May is Mental Health Awareness Month. During this month, we would like to remind our community about the value of mental health. This seems especially timely as we continue to live through these challenging times.
Overall, exercise helps treat and prevent anxiety and depression, but that does not mean that student athletes are immune to these conditions. In fact, student athletes may be more prone to certain traits such a perfectionism or burnout. The National Federation of High School Leagues (NFHS) published an article recently about the prevalence of mental health issues in student athletes and what some of these factors are.
Concordia has recently developed a professional development plan with our coaches and many of them have already taken the course provided by the NFHS about how to identify mental health issues and what actions should a friend, coach, and parent take. This course is free and available to anyone.
Importance of Mental Health in Adolescent Activities
By Kody Moffatt, MD, MS, and Alex Diamond, DO, MPH on February 09, 2022
Many athletes are affected by underlying mental health conditions. The social stigma that is often associated with a mental health condition may limit the teenager’s willingness to disclose these issues to their teachers, coaches or health care team. Illness or injury may produce a variety of psychological responses in athletes, some of which adversely affect sports participation or performance. Psychological factors, especially high levels of stress on or off the field, may predispose athletes to injuries. These factors may play an important role in injury recovery and interfere with successful return-to-play (RTP).
Certain personality traits such as perfectionism and athlete identity can aid in athletic success, yet these same traits can also be associated with mental health disorders. Clearly mental health issues are not unique to athletes, but athletes often have unique presentations and/ or treatment needs. Screening at every medical encounter or anytime concerning behaviors are observed during athletic participation may promote early identification of athletes at risk for mental health disorders.
Several psychological issues, including depression, stress, anxiety, eating disorders and substance use disorders can have illness or injury as triggers and/or have unique presentations in adolescents and athletes.
The Preparticipation Physical Examination (PPE) is a text now in its 5th edition, which outlines the components and process related to performing a PPE. As part of the health history portion of the PPE, questions addressing the mental health status of the athlete are now considered, along with a plan for referral and follow-up. Health care professionals need to be familiar with the screening questionnaire used in the PPE. The screening tool used combines depression and anxiety screening in a short question format.
One of the more common mental health concerns is depression/ major depressive disorder (MDD). The average age of onset for major depression and dysthymia (prolonged minor depression) is between 11 and 14 years of age. The 12-month presence of major depression in 12–17-year-olds is 8% and for 18-25-year-olds is 8.9%. Athletes may under-report symptoms of depression and be less likely to discuss concerns or seek treatment for depression. Depression is a risk factor for suicide in athletes. With appropriate education on warning signs and the increased contact with student- athletes the coaches, athletic trainers and team physicians may recognize depression early and prevent the associated tragedies. If an athlete denies current suicidal thoughts or plan, provisional medical eligibility can be granted, and additional evaluation arranged. If there are current suicidal thoughts with a plan, the suicide prevention action plan should be implemented.
In addition to usual diagnostic symptoms of depressed mood and inability to feel pleasure, adolescents may experience other symptoms of depression (e.g., anger, guilt, hopelessness, low self-esteem, concentration or attention problems, feeling of helplessness, irritability, sleep disturbance, risk-taking behavior, substance misuse/abuse, prolonged/incomplete recovery, staleness, or decreased performance).
Separate from depression, suicide may also be associated with substance abuse, risk taking behavior, bullying, and post-traumatic stress disorder. Sports participation appears to have a protective effect against suicide in males and females. This may be due to physical activity, social bonding/connectedness, and/or achieving success in the sport.
Nearly one third (31.9%) of adolescents in the United States meet criteria for an anxiety disorder. Of those, half begin experiencing their anxiety disorder by age 6.
Signs and symptoms of an anxiety disorder include the following and may be associated with other athletic injuries/illnesses such as concussion:
- Feeling apprehensive
- Feeling powerless
- An impending sense of danger, panic or doom
- Breathing rapidly
- Feeling weak or tired
Generalized anxiety disorder (GAD) and panic disorder/panic attack are two common anxiety disorders in adolescents.
Attention Deficit Hyperactivity Disorder (ADHD) is characterized by a pattern of inattention/hyperactivity-impulsivity that is more prominent than peers at a comparable level of development for six or more months. Although common in adolescents, ADHD in and of itself is not a disqualifier for athletic participation, its diagnosis and management may appear during the process of the PPE, especially if done in the primary care setting. It is important to encourage a medical evaluation for an adolescent with suspected ADHD for reasons related to academic accommodations, possible treatment with medication, and regulations related to medication use and drug testing for a regulated amateur athlete.
There are several other conditions that can affect the mental health of adolescents (athletes and nonathletes alike). These include bullying, hazing, sexual abuse, sex and gender issues, sleep disorders, eating disorders, and transition from sport. There are resources readily available which describe the prevention, evaluation and treatment of each of these in detail below.
Most of the mental health-related conditions will require more detailed assessment to determine the diagnosis, severity of the disease symptoms, and the need for treatment with counseling and/ or medication.
Chang C, Putukian, M, Aerni, G, Diamond, A, Hong, ES, Ingram, YM, Reardon CL, Wolanin, Mental Health Issues and Psychological Factors in Athletes: Detection, Management, Effect on Performance, and Prevention: American Medical Society for Sports Medicine Position Statement, Clin J Sport Med: 30(2), e61-87, March 2020, doi: 10.1097/JSM.0000000000000817.
Asif I, Asplund C, Dexter W, Franks RR, Joy E, Koutures C, Leary P Matuszak J, Moffatt K, Perez J, Sutton K. Preparticipation Physical Examination, 5th Edition; David Bernhardt & William Roberts (Eds.) American Academy of Pediatrics Publishing Staff. ISBN: 978-1-6002-301-6. 2019
Herring SA, Kibler WB, Putukian M, et.al. Psychological issues related to illness and injury in athletes and the team physician: a consensus statement (2016 Update). Med Sci Sport Exerc. 2017;49(5):1043-54. DOI: 10.1249/MSS.0000000000001247.
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 secondary school level: a consensus statement. J Athl Train. 2015;50(3):231-249. Jonas J, National Federation of State High School Associations. Hazing in high school athletics. http://www.nfhs.org/articles/hazing-in-high-school-athletics