Chronic traumatic encephalopathy (CTE) is a unique neurodegenerative tauopathy 1 associated with repetitive head impacts (RHIs). 2 By definition, CTE is a neuropathological diagnosis, 1,3 and it has been frequently diagnosed in deceased American football players. Traumatic encephalopathy syndrome (TES) represents research diagnostic criteria for the clinical syndrome of CTE neuropathology. 4 Initial TES criteria, published in 2014, were highly sensitive and poorly specific. 5 A 2021 revision of TES attempted to improve specificity 4 ; however, its validity is being evaluated and is not currently recommended for clinical practice. Core clinical features include cognitive impairment and/or neurobehavioral dysregulation while supportive features include various psychiatric symptoms. Suicidality was a supportive feature of the 2014 TES criteria. Due to the absence of evidence directly linking CTE neuropathology and suicidality, it was not included in the 2021 criteria. Brain bank studies investigating CTE neuropathology have shown suicide to be a common cause of death, 6 raising the question of whether suicidality is a symptom and/or a function of selection bias as autopsies are often performed after suicide. There have been several public-facing cases of high-profile football players who have died by suicide. Overall, some contend there is a public perception that an association between CTE neuropathology and suicide/suicidality exists. There is concern that people who play or played American football and develop psychiatric symptoms might attribute them to CTE neuropathology when in fact it may or may not be related and there is opportunity for treatment and hope.In this issue of JAMA Neurology, Grashow et al 7 examined the association between perceived CTE and various clinical correlates including suicidality among 1980 former professional American football players. The participants are from the Football Players Health Study (FBHS), which enrolled 4180 football players who played in a professional league between 1960 and 2020 (n = 15 011). For the current study, 1980 (about 47% of eligible participants) had follow-up surveys and were asked, "Do you believe you have chronic traumatic encephalopathy (CTE)?" with those responding yes classified as having perceived CTE. While we use perceived CTE in this Editorial to align with the study, we do not encourage continued use of this terminology until validation is conducted. Of the participants who responded, 681 (34.4%) were classified as having perceived CTE with the strongest predictors of perceived CTE being subjective cognitive difficulties, followed by low testosterone, greater concussion burden from football, symptoms of depression, emotional and behavioral dyscontrol symptoms, and pain intensity. The participants with perceived CTE were more likely Related article Opinion EDITORIAL jamaneurology.com (Reprinted) JAMA Neurology
