By Ian Simpson
Reuters

The U.S. government launched on Monday a sweeping study of rising sports-related concussions among the youth, amid concerns that the injuries may have contributed to the suicides of professional football players.

The Institute of Medicine, part of the National Academies of Science, will probe sports-related concussions in young people from elementary school through early adulthood. The study will include military personnel and their dependants, and review concussions and risk factors.

The study, one of the most extensive ever done, will be scrutinized intently by Americans worried about brain injuries in sports, said Robert Graham, head of the panel carrying out the study.

"You start talking about, 'Is it safe for Sally to be playing soccer?,' you get lots of public interest," Graham, a public health expert at George Washington University in Washington, told Reuters after the committee's first meeting.

He said the panel likely would submit its report to the Institute of Medicine in the middle of the summer, with publication expected in late 2013.

A 2010 study by the U.S. Centers for Disease Control and Prevention (CDC) found that U.S. emergency rooms yearly treat 173,000 temporary brain injuries, including concussions, related to sports or recreation among people less than 19 years of age.

The number of emergency room visits for such injuries rose 60 percent in the previous decade among children and adolescents, the CDC study showed.

A separate 2007 study showed that the incidence of brain injury was highest in football and girls' soccer.

About 2,000 former National Football League players sued the league last year, alleging it concealed the risk of brain injury from players while marketing the ferocity of the game.

Concerns about a possible link between concussions and mental illnesses, such as depression, grew in the wake of the suicides of former NFL players Junior Seau, Ray Easterling and Dave Duerson in the last two years.

Participants at the committee's meeting said there was a shortage of data on sports-related concussions among young people. The number of relevant brains available for study is in the single digits, and many studies lack breakdowns by age.

Sponsors of the study include the Department of Defense, the CDC and the National Institutes of Health. The panel will also examine studies being done by the CDC and the American Academy of Neurology.

Ed Zurga / AP file

Kansas City Chiefs inside linebacker Jovan Belcher, shown in a September game, two months before the 25-year-old killed his girlfriend and committed suicide.

Four months after the NFL sought to curb domestic violence in its ranks by launching a crisis hotline, a bolstered mental-health program and fresh encouragement for troubled players to seek help, that fortified safety net could not prevent the murder-suicide Saturday involving Jovan Belcher. The Kansas City Chiefs linebacker, 25, shot his girlfriend Kasandra Perkins, 22, at their home, then drove to Arrowhead Stadium and killed himself in front of two coaches and the team's general manager.

After the high-profile suicide of retired NFL superstar Junior Seau, 43, last May — two years after Seau drove his car off a cliff following his assault on a girlfriend — NFL commissioner Roger Goodell installed the 24-hour hotline for players and a reinforced mental-health initiative on July 26. That same week, following a spate of NFL-related domestic attacks — at least six other family violence cases in the NFL have been reported since 2010 — Goodell met with the player’s union to discuss possible solutions. 

Yet even as the league was taking steps to help mentally troubled players and their families, the Kansas City Chiefs were aware of Belcher's problems, Kansas City police spokeswoman Sgt. Marisa Barnes told NBC News.

And Police Sgt. Richard Sharp told the Kansas City Star that team officials "were bending over backwards" to help the couple.

The Belcher murder-suicide is the type of nightmarish incident the league has been working harder to prevent, said Robert Gulliver, the NFL’s executive vice president of human resources/chief diversity officer. 

“One of the biggest things that we are trying to do here (in the NFL) is to change the culture, where people realize that it’s OK to seek out help for mental health issues,” Gulliver told NBC News. “We were very deliberate in ... making the point that mental health is part of total wellness, that it’s OK to seek out help for mental health issues because that’s part of your overall well-being."

In addition to help from the team's counselors, Belcher and his girlfriend Perkins, who was mother of his 3-month-old daughter and shared his home, would have had access to the hotline and the league's mental health program. 

At the end of July, the NFL emailed information on its new crisis line and on the league's available mental-health help to the home of every NFL player, Aiello said, adding: "The information is sent with the idea that the player's wife also sees it. If a player's girlfriend sees it, it would be the same thing."

What's more, all 32 NFL teams employ a player development director to help encourage use of the programs, Aiello said.

In addition, the NFL Players Association — the labor union for players — staffs its own 24-hour, toll-free hotline for players to use "if they need any support whatsoever," said George Atallah, NFLPA spokesman. "If a player has an alcohol-addiction problem (for example), he calls in and we route that call to a facility near them, and (facility members) then come pick him up and give him the assistance he needs. That goes for any depression issues and mental health issues." The NFLPA also offers counseling services to players, and it employs a group of retired players "to get a pulse of what’s going on in the locker rooms, handle situations confidentially, and provide support when necessary."

As part of what the NFL calls its “new comprehensive health program” — formally dubbed NFL Total Wellness — Goodell and the league worked with former U.S. Surgeon General David Satcher last summer to strengthen its mental health tools and assistance. The new program encourages players and their families to seek support for behavioral issues, provides health and safety information and offers confidential, free advice via telephone and the Internet. That aid is available to all players and “all members of the NFL family” who find themselves “in times of need,” the NFL says. The same experts who operate the "NFL Life Line" run a similar emergency system for members of the U.S. military.

However, even with best intentions, the NFL remains essentially an elite club in which players have long been trained to hide physical pain — if not injuries — to keep their jobs. That environment could keep players from truly opening up about possible symptoms of depression, anxiety or other mental-health woes.

Gulliver declined to say how many players have phoned the hotline and tapped into the league’s enhanced mental-health program via the web since its launch.

"We don’t publicize the actual usage or percentage numbers," Gulliver said.

As the program has become more widely known by players, however, Satcher said: "The usage of it is increasing."

Gulliver wouldn't comment whether Belcher, his family, friends or any Chiefs players called the crisis line ahead of the murder- suicide, or tried to contact the league’s new mental health services professionals about Belcher.

“That, too, is information that we do not publicize. There are lots of privacy laws that we make sure we uphold. The program is actually administered by the third-party provider so it’s not information that comes into the NFL office. We wanted this to be independent and completely confidential for the members for the NFL family," Gulliver said. 

He added: "Our hearts really hurt for the tragedy that has played out in Kansas City. And we absolutely want to make sure that we provide resources so that people realize there is another way that they can get the help that they need."

Seau’s suicide last May served as the ultimate spark for the new hotline and the league's extra mental-health measures.

“It really did prompt us to step back and say: What more could we be providing for our players and for the NFL family?” Gulliver said. 

But even with a beefed-up program available to players and their spouses, it's difficult to predict this kind of tragedy, Satcher said, adding: "I don’t know that anybody could." 

The American Foundation for Suicide Prevention lists warning signs that someone may be considering suicide due to depression:

• Relentlessly low mood; pessimism; hopelessness; desperation; anxiety or inner tension
• Withdrawal; sleep problems
• Increased alcohol and/or other drug use
• Recent impulsiveness and taking unnecessary risks; threatening suicide or expressing a strong wish to die
• Making a plan; giving away prized possessions
• Sudden or impulsive purchase of a firearm; obtaining other means of killing oneself such as poisons or medications
• Unexpected rage or anger.

Anyone can call the National Suicide Prevention Hotline at 1-800-273-8255.

During the planning meetings for the NFL’s revamped mental-health platform, Satcher said he and league leaders discussed the hot-button issue of chronic concussions sustained by NFL players — and the behavioral instability those injuries are known to carry.

“The brain is a delicate organ and, therefore, head-to-head contact can no longer be viewed as acceptable. The hits start early - in junior high and high school," said Satcher, head of the Satcher Health Leadership Institute at the Morehouse School of Medicine in Atlanta. 

Satcher called the NFL's around-the-clock telephone “lifeline” and the other added mental-health backstops “a major advance” for the league.

Since 2010, these high-profile domestic violence cases have involved NFL players:

• Chad Johnson was released by the Miami Dolphins during the team’s 2012 training camp after the receiver was arrested in early August for allegedly striking his wife in the head.
• Erik Walden, a Green Bay Packers linebacker, was jailed during Thanksgiving 2011, originally charged with a felony after he allegedly assaulted his girlfriend. Later, he received a deferred judgement and agreed to do community service work.
• Dez Bryant, a receiver for the Dallas Cowboys, was arrested in July after allegedly shoving his mother. He was charged with a misdemeanor.
• Seau, a linebacker who spent most of his career with the San Diego Chargers, allegedly assaulted his girlfriend in 2010, two years before he shot himself to death.
• Chris Cook, a cornerback for the Minnesota Vikings, was arrested in October 2011 for domestic violence after he allegedly choked his girlfriend. He was acquitted at trial.
• Brandon Marshall, a wide receiver for the Chicago Bears, has a history of domestic crimes dating back to 2004. In March, he was accused by a 24-year-old woman of punching her in the eye. Marshall’s attorney said Marshall’s wife was the woman injured and that Marshall was a victim in the assault.

The National Suicide Prevention Hotline number is 1-800-273-8255.

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Members of the military exposed to blasts in combat can develop the same brain disease as professional athletes who experience multiple concussions, a new study suggests.

Researchers found evidence of chronic traumatic encephalopathy, or CTE, in the brains of all four deceased U.S. military veterans they examined. The men were exposed to blasts or to multiple concussions during combat.

CTE is a degenerative brain disease previously seen mainly in professional athletes, including boxers, hockey players and football players. It is usually caused by repeated blows to the head, but results from the new study suggests that exposure to a single blast equivalent to that of a improvised explosive device (IED) can result in CTE. The condition causes symptoms such as impaired learning and memory, and has been linked with suicide, the researchers said.

"Our study, for the first time, shows military personnel that have experienced blast exposure exhibit CTE that's basically indistinguishable from the athletes we've looked at," said study researcher Patric Stanton, a cell biology professor at New York Medical College in Valhalla, N.Y.

The findings indicate that brain injuries with different causes — concussions and exposure to blasts — may trigger the same disease in the brain, Stanton said.

The link between CTE and suicide can be seen in the case of former National Football League star Dave Duerson, who committed suicide last year. An examination of his brain after his death revealed he had CTE, as he suspected. CTE has also been suspected of playing a role the suicide of NFL player Junior Seau earlier this month.

The new findings suggest that blasts on the battlefield may lead to suicidal thoughts in veterans, Stanton said. Blasts may be a factor in the recent rise in military suicides, he said, and researchers should investigate this..

Degenerative brain disease
The researchers analyzed the brains of four male military veterans, ages 22 to 45 (CTE can be diagnosed only after death). Three of the men had been exposed to at least one blast from an IED, and two of them had concussions earlier in life. One soldier experienced four concussions throughout his life, although he was not exposed to a blast.

All the men had symptoms such as headaches, irritability, difficulty sleeping, depression and short-term memory loss.

One man died from a brain aneurysm, one from a brain hemorrhage and one from a self-inflicted gunshot wound. The fourth man inhaled foreign material while under the influence of pain medication and later died from lung complications. About two years had passed between their last brain injury and their death.

The researchers also examined the brains of three football players, a professional wrestler and four men of similar ages with no history of blast exposure or concussions.

Signs of CTE were seen in the brains of the military veterans and the professional athletes. One characteristic of CTE is abnormal deposits of a protein called tau, which can kill brain cells, Stanton said.

Mouse model
It can be difficult to say whether CTE was definitely caused by a blast, by previous events in a person's life, or a combination of both, Stanton said.

To study CTE in a more controlled environment, the researchers created a mouse model and simulated blasts from an IED.

The rapid movement of air that occurs after an explosion may play the biggest role in causing blast-related brain injuries, Stanton said. This blast wind can be stronger than the winds of a hurricane, and can rapidly shake the head back and forth, compressing the brain, Stanton said.

About two weeks after exposure to a simulated blast, the mice showed learning and memory problems. These problems were averted when the animals' heads were prevented from moving during the blast, the researchers said.

The findings provide a new pathway for developing methods to prevent blast-related brain injuries, the researchers said.

The study is published today (May 16) in the journal Science Translational Medicine. Study experiments were conducted by researchers at Boston University, New York Medical College and the Veterans Affairs Boston Healthcare System.

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Stephen Dunn / Getty Images

Junior Seau, former linebacker for the San Diego Chargers, was found dead in his home Wednesday in what police are calling an apparent suicide.

Former NFL star Junior Seau’s death on Wednesday is fueling debate over whether football’s big hits leave some players with lingering brain damage that can lead to depression and possibly even suicide.

The police have yet to determine whether the 43-year-old linebacker did, in fact, commit suicide. But because his death follows so closely on the heels of two high-profile suicides in former NFL defensive backs, many are wondering if the concussions Seau sustained during his 20 years as a hard-hitting star, known mostly for his stint with the San Diego Chargers, including the 1994 Super Bowl team, were implicated in his death. 

In February 2011, former Chicago Bear Dave Duerson committed suicide at age 50, choosing to shoot himself in the chest so that scientists could look for signs of chronic traumatic encephalopathy (CTE), a brain disease linked to head blows that can culminate in dementia and other symptoms. And just last month, former Atlanta Falcon Ray Easterling, who had sued the NFL for mismanaging players’ concussions, shot and killed himself at age 62.

Experts interviewed by msnbc.com were mixed in their opinions on whether Seau’s concussions could have led to his apparent suicide. All agreed that there should be more research on the impact of head injuries on the risk for depression and suicide.

“I think the evidence is very strong in both human and animal studies that repeated concussions that occur very close in time can result in depression and other emotional disorders that can lead to suicide,” said David Hovda, a professor of neurosurgery and director of the University of California, Los Angeles, Brain Injury Research Center. “Whether they are the sole reason for the suicide, I don’t think can be determined.”

Hovda believes it’s possible that Seau shot himself in the chest so that he, like Duerson, might leave his brain for scientists to study.

Dr. Douglas Smith was more cautious.

“There’s beginning to be an assumption that repeated exposure to head injuries can make you suicidal,” said Smith, a professor of neurosurgery and director of the Center for Brain Injury and Repair at the Perelman School of Medicine at the University of Pennsylvania. “It’s certainly suspicious and something that we should absolutely look into.”               

But Smith cautioned that people shouldn’t assume that concussions will always lead to permanent brain damage. “There are many highly functioning individuals who have had a series of concussions -- captains of industry, politicians -- who are doing very well,” he said.

The issue is a lot more murky for Pittsburgh Steelers' team neurosurgeon, Dr. Joseph Maroon, who was quick to point out the high incidence of depression among Americans who haven’t ever had an injury to their brains.

“Depression is one of the most common diseases that affect people in the United States,” said Maroon, a professor of neurosurgery and the Heindl Scholar in Neuroscience at the University of Pittsburgh. “Some 10 to 15 percent of American who have not played football will have pathologic depression at some time in their lives. The most commonly prescribed drugs in the United States are antidepressants.

“Given that, we also know that there may be a relationship in some individuals between multiple blows to the head, or even a single blow to the head, that can result in abnormal and pathological behavior. In an individual case, in this one for instance, from what I’ve read so far, I don’ t think there’s any way you can definitively say that this was directly related to football.”

Nevertheless, Maroon said, people are taking concussion damage far more seriously these days. “There’s been a major cultural shift in the recognition and appreciation of post-concussive effects,” he said.

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Sanford Myers / AP

Some parents are reconsidering whether to let their kids play youth hockey because of the risk of serious injuries. Bioethicist Art Caplan says they have a point.

The NHL hockey playoffs are under way. The contact is fierce and the fans love it. I do, too. But there is big trouble brewing for the future of hockey, football and other contact sports -- concussions. If hockey does not change, it has a dim future. Not because of the injuries being suffered by professional players but because of parents trying to do the right thing by keeping their kids away from a dangerous sport.

The rates of injury in youth hockey, especially concussions, are frightening. Among some 9,000 11- and 12-year-old players in Alberta, Canada, there are some 700 concussions in a season, as the New York Times reported in 2010. They are so bad, it is hard to imagine a parent letting a kid play contact hockey. 

Given what is being learned about the long-term damage caused by concussions, how long will parents be willing to let their kids play hockey? Not long, I think.

The number of kids playing contact hockey in Canada is, according to recent studies, dropping. It is easy to see why. With high-profile stars such as Sidney Crosby, Chris Pronger, Claude Giroux, Zbynek Michalek, Jeff Skinner and Mike Richards all sidelined this season for long stints because of concussions, what is a parent to think about encouraging a child to play? The Canadian Medical Association in a just-published article asks a question that parents will dread and the NHL won’t like: “Hockey concussion: Is it child abuse?” The answer for many parents seems to be: yes.

If you listen to sports talk radio, the airwaves are full of hosts and callers decrying the "wussification" of hockey -- and football, too.  "You cannot take the big hits out of these games without destroying them," the lamentation goes. 

Perhaps. But how many parents are going to let their kids play a game trying to emulate their heroes when the icons are regularly getting their bells rung? It is one thing to face the risk of brain damage as an adult to get a big paycheck. It is another thing for a parent to watch a school-age son get smacked in the head with a stick or have his head knocked into the boards. Parents increasingly are going to feel they ought not let their kids play. 

Think I am wrong? Shift over to football.

Not so long ago, I had a chance to talk to former NFL pro middle linebacker Harry Carson, who played with distinction for the New York Giants. I asked him if he would want his son to play college or pro football.  He said no, that the game is far too dangerous. The risk of concussion in the game now makes encouraging a kid to play football irresponsible.

Parents are in a horrific bind. Their kids want to play contact sports but their coaches want them to emulate the pros. Oversight groups make noises about a safer game, but the concussion rate grows and grows. Parents want their kids to play sports to keep them out of trouble and to encourage habits and virtues that will help them later in life. But they certainly don't want to see them with headaches, memory loss and learning difficulties later on, either.

The industry that is contact sports in North America is not going away any time soon. But it is in trouble, even if few are willing to say so. If the NHL and NFL cannot make their games safer, those who insist on the big hits will find fewer pros available to play because more parents will chose safety over risk. As evidence grows about the toll concussions take on the pros, the chance that a parent will let a child take those risks gets smaller every day.

Should youth sports emulate the pros? Do you think games like contact lacrosse or hockey can be made safer for kids? Share your thoughts on Facebook

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Arthur Caplan, Ph.D., is a professor in the Department of Medical Ethics and Health Policy at the University of Pennsylvania.