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Depression is under-recognised in the sport setting: time for primary care sports medicine to be proactive and screen widely for depression symptoms
  1. Thomas Trojian
  1. Correspondence to Dr Thomas Trojian, Division of Sports Medicine, Department of Family, Community & Preventive Medicine, Drexel University College of Medicine, Philadelphia, PA 19130, USA; ttrojian{at}

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An important role of the team physician is to provide care for the whole athlete. This includes mental health issues for instance screening for depression and knowing the factors that affect the onset of depression. The USA Preventive Service Task Force (USPSTF) recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment and follow-up.1 Most studies report prevalence rate of depression among college athletes ranges from as low as 15.6% to as high as 21%.2 Depression levels were significantly higher in current college athletes (about 17%) compared with former, graduated college athletes (8%).

The stress of sports and athletic participation place athletes at risk. Performance failure was significantly associated with depression. The statistically strongest predictors of depression in student-athletes were female gender, lower self-esteem, less social connectedness and decrease sleep. Female student-athletes had 1.32 greater odds (95% CI 1.01 to 1.73) of experiencing symptoms of depression compared to male student-athletes. Freshmen had 3.27 greater odds (95% CI 1.63 to 6.59) of experiencing symptoms of depression than their more senior counterparts.3

USPSTF recommends the use of one of these three screening tools; 9-Question Patient Health Questionnaire—Depression Screener (PHQ-9), Beck Depression Inventory-II (BDI-II), Depression Screener from the Center for Epidemiologic Studies Depression Scale (CES-D). The PHQ-9, a nine-question survey, when the cut-off is a score of 5 or more has 95% sensitivity and 88.3% specificity when scored with a cut point of 11. The CES-D, 10-question survey, when the cut-off is 22 has sensitivity 84%, specificity 60% and positive predicted value 77%.4 Most recommend a cut-off of 16 to increase sensitivity but it decreases the specificity.4 The BDI-II has been validated using college students, adult psychiatric outpatients, and adolescent psychiatric outpatients.4 It has good sensitivity and specificity and excellent reliability.4 It is a 21-question survey, with a cut-off score of 14 or more. One of these three screening tools should be chosen. Examine each screening tool and determine which will work best at your facility.

The mechanics of setting up the screening process is important to have everyone in place prior to starting screening. First, determine what screening test is to be used and what score needs follow-up. Second, you need to determine how you or your designate tell people that they have a high score. Third, you need in place a method to handle athletes that do not want follow-up at the time of notification. For instance, we give people an information card about mental health centre with important phone numbers. We encourage future follow-up and remind the athlete we are here for them if they want help. Fourth, after following up with the athlete postscreening, you need a plan for referral or follow-up counselling sessions. Fifth, schedule follow-up visit is to ensure that the athlete has been able to get to referrals and to discuss any laboratory test results.

There has been an increase in the concern about head injuries in sports over the last decade. NCAA is recommending baseline neurocognitive testing, but baseline testing can be variable and one important factor is depression.5 One of the aforementioned depression screens should be included in baseline neurocognitive assessments to help disentangle depression from concussion symptoms.5 The problem is not just the baseline neurocognitive but postconcussion, as well. The best predictor of postconcussion depression is baseline depression symptoms. These studies highlight why depression screening is needed along with any baseline neurocognitive testing. Depression screening helps to increase the validity of baseline neurocognitive testing and they help predict those student-athletes who will develop postconcussion depression.

I have highlighted the recent concern about concussions and depression in athletes but we need to remember that any athletic injury is often accompanied by depression, anger and low self-esteem, particularly in seriously injured athletes. Both concussion and musculoskeletal injured athletes experience emotional disturbances after injury. Athletes with ACL injury reported higher levels of depressive symptoms for a longer duration than athletes with concussion. Athletes experience significant mood changes throughout rehabilitation, which may hinder rehabilitation early in the process. One important factor in the care of the athlete is a skilled athletic trainer will know it is important to monitor the mental well-being of the injured athlete.6 Mood disturbance is related to the athlete’s perceiving lack of progress in rehabilitation and it relates to missing rehabilitation sessions. Interventions such as positive self-talk, relaxation, goal setting and healing imagery can be appropriate to assist athletes in coping with injury.

One of the traumas experienced by student-athletes that all healthcare providers need to be cognisant of is sexual assault. The National College Health Association conducted a survey; student-athletes were asked a series of questions about their mental health status within the past 30 days and 12 months. The survey revealed that student-athletes, both males and females, who self-reported experiences of sexual assault, were significantly more likely to experience hopelessness, mental exhaustion, depression or suicidal thoughts. Those who indicated experiences of sexual assault within the past 12 months were three times more likely to have had recent suicidal thoughts than those who did not (13% vs 4% for women, and 12% vs 4%for men). The per cent of female and male athletes reporting having experienced unwanted sexual touching or penetration in past 12 months in the NCHA survey is 9.1% and 4.6%, respectively. The numbers are even higher in athletes diagnosed with depression, with 1 in 8 females and 1 in 15 males will have been sexually victimised in the past 12 months. While athletes who ‘felt so depressed it was hard to function within last 30 days’ it was even higher with 1 in 6 females and 1 in 10 males will have been sexually victimised in the past 12 months. When discussing depressive symptoms one should make sure to assess for sexual assault in men and women. It is important that student-athletes are connected with the sexual assault response centre, mental health provider and encourage the student-athlete to contact law enforcement. It is important as with depression to provide a listening environment.

A good approach to address mental health issues is similar to good patient care. It is important to have patience (do not appear rushed), express interest (make eye-contact, disconnect phones, be in the here and now), maintain confidentiality (assure confidentiality but define the bounds of confidentiality), express understanding (an athlete who feels understood will readily open up) and to give support (be accepting and non-judgmental of the patient's current state. The patient's pain may be both emotional and physical).7 Mental health treatment services may be underutilised by individuals participating in athletics due to a myriad of variables such as time constraints and social stigma. Recommendations for working with college and elite athletes include being flexible within reason about timing of sessions, involving family members when relationship issues are involved, and not compromising on delivering the appropriate treatment, including medications and hospitalisations as necessary. As a team physician, it is important to meet with mental health providers to help coordinate referrals and assist them in understanding the difficulties athletes might have in seeking care.

Screening for depression should be recognised as a screen of depressive symptoms. Those that are found to be high on the mental health screen need to have a follow-up visit to determine if the positive screen is depression or another disorder. Though, most commonly psychiatric in nature, other illnesses can present with depressive symptoms. Depression was found to be the most common affective prodromal of medical disorders and was consistently reported in Cushing's syndrome, hypothyroidism, hyperparathyroidism, pancreatic and lung cancer, myocardial infarction, Wilson's disease and AIDS. An association between depression and decreased ferritin levels before the occurrence of anaemia. Athletes with suspected depression should be tested for iron-deficiency (ferritin), subclinical thyroid (thyroid-stimulating hormone, free T4) and vitamin D deficiency (vitamin D 25-OH).8

In summary, it is important to screen for depression in athletes. Now is the time to start a depression screening programme as a Sports Medicine physician. Whether it is to maximise athletic performance, or to assist in concussion care, or evaluating how athletes are coping with injury, depression screening is important tool for the sports medicine physician.


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  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.