Athletes and Mental Health Difficulties

• Mental health difficulties can affect anyone, including athletes.
• Sport culture can stigmatize athletes with mental health difficulties, leading to avoidance or delay of treatment.
• Mental health symptoms can be misdiagnosed as physical issues, resulting in inappropriate treatment.
• Early identification of mental health difficulties allows for appropriate treatment and improved prognosis.
• Mental health screening can help identify potential issues early.
• It is important to be appropriately trained or to refer the athlete to a professional with specialized mental health training
• Performance work with the athlete can continue while addressing mental health, with collaboration between professionals.
• Screening for mental health difficulties is ethically responsible and in the best interests of athletes.
• Developing a network of competent, reliable, trustworthy mental health providers is essential.
• Referrals often originate from coaches, athletic trainers, team physicians, family members, or teammates.
• Personal connections with referral sources can increase the likelihood of athletes seeking help.
• The chapter reviews common mental health difficulties in athletes and recommends screening measures.
• Inventories were chosen based on usefulness, ease of use, popularity, and use with athletes.
• Assessment tools in the chapter generally have sound psychometric properties.
• The chapter does not cover mental status exams or diagnosing mental illness, which require specialized training.
• Recommended measures are for nonlicensed individuals to screen for mental health difficulties.
• Diagnoses are best left to trained professionals who engage in comprehensive evaluations.

Stress

• The central concern is differentiating reasonable responses from those suggesting a need for evaluation and treatment.
• Stress results from an imbalance between perceived demands and coping resources.
• Athletes often manage stressful situations effectively, but failure to recover can lead to burnout and decreased performance.
• Outside concerns and internal issues can contribute to stress.
• Underlying disorders like anxiety or depression may exacerbate stress reactions.
• Understanding stress in athletes is important due to its various effects.
• Acute stress reactions can increase heart rate, blood pressure, and cortisol production.
• Elevated cortisol levels are linked to health problems like insomnia, obesity, and depression.
• Prolonged psychological distress is linked to injury and illness and may predict injury.
• Stress can also lead to difficulties with affect, attention, memory, behavior, and burnout.
• Athletes often become stressed when they feel incapable of meeting competitive demands.
• Reactions result from factors like personality, coping resources, competitive situation, and personal history.
• Success in coping with stress can result from internal factors or situational factors.
• The Perceived Stress Scale (PSS-10) can evaluate stress in athletes.
• The PSS-10 is a 10-item self-report inventory, measuring perception of and ability to cope with stress over the past month.
• Normative data are available for the PSS-10, and it is easily administered.
• The PSS-10 can be administered periodically as circumstances change.
• The PSS-10 can help identify athletes who are having difficulty coping with stress.
• The Recovery-Stress Questionnaire for Athletes (RESTQ-Sport) can also screen for stress.
• The RESTQ-Sport measures stress and recovery specifically in athletes.
• It identifies physical and mental stress, as well as capabilities for recovery.

Depression and Suicide

• Major depression involves a period of at least two weeks with depressed mood or loss of interest and five specific symptoms.
• Symptoms must be associated with significant life interference or distress to be considered a depressive episode.
• Studies using screening questionnaires found depression rates of 15-27% in athletes across cultures.
• Female athletes tend to report higher levels of depressive symptoms.
• Freshman athletes report higher levels of depressive symptoms than upperclassmen.
• Athletes in individual sports endorse more depressive symptoms than those in team sports.
• Current college athletes are more likely to report symptoms of depression than retired college athletes.
• High comorbidity exists between depression and other difficulties like sport-specific stress, anxiety, and substance use.
• Injured athletes (concussed and nonconcussed) report higher levels of depression.
• Several sport-related variables are associated with depressive symptoms.
• Psychosocial factors may trigger depressive episodes, especially during transitions, high stress, and competitive failures.
• Retirement from sport is also a trigger for depressive episodes.
• The Center for Epidemiological Studies Depression Scale Revised (CESD-R) can be used to evaluate depression.
• The CESD-R is a 20-item self-report inventory used to evaluate symptoms of depression in adolescents and adults.
• Total scores on the CESD-R range from 20 to 60, with a score of 16 or above associated with a depression diagnosis.
• Suicidal ideation or behavior is a criterion of depression.
• It is important to assess suicide in the context of depression, but also when it may occur in other disorders.
• Athletes generally have a lower risk of suicide than nonathletes.
• Factors such as being a multisport athlete, playing football, and experiencing sport-related loss are associated with suicidal behavior.
• Take any endorsement regarding suicide seriously and refer any athlete you are concerned about to a qualified mental health professional as soon as possible.
• Talking about suicide does not promote thoughts or increase the risk of suicide.
• Suicide items are often embedded within depression screening inventories, but this may be insufficient.
• It may be useful to include an additional screening inventory when concerned about suicidality.
• If you have little or no education or training in mental health, seek consultation with a qualified mental health professional.
• The Suicidal Behaviors Questionnaire-Revised (SBQ-R) can be used to screen for suicide.
• The SBQ-R is a four-item inventory that addresses dimensions of suicidality in adolescents and adults.
• The SBQ-R addresses lifetime suicidal ideation, frequency of ideation, threat of attempt, and likelihood of future behavior.
• A score of >7 led to 93% sensitivity and 95% specificity.
• It is important to address endorsement of items at any level.

Anxiety

• Significantly less attention has been paid to anxiety disorders in athletes.
• Athletes are often more comfortable seeing a consultant for competitive anxiety.
• Competitive anxiety is situation specific and short in duration, while anxiety disorders are ever present.
• The DSM-5 includes diagnostic criteria for three anxiety disorders: generalized anxiety disorder (GAD), panic disorder, social anxiety disorder.
• Generalized anxiety disorder (GAD) is characterized by persistent and uncontrollable worry most of the time.
• Panic disorder is characterized by the presence and fear of panic attacks that peak within 10 minutes.
• Social anxiety disorder is characterized by fear and anxiety in social and evaluative situations.
• There is little research examining prevalence rates of anxiety disorders in athletes.
• Female athletes generally report higher levels of anxious symptomatology than male athletes.
• The following rates have been identified for clinical levels of anxiety symptoms in athletes: -GAD is found in up to 7% of men and 10% of women. -Social anxiety disorder is found in approximately 14% of men and 15% of women. -Panic disorder is found in up to 3% of men and 6% of women.
• Several sport-related factors are associated with anxiety disorders.
• Symptoms of anxiety are common during the injury rehabilitation process.
• Injured athletes also report higher symptoms of GAD than noninjured athletes.
• Athletes who perceive their anxiety as debilitating are more likely to report burnout.
• Athletes in aesthetic sports may experience higher levels of generalized anxiety symptoms.
• A number of screening measures have been developed to evaluate the anxiety disorders mentioned earlier.
• The Generalized Anxiety Disorder 7 (GAD-7) is a seven-item self-report inventory.
• The Panic Disorder Severity Scale-Self-Report (PDSS-SR) is a five-item self-report inventory used to screen for panic disorder symptoms in adults.
• The Social Phobia Scale (SPS-6) is a six-item self-report inventory evaluating fears of general social interaction.

Disordered Eating and Eating Disorders

• Disordered eating and eating disorders include abnormal eating and weight-control behaviors.
• These include restriction of food intake, binging and purging, and other compensatory behaviors.
• Symptoms are typically accompanied by body dissatisfaction.
• The DSM-5 includes diagnostic criteria for four eating disorders: -Anorexia nervosa (AN). -Bulimia nervosa (BN). -Binge eating disorder (BED). -Avoidant/restrictive food intake disorder (ARFID).
• Concerns about body image and eating pathology are often comorbid with other mental health issues.
• Research regarding the prevalence of eating disorders among athletes is conflicting.
• AN and BN may be more prevalent among athletes than nonathletes.
• Higher rates are seen among female athletes than male athletes and elite versus recreational athletes.
• Eating disorders are more prevalent among athletes in lean and aesthetic sports.
• It can be difficult to identify athletes struggling with eating concerns.
• Several traits of a so-called good athlete are similar to traits found among people with AN.
• Red flags in nonathlete populations may be attributed to the athlete's activity status.
• There are short and long-term physical and psychological risks of eating disorders.
• It is essential to recognize individuals with symptoms and encourage them to seek treatment.
• ACSM, NATA, and IOC advocate for screening of eating disorders.
• Screening and assessment should include multiple sources of information.
• It should be sensitive to the athlete's age and competitive level.
• A number of assessment and screening tools have been developed and validated.
• The Eating Attitudes Test (EAT-26) is a 26-item self-report screening tool of eating disorder symptoms.
• The EDE-Q is a 41-item self-report questionnaire designed to evaluate the frequency of disordered eating.
• The FAST is a 33-item questionnaire developed to identify eating pathology and atypical exercise and eating behaviors in female athletes.
• Using general eating disorder assessments, athletes may appear more pathological than they are.
• Athlete-specific screening tools have been developed.
• Unfortunately, athlete-specific screening tools for eating disorders typically have less established psychometric properties.
• Therefore, the measures recommended for their utility in screening for eating disorders was chosen for their sound psychometric properties.
• It would be prudent to incorporate more than one screening tool when assessing athletes for eating disturbances given the aforementioned concerns.

Attention-Deficit/Hyperactivity Disorder

• ADHD is a neurodevelopmental disorder commonly diagnosed in children.
• It can also be present in adulthood.
• It is characterized by persistent symptoms of inattention, hyperactivity, and impulsivity.
• Similar to depression and anxiety, there is no epidemiological research examining the prevalence of ADHD in athletes.
• Researchers suggest the prevalence of ADHD may be higher in athlete populations.
• Athletes with ADHD may have advantages such as heightened reaction time.
• Athletes may have subthreshold symptoms that do not fully manifest until the demands of their environment are greater.
• Academic difficulties may then increase the stress level of the student-athlete because eligibility is threatened.
• Athletes with ADHD may also be misdiagnosed with behavioral difficulties.
• One example of a screening measure for ADHD is the Adult ADHD Self-Report Scale (ASRS-v1.1).
• A second screening measure that can be used for ADHD is the Conners' Adult ADHD Rating Scales (CAARS).
• One challenge of using screening inventories for ADHD is the high degree of symptom overlap between ADHD and other disorders, such as anxiety and depression.
• Referral for a comprehensive evaluation is recommended.

Substance Use and Abuse

• According to the DSM-5, substance use disorders involve cognitive, behavioral, and physiological symptoms.
• They also involve continued use despite difficulties.
• There are 10 classes of substance use disorders.
• Each is measured on a continuum from mild to severe.
• A substance use problem consists of a problematic pattern of use, tolerance, and withdrawal.
• Males and lacrosse players report the highest rates of substance use.
• Athletes report using alcohol, marijuana, and smokeless tobacco most frequently.
• Some studies found up to 80% of athletes use alcohol.
• Athletes may engage in binge drinking at higher rates than nonathletes.
• Use of other substances is generally lower in athletes compared with nonathletes.
• Athletes may also use substances to build muscle and control weight.
• Social reasons for substance use can include peer pressure, modeling of drug use behaviors, and fun.
• College student-athletes are susceptible to heavy drinking.
• Detecting problems can be difficult.
• Therefore, it may be beneficial to screen for substance use difficulties where alcohol-related injuries or illnesses may be present.
• Should screening confirm suspected problems with substance use, an appropriate referral should be made.
• The Alcohol Use Disorders Identification Test (AUDIT) is a 10-item self-report inventory.
• The Drug Abuse Screening Test (DAST) was developed as a brief screening not including alcohol and tobacco.