Mental Health Education for Coaches, Parents, and Athletes
Mental Health Education for coaches, parents, and athletes: How do you know when it’s not just a bad day?
Anna Enright, DNP, PCNS-BC
The following is a resource coaches and parents can use to effectively and quickly identify athletes who are at risk or are experiencing emotional symptoms. How do we know when it’s not just a bad day? What are the signs that our athletes are struggling? Like other medical problems, early identification of mental health problems means less disruption to the athlete’s life, fewer severe health complications and quicker recovery. In a study by Gulliver, Griffiths and Christenses (2012) lack of knowledge about symptoms of mental health disorders and the stigma and embarrassment of asking for help were listed as a barrier by over 40% of the athlete participants.
Unattended stress can lead to mental health problems, therefore, education regarding the signs and symptoms of mental disorders and early intervention is critical. Here you will find information on signs and symptoms of the most common mental health issues: Depression, anxiety, eating disorders (Anorexia and Bulimia, Relative Energy Deficiency in Sports (RED-S) and substance abuse. This information is for educational purposes only.
Let’s start with some statistics
General population:
Mental health issues increased significantly in young adults over the past decade. On college campuses, mental health diagnosis increased from 22% to 36% between 2007-2017. A 2021 survey from the National Alliance on Mental Illness reports 80% of students feel overwhelmed by the responsibilities of being a student and only 40% seek help. As a psychiatric clinician in private practice, I have seen referrals skyrocket in the last year as the Covid pandemic has upended our lives.
National Alliance on Mental Illness statistics for the general population:
1 in 5 U.S. adults experience mental illness each year.
1 in 20 U.S. adults experience serious mental illness each year.
1 in 6 U.S. youth aged 6-17 experience a mental health disorder each year.
50% of all lifetime mental illness begins by age 14, and 75% by age 24.
Suicide is the 2nd leading cause of death among people aged 10-34.
Athletes and mental health
The statistical evidence regarding the mental health and wellbeing of athletes is limited. Participation in athletics has many benefits, however, the very nature of competition can provoke, add to, or expose specific psychological issues in athletes. A study where data was collected from 1,118 incoming student athletes at a Division One institution between 2011 and 2017 found a lifetime prevalence of mental health conditions was 14% for all athletes, 14.2% for male athletes and 13.6% for female athletes. Individual sports reported a greater prevalence, 17.2% than did team sports, 11.8%. Other findings include a significant association between mental health conditions and injuries.
The American College of Sports Medicine Statement on Mental Health Challenges for Athletes (2021) reported about 30% of women and 25% of men who were student-athletes and 35% of elite athletes struggle with mental health issues. Only a fraction (10%) of all college athletes with known mental health conditions seek help from a mental health professional!
These are formidable percentages when one considers there are 8 million students participating in high school sports and about 480,000 competing as National Collegiate Athletic Association (NCAA) athletes. When we look at the sport of climbing, according to Statistica.com in 2019 there were 9.89million climbers in the United States. USA Climbing’s 2020-2024 Strategic Plan outlines growth by 2028 to 100,000 athletes. There are no studies currently reporting on the prevalence of mental illness in climbing athletes. What we do know is that as an individual sport, climbing carries a greater risk for athletes developing a mental health condition.
How do you know it’s a Disorder?
We can categorize symptoms related to mental health challenges in four categories. The more signs and symptoms exhibited, the stronger the case for doing one of the following: Check in with the athlete to gather more information; alert a legal guardian; or recommend a referral to a mental health provider.
1. Behavioral - Symptoms may include social withdrawal, challenging authority, a drop in school or sport performance or substance use
2. Cognitive - Symptoms may include negative self-talk, difficulty making decisions, decreased ability to concentrate, all or nothing thinking, suicidal thoughts
3. Psychological - Symptoms may include excessive worry and agitation, lack of motivation, hopelessness, mood swings, feeling out of control, not feeling worthy, guilt
4. Physical - Symptoms may include changes in appetite, sleep difficulties, fatigue, headaches, stomach issues, frequent injuries, shaking or trembling.
Is it More Than a Bad Day?
Signs and Symptoms of common mental health disorders
Keep in mind that mental health disorders don’t often show up as distinctly as described. For example, anxiety and depression have a likelihood of occurring together and an untreated condition increases the risk of struggling with another. For example ,untreated depression or anxiety can lead to the coping style of using substances, ultimately increasing the risk for an addiction. Luckily, treatment can address multiple disorders at onceThe most important message is THESE MENTAL HEALTH CONDITIONS ARE TREATABLE AND CAN GO INTO REMISSION!! THERE IS HELP FOR ALL OF THE FOLLOWING CONDITIONS! NO ONE NEEDS TO SUFFER ALONE!!
Depression
We all go through times when we feel sad. Typically, these moments pass within a few days. Depression interferes with day-to-day activities and persists. If you have 3-4 of the following symptoms for more than 2-weeks, please seek professional help. The following signs and symptoms are an indication that you may have clinical depression.
Feeling Sad
Anxious
Empty
Hopeless
Guilty
Worthless
Helpless
Irritable
Restless
Indecisive
Aches, pains, headaches, cramps, or digestive problems
Lack of energy, sad mood
Loss of interest in activities previously enjoyed (hanging out with friends, practice, school, sex)
Decreased performance in school or sport
Loss of appetite or increase in appetite resulting in weight loss or weight gain
Problems falling asleep, staying asleep, or sleeping too much
Problems concentrating, remembering information, or making decisions
Unusual crying
Reoccurring thoughts of death and suicide, or suicide attempts (seek help immediately). National Suicide Prevention Lifeline 1-800-273-8255.
Although most depressions occur due to either acute or chronic stressful life events such as a significant loss or trauma, and some can occur out of the blue due to a genetic predisposition, some athletes may experience depression from their sport participation. For example, if the athlete has an injury which takes them out of the sport they love. Overtraining syndrome can also be a risk factor. The symptoms of overtraining syndrome include fatigue, muscle soreness, weight loss, sleep disturbance, anxiety, irritability, decreased concentration and ultimately, decreased performance which can further add to depression.
Depression and Risk of Injury
Although an injury can be a risk factor to an athlete developing a depressive episode, the reverse is also true. Being depressed can increase an athlete’s risk for injury. Depressive symptoms may increase the likelihood of injury primarily through distraction, decreased concentration resulting in being less mindful, a slowed reaction time or being medically compromised due to lack of sleep or poor nutrition.
Suicidal Risks Research suggests that suicide is the second leading cause of death among college students. Approximately three suicides occur daily among college students, and each year, 7 to 10%of college students either attempt or contemplate suicide. The increased possibility of suicide attempts and suicides makes depression the most critical disorder. Although early identification and treatment are important for all mental disorders, they are most important for depression because of the potential for self-harm. Do not ever assume the person is having suicidal thoughts or behaviors for “attention.” (National Suicide Prevention Lifeline 1-800-273-8255).
Source: National Institute of Mental Health
For more information on depression:
http://www.nimh.nih.gov/health/topics/depression/index.shtml
https://apa.org/topics/depress/index.aspx
http://www.nimh.nih.gov/health/publications/depression-and-college-students/index.shtml
http://www.ulifeline.org/topics/128-depression
Anxiety
Occasionally experiencing symptoms of anxiety is normal. Most, if not all athletes experience some form of performance anxiety. If channeled and managed well, this type of anxiety is useful and can enhance sport performance. It becomes a disorder when symptoms persist daily and worsen with pressure or stress. Anxiety symptoms which make it hard to keep up with social relationships as well as academic and sport responsibilities are a sign that one may need to seek help. According to the National Institute of Mental Health, anxiety disorders are the most common type of mental illness in the U.S. Approximately 40 million people over the age of 18 are affected each year.
The most common types of anxiety disorders are:
Generalized anxiety disorder- “free-floating” anxiety that can occur without a specific cause; excessive worry about everyday problems that can affect sport performance, academics, health, and relationships.
Panic attacks or panic disorder-anxiety and physical symptoms such as a pounding heart, tingling in the extremities, shortness of breath, a feeling of doom, to some it feels like they are having a heart attack.
Obsessive-compulsive disorder-obsessive thoughts and compulsive behaviors related to anxiety.
Phobias-an exaggerated fear of a particular situation or object.
If you experience Anxiety you may:
Feel apprehensive
Feel powerless
Have a sense of impending danger, panic, or doom
Have an increased heart rate
Breathe rapidly
Sweat
Tremble
Feel stressed
Feel weak or tired
Feel like worry is interfering with school, sports, relationships, or other parts of life
Feel depressed
Have trouble with alcohol or drug use, or have other mental health concerns
Be anxious about other physical health problems
Have suicidal thoughts or behaviors (seek emergency treatment immediately. National Suicide Prevention Lifeline 1-800-273-8255). 5
For more information on anxiety:
http://www.adaa.org/
https://apa.org/topics/anxiety/index.aspx
http://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml
http://www.ulifeline.org/topics/132-anxiety-disorders
Eating Disorders
The estimated prevalence of eating disorders and/ or disordered eating among athletes are higher than in non-athletes. Among athletes the ranges of eating disorder/disordered eating range from 0 to 19% in men and from 6 to 45% in women. (Bratland-Sanda and Bratland-Sanda, 2013; oy, E., Kussman, and Nattiv, 2016). Athletes in sports where weight to strength ratio is important for performance are at higher risk of developing an eating disorder (Rock-climbing, gymnastics, running). (Mancine, et al., 2020)
Anorexia nervosa, bulimia nervosa, and binge eating disorder are all types of eating disorders. Many people with eating disorders start out wanting to lose or gain a few pounds, but find that things have spiraled out of control. Eating disorders can negatively impact physical health, mental health, and sport performance. Athletes with eating disorders may become malnourished, dehydrated, depressed, anxious, and overly focused on: Eating; food; body image; and weight. Ten percent of people with untreated eating disorders will die from their illness. Anorexia has the highest death rate. Depression and anxiety are also common in people with eating disorders.
Relative Energy Deficiency in Sports (RED-S)
Intentional or unintentional undernourishment in athletes that decreases endurance and increases injuries.
Check out this informative article by Mina Leslie-Wujastyk https://www.ukclimbing.com/articles/features/relative_energy_deficiency_in_sport_-_a_cautionary_tale-12345
The consequences impact various physical and psychological functions as depicted in the figures below.
The following figures are from the IOC Consensus Statement (2014).
Health Consequences of Relative Energy Deficiency in Sport (RED-S) showing an expanded concept of the Female Athlete Triad to acknowledge a wider range of outcomes and the application to male athletes (*Psychological consequences can either precede RED-S or be the result of RED-S.
Potential Performance Effects of Relative Energy Deficiency in Sport (*Aerobic and anaerobic performance).
Anorexia Nervosa
People with anorexia nervosa obsess about their weight and the food they eat.
Extreme thinness (emaciation)
A relentless pursuit of thinness and unwillingness to maintain a normal or healthy weight
Intense fear of gaining weight
Distorted body image, a self-esteem that is heavily influenced by perceptions of body weight and shape, or a denial of the seriousness of low body weight
Lack of menstruation among girls and women (amenorrhea)
Extremely restricted eating
Compulsive exercise
Other symptoms may develop over time, including
Thinning of bones (osteopenia or osteoporosis)
Brittle hair and nails
Dry and yellowish skin
Growth of fine hair all over the body (lanugo)
Mild anemia and muscle wasting and weakness
Severe constipation
Low blood pressure, slowed breathing, and pulse
Damage to the structure and function of the heart
Brain damage
Multi-organ failure
Drop in internal body temperature, causing a person to feel cold all the time
Lethargy, sluggishness, or feeling tired all the time
Infertility
Chronically inflamed and sore throat
Swollen salivary glands in the neck and jaw area
Worn tooth enamel, increasingly sensitive and decaying teeth as a result of exposure to stomach acid
Acid reflux disorder and other gastrointestinal problems
Intestinal distress and irritation from laxative abuse
Severe dehydration from purging of fluids
Electrolyte imbalance (too low or too high levels of sodium, calcium, potassium, and other minerals), which can lead to heart attack.
Source: National Institute of Mental Health
For more information on eating disorders:
http://www.nimh.nih.gov/health/topics/eating-disorders/index.shtml
http://www.apa.org/topics/eating
http://www.ulifeline.org/topics/131-eating-disorders
Bulimia Nervosa
Bulimia nervosa often involves recurrent and frequent episodes of eating unusually large amounts of food and feeling a lack of control over these episodes. Binge eating is often followed by behavior that compensates for the overeating such as forced vomiting, excessive use of laxatives or diuretics, fasting, excessive exercise, or a combination of these behaviors.
People with bulimia nervosa usually maintain what is considered a healthy or normal weight or are slightly overweight. They often fear gaining weight, want desperately to lose weight, and are intensely unhappy with their body size and shape. Bulimic behavior is often done secretly because it is typically accompanied by feelings of disgust or shame. The binge-eating and purging cycle happens anywhere from several times a week to many times a day.
Chronically inflamed and sore throat
Swollen salivary glands in the neck and jaw area
Worn tooth enamel, increasingly sensitive and decaying teeth as a result of exposure to stomach acid
Acid reflux disorder and other gastrointestinal problems
Intestinal distress and irritation from laxative abuse
Severe dehydration from purging of fluids
Electrolyte imbalance (too low or too high levels of sodium, calcium, potassium and other minerals) which can lead to heart attack.
For more information on eating disorders:
Check out the documentary ‘Light’ by Caroline Treadway https://www.youtube.com/watch?v=GZL_JgYDPkI
http://www.nimh.nih.gov/health/topics/eating-disorders/index.shtml
http://www.apa.org/topics/eating
http://www.ulifeline.org/topics/131-eating-disorders
Substance Abuse
Alcohol
The consequences of drinking include:
Death: 1,825 college students between the ages of 18 and 24 die each year from alcohol-related unintentional injuries.
Assault: More than 690,000 students between the ages of 18 and 24 are assaulted by another student who has been drinking.
Sexual Assault: More than 97,000 students between the ages of 18 and 24 are victims of alcohol-related sexual assault or date rape.
Injury: 599,000 students between the ages of 18 and 24 receive unintentional injuries while under the influence of alcohol.
Academic Problems: About 25 percent of college students report academic consequences of their drinking including missing class, falling behind, doing poorly on exams or papers, and receiving lower grades overall.
Health Problems/Suicide Attempts: More than 150,000 students develop an alcohol-related health problem and between 1.2 and 1.5 percent of students indicate that they tried to commit suicide within the past year due to drinking or drug use.
Source: National Institute on Alcohol Abuse and Alcoholism
Warning signs of alcohol abuse and addiction include:
Difficulty limiting the amount of alcohol consumed
Feeling a strong need or compulsion to drink
Developing tolerance to alcohol so that more is needed to feel the effects
Drinking alone or hiding drinking
Experiencing physical withdrawal symptoms such as nausea, sweating and shaking when not drinking
Not remembering conversations or commitments, sometimes referred to as a "blackout"
Making a ritual of having drinks at certain times and becoming annoyed when this ritual is disturbed or questioned
Keeping alcohol in unlikely places at home, in the dorm, or in your car
Gulping drinks, ordering doubles, or becoming drunk intentionally to feel good, or drinking to feel "normal"
Having legal problems or problems with relationships, school, work, or money due to drinking
Losing interest in activities and hobbies that used to bring pleasure
For more information on substance abuse:
https://apa.org/topics/addiction/index.aspx
http://www.ulifeline.org/topics/134-alcohol-drugs
Marijuana
It's possible to develop a psychological addiction to cannabis compounds including tetrahydrocannabinol (THC) found in marijuana and hashish. People who have a marijuana addiction generally use the drug on a daily basis to deal with issues such as stress, lack of sleep, and anxiety.
Signs of use and dependence can include:
A heightened sense of visual, auditory, and taste perception
Poor memory
Increased blood pressure and heart rate
Red eyes
Decreased coordination
Difficulty concentrating
Increased appetite
Slowed reaction time
Paranoid thinking
For more information on substance abuse:
https://apa.org/topics/addiction/index.aspx
http://www.ulifeline.org/topics/134-alcohol-drugs
Narcotic painkillers
Opioids are narcotics used for management of pain and produced naturally from opium or made synthetically. This class of drugs includes heroin, morphine, codeine, methadone and oxycodone (OxyContin). If you're prescribed these medications by a doctor, take them exactly as directed. Don't increase your dose without first talking to your doctor.
Signs of narcotic use and dependence can include:
Reduced sense of pain
Sedation
Depression
Confusion
Constipation
Slowed breathing
Needle marks (if injecting drugs)
Seek emergency help if you or someone you know has taken a drug and:
May have overdosed
Loses consciousness
Has trouble breathing
Has seizures
Has signs of a heart attack, such as chest pain or pressure
Has any other troublesome physical or psychological reaction to use of the drug
For more information on substance abuse:
https://apa.org/topics/addiction/index.aspx
http://www.ulifeline.org/topics/134-alcohol-drugs
Further Readings
Bratland-Sanda, S. and Sundgot-Borgen, J. (2013) Eating disorders in athletes: overview of prevalence, risk factors and recommendations for prevention and treatment� European Journal of Sport Science, 13(5), pp.499-508.
Gulliver, A., Griffiths, K. and Christensen, H. (2012). Barriers and facilitators to mental health help-seeking for young elite athletes: a qualitative study. BMC Psychiatry, 12(1), no. 157, pp.157-157.
Hibbs, J. B., & Rostain, A. (2019). The stressed years of their lives: Helping your kid survive ang thrive during their college years. New York, New York: St. Martin's Press.
Lipson, S. K., Lattie, E. G., & Eisenberg, D. (2018, November 5). Increased rates of mental health service utilization by U.S. college students: 10-year population-level trends (2007-1017). Psychiatric Services, 70(1), 60-63. http://dx.doi.org/10.1176/appi.ps.201800332
Mancine, R. P., Gusfa, D. W., Moshrefi, A., & Kennedy, S. F. (2020). Prevalence of disordered eating in athletes categorized by emphasis on leanness and activity type–a systematic review. Journal of Eating Disorders, 8(1), 1-9.
Mountjoy, M., Sundgot-Borgen, J., Burke, L., Carter, S., Constantini, N., Lebrun, C., ... & Ljungqvist, A. (2014). The IOC consensus statement: beyond the female athlete triad—relative energy deficiency in sport (RED-S). British journal of sports medicine, 48(7), 491-497.
oy, E., Kussman, A., and Nattiv, A. (2016). 2016 update on eating disorders in athletes: A comprehensive narrative review with a focus on clinical assessment and management� British Journal of Sports Medicine, 50, pp.154-162.
https://www.nami.org/getattachment/About-NAMI/Publications-Reports/Survey-Reports/College-Students-Speak_A-Survey-Report-on-Mental-Health-NAMI-2012.pdf
Sarac, N., Sarac, B., Pedroza, A., & Borchers, J. (2018). Epidemiology of mental health conditions in incoming division I collegiate athletes. The Physician and sportsmedicine, 46(2), 242-248.
Twenge, J. M., Cooper, A. B., Joiner, T. E., Duffy, M. E., & Binau, S. G. (2019). Age, period, and cohort trends in mood disorder indicators and suicide-related outcomes in a nationally representative dataset, 2005–2017. Journal of abnormal psychology, 128(3), 185.
