When They’re Down

Contrary to popular belief, student-athletes are no less susceptible to depression than anyone else. It’s critical that athletic trainers know the warning signs and how to assist.

By David Hill

David Hill is an Assistant Editor at Training & Conditioning.

Training & Conditioning, 12.9, December 2002, http://www.momentummedia.com/articles/tc/tc1209/whendown.htm

Last fall, a sample of student-athletes at New Jersey’s Rowan University were given a questionnaire about stress they faced in their lives. The survey asked each athlete if any of certain major life events had happened to him or her in the past year, and if so, to rate the intensity of each on a scale of 1 to 4.

The survey was a research inquiry for Douglas Mann, DPE, ATC, Director of Athletic Training at Rowan. But for one young woman, a lacrosse player, it may have been a lifeline.

“Her negative numbers were off the scale,” recalls Mann. After some major events at home, her survey results suggested she was at risk for suicide. So during her next visit to the athletic training room, Mann asked if they could talk.

“We talked about five minutes. She was hysterical and crying. I eventually referred her to someone with the skills to carry it on,” he says. She first went to the campus counseling center, then was sent to a psychiatrist. “When I saw her this summer, she was doing great.”

Although Mann was not looking to immediately save anyone’s life in doing his research, he may have. And, just as important, he found out that an athlete can be suffering from depression without anyone knowing.

Despite student-athletes’ talents, determination, willingness to work hard, and history of excelling, they are no less susceptible to depression than anyone else. And as the health professional working closest to them, athletic trainers have a unique opportunity and responsibility to see that their mental health is cared for, along with their muscles and bones.

No one’s suggesting that athletic trainers become counselors. Instead, their role is to be on the lookout for athletes who may need professional help and to get them to it. It’s being observant, having a keen ear, understanding the stresses athletes face, and knowing how to refer to specialists. It also entails understanding what clinical depression is and is not.

About 18.8 million American adults, or 9.5 percent of the population, suffer from a depressive illness at some time in any given year, according to the National Institutes of Mental Health (NIMH). These conditions aren’t sadness or “the blues,” something everyone experiences from time to time as a natural and healthy reaction to events. According to the American Psychiatric Association, depression includes feelings of hopelessness, helplessness, and an inescapably bleak future that persist for more than two weeks.

The NIMH classifies depressive disorders into three types. Major depression is manifest by a combination of symptoms that interfere with the ability to work, study, sleep, eat, and enjoy once-pleasurable activities. Dysthymia is the term for chronic, long-term symptoms that do not disable a person but DO keep him or her from functioning fully or feeling good. The third type is one half of bipolar disorder, also called manic-depressive illness, which is characterized by cycles of extreme highs, with lots of energy and often impaired judgment, thinking, and social behavior, and lows that match that of depression.

Symptoms of depression, as listed by the NIMH, include:

• A persistent sad, anxious, or “empty” mood.
• Feelings of hopelessness, pessimism.
• Loss of interest or pleasure in hobbies and activities that were once enjoyed.
• Decreased energy, fatigue, being “slowed down.”
• Difficulty concentrating, remembering, and in making decisions.
• Insomnia, early-morning awakening, or oversleeping.
• Appetite or weight loss, or overeating and weight gain.
• Thoughts of death or suicide; suicide attempts.
• Restlessness, irritability.
• Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain.

The American Psychiatric Association recommends professional help for anyone who has four or more of these symptoms continuously for more than two weeks.

Scientists believe depression is caused by a combination of genetic, psychological, and environmental factors. It may often run in families but can occur in people whose families lack a history of depressive disorders. Women are about twice as likely to experience depression as men, and some studies have suggested a link with sex hormones in women.

Examples of psychological factors are low self-esteem, a tendency to berate oneself excessively, or a susceptibility to stress. Environmental factors include anything from parents getting divorced to an athletic dream that is not coming to fruition.

In the big picture, depression in athletes is not different from depression in the general population. But there are nuances to be aware of in terms of how it manifests itself in the athletic world.

Number one for athletic trainers to be aware of is that injury, especially one that takes a student-athlete out of action for an extended time, can be a risk factor. According to a review of literature published in the Journal of Athletic Training in 1995, seriously injured student-athletes between the ages of 15 and 24 may be at increased risk for depression and possibly suicide attempts, Mayo Clinic researchers found.

“That doesn’t necessarily mean all injured athletes are going to get depressed,” cautions David Yukelson, PhD, the staff sports psychologist for Penn State athletics. “But it’s a red flag. The person could be devastated because his or her goals have been thwarted and could go through initial phases of depression.”

Another potentially susceptible person is the marginal athlete who is not living up to his or her own expectations. These athletes sometimes slip through the cracks because they are not on the coach’s priority list.

“Some athletes who weren’t performing satisfactorily will push themselves even harder, too hard, and that leads to a state of chronic fatigue and depression,” says Ronald Kamm, MD, a sports psychiatrist in Oakhurst, N.J., who has treated several high-profile professional and Olympic athletes. “You have to watch that with the marginal athlete who’s trying everything he or she can off the field to get a spot on the team but overtrains to the point of burnout.”

Another factor to be aware of is that certain commonly used anti-inflammatory drugs have been shown to trigger depression. “If a person gets depressed while taking them, you better change to Tylenol or something else,” Kamm says. “Of course, they may be taking the anti-inflammatories because they’re injured and there may be post-injury depression, but I’d get people off the anti-inflammatories because it could be a factor.” Kamm adds that certain herbal supplements may also bring on mania, the flip-side of depression in bipolar disorder.

Sometimes, athletic endeavors can cover up depression, and athletic trainers should also be on the lookout for these. Kamm points out that a regimen of intense exercise may mask depression. “A lot of times, athletes train harder to fend off a depression that they’re aware of, and a lot of times exercise works pretty well,” he explains. “Although with moderate to severe depression, it won’t do the trick.”

The euphoria of winning may mask depression, too. Kamm says Derek Atkins, 1996 Olympic gold medalist in the 400-meter hurdles, took medication for depression off and on while training and competing. “He had a little chemistry experiment with the medication, coming off it right before the race and then getting back on it right after the race because it was slowing him down in practice and would have affected him in the finals. Unfortunately, after he won, he was so euphoric that he said, ‘I’m not depressed and I don’t need it.’ A month later he was back in depression.”

Finally, don’t make light of the pressures today’s student-athletes face. From doing well in the classroom to performing community service to facing new social situations to dealing with family stresses to being successful on the athletic field, there’s a lot a young person in your care may be dealing with. In Mann’s survey, sources of stress for Rowan student-athletes were nutrition (what to eat, when to eat), finances (they usually can’t work because they spend so much time on their sport), home issues (including parents who either are divorced or are getting divorced), relationship issues, and stress within their sport (an increase or decrease in playing time, a change in their role on a team).

“I’m amazed at the huge amount of stuff they’re carrying with them,” Mann says. “I know people have stress going on in their lives, but I was amazed at how much college kids are dealing with.”

Being on the lookout for depression tests an athletic trainer’s bed-side manner and interpersonal skills. It can be mastered, however, with practice and a sense of what to look for.

Yukelson says athletic trainers should practice some basic interview techniques that get athletes talking about their lives. It’s not necessarily getting personal, he adds, but you might ask how they’re doing in the classroom, how their social life is going, what else is happening.

“If there’s an injury and they’re kind of withdrawing, how are their behavior reactions to this, how are their emotional reactions?” Yukelson continues. “Are they talking to people, is there a source of social support?”

Also, look for a change in sleeping and eating patterns, says Elizabeth Hedgpeth, RN, PhD, a registered nurse who works with injured and rehabilitating athletes at the University of North Carolina and completed her dissertation in sports psychology on injured football players. She suggests that if you get the sense an athlete is depressed, try to determine whether he or she has feelings of hopelessness. “Does school or the sport seem overwhelming? Can they see a light at the end of the tunnel?” she says.

Remember, she adds, that there may be other reasons, such as a coach giving the athlete a hard time, or exams coming up. But if there are no other explanations, investigate further, she says.

“One thing to talk about with student-athletes is if they’re having fun, if they’re doing the sport for the right reasons,” Hedgpeth says. “If it isn’t fun for them now, talk about when it was fun for them.” That may help them see things differently, and it keeps them talking so you can learn more.

A key thing to find out is whether the athlete has thought or is thinking of suicide, Hedgpeth says. This includes coming out and asking them directly. If so, experts say the athlete should have immediate professional intervention.

Kamm suggests keeping an eye out for other signs, many of them observable from a distance. An athlete may have slumped posture, lack enthusiasm when taking his or her position in the field, be frequently late or skip practice, or not do all the proscribed reps in the weight room, he says. Another tip-off is excessive self-criticism or setting his or her own unrealistically high standards.

“They might be more critical of themselves if they made a mistake in a game,” Kamm says. “They might be harshly judgmental about their performance, because when you’re depressed, your criticism turns inward. They may have trouble concentrating. They may miss a play or a throw—that kind of thing.”

Edward Livingston, ATC, Assistant Athletic Trainer at Less-McRae College in Banner Elk, N.C., worked with a depressed athlete this fall, and says one of the hardest parts is knowing how to bring up the athlete’s current mental state and what to say. “A lot of times you have to let them come to you, or they’ll throw up their defenses and they won’t come see you when they have a problem,” he says. “And when they do come to you, you don’t want to say anything that might make them not want to come back and see you,” he says.

So Livingston tries to simply listen, asking, “‘Is there anything you want to talk to me about,’ and ‘If there is, let me know.’” Sometimes he mentions his concern to coaches, and he might ask teammates about the athlete, too.

Kamm suggests a three-step approach to inquiring. The first is to make objective observations about the athlete’s behavior combined with an open-ended inquiry. “The athletic trainer ought to say, ‘You’ve been looking down, you haven’t really been looking like yourself for a while. How are you?’” suggests Kamm.

“If the person says, ‘Okay,’ the second thing would be to ask, ‘Is there anything you want to talk to me about?’” Kamm continues. If the answer is “No,” then suggest that the athlete talk to the team physician or athletic department psychologist, if one is on staff. “Try, ‘Maybe you’d like to talk to the doc. He’s a real help to other athletes who’ve had problems. I could give you his card or his number and you could talk to him,’ or, ‘He’s coming by on Tuesday. Let’s see what happens.’

“As far as athletic trainers getting into it deeply, if the athlete doesn’t want to, I think they should back off,” adds Kamm. He cites a survey by Pfizer, maker of the popular antidepressant Zoloft, of 150 athletes and coaches in pro and amateur sports. The athletes said they would prefer that if the coach felt an athlete was depressed that the coach refer him or her to a mental-health professional rather than have a deep discussion about the athlete’s personal life. “I don’t know if they would feel the same way about the athletic trainer, but they might,” Kamm says.

“I think athletes are uncomfortable talking about things deeply,” Kamm continues. “There’s a stigma in sports against emotional problems, so they’re afraid that if they talk about it—even to an athletic trainer—they may get less playing time.”

In some cases, it may work well to suggest the athlete speak to a member of the clergy. Sometimes a priest, rabbi, or minister might suggest seeing a psychiatrist or psychologist, and hearing concern from another source can push a reluctant person to see a professional, Kamm says.

He adds, however, that among athletics staff members, it is usually better for the athletic trainer than the coach to approach an athlete. Coaches, after all, control playing time and, despite exceptions, are less likely to show any empathy. He recalls the case of pitcher Pete Harnisch, who faced depression while one of the New York Mets’ top starters. “[Then-Manager] Bobby Valentine wanted him to start and he said, ‘Skip, I don’t think I can do it.’ Valentine just ripped him. ‘What do you mean, you can’t do it? You gotta do it.’ There was just no empathy at all, no awareness that depression could be in play, that depression could be an illness that takes away most competitive athletes’ drive and desire and performance.”

Another caution, Kamm says: Be sure you and the athlete understand your organization’s confidentiality policy. In some cases, the coach must or should be told. It could be that the coach can help. In any event, make sure the athlete knows the ground rules before he or she starts to open up to you.

“The athlete should know if it’s not going to be absolutely confidential so the athlete won’t feel betrayed, or so they can talk more openly,” Kamm says.

Since one of the big triggers for depression is an injury, it’s important for athletic trainers to know how to help athletes cope during rehab. Perhaps the most important job is to help athletes maintain their perspective. This can take many forms.

First, make sure you understand how new—and frightening—entering rehab may be to an athlete. A seriously injured athlete is having a major life experience, Hedgpeth says. First, he or she is crossing cultures, which alone is a stressor.

“A coach says, ‘Suck it up, play through pain,’” she says. “But the athletic trainers and the doctors say, ‘Listen to your body.’”

Rehab also entails a new set of rules, with no score kept, no instant feedback when you make the play or don’t. “The athlete asks about something, and the athletic trainer says, ‘Well, we’ll wait and see.’”

A football player may have been in the sport since he was an adolescent and knows the game, but upon entering rehabilitation, he may be lost, literally and figuratively. “‘Where’s the ice? Where’s the whirlpool?’ They’ve gone from being a veteran to a rookie again,” says Hedgpeth.

Keep in mind that if the athlete is depressed, he or she will have an outlook quite different from others. The situation might not seem so bleak from the outside, especially to someone with more and broader life experiences, such as a veteran professional athletic trainer. But that’s not the point, notes Hedgpeth. “What matters is the kid’s perception of what’s going on,” she says.

“You encourage them to go out and work harder,” Yukelson says, “but when he’s depressed he might want to just go back to bed or not get out of bed to go to class.”

The athlete’s perspective on what others are thinking may also be a source of stress. You may know the coach has the proper view of rehab, but the player may not, which can be a tremendous source of agony.

The best way to counter the above stressors is helping the athlete to maintain a positive outlook, Kamm says. “There’s an awful lot of negative thinking in depression,” he says. “If the athletic trainer can counter that with a lot of positives, that helps. If he or she says, ‘You’re stronger, you’re doing more reps, your range of motion’s better, you’re going to be back soon,’ that’s great.”

Yukelson recommends showing the athlete that the rehab plan is a good one, that it’s a means to the end of returning to competition, and that, despite his or her dedication to and enjoyment from the sport, there’s more to a person than athletic ability. Show them, he says, that the ability to focus and work hard, a trait that makes them special, can also be turned toward rehab.

“I talk a lot about controlling the controllables, and what kinds of things are in your control and what things are out of your control,” Yukelson says. “I tell them to apply mental skills to their rehab, which then helps them sort through the emotional frustration that comes along with the progression of rehabilitation. I remind them that this is a part of the process they have to go through.”

Many also advocate keeping the athlete tied to the team, which can include pulling rehab equipment out on the field so the athlete can do his or her work while their teammates do theirs. “They can ride the exercise bike during regular practice. That way, they don’t lose the connection,” says Hedgpeth. Be creative and open-minded, and think about what is possible, she adds. At North Carolina, for example, volleyball players in casts sometimes take the court for a part of a workout.

Be sure to maintain the athletes’ dignity, she cautions. An athletic trainer can advocate to coaches that rehabbing athletes are given roles that acknowledge and use their experience and knowledge. Instead of a ball-chaser or scorekeeper, suggest making an injured athlete a bench coach, or pair him or her up with an underclassman who needs a mentor.

But mostly, be there with them, listen to what is difficult, and help them articulate their feelings, says Yukelson. “Tell them, ‘There are ups and downs but you don’t want to dwell on it,’” he says. “‘You don’t want to get to the point where you don’t want to get out, that your classes are suffering, that you don’t want to do the other things you need to do that are part of your whole identity, not just your athletic identity. If you sort through the emotional baggage, then it’s how you work through those things that keeps moving you forward.’”

Drugs & Performance

Another concern of athletes to address is how antidepressant medication may affect athletic performance. The effects are being studied but, anecdotally, they can vary widely, with many athletes saying they actually perform better once on the medications, says Oakhurst, N.J., sports psychiatrist Ronald Kamm, MD.

“Julie Krone [a retired successful professional jockey] felt she rode better, and [baseball pitcher Pete] Harnisch would say that he was at least as good or better,” Kamm says. “Diver Wendy Williams feels that way, and these are just people I know personally. I had a world-class trap shooter say he never shot better than when he was on antidepressants because they also have an anti-anxiety component, so he was much steadier.”

In a course of treatment, the medicine typically lifts depression within a month or six weeks, with significant improvement in two to two-and-a-half months, Kamm says. To prevent a relapse, patients often stay on the medication several months later even though the depression is gone. This is something to be worked out between the patient and doctor.

Widely used antidepressants are not on the NCAA list of banned substances. The hypertension drug pindolol, also known by the trade name Visken, has been used as a potential supplement to certain antidepressants and is banned for use in rifle for its effect on the heartbeat.