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Mind, Body and Sport: Mood disorders and depression

An excerpt from the Sport Science Institute’s guide to understanding and supporting student-athlete mental wellness

By Chris Bader

Mental health and mental health disorders are a growing topic of conversation for athletics departments. Like the campuses with which they are affiliated, athletics departments have seen a rise in the number and severity of individuals with mental health concerns. One of the more common mental health concerns is depression. While there are a number of different clinical disorders that involve a depressed mood (see “What is new in depression?” below), for the purposes of this article, the focus will be on what most people refer to as “depression,” which is clinically considered Major Depressive Disorder.

While most people can feel down or blue from time to time, individuals who are depressed experience prolonged times of sadness that interfere with their ability to function in daily life. When someone is depressed, the feeling of sadness is pervasive, and it is difficult for the individual suffering to imagine not feeling depressed.

According to the National Institute of Mental Health (NIMH) with data from the Substance Abuse and Mental Health Services Administration (SAMHSA), approximately 6.7 percent of U.S. adults experience Major Depressive Disorder in a given year. That 12-month prevalence is actually higher among college-aged individuals (8.9 percent in 18-25-year-olds). Women are at increased risk, as are non-Hispanic Whites (when compared with non-Hispanic Blacks).

What is new in depression?

With the recent release of the newest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), there are some changes with regard to disorders that include depression. These disorders are now classified as “Depressive Disorders,” and they include:

  • Disruptive mood dysregulation disorder
  • Major depressive disorder
  • Persistent depressive disorder (dysthymia)
  • Premenstrual dysphoric disorder
  • Substance/medication-induced depressive disorder
  • Depressive disorder due to another medical condition
  • Other specified depressive disorder
  • Unspecified depressive disorder

The DSM-5 explains that the common feature of all of these is “sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function.” The differentiating features of these disorders include duration, timing and presumed cause.

It is important to understand and recognize the breadth of depressive disorders in order to properly identify, diagnose and treat the disorder most closely corresponding to the symptoms of the individual.

What are the signs/symptoms of depression?

For a proper diagnosis of depression, most of the following symptoms must be present. Some of the individual symptoms could appear to be other conditions of concern (for example, ADHD, a sleep disorder, etc.)

  • Depressed mood
  • Loss of interest or pleasure
  • Significant weight loss or gain
  • Insomnia or hypersomnia
  • Psychomotor agitation or retardation
  • Fatigue or loss of energy
  • Feelings of worthlessness or excessive or inappropriate guilt
  • Diminished ability to think, concentrate or make decisions
  • Recurrent thoughts of death, recurrent suicidal ideation, suicide attempt or plan

These symptoms need to be present for more days than not over a period of at least two weeks. We all display some of these symptoms some times, but the key to proper diagnosis (and thus effective treatment) is the symptom picture, the timeframe and the level of disturbance in daily functioning.

What causes depression?

The cause of almost any mental health disorder generally consists of a number of interrelated factors, including: (1) biology – the genetic, biological, and physiological make-up of the individual; (2) psychology – the mindset and mental state of being; and (3) social factors – stressors, changes in environment and related factors.

Taken together, this suggests that we need to consider the biopsychosocial factors in the individual’s development and current state to determine his or her individual cause. The root causes of depression have been linked to the levels of various chemicals in the brain. A combination of genetics and brain chemistry lay the groundwork for developing depression, and the individual’s day-to-day functioning and state of mind about life can lead to the expression of that genetic predisposition.

For example, someone may have a parent who suffers from depression, but may perceive himself to be a positive agent for change in his own life and has set up a very supportive social network. This individual may not ever have a depressive episode despite his genetic predisposition for depression.

How is depression treated?

Individuals choose a number of ways (some healthy and some less so) to treat depression. Some individuals do not seek treatment – sometimes that is related to not wanting to ask for help or not feeling worthy of someone else’s time. Other individuals choose to treat depression on their own – anything from self-help readings (healthy) to substance use/abuse (unhealthy).

It is now a widely accepted practice to suggest counseling and consideration of medication management for an individual suffering from depression. Research has suggested that a combination of psychological intervention (counseling), with medication management as warranted, has shown the most promise for positive outcomes associated with the treatment of depression. While many people do not seek treatment, it is important to try to guide individuals suffering from depression toward effective resources that may be beneficial.

What else can affect and can be affected by depression?

  • Health/Performance. When we feel depressed (or suffer from diagnosed depressive disorder), our health and general performance in life can suffer. This can become a downward spiral into a deeper depression if not noticed and addressed. And, our physical health can begin to suffer as our depressed mental state is prolonged.
  • Injury Risk. In dealing with athletes, depression can be both a precursor to and a result of injury. A gymnast may not be feeling quite right and may be displaying some of the symptoms of depression. Because of that, his or her concentration is lacking and he or she lands a skill awkwardly, leading to a serious injury. On the other hand, athletes performing at their best who are injured in a unpredictable situation may begin to display symptoms of depression once their athletics status is threatened or taken away completely.
  • Suicidal Risk. Suicide risk has been linked to feelings of hopelessness and talk of death or suicide (both symptoms of depression). Recent genetic findings suggest a strong genetic link to suicidal behavior and action. So again, we see the interaction of a number of factors. The main takeaway is to consider any talk of or threat of suicide seriously and to understand the aforementioned factors that can increase suicidal risk. Just because someone is depressed does not mean that he or she is suicidal, but we should be aware of the connection of these two serious clinical situations. (See David Lester’s article on suicidal tendencies later in this chapter.)
  • Sport Participation. Participation in sports can help or hurt, depending upon the individual suffering the depressive episode. Student-athletes often have a high athletics identity, and if that identity is threatened because their position is taken away because of depression, that can serve to further the depression. At the same time, forcing athletes with depression to perform while they are in a depressive state can be detrimental to their ability to perform and to manage their depression. Given this paradox, it is important to talk with the student-athlete and all individuals involved in their care in order to determine the best course of action.

Additional resources

Case Presentation. Consider this hypothetical situation: A student-athlete is benched for the first competition of the season. She is new to the university and is expected to contribute significantly to the success of her team. Recently, however this student-athlete hasn’t been feeling “right.” At times, things seem fun and manageable; but, increasingly, things seem boring and hopeless. These symptoms began soon after the student-athlete arrived on campus and have gone on for about six weeks. In the past two weeks, the student-athlete has missed class more than usual and has stopped hanging out with friends. Additionally, this student-athlete’s grades have dropped and she has avoided the academic center and dining hall where most of the student-athletes gather. This student-athlete’s teammates have approached the coach about some concerns they have about this person’s behavior.

This presentation is more common than one might think. This student-athlete is displaying a number of symptoms of the depressive disorders, and the timing and duration seem to be in line with Major Depressive Disorder. In this case, this student-athlete would likely benefit from someone reaching out to her in a non-evaluative manner and expressing concern while also helping her find psychological and medical resources.

Difficulties in Identification. At times, identifying a depressive disorder (especially Major Depressive Disorder) can be difficult given the nature of the life of student-athletes. Because they are busy and because they interact with a number of areas of campus, consolidating the identifying symptoms can be tough. For example, if someone in academics sees some of the symptoms mentioned earlier, they may not know if that student-athlete is showing the same symptoms in his or her athletics and social pursuits.

It is also possible that student-athletes who try to hide their symptoms (through substance use, for instance) or withdraws such that even their closest friends/teammates do not know what is going on.

It is important to note here that there are other disorders or situations (for example, substance use/abuse) that lead to similar symptoms. Thus, talking with the student-athlete as well as others in the student-athlete’s life can be important in identifying and possibly treating a depressive disorder. Most (if not all) college campuses now have someone who provides clinical psychological service to that campus; thus, consulting with that person can help properly identify symptoms and provide a proper diagnosis.

Suicide Intervention. A number of national programs address the topic of suicide intervention. One of the most important factors in intervening with someone who may be considering suicide is simply to ask if he or she is considering suicide. Secondary to that is to not be afraid of the answer given. The person may say, “Yes, I’ve considered it,” and your reaction at that point is very important. Communicating your support for that individual is very important and could save a life. Again, at this point, it is important to consult with a mental health provider or physician to get that person immediate help.

Suicide Prevention: Having a Plan. One thing to consider before needing hospitalization after a threat or attempt of suicide is a plan of action. For example, if your department works closely with a mental health practitioner, talk with that practitioner about the steps involved in crisis response given a suicidal threat or gesture. In most cases, a mental health practitioner will have an idea of what needs to take place to ensure the safety of the student-athlete, depending upon the situational factors involved.

About the Author

Chris Bader has been the counseling and sport psychologist for the University of Colorado athletics department since August 2012. Chris provides clinical, assessment and individual and team consultation to the student-athletes and coaches and helps incoming student-athletes adjust to their new environment. From 2007-12, Chris was on staff in the Psychological Resources for Student-Athletes office at the University of Oklahoma. He earned his bachelor’s degree in psychology at Louisiana State University in 1998, where he was a member and president of the Rugby Football Club. Chris earned his master’s degree in psychology with an emphasis in psych neuroendocrinology at the University of Louisiana at Lafayette.

 

Former Michigan star recounts depression’s effects

At 6 feet, 6 inches and 295 pounds, Will Heininger cuts a formidable figure. Now working in the investment industry, Heininger was a four-year letter-winner during his time on Michigan’s football team, where he graduated in the winter of 2011. In conversation he is cheery and outgoing, fitting the image of a successful student and football player.

It is less apparent that Heininger was depressed for months during his time on campus.

Heininger grew up in Ann Arbor and always dreamed of playing for the Wolverines one day. He was living that dream; everything was going smoothly. Then the symptoms of depression set in after the summer of his freshman year. Heininger said a contributing factor to his depression was his adjustment to a new life at home after his parents’ divorce, which occurred when he left for college. He kept himself busy, avoiding free moments that would fill with negative thoughts as he stared off into space and faced the dreadful specter of personal failure that others couldn’t imagine in a Division I football player.

When he returned to Michigan as a sophomore, he carried his depression with him, although the return to the activity and normalcy of university life helped him stave it off more effectively than at home. Heininger at first tried to combat his depression with the same single-minded determination that had brought him success both as a student and an athlete.

“That athletics mindset got me so far, so
I tried to attack it that way. It just made it worse. I felt like I’d failed because I couldn’t beat it myself,” he said. “Sometimes I just sat on the couch and cried.”

Heininger decided to ditch the “carry-the-burden” approach that sport psychologists so often see and began to reach out for help. He confided to his mother first, a step he found worthwhile, but that alone was not enough to bring him out of his depression. It was not until he began to use the resources available at Michigan that he truly made progress on his path to recovery.

Heininger had previously been reluctant to confide in his teammates or coaches because he feared the stigma attached to mental illness.

“I had an irrational fear that I’d be weak in their eyes, that they’d see me as unstable, someone they couldn’t trust,” Heininger said.

He also worried about how it might affect his reputation outside the team.

“There’s some amount of celebrity, where students don’t understand that athletes are like them. Some people don’t think of athletes as human; they just see them for what they do and their success on the field,” Heininger said. “The more athletes define themselves by what they do, the more susceptible they are.”

But he did eventually open up to his coach, experiencing a self-described breakdown in his office.

“It wasn’t so much courage that finally made me come forward; I was just so sad I didn’t care,” Heininger said.

That is when he found out about the support services available to him and began to have therapy sessions with an athletics counselor. Once he started therapy, Heininger began to better understand depression. Rather than an indictment of himself, he began to recognize its true causes.

“It’s chemicals of the brain really; it’s not anything that’s a representation of you,” he said. “But there’s so much misinformation out there. Most people don’t really understand depression. I didn’t either.”

He also found that instead of being stigmatized, there was an outpouring of support among his friends, family and teammates. Heininger said that contrary to what he imagined, almost everybody was “super receptive” and helpful.

After his own experience as a student-athlete suffering from mental illness, Heininger decided to use the knowledge he gained to help other people experiencing mental illness.

Initially he applied his new understanding of the nature of depression and why people experience it to help his father, who had been experiencing some issues at the time.

Heininger also presented Michigan’s 2013 Mental Health Advocate Awards in February, which are given to graduate and postgraduate students across the country who advance de-stigmatization and improved awareness of mental health issues.

Heininger continues to advocate for better mental health himself, driven by a desire to help others who may be experiencing the same struggles he did.

“I believe in it – if you save one life, you’ve done well,” he said. “I want everyone in the world out there to know that mental illness is a disease, which means that there are professionals who can help you get better. In my ideal world, there is zero stigma associated with mental illness. None.

“Everybody would go to therapy, and there would be nothing wrong with it.”

 -- The preceding was excerpted from “Mindful Healing,” a feature story on student-athlete mental health issues written by Jassim Kunji and published in the Fall 2013 issue of NCAA Champion magazine.