Mental Health

A pragmatic approach

The University of Michigan was one of six awardees that received an NCAA Innovations in Research and Practice Grant in 2014, the first year of the program. The grants are intended to provide tangible benefits to student-athletes, by both informing research geared toward their wellness and more directly, by creating programming aimed at enhancing well-being and mental health outcomes.

Mental health referral for student-athletes: Web-based education and training

Physically and mentally healthy student-athletes are in a good position to thrive academically, socially, and athletically. Unfortunately, many student-athletes fail to get the mental health help they need due to lack of knowledge and/or concerns about mental health stigma. The purpose of this innovation in practice program was to educate NCAA student-athletes via a multimedia, interactive website to enable student-athletes to gain the necessary knowledge, confidence, and skills to make effective mental health referrals. Because this program is web-based, it has the potential to affect student-athlete well-being and mental health across NCAA divisions, geographic regions, and resource availability levels.

Developing and evaluating a model program for supporting the mental health of student athletes

Many student athletes experience mental health problems such as depression, but they are often reluctant to seek help. This project developed and evaluated a multi-faceted program to increase awareness of mental health issues, reduce the stigma of help-seeking, and promote positive coping skills among student-athletes. Brief and engaging videos featuring former Michigan student-athletes who successfully overcame mental health struggles were developed. Support groups were also developed, which used the videos to attract participants and stimulate discussion. The videos and support group protocol were rigorously evaluated to determine their effectiveness.

The Female Athlete Body Project

Female Athletes are a special population of college women, and special attention is required to inform them of the proper nutritional needs of their athletic bodies.

The psychology of sports injuries

The magnitude of the injuries within NCAA athletics is significant. Injuries can hinder performance and negatively impact collegiate athletes’ mental health and well-being, including: threats to self-esteem, social isolation and motivational demands associated with rehabilitation.

Ask the expert: Anxiety and athletes – what can we do?

Anxiety disorders can affect a student athlete’s ability function effectively – academically, athletically or socially. Symptoms of anxiety disorders often worsen under stress.  A student-athlete may be experiencing stress because of the transition of being away from home and adjusting to a new living situation, or worrying about achieving academically, or meeting performance expectations in his or her sport.

Mind, Body and Sport: Mental health checklists

By Scott Goldman

Clinical and sub-clinical changes in mood and mental states can affect the ability of student-athletes to function effectively – on the field of play, in the classroom and during their lifecourse. Many mental health disorders are at least partially rooted in biology. However, environmental stressors – including stressors associated with being a student-athlete – can play a critical role in whether these vulnerabilities turn into burdensome health conditions. One of the best ways to limit the negative consequences of most mental health conditions is early detection and treatment. This is where athletics departments and sports medicine departments can play a critical role: establishing prevention programming and reducing stigma around care-seeking, setting a plan to encourage effective early detection, and communicating to all stakeholders about how to manage emergency and nonemergency mental health issues.  

The following four checklists can help athletics departments and sports medicine departments assess and plan for managing mental health issues among student-athletes.

Checklist No. 1 Prevention And Preparation

1.  Conduct a needs assessment                                       

  • Get input from all relevant stakeholder groups. Learn about perceptions of student-athlete mental health/performance needs, ideas for enhancing mental health performance services for student-athletes and barriers to change. These stakeholders groups will vary by campus but should include:
    • Athletes (talking to your Student-Athlete Advisory Committee is a good place to start).
    • Sports medicine and athletic training staff members.
    • Athletics administrators.
    • Coaches and other staff who have direct contact with student-athletes.
    • Faculty athletics representatives.
  • If you are concerned about getting honest feedback from these stakeholder groups, consider using an anonymous needs assessment form (an example is available at
  • Be sure to talk with your compliance director about concerns she/he may have about pursuing enhanced mental health/performance services for your student-athletes, or to review rules associated with these types of services.

2.  Build relationships

  • •    Contact your state psychology licensing board ( to help identify individuals who could serve as competent referral sources for your student-athletes on your campus and in your community.
  • •    If your campus has a counseling center or other mental health service for students, arrange to meet with the director. Consider asking some of the following questions to get the conversation started:
    • How often do student-athletes use the campus counseling center?
    • Given identified student-athlete needs related to mental health, what do you recommend to better meet these needs?
    • What is the average wait for a student to get services?
    • Have you had specific counselors identified as liaisons to certain areas of campus?
    • Is there anyone in the center who has a background in athletics, or who would be interested to learn about the unique culture of athletics?
    • If a particularly high-profile student-athlete needed to receive counseling services, is there any provision you could offer to protect his/her privacy?
    • Would someone on your staff be willing to provide outreach programs to our student-athletes, or at least come and introduce yourselves to our student-athletes each year?
    • How do you handle psychotropic medication referrals?
    • What kind of psycho-educational assessment services do you offer?
  • Whether working with an on-campus resource (such as the counseling center or psychology department) or an off-campus provider (such as a private practitioner), make sure the provider has the following traits:
    • They are a licensed mental health professional.
    • They have expertise and/or credentialing in clinical AND performance services.
    • They understand and appreciate the unique needs of student-athletes.
  • Initiate interactions with the mental health provider and your student-athletes when there is not a need for service. These non-clinical interactions will establish a rapport between the provider and your student-athletes, which will make it easier when the provider’s services are needed. Some non-clinical interactions include:
    • Presentations about sport psychology to teams.
    • Attending staff meetings with coaches, academic counselors and sports medicine personnel.

3.  Make a plan

  • Before an incident, develop a general plan to address mental health issues and make sure your staff is aware of it. Your plan should be written into your policy and procedures. The plan should include:
    • Flexibility.
    • How to refer and triage.
    • How to educate staff.
    • What to do after hours.
  • Know your school’s policies and procedures for on-campus mental health issues. Ensure that your plan and program are consistent with the campus’ general student population.
    • Know your school’s “duty-to-report” policy on mental health issues.
    • Know how your school manages “conflict of laws.”  For example, do licensed mental health providers on your campus follow HIPAA or FERPA?
  • Establish a liaison between the mental health care provider and the athletics department.

Checklist No. 2

Managing a Nonemergency Mental Health Issue

When student-athletes come to you in emotional distress and they do not present an immediate threat to the safety of themselves or others:

1. Demonstrate compassion

Some helpful tips for calming the student-athlete and demonstrating compassion are:

  • Remaining calm yourself — maintain calm body language and tone of voice.
  • Listen to the student-athlete. Allow him/her to express his/her thoughts. Provide him/her a forum in which he/she can be heard. It’s OK to have a moment of silence between you and the student-athlete.
  • Avoid judging the student-athlete.
  • Provide unconditional support. You do not have to solve his/her problem.
  • Normalize the student-athlete’s experience and offer hope.

2.  Gather information

  • Ask questions, including questions of safety (“Are you thinking of hurting yourself?” and “Are you thinking of suicide?”)
  • Asking the important questions will NOT plant the idea in his/her head.
  • By asking questions about suicide, you will receive valuable information. If he/she hesitates or confirms, you know to elevate the intervention (see “Managing an Emergency Mental Health Issue” checklist).

3.  Make a referral

  • Present the student-athlete with treatment options.
  • When you identify a student-athlete who would benefit from mental health services, but he/she doesn't appear to be aware of this need:
    • Inform the student-athlete matter-of-factly that you believe he/she would benefit from counseling. Base your recommendation on his/her behaviors, or identify specific behaviors that you have noticed and are concerned about.
    • Ask the student-athlete how he/she is feeling, how his/her actions are affecting his/her life, and if he/she has done anything about it so far.
    • Leave open the option for the student-athlete to accept or refuse the recommendation.
    • Encourage time to “think it over.” But, remember to follow up.
    • If the student-athlete refuses to attend counseling, leave the issue open for possible reconsideration.
    • Notify the student-athlete’s team athletic trainer, the director of sports medicine, and the mental health provider affiliated with your department.
    • If the recommendation is accepted, help create a plan to schedule an appointment, and follow up with the student-athlete in a timely manner. You may call the mental health provider with the student-athlete. If you call with him/her, you will know that an attempt to schedule has been made and when the student-athlete’s appointment is, which can assist you in follow-up.
    • Inform your mental health provider that a referral had been made.

4.  Respect boundaries and abilities

  • Know what you’re comfortable doing and what you’re not comfortable doing.
  • Don’t promise secrecy. If necessary, you can say to the student-athlete, “It took courage for you to disclose this information to me. And, by telling me, it says you want to do something about what is going on. The best thing we can do is to inform someone else, such as a mental health provider, who can give you the care you need.”

Checklist No. 3

Managing an Emergency Mental Health Issue

1.  Identify whether there is an immediate threat to safety

  • To identify whether the situation is an immediate threat to safety, ask the following:
    • Am I concerned the student-athlete may harm himself/herself?
    • Am I concerned the student-athlete may harm others?
    • Did the student-athlete make verbal or physical threats?
    • Do I feel threatened or uncomfortable?
    • Is the student-athlete exhibiting unusual ideation or thought disturbance that may or may not be due to substance use?
    • Does the student-athlete have access to a weapon?
    • Is there potential for danger or harm in the future?

2.  Manage immediate risks

  • •    In the case of an immediate risk to safety:
  • o Keep yourself safe — do not attempt to intervene.
  • o Keep others safe — try to keep a safe distance between the student-athlete in distress and others in the area.
  • o Get help from colleagues.
  • o If the student-athlete seems volatile or disruptive, alert a co-worker for assistance. Do not leave the student-athlete alone. However, do not put yourself in harm’s way if he/she tries to leave.
  • o Call 911 or campus security, or have the person taken directly to the emergency department at the nearest hospital.
  •      ◊ When you call, be prepared to provide the following information:
  •             ○ Student-athlete’s name and contact information.
  •             ○ Physical description of the student-athlete.
  •                 ♦ Height, weight, hair and eye color, clothing, etc.
  •             ○ Description of the situation and assistance needed.
  •             ○ Exact location of the student-athlete.
  •             ○ If the student-athlete leaves the area or refuses assistance, note the direction in which he/she leaves.
  •             ○ Follow campus and department protocols and policies.
  • •    If possible, offer a quiet and secure place to talk.
  • o Listen to the student-athlete; maintain a consistent, straightforward and helpful attitude.
  • o If the student-athlete is expressing suicidal ideation:
  •      ◊ Listen.
  •      ◊ Show your genuine concern.
  •      ◊ Emphasize risk to safety.
  •      ◊ Do NOT leave the person alone.



How to ask about suicide:

“Are you/Have you been thinking about suicide?”

“Are you/Have you been thinking about killing yourself?”

“Sometimes when people are (your observations), they are thinking about suicide. Is that what you’re thinking about?”


How NOT to ask about suicide:

“You’re not thinking about suicide, are you?”



3.  Contact a mental health care provider

•    Make arrangements for appropriate university intervention and aid.

•    Call the mental health provider to initiate next steps of care.

•    If medical care seems appropriate, head to the nearest hospital or call 911.

•    If the student-athlete is expressing suicidal ideation, make a referral for a suicide risk assessment.

    o On-site mental health professional.

    o Local hospital.

    o Local crisis line/mobile assessment team.

        ◊  Suicide hotline: 1-800-784-2433 or 1-800-273-Talk.




Checklist No. 4

After Managing a Mental Health Issue


1.  Initiate follow-up care

•    Identify what is needed for follow-up care.

•    Identify available resources.

•    Initiate continuity of care:

    o How is the mental health issue going to be managed within the athletics department?

    o If the issue is not to be managed within the athletics department, how do you make appropriate referrals and

    transitional steps to ensure the safety and well-being of those involved?



2.  Debrief and plan for the future

•    Schedule a meeting with athletics department staff involved with the intervention and athletics department staff who will be involved moving forward. While maintaining appropriate confidentiality:

    o Identify the strengths of the intervention approach.

    o Identify what did not work with the intervention approach.

    o Identify what improvements could be made to the departmental protocol for prevention, early detection and

    management of mental health issues.


 For more resources, see

Mind, Body and Sport: Understanding and supporting student-athlete mental wellness


Brian Hainline, NCAA Chief Medical Officer


Chapter 1 – First-Person Perspective

  • Game Face Is Not the Only Face (By Aaron Taylor, former football student-athlete)
  • Living the Dream – and Waking Up To Reality (By Cathy Wright-Eger, former coach)
  • Resilience, Empathy and True Toughness (By Molly McNamara, cross country and track student-athlete)
  • One Coach’s X and O: Pay Attention, Give Permission (By Mark Potter, current coach)
  • Make the Experience Positive (By Bradley Maldonado, Division II Student-Athlete Advisory Committee)
  • Solving the Mental Health Puzzle (By Rachel Sharpe, current assistant athletic trainer)

Chapter 2 – Positioning the Experts

The Psychologist Perspective (By Chris Carr and Jamie Davidson)

The Psychiatrist Perspective (By Todd Stull)

Chapter 3 – Dissecting the Disorders

Eating Disorders (By Ron Thompson)

Anxiety Disorders (By Scott Goldman)

Mood Disorders and Depression (By Chris Bader)

Depression and Anxiety Prevalence in Student-Athletes (By Ann Kearns Davoren and Seunghyun Hwang)

Substance Use and Abuse (By Brian Hainline, Lydia Bell and Mary Wilfert)

Gambling Among Student-Athletes: Cause for Concern (By Jeffrey L. Derevensky and Tom Paskus)

Sleeping Disorders (By Michael Grandner)

Suicidal Tendencies (By David Lester)

Education-Impacting Disabilities and the NCAA Waiver Process (By Marcia Ridpath)

Chapter 4 – The Big Injury (And Small Ones, Too)

How Being Injured Affects Mental Health (By Margot Putukian)

Post-Concussion Syndrome (By David Coppel)

Supporting Student-Athletes in Transition (By Penny Semaia)

Chapter 5 – Social and Environmental Risk Factors

Risk Factors in the Sport Environment (By Emily Kroshus)

Harassment and Discrimination – Ethnic Minorities (By Terrie Williams)

Harassment and Discrimination – LGBTQ Student-Athletes (By Susan Rankin and Genevieve Weber)

The Haunting Legacy of Abuse (By Cindy Miller Aron)

Interpersonal Violence and the Student-Athlete Population (By Lydia Bell and Mary Wilfert)

Potential Barriers to Accessing Mental Health Services (By Ken Chew and Ron Thompson)

Chapter 6 – What Do You Do Now?

Best Practices for Athletics Departments (By Chris Klenck)

Interassociation Recommendations (By Timothy Neal)

Mental Health Checklists (By Scott Goldman)

Mind, Body and Sport: Interassociation recommendations

By Timothy Neal

The athletic trainer holds a unique position in college sports. In addition to being charged with protecting student-athlete health and safety, the athletic trainer often is a friend and companion – sometimes even a confidant – for the hundreds of student-athletes in his or her care. In fact, it is the athletic trainer who is often alongside even during a student-athlete’s worst moments. Usually, those worst moments entail a physical injury that ends the student-athlete’s season or career, and in some cases may threaten the student-athlete’s life.

Increasingly, though, some student-athletes’ worst moments are not physical in nature, but are a result of psychological concerns that affect the student-athlete’s well-being.

As such, the following is an executive summary of the NATA-sponsored, Interassociation Consensus Statement: “Recommendations in Developing a Plan for Recognition and Referral of Student-Athletes with Psychological Concerns at the Collegiate Level.”

These recommendations should help athletic trainers create a student-athlete “psychological concerns plan” in their athletics departments, and encourage them to collaborate with university departments to better assist student-athletes and manage institutional risk.


Studies are starting to reveal the growing prevalence in the types, severity and percentage of mental illnesses in young adults ages 18 to 25, the same age group that includes most college students and student-athletes. Data indicate that approximately one in every four to five youths in America meets criteria for a mental health disorder, with severe impairment across a lifetime.

The U.S. Substance Abuse and Mental Health Services Administration reported in 2012 that 45.9 million American adults age 18 or older (20 percent of the survey population) experienced a mental illness in 2010. The rate of mental illness was more than twice as high in those in the 18- to 25-year-old range (29.9 percent) as it was in those age 50 years and older (14.3 percent).

Given that more than 460,000 student-athletes participate in NCAA intercollegiate sports, it’s likely that every athletic trainer will encounter at least one student-athlete with a mental health issue during his or her career.

Behaviors to monitor

Most student-athletes manage the stressors of being both a student and an athlete without any long-term consequence to their mental well-being. Some student-athletes, however, will not be aware of how a stressor is affecting them – or if they are aware of their potential psychological concern, they will not inform anyone but may well act out in a non-verbal way to alert others that something is bothering them.

Following are some of the behaviors athletic trainers should monitor that may indicate a psychological concern in a student-athlete:

  • Changes in eating and sleeping habits
  • Unexplained weight loss or gain
  • Drug or alcohol abuse
  • Gambling
  • Withdrawing from social contact
  • Decreased interest in activities the student-athlete previously considered enjoyable, or taking up risky behavior
  • Talking about death, dying, or “going away”
  • Loss of emotion or sudden changes of emotion within a short period
  • Problems concentrating, focusing or remembering
  • Frequent complaints of fatigue, illness or being injured that prevent participation
  • Unexplained wounds or deliberate self-harm
  • Becoming more irritable or having problems managing anger
  • Irresponsibility, lying
  • Legal problems, fighting, difficulty with authority
  • All-or-nothing thinking
  • Negative self-talk
  • Feeling out of control
  • Mood swings
  • Excessive worry or fear
  • Agitation or irritability
  • Shaking, trembling
  • Gastrointestinal complaints, headaches
  • Overuse injuries, unresolved injuries, or continually being injured

Circumstances that may affect a student-athlete’s mental health

By nature of the profession, athletic trainers are accustomed to dealing with injury. But as has been pointed out earlier in this publication (Chapter 4), the athlete’s psychological response to an injury can manifest in many ways.

Injury. Whenever a student-athlete is injured, those caring for the student-athlete should consider a possible psychological response to the injury. Any injury, especially a season-ending or career-ending injury, or a chronic injury that needs constant attention to participate, may become a source of stress to the student-athlete. Additionally, a student-athlete returning from a significant or time-loss injury may also experience a fear of re-injury.

Concussion. Our evolving awareness of the aftereffects of concussions includes the cognitive and psychological consequences on the student-athlete. After a concussion, the student-athlete should be monitored for any changes in behavior or self-reported psychological difficulties, both while recovering from the concussion and during their return to play after the injury.

ADHD. The prevalence of behavior disorders includes attention deficit hyperactivity disorder (ADHD) at 8.7 percent of the population. Some legitimate medications for this disorder contain NCAA-banned substances, namely stimulants; however, student-athletes with ADHD may need these medications to support their academic performance and general health. The NCAA has specific requirements for student-athletes with ADHD who want to compete while taking a banned stimulant.

Alcohol and substance abuse. Despite the risk of negative results, including diminished performance and the loss of scholarships, some student-athletes use illegal substances and alcohol at higher rates than do age-matched non-athletes. Student-athletes also report more binge drinking than the general student population because they view alcohol use as “normal.”

Approach and referral

The stigma that is still stubbornly attached to mental health issues can inhibit a student-athlete from seeking an evaluation and care. Approaching a student-athlete with a concern about his or her mental well-being can be an uncomfortable experience for anyone, including an athletic trainer. It is important that you have the facts correct, with context, relative to the behavior of concern before arranging for a private meeting with the student-athlete. The conversation should focus on the student-athlete not as an athlete, but as a person. Empathetic listening is vital. Encouraging the student-athlete to seek a mental health evaluation can be put in perspective, reminding the student-athlete that his or her psychological health is just as important as physical health. As Newman University men’s basketball coach Mark Potter said in Chapter 1 of this publication, permission to seek help is sometimes the best tonic for the problem.

Once a student-athlete self-reports wanting an evaluation, or agrees to go for a mental health evaluation, the student-athlete should be referred expeditiously to a mental health care professional. If possible, help set up the initial appointment. Having an established relationship with counseling services or community mental health professionals is highly recommended to expedite referrals.

If student-athletes demonstrate or voice an imminent threat to themselves, others or property (which, in many cases, rises to a code-of-conduct violation), or they report feeling out of control or unable to make sound decisions, then an emergent mental health referral is recommended. A university’s psychological concerns plan should include the protocol for emergent referral.


The issue of informing the student-athlete’s coach or parents invariably comes up. In a routine referral, inform student-athletes that while their referral is confidential, it may be helpful if they informed their coach and parents of their appointments. The student-athlete is not compelled to do so, but the athletic trainer should emphasize that coaches and parents are concerned about each student-athlete’s well-being, and keeping health care providers and coaches informed of their mental health care (without disclosing confidential information) is no different than any other forms of physical care. Encourage the student-athlete to inform his or her coach or parents, but do not insist on it.

When referring to community-based mental health care professionals where the student-athlete’s medical insurance may be used, it is important to inform student-athletes that their parents or guardians will receive notification of their mental health care treatment from their insurance company in the form of an explanation of benefits notification.

Campus counseling services and satastrophic incidents

It is important that the campus counseling center has a relationship with the athletics department, and that its mental health professionals understand the unique variables of student-athletes. It helps to identify an individual within the athletics department who is the primary contact. Because health and wellness falls under the purview of the athletic trainer, it is acceptable that the athletic trainer serve as the point person for referrals.

Stress reactions after a catastrophic incident are typical human reactions to the event. Many, if not most, of these reactions are self-limiting and will resolve with support, time and natural resilience. However, whenever a reaction persists, referral for mental health support is indicated. After a catastrophic incident (for example, death of a student-athlete or coach, or a disabling injury), offering early psychological intervention for those potentially affected has shown to be more effective in resolving traumatic stress than waiting before mental health care is implemented.

Risk management and legal counsel

University administrators face the challenge of managing the risks associated with mental health within the student-athlete population. To prepare for and respond to mental health incidents, administrators should be aware of risk management implications and be involved in developing the psychological concerns plan.

Legal considerations promote the idea that an interdisciplinary approach, including individuals in various departments within the institution of higher education, should be a goal in confronting the complex issues of mental health and the student-athlete. Two good resources for a university general counsel on the issues involved are “Managing the Student-Athletes’ Mental Health Issues” from the NCAA, and “Student Mental Health and the Law: A Resource for Institutions of Higher Education” from the Jed Foundation.

For in-depth information on how to develop your own institutional plan and develop an educational component on psychological health for your student-athletes, download the full NATA Consensus Statement on Developing a Plan for Recognition and Referral of Student-Athletes with Psychological Concerns at the Collegiate Level at

Timothy Neal is the assistant director of athletics for sports medicine at Syracuse University, where he provides leadership and supervision of seven full-time athletic trainers and 10 graduate assistant athletic trainers. He’s also a member of the New York State Board of Athletic Training and received the National Athletic Trainers’ Association’s Most Distinguished Athletic Trainer Award in 2010. Neal authored the “Catastrophic Incident in Athletics” guideline, and authored revisions in the “Mental Health: Interventions for Intercollegiate Athletics” guideline, in the NCAA Sports Medicine Handbook. He also served on the panel for the NCAA Concussion in Sport Medical Management Summit. In addition, Neal served as the NATA liaison to the NCAA Football Rules Committee from 2004-09, writing language for the helmet contact penalty, defenseless opponent penalty, and the horse-collar tackle penalty in college football.

Mind, Body and Sport: Best practices for athletics departments

By Chris Klenck

While the previous chapters in this publication have expertly documented the unique challenges student-athletes face regarding mental health, individuals charged with caring for student-athletes need help recognizing and managing these concerns.

The purpose of this article is to identify “best practices” for establishing mental health services at the collegiate level. While “best practices” are defined as “methods or techniques that have consistently shown results superior to those achieved with other means,” medical “best practices” often are considered to be no more than expert opinion.

In addition, individual athletics departments (and campuses overall) vary regarding the resources they have available to allocate toward mental health services. Thus, perhaps the best approach is to suggest key components believed to be consistent with “best practices” for establishing mental health services at the collegiate level, while allowing individual institutions to formulate their own consensus as to the best way to incorporate these components into the fulfillment of their unique needs.

The following eight components are suggested for constructing mental health services on college campuses:

Identifying members of the mental health services team. While institutions will vary greatly with respect to human resources available to them, all collegiate athletics programs should have both an athletic trainer and designated team physician who will serve as core members of the mental health team. These individuals may not be mental health experts, but they can serve as a “point person” for referring student-athletes to the appropriate professional for evaluation and treatment.

Other ideal core members should include a psychiatrist, a clinical psychologist or a licensed clinical social worker with experience in mental health counseling. As these professionals may not be readily available to all athletics departments, it is critically important that the institution collaborate with on-campus services such as university counseling services or student health services, or off-campus services such as community mental health facilities or hospital clinic, private psychiatric, psychological, or other psychotherapy practices, and disordered eating clinics.

Establishing these relationships before a specific need is particularly important when timely referrals are essential. Additional team members may include sport psychologists, licensed drug and alcohol counselors, a team chaplain, academic counselors, sport dietitians, athletics directors or sport administrators, and coaches. Finally, the confidentiality of the student-athlete should always be of utmost importance and taken into consideration when involving various members of the team.  

Raising awareness of the mental health services available. The goal is to ensure that every student-athlete or athletics department member is familiar with the services available and how to access them. Potential ways to accomplish this goal include: (1) presentations at team meetings; (2) presentations at coaches or staff meetings; (3) printed handouts or pamphlets with program information and contact numbers; (4) information posted on athletics department websites; and (5) use of social media (such as Facebook). Increased awareness will enhance the likelihood of self-referrals by student-athletes or referrals from teammates, coaches or other staff, and improving the timely evaluation of those student-athletes in need.

Screening, recognition and appropriate referral. Screening student-athletes for psychological concerns such as depression and anxiety is extremely important for early recognition and intervention. Pre-participation physical examinations (PPE) afford an excellent opportunity to screen for and discuss issues such as depression, anxiety and disordered eating. Many PPE questionnaires specifically address these issues and can be a useful tool for screening. Other validated screening tools include the PHQ-9 Patient Depression Questionnaire.

It’s also important to ask about current and past prescription medications, recreational drug and alcohol use, and family history of mental health issues, as these are important indicators of possible psychological and psychiatric concerns.  

In addition to screening, it is important that both student-athletes and those working with them are able to recognize signs and symptoms of potential mental health issues. Behaviors such as missing classes, uncharacteristically poor academic or athletics performance, frequent physical complaints, disheveled appearances, and fighting with teammates or coaches can suggest an underlying mental health issue.  

Educational sessions with student-athletes and staff about the recognition of mental health concerns and the importance of timely referral will help improve outcomes for those affected. Special emphasis should be made to discourage unqualified individuals from attempting to counsel or treat student-athletes in need of professional care.  

Communication among members of the mental health services team. Communication among appropriate team members enhances appropriate follow-up and helps track progress. As confidentiality is always a chief concern, it is important early on to identify those individuals with whom the student-athlete will allow to share information, and to obtain appropriate written releases as indicated.  

The mental health services team should meet weekly to discuss the care of student-athletes. These sessions help identify those student-athletes who are not attending appointments or making progress toward their goals.

HIPAA-compliant text messaging or emailing can also help facilitate communication among providers.

Medication management. It is important to help student-athletes manage medications that may be prescribed to them. Many medications, such as antidepressants, may have undesirable side-effects or provide inadequate efficacy, which leads to poor compliance. Consideration should be given to having one provider, such as the team physician, prescribe all medications when indicated. The team physician frequently interacts with the student-athletes and athletic trainers. As such, this strategy may improve communication of adverse effects and will allow monitoring of refill requests to ensure compliance and appropriate use.  

Crisis management. A student-athlete may present in “crisis” at any time. Issues such as active suicidal or homicidal ideation, acute psychotic episodes, or death of a family member, teammate or staff often require immediate professional attention. Having an established crisis management plan prevents lapses in care and improves outcomes. Every student-athlete who is at risk of a crisis should have a “safety plan” developed with a member(s) of the mental health team. He or she should be provided with contact numbers and a written plan of how to access services at any time if a crisis should arise. In addition, collaborating in advance with local resources such as crisis stabilization units, mobile crisis evaluations, or emergency rooms at hospital facilities will streamline care when needed.

Risk management. Mental health service members and athletics department staff should be aware of their responsibilities to report specific behaviors to appropriate institution officials or law enforcement officials when indicated. Examples of such behaviors may include expressing intent to harm another person or suspected sexual involvement with a minor. Educational sessions with university officials involved in risk management are strongly encouraged so each mental health services team member is aware of his or her legal responsibilities while providing care.

Transition of care. A final component for establishing mental health services is the transition of care for student-athletes who are leaving the athletics department. As student-athletes graduate, transfer, are dismissed from teams or are removed from continued participation due to their condition, a plan should be in place for the timely and orderly transition of their care to another provider. Helping the student-athlete identify a primary care physician, mental health care professional, or other provider in his or her community will ensure appropriate follow-up and continued care. Providing written information about mental health resources available to the student-athlete in his or her community may also facilitate his or her care. Finally, providing the student-athlete with a sufficient supply of prescription medications until he or she can establish care with another provider, and arranging for delivery of medical documentation to appropriate providers, will ensure a smooth transition of care.  

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While diagnosis and treatment of physical injuries and illnesses are critical to the success of student-athletes, so should management of their mental health needs.  

Mental health services should be a part of the comprehensive care provided to student-athletes at the collegiate level. In successfully integrated healthcare programs, mental health issues are treatable, and positive outcomes through timely access to care are likely.  

Even though available resources vary from one athletics department to another, all institutions should be able to establish certain basic components for establishing mental health services. Care that encompasses the entire well-being of the student-athlete is certain to translate into success both on and off the playing field.

Chris Klenck was named team physician at the University of Tennessee, Knoxville, in November 2006 after a primary care sports medicine fellowship at Indiana University Medical Center. During his fellowship training, Klenck was an assistant team physician for the Indianapolis Colts preseason training camps and at Purdue University (his alma mater), and he worked the NFL Scouting Combines in Indianapolis. He has NCAA championships experience and served as a team physician in the Indiana high school ranks. Chris earned his doctor of pharmacy degree from Purdue before completing his doctor of medicine degree at Indiana University School of Medicine. He is a member of the American Academy of Pediatrics, American College of Physicians, American Medical Society for Sports Medicine and America College of Sports Medicine.



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