Recognizing the Signs

January 29, 2015
There are likely student-athletes in your program suffering with a mental health issue. Here's how to develop procedures so your staff can help them.
By Timothy Neal

Timothy Neal is the Assistant Director of Athletics for Sports Medicine at Syracuse University. He has served as the National Athletic Trainers Association (NATA) liaison to the NCAA Football Rules Committee, authored a chapter in the 2012-13 NCAA Sports Medicine Handbook, and was presented with the 2010 NATA Most Distinguished Athletic Trainer Award. He can be reached at:

At Georgetown University, a research project was recently begun in order to study the rates of depression in former collegiate athletes. The hypothesis was that hanging up one's uniform might mean losing a part of one's identity, which could lead to mental health problems.

To test their theory, the researchers polled 280 current and former NCAA Division I student-athletes from a range of sports. Their responses, now published in Sports Health: A Multidisciplinary Approach, were not as expected.

Instead of former athletes showing greater rates of depression once they graduated, it was the current participants who did so. In fact, the study found that 17 percent of present-day intercollegiate athletes exhibited signs of depression.

When you translate that 17 percent to specific teams, it means 17 football athletes on a 100-man roster, two members of a 12-person basketball squad, three softball players, and so on. Unfortunately, the study suggests there are many student-athletes dealing with psychological issues in an athletic department at any one time.

Because the topic is difficult for many people to talk about, the prevalence of mental health disorders often gets ignored. However, it is necessary to broach the subject, because early detection is critical for treatment, which can help athletes get back to performing at their best.

So how should athletic administrators respond to the issue of mental health problems among student-athletes? A consensus statement to be released by the National Athletic Trainers Association (NATA) this fall recommends that college athletic departments set up specific policies to handle student-athlete psychological concerns. These guidelines should include a plan to recognize student-athletes who are suffering and procedures to refer them for treatment.

Here at Syracuse University, we developed and implemented a mental health considerations document for the athletic department a few years ago. As Assistant Director of Athletics for Sports Medicine, I took the lead on this project, but a similar undertaking could be spearheaded by almost any athletic department staff member. The initiative has proven very effective in helping us respond to our student-athletes who have psychological concerns.

When beginning the process of developing a mental health document, the first step is getting many different people involved--including those not on campus. I started by collaborating with members of our school's counseling services. I met with them to not only ask their advice but to get to know them. Establishing these relationships has made the process of referring athletes to them much easier. It also helped me learn more about the mental health issues facing today's college students.

Collaborating with off-campus mental health care professionals was done in a similar way. We established relationships with psychologists and psychiatrists in the local community to whom we now refer student-athletes. While our health center staff is able to handle a majority of issues, there are times when an athlete needs specialized care that can only be found off campus. Having strong connections with professionals in the community has proven invaluable.

I also reached out to our school's Division of Student Affairs, risk manager, institutional legal counsel, and Department of Public Safety to get their input on the document's development. It is vital to cultivate a relationship with each of these departments because a student-athlete is first and foremost a student.

Once you have others on board, developing the mental health document entails putting together policies and resources. Our document contains the following:

- Information on the prevalence of mental health issues in student-athletes
- Education on what stressors could play a role in exacerbating symptoms
- Explanations of how to refer athletes for treatment and why only credentialed mental health professionals should be evaluating student-athletes
- Confidentiality issues
- Behaviors to monitor
- NCAA regulations regarding drug testing and ADHD medications
- Disordered eating guidelines
- Emergency referral procedures (e.g., in cases of possible suicide attempts) and phone numbers.

We provided an initial draft to our risk management manager and legal counsel for their review and also asked for feedback from the counseling center and Division of Student Affairs. After taking everyone's advice into account, revising the document, and getting final approval on it, we then distributed it to all athletic department staff. We also spoke directly with sport coaches, athletic trainers, strength coaches, and administrators who work closely with athletes about the importance of knowing the warning signs of mental illness and how to talk to any student-athlete who may need referral.

We update the plan annually and re-issue it at the start of each academic year. As the point person, I try to keep up with research in this field and communicate regularly with mental health professionals on campus in order to decide what to add.

As I learned when putting together our document, the major way in which coaches and other staff can help student-athletes with mental health issues is by paying attention to them. Therefore, we outline specific behaviors for coaches to look out for in the document.

The two most prevalent mental health disorders in young adults are depression and anxiety. However, there are many other psychological illnesses a student-athlete may suffer from, and it is common to be diagnosed with more than one. Our guidelines explain some facts about behaviors and how they may relate to a certain type of mental health disorder, but they also clearly state that the coach or administrator is only being asked to notice the behavior and leave any diagnosis to a mental health professional.

Our document also clarifies that behaviors may be singular or multiple in nature and range from mild to severe in presentation. Our explanation notes that everyone experiences and reacts to stress in varying degrees, and an athlete exhibiting a behavior does not necessarily have a mental health disorder. The overarching idea is that if the described behaviors are out of character for the athlete, the referral system (detailed in the next section) should be activated.

Below are potential behaviors that could indicate a student-athlete is suffering:

Withdrawal from social contact: Although some student-athletes may naturally be shy or less outgoing than their teammates, withdrawal from social contact is a prime symptom of clinical depression. It is normal for student-athletes to want "alone time," but if this time increases to uncharacteristic levels, it can be a sign of distress.

Changes in sleeping and eating habits: Changes in sleeping habits could include a student-athlete regularly falling asleep in class or team meetings or missing or being late to practices, meetings, or games because he or she overslept. Noticeable weight gain or loss is also cause for concern, as is an individual who used to eat with teammates suddenly choosing to eat alone. A student-athlete who incessantly talks about their weight or diet may also have an eating or body image disorder, which needs to be addressed.

Decreased interest in activities: Student-athletes who no longer participate in activities they once enjoyed, like playing video games, listening to music, watching movies, or dating, may be depressed. Some may even openly express a loss of interest in their sport, and quitting the team is a major red flag.

Problems concentrating, focusing, or remembering: High levels of stress, as well as depression, can affect daily mental activity and lead to difficulty clearly expressing thoughts. For example, depressed athletes may have a hard time describing what they are going through or require more time to collect their thoughts before they can verbalize how they feel.

It's also important to note that recent research suggests concussions impair both cognitive and emotional abilities. Any student-athlete who has sustained a concussion should be monitored for depression--especially someone with a history of the disorder.

Frequent complaints of fatigue, illness, or injury: Mental illnesses, especially clinical depression, are both a mind and body phenomenon. Depressed student-athletes may report feeling like they are in a fog, tired all the time, or that they have constant headaches, body aches, or an upset stomach. Injuries that should have healed with treatment and rest may seem to linger.

Loss of or heightened emotion: As depression or other mental illnesses set in, student-athletes may become less emotional or have what is referred to as a "flat affect"--where they look expressionless or their reaction to conversation is lacking. However, some students may have the opposite occur, tearing up or crying over minor events. Others may become more animated, laughing at inappropriate times.

Deliberate self-harm: Someone who is suffering from a mental illness may resort to self-harm, such as cutting or branding. Wearing long-sleeved shirts and/or pants to cover up cuts in spite of warm weather may indicate that self-harm is occurring.

Irritability: Mental health experts believe that depression is associated with high levels of anger and frustration, including violence, particularly in men. Lashing out at others, overreacting to minor incidents, impulsive behavior or language, and impatience may be signs of depression and other types of mental illnesses.

Drug and alcohol abuse: If drinking or drug use becomes excessive or occurs at odd times of the day, such as early morning, it can be indicative of a mental health issue. This can be tough for a coach or athletic trainer to notice, but teammates may pick up on a problem and should be encouraged to report it to a coach or administrator.

Talking about death, dying, or going away: Making comments about dying, even in generalities, is an indication that a student-athlete could be severely depressed or is experiencing a significant mental illness. Predicting whether someone will attempt suicide is quite difficult, even for mental health experts and medical personnel, but any mention of suicide by a student-athlete should be treated very seriously and action should be taken.

Our mental health considerations document also includes advice on how to approach a student-athlete suspected of having a psychological issue, as well as information on when and how to refer them for specialized care. Unless they are a licensed counselor, no member of the athletic department should ever attempt to treat an athlete with a mental health illness, and this must be made clear in every school's policy. However, if they suspect an individual has a problem, athletic department personnel should act quickly to find out if the athlete needs help.

Approaching anyone with concern about their psychological well-being can be an uncomfortable experience. A private meeting with the athlete is usually best, but it may be helpful to have another coach, team physician, athletic trainer, or staff member present--especially if this other person has a positive relationship with the student-athlete.

Empathetic listening and encouraging the student-athlete to speak openly is recommended. It is also important to let the athlete know that people care about him or her as a person. To accomplish this, try to ask open-ended questions:

- How are things going?
- Can you tell me what's going on?
- Your behavior has me concerned ... Is there something I need to know to understand what is happening?
- Can I ask you how those cuts got on your arm?
- Have you talked to someone about what's going on?
- Would you like to talk to someone about the situation?

You may encounter incidents when the student-athlete is less than honest or is hesitant to share the details of their psychological state. This is a natural reaction to the stigma that many still associate with mental health issues. In these instances, it can be helpful to remind them that an emotional or mental issue is cause for medical concern--just as a musculoskeletal injury is--and it's important that the problems be evaluated further.

On several occasions in the past, I have convinced student-athletes to go for a mental health screening. I usually start by having a conversation with the student-athlete and our team physician. I never tell them they have a mental disorder because I am not a trained mental health care professional. Saying that it might be a good idea to "go for an evaluation" is a gentle way of getting them to a specialist to determine if there is an issue that needs to be treated. I usually make the initial contact with the counselor, psychologist, or psychiatrist for the student-athlete. This is where a prior relationship is beneficial--the mental healthcare professional already knows of your interest in referring student-athletes for an evaluation.

There are student-athletes who will refuse counseling for various reasons. Unless their behavior makes you worried about their imminent health or safety or you suspect a code of conduct violation has taken place, the student-athlete cannot be compelled to report for an evaluation.

The best tactic you can take if faced with this situation is to encourage them to consider an evaluation as something that may help them deal more effectively with their stress or personal issue. Assure the student-athlete that being referred for a mental health screening is not any different than being evaluated for a physical injury or illness. You should also promise them that you will not talk about the situation to their coaches, parents, or teammates without their permission.

If a student-athlete reports suicidal feelings or makes comments referencing suicide or harming themselves, do not under any circumstances leave them alone. You should be familiar with your institution's emergency mental health action plan, which is usually produced by the office of student affairs. Call for assistance using this procedure. These individuals must be monitored very closely.

Mental health issues are present among student-athletes, and they should not be ignored. The key to helping young people in our programs is to have policies in place and every member on staff cognizant of warning signs and referral protocols. Having a proactive approach on student-athlete mental health is important for athlete safety and well-being.

To access the NATA's consensus statement and guidelines, which will be available after Sept. 30, look for the title, "Developing a Plan for Recognition and Referral of Student-Athletes with Psychological Concerns at the Intercollegiate Level: A Consensus Statement" at:

Sidebar: ONE STORY
Although we did not put our official mental health plan in place here at Syracuse University until recently, we have been consciously looking out for psychological concerns for many years. This approach has helped numerous athletes in a variety of different ways.

One example is a student-athlete who had a history of depression coming into his freshman year. He also suffered an injury that necessitated his medical disqualification from his sport. Knowing that the loss of his playing career may be a triggering mechanism for anxiety and depression, we paid close attention to him to spot any warning signs.

After a while, we did notice behaviors that indicated he was struggling. I gently talked to him about it, and he agreed that he had a relapse of his depression. He was evaluated by a mental health professional, prescribed medication, and began counseling, which had a marked improvement in his quality of life.

Today, he is a very successful professional. He continues to take his medication and attend counseling sessions. When he comes back to campus, he thanks me for the care he received for his condition.
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