The NCAA Committee on Competitive Safeguards and Medical Aspects of Sports acknowledges the significant input of Sam Maniar, Licensed Psychologist, Ohio State University; Margot Putukian, Team Physician, Princeton University, and the National Institute of Mental Health, Bethesda, Maryland; for their original content.
Depression is more than the blues, let-downs from a game loss, or the normal daily ups and downs. It's feeling "down" and "low" and "hopeless" for weeks at a time. Depression is a serious medical condition.
Little research has been conducted on depression among student-athletes; however, preliminary data indicate that student-athletes experience depressive symptoms and illness at similar or increased rates than non-athlete students. Approximately 9.5 % of the population - or one out of 10 people - suffer from a depressive illness during any given one-year period. Women are twice as likely to experience depression as men; however, men are less likely to admit to depression. Moreover, even though the majority of people's depressive disorders can be improved, most people with depression do not seek help.
Depression is important to assess among student-athletes because it impacts overall personal well-being, as well as athletic performance, academic performance and injury healing. No two people become depressed in exactly the same way, but with the right treatment 80 percent of those who seek help get better, and many people begin to feel better in just a few weeks.
Depression and Intercollegiate Athletics
Student-athletes may experience depression because of genetic predisposition, developmental challenges of college transitions, academic stress, financial pressures, interpersonal difficulties and grief over loss/failure.
Participation in athletics does not provide student-athletes any immunity to these stresses, and if has the potential to pose additional demands. Student-athletes must balance all of the demands of being a college student along with athletics demands. This includes the physical demands of their sport, along with the time commitment of participation as well as strength and conditioning and skill instruction.
Most athletes participate almost year-round, often missing holidays, school and summer breaks, classes and even graduation. In addition, if they struggle in their performance, have difficulty interacting with the coach or teammates, or if they lose their passion for their sort, if can be very difficult to handle. In addition, many athletes define themselves by their role as an athlete, and an injury can be devastating.
Some attributes of athletics and competition can make it extremely difficult for student-athletes to obtain help. They are taught to "play through the pain," struggle through adversity, handle problems on their own, and "never let your enemies see you cry." Seeking help is seen as a sign of weakness, when it should be recognized as a sign of strength.
Team dynamics also may be a factor. Problems often are kept "In the family," and it is common for teams to try to solve problems by themselves, often ignoring signs or symptoms of more serious issues. Depression affects approximately 19 million Americans, and for many, the symptoms first appear before or during college.
Early identification and intervention (referral/treatment) for depression or other mental illness is extremely important, yet may be inhibited within the athletics culture for the following reasons:
- Physical illness or injury is more readily measured and treated within sports medicine, and often there is less comfort in addressing mental illness.
- Mental wellness is not always perceived as necessary for athletic performance.
- The high profile of student-athletes may magnify the attention paid on campus and in the surrounding community when an athlete seeks help.
- History and tradition drive athletics, and can stand as barriers to change.
- The athletics department may have difficulty associating mental illness with athletic participation.
Enhancing knowledge and awareness of depressive disorders
Sports medicine staff, coaches and student-athletes should be knowledgeable about the types of depression and related symptoms. Men may be more willing to report fatigue, irritability, loss of interest in work or hobbies, and sleep disturbances rather than feelings of sadness, worthlessness, and excessive guilt, which are commonly associated with depression in women. Men often mask depression with the use of alcohol or drugs, or by the socially acceptable habit of working excessively long hours.
Types of Depressive Illness
Depressive illnesses come in different forms. The following are general descriptions of the three most prevalent, though for an individual the number, severity and duration of symptoms will vary.
Major depression, or "clinical depression," is manifested by a combination of symptoms that interfere with a person's once pleasurable activities (school, sport, sleep, eating, and work). Student-athletes experiencing five or more symptoms as noted in Table 1 for two weeks or longer, or noticeable changes in usual functioning, are factors that should prompt referral to the team physician or mental health professional. Fifteen percent of people with major depression die by suicide. The rate of suicide in men is four times that of women, though more women attempt it during their lives.
Dysthymia is a less severe form of depression that tends to involve long-term, chronic depressive symptoms. Although these symptoms are not disabling, they do affect the individual's overall functioning.
Bipolar Disorder, or "manic-depressive illness, "involves cycling mood swings from major depressive episodes to mania. Depressive episodes may last as little as two weeks, while manic episodes may last as little as four days. Manic sign and symptoms are presented in Table 2.
In addition to the three types of depressive disorders, student-athletes may suffer from an Adjustment Disorder. Adjustment disorders occur when an individual experiences depressive (or anxious) symptoms in response to a specific event or stressor (e.g., poor performance, poor relationship with a coach). An adjustment disorder can also progress into major, depressive disorder.
Establishing a relationship with mental health services.
The UNLV Counseling and Psychological Services (CAPS) provide mental health resources for our student-athletes. Because student-athletes are less likely to utilize counseling than non-athlete students, increasing interaction among mental health staff members, coaches and student-athletes will improve compliance with referrals.
Screening for depression
One way to ensure an athletics department is in tune with student-athletes' mental well-being is to systematically include mental health check-ups, especially around high-risk times such as the loss of a coach, significant injury, being cut from the team and catastrophic events. Members of the sports medicine team and/or licensed mental health professionals should also screen athletes for depression at pre-established points in time (e.g., pre-participation, exit interviews). Research indicates that sports medicine professionals are better equipped to assess depression with the use of appropriate mental health instruments; simply asking about depression is not recommended.
A thorough assessment on the part of a mental health professional is also imperative to differentiate major depression from dysthymia and bipolar disorder, and other conditions, such as medication use, viral illness, anxiety disorders, over-training and illicit substance use. Depressive disorders may co-exist with sub stance-abuse disorders, panic disorder, obsessive-compulsive disorder, anorexia nervosa, bulimia nervosa and borderline personality disorder.
For depression screening, it is recommended that sports medicine teams utilize the Center for Epidemiological Studies Depression (CES-D) Scale published by the National Institute for Mental Health (NIMH). The CES-D is free to use and available at www.nimh.nih.gov. Other resources include such programs as QPR (Question, Persuade, and Refer) Gatekeeper training; the Jed Foundation U lifeline; and the Screening for Mental Health Depression and Anxiety Screenings. Information about these programs, and ways to incorporate them into student-athlete check-ups, can be found at NCAA.org/health-safety.
Most individuals who suffer from depression will fully recover to lead productive lives. A combination of counseling and medication appears to be the most effective treatment for moderately and severely depressed individuals. Although some improvement in mood may occur in the first few weeks, it typically takes three to four weeks of treatment to obtain the full therapeutic effect. Medication should only be taken and/or stopped under the direct care of a physician, and the team physicians should consult with psychiatrists regarding complex mental health issues.
A referral should be made to a licensed mental health professional when coaches or sports medicine staff members witness any of the following with their student-athletes:
Coaches and athletic training staff members should follow the following guidelines in order to help enhancing student-athlete compliance with mental health referrals:
- Suicidal thoughts.
- Multiple depressive symptoms.
- A few depressive symptoms that persist for several weeks.
- Depressive symptoms that lead to more severe symptoms of destructive behaviors.
- Alcohol and drug abuse as an attempt at self treatment.
- Overtraining or burnout, since depression has many of the same symptoms.
The following self-help strategies may improve mild depression symptoms:
- Express confidence in the mental health professional
- Be concrete about what counseling is and how it could help
- Focus on similarities between the student-athlete and the mental health professional
- Offer to accompany the student-athletes to their initial appointment.
- Offer to make the appointment (or have the student-athlete make the appointment while in your office.
- Emphasize the confidentiality of medical care and the referral process.
Table 1 Depressive Signs and Symptoms
Individuals might present:
- Reduce or eliminate the use of alcohol and drugs.
- Break large tasks into smaller ones; set realistic goals.
- Engage in regular, mild exercise.
- Eat regular and nutritious meals.
- Participate in activities that typically make you feel better.
- Let family, friends and coaches help you.
- Increase positive or optimistic thinking.
- Engage in regular and adequate sleep habits.
Individuals might express:
- Decreased performance in school or sport.
- Noticeable restlessness.
- Significant weight loss or weight gain.
- Decrease or increase in appetite nearly every day.
Table 2 Manic Signs and Symptoms
Individuals might present
- Feeling sad or unusually crying.
- Difficulty concentrating.
- Lack of or loss of interest or pleasure in activities that were once enjoyable.
- Depressed, sad or "empty" mood for most of the day and nearly every day.
- Recurrent thoughts of death of thoughts about suicide.
- Frequent feeling of worthlessness, low self-esteem, hopelessness, helplessness or inappropriate guilt.
Individuals might express
- Abnormal or excessive elation.
- Unusual irritability.
- Markedly increased energy.
- Poor judgment.
- Inappropriate social behavior.
- Increased talking.
Using a simple tool such as this can help students and staff look for signs of depression.
Put a check mark by each sign that sounds like you:
- Racing thoughts.
- Increased sexual desire.
- Decreased need for sleep.
- Grandiose notions.
- I am really sad most of the time.
- I don't enjoy doing the things I've always enjoyed doing.
- I don't sleep well at night and am very restless.
- I am always tired. I find it hard to get out of bed.
- I don't feel like eating much.
- I feel like eating all the time.
- I have lots of aches and pains that don't do away.
- I have little to no sexual energy.
- I find it hard to focus and am very forgetful.
- I am mad at everybody and everything.
- I feel upset and fearful, but can't figure out why.
- I don't feel like talking to people.
- I feel like there isn't much point to living, nothing good is going to happen to me.
- I don't like myself very much. I feel bad most of the time.
- I think about death a lot. I even think about how I might kill myself