Mental Health & the Student-Athlete

1. Mental Health & the Student-Athlete Jamie DeRollo, DAT, MBA, ATC Head Athletic Trainer/Faculty Modesto Junior College

2. Disclosures & Disclaimers • None • Not a psychologist, counselor, mental health professional, etc. Content not substitute

3. Objectives • Identify and recognize mental health issues in the student-athlete. • Describe medication use and non use on performance. • Apply strategies to help with compliance of seeking help and/or taking medication for mental health.

5. Mental Health “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community”.1

6. Factors that Contribute • Biological factors, such as genes or brain chemistry • Life experiences, such as trauma or abuse • Family history of mental health problems

7. Mental Health • Contributes to the global burden of disease among young people 2,3 • Significant personal, social, and economic costs that can last a lifetime.4 • Costs of supporting children and adolescents with mental health issues can be far higher than for • Reduced participation in the labor market.2, 4

8. Mental Disorder • “a mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotional regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental process underlying mental functioning.” 4

9. Student-Athlete • Stressors 7 work academics athletic performance injury

10. Epidemiology Globally US 20% of adults experience a mental health problem with 30% of that is among 18–25-year-olds.10 • 350 million people are affected by depression9 • 60 million by bipolar affective disorder 9 • 21 million by schizophrenia/other psychoses.9

11. Stigma Associated with mental health and depression, it often goes unreported and undiagnosed, which may lead to inaccurate statistics 11

12. Experiencing one or more of the following feelings or behaviors can be an early warning sign of a problem: • Eating or sleeping too much or too little • Pulling away from people and usual activities • Having low or no energy • Feeling numb or like nothing matters • Having unexplained aches and pains • Feeling helpless or hopeless • Smoking, drinking, or using drugs more than usual

13. Experiencing one or more of the following feelings or behaviors can be an early warning sign of a problem: • Feeling unusually confused, forgetful, on edge, angry, upset, worried, or scared • Yelling or fighting with family and friends • Experiencing severe mood swings that cause problems in relationships • Having persistent thoughts and memories you can't get out of your head • Hearing voices or believing things that are not true • Thinking of harming yourself or others • Inability to perform daily tasks like taking care of your kids or getting to work or school

14. Mental Health Problems • Depression • Anxiety • Psychosis • Substance Use Disorders • Eating Disorders

15. Depression or Major Depressive Disorder (MDD) • 17% of college students reporting depressive symptoms • 9% meeting criteria for major depression 6 • Suicide is the second leading cause of death among college students,17 accounting for approximately 1,100 deaths each year 18 • depressed mood • also in patients with "medically unexplained symptoms" (headache, fatigue, abdominal pain, gastrointestinal symptoms, weight change).

16. Types of Depression • Melancholic • Atypical • Psychotic • Seasonal (SAD) • Catatonic • Pregnancy related4

17. Warning Signs of Suicide • Threatening to hurt or kill him/her self • Looking for ways to kill him/her self; seeking access to pills, weapons or other means. • Talking writing or posting on social media thoughts on death, dying or suicide • Hopelessness • Rage, anger, seeking revenge • Acting recklessly or engaging in risky activities, seemingly without thinking • Feeling trapped, like there is no way out • Increasing alcohol or drug use • Withdrawing from friends, family or society • Anxiety, agitation, unable to sleep or sleeping all the time • Dramatic changes in mood • No reason for living, no sense of purpose in life

18. 1st Aid for Suicidal Thoughts & Behaviors Activity

19. 1st Aid for Suicidal Thoughts & Behaviors • Ask directly • Do not avoid using the word suicide • Ask without dread or negative judgement • Direct & to the point • “Are you having thoughts of suicide?” • OR • “Are you thinking about killing yourself?”

20. Do they have definite intentions? • 3 questions • 1. Have you decided how you would kill yourself? • 2. Have you decided when you would do it? • 3. Have you taken any steps to secure the things you would need to carry out your plan?

21. How can I help? • Never leave the person alone • Never agree to keep their suicide plan a secret • Do not use guilt or threats to prevent suicide • Give safety contact information available 24/7 • National Suicide Prevention Hotline 1-800-273-TALK • Friend or Family member • Mental Health Professional • Immediate safety concern 911

22. 1st Aid for Nonsuicidal Self-Injury • Cutting, scratching or pinching skin enough to cause bleeding or a mark that remains on the skin • Banging or punching objects to the point of bruising or bleeding • Ripping & tearing skin • Carving words or patterns into skin • Interfering with the healing of wounds • Burning skin with cigarettes, matches or hot water • Pulling out large amounts of hair • Deliberately overdosing on medications

23. How can I help? • Discuss it calmly • Do not ignore • Do not express negative reaction • If you interrupt them in process-intervene in a non-judgmental way • 911 and/or professional help

24. Anxiety • Anxiety is an emotion characterized by feelings of tension, worried thoughts and physical changes like increased blood pressure • Sweating • Trembling • Dizziness • Rapid heartbeat

25. Types of Anxiety • Generalized Anxiety Disorder • Obsessive-Compulsive Disorder (OCD) • Panic Disorder • Post-Traumatic Stress Disorder (PTSD) • Social Phobia (or Social Anxiety Disorder)

27. Evaluation & Diagnosis of Mental Health • Only credentialed, licensed mental health care professionals can legally evaluate, diagnose, treat, and classify a patient with a mental illness.36 • Before a diagnosis or treatment, a health professional should conduct a thorough diagnostic evaluation, including an interview and possibly a physical examination.36 • blood test might be done to make sure the depression is not due to another medical condition.24 • identify specific symptoms, medical and family history, cultural factors and environmental factors to arrive at a diagnosis and plan a course of action.4

28. Screening Tools • PROs • National Health and Nutrition Examination Survey (NHANES) Patient Health Questionnaire (PHQ–9)39 • Hamilton Depression Rating Scale (HAMD)40 • less than 5% of adults were screened for depression in primary care settings.41

29. Medication • PCP or psychiatrist can prescribe • Some improvement initially • Full benefits 2-3 months • Selective serotonin reuptake inhibitors (SSRIs) • Serotonin-norepinephrine reuptake inhibitors (SNRIs) • Tricyclic antidepressants • Monoamine oxidase inhibitors (MAOIs)

30. Pros vs. Cons of SSRI • Improve mood • Improve appetite • Increased focus • Resolve sleep disturbance associated with depression • Decrease anxious symptoms that can occur with depression • Decrease depressive symptoms that can trigger suicidal thoughts • Gastrointestinal symptoms • Insomnia or sedation • Dry mouth • Dizziness • Weight gain • Headaches • Sexual side effects

31. Performance Status on team/playing time may be affected Therapists in a positive manner & understood athletics Campus counseling has relationship with athletic department34

32. Compliance with Medication • Perception • Reliance • Improvements • Never abruptly stop taking

33. Policies in Place • Do you have a mental health policy? • Have you reviewed NCAA SSI BP or Resources? • www.ncaa.org/sport-science-institute/mental-health • NATA 10 for 10 Mental Health PPT • Journal articles • Any others?????

34. Positive mental health allows people to: • Realize their full potential • Cope with the stresses of life • Work productively • Make meaningful contributions to their communities

35. Ways to maintain positive mental health include: • Getting professional help if you need it • Connecting with others • Staying positive • Getting physically active • Helping others • Getting enough sleep • Developing coping skills

36. What can the AT do??? • Eyes open • Ears open • Establish rapport • Educate • Student-athletes • Coaches

37. What can the AT do??? • Mental Health 1st Aid • Communicate-health center & department • LISTEN • Add questions on PPE • Have mental health policies • QPR Gatekeeper Training for Suicide Prevention (www.qprinstitute.com/).

38. Mental Health Emergency Action and Management Plan (MHEAMP) • Managing suicidal and/or homicidal ideation. • Managing victims of sexual assault, with clarification regarding exemption from mandated reporting in this context. • Managing highly agitated or threatening behavior, acute psychosis (often involving hallucinations and/or delusions) or paranoia. • Managing acute delirium/confusional state. • Managing acute intoxication or drug overdose

40. Questions?????? • Thank You

41. References: • 1. World Health Organization. Mental health: A state of well-being. 2014. • 2. Costello EJ, Egger H, Angold A. 10-year research update review: The epidemiology of child and adolescent psychiatric disorders: I. Methods and public health burden. J Am Acad Child Psy. 2005; 44: 972–986. doi: 10.1097/01.chi.0000172552.41596.6f. • 3. Vella SA, Swann C, Batterham M, et al. Ahead of the game protocol: A multi-component, community sport-based program targeting prevention, promotion and early intervention for mental health among adolescent males. BMC Public Health. 2018; 18:390. doi:10.1186/s12889-018-5319-7. • 4. Beecham J. Annual Research Review: Child and adolescent mental health interventions: a review of progress in economic studies across different disorders. Journal of Child Psychology and Psychiatry, and Allied Disciplines. 2014;55(6):714-732. doi:10.1111/jcpp.12216. • 5. American Psychiatric Association. (2013) Diagnostic and statistical manual of mental disorders (5th ed.), Washington, DC. • 6. Neal TL, Diamond AB, Goldman S, Liedtka KD, Mathis K, Morse ED, et al. Interassociation recommendations for developing a plan to recognize and refer student-athletes with psychological concerns at the secondary school level: A consensus statement. J Athl Train. 2015; 50(3): 231-249. • 7. RickwoodD, Deane F, Wilson C, Ciarrochi J. Young people's help-seeking for mental health problems. Adv Mental Health. 2005;4:218–251. • 8. Wei Y, McGrath PJ, Hayden J, Kutcher S. Mental health literacy measures evaluating knowledge, attitudes and help-seeking: a scoping review. BMC Psychiatry. 2015;15:291. doi:10.1186/s12888-015-0681-9.

42. References: • 9. World Health Organization. http://www.who.int/mediacentre/factsheets/fs369/en/. 2014. • 10. Abuse S. Mental health services administration (2012) results from the 2011 National Survey on drug use and health: Summary of national findings, NSDUH series H-44, HHS publication no.(SMA) 12-4713. Rockville: Substance Abuse and Mental Health Services Administration; 2012. • 11. Griffiths KM, Christensen H, Jorm AF, Evans K, Groves C. Effect of web-based depression literacy and cognitive-behavioural therapy interventions on stigmatizing attitudes to depression: randomized controlled trial. Br J Psychiatry. 2004;185:342–9. doi: 10.1192/bjp.185.4.342. • 12. Yang J, Peek-Asa C, Corlette JD, Cheng G, Foster DT, Albright J. Prevalence of and risk factors associated with symptoms of depression in competitive collegiate student athletes. Clin J Sport Med. 2007;17(6):481–487. • 13. AppanealRN, Levine BR, Perna FM, Roh JL. Measuring postinjury depression among male and female competitive athletes. J Sport Exerc Psychol. 2009;31(1):60–76. • 14. HootmanJM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train. 2007;42(2):311–319. • 15. Results from the 2010 National Survey on Drug Use and Health: Mental Health Findings. NSDUH Series H-42, HHS Publication No. (SMA) 11–4667. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2012. http://www.samhsa.gov/data/ nsduh/2k10MH_Findings/2k10MHResults.pdf. Accessed June 11, 2018. • 16. Eisenberg D, Gollust SE, Golberstein E, Hefner JL. Prevalence and correlates of depression, anxiety, and suicidality among university students. American Journal of Orthopsychiatry. 2007;77(4):534–542.doi: 10.1037/0002-9432.77.4.534

43. References: • 17. American Foundation for Suicide Prevention The truth about suicide. 2010. • 18. CDC. Suicide and Self-Inflicted Injury. Centers for Disease Control and Prevention; Washington D.C.: 2009. • 19. Richmond TS, Amsterdam JD, Guo W, et al. The effect of post-injury depression on return to pre-injury function: a prospective cohort study. Psychol Med. 2009;39(10):1709–1720. • 20. McDonald SA, Hardy CJ. Affective response patterns of the injured athlete: An exploratory analysis. Sport Psychol. 1990;4(3):261–274. • 21. Chan CS, Grossman HY. Psychological effects of running loss on consistent runners. Percept Motor Skills. 1988;66(3):875–883. • 22. Mainwaring LM, Bisschop SM, Green R, et al. Emotional reaction of varsity athletes to sport-related concussion. J Sport Exerc Psychol. 2004;26(1):119–135. • 23. LevavI, Rutz W. The WHO World Health Report 2001 new understanding–new hope. Isr J Psychiatry Relat Sci. 2002; 39 (1): 50–6. • 24. Patten SB, Kennedy SH, Lam RW, O'Donovan C, Filteau MJ, Parikh SV, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. I. Classification, burden and principles of management. J Affect Disord. 2009; 117 Suppl 1:S5–14.

44. References: • 25. National Collegiate Athletic Association. 2012–2013 Sports Medicine Handbook, guideline 20. Mental health: Interventions for intercollegiate athletics. http://www.ncaapublications.com/productdownloads/MD12.pdf. Accessed June 13, 2018. • 26. Gulliver A, Griffiths KM, Christensen H. Barriers and facilitators to mental health help-seeking for young elite athletes: a qualitative study. BMC Psychiatry. 2012;12(1):157. doi: 10.1186/1471-244X-12-157. • 27. Reardon CL, Factor RM. Sport psychiatry: a systematic review of diagnosis and medical treatment of mental illness in athletes. Sports Med. 2010;40(11):961–980. doi: 10.2165/11536580-000000000-00000. • 28. Hamer M, Stamatakis E, Steptoe A. Dose-response relationship between physical activity and mental health: the Scottish Health Survey. Br J Sports Med. 2009;43(14):1111–1114. doi: 10.1136/bjsm.2008.046243. • 29. Daley A. Exercise and depression: a review of reviews. J ClinPsychol Med Settings. 2008;15(2):140–147. doi: 10.1007/s10880-008-9105-z. • 30. PelusoM, Andrade L. Physical activity and mental health: the association between exercise and mood. Clinics. 2005;60(1):61–70. doi: 10.1590/S1807-59322005000100012. • 31. Sundgot-BorgenJ, Torstveit MK. Prevalence of eating disorders in elite athletes is higher than in the general population. Clin J Sport Med. 2004;14(1):25–32. doi: 10.1097/00042752-200401000-00005. • 32. Baum AL. Suicide in athletes: a review and commentary. Clin Sports Med. 2005;24:853–869. doi: 10.1016/j.csm.2005.06.006. • 33. Pratt LA, Brody DJ. Depression in the U.S. household population, 2009–2012. NCHS data brief, no 172. Hyattsville, MD: National Center for Health Statistics. 2014. • 34. Mayo Clinic 2018. https://www.mayoclinic.org/diseases-conditions/depression/diagnosis-treatment/drc-20356013 Accessed on June 15, 2018.

45. References: • 35. Kroenke K. When and how to treat subthreshold depression. JAMA. 2017; 317(7): 702–704. • 36. Neal TL, Diamond AB, Goldman S, Liedtka KD, Mathis K, Morse ED, et al. Interassociation recommendations for developing a plan to recognize and refer student-athletes with psychological concerns at the secondary school level: A consensus statement. J of Athl Train. 2015; 50(3): 231-249. • 37. PignoneMP, Gaynes BN, Rushton JL, Burchell CM, Orleans CT, Mulrow CD. Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine. 2002;136:765-76. • 38. National Institute for Clinical Excellence. Depression: core interventions in the management of depression in primary and secondary care. London: HMSO, 2004. • 39. Kroenke K, Spitzer RL, Williams JBW. The PHQ–9: Validity of a brief depression severity measure. J Gen Intern Med. 2001; 16(9):606–13. • 40. Hamilton M. A rating scale for depression. J NeurolNeurosurg Psychiatry. 1960;23:56–62. • 41. O’Neal G, Connors E. Depression screening rates in primary care remain low. Psychiatry. 2017. https://www.psychiatry.org/newsroom/news-releases/depression-screening-rates-in-primary-care-remain-low Accessed on June 15, 2018. • 42. Patten SB, Kennedy SH, Lam RW, O'Donovan C, Filteau MJ, Parikh SV, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. I. Classification, burden and principles of management. J Affect Disord. 2009; 117 Suppl 1:S5–14. • 43. Kennedy SH, Lam RW, Parikh SV, Patten SB, Ravindran AV. Canadian Network for Mood and Anxiety Treatments (CANMAT) clinical guidelines for the management of major depressive disorder in adults. Introduction. J Affect Disord. 2009; 117 Suppl 1:S1–2. 

46. Questions?????? • Thank You