Health care of collegiate student-athletes involves both physical and psychological well-being. The prevalence in terms of type, severity, and frequency of mental illness in college-aged students has gained increased recognition in recent years. Because athletic activity can often result in injury or illness, a variety of psychological factors can occur. These may include stress, anxiety, depression, withdrawal, disordered eating, and substance abuse. Many of these factors have unique presentations within the athletic population; therefore, athletic health care providers must be skilled in recognizing at-risk student-athletes and providing appropriate care and referral for mental health issues.
Scifers: In what ways are you addressing student-athlete mental health in your clinical practice? How are you incorporating a multidisciplinary and collaborative approach to addressing mental health in student-athletes?
Hong: Addressing student-athlete mental health requires educating the community and speaking with student-athletes, coaches, athletic trainers, and staff at the college level to raise awareness of the importance of mental health and wellness in athletes. One important message to deliver is that being an athlete does not decrease the risk of mental health issues or concerns.Screening in this population is also critical. All returning student-athletes should have to complete a validated depression screening tool, such as the Center for Epidemiologic Studies–Depression (CES-D). Additionally, team physicians should provide student-athletes with an open invitation to discuss any mental health concerns at the time of the pre-participation physical examination or at any time throughout the academic year. A multidisciplinary team, including a team physician, clinical psychologist, and athletic trainer, should meet regularly to discuss the health and wellness of the student-athletes. This team should work diligently to improve the referral process to mental health/behavioral health professionals. Finally, co-locating services, such as the counseling center, student health, and sports medicine, in one geographic location is useful in coordinating care for the student-athlete.
Keenan: During the past 2 years, we have begun developing protocols for addressing mental health issues in our student-athletes from all angles. Because we are a National Collegiate Athletic Association (NCAA) Division II institution, our resources are limited. The athletic trainers took the lead on addressing student-athlete mental health by reaching out to various personnel or “stakeholders” involved in our student-athletes' well-being. Our Department of Sports Medicine has collaborated with the University Counseling Center and the Athletics Department, along with colleagues from the Nutrition Department and others across campus, to use as many resources as possible that may be beneficial to our student-athletes. We have specifically used valuable guidance and recommendations from counseling faculty regarding the best approaches to recognizing and referring student-athletes with potential mental health issues. This collaborative approach has helped disperse the work put into casting a wide net when approaching mental health and has ensured that we are involving and educating all stakeholders in our student-athletes' well-being.
Putukian: We include mental health screening questions as part of our yearly pre-participation physical examinations, specifically the Patient Health Questionnaire (PHQ-9) for depression, the Generalized Anxiety Disorder 7-item Scale (GAD-7) for anxiety, the SCOFF for eating disorders/disordered eating, and the Alcohol Use Disorders Indentification Test (AUDIT) for alcohol (the same audit that our inpatient unit uses for all students). We ask about recreational and prescription drugs.The PHQ-9 and GAD-7 are also instruments we use at baseline for all student-athletes as part of their concussion assessment and are repeated after an athlete sustains a concussion and is returning to participation. At Princeton, we address mental health in student-athletes in a variety of collaborative and multidisciplinary methods. Our Athletic Medicine team, including our athletic trainers and team physicians, is part of University Health Services, which also includes our Counseling and Psychological Services team of psychologists, psychiatrists, and mental health social workers. We have a multidisciplinary Eating Disorders team that includes nurse practitioners, physicians, athletic trainers, and psychologists who meet on a weekly basis to discuss students with eating disorders. We have a multidisciplinary team called TIGER Student Performance and Wellness that includes our team physicians, an athletic trainer, and our clinical sports psychologists, which meets to discuss student-athletes of concern throughout the course of the year.In addition, we have a larger team that includes members of the Athletic Department. Finally, we have a Student-Athlete Wellness Leaders program, in which our student-athletes complete bystander intervention and other training related to common mental health issues so they can assist teammates and other students in need.
Scifers: In 2013, the National Athletic Trainers' Association (NATA) published a consensus statement on developing a plan to recognize and refer collegiate student-athletes with psychological concerns. In 2016, the NCAA also published a Mental Health Best Practices consensus document on understanding and supporting student-athlete mental wellness. These consensus documents recommend developing routine and emergent mental health referral protocols. In your experience, how has having written referral protocols in place helped the medical staff approach the mental health of student-athletes?
Hong: Although having protocols is helpful, having a written policy is critical to engaging the community. A written policy addressing the mental health and wellness of the population may be helpful to get all parties on the same page and to raise awareness and understanding of this key concern. As an example, it is important that all parties (ie, student-athletes, coaches, and athletics staff) understand there is a difference between performance psychology and clinical psychology. As an analogy, having the NCAA mandate the creation of a written concussion policy for its member institutions was helpful to raise awareness and engage the community and then implement a concussion protocol. We could consider a similar approach to mental health in athletes. The NCAA has convened a second task force on mental health in athletes to follow up on the work of the first task force in 2016 (which resulted in the Best Practices statement). I was asked to serve on this task force and we met for the first time in November. A second consensus document from the NCAA is anticipated in 2018 and will focus, in part, on the challenges of implementing best mental health practices.
Keenan: Our institution is part of the Pennsylvania State Athletic Conference (PSAC), which instituted a policy adopting the NCAA Mental Health Best Practices across the conference. Once adopted, our institution formed a committee within our Department of Sports Medicine to develop a formal protocol that addressed the mental health of our student-athletes. This protocol involved collaboration from all stakeholders, including athletic trainers, team physicians, coaches, athletic directors, and university counseling services faculty. It has allowed those stakeholders to use the protocol as a foundation for starting a conversation about mental health, something these professionals may not have previously experienced. Implementing both emergency and routine mental health referral protocol has already improved the health and welfare of our student-athletes. This protocol has also begun to change the environment surrounding mental health by reducing the stigma and engaging important conversation around the psychological aspects of being student-athletes and caring for their mental health.
Putukian: There might be existing written referral protocols that each university has addressing these same needs for all students, not only student-athletes. Having written protocols and following the NCAA Mental Health Best Practices document can be helpful. In addition, Psychological Issues Related to Illness and Injury in Athletes and the Team Physician: A Consensus Statement–2016 Update was published in 2017. We presented the information from the NCAA to our Athletic Medicine and Strength and Conditioning Staff after it was published and it is also discussed and distributed to our student-athletes and our coaches and administrators.
Scifers: How have you or your institution incorporated addressing mental health into the pre-participation examination? How have you observed or measured student-athletes benefitting from this clinical approach?
Hong: The CES-D is a validated tool for depression screening and we have every returning student-athlete complete this tool. Those with appropriate scores are referred for further mental health evaluation in person. In the office, the PHQ-2, another validated depression screening tool, is mandatory for all patients, including student-athletes. Those who are “positive” are then given a more sensitive screening tool (the PHQ-9) and then referred on as appropriate. We are currently conducting a study that examines the responses of the student-athletes to the CES-D tool when their responses are de-identified versus identified. The hypothesis is that the responses to the screening will be different if the athlete data is anonymous. We would also like to see the implementation of sleep health, alcohol use, and screening for other aspects affecting mental health and wellness. Time is the biggest challenge for conducting this additional screening.
Keenan: Our institution has adopted several self-report mental health screening surveys into our pre-participation examination. These include the PHQ-9 for depression symptoms, the GAD-7 questionnaire for anxiety, the SCOFF and EAT-26 for eating disorders, the Insomnia Severity Index for sleeping issues, the ADHD Self-Report Scale (ASRS) for attention deficit hyperactivity disorder, and the AUDIT for alcohol use. The athletic trainers also administer specific screenings throughout the athletic season, when necessary, such as administering the PHQ-9 after injury. A specific mental health referral protocol was implemented that involves offering a referral to on-campus counseling services or off-campus mental health care providers.Student-athletes have benefitted from our mental health screening because many have disclosed elevated symptoms of mental health issues through the screening; these are athletes with issues that likely would not have been identified without private, confidential screening during the pre-participation examination. Numerous student-athletes have been referred for various mental health services through this protocol. Additionally, by incorporating the mental health screening within the pre-participation examination, student-athletes quickly come to learn that their athletic trainers and team physicians are just as concerned about, and have the tools to address, their mental health as their physical health.
Putukian: As mentioned previously, we have incorporated numerous questions into our pre-participation examinations. It has been beneficial in that we have been able to detect student-athletes who are struggling with mental health issues early on, have them meet with our team physicians, and then help provide referrals to our mental health providers. It can help to normalize help-seeking behaviors and allow student-athletes to understand that their mental health is an important part of their overall health and wellness.
Scifers: What challenges have you experienced in developing and implementing a mental health management plan into athletic training and sports medicine clinical practice? How have you or your colleagues addressed or overcome these challenges?
Hong: One challenge is educating the community that not all sports psychology is the same: performance focused versus clinical health/wellness focused. Another challenge is that we are still combating the perception that student-athletes are at less risk for mental health concerns compared to their non-athlete peers. This perception may be held by the athletes, coaches, staff, and institution. We believe this perception to be false. Time is also a significant challenge to implementing a mental health management plan. Integrating the coaching staff, raising awareness of mental health concerns, and educating the community are time-intensive undertakings. Most individuals understand performance in athletics but fail to understand the importance of mental health in athletes. We need to provide the opportunities and the tools and resources for the community to embrace “mental health and athletes.” A final challenge is the relative paucity of strong research in mental health and athletes.
Keenan: Although the NCAA mental health best practices have been adopted in our athletic conference, some stakeholders have expressed concern regarding the limitations of resources. Every institution will be different regarding what type of resources it has access to, but even creating a basic referral protocol can be implemented with limited resources. Additionally, not everyone may be comfortable discussing mental health issues because this has historically been stigmatized in the sports arena. However, by continuing to have conversations and addressing mental health, the environment will eventually shift in normalizing the discussion around mental health. This shift in destigmatizing mental health does not happen overnight and does not end by simply implementing a protocol. It takes consistent, purposeful, and thoughtful approaches to addressing mental health, and it is imperative that all stakeholders are on board. What has helped at our institution is having supportive administrators and athletic directors, having conversations and gaining support from coaches, and having a willingness of the counseling center faculty to collaborate to begin to develop an environment that emphasizes positive mental health in our student-athletes.
Putukian: There can be challenges when interacting with mental health providers, especially if they are off campus and do not understand the climate of health and wellness that you are trying to support as it relates to mental health issues. Despite how far we have come in terms of removing the stigma of seeking help for mental health issues, there are still many obstacles to treatment. In addition, there are situations when student-athletes need to be evaluated by a clinical psychologist who has expertise and understanding of the unique demands of student-athletes, and this resource can at times be limited.
Scifers: There is a limited amount of clinical research regarding collegiate student-athlete mental health and clinical approaches to addressing student-athlete mental health. How would you like to see this area of clinical practice investigated in the future?
Hong: Best practices, as they are best understood at this point, should be shared. Best practices should continue to be studied to support their use. We need support and resources for this effort and more research on mental health and student-athletes, and this needs to come from the institutions, athletic directors, coaching staffs, student-athletes, student health centers, mental health providers, and the larger organizations who are charged with the health and wellness of collegiate athletes.
Keenan: It is clear that mental health issues in student-athletes need further research. In particular, the epidemiology of specific mental health disorders and the stressors that may lead to the prevalence of mental health issues in student-athletes. There is also a need to investigate the mental health of student-athletes at varying levels of competition and types of sports. We will be able to better address mental health issues if we can also address sport-specific issues and concerns that our collegiate student-athletes face.
Putukian: We need to have a better understanding of the stressors that student-athletes face and knowing how these change over time. There are some troubling numbers relating to depression, anxiety, and substance abuse on our campuses. It would be helpful to not only know what the numbers are, but also to put in place detection and treatment protocols specific to student-athletes. The psychological response to injury is something that we see frequently and yet have such little objective information about. As more of us collect data and observe our patients over time, it would be ideal to have multisite prospective data collected that could provide a framework for future research.
Scifers: For a clinician who has not formally addressed student-athlete mental health, or who is interested in developing a student-athlete mental health management protocol in their clinical practice, what advice would you offer for getting started?
Hong: My advice for clinicians interested in getting started in this area is to engage their community. They should speak to the student-athletes, coaches, athletic trainers, athletic department administrators, their mental health counseling providers and student health providers, and institutional leadership. Improving the mental health and wellness of the student-athletes will require a multidisciplinary team and support from all of the various parties of the community. By talking with the community, the clinician will be able to see who is on board, who may get on board and what it may take, and who may never get on board with the idea that addressing mental health and wellness in athletes is important. Once the engagement work has started, the clinician can examine the literature, talk with peers and other institutions (and the NCAA), and look for resources external to the institution.We are all struggling with the same issue—how do we improve the mental health and wellness of our student-athletes? The answers are not easy or forthcoming. In my humble opinion, we should be looking at this issue within the framework of a community medicine model (which has been researched and published).The effort to improve mental health in student-athletes is a key part of a larger community medicine effort (ie, improving the health of a population). Engaging and working with the community is a critical component of a successful community medicine initiative.
Keenan: As Dr. Hong discussed, engaging within the campus community is the first step. After this, a working committee made up of student-athlete stakeholders (health care providers, athletic directors, counseling services, etc.) should be formed to evaluate what resources may be available on and off campus. Using the previously mentioned NCAA mental health best practices and NATA consensus documents is an excellent starting point. Finally, reaching out to clinicians at other institutions who may have already implemented a mental health management plan can be helpful.
Putukian: There are several resources that can provide clinicians with the basic information regarding student-athlete mental health needs. Ongoing continuing education modules have been created regarding mental health, and different organizations have created useful documents that summarize these issues in athletes and provide resources. Some of these resources include the Team Physician Consensus Statement on Psychological Issues in Athletes and the NATA and NCAA documents mentioned by Dr. Keenan. Finding mental health providers in your area is probably the next best place to start. Trying to work with them to create or participate in multidisciplinary teams is ideal because that is often a collaborative environment through which we all learn from each other.
- Herring, SA, Kibler, WB & Putukian, M. Psychological issues related to illness and injury in athletes and the team physician: a consensus statement—2016 update. Curr Sport Med Reports. 2017;16:189–201. doi:10.1249/JSR.0000000000000359 [CrossRef]
- Neal, TL, Diamond, AB & Goldman, S et al. Inter-association recommendations for developing a plan to recognize and refer student-athletes with psychological concerns at the collegiate level: an executive summary of a consensus statement. Athl Train. 2013;48:716–720. doi:10.4085/1062-6050-48.4.13 [CrossRef]
- NCAA Sport Science Institute. Mental Health Best Practices: Understanding and Supporting Student-Athlete Mental Wellness. Indianapolis: Author; 2017.