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Depression and suicide remain major public health concerns affecting broad segments of the population. The prevalence rates for depression are notably high in young adults. According to the US Department of Health and Human Services, the prevalence of depression in individuals aged 18–25 years is 8.7%.1 Clinically significant depression symptoms appear to be as prevalent in collegiate athletes as in the general college student population.2 Suicide remains the third leading cause of death among individuals of collegiate age and is reported as the second leading cause of death among the general college student population.3 ,4 In college athletes, a suicide ranks fourth as a leading cause of death.5 Current estimates of depression and suicide prevalence in these populations are challenged by the lack of consistent methodology, inconsistent reporting by schools and a poor understanding of relevant screening tools to effectively evaluate athletes. Thus, under-reporting of mental health concerns in athletes is a significant concern, and depression and suicide are tangible concerns to address in athletes of all ages and levels of ability.
Some studies suggest that athletic participation confers self-esteem and social connectedness in athletes.6 ,7 These beneficial psychological effects of athletic participation may be counteracted by a number of stressors unique to the athletic experience: coach, peer and parental pressure; inability to participate due to illness or injury; failure to meet performance expectations; termination of an athletic career; and willingness to participate in high-risk behaviour.8 ,9 Student athletes also face pressures of balancing athletic participation with academic, financial and social obligations. Injury or a failure to meet performance expectations may interrupt an athlete's social structure and disturb his or her own concept of identify and self-worth.10 Athletes are more likely to participate in risk-taking activities such as binge drinking, which is linked to suicidal impulsivity and depressive behaviour.11 ,12 A recent systematic review suggested higher rates of alcohol abuse and related violence in athletic populations compared to non-athlete populations.13 The psychological context for athletes may be more complex than previously considered and further study is critical to understand and promote athlete health and well-being.
Risk factors for depression and suicide in athletes
Management of depression and suicidal ideation must involve a better understanding of risk factors. Male and African-American college athletes appear to be at increased risk of suicide.5 Female college athletes, on the other hand, are more likely to report depressive symptoms, though less likely to complete suicide.14 ,15 National Collegiate Athletic Association (NCAA) football athletes demonstrated the highest rate of suicide for unclear reasons, though a prior study found that athletes invested in violent sports show higher levels of violent behaviour outside of athletic participation.5 Ideally, student-athlete mental health, athletic trainer and physician resources should identify athlete and sport-specific risk factors and target high-risk groups for intervention. Steps should be taken to establish validated screening tools relevant to the athletic population. For example, injured athletes, especially those missing a prolonged period of participation, could be screened with mental health inventories (such as the Physical Health Questionnaire-9 and Generalised Anxiety Disorder-7) until they have successfully returned to full athletic participation to better gauge the mental health consequences of injury and restricted participation.
Improving management of mental health concerns
The sports psychology literature describes a multimodal approach involving ecological prevention, proactive prevention, early intervention and crisis intervention.16 The NCAA has begun to introduce these concepts through publications, including Managing Student Athletes’ Mental Health Issues and Mind, Body, Sport.17 ,18 The employment of a multidisciplinary approach, involving team physicians, athletic trainers, licensed mental health providers and campus mental health centres provides the depressed or suicidal athlete with a range of supportive resources. While much effort has been put into developing and maintaining emergency action plans to manage on-field medical emergencies, only preliminary efforts have been developed to assist the acutely depressed or suicidal athlete through an organised emergency mental health crisis plan. Each organisation should take inventory of its available mental health resources and develop a coordinated plan to direct athletes to necessary resources.
Other challenges face providers who care for athletes. A survey of 827 sports medicine physicians found that only 80% of respondents reported often or sometimes discussing psychological issues related to injury when treating an athlete.19 Most respondents noted a lesser degree of comfort in discussing the psychological issues compared to the injury itself. Providers and affiliated athletic staff who directly care for athletes benefit from established relationships, and such trusted associations can permit athletes to feel safe in disclosing their mental health concerns. However, providers must become more familiar and comfortable with exploring mental health concerns with athletes and related circumstances to facilitate discourse, disclosure and subsequent intervention.
As healthcare professionals responsible for athlete health and well-being, we must increase our attention to the mental health of athletes. A growing recognition of this concern will help drive identification, prevention and management strategies, while facilitating a better understanding of the scope of mental health disorders within the athletic culture and the challenges to proper management within the context of athletic participation. As a community, we have performed well to embrace the concepts of screening for health-related issues and managing medical conditions. The critically important issue of athlete mental health should be no different and deserves our attention now.
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