Supporting Mental Health

a n d Well- b ei n g A mo n g
Student-Athletes
Karen P. Egan, PhD

KEYWORDS
 Student-athlete mental health  Student-athlete well-being  Holistic care
 Integrative care

KEY POINTS
 Although athletics participation provides multiple benefits that can be protective factors
for mental health, stressors unique to athletics participation are also present.
 This article reviews the frequency and symptoms of the most common mental health con-
cerns impacting collegiate student-athletes and discusses treatment approaches.
 This article reviews the importance of prioritizing mental health and well-being by trying to
reduce stigma and provide access to qualified licensed providers.
 The value of multidisciplinary treatment teams and the ensuing coordination of care is also
discussed.

INTRODUCTION

Mental health and well-being is essential to being able to perform one’s best within
career, academics, relationships, and sport. Athletics provides multiple benefits that
can be protective factors for mental health. Exercise has been found to reduce symp-
toms of anxiety and depression.1,2 For collegiate student-athletes (SAs), starting fresh
in the new college environment with a group of people they can get to know and spend
time with for social support can help to ease the transition into college life and improve
well-being. In addition, collegiate SAs frequently have access to a greater number of
resources than their nonathlete peers by nature of their sport. For example, SAs may
find support from coaches, teammates, and support staff, including physicians, certi-
fied athletic trainers, mental health providers, sports nutrition staff, operations staff,
administrators, academic staff, and professors. Finally, working toward a goal or pur-
pose through sport often adds meaning and value to many people’s daily life.
Conquering small goals each day can help individuals to see measurable progress
for the work they put in and can serve to enhance self-esteem.

Disclosure Statement: The author has nothing to disclose.

University of Virginia Athletics Department, McCue Center, PO Box 400845, 290 Massie Road,
Charlottesville, VA 22904-4845, USA
E-mail address: [email protected]

Clin Sports Med 38 (2019) 537–544

https://doi.org/10.1016/j.csm.2019.05.003 sportsmed.theclinics.com
0278-5919/19/ª 2019 Elsevier Inc. All rights reserved.
538 Egan

However, a sport experience can also include a number of widespread stressors. Ath-
letes experience the same stressors as their nonathlete peers, such as coping with
symptoms of anxiety, mood disorders, challenges with eating behavior or substance
use, gender-based violence or sexual assault, racism, and harassment or violence
based on sexual orientation. Yet, in addition to these difficulties, athletes are often highly
visible to others, particularly through social media, placing them in a more vulnerable
position, and they may experience bullying, hazing, threats, harassment, and/or criti-
cism because of this increased attention. This visibility can also impact body image
and eating behavior in unique ways within the sport environment. Furthermore, for ath-
letes there is often not only the expectation to perform at a high level, but also to win, a
pressure that can come from within the athletes themselves, as well as from coaches,
administrators, fans, or family members. Transitioning to the next level in sport (whether
collegiate or professional) can also bring a reduced role on the team and reduced play-
ing time. This position can create stress and a negative view of oneself if the athlete’s
previous identity was defined by success in sport. Athletic injury can also generate
added stress because it often results in a mix of emotions typically highlighted by worry
about returning to pre-injury level of competition,3 isolation from teammates for a period
of time,4 and/or sadness or depressive symptoms.5 Ironically, the same support sys-
tems that can be protective for athletes can also become a source of stress when con-
flict emerges with coaches and/or teammates. Transitioning out of sport owing to injury
or illness or the end of one’s playing career can also be a challenging adjustment.
Exploring career options outside of athletics can prove challenging for SAs who have
busy schedules and who may fear that coaches will view them as less committed if
they explore career options outside of professional sport.
Depending on the level of sport being played, additional challenges may also be
present. For collegiate SAs, the time demands of balancing the equivalent of 2 full-
time jobs—academics and athletics—is a huge source of stress because the long
hours decrease time for sleep and self-care. Travel time results in missed classes
that have to be made up, and SAs often cannot access many resources available to
nonathlete students during business hours owing to their schedules. Time demands
among this population may also be increasing as a National Collegiate Athletic Asso-
ciation (NCAA) study found that collegiate SAs reported an increase in the time spent
on both athletics and academics in 2015 as compared with 2010.6 These division I SAs
reported spending a median of 34 hours per week in season on athletics in 2015
versus 32 hours per week in season in 2010 while reporting a median of 38.5 hours
per week on academics in-season in 2015 versus 35.5 hours per week in 2010.6
There exist differing stressors on other levels of sport participation. For middle and
high school SA, for example, the burden of seeking collegiate scholarship opportu-
nities can affect the younger athletes hoping to pursue their sporting and academic
careers. On the other end of the spectrum, professional athletes may struggle with
the time spent away from family, friends, and support systems owing to travel de-
mands. These factors, in conjunction with the physical demands of sport, can prove
to be exceedingly challenging.
Athletes often excel at embracing challenges, setting goals, making sacrifices to
achieve these goals, staying motivated, and being open to feedback to help them
improve. However, these same strengths can make some athletes reluctant to seek
care owing to fear of negative perceptions. The stigma persists that mental health
should be something that SAs can “push through” and “fix on their own” or that
seeking care is a “sign of weakness,” particularly among male SAs. Changing this
stigma is essential to promoting the proactive use of mental health resources and
prioritizing well-being.
 Mental Health 539

COMMON MENTAL HEALTH CONCERNS

Anxiety and depression are the most common mental health diagnoses among college
students.7 In a 2018 survey of college students with 88,178 respondents, 22.1% of re-
spondents reported having been diagnosed or treated by a professional for anxiety
and 18.1% diagnosed or treated by a professional for depression.7 In this section, I
focus on the most common mental health concerns impacting collegiate SAs, though
many other symptoms can be present in SA populations as well. Symptoms can
create a large disruption to well-being and functioning in relationships, academics,
and athletics so identification and management are imperative for health.

Anxiety Disorders
Approximately 87% of college student respondents to a 2018 survey said that they
have “felt overwhelmed by all you had to do” and approximately 63% said that they
have “felt overwhelming anxiety” at any time over the past 12 months.7 When
comparing collegiate SAs with nonathletes across 8 surveys from 2008 to 2012, fewer
SAs reported experiencing anxiety than their nonathletes peers within the last
12 months (31% of male SAs vs 40% of male nonathletes and 48% of female SAs
vs 56% of female nonathletes).8 Although fewer SAs reported experiencing anxiety,
nearly one-third of male SAs and nearly one-half of female SAs reported being
impacted by anxiety, indicating this experience remains common among SAs.8 Symp-
toms can range from mild to severe and may include feeling agitated, difficulty concen-
trating, irritability, physical distress, disruptions in sleep and/or appetite, panic attacks,
phobias, obsessive thinking, and behavioral routines.9 Anxiety symptoms can be con-
nected to a specific topic, such as athletic performance, academic performance, or so-
cial interactions, but most commonly is experienced across multiple areas. SAs often
defer self-care to prioritize athletic and academic obligations, which may enhance
stress and worry because they frequently sacrifice much-needed time to decompress.

Depressive Disorders
In the general population, roughly 7% of people are estimated to have experienced a
major depressive disorder within the past 12 months with certain subpolulations hav-
ing a greater incidence, namely, those between the ages of 18 and 29 experience ma-
jor depressive disorder at a higher rate than older individuals and women experience
major depressive disorder more often than men.9 Looking more closely across the uni-
versity setting, it is apparent that college students also struggle with depression.
Approximately 53% of college students have reported they “felt things were hope-
less,” 63% “felt very lonely,” 69% “felt very sad,” and 42% “felt so depressed it
was difficult to function” at any time over the past 12 months.7 When comparing col-
legiate SAs with nonathletes across 8 surveys from 2008 to 2012, fewer SAs reported
that they “felt depressed” than nonathletes within the last 12 months (21% of male SAs
vs 27% of male nonathletes and 28% of female SAs vs 33% of female nonathletes).8
Again, SAs reported fewer of these symptoms than their nonathlete peers; however, a
significant portion of SAs did report having been impacted by depressive symptoms.
Symptoms range in severity and may include feeling down, anhedonia, decreased
motivation, fatigue, difficulty concentrating, disruptions in sleep and/or appetite, feel-
ings of worthlessness, and/or suicidal ideation.9 Depressive symptoms can make it
feel nearly impossible to get out of bed each day and complete tasks, which can be
particularly challenging for SAs who typically have many mandatory tasks each day.
Suicidal ideation can also occur with depressive symptoms or with other mental
health concerns. At any time over the past 12 months, 12.1% of college student
540 Egan

respondents endorsed that they have “seriously considered suicide,” 1.7% “attemp-
ted suicide,” and 7.8% “intentionally cut, burned, bruised, or otherwise injured” them-
selves.7 Ensuring athletics staff and other SAs feel comfortable asking individuals
directly about potential thoughts of suicide or self-harm and how to refer them to
licensed mental health providers can help connect individuals to treatment providers
quickly.

Bipolar Disorders
Approximately 2% of college student survey respondents reported having been diag-
nosed or treated by a professional for bipolar disorder within the past 12 months.7 Bi-
polar I disorder is defined as experiencing a manic episode has occurred, whereas
bipolar II disorder is the presence of a hypomanic episode as well as a major depres-
sive episode.9 Hypomania is a symptom that can be overlooked at times, particularly
in college environments where a decreased need for sleep and increase in goal-
directed activity can be perceived as beneficial for short-term gains in academics or
athletics. Recognizing symptoms early can help to decrease long-term risk and assist
the SA to engage in treatment to promote their health and well-being.

Substance Use
Approximately 1% of college student survey respondents reported having been diag-
nosed or treated by a professional for substance abuse or addiction to substances
within the past 12 months.7 NCAA studies have found that reported incidents of binge
drinking among SAs have decreased over time (Table 1).
The highest rates of binge drinking were reported in lacrosse (69% of men, 57% of
women), hockey (64% of men, 56% of women), and swimming (55% of men, 49% of
women).10 Marijuana use was reported to be the next most commonly used substance
among SAs; 24% reported inhaling marijuana in the last year and 11% using edible
forms.10 For nicotine use in the past year, 17% of SAs reported smoking a cigar at
least once, 13% used spit tobacco, 11% smoked cigarettes, 10% used hookah,
and 8% used e-cigarettes.10 Tobacco use was highest among male ice hockey and
baseball players, with nearly 20% of male SAs in these sports reporting daily use.10
These data came from 2017 and recent trends in the use of e-cigarettes may impact
these data in the future. Substance abuse can result in an inability to complete aca-
demic and athletic obligations, harm relationships, and negatively impact mood, phys-
ical health, and financial health.

Eating Behavior and Body Image

Concerning eating behaviors typically include restricting food intake, self-induced
vomiting or other compensatory behaviors and/or binge eating. Among college stu-
dents, 1.6% reported having been diagnosed or treated by a professional for anorexia
nervosa and 1.2% for bulimia nervosa in the past 12 months.7 Many SAs experience
challenges in eating behavior and body image and can experience subclinical distur-
bances in eating behavior (often called disordered eating behavior) or can meet the

Table 1
NCAA studies on drinking

NCAA Research findings10 2009 2013 2017

Percentage of SAs who reported “binge drinking” (defined as 55 51 42
4 drinks in 1 sitting for women, 5 drinks in 1 sitting for men)
Percentage of SAs who reported drinking 10 drinks in 1 sitting 15 12 8
 Mental Health 541

diagnostic criteria for an eating disorder. Sometimes disturbances in eating behavior

are difficult to detect among SAs where a focus on healthy eating and exercising
above and beyond regular training is typically celebrated as progress toward athletic
goals and good work ethic. Although eating disorders and disordered eating behavior
occur across all sports, sports that have an increased risk fall into 2 categories: those
that are judged in part on aesthetics where body size and shape can influence a score
or evaluation (ie, gymnastics, diving, dance, cheer) and those that believe a lower
weight will increase athletic performance (ie, distance running, distance swimming,
rowing).11 Another risk factor for athletes is revealing uniforms.11 The added pressure
of appearing in a small amount of clothing for competition, practice, and in media
coverage of sport can be difficult to cope with. In addition, SAs may experience chal-
lenges when the media portrays a societal ideal body image that contradicts the ideal
body image presented for their sport. This often impacts women in sports who require
a higher body weight or greater muscularity and men in sports requiring a lower body
weight or less muscularity. Negative body image is correlated with low self-esteem,
depression, and the development of eating disorders and disordered eating
behavior.11

Gender-Based Violence and Sexual Assault

Gender-based violence, sexual assault, and other traumatic experiences also have a
large impact on well-being and mental health. Symptoms may include flashbacks,
nightmares, avoidance of reminders of the event, changes in mood, persistent nega-
tive cognitions, difficulty concentrating, sleep problems, reckless behavior, hypervig-
ilance, and more.9 Trauma experienced by an SA from a perpetrator who is also an SA
or who is a staff member within the athletics department can have a particularly diffi-
cult impact on SAs’ well-being. Additional experiences of trauma among peers, family
members, and/or from others receiving coverage from news media can also trigger
past experiences of trauma and result in current symptoms.

Other
SAs are also impacted by psychosis, sleep disorders, personality disorders, attention-
deficit hyperactivity disorder (see Mario Ciocca’s article, “Attention Deficit
Hyperactivity Disorder and Treatment for Athletes”, in this issue for more information),
and many other mental health concerns that impact the general population as well.

TREATMENT

There are many well-established forms of psychotherapy from a number of different

theoretic backgrounds that are effective for symptom reduction, improvement in qual-
ity of life, and improved relationships. Many forms of psychotherapy can be effective
for working with SAs, such as cognitive-behavioral therapy, acceptance and commit-
ment therapy, interpersonal therapy, positive psychology, humanistic therapy, and
more. Although each approach differs in terms of how symptoms are conceptualized
and the work is structured in therapy sessions, each approach can integrate aspects
of athletic culture to adapt to each SA’s needs. For example, cognitive-behavioral
therapy may include helping SAs to identify their automatic negative thoughts and
teaching them ways to use thought-challenging techniques to identify an alternative
consideration that can then result in a change in their emotions and behaviors that
impact mood, athletic performance, relationships, and academic performance.12 As
another example, positive psychology may focus on identifying an SA’s strengths
and capitalizing on those to make changes in thoughts, behaviors, and purpose as
542 Egan

well. SAs often spend a lot of time and energy focusing on their weaknesses to identify
areas to improve in athletics, so shifting their focus to increasing awareness of positive
qualities they posses can provide them new tools to cope in moments of distress.
Licensed mental health providers working with SAs ideally have experience working
with individuals with a strong athletic identity13 and should also be familiar with ath-
letics culture to provide the best care.
To provide holistic care for SAs experiencing mental health concerns, collaboration
between a multidisciplinary team of a licensed mental health provider, team physi-
cians, certified athletic trainers, psychiatrists, and/or dieticians helps to ensures that
everyone is working toward the same goals. For SAs taking psychiatric medications,
coordination between the medical provider prescribing medication and the mental
health provider doing psychotherapy with the client is particularly important for the
health and well-being of the client. Collaboration is also essential for determining
when participation in athletics should be limited for a period of time owing to mental
health concerns. This limitation may be due to safety concerns and/or due to the
severity of symptoms. Limited participation may be short term to allow an SA to
reduce athletic stress while also prioritizing seeking mental health services. Participa-
tion may be limited for a longer period if an SA requires a higher level of care, such as
an intensive outpatient program, partial hospitalization program, or inpatient services.
Engaging supportive family members proves helpful as well. Many SAs communicate
with parents frequently; 55% of collegiate SAs reported that they communicate with
their parents once or more per day.14 When SAs wish to sign a release of information
document to coordinate care with specific family members, this can be another source
of support for the SA. SAs may also request a mental health provider coordinate care
with professors, academic coordinators, coaches, administrators, or other important
individuals in their lives.
The early identification of SAs who could potentially benefit from psychotherapy can
also help to get them connected to resources. Doing a preparticipation screening
when SAs arrive on campus can allow SAs to self-identify that they wish to be con-
nected to a licensed mental health provider and potentially identify SAs who may be
struggling with mental health concerns.15 Owing to the self-report nature of these
screenings, these methods will inevitably not capture SAs who wish to hide potential
symptoms owing to stigma and/or concern about their role in athletics or scholarship
status.

PROMOTING MENTAL HEALTH AND WELL-BEING

It is essential for SA well-being that mental health be prioritized at every level within the
university and athletics department by working to reduce the stigma surrounding
mental health concerns and by providing qualified resources accessible to all SAs.
Stigma reduction is a key role for every medical provider, administrator, coach, staff
member, and SA. Advocating for others to view seeking treatment as a sign of strength
by acknowledging the courage it takes to be vulnerable helps to support SAs proac-
tively seeking treatment. Every staff member and SA leader can address the impor-
tance of promoting mental health and well-being by partnering with mental health
providers to:
 Normalize not feeling your best at all times.
 Provide educational material to teams.
 Share stories from other SAs and professional athletes who have chosen to
speak publicly about their experiences with mental health concerns.
 Model the importance of self-care.
 Mental Health 543

 Encourage SAs to engage in important conversations about mental health and

how mental health is portrayed in sport culture and US culture.
Changing stigmatizing language within departments and teams can additionally
have a large impact on well-being.
It is valuable for all staff members and SAs to be familiar with available licensed
mental health providers and to know how to refer directly to these providers to
encourage the use of these services. The NCAA Mental Health Best Practice Guide-
lines emphasizes the importance of planning in advance what procedures will exist
for referring SAs to qualified licensed mental health providers.15 Inviting licensed
mental health providers to attend athletic events or give talks to athletic teams also
helps to increase visibility to SAs and decrease potential barriers to seeking care.
Those licensed mental health providers experienced in sport performance can addi-
tionally offer these skills to teams, which may also create more comfort for the SA
reaching out to that provider for personal concerns as well. Some topics for perfor-
mance work may include precompetition anxiety; coping with negative thoughts dur-
ing practices, competition, or conditioning sessions; recovering from athletic injury;
the use of visualization strategies; the use of mindfulness strategies; and sleep hy-
giene. SAs and staff members should also be familiar with how to contact licensed
mental health providers in emergency situations.
Supporting mental well-being among SAs further involves observing SAs for signs of
concern and then engaging them in a conversation about how they are doing. Poten-
tial signs of distress may include:
 Withdrawal from friends or activities
 Agitation or difficulty appearing calm
 Seeming to be down, sad, or having low energy
 Significant changes in eating behavior, sleep, and/or substance use
 Substantial weight loss or weight gain
 Making critical statements about oneself, one’s value, and/or one’s body shape,
size, or weight
 Expressions of hopelessness
 Violent behavior
 Changes in personal hygiene
 Other statements of concern
Ideally someone who has a connection to the SA will approach them in a
private setting or near-private setting. Private settings should not occur if the safety
of the individual speaking to the SA would be comprised to meet one on one. A
licensed mental health provider can train staff members and/or SA leaders
about how to talk to an SA they are concerned about. A licensed mental health pro-
vider can teach communication strategies for this conversation, such as stating
observed behaviors of concern, expressing care for the SA’s well-being, using
destigmatizing language, how to make a referral to a licensed mental health provider
or medical provider with a background in mental health, assessing potential barriers to
seeking care, discussing a plan to follow-up with the SA, and then following up after-
ward to see if they were able to get connected to a mental health provider.
Promoting a positive environment for mental health and well-being among SAs is an
important mission for every athletics department to allow SAs to perform at their best
socially, academically, and athletically. Every staff member and SA can actively take
steps to decrease stigma and encourage discussions about mental health and well-
being. Ensuring that all SAs can access care with a licensed mental health provider
544 Egan

who understands the culture of sport and the importance of athletics in many SAs’
identities can help ensure high quality care. Coordination of care among a multidisci-
plinary treatment team allows holistic care to ensure that SAs are able to focus on their
personal and professional development goals.

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