The Epidemiology and Sociology of Suicide

Epidemiological work suggests that the prominence of suicides in sport is actually quite predictable. Sport is dominated by young men and studies show a 4:1 ratio of male to female suicides.1 Although suicide rates increase with age, suicide is the third leading cause of deaths among 18 to 24-year-olds in the USA.2 Suicide is often also linked to occupational contingencies that are common in professional sport – demotion, relocation, job loss, retirement. Studies show that suicide is more prevalent in certain occupations and it is well established that the suicide rate among English test cricketers is almost double that of the UK's male population.3

Sociology tells us that these individual tragedies are shaped by social relations. The classic sociological text, Emile Durkheim's On Suicide, identified two key factors: integration (the sense of social belonging or inclusion) and regulation (the social monitoring of behaviour).4 Durkheim said that people kill themselves when they experience too much or too little of either, yet unfortunately sporting success requires extreme levels of both. For integration, read teamwork, commitment and a good attitude. For regulation, read the physical training and emotion management required to reproduce complex skills under pressure. The frequency of suicide among cricketers is mainly attributed to the social disintegration and reduced regulation that comes with retirement from sport. Sport, therefore, also conforms to sociological explanations of suicide.

The Role of Sports Medicine

Few would expect sports medicine to lead the way in the biopsychological understanding of suicide (unless stronger evidence emerges linking suicides to concussion in ice hockey and American football), but those who practice in sports medicine have an important role to play in managing mental health issues. The biography of Robert Enke, the Bundesliga goalkeeper who killed himself in 2009, shows how the particular conditions under which sports clinicians work affect their ability to help athletes with suicidal tendencies.5 Enke's team doctor at the onset of his depression agreed to falsify medical records to keep his patient's condition confidential. Enke would later find closest support from the club physiotherapist. Enke and his agent went ‘treatment shopping’, accessing medical support away from football in an attempt to keep the illness secret. Enke also deliberately misled doctors, for example, failing to reveal his use of psychotropic drugs to explain the irregular results of a heart test. He saw various psychiatrists but ultimately chose to be treated by the one who had also been an international handball goalkeeper. The coaches of the national team instructed a sports psychologist to investigate Enke's state of mind, but he failed to link the symptoms of depression to an underlying aetiology.

We do not know how different clinical help would have altered Enke's story, but his biography resonates with our understanding of the culture of sport and its effects on the social organisation of sports medicine.6 This is a story which includes a non-compliant patient who resists clinical treatment, doctors and physiotherapists who do not share information but are both constrained by the pressure exerted by coaches, the balance between short-term performance goals and longer term health, and patients who evaluate healthcare providers on the basis of friendship, trust and sporting experience rather than clinicians' professionally validated expertise.

Three lessons stand out from these reflections. First, we need to assess the degree to which athletes experience mental health problems. The Professional Footballers Association has initiated research. Some prominent former athletes (Andrew Flintoff, Ricky Hatton and Neil Lennon) have begun to talk about their experiences. But so far, our knowledge is limited to male athletes, even though women are almost twice as likely to experience major depression.7 Until we generate comprehensive survey data, the scale of the problem will remain unknown. Second, a clearer view of the training needs of sports medicine personnel needs to be established so that mental health problems are identified early and appropriate treatment given (or sourced). Perhaps most importantly, sports psychology curricula need a better balance between performance enhancement and a duty of care to athletes' health. Third, we need to address the way sports medicine is organised in professional sport. The autonomy of clinicians from coaching staff, the respect for confidentiality and the scope to build collaborative relations between athletes and clinicians will be central to the ability of medical staff to address suicide in sport.

Estimates for the ratio of failed (or parasuicide) attempts to ‘successful’ suicides range from 5:1 to 100:1. For those whose tragic deaths have recently appeared in our newspapers it is too late, but if these suicides lead to better mental healthcare support in sport their lives will not have been entirely wasted.