Jan 29, 2015
Recognizing the Signs

Do the members of your athletic department know how to recognize when an athlete is struggling with a mental health issue?

By Timothy Neal

Timothy Neal, MS, ATC, is the Assistant Director of Athletics for Sports Medicine at Syracuse University. He was presented with the NATA Most Distinguished Athletic Trainer Award in 2010 and can be reached at: [email protected].

It’s 3 p.m. and you hear a knock on your office door. “Can I talk to you about something?” asks a men’s soccer player. You invite him in and he proceeds to tell you that he has a history of depression and feels like it is getting out of control as a result of recently losing his starting position on the team. He admits to not listing his history of depression and use of anti-depressant medication on his health history form because he was worried about the stigma that comes with “being depressed.”

You are on a team bus traveling to an away game with the basketball team when your cell phone rings. On the other end of the line is the women’s track and field coach and she is talking quickly without taking a breath. One of her athletes just told her she has been having thoughts about suicide. The coach explains that the athlete had been underperforming for some time, but she didn’t think too much of it–until now.

Now take into account the following statistics: The Centers for Disease Control and Prevention (CDC) released research last fall that says one in 25 U.S. teenagers takes anti-depressant drugs and that one in 100 U.S. adults made plans to commit suicide within the past year. The CDC also reported that adults ages 18 to 29 are more likely to have suicidal thoughts, make plans to attempt suicide, and actually attempt suicide than adults over age 30.

These scenarios and statistics serve as reminders that college athletic departments need effective policies on how to handle student-athlete mental health concerns. If your school doesn’t have one, it should. If your school has a longstanding one, it likely needs an update.

As athletic trainers, we are in a great position to champion these efforts. Student-athletes see us as trusted allies and often come to us when they are having personal problems, so who better to push for a comprehensive policy that protects their mental health and well-being?


Here at Syracuse University, we are constantly working to address mental health concerns on campus. That’s why developing a mental health considerations document for the athletic department was a natural step to stay in front of mental health concerns that are continuing to escalate on campuses nationwide. But before beginning to put together your own document, there are several proactive steps you can take:

Do research on mental health issues and concerns in the college student population to enhance your knowledge of the subject matter. You may know that college students struggle with mental health issues, but do you know any statistics to back up your creation of a policy? I decided to start our document with an introductory portion that highlighted the need for such a document. Going on the Internet and researching recent mental health incidents made it easy for me to develop this introduction. (See “Resources” below for links to helpful Web sites.)

Collaborate with your school’s counseling services long before you need them. Meet with the counselors on campus so that you can get to know them. Talk with them about your plan to develop a mental health policy for the athletic department and establish relationships with them so you can easily refer athletes to them in the future. This is also a good way to learn about recent trends in mental health issues facing today’s college students.

And you can collaborate with off-campus mental healthcare professionals in similar ways. This includes psychologists and psychiatrists in the local community who you can refer student-athletes to, or who know of other mental healthcare providers you can refer student-athletes to. There have been past instances in our department–and I anticipate future ones–when an athlete needed specialized care and the only place to go was off campus. Having already established relationships with professionals in the local community has proven invaluable.

Develop relationships with your school’s office of student affairs, risk manager, institutional legal counsel, and public safety department. Reach out to them, discuss your desire to develop a mental health plan, and get their input on its development. It is vital to develop a relationship with each of these departments because the student-athlete is first and foremost a student. Any incident that occurs must be treated in collaboration with these university departments for the benefit of the student as well as managing risk to the institution.

Convince athletic administrators that a mental health policy is necessary. You will also need to work closely with administrators when developing your plan. This may be the easiest part of the process because the institutional and athletic department leaders’ primary concern for any student is their safety, health, and well-being.

It has been my experience that when developing a document, one needs to illustrate the need to administration, draft a plan for consideration by all pertinent parties, then work collaboratively to finalize the plan based on input from these various entities. This proactive approach reduces confusion for athletic department personnel and gets student-athletes any help they may need quickly.


By meeting with and collecting input from other stakeholders, you’ll get a sense of exactly what to include in your policy. Here at Syracuse, I also informally polled both athletic department personnel and a group of area mental healthcare professionals including counselors, psychologists, and psychiatrists. I asked them what they thought was most important to know or be aware of when it comes to potential mental health issues facing the student-athlete population.

The athletic department personnel I spoke with said it was most important for them to know who to call for help, while the healthcare professionals emphasized how important it is to be able to identify a mental health issue. As a result, when I developed our policy, my two goals were to educate the athletic department staff about behavior(s) that might indicate a mental health problem and put in place a referral mechanism so that student-athletes get the professional care they need.

The piece of our policy that addresses the first goal is a list of “behaviors to monitor.” This list is meant to educate coaches and staff members about the signs and symptoms of a mental health problem. Coaches should take the time to familiarize themselves with and truly understand the signs so they can quickly recognize a problem and step in to find help.

However, it must be noted that everyone experiences stress and reacts to stressful situations in varying degrees. And not all student-athletes who exhibit one or more of the following behaviors necessarily have a mental health problem.

Behaviors may be singular or multiple in nature, and range from mild to severe in presentation. The overarching idea is that if any of the following are out of character for the athlete, the referral system (detailed in the next section) should be activated.

Withdrawal from social contact: Though some student-athletes may be shy or less outgoing than their teammates, withdrawal from social contact is a prime symptom of clinical depression. It is normal for student-athletes to want “alone time,” but extending their time alone to uncharacteristic levels can be a sign of distress.

Changes in eating and sleeping habits: Changes in sleeping habits could include a student-athlete regularly falling asleep in class or team meetings, or the athlete missing or being late to practices, meetings, or games because they overslept. Noticeable weight gain or loss is also cause for concern, as is a student-athlete who used to eat with teammates suddenly choosing to eat alone. A student-athlete obsessed with their eating, or who is incessantly talking about their weight may also have a mental health issue that includes an eating or body image disorder, which needs to be addressed as well.

Decreased interest in activities: Student-athletes who no longer participate in activities they once enjoyed, like playing video games, listening to music, watching movies, or dating, may be depressed. Some student-athletes may even openly express a loss of interest in their sport, and quitting the team is a definite red flag.

Problems concentrating, focusing, or remembering: High levels of stress, as well as depression, can affect daily mental activity and lead to difficulty expressing thoughts. For example, depressed athletes can have a hard time describing what they are going through, or require more time to get their thoughts together before they can verbalize how they are feeling.

It’s also important to note that recent research suggests concussions impair both cognitive and emotional abilities. Any student-athlete who has sustained a concussion should be monitored for depression–especially a student-athlete who has a history of depression.

Frequent complaints of fatigue, illness, or injury: Mental illnesses, especially clinical depression, are a mind and body phenomenon. Student-athletes may report feeling like they are in a fog, tired all the time, or that they often have headaches, body aches, or an upset stomach. Injuries that should have healed with treatment and rest may all of a sudden seem to linger, continually “nagging” or hanging on longer than expected. The student-athlete may even appear to constantly be “injured,” moving from one injury to the next, always unavailable for full participation.

Loss of emotion or heightened emotion: As depression or other mental illnesses set in, a student-athlete may become less emotional, or have what is referred to as a “flat affect” where they look expressionless or their reaction to stimulation or conversation with others is lacking. However, the opposite may also occur with some student-athletes tearing up or crying over minor events. Others may become more animated, laughing at inappropriate times.

Deliberate self-harm: Someone who is suffering from a mental illness may resort to self-harm, such as cutting or branding themselves, as a way of dealing with their problems. Wearing long-sleeved shirts and/or pants in spite of warm weather to cover up the cuts are indicators that self-harm may be occurring.

Becoming more irritable: Mental health experts believe that depression is associated with high levels of anger and frustration, including violence, particularly in men. Lashing out at others, overreacting to minor incidents, impulsive behavior or language, and impatience may be signs of depression and other types of mental illnesses.

Drug and alcohol abuse: While many college students, athletes included, consume alcohol, if consumption regularly becomes excessive in terms of volume or at odd times of the day, it can be indicative of a mental health issue. This can be tough for a coach or athletic trainer to notice, but teammates may pick up on a problem and should be encouraged to report it to you.

Talking about death, dying, or going away: Making comments about this subject matter, even in generalities, is an indication that a student-athlete is severely depressed or is experiencing a significant mental illness. Predicting whether someone will attempt suicide is quite difficult, even for mental health experts and medical personnel, but any mention of suicide by a student-athlete should be taken very seriously.


To meet the second goal of making sure that our student-athletes get the help they need, our policy includes advice on how to approach a student-athlete suspected of having a mental health issue, as well as information on when and how to refer them for specialized care. Unless they are a licensed counselor, no member of the athletic department should ever attempt to treat an athlete with a mental health illness, and this must be made clear in every school’s policy. However, if they suspect an athlete has a problem, athletic department personnel should act quickly to find out if the athlete needs help.

Approaching anyone with concern about their mental well-being can be an uncomfortable experience. A private meeting with the athlete is usually best, but it may be helpful to have another coach, team physician, athletic trainer, or staff member present–especially if the other person has an established relationship with the student-athlete.

Empathetic listening and encouraging the student-athlete to speak so that you can figure out what is going on is recommended. It is also important to let the student-athlete know that people care about them as a person. Consider asking questions that are open ended:

– How are things going? – Can you tell me what’s going on? – Your behavior has me concerned… Is there something I need to know to understand what happened? – Can I ask you how those cuts got on your arm? – Have you or are you now talking to someone about what’s going on? – Would you like to talk to someone about the situation?

There may be incidents when the student-athlete is less than honest or is resistant to share the details of their mental health. This is a natural reaction to the stigma that many still associate with mental health issues. In these instances, gently illustrating that an emotional or mental issue is cause for medical concern or–just as a musculoskeletal injury is–it’s important that the problems be evaluated further.

In several instances, I have convinced student-athletes to go for a mental health evaluation because I feared a potential issue could arise. I don’t tell them that they have a mental disorder because I am not a trained mental healthcare professional. Saying that it might be a good idea to “go for an evaluation” is a gentle way of getting them to a mental healthcare professional to determine if there is a problem that needs to be treated. I usually start by having a private conversation with the student-athlete and our team physician. During the meeting I bring up the benefit of visiting a counselor in addition to any other treatment the physician feels is warranted.

Whether the athlete is willing to discuss their behavior with you or not, once you have approached an athlete about your concerns and they are willing to go for an evaluation, they should be referred to a counselor, psychologist, or psychiatrist as soon as possible. I usually make initial contact with the mental healthcare professional for the student-athlete. This is where a prior relationship is beneficial–the mental healthcare professional knows of your background and interest in referring student-athletes for a mental health evaluation.

I also ask the student-athlete to sign a release so that I can be updated on whether they are attending their sessions. I do not want or need to know the nature of the sessions, just if they are going. An attendance binder is kept in a locked cabinet, separate from their regular medical chart and I make sure the athlete knows this.

There are student-athletes who will refuse counseling for various reasons, namely the long-held belief that counseling carries a stigma. Unless the student-athlete’s behavior raises concern for imminent health or safety reasons, or a code of conduct violation has taken place, the student-athlete cannot be compelled to report for an evaluation.

The best tactic you can take is to encourage them to consider an evaluation that may help them deal more effectively with their stress or personal issue. Assure the student-athlete that being referred for an evaluation is not any different than being evaluated for a physical injury or illness. You can also assure them that you will not talk about them to their coaches, parents, or teammates without their permission.

If a student-athlete reports suicidal feelings or makes comments referencing suicide or harming themselves, do not under any circumstances leave them alone. You should be familiar with your institution’s emergency mental health action plan, which is usually produced by the office of student affairs. Call for assistance using this mechanism.


Once the document has been developed and approved by all concerned parties, it should be distributed annually to all administrators, coaches, athletic trainers, team physicians, and support staff. Encourage those receiving the document to familiarize themselves with the contents, and to ask questions about the document or address other concerns to the sports medicine department. Stress to all that early detection and intervention is important in assisting the student-athlete with a potential mental health issue.

Of course it would be ideal if a mental health document were never needed, but it’s better to be prepared. Having a proactive approach that includes a solid athletic department policy on student-athlete mental health is important for athlete safety and well-being. In the scenarios detailed at the beginning of this article, the right policy would guide you through the process of helping the athlete.


NCAA www.ncaa.org/health-safety

Mental Health America www.mentalhealthamerica.net

National Institute of Mental Health www.nimh.nih.gov

Depression and Bipolar Support Alliance www.dbsalliance.org

National Suicide Prevention Lifeline www.suicidepreventionlifeline.org


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