Mental Health

Mind, Body and Sport: Suicidal tendencies

By David Lester

While there’s no “good” news when it comes to suicide, the silver lining at least is that it is not especially common in undergraduate college and university students. Some studies report suicide rates that are lower than young people of the same age who are not in college, and some studies report similar suicide rates for the two groups.

As a result, when we turn to college student-athletes, there are very few cases of completed suicide. However, we do know what kinds of factors and stressors might lead to an attempted suicide, and we do know that participation in sports can actually protect against some of those stressors.

At the present time, student-athletes appear to be less likely to have suicidal ideation and to make suicide attempts than other college students, but the protective impact of sports varies with the type of sport, sex and ethnicity. The protective effect is most evident in white male student-athletes playing in traditionally “male” sports.

For amateur athletes, researchers have focused on suicidal ideation and attempted suicide, and most of the research has been conducted on high school athletes. The Centers for Disease Control and Prevention have conducted a Youth Risk Behavior Surveillance of high school students every two years from 1991 to 2011.

Of those studies, eight showed a protective effect for boys while three showed no effect. For girls, six studies showed a protective effect, one a detrimental effect, and four no effect. The protective impact of sports on suicidal ideation and attempts was, therefore, more evident for boys than for girls.

There also seemed to be an impact of ethnicity, with the protective effects more evident for white boys than for boys of other ethnicities.

We can only speculate about the reason why participation in sports generally finds a protective impact for suicidal behavior in most studies. First, participation in sports involves physical activity, and exercise may reduce depression. Second, participation in sports has many positive side effects, including the social bonding from being in a team and the increase in self-esteem from achieving success in the sport.

On the other hand, participation in some sports may increase the likelihood of hazing (especially of rookies), alcohol abuse, risky sexual behavior and violence. Since the limited research indicates a protective impact from sports participation, it would appear that the positive effects outweigh the negative ones.

A recent study reported that the protective impact of sports was found for some team sports, but that participation in a sports activity not generally engaged in by those of one’s own sex is detrimental. For example, boys who were cheerleaders and girls who were wrestlers more often reported suicidal ideation. The study also found that the protective effects of sports participation were not as clear in African-American, Hispanic-American and Asian-American students.

Some studies have been conducted recently that explore suicide in professional athletes and the risk factors that predict these suicides. Many of these factors may apply to the student-athlete population as well.

Anabolic-Androgenic steroids. Professional athletes’ anabolic-androgenic steroid use has been clearly documented in recent years, and research has found that it increases the risk of both suicide and outwardly directed violence such as assault and murder. One study of power lifters in Finland found that 38 percent of the deaths of power lifters who used steroids were from suicide as compared with only 3 percent of the deaths of Finnish men in general.

Concussions. Concern about the role that concussions (mild traumatic brain injury) in sports play in athletes has increased, especially with the revelation that some former professional football players have developed chronic traumatic encephalopathy (CTE). Although depression is more common in professional football players who have suffered with multiple concussions, there is no clear relationship that has been described in collegiate football players. Suicide has occurred in professional football players who developed CTE, but the causal relationship between CTE and concussion is unknown, and the relationship – if any – of suicide and CTE is also unknown.

Drug abuse and alcoholism. Both are common in professional athletes, and college student-athletes, as noted in the prior article “Substance Use and Abuse,” are also at risk for these issues. Substance abuse of any kind is a risk factor for suicide.

Psychiatric problems. Many professional and collegiate athletes have psychiatric symptoms, some of which predate their involvement in athletics and some of which are exacerbated by their sports careers. Psychiatric problems are another major risk factor for suicide.

Bullying and sexual abuse. Some studies indicate that up to 10 percent of Olympic athletes endured bullying and sexual abuse as children and adolescents, often as part of their sports involvement. In recent years, several coaches have been found guilty of sexually abusing players, and hazing and bullying, especially of rookies, are part of the culture of sports. Again, these experiences are important risk factors for suicide.

Retirement. Retirement is perhaps the most important risk factor for suicide in professional athletes. Studies of baseball players and cricket players who died by suicide found that very few professional athletes died by suicide during their careers. Most killed themselves after their careers were ended either by injury, being fired or retiring. Many professional athletes have made no plans for their lives after their careers are over and when they are no longer in the spotlight. They may have pain and physical impairment from the injuries that they received during their careers, and they may face serious financial problems once their income ends, especially if they have incurred expensive long-term costs (such as alimony and child support) and if they spent their wealth unwisely during their professional careers.

Given all of these risk factors, how common is suicide in professional athletes? A 2013 study found that, after controlling for age and sex, those currently listing their occupation as athletes did not have a higher risk of suicide, although they did have a higher risk of death from all violent causes (suicide, accidents and murder). In baseball, 1 percent of deceased players are documented to have died from suicide, less than expected for men in the United States. And for cricket in Great Britain, a 2001 study found that 1.5 percent of deaths were from suicide, again not especially high. Most of these suicides occurred in players no longer active in the sport.

Clearly, much more research is needed on this important topic to identify the reliable associations regarding suicide and suicidal ideation, and the causal mechanisms underlying these associations.

David Lester is a distinguished professor of psychology at the Richard Stockton College of New Jersey. He is a former president of the International Association for Suicide Prevention. Lester has published extensively on suicide, including “Understanding and Preventing College Student Suicide” (Charles C. Thomas, 2011) and “Suicide in Professional and Amateur Athletes” (Charles C. Thomas 2012).

Mind, Body and Sport: Sleeping disorders

By Michael Grandner

There’s a reason most people spend about one-third of their lives asleep. Sleep is not a passive state of rest, but an active state of rebuilding, repair, reorganization and regeneration.

During waking hours, we engage with the environment, taking in information, interacting with others and forming new memories and experiences. During sleep, the body performs many other vital functions for which it needs to be disconnected from the environment. For example, sleep plays an important role in memory consolidation, emotional regulation, growth and cell repair.

Despite the importance of sleep, difficulties are common. Most adults need seven to eight hours of sleep to maintain optimum functioning, and younger adults need more (eight to 10 hours). However, many people – including student-athletes – do not get the amount of sleep they need, often due to insomnia, sleep apnea or another sleep disorder.

Lack or loss of sleep can also be due to the many competing demands for time, which is a prominent concern in the student-athlete population. Either way, understanding and dealing with sleep problems may have a profound effect on mental clarity and health.

Inside the sleep process

Sleep is made up of two distinct states – REM (rapid eye movement) sleep, and non-REM (NREM) sleep. Most of the night is spent in NREM sleep, which is made up of:

  • Stage 1 (very light, transitional sleep)
  • Stage 2 (moderate sleep)
  • Stage 3 (deep sleep)
  • Stage 4 (very deep sleep)

REM sleep makes up about 20 percent of the night and is associated with (as the name implies) rapid eye movements. It is also characterized by a high degree of brain activity (similar to light sleep or waking). Dreams are common in REM sleep, and people would act out their dreams if it were not for signals from the midbrain that actively prevent skeletal muscle activity. Therefore, REM sleep is accompanied by lack of muscle tone (similar to paralysis).

Stages 3 and 4 of NREM sleep are crucial for growth, and cell rebuilding and repair. Stage 2, which accounts for more than 50 percent of the night, is important for many cognitive and bodily functions. For example, sleep is critically important for regulating many hormones that control stress, hunger and appetite, growth and healing, and biological rhythms. As such, sleep disruption is likely to disrupt any combination of these systems.

Almost 40 percent of American adults (about 80 million people) get six hours of sleep or less. The average American adult reports about two nights of insufficient sleep per week.

Insomnia, defined as a persistent difficulty falling or staying asleep, accompanied by daytime impairment, is common. Approximately one in three U.S. adults suffer from symptoms of insomnia, and about one in three of those meet criteria for an insomnia disorder (which is associated with increased risk of depression, substance use and medical problems).

Sleep apnea is also common. It is a condition in which an individual has difficulty breathing during sleep, usually because of a blocked airway, in which case it is referred to as “obstructive sleep apnea.”

It is estimated that among adults age 30 and older, rates for sleep apnea are 10-15 percent and 3-9 percent among men and women, respectively. This is significant, since sleep apnea is associated with obesity, cardiovascular disease, diabetes and neurological problems. Diagnosing and treating sleep apnea is a critical issue, since most people with the disorder do not know they have it, and untreated sleep apnea is a major health risk factor.

Since body type (such as obesity and thick neck) can play a role in developing sleep apnea, certain student-athletes may be at high risk for the disorder, especially football linemen.

How student-athletes are affected

There hasn’t been much research on student-athlete sleep patterns and problems, but given the timing of practices, travel and competition, student-athletes are likely at high risk of sleep difficulties. In addition, extra time demands, including balancing athletics with academics, can reduce sleep opportunity.

An American College Health Association survey found that on average, most student-athletes report four nights of insufficient sleep per week. However, insomnia diagnosis was very low, at 3 percent in athletes versus 2 percent in non-athletes.

An NCAA study showed that one-third of student-athletes get fewer than seven hours of sleep per night, with greater values among women.

Other studies have shown that improving sleep can lead to better performance. As such, it would benefit athletics departments to monitor their student-athletes’ sleeping patterns to ensure proper behaviors.

As to the causes for sleep deprivation in the student- athlete population, the balancing act they must perform in being both a student and an athlete (and having a well-rounded college experience) can frequently impinge on sleep time. Making sleep an important priority and a part of more general work-life balance may help student-athletes better manage their time, their stress – and their sleep.

Athletics departments also should pay closer attention to student-athletes who travel frequently for competition. Travel across time zones can result in jet lag, which can take a physiologic toll on the body and also impair physical and cognitive performance. In addition, travel (even within a time zone) can involve uncomfortable sleeping arrangements, disrupted schedules, and other changes that can impair physical and mental health in the short and long term.

What athletics departments can do

It would behoove athletics departments to have a comprehensive sleep disorders screening and treatment program available for their student-athletes. And before you say your school doesn’t have the resources to create or maintain such a program, assessing sleep problems doesn’t have to be costly or cumbersome.

Polysomnography (“sleep study” in the laboratory) is the most intensive approach to sleep assessment. It measures brain activity, muscle activity on the chin and legs, heart rhythm, and breathing effort in the chest and abdomen, among other things. Polysomnography is usually performed at a sleep center accredited by the American Academy of Sleep Medicine.

These types of studies are most useful for the detection of sleep apnea and sleep-related movement disorders, especially complex cases. For the detection of routine sleep apnea, home-based sleep recording, using portable devices that measure respiratory flow and effort and oxygen saturation, have been shown to be a useful, lower-cost option.

Insomnia and other problems with habitual sleep schedules are usually assessed with a daily sleep diary or wrist actigraphy (a device that records movement, providing an objective estimate of sleep and wake time).

Several brief screening questionnaires that can detect problem sleep are also available, including the Pittsburgh Sleep Quality Index, the Insomnia Severity Index, the STOP questionnaire and the Berlin Questionnaire.

In assessing general problems, getting information about weekday and weekend time into bed, the time it takes to fall asleep (sleep latency), the number of awakenings, the duration of awakenings (wake after sleep onset), the final awakening time and final time out of bed can discern sleep timing, duration and overall quality of sleep, thus revealing the nature of many sleep problems.

Athletics departments can develop partnerships with local or regional sleep centers (accredited by the American Academy of Sleep Medicine: to develop and implement long-term solutions for the problems that sleep disorders pose.

Taken together, raising awareness about sleep, getting students (and staff) appropriately screened, monitoring patterns and delivering helpful treatments are critical for maintaining student-athletes’ long-term mental health.

Michael Grandner is an instructor in the department of psychiatry and a member of the Center for Sleep and Circadian Neurobiology at the University of Pennsylvania’s Perelman School of Medicine. He completed his graduate training in clinical psychology at San Diego State University and the University of California, San Diego, including an APA internship with the behavioral medicine service at the San Diego VA Healthcare System and Outpatient Psychiatric Services at UCSD. Read more about Grandner’s work at and

Mind, Body and Sport: Gambling among student-athletes

By Jeffrey L. Derevensky and Tom Paskus

Gambling remains one of the fastest-growing industries in the world, with multinational corporations investing billions of dollars to attract customers. While age restrictions exist in most jurisdictions (the age often is dependent upon the type of gambling), it is an activity in which many colleges students participate.

Most individuals gamble legally, occasionally and in a generally responsible manner (that is, setting and maintaining time and money limits). However, for a small but identifiable subset of youth, gambling can quickly escalate out of control and affect both psychological and physical well-being.

Excessive, problematic or pathological gambling has been repeatedly shown to result in consequences that can include deviant anti-social behaviors, decreased academic performance, impaired athletics performance, and criminal and legal problems.

Generally, the social and problem gambling experiences of college student-athletes are similar to those of other youth gamblers. Results of a 2012 study that the NCAA commissioned found that 57 percent of male student-athletes and 39 percent of female student-athletes reported gambling in some form during the past year, with those student-athletes in Division I reporting the lowest incidence of gambling (50 percent for males; 30 percent for females).  

While pathological gambling is a problem that affects relatively few student-athletes, it is nonetheless a persistent health concern for some individuals: 1.9 percent of males and 0.2 percent of female student-athletes are exhibiting some clinical signs of problem gambling, placing them at extremely high risk for mental health issues.

One notable difference between student-athletes and their peers is that student-athletes tend to be drawn to sports wagering at higher rates. This is not surprising, given their background and interest in sports. However, for student-athletes, wagering on sports can have negative consequences even if the behavior is not classified as excessive or pathological.  

To protect the integrity of college athletics contests, NCAA regulations prohibit student-athletes from betting money on any sporting event (college, professional or otherwise) in which the NCAA conducts collegiate championships. Violations of this regulation can result in a student-athlete losing his or her athletics eligibility, which has clear negative repercussions for the individual and his or her team.

Despite NCAA regulations prohibiting sports wagering for money, 26 percent of male student-athletes report doing just that, with 8 percent gambling on sports at least monthly.  Of particular concern is the culture surrounding golf, where on-course wagering is considered a normative aspect of the experience. Males who participate in NCAA golf are approximately three times more likely to wager on sports (or engage in other gambling behaviors) than other student-athletes.  

While most student-athlete sports wagering occurs solely among friends and teammates, many are now placing bets with online sites or using bookmakers they can access easily via their smartphone. Technology is also allowing outside gamblers seeking “inside” betting information easier access to college student-athletes (for example, through social media). Nearly 1 in 20 Division I men’s basketball student-athletes in the 2012 study reported having been contacted for such inside information.    

Unlike other more publicized addictive behaviors (for example, alcohol, drug abuse, tobacco consumption), gambling problems often go undetected. It is important that student-athletes and athletics personnel understand that a gambling problem parallels other addictive behaviors. Helping student-athletes with a gambling disorder requires education, early assessment, an acknowledgment of a potential problem and effective referrals into the mental health care system.

The ability to identify the college-age problem gambler may be more difficult today because more of it is occurring online. But two-thirds of student-athletes believe that teammates are aware when a member of the team is gambling. They also report that the coach has a strong influence on tolerance for gambling behaviors and for empowering members of the team to intervene when a teammate needs help. Athletics departmental personnel, including athletic trainers and coaches, are in a unique position to observe and interact with student-athletes on a daily basis and help refer student-athletes for the appropriate assistance should such a need arise.

Gambling behaviors among male student-athletes

  2004 Study 2008 Study 2012 Study
  Past Year 1/month + Past Year 1/month + Past Year 1/month +
Played cards for money 46.8% 20.6% 45.9% 14.3% 27.4% 6.1%
Bet horses, dogs 9.8% 2.0% 8.5% 1.4% 6.5% 1.5%
Games of personal skill 39.7% 16.3% 33.1% 13.0% 25.4% 9.9%
Dice, craps 13.4% 4.3% 11.7% 3.9% 7.8% 2.5%
Slots 19.8% 3.6% 15.1% 2.0% 11.9% 1.8%
Lottery tickets 36.2% 11.1% 31.4% 9.1% 35.2% 11.1%
Played stock market 10.2% 4.7% 9.2% 4.5% 7.4% 3.6%
Commercial bingo 6.5% 0.9% 6.9% 1.1% 5.3% 1.2%
Gambled in casino 22.9% 3.8% 18.7% 3.3%
Bet on sports 23.5% 9.6% 29.5% 9.6% 25.7% 8.3%
Casino games on Internet for money 6.8% 2.8% 12.3% 4.7% 7.5% 1.9%

Percentages displayed are cumulative rather than independent. A student-athlete reporting having wagered “once/month or more” is also included in the “past year” figure.


Gambling behaviors among female student-athletes

  2004 Study 2008 Study 2012 Study
  Past Year 1/month + Past Year 1/month + Past Year 1/month +
Played cards for money 19.0% 4.4% 10.7% 1.3% 5.3% 0.6%
Bet horses, dogs 4.8% 0.4% 3.2% 0.1% 2.8% 0.2%
Games of personal skill 14.1% 3.2% 7.2% 1.2% 4.0% 0.7%
Dice, craps 3.5% 0.7% 2.2% 0.3% 2.0% 0.3%
Slots 14.3% 1.3% 9.9% 0.5% 8.4% 0.6%
Lottery tickets 29.7% 5.4% 24.0% 3.5% 30.5% 5.1%
Played stock market 3.5% 1.3% 2.1% 0.6% 1.1% 0.4%
Commercial bingo 7.3% 0.8% 6.8% 0.8% 6.2% 0.8%
Gambled in casino -- -- 11.0% 0.6% 9.4% 0.6%
Bet on sports 6.7% 1.5% 6.6% 0.8% 5.2% 0.6%
Casino games on Internet for money 2.1% 0.8% 1.9% 0.2% 1.8% 0.3%

Percentages displayed are cumulative rather than independent. A student-athlete reporting having wagered “once/month or more” is also included in the “past year” figure.

Q&A with Jeff Derevensky

When it comes to understanding the effects of gambling behavior on student-athletes (or the population in general), few people are more knowledgeable than Jeff Derevensky, the director of the International Center for Youth Gambling Problems and High-Risk Behaviors at McGill University in Montreal.

Following is a Q&A that probes Derevensky’s insights on gambling behaviors.

Question: What are the most alarming trends you’ve seen to date?

Jeff Derevensky: There are several. Perhaps the one from which all others emerge is the global normalization of the behavior. The gambling industry has done a terrific job in that regard – they don’t even call themselves gambling anymore. Now it’s “gaming.” They’re selling entertainment. They’ve gotten away from the sin-and-vice image that had been associated with gambling to where it’s now a normal socially acceptable behavior. TV also has done a remarkable job advertising gambling, not just through sports but through poker tournaments. ESPN has been able to develop inexpensive programming along those lines that has attracted millions of people. The electronic forms of gambling have made it accessible to the average person 24 hours a day, seven days a week. Even the government is in on the act, supporting lotteries as an easy kind of “voluntary taxation.”

Self-reported personal beliefs of student-athletes about sports wagering
(all divisions, among student-athletes who reported wagering on sports in the last year)

2012 study Males Females
Most athletes in college violate NCAA sports-wagering rules 59% 48%
Wagering is acceptable as long as you don’t wager on your own sport 57% 41%
Coaches see wagering as acceptable as long as you don’t bet on your own games 41% 26%
Athletes and coaches take NCAA sports-wagering rules seriously 62% 68%
I think sports wagering is a harmless pastime 68% 58%
People can consistently make a lot of money gambling 59% 49%

Q: What about other trends and concerns?

JD: The landscape has changed dramatically. There are more states with casinos than ever before. When the NCAA initiated its first gambling task force in 2003, only Nevada and New Jersey had casinos. Now there are plenty of casinos in Florida, Oklahoma, Pennsylvania, Maryland, Virginia, Louisiana and many other states. Also, electronic forms of gambling are becoming increasingly popular. In 2003, very few people even thought of gambling online. Now you can wager virtually on anything online. There were odds on what Prince William and Kate Middleton were going to name their baby. You can gamble on who’s going to be the next pope, or the next president. There were odds on where Angelina Jolie would adopt her next child from. In that vein, there is now live in-game betting – odds generated in real time for participants to bet on various aspects of a game as it unfolds. About 10 percent of male student-athletes in the 2012 study who wager on sports have engaged in live in-game betting. “Spot fixing” is another one. Spot fixing is just a single midgame event or portion of a contest needing to be fixed for a bet to pay off. It’s generally seen as easier to do and harder to detect than manipulating a final outcome.

Q: What about the technology? Has gambling through social media become pervasive?

JD: Simulated forms of gambling – often referred to as “practice sites” – that’s the new phenomenon. We currently don’t know if there’s a causal relationship between simulated forms of gambling (for virtual currency) and actual gambling. We do know, however, that as simulated gambling goes up, so does actual gambling and gambling-related problems.

Percentage of student-athletes reporting that they played simulated gambling activities in the past year

  Males Females
Played activity via video game console 18.2% 4.8%
Played activity via social media website 12.0% 4.2%
Played activity via Internet gambling site 10.3% 2.4%
Played activity on a cell phone 14.5% 5.4%
Played a free sports-betting or bracket game online 11.7% 2.2%

Q: What do you mean by simulated forms of gambling?

JD: If you play a simulated form of gambling online, such as virtual slots or fantasy sports or filling out brackets for “virtual money,” it hasn’t been proven that it will prompt you to gamble for real money. But the link is rather intuitive, isn’t it? Playing for “fun” or the “social media-type” games often have greater payouts than the real-money games do. So if you’re playing these games and you’re winning all this virtual money, the natural thought is that, gee, if I had only been playing for real money, look how much I would have made. One of the most frightening findings we’ve recently found in terms of motivation for gambling is that children, teens and even young adults are gambling either for virtual or real money to relieve boredom. It’s just a click away.

Q: How do audiences accept you when you’re presenting around the world?

JD: These days, the most receptive crowd is the industry itself. Years ago, I gave a talk to the Internet gambling industry and they regarded me as a pariah. Somebody in the audience emailed me afterward in fact and said that while it was an interesting presentation, why was I walking back and forth across the stage so much? I answered, “It’s harder to hit a moving target.” Now, the industry is looking at “responsible gaming.” They are concerned about keeping players safe; making sure that people don’t lose their homes, drop out of school, get involved in illegal behaviors or commit suicide because they’re overwhelmed by their gambling problems. Nobody wants that.

Q: What about the reception from colleges and universities?

JD: It’s a little more under the radar at the collegiate level. Most people are more familiar with drug and alcohol issues and violence on campus. But gambling is just like alcohol. While it’s a normalized behavior – for example, with drinking, the message is “as long as you’re old enough and you drink responsibly, then you’re OK.” But you can’t become an alcoholic if you don’t start drinking. And you can’t become a problem gambler if you don’t start gambling. At the youth level, authorities talk with young people about drinking, but not about gambling. We do need more prevention, education, awareness and treatment programs for our youth and their parents.

Q: What’s your advice for colleges and universities now?

JD: First of all, don’t ignore it. Does it affect, or is it harmful to, the majority of your student population? Probably not. But is it negatively affecting at least some of your students? Absolutely. I was with a university president once whose school had collected research on gambling behaviors on campus, but he said he wasn’t going to release the results. I asked him why, and he said he couldn’t trust “gambling researchers” because they would make a big deal of three people out of 5,000 having a problem. I said I understood, but I added that by not releasing the findings, people think you’ve got something to hide. That convinced him to be more transparent. Just like most campuses have policies on drugs and alcohol, they need a policy on gambling.

Q: What is a good way to spot problem gambling behavior?

JD: It’s difficult to do, because not many problem gamblers are open about their situation. But if you notice someone who maybe talks a lot about gambling or is pretty secretive about where he’s going, then that’s a clue. Also, problem gamblers become consumed with the behavior, and everything else tends to slide. If someone who had been doing well in class begins to let his or her grades slip, or if a usually outgoing person becomes reclusive, and of course if that person starts having financial trouble, then problematic gambling might be at the root of those behaviors.

Q: Are there approaches on campus that are known to work?

JD: Student-athletes report that coaches and teammates are their primary influences, so programs targeting those people – particularly coaches – are helpful. I like the idea of involving student services groups as well. The more campus-wide involvement, the better. This is a more general student issue, and not one that affects only student-athletes. It’s important to understand that what starts off as a fun, harmless activity can lead to other serious problems. One or two out of 100 college students having a problem isn’t likely to set the world on fire, but if you approach the gambling issue as being among a number of things that can negatively impact student health and well-being, then your odds of resonating, so to speak, are much greater. It’s important to remember that every problem gambler tends to seriously impact a dozen other people: boyfriends, girlfriends, peers, teammates, coaches, parents and employers. And for student-athletes, it can jeopardize their eligibility.

Most effective ways to influence student-athletes not to wager on sports
(as reported by student-athletes who have wagered on sports in the past year)

Rank Males Females
1 Coach Teammates
2 Teammates NCAA penalties
3 NCAA penalties Coach
4 Pro athlete presentation Pro athlete presentation
5 Parents Law enforcement presentation
6 Athletics department info Athletics department info

Jeff Derevensky is the director of the International Center for Youth Gambling Problems and High-Risk Behaviors at McGill University in Montreal. The National Center for Responsible Gaming recently honored Derevensky with its coveted Scientific Achievement Award, one of dozens of accolades he has earned from his research over time. He and NCAA Principal Scientist Tom Paskus co-authored the 2008 and 2012 NCAA studies on student-athlete wagering behaviors.

Tom Paskus is the principal research scientist for the NCAA. In this role, he directs the NCAA’s national portfolio of studies on the academic trajectories of college student-athletes and oversees the NCAA’s data collections and research initiatives pertaining to the academic, athletic, social, and personal well-being of current and former student-athletes. Before joining the NCAA, Paskus was a faculty member in the quantitative research methods program in the College of Education at the University of Denver. He received his Ph.D. and M.A. in quantitative psychology from the University of Virginia, and an A.B. in psychology from Dartmouth College.

Mind, Body and Sport: Substance use and abuse

By Brian Hainline, Lydia Bell and Mary Wilfert

The prevalence of mood-altering substances on campus – alcohol, marijuana, narcotics, stimulants, depressants, hallucinogens – has been tracked by campus prevention professionals for decades, evoking varying degrees of effort and success to reduce use and negative consequences.  

More recently, a keen understanding of the interplay between substance use and mental health brings two distinct fields – prevention specialists and treatment specialists – together to define more comprehensive and evidence-informed approaches to address these issues, including population-based environmental management, large screening events, and personalized assessment, feedback and intervention.

College students, including student-athletes, are susceptible to the college effect, in which heavy and frequent alcohol use increases when students arrive on campus, buying into the cultural myth that campus life is about alcohol abuse and drug use. Such beliefs result in an increase in negative impact on academic success, increased risk of sexual assault and other interpersonal violence, and other negative consequences.  

Student-athletes, compared with other students on campus, report higher rates of heavy episodic drinking, sometimes referred to as “binge drinking” (defined as four or more drinks for women and five or more for men). Even more disturbing is that one in five male student-athletes who use alcohol report drinking 10 or more drinks in an outing when they drink.

For marijuana, the good news is that fewer NCAA student-athletes report using marijuana than other students on campus. But the percentage of student-athletes who use marijuana has remained relatively flat over the last 10 years.  

And though alcohol and marijuana are the two most reported recreational drugs student-athletes use, the new illicit drug-use concern is the abuse of prescription stimulants and narcotics.

Substance abuse and mental health

There is no doubt that for many, substance abuse co-occurs with mental health issues. A 2004 Harvard University study described patterns of depression and alcohol abuse among young adults in college, and confirmed that “a substantial fraction of college youth are experiencing poor mental health – at any given time approximately 5 percent – and that these youth are at high risk for alcohol abuse, with depressed young women at highest risk.”  

The Harvard study noted the age of traditional students, 18-24, coincides with peak years for onset of common mental health problems among youth related to alcohol, tobacco and other drug use, depression and anxiety disorders and suicide.

The 2012 National Survey on Drug Use and Health of the Substance Abuse and Mental Health Services Administration identifies that 8.9 million adults have co-occurring mental and substance use disorders and recommends integrated treatment to improve outcomes.

Student-athlete substance use

Since 1985, the NCAA has conducted a quadrennial research study of substance use of college student-athletes, and collected survey data again in the spring of 2013 from more than 20,000 NCAA student-athletes from all three divisions and NCAA-sponsored championship sports.


Figures 3A and 3B present data about heavy episodic drinking and the negative consequences reported as a result of alcohol use.

When you drink alcohol, typically how many drinks do you have in one sitting? (Figure 3A)

Female Student-Athletes

  Division I Division II Division III
More than 4 drinks 31.9% 32.6% 37.8%
10+ drinks 2.4% 3.2% 3.3%

Male student-athletes

  Division I Division II Division III
More than 5 drinks 39.6% 39.6% 50.4%
10+ drinks 15.5% 16.8% 20.4%


It is particularly alarming that 30 percent of these student- athletes report experiencing blackouts, which are red flags for developing an alcohol addiction. In addition, more than 30 percent have done something they later regretted and more than 25 percent have been criticized for their drinking. 

Student-athlete drinking behavior — During the past 12 months (Figure 3B)

  Never Once Twice 3-5 times 6-9 times 10+ times
Had a hangover 36.7% 14.3% 11.5% 14.8% 7.4% 15.3%
Performed poorly on a test or important project 83.3% 6.9% 4.3% 3.3% 1.1% 1.1%
Been in trouble with police or other college authorities 91.0% 6.7% 1.5% .6% .1% .2%
Damaged property, pulled fire alarm, etc. 92.9% 3.2% 1.8% 1.2% .3% .5%
Gotten into an argument/fight 77.0% 9.6% 6.2% 4.5% 1.2% 1.5%
Gotten nauseated or vomited 48.5% 19.8% 13.0% 11.7% 3.7% 3.3%
Driven a car while under the influence 86.3% 5.5% 3.5% 2.4% .8% 1.5%
Missed a class 73.9% 7.9% 6.7% 6.7% 2.0% 2.7%
Performed poorly in practice or game 84.0% 6.6% 4.3% 3.2% .9% 1.0%
Have showed up late or missed practice or game 94.3% 3.0% 1.4% .8% .2% .3%
Been criticized by someone you know 74.6% 9.8% 6.6% 5.1% 1.5% 2.4%
Thought you might have a drinking or drug problem 94.4% 2.5% 1.2% .8% .4% .7%
Had a memory loss 70.0% 10.4% 7.0% 6.4% 2.9% 3.3%
Done something you later regretted 68.0% 12.0% 8.0% 6.6% 2.3% 3.1%
Been arrested for DWI/DUI 99.0% .7% .1% .1% .0% .1%
Tried unsuccessfully to stop using 96.7% 1.6% .7% .5% .2% .3%
Had feelings of depression, feeling sad for two weeks or longer 92.9% 3.7% 1.6% .9% .3% .6%
Been hurt or injured 87.7% 6.0% 3.5% 1.9% .3% .5%

These data also identify implications of use on both academic and athletics success, with more than 25 percent missing class and 16 percent performing poorly on a test or in practice due to use.


Another substance concern is the use of marijuana, which has remained fairly constant in this population over the past 10 years as noted in this table:

Marijuana use within the last 12 months

2005 2009 2013
21.2% 22.6% 21.9%

The college literature on marijuana use demonstrates strong links between use, especially chronic use, and cognitive deficits. Even for those who do not use regularly, marijuana use can impede concentration and attention, and interfere with student-athlete academic and athletics success.  

Student-athlete marijuana and grades

  Never used Used in last 30 days Used in last 12 months Used, but not in last 12 months
A (3.84 - 4.00) 10.5% 5.2% 5.8% 6.7%
A- (3.50 - 3.83) 19.8% 14.6% 16.1% 17.0%
B+ (3.17 - 3.49) 23.3% 20.7% 24.9% 23.0%
B (2.84 - 3.16) 21.4% 23.9% 23.2% 25.2%
B- (2.50 - 2.83) 13.5% 16.9% 15.3% 14.7%
C+ (2.17 - 2.49) 7.7% 11.8% 10.1% 9.1%
C (1.84 - 2.16) 2.9% 4.4% 3.6% 3.1%
C- (1.50 - 1.83) .6% 1.5% .8% .9%
D or below (< 1.50) .3% 1.0% .2% .3%

Depression and anxiety are the most commonly reported psychological issues reported by traditional-aged students, including student-athletes, and the peak age of onset for schizophrenia is in the teenage years and 20s.  

Marijuana use is implicated in exacerbating symptoms of anxiety, depression and schizophrenia, and those at risk of developing schizophrenia will have worsening symptoms if they use marijuana.

The NCAA study looked at marijuana use and grades, and found in the table above that those who have used in the last 30 days reported failing grades at three times the rate of those who don’t use. The table also notes that for those student-athletes who have never used, more than 30 percent report A grades compared with 20 percent of those who have used, either in the last 30 days or ever. (See Figure 3C)

prescription drug use. The following table notes that under 5 percent of NCAA student-athletes report prescribed ADHD stimulant medication use, similar to the estimates of ADHD in this population, but more than 5 percent report use without a prescription. The percentage of student-athletes prescribed narcotics for pain medication is higher than the general student body, which is understandable with injury and pain a part of competitive athletics, but use without prescription is of great concern given the potential for addiction to these medications. Whether this nonprescribed use is self-medication for inadequate response to sports injury is an area for further research. 

Prevention is a science!  

The substance abuse prevention field has matured quickly since the 2002 publication of the National Institutes of Alcohol Abuse and Alcoholism. This report provided evidence of alcohol education and policy strategies that demonstrated an effect on use, strategies that held promise, and those that did not deliver.

Over the convening decade, prevention science has provided us greater insights into the kinds of campus efforts that support healthy choices, those that are ineffective, and even those that contribute to abuse.

The CDC’s social-ecological model provides the framework for targeting our efforts, noting that individual behaviors are influenced by the individual’s peer group, broader community and society. For the campus athletics culture, this translates into team, department and campus as a whole.

Understanding the process of behavior change, the role perception plays in use, the power of setting expectations, and the influence of environment and policy on individual choices is critical to effective alcohol abuse prevention.  "Just say no" is not a method.  Research has redirected our efforts toward more effective approaches to reduce substance abuse and its negative consequences, providing us evidence-informed strategies that affect behavior change, such as brief motivational interventions, correcting norms, engaging peers in intervention, and clear and consistent policy enforcement. As with any culture, educational efforts need to address student-athletes’ motives, beliefs and expectations.

Athletics administrators will experience greater success in reducing substance abuse among their student-athletes when they partner with campus prevention specialists who have background and expertise in substance abuse prevention and mental health promotion.  

The NCAA Division III and NASPA (Student Affairs Professionals in Higher Education) have entered into a collaborative project that intends to bring the best of prevention science to their constituents, administered in partnership between athletics and student affairs administrators, in a project called 360Proof. This effort combines personalized feedback process with campus support and intervention, relying on the very evidence-based strategies defined by these recent efforts.  

The NCAA provides resources to help its membership address substance abuse prevention and promote mental health. The NCAA-sponsored APPLE Conferences (Promoting Student-Athlete Wellness and Substance Abuse Prevention) bring campus "prevention teams" composed of four to six members, including at least two student-athletes, through a strategic planning weekend that provides a framework to identify gaps in the institution’s substance abuse efforts and walks them through the development of their institutional-specific plan to address those gaps.  

The University of Virginia’s Gordie Center for Substance Abuse Prevention ( administers the program and houses the emerging support for "Coaches Assist," which recognizes the critical role coaches play in addressing student-athlete substance abuse.

The NCAA 2012 Student-Athlete Social Environment Study found that of the 21,000 student-athletes surveyed across all divisions and sports:

  • 42 percent of men and 39 percent of women said they would turn to their parents first when seeking help/advice/support for substance use.
  • 89 percent of student-athletes report coaches or others in the athletics department have talked to them about expectations regarding drinking and substance use, yet a quarter of men and a third of women would like them to talk more about it with their team.
  • 85 percent of men and 93 percent of women would be likely or extremely likely to accompany a teammate home if he/she had a lot to drink.
  • 79 percent of men and 93 percent of women would be likely or extremely likely to stop a teammate from driving if drinking.

The Step UP! Bystander Intervention Program ( provides administrators with training materials to help student-athletes exercise leadership and to "step up" when a teammate or friend is engaged in potentially harmful or dangerous situations. Step UP! was developed from research that recognizes the desire of students to help a friend in distress but feel ill-equipped to do so safely and effectively. Step UP! training overcomes the bystander effect that sustains  inertia, and takes students through the five-step process to recognize a problem and to take personal responsibility to help.

In the meantime, above all, athletics administrators must demonstrate leadership in recognizing the relationship of substance use, mental health and academic success by:

  • Viewing substance use prevention as critical to student success.
  • Establishing an environment that is supportive of student success and deters excessive drinking/drug use.
  • Working with campus and community constituents and experts to implement a comprehensive program of evidence-based strategies.


Brian Hainline began his tenure as the NCAA’s chief medical officer in January 2013. As the first person to hold that position in the organization, Hainline oversees the newly created NCAA Sport Science Institute, a national center to promote and develop safety, excellence, and wellness in college student-athletes, and to foster lifelong physical and mental development. The NCAA Sport Science Institute works collaboratively with member institutions and centers of excellence across the United States. A graduate of Notre Dame and Chicago’s Pritzker School of Medicine, Hainline completed his neurology residency at The New York Hospital-Cornell. He was chief medical officer of the US Open Tennis Championships for 16 years, and then served as chief medical officer of the United States Tennis Association before moving to the NCAA.


Mary Wilfert is an associate director in the NCAA Sport Science Institute. Since 1999, she has administered the NCAA drug-education and drug-testing programs and worked to promote policies and develop resources for student-athlete healthy life choices. She serves as primary liaison to the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports, the governing body charged with providing leadership on health and safety recommendations to the NCAA membership. Wilfert has worked in the health education field for more than 30 years to empower individuals to make informed choices for lifelong health and success.


Lydia Bell is the associate director of research for academic performance at the NCAA. In this role, Bell assists in all aspects of development and analysis of research on current and former student-athlete academic performance and well-being. Before joining the NCAA, she was an assistant professor of practice and director of Project SOAR in the Center for the Study of Higher Education at the University of Arizona. She received her Ph.D. in language, reading and culture and M.A. in higher education from Arizona, and an A.B. in government and legal studies and sociology from Bowdoin College.

Mind, Body and Sport: Eating disorders

By Ron Thompson

Participation in sports has a number of positive effects on student-athletes. They tend to live healthier lives than non-athletes, and they gain skills in teamwork, discipline and decision-making that their non-athlete peers may not.

However, some aspects of the sports environment can increase the risk of disordered eating (and eating disorders). That means student-athletes and those who oversee athletics must be vigilant to detect signs of trouble.

Disordered eating and eating disorders are related but not always the same. All eating disorders involve disordered eating, but not all disordered eating meets diagnostic criteria for an eating disorder.

As first conceived, the term "disordered eating" was a component of the female athlete triad – a syndrome that also includes decreased bone mineral density and osteoporosis – and defined as "a wide spectrum of harmful and often ineffective eating behaviors used in attempts to lose weight or attain a lean appearance." The term was later supplanted by "low energy availability" to reflect the role insufficient energy plays in accounting for all physical activity, as well as to fuel normal bodily processes of health, growth and development.

Eating disorders are not simply disorders of eating, but rather conditions characterized by a persistent disturbance of eating or an eating-related behavior that significantly impairs physical health or psychosocial functioning. The eating disorders most often diagnosed are:

Anorexia nervosa is characterized by persistent caloric intake restriction, fear of gaining weight/becoming fat, persistent behavior impeding weight gain, and a disturbance in perceived weight or shape.

Bulimia nervosa is recurrent binge eating, recurrent inappropriate compensatory behaviors to prevent weight gain (for example, induced vomiting and excessive exercise), and self-evaluation unduly influenced by shape and weight.

Binge-eating disorder is recurrent episodes of binge eating without compensatory behaviors but with marked distress with the binge eating.

Why student-athletes are at risk

Prevalence. Eating disorders occur in all sports, but not equally in all sports. As in society, eating disorders in sport occur more frequently in females than males. One area in which research findings are more definitive is for "lean" sports for which a thin/lean body or low weight is believed to provide a biomechanical advantage in performance or in the judging of performance. Women in these sports are considered to be at the highest risk.  

Genetics. Epidemiological and molecular genetics studies suggest a strong genetic predisposition to develop an eating disorder, and that these disorders aggregate in families in part due to genetics. Family and twin studies have found heritability estimates of 76 percent for anorexia nervosa and 83 percent for bulimia nervosa. Not all individuals with a genetic predisposition develop the disorder, as other factors are involved.

Sociocultural factors. Before genetics-related findings, the primary explanation for the development of eating disorders involved sociocultural factors. Certainly, from a sociocultural perspective, most individuals are exposed to societal or cultural pressures regarding weight or appearance, but again, not all will develop an eating disorder. Most who do are female, and the disorder’s onset often occurs during adolescence.

A simple conceptualization is that genetics sets the stage for the disorder, but sociocultural pressures can precipitate it. Once the disorder begins, sociocultural pressures usually assist in maintaining the disorder. Also, from a sociocultural perspective, eating problems can begin or worsen during transition periods, which makes freshman student-athletes particularly vulnerable.

Additionally, student-athletes may experience more stress than non-athletes because they deal not only with the transition away from home and pressures related to academic demands of college but also the pressures associated with sport participation. Eating problems are often the way individuals deal with such stressors.

Sport-related factors. Just as society and culture emphasize the "thin ideal," similar pressures exist in the sport environment regarding being thin/lean and its purported positive effect on sport performance.

This emphasis on reducing body weight/fat to enhance sport performance can result in weight pressures on the student-athlete from coaches (or even teammates) that increase the risk of restrictive dieting, as well as the use of pathogenic weight loss methods and disordered eating. Even the student-athlete’s perception that her coach thinks she needs to lose weight can heighten weight pressures and increase the risk of disordered eating.

For some student-athletes, revealing uniforms can increase body consciousness, body dissatisfaction, and the use of pathogenic weight loss methods. One study found that 45 percent of swimmers surveyed reported a revealing swimsuit as a stressor. Another study in volleyball found not only that revealing uniforms contributed to decreased body esteem but also distracted players and negatively affected sport performance.

The relationship between body image and body dissatisfaction in female student-athletes is more conflicted and confused than in the general population. Sportswomen have two body images – one within sport and one outside of sport, and disordered eating or an eating disorder can occur in either context or both. Additionally, some female student-athletes are conflicted about having a muscular body that facilitates sport performance but may not conform to the socially desired body type and may be perceived as being too muscular when compared to societal norms regarding femininity.

Coaches have considerable influence with their athletes, and it appears that their relationship with their student-athletes – and more specifically their motivational climate – can influence the risk of disordered eating. A relationship between coach and athlete characterized by high conflict and low support has been associated with increased eating pathology among athletes. Additionally, an ego/performance-centered motivational climate (vs. a skills-mastery climate) that some coaches use has been associated with an increased risk of disordered eating.

Another risk to student-athletes relates to aspects of the sport environment that make identification of disordered eating/eating disorders more difficult. In society and sport, athletes are often expected to display a particular body size or shape that becomes characteristic of a particular sport, such as distance runners being thin. Such "sport body stereotypes" can affect coaches’ perceptions of athletes, and athletes who fit the "thin" stereotype are less apt to be identified as having an eating problem. Identification by coaches is sometimes influenced by sport performance, and student-athletes are less likely to be identified if their sport performance is good.

Finally, eating disorder symptoms (such as dieting, weight loss and excessive training) may be misperceived as "normal" or even desirable in the sport environment, and personality characteristics/behaviors similar to those of eating disorder patients (such as perfectionism and excessive training) may be misperceived as "good athlete" traits.

Treatment. As a special subpopulation of eating-disorder patients, student-athletes need specialized approaches to treatment. However, treatment per se is not different; that is, standard treatment approaches (such as cognitive behavioral therapy) work as well for athletes as for non-athletes.

Recommended treatment differences relate to treatment staff. Treatment professionals working with student-athletes need experience and expertise in treating eating disorders and athletes, but more importantly need to understand and appreciate the importance of sport in the life of a serious student-athlete.

Student-athletes often resist treatment for the same reasons as non-athletes but also for additional ones related to sport. Some resist because they assume they will gain so much weight that it will negatively affect sport performance. They may resist due to a concern that having a mental health problem will result in a loss of status or playing time. Some fear that being in treatment for a mental health problem will displease significant others (like family, coaches and teammates).

Also, student-athletes sometimes resist treatment because they fear their treating professional(s) will not value the importance of sport in their lives. Given these common reasons to resist treatment, motivation for treatment and recovery is particularly important. Regarding treatment motivation, research investigating factors that facilitated student-athletes’ recovery from their eating disorder found the desire to be healthy enough to perform in sport to be most helpful.

Where do we go from here?

Given the prevalence of eating disorders in the college and sport populations, athletics departments are encouraged to develop a treatment protocol for student-athletes with eating disorders. Included in that protocol should be guidelines regarding how affected student-athletes are identified, managed and referred for evaluation and treatment by sport personnel. Sport personnel charged with these responsibilities should be trained by health care professionals with experience and expertise regarding student-athletes and eating disorders.

The protocol should also include recommendations regarding education for both student-athletes and sport personnel. Education is the first step in prevention, but more is needed in the form of a program designed to change student-athletes’ attitudes and behaviors that are associated with disordered eating/eating disorders. Some NCAA schools already employ such a program.

Early identification of "at risk" and affected student-athletes is most important. Eating disorders can be more easily treated early in the process. More importantly, timely and appropriate treatment can prevent medical and psychological complications of these disorders, thereby decreasing the risk to the student-athlete and decreasing time away from sport.

Coaches and other sport personnel are encouraged to improve their identification skills, as well as their skills in making an appropriate referral for an evaluation and treatment. Such training can be made available to coaches, athletic trainers and other sport personnel, and can be endorsed and strongly recommended by sport administrators. Such training opportunities are even more important for smaller colleges that may have fewer treatment options available on campus.

The primary risk for developing disordered eating/eating disorders involves the emphasis on a lean body and its purported relationship with enhanced sport performance. Coaches and others in the sport environment are urged to recognize that such an emphasis on weight or leanness puts the student-athlete at greatest risk for developing eating problems.  

Finally, the stigma associated with seeking mental health treatment must be eliminated. Those with influence in the sport environment can play a key role by recommending and encouraging timely and appropriate mental health treatment for their student-athletes.

Ron Thompson is a consulting psychologist for the Indiana University department of athletics and co-director of the Victory Program at McCallum Place, which offers a specialized eating disorder treatment staff to meet the unique needs of athletes. Thompson has served as a consultant on eating disorders to the NCAA and on the Female Athlete Triad with the International Olympic Committee Medical Commission. He can be reached at

Mind, Body and Sport: The psychiatrist perspective

By Todd Stull

Many changes are taking place in our culture that influence the mental and emotional well-being of today’s student-athletes. The pressure associated with student-athletes’ daily routine can create intense emotional responses. The time, energy and effort put into developing skills in a given sport can result in imbalances in other areas of life. Developmental and environmental influences shape emotional, motor and social aspects of the brain. Eating patterns, impulse control and interpersonal relationships are also affected.

While many colleges and universities have employed sport psychologists – or at least have access to such services – to help student-athletes navigate their unique stressors, it’s also helpful from a psychiatrist perspective to describe factors contributing to adolescent brain development and mental health and substance problems in today’s student-athletes.

The psychiatrist’s role in working with student-athletes is to optimize health, improve athletics performance and manage psychiatric symptoms while operating within an interdisciplinary team. Medical problems and substance-induced conditions need to be ruled out before the psychiatric diagnoses are made.  

The most common psychiatric disorders in student- athletes are represented in the following categories:

  • Anxiety disorders
  • Mood disorders
  • Personality disorders
  • Attention deficit hyperactivity disorder
  • Eating disorders
  • Body dysmorphic disorder
  • Adjustment disorders
  • Substance use disorders
  • Impulse control disorders
  • Psychosomatic illnesses

Anxiety Disorders are among the most common psychiatric problems in student-athletes. Performance anxiety, panic disorder and phobic anxiety after an injury are more likely to be sports-related. Generalized anxiety disorder and obsessive-compulsive disorder are less likely to be sports-related but are still common.  

Many athletes can experience anxiety that is either related to a medical problem or induced by a medical problem or substance use. The typical presentation is with physical symptoms and the psychological symptoms of worry and obsession. Feeling “overwhelmed” or “stressed” are frequent terms used at the time of presentation.

Performance anxiety is connected to the anticipation of the act and becoming overwhelmed during specific components of performance. Panic attacks are intense feelings of being overwhelmed with many physical symptoms such as racing heart, shortness of breath, shakiness and sweating that surface quickly. Phobias may be related to an injury, recovery and return to play.

Generalized anxiety disorder often presents with excessive worry or apprehension that is difficult to control. Obsessive-compulsive disorder presents with intrusive ideas, thoughts, urges or images that come into one’s mind with a ritualized behavior to try to undo or dissipate the obsession.

Mood Disorders include major depressive disorder (clinical depression), bipolar disorder, substance-induced depression (such as alcohol) and a mood disorder secondary to a medical problem (for example, thyroid disorder).  

Fifteen to 20 percent of the population will suffer an episode of depression in their lifetime, and it is among the most common conditions a sports psychiatrist will treat.  

The average age for onset of depression is approximately 22, but it is decreasing. Symptoms of depression include depressed mood, loss of interest, sleep and energy disturbance, appetite and weight changes and impaired concentration. Anxiety is a common symptom. A low frustration tolerance, isolation from teammates and lack of enjoyment with deterioration in performance is a part of the presentation with depression as well. Males are more likely to present with anger and excessive alcohol use.

To meet the diagnosis of bipolar disorder, an individual must have had some degree of mania in his/her life. Initial presentation for bipolar is an episode of depression. Other defining features of bipolar disorder include a strong family history of a mood disorder, chronic sleep problems, irritability, erratic performance, stormy relationships and impulsivity. A substance use disorder commonly co-occurs with bipolar disorder.

Personality Disorders are fairly common in athletes. The most common personality traits in student-athletes associated with performance are extraversion, perfectionism and narcissism. Individuals with personality disorders experience interpersonal difficulties, impulse control problems, misperception of comments or situations and affective instability. Individuals with personality disorders have maladaptive coping skills.

Attention Deficit Hyperactivity Disorder (ADHD) is common in athletes and presents with problems focusing, concentrating, learning, attention shifting and sustained attention. ADHD is probably the most common psychiatric condition that sport psychiatrists treat. Males tend to be more hyperactive. Females more likely will have the inattentive type.

The number of student-athletes with ADHD appears to be increasing and may be related to the influences of social media and a rewiring of the brain. This condition carries over into adulthood in about half of the cases. The symptoms can change with age and can be temporary.

The severity of the symptoms can result in limitations in a number of areas of life and result in performance slumps or interpersonal conflict. Males often present with denial, while females present tired and exhausted.

Eating Disorders occur in both sexes but are more common in females, and in sports in which lower body weight/fat improves performance or weight is divided into classes. The triad of impaired eating, amenorrhea and osteoporosis are the classic features in females.  

Full-symptom presentation usually occurs as the eating disorder progresses; however, disordered eating is more common at presentation. As the condition worsens, more impairment occurs. Individuals affected with eating disorders have decreased energy and a special relationship with food.  

Eating disorders are more common in gymnastics and swimming/diving, which are judged on aesthetics, and in wrestling, cross country and distance running. Eating disorders can be life-threatening, especially anorexia nervosa.

Body Dysmorphic Disorder is a preoccupation with an imagined defect in appearance that causes distress. It is more common in males. Muscle dysmorphia is a subtype that is characterized by an unhealthy preoccupation with muscularity, mirror checking and dieting. Student-athletes in sports in which large physical size and physique are emphasized are more susceptible to the disorder.

Adjustment Disorders are emotional and behavioral responses to a perceived stressful situation that exceeds the athlete’s ability to adapt. The most common emotions are anger, anxiety, sadness and guilt. The most common behaviors include aggression, arrests, insomnia, social isolation, substance use, relationship conflicts, quitting and poor performance.

Substance Use Disorders in student-athletes are different than in the general population. Student- athletes most commonly use alcohol, marijuana, opiates, stimulants (such as Adderall), caffeine, tobacco and performance enhancers.  

Alcohol and drug use is more common in males and more common in the offseason for all student-athletes. Some of the consequences related to substance use include academic problems, vandalism, assault, injury, driving under the influence, sleep deprivation, sexual abuse and, in severe cases, death.  

The brain pathways involved can be reinforced from use and create fundamental changes in the brain. Over time, the effects can hijack the brain. Alcohol and drug use commonly co-occur with mental health problems. Since alcohol is difficult to detect on a drug screen, the effects of alcohol often present with performance problems. Cannabis can be perceived as “safe,” but is detectable for longer periods of time on a drug screen.

Stimulant use [for example, amphetamine/dextroamphetamine (Adderall), methylphenidate (Concerta and Ritalin)] is an increasing problem for student-athletes, especially since they are used for a number of non-medical reasons. Student-athletes who begin using an opiate [for example, hydrocodone (Vicodin), oxycodone (Percocet and Oxycontin)] may continue to use it after their medical problems have been resolved.

Impulse Control Problems can manifest in erratic behavior and performance. An individual who suffers from an impulse control problem might exhibit episodes of aggression, fighting, and risky sexual behavior.

Psychosomatic Illnesses and presentations include pain without supporting evidence, prolonged recovery from injury, frequent injuries and performance problems. Symptoms are often manifestations of an emotional issue and occur more commonly in collision sports.  

Individuals with pain are at increased risk for depression, post-traumatic stress disorder, substance use problems and adjustment reactions. A serious injury that leads to chronic functional impairment (or pain) in a student-athlete may manifest as a psychosomatic condition.

In addition to all of these, pain presents another challenge with today’s student-athletes. There may be pressure to play through the pain for fear of loss of a position or status. An athlete who is injured may experience a loss of identity.

Pain, injury and recovery, sleep, traumatic brain injury, suicidal ideation, transition and ending one’s athletics career bring challenges that have multiple associations to physical health, mental health and emotional well-being and substance use.  

Over-training can look like clinical depression. Sleep disturbances are associated with decreased performance and mental health problems (like depression and ADHD).  

Suicide presents another challenge and often is a part of a psychiatric illness with a strong connection to substance use, mental illness and perfectionism. Many warning signs emerge before suicide attempts that are often missed. More than two-thirds will have alcohol in their system at the time of the suicide attempt.

The challenge for any athletics department is to be aware of mental health issues and be trained to spot them when they emerge. Emotional well-being is important to any athlete’s success academically, athletically, socially and spiritually. Untreated mental health problems result in undue suffering, diminished positive affect and balance in life.  

Most psychiatric disorders in student-athletes improve and resolve with proper treatment. Early recognition is important to shorten the time between illness onset and treatment, thus improving the mental health and emotional well-being for our student-athletes.

Todd Stull, founder of Inside Performance Mindroom, holds an M.D. from the University of Nebraska Medical Center and is a board-certified psychiatrist in addiction medicine as well as general and addiction psychiatry. He is a former high school and college football quarterback (Hastings College) and has spent a number of years working with college student-athletes while serving as consulting sport psychiatrist at the University of Nebraska. He serves as the treasurer for the International Society for Sports Psychiatry.

Mind, Body and Sport: The psychologist perspective

By Chris Carr and Jamie Davidson

Intercollegiate athletics embodies a unique and demanding culture. The pressures and demands on 18- to 21-year-old student-athletes are great. Their wins and losses are seen by many, questioned by many, and often criticized publicly.

Even within the athletics environment, student-athletes' time demands are enormous – daily practices, competitions that may involve travel (some across time zones), a full academic course load, strength and conditioning programs, and sports medicine/rehab appointments present a demanding schedule indeed. Social interactions and relationships often take a back seat to the athletically related challenges and commitments.

It is no surprise that these pressures can affect a student-athlete's mental health. A well-trained psychologist with expertise in sport psychology is an ideal resource to provide care and services. But over the past 20 years, the sports psychologist's role in college sports has evolved more slowly than student-athletes' needs.

The ways colleges and universities use sport psychologists also vary, often depending on resources and how well the athletics department understands how to incorporate these services.

The following explains both the challenges related to the integration of sport psychologists within college athletics, and the models schools currently use when they do take advantage of such expertise.

*  *  *  *

First, here are the challenges related to the slow growth of psychologists in the arena of student-athlete mental health care.

The ongoing "stigma" within the sport context. Student-athletes, coaches and staff tend to minimize mental disorders or psychological distress because of the expectations of strength, stability and "mental toughness" inherent in the sports culture. As a result, student-athletes often avoid disclosing a mental health concern, especially if the perceived negative consequence includes being rejected by teammates or coaches due to the disclosure. In many ways, this stigma further exacerbates the problem of student-athlete mental health as it inhibits effective dialogue, education and development of resources to address these issues.

Once a mental health issue is identified, resources may be limited or difficult to access. As sports medicine and athletic training have evolved, it is now common for a Division I athletics department to employ four or more full-time certified athletic trainers. Some schools even have in-house sports medicine physicians specifically providing medical care for student-athletes. Additionally, more and more athletics departments employ registered dietitians/sport nutritionists to provide optimal nutritional care for their athletes. However, not many programs employ full-time or even part-time licensed psychologists. Instead, they depend on campus resources such as student counseling centers to refer for mental health issues. The problem there is that few student counseling centers employ a psychologist who has the training/education to address student-athletes' unique psychological needs.

The issue of "sport" psychology vs. "clinical/counseling" psychology is often confusing to athletics department personnel. In most of the 50 states, if not all, the term "psychologist" (in any form) is protected as a licensed profession. If professionals identify themselves as "sport psychologists," then they should be able to produce their license number within their state of practice. The "sport" designation, for those licensed psychologists, should denote a competency in their training. Competency, as defined in most states, includes academic preparation, training, supervision and experience within a specific domain (for example, child psychology, forensic psychology). Therefore, a licensed psychologist identifying as a "sport psychologist" should also be able to demonstrate training (such as graduate coursework, or perhaps a master's degree in physical education and ongoing supervised experiences) in sport psychology. Further clarifying this distinction in training and competency is a key element in enhancing the ongoing development of providers for collegiate student-athletes.

The competency of licensed mental health providers/psychologists to understand the unique nature of the collegiate athletics environment. Whether it be a Division I, II or III athletics department, it is important for the provider to understand the culture of the athletics environment to best understand the external stressors, motivations and dynamics (team, for example) within that athletics environment. This often requires that a licensed provider have previous experience as perhaps a student-athlete or coach, or a prior role within an athletics department (like an academic adviser), or have supervised experience during their training (for example, as a pre-doctoral intern with a rotation in sport psychology/athletics). This immersive experience offers observational and experiential learning opportunities for the psychologist, which builds competency to provide care for the athlete.

Lack of training models for psychologists and mental health providers in the domain of sport and performance psychology. As the role of psychologists within collegiate athletics has increased, it is important to note that many clinical/counseling psychology programs do not typically offer graduate coursework in the domain of sport and performance psychology. However, a few programs train students to be doctoral-level psychologists and provide graduate training/experience in the domain of sport psychology (the University of North Texas and Indiana University, Bloomington, do so, for example, both in counseling psychology).

Professional "contamination" and disruption of current services. Because collegiate athletics continues to focus on concepts such as "performance excellence" and "mental toughness," the realm of "motivational gurus" and "mental coaches" finds college athletics a prime target for their services, and they may very well ignore, minimize or neglect the real issues of psychological health. Individuals not trained in mental health/psychology often say they will refer any athlete with a personal issue, but if they are not trained in diagnostic interviewing, then they are not likely to identify potential issues. Thus, the athletics administrator must struggle with the challenge of providing effective mental health services for student-athletes, as well as providing a resource to teach coaches and student-athletes psychological skills to enhance sports performance. Competent and well-trained licensed psychologists can often provide both services within a collegiate athletics department. They also may be able to supervise and coordinate an effective "sport psychology team" for both performance and personal counseling services.

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With those challenges as a backdrop, here are the models college athletics departments currently use to provide student-athlete mental health services. The depth and breadth of these models of course depend on the commitment of the athletics administration, sports medicine, academic services, compliance and coaching staffs to optimize psychological resources for their student-athletes.

The most common models include:

Full-time athletics department sport psychologist. This position is typically held by a licensed counseling/clinical psychologist with graduate training (often a master's degree) in physical education/sport psychology. The sport psychologist usually provides:

  • Individual counseling for student-athletes (mental health concerns such as anxiety disorders, mood disorders, and performance-related counseling for issues related to performance anxiety and confidence issues);
  • Coordination of substance abuse/eating disorder services for student-athletes (often being involved with NCAA and institutional drug-testing referrals); team consultations for both clinical (for example, grief counseling) and performance (for example, team-building) issues;
  • Staff education and consultation; and
  • Consultation with athletics administrators on psychological care issues within the athletics department (for example, establishing postgraduate support programs for former student-athletes).

These positions are typically housed in the athletics department, either within sports medicine, academic services or an office affiliated with athletics.

Schools that have incorporated this model include Oklahoma, Virginia, Ohio State, Virginia Tech, Arizona, Southern California, Washington, Iowa, Arkansas, LSU, Missouri, Kansas and New Mexico.

Part-time consultation model. Some athletics departments retain external consultants or counseling center staff psychologists who are given time to work within the athletics department. These people typically provide the same services as their full-time counterparts, though with less time per week (about 10-30 hours as opposed to 40-50), there is less service provision.

Athletics departments wanting to develop sport psychology/psychological care for their student-athletes but do not have the budget to develop a full-time position with benefits often choose this model. It's economically more efficient and allows an athletics department with limited funds or resources to provide "in-house" services for their student-athletes.

A skilled provider on a part-time consulting contract may also be able to coordinate a sport psychology services "program" that identifies specific individuals (for example, substance abuse counselor at counseling center, mental skills consultant in physical education department) to be part of the team that the primary consultant coordinates, supervises and directs.

Most of these providers have an office within athletics to provide the services, and the department often will market this position within its department website/directory.

Among schools incorporating this model include Purdue, Wisconsin, Stanford, Oregon State, Minnesota, Nevada, Maryland and Oklahoma State.

Referral model of services. This model does not employ or retain an "in-house" provider; rather, it identifies a specific provider within the community or counseling center that will take referrals for student-athlete psychological issues.

This model tends to be more of an "intervention" (rather than prevention/education), as the student-athlete often has to present with psychological distress or self-referral in order to access this system.

The provider typically does not have an "in-house" office, so the student-athlete is referred to the provider's office for services. This is not an immersive model of care, but rather a "referral" model in which the athletics department can indicate that it provides services, but only through external referral. (For more on how to make the referral model effective, see Chris Klenck's article in Chapter 6.)

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So, which of these models is the best fit? It is important that schools explore all the options for a psychological services model for their student-athletes.

Clearly, an immersed program with full-time or part-time licensed psychologists allows for better service, communication and delivery of services. Having an immersed sport psychologist allows the athletics department to best address the variety of psychological issues (individual, team, staff) that may be present. Providing a psychologist as part of the support staff also helps to de-stigmatize and normalize the issues related to student-athlete mental health.

Just as having a full-time sports medicine physician and athletic training staff does not eliminate musculoskeletal injuries, having an immersed full-time/part-time sport psychologist will not eliminate mental health issues. However, as sports medicine care has greatly enhanced prevention, intervention and rehabilitation of athletics injuries, an immersed and comprehensive sport psychology program can enhance the prevention, intervention/counseling and care of student-athlete mental health/psychological issues.

A key element in improving student-athletes' emotional well-being is to establish a strong working alliance with the university counseling center, regardless of whether an athletics department has the services of a sport psychologist available.

University counseling centers offer unique services and benefits to student-athletes, including professionals who are highly skilled in treating the mental health concerns common to college students and who are of diverse backgrounds and embrace all walks of life. Counseling centers also offer student-athletes a high level of confidentiality.  

To properly address student-athletes' psychological concerns, it is best to incorporate the services of a sport psychologist into your mental health team. Student-athletes will reap the benefit of this collaboration through improved emotional well-being.

The good news in all of this is that the role of the licensed counseling/clinical psychologist in the mental health care of collegiate student-athletes continues to evolve in a positive direction.

As more athletics departments create sport psychologist positions (either full-time or part-time) that are immersed within the department, there will be greater education opportunities, greater awareness of student-athlete mental health concerns, greater opportunities for coaches/staff to have positive interactions with psychologists, and greater training opportunities in the future for aspiring psychologists who desire to work with athletes as clients.

Chris Carr is a psychologist at St. Vincent Sports Performance in Indianapolis and a counseling sport psychologist and coordinator of sport psychology services for the Purdue University athletics department. Carr also provides individual counseling and consultation services, and he is a licensed psychologist in the state of Indiana. He is currently the consulting sport psychologist for the Indiana Pacers and has previously been the counseling sport psychologist for Indiana University, Bloomington, The Ohio State University and Washington State University. Carr played football while receiving his B.A. in psychology at Wabash College. He has an M.A. in counseling psychology from Ball State University, where he was a graduate assistant football coach from 1983 to 1984. He completed his Ph.D. in counseling psychology (with a doctoral minor in sport and exercise psychology) at Ball State and did a one-year clinical research assistant position in sport psychology at the United States Olympic Training Center in Colorado Springs, Colorado.


Jamie Davidson is a licensed psychologist with more than 20 years of clinical practice in higher education. He serves as the associate vice president for student wellness at the University of Nevada, Las Vegas, after having previously been the director of student counseling and psychological services there. Under Davidson's leadership, the UNLV student wellness center has received national and regional awards for innovation and excellence in the delivery of integrated medical and mental health services. Most recently, UNLV was one of only 30 universities in the country to receive an award for providing comprehensive mental health services and suicide prevention programming from the Jed Foundation.

An introduction to Mind, Body and Sport

By Dr. Brian Hainline

When I began my tenure as NCAA Chief Medical Officer in January 2013, my first task was to connect with NCAA stakeholders and constituents to understand their concerns. I have since met with hundreds of student-athletes and dozens of student-athlete groups to ask them their primary challenges from a health and safety standpoint. Almost to a person, the No. 1 response is student-athlete mental health and wellness.

That may surprise people whose only contact with student-athletes is from watching them compete on television. It's just a game, after all – what could be so hard about that?

But those of you in the trenches working with student-athletes on a daily basis know the challenges they face – and you know that while student-athletes may play games, being a student-athlete isn't a game at all.

Student-athletes are college students, with all the challenges and opportunities presented to emerging adults, and with an additional role – as sports performer and in many cases campus celebrities, wearing the colors of their school and representing hopes and expectations of their campus and community.

College students in general represent a healthy cohort among same-aged peers, and student-athletes an even healthier subpopulation, buttressed by a discipline, commitment and attention to exercise and nutrition required to meet the demands of their sport. As such, and rightly so, athletics departments have developed sports medicine services that increasingly engage a multitude of resources and expertise to address student-athletes' injuries and illnesses to ensure they are in the best condition to compete. 

But there's more to being a student-athlete than just physical preparation and performance. As more media coverage, commentary and public scrutiny are devoted to what student-athletes do off the field, along with the accompanying pressures to perform (and win games) on the field, student-athletes are inundated with factors that may affect their mental health and wellness. And the “culture” of athletics may inhibit student-athletes from seeking help to address issues such as anxiety, depression, the stress associated with the expectations of their sport, and the everyday stress of dealing with relationships, academic demands, and adjusting to life away from home.

Student-athletes themselves have begun to speak out about issues and resource needs. Consider the insightful words from former Notre Dame football player Aaron Taylor. Aaron completed his undergraduate degree in three and a half years, was a two-time All-American, won the esteemed Lombardi Trophy as college football's top lineman, and was a first-round NFL draft pick.

As Aaron says, his was the classic story of the quintessential overachiever whose success was the result of equal amounts of talent and hard work. But in his words, his experience wasn't as rosy as it appeared. Hidden just behind the accolades, trophies and championships was a young man suffering from anxiety and depression.

Here's what he told us:

“I later discovered that many of my issues stemmed from the internal pressure I placed on myself to reach some unattainable level of greatness as a way to mitigate the effects of an early childhood divorce and a variety of other challenges. I brought these issues with me to campus, but no one was the wiser, as my ‘game face' helped hide my condition with relative ease…even from myself.

“Beginning in college and throughout my professional career, I battled depression with the same regularity as blitzing defenses, but the external opponents were much easier to deal with than the internal ones. Due to fear of looking weak or being judged, I hid my condition from those closest to me, including my coaches and teammates. Even though I lived my life in the spotlight, I was suffering in silence.”

Aaron is not alone, which is why we have developed this resource to present a comprehensive look at the student-athlete experience from a mental health perspective – from the relationships with faculty, peers, administrators, coaches and fans to the struggles student-athletes may face in their sport. Some struggles are immense, including pain and injury that preclude competition; criticism and blame for poor sport outcomes; and prevailing attitudes that asking for help demonstrates weakness of spirit and drive.

We've selected Aaron's story to lead off the publication as a first-person account of the inner life underneath the toughness that student-athletes are conditioned to show on the surface. We've also sought advice from dozens of experts in the field. In all, this publication is designed to help athletics departments, campus mental health providers, and all sport stakeholders promote and develop effective strategies to understand and support student-athlete mental wellness. The chapters address:

  • Stressors specific to student-athlete identify, such as transition, performance, injury, academic stress and coach relations
  • Overview of clinical diagnoses, including depression, anxiety, eating disorders, substance abuse and gambling
  • Key components in developing best practices for constructing mental health services for student-athletes
  • The role and perspective of sports medicine staff in identification and referral
  • Cultural pressures and impacts on minority groups
  • How sexual assault, hazing and bullying affect mental health

This publication is the most comprehensive overview to date of college student-athlete mental health, and we hope this becomes a springboard for addressing mental health in the continuum from youth sport to intercollegiate sport and beyond. NCAA member institutions have committed to supporting student-athlete health and safety and ensuring that athletics departments are an integral part of the institutional mission for more than 100 years. But only recently have we begun to fully understand the mental health component of being a student-athlete.

I hope that you join us in our journey of understanding and supporting student-athlete mental wellness, and that you'll benefit from the best practices our experts provide in the following chapters. The contributing authors suggest dozens of recommendations for institutions to consider based on the individual circumstances and needs of the campus.

Our intent is for this publication to become a living and breathing document  through social networks and online discussions that help break down the topics – and the barriers – to providing student-athletes the help they need. Remember that the student-athletes have spoken: Mental health is their No. 1 concern – and it is our responsibility to provide the services and care to help each student-athlete reach his or her full potential.


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 that details how to identify and treat mood disorders and depression.

Mind, Body and Sport: Depression and anxiety prevalence in student-athletes

An excerpt from the Sport Science Institute’s guide to understanding and supporting student-athlete mental wellness that details how common depression and anxiety disorders are in student-athletes.


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