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In the words of sports journalist Jourdan Rodrigue, “Football is a merciless churn” — one that doesn’t subside even after those blessed to play the sport at the highest level have hung up their cleats. Although it has been a longstanding colloquialism that the NFL actually stands for “Not For Long,” the impacts of playing the sport can be life-long. Heightened by social media, the glitz and glam of fame and fortune mask the stark realities of life after football – the injuries, the cognitive challenges, the identity struggles, and the mental health effects.

For many players, football has been a part of their lives for as long as they can remember, and consequently form a large part of their identity. When the glory on the gridiron is gone, a search for purpose often ensues according to Marlene Holmes, Ph.D Candidate, MSW, who works with current and former athletes on post-career mental health. “Transitioning and accepting the loss of your athletic identity is a psychological process. Never forget your journey of becoming an athlete typically required support, practice, and consistency,” she says. “Let a therapist be your new coach and help you unfold layers that will mentally and emotionally contribute to your healthy lifestyle. You may have won some games, races, or even championships, but committing to your mental health is the win of a lifetime.”

That quest becomes even more difficult when debilitating injuries hinder the mind and body. With a sport as physical as football, injuries are basically a non-negotiable part of the game. Lingering aches and pains can contribute to depression and anxiety. However, within the sports world, there is a stigma rooted in the idea that a lapse in mental health equates to weakness. In a memoir for The Players Tribune, former NFL player Brandon Marshall stated, “When I first heard the term ‘mental health,’ the first thing that came to mind was mental toughness. Masking pain. Hiding it. Keeping it inside. That had been embedded in me since I was a kid. Never show weakness. Suck it up. Play through it. Live through it.”

Some aren’t lucky enough to live through it. In fact, according to the Indiana Law Journal, suicide is the third leading cause of death for athletes. A rash of recent NFL suicides and violent streaks have been determined to be caused in part by Chronic Traumatic Encephalopathy, referred hereafter as CTE. It is a progressive and fatal disease associated with repeated traumatic brain injuries such as concussions. While concussions are the most common injury suffered in the NFL, the league’s doctors have been adamant that football is not directly associated with CTE. It’s hard to argue otherwise when you factor in the deaths of Junior Seau, Jovan Belcher, Andre Waters, Mike Webster, and Ray Easterling – whom all suffered from CTE. All of the aforementioned players, excluding Webster, died of self-inflicted gunshot wounds. He was the first football player to be diagnosed with CTE and died of a heart attack at the age of 50 after years of depression.

Known for his toughness, the former athlete played 17 years in the NFL and was known as “Iron Mike” due to his toughness. Within years of his retirement, his mental health plummeted into dementia, frightening his wife and children. He self-harmed by using a taser on himself to render himself unconscious and he tried to glue his teeth back in with super glue after they had fallen out. Pathologist Bennet Omalu conducted over a month of research on Webster’s brain after his death and arrived at the conclusion that he suffered from CTE. The disease produces abnormal proteins that clog up the brain, destroying healthy cells. Brain function is interrupted causing a multitude of issues such as memory loss, impaired judgment, difficulty controlling impulses, aggression, depression, and suicidal tendencies.

Such bouts of aggression and violent impulses put other people close to CTE victims at risk such as in Belcher’s case. The former Kansas City Chiefs linebacker shot Kasandra Perkins, his girlfriend and the mother of his then three-month old daughter, nine times before killing himself in front of his head coach and general manager. Ironically, he had been active in Male Athletes Against Violence, an organization that urged jocks to speak out against abusive acts. But, concussions suffered over the course of his short career took their toll and evidence of CTE was discovered during his autopsy.

While these are all tragic, the case of Aaron Hernandez may arguably have been the most publicized. The former New England Patriots tight end was in the prime of his career when he was charged and convicted of the murder of Odin Lloyd, who was dating the sister of Hernandez’ girlfriend. He later stood trial for a double homicide while serving his sentence for Lloyd’s murder. Days after being acquitted on the double murder case, he committed suicide in his jail cell. He too was diagnosed posthumously with CTE.

More recently, tragedy struck once again in Rock Hill, South Carolina where former NFL player Phillip Adams killed five people before taking his own life. On the afternoon of April 7, he went to the home of Dr. Robert Lesslie and killed the doctor, his wife, their two grandchildren, and a man who was doing some work at the home. Adams was found dead from a self-inflicted gunshot would a few houses away. While no conclusion has been made, it is suspected that CTE may have played a part in the deadly rampage. The former defensive back had previously been under the care of Dr. Lesslie.

So, what is the NFL going to do about it? The league continues to catch slack for not putting their players first, whether it was staying mum on social justice issues and systemic racism or failing to support players after their careers end. Their disability program won’t gain them any more likeability. Mike Freeman recently tackled the subject for USA TODAY. Former Minnesota Vikings offensive lineman Brent Boyd used this phrase to describe the program: “Delay, deny, and hope we die.” Ouch.

Adams’ sister Lauren told USA TODAY Sports that her brother struggled to get treatment for his mental health issues through the program and felt he was getting the run around, contributing to his “me against the world” feeling in his final days. Now, this is no way, shape, form, or fashion alludes to the NFL being responsible for Adams’ heinous acts, but it does shed light on the deficiencies of the league’s post-career support. The previously mentioned Webster had to take the league to court for only receiving partial disability payments. The ruling that the Steelers Hall of Famer was rendered completely and permanently disabled as a result of his brain injuries while in the NFL did not come until four years after his death.

Somehow the NFL has remained a billion dollar industry even with the dangers of concussions and CTE weighing on the minds of parents and athletes alike. The league has made changes to the rule book and to equipment in efforts to make the game safer. These moves include stricter targeting guidelines, elimination of the blindside block, and kickoff rule changes. It was found that concussions decreased 35% in the immediate season following the rule change. However, helmets and cosmetic changes don’t tackle the underlying problem. Not all progress to CTE, but physical limitations that negatively affect the quality of life for former players need to be addressed as they weigh heavily on the psyche and can become a breeding ground for mental health issues.