Mental health concerns in student athletes after injury
What are the psychosocial implications when a student athlete can no longer play their chosen sport?
(Editor's note: This is part 1 of a 2-part series on the mental health of the student athlete).
Upon seeing an operative report that said a 15-year-old football player required surgery to repair a dislocated patella, his pediatrician became suspicious. This was the teen’s second operation for a joint injury, after treatment for an elbow dislocation a few years earlier. Although the pediatrician had cared for this patient for more than a decade, the family often chose last-minute visits to urgent care centers for school sports physicals rather than visiting the pediatrician. A quick chart review revealed no office examination in 4 years. The doctor picked up the phone and asked the parents to make an appointment.
Examination revealed a heart murmur. Now suspecting a connective tissue disorder with cardiovascular complications, the pediatrician referred the patient to a pediatric cardiologist. Echocardiogram showed a significant aortic root dilation, and genetic testing confirmed Loeys-Dietz syndrome, despite a negative family history. Within months, the patient required a valve-sparing aortic root replacement with graft. The surgery and recovery went smoothly, but a longer-term concern now existed. At the age of 16, this athlete would never play another competitive contact sport.
For most young athletes, sport is a significant part of identity at a time when identity formation is a crucial developmental process.1 Furthermore, sports typically provide their most important social outlet as well as the exercise that promotes physical and emotional health.2 Any athlete who experiences a career-ending or season-ending injury is likely to feel significant loss and grief and develop depression, anxiety, or traumatic stress.2
So it was with this patient. Ten months post-operative, after diagnosing major depressive disorder, the pediatrician prescribed him an SSRI and referred him to a mental health counselor. During the next 18 months, the pediatrician helped the patient cope with his loss and encouraged him to try other physical activity. The patient agreed to pursue swimming and eventually, with the help of his pediatrician and therapist, his depression resolved. Now in college, the patient rides a bike as his major form of exercise and enjoys coaching youth sports.
By contrast, several years earlier, a young collegiate athlete named Morgan Rodgers had died by suicide in the same community after a knee injury ended her lacrosse career at Duke University. Sidelined and isolated from teammates, Morgan underwent 12 months of rehabilitative treatment but felt that her life was no longer under her control. Her signs of depression and anxiety went unnoticed by those around her, who were not trained to identify indicators, and she went undiagnosed. Due to the stigma surrounding mental health struggles, Morgan did not reach out for help, and the potential effects of her injury went unrecognized. Her death made headlines and deeply affected many communities.
These cases illustrate the importance of awareness about the psychological repercussions student athletes face after physical injuries. According to an annual survey from the National Federation of State High School Associations, more than 7.6 million young people engaged in school-sponsored sports in 2021–2022: 4.4 million boys and 3.2 million girls.3 Estimates of the number of children taking part in all forms of organized sports are as high as 60 million.4 The American Orthopaedic Society of Sports Medicine estimates that 3.5 million child and teen athletes experience sport-related injuries each year.4 The increasingly common practice of specializing in one sport at an early age is associated with higher risk of physical injury and psychosocial complications.4,5
Some studies find that physical activity in general, and involvement in team sports specifically, correlate with a lower incidence of psychological distress among adolescents.2,6 The mechanism of effect includes not only the physical benefit of regular exercise, but also the social support teens experience when they are part of a team.2
Other studies suggest that student athletes may be at least as much at risk as other teens for a broad range of mental health conditions, including anxiety, ADHD, and substance use and eating disorders.1 The US Preventive Services Task Force recommends regular screening for major depressive disorder by primary care physicians in all patients aged 12 to 18 and for anxiety in all patients 8 to 18.7,8
In addition, pediatricians should consider administering anxiety and depression screening to young athletes who present with a sports injury. Study results of young adult (usually collegiate) athletes have shown a clear connection between sports injuries and symptoms of anxiety, depression, and traumatic stress.2 Besides the psychosocial stressors that can follow an injury, research has established a link between concussion and depressive disorders in athletes, including immediately after injury.9 Results of the limited research in middle and high schoolers are similar. Gonzales et al conducted screenings for anxiety and depression in athletes aged 12 to 18 who presented with injuries at a sports medicine clinic and found that 24% had elevated anxiety scores and 28% elevated depression scores.10
When injury or disease ends an amateur athlete’s career, as in the cases discussed above, pediatricians should be alert to the possibility of mental health consequences. Staying on the sidelines for several weeks to heal or reduce the risk of second impact syndrome after a concussion can be difficult on a young person who counts on sport for identity, social connections, and future prospects. If the recovery period coincides with a season-ending tournament or an invitational event attended by college coaches, the inability to compete can significantly affect the individual’s mental health.
Pediatricians and other primary care providers who are trained to diagnose and treat mental health disorders as well as physical injuries are ideally situated to address the overall well-being of their patients who participate in sports. At minimum, pediatricians should administer questionnaires validated for use in adolescents, such as the Screen for Child Anxiety Related Disorders (SCARED) and the Patient Health Questionnaire-Adolescent (PHQ-A).7,8 Pediatricians without training in the diagnosis and/or treatment of mental health disorders can refer patients with concerning screening results to mental health professionals. Unfortunately, demand for mental health services exceeds supply in many parts of the United States,11,12 and many pediatric residencies offer limited mental health training.13
The aforementioned cases occurred in a part of rural Virginia where mental health services are scarce. Thankfully, pediatricians and other child health providers can contact the Virginia Mental Health Access Program (VMAP), which connects primary care providers to child and adolescent psychiatrists and licensed counselors in the region. VMAP also offers the REACH Institute’s Patient-Centered Mental Health in Pediatric Primary Care mini-fellowship. The program, which includes 3 days of intensive hands-on learning followed by 12 case-based conference calls with experts, teaches pediatricians and other providers to diagnose and treat anxiety, depression, and other common mental health disorders in children and teens. Its psychopharmacology segments offer pediatricians evidence-based guidelines on appropriate medications and dosage.
The Health Resources and Services Administration, an agency of the US Department of Health and Human Services, funds Pediatric Mental Health Care Access programs in 43 states, the District of Columbia, and certain US territories and tribal nations.14 All offer mental health referrals. Like Virginia, North Carolina provides training in pediatric mental health care (NC-PAL). Other states use other funding streams for training; for example, New York’s Project TEACH offers 5 hours of training on mental health in primary care.15 These programs are vital for pediatricians to deal with the mental health repercussions of sports injuries in young athletes.
The pediatrician previously mentioned recognized a suspicious medical condition and was able to diagnose a major depressive disorder because of his familiarity with the patient’s medical history and awareness of the vital role sports played in his life. His continued efforts to encourage the patient to try a different sport in which he could safely participate supported the patient’s physical and mental health. When an injury-induced break from sports is temporary, pediatricians can suggest ways for patients to stay in touch with teammates; for instance, by attending practice, stretching with the team if their condition permits, helping with equipment, and cheering from the sidelines. The pediatrician can contact the coach to discuss what activities would be safe and beneficial.
To broaden their impact, pediatricians may engage in advocacy and encourage the use of mental health services by athletes. Studies of college athletes suggest there are substantial levels of stigma related to mental illness in these institutions.16,17 Pediatricians can partner with community-based organizations that seek to expand education and awareness. For example, Morgan’s Message was founded by the family, friends, and teammates of Morgan Rodgers to eliminate the stigma, normalize conversations, and equalize the treatment of physical and mental health among student athletes. It strives to help overcome the barriers that keep them from seeking help. Similar organizations include the Athletes Against Anxiety and Depression Foundation, Athletes for Hope, and Let’s Get Real About Athlete Mental Health.
Besides therapy referrals and appropriate medication management, pediatricians are uniquely positioned to support the mental health of injured athletes because of the long-term relationships they have with patients. Medical knowledge and a phone call to the family ensured the timely diagnosis of the young man discussed above, whose healing was facilitated by the continuity of primary medical care and supportive mental health interventions.
References
1. Neal TL, Diamond AB, Goldman S, 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. doi:10.4085/1062-6050-50.3.03
2. Haraldsdottir K, Watson, AM. Psychosocial impacts of sports-related injuries in adolescent athletes. Curr Sports Med Rep. 2021;20(2):104-108. doi:10.1249/JSR.0000000000000809
3. NFHS releases first high school sports participation survey in three years. National Federation of State High School Associations. October 10, 2022. Accessed January 24, 2023. https://www.nfhs.org/articles/nfhs-releases-first-high-school-sports-participation-survey-in-three-years/
4. American Orthopaedic Society for Sports Medicine. Early sports specialization tied to increased injury rates in college athletes. ScienceDaily. March 16, 2019. Accessed January 24, 2023. www.sciencedaily.com/releases/2019/03/190316162202.htm
5. Brenner JS, LaBotz M, Sugimoto D, Stracciolini A. The psychosocial implications of sport specialization in pediatric athletes. J Athl Train. 2019;54(10):1021–1029. doi:10.4085/1062-6050-394-18
6. Guddal MH, Stensland SØ, Småstuen MC, Johnsen MB, Zwart JA, Storheim K. Physical activity and sport participation among adolescents: associations with mental health in different age groups. Results from the Young-HUNT study: a cross-sectional survey. BMJ Open. 2019; 9(9):e028555. doi:10.1136/bmjopen-2018-028555
7. US Preventive Services Task Force. Depression and suicide risk in children and adolescents: screening. October 11, 2022. Accessed January 24, 2023. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-depression-suicide-risk-children-adolescents
8. US Preventive Services Task Force. Anxiety in children and adolescents: screening. October 11, 2022. Accessed January 24, 2023. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-anxiety-children-adolescents
9. Yrondi A, Brauge D, LeMen J, Arbus C, Pariente J. Depression and sports-related concussion: a systematic review. Presse Méd. 2017;45(10):890-902. doi:10.1016/j.lpm.2017.08.013
10. Gonzales G, Young J, Valasek AE. Screening for physical activity and mental health in pediatric sports medicine. Pediatrics. 2022;149(1):215. https://publications.aap.org/pediatrics/article/149/1%20Meeting%20Abstracts%20February%202022/215/186017/Screening-for-Physical-Activity-and-Mental-Health
11. McBain RK, Kofner A, Stein BD, Cantor JH, Vogt WB, Yu H. Growth and distribution of child psychiatrists in the United States: 2007-2016. Pediatrics. 2019;144(6):e20191576. doi:10.1542/peds.2019-1576
12. Whitney DG, Peterson MD. US national and state-level prevalence of mental health disorders and disparities of mental health care use in children. JAMA Pediatr. 2019;173(4):389-391. doi:10.1001/jamapediatrics.2018.5399
13. Green C, Walkup JT, Bostwick S, Trochim W. Advancing the agenda in pediatric mental health education. Pediatrics. 2019;144(3):e20182596. doi:10.1542/peds.2018-2596
14. US Health Resources & Services Administration. Pediatric mental health care access. November 2022. Accessed January 24, 2023. https://mchb.hrsa.gov/programs-impact/programs/pediatric-mental-health-care-access
15. New York State Office of Mental Health. Project TEACH. Accessed January 24, 2023. https://projectteachny.org/education-overview/
16. Biggin IJR, Burns, JH, Uphill, M. An investigation of athletes’ and coaches’ perceptions of mental ill-health in elite athletes. J Clin Sport Psych. 2017;11(2): 126-147. doi:10.1123/jcsp.2016-0017
17. Moreland JJ, Coxe KA, Yang J. Collegiate athletes’ mental health services utilization: a systematic review of conceptualizations, operationalizations, facilitators, and barriers. J Sport Health Sci. 2018;7(1):58-69. doi:10.1016/j.jshs.2017.04.009
