Suicide is a predominantly male problem in western culture (1). And in the United States something like 4-5 men take their own lives for every woman who does the same (2). With the female rugby community representing around 10-15% of the total and suicide rates being so overwhelming skewed towards men, I’m sure our female readers will forgive me this one time.

The cliche is true, rugby is a family

We need to talk about suicide because outside my direct family, the guys I play rugby with are the most important people in my life. In no particular order, here are some of the things my rugby-playing mates have done for me in my relatively short time on this earth:

Babysat my daughter

Found me a place to live

Invested in my businesses

Handed me cash when I was struggling financially

Helped my family sell and move furniture

Let me stay with them for extended periods

Supported my immigration petitions

Paid for my tertiary education

Helped me through addiction problems

Taken me to hospital when I’ve suffered injuries

That’s not just one club either. I’ve played for 4 different clubs and the level care, love and support I’ve gotten at all of them was comparable. I dare say anyone reading this could say the same if not more about the rugby clubs and teammates that they’ve played with in their lives. There are things that I can ask for help with from my rugby playing friends that I would NEVER ask of my parents or children. It is a special relationship, one that we all cherish.

Why do our mates choose to leave us forever?

This is a complex question with no simple answer. Every case is different. Depending on the individual, there may be medical, career, relationship, financial or other personal challenges facing any of the guys we play with. But some people are clearly at more risk than others and it’s worth us acknowledging that.

The statistics

Looking just at the US, suicide is:

The 10th leading cause of death

Responsible for 45K deaths per year

Only effective in 4% of attempts (1 in 25)

A $44 B / year cost to the economy

But when we talk about the rugby community there are a couple of other data points we need to think about. In particular that white males accounted for 7 of 10 suicides in 2015 with the rate of suicide highest in middle age — white men in particular. And that Firearms account for almost 50% of all suicides. This is instructive for us in thinking about who the most at-risk members of the rugby community are. Though it might not be immediately obvious, current rugby players are statistically less likely to commit suicide than our retired counterparts.

If we’re going to talk seriously about the problem of suicide in the rugby community, we need to remember that retired players, and those who are forced out through injury at any point in their careers are the most at-risk people we probably know.

Medical problems

CONCUSSION

After almost 15 years of research into the long-term psychological problems associated with Concussion and mTBI, it’s now fairly clear that there is a link between sports concussion and cognitive decline (3). That cognitive decline can take many different forms, the most severe (yet to date still undetectable) is Chronic Traumatic Encephalopathy (CTE). Despite it’s recent notoriety, the diagnosis of CTE isn’t new (4). It was originally given to boxers in the early 1920s who suffered both symptomatic and asymptomatic concussions in the ring. In recent years, a shocking number of ex-football and rugby league players have been diagnosed post-mortem with CTE or have been thought to have CTE while still alive based on currently available medical imaging procedures available for testing mTBI (5)(6)(7).

But while it’s not currently possible to get a definitive diagnosis of CTE in rugby players. We can be on the lookout for friends of ours who are suffering from any of the following symptoms (8):

Memory loss

Confusion

Personality changes (including depression, anxiety and suicidal thoughts)

Erratic behavior (including aggression)

Problems paying attention and organizing thoughts

Difficulty with balance and motor skills

A single concussion is unlikely to lead to suicide. So if a player is knocked unconscious during a game, this doesn’t necessarily mean they need to be watched 24/7. What’s most concerning, however, is the cumulative effect concussions can have on an individual’s cognitive function and feelings of depression and anxiety (9)(10).

Second-impact Syndrome (SIS) is the term given to a second concussion which occurs before the symptoms of the first concussion have subsided. While Repetitive Head Injury Syndrome (RHIS) refers to repeated head trauma that can occur at different interval during a person’s life(11). SIS occurs in rugby players who return to rugby too soon after a concussion injury and then receive another head trauma. While RHIS occurs in rugby players who have received multiple concussion diagnoses during their careers.

I have Repetitive Head Injury Syndrome. I fell from a ski lift landing onto my head in 2001. I was knocked unconscious for around 2mins in a rugby game during 2007 resulting in hospitalization. And I received another blunt force head trauma in 2015. Fortunately, thanks to good coaching and player welfare procedures, I have not suffered SIS.

Cognitive decline as a result of head trauma experienced through SIS and RHIS is a major risk factor for suicide. Players who have experienced either condition during their playing careers are much more likely to suffer from depression. If you or anyone you know has experienced either of these during your careers, I encourage you to seek a professional diagnosis and undergo regular memory and cognitive function tests.

CAREER-ENDING INJURY

There appears to be a direct causal link between head injury and cognitive decline that can result in depression and suicide. But this is by no means the only medical risk factor. Rugby players have all sorts of career-ending injuries completely unrelated to concussion and mTBI. For the front row, these are very often neck injuries as we spoke about earlier this week. For wingers and fullbacks it’s most likely to be chronic hamstring problems. While for the rest of the forward pack, it’s shoulders and knees.

Modern sports medicine has made it much more realistic for even amateur rugby players to return to rugby after major injuries like broken legs and torn ACLs (12)(13). But not everybody makes it back on the field. Some careers are cut tragically short by all kinds of injuries. Very often it’s the player’s doctor who needs to advise them not to continue playing. Other influences might include their family and their employer asking that they give the game away.

I can’t imagine what’s it’s like being told you can’t play rugby anymore. But I’ve known dozens of guys who this has happened to. And I am yet to hear one of them say they don’t miss the sport, the team, the competition and the family. When something as special as rugby is taken away from you because of injury, the results can be devastating. On it’s own, a career ending injury might not be enough to convince a player to take their own life. But it is absolutely a risk factor that we should all be aware of, especially if the player goes into a post-injury state of depression.

DEPRESSION

Most people who attempt suicide are suffering from symptoms of depression at the time (14). But this does not necessarily mean that depression is the only cause of suicide, or even that people who commit suicide have been depressed for an extended period of time. Depression is seldom the sole cause of suicide (15) and is often thought of (like suicide itself) as a symptom of a more significant medical or relationship problem happening in the person’s life at the time.

Depression is also not necessarily a terminal illness. While some people will suffer with depression for much of their lives as a result of childhood trauma (16), others will encounter depression for brief periods as a result of major changes in their life. This is most commonly known as ‘Situational Depression’ which can come about after the loss of a loved one, a career difficulty or a relationship break up. Situational depression can even be affected by geography and is known by the term ‘Seasonal Affective Disorder’ (17).

During winter for example when there is less sunlight, people are more prone to bouts of depression. As you can imagine, seasonal affective disorder is more severe the further away from the equator you go. Long-term depression is incredibly difficult to treat and the best course of action is generally for the patient to see medical professionals who will likely recommend psychotherapy and grief counseling.

In certain circumstances however, the symptoms of Situational Depression can be mitigated with exercise, sunlight and a balanced healthy diet free from alcohol. For members of the rugby community, we need to understand that depression can be temporary but it is a major risk factor for suicide. Fortunately, we all have access to exercise, sunlight and good food. So we have the tools to help any of our mates suffering with Situational Depression (18).

The key to recognizing and assisting a mate with situational depression is to genuinely care about their lives and circumstances and use that knowledge to watch for an increase in alcohol consumption, deterioration in diet or insular behavior. Remember, while not every depressed person will attempt suicide, well above 90% of those who do are suffering from depression-like symptoms.

To better understand what’s actually happening in the mind of a person suffering with depression, this story by Alan Stokes paints a vivid and incredibly sad picture of what it means to live with the debilitating condition (19).

PARALYSIS OR INCAPACITATION

Thankfully, very few rugby players become paralyzed on the field. But it does happen. And in these rare circumstances, suicide is not only incredibly common, but it can be carefully considered and rational approach to being paralyzed. Taking a position on the legalization of euthanasia isn’t something I can do today. But it is worth being aware that some rugby players who become paralyzed will plan, attempt and even ask for assistance with suicide (20).

The most publicized case of assisted suicide in rugby was Daniel James. At the age of 23, Daniel was paralyzed in a training accident in the UK (21). Months later, his parents assisted in his suicide by taking him to the Dignitas clinic in Switzerland. They were later forced to defend their actions (22).

The point of this story is to say that although rugby has gotten much safer in recent years, it does carry risks and in certain circumstances, those risks can result in catastrophic injury. We as a community are constantly seeking to make the game safer. And for the most part I think we’ve done an incredible job. We’ve all but eliminated lifting tackles, changed scrum laws to reduce neck injury risk and put much tougher sanctions on any contact with the head or neck at the tackle (23)(24)(25). But it is impossible to legislate accidents out of existence so the incredibly small chance of a player being paralyzed will remain.

When a player is incapacitated during a rugby game, or even in an off-field accident, there are things we can and must do to help them. While medical professionals will be able to take care of the person’s physical well being, their home life will change forever. They’ll need changes made to their home, workspace and relationships. You can help with all of those things if you so choose. There are also numerous resources for the newly paralyzed which can help you in dealing with a mate who has been injured. And perhaps fortunately there is the option that they can continue to play rugby after paralysis (26)(27).

Career and financial problems

TRANSITIONING OUT OF PLAYING RUGBY

All rugby careers end in one way or another. As I outlined earlier, injuries can be an awful way for this to happen. But even if you don’t blow out your knee for the 3rd time, your rugby career will still come to an end one day. For us mere mortals, who have played club rugby our whole lives, the transition from weekend warrior to high-school coach probably isn’t all that severe.

But in recent weeks, it’s become quite obvious that the higher the highs you reach as a rugby player, the lower the lows when your career comes to an end. Hearing about Dan Vickerman’s recent passing was a very sobering experience. Dan was, from all reports, a lovely, articulate and caring guy. It’s also important to understand that at this stage, we do not know if his death was as a result of suicide (28).

What we do know is that Dan, like many elite rugby players, expressed to his mates that he had struggled at times with life after rugby (29). Many top level athletes go through periods of situational depression when their careers end. The need to compete is incredibly instinctual. To have performed at the top level of your sport for over a decade and see that disappear must be a frustrating experience. Former international players like Rory Lamont and Andy Powell have each come out and described the challenge of life after rugby with heartbreaking clarity. “Coming out of rugby, my world pretty much collapsed.” says Lamont.

It seems that for some, staying “involved in the game” might not be enough either. In recent years, Vickerman has been a student at Cambridge University, a successful property developer and most recently the chairman of a joint Australian Rugby Union and Rugby Union Players’ Association committee dedicated to player development.

It’s been made painfully clear this week that when rugby players retire, they are more at risk of depression and suicide. So as friends and teammates, we need to stay vigilant when we see or hear that someone is struggling with this transition. Playing careers end. But the rugby community is not going anywhere. Understanding that retiring players are at risk means we at least know who to watch out for.

If you’re a current or recently retired rugby player who suffers with depression, it’s absolutely critical that you know two things:

1. You are not alone.

Men are bad at talking about how we feel and even worse at making ourselves vulnerable socially. So the natural inclination is to keep things close to the chest for fear of judgment or criticism. Being the ‘strong, silent type’ is almost a status symbol in modern culture. The challenge this creates for all of us socially is that by staying silent, we don’t allow others to feel safe sharing their experiences. But even though guys aren’t sharing, it seems they’re suffering in silence. Studies suggest that as many as 25% of retired athletes will battle with depression at the end of their careers (30). But it’s not just retired professionals. In the United States, upwards of 8% of retired college athletes will show depression symptoms post-graduation (31). Depression is unbelievably common, you are not alone.

In response to Dan Vickerman’s sad passing, All Black great John Kirwin offered some thoughts (32) on his own issues post-retirement and urged anyone with depression to seek a professional diagnosis for their condition: