought that you might be depressed?’ can capture a lot of this,” Dr. Schwenk said.          

—Janis Kelly

Suggested Reading
Schwenk TL, Gorenflo DW, Dopp RR, Hipple E. Depression and pain in retired professional football players. Med Sci Sports Exerc. 2007;39:599-605.

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