Depression/Suicide: Athletes are not Immune Leonard Zaichkowsky, PhD Frank Perna, Ed.D, Ph.D Boston University & John Sullivan, PsyD University of Rhode Island
What is depression? � Depressed mood � Diminished interest or pleasure in most activities most of the time � Significance weight loss or weight gain or decrease or increase in appetite � Sleep disturbances � Psychomotor agitation or retardation � Fatigue or loss of energy � Feelings of worthlessness or excessive guilt � Diminished ability to concentrate � Recurrent thoughts of death or suicide ideation
Prevalence of symptoms � At least five of the symptoms must be present during a two-week period � At least one symptom must be either – Depressed mood – Loss on interest or pleasure
Depression in the community: Some Stats � The lifetime prevalence risk for major depressive disorder in the community it estimated to be 17% – 21% Females – 13% Males – Nearly 2x for females � Only half of subjects suffering from depression seek treatment, and out of these only one half get a correct diagnosis
Depression and adolescents: More Stats � Approximately one-third of adolescents who go to a mental health clinic suffer from depression. (Fleming, Boyle, & Offord, 1993) � Depression is more common in the adolescent years than the elementary years � By age 15, adolescent girls have a rate of depression that is twice that of males
Athletes vs. Non-Athletes � What do we know?
Some Publicized Cases � Terry Bradshaw � Picabo Street � Barret Robbins (bipolar disorder) � Mike Tyson � Jimmy Piersall � Pat LaFontaine � Pete Harnisch � Vin Baker � Jim Shea
Heredity & Stress � The big predictors of depression � The “stress” of injury
Clinical Depressive Disorders DSM-IV Diagnostic Symptom Injured vs. Categories Criteria Non-injured Depressed Mood X Major Depressive Episode Anhedonia X Loss of Appetite/Weight Depressive Disorder NOS Impaired Sleep X Psychomotor Disturbance X Fatigue/Energy Loss Differential Diagnosis: Guilt/Worthlessness Adjustment Disorder Impaired Concentration Suicidal Ideation Anxiety/Hypochondriasis X
Psychological Stress Athletic Injury ?
Psychological Stress Injury How does this happen? (Mechanisms) – Cognitive: Peripheral Narrowing – Physiological: Neuroendocrine Response Immunosuppression “Window of Susceptibility”
Health & Healing Implications PSYCHOLOGICAL DISTRESS NEUROENDOCRINE RESPONSE Catecholamines NEGATIVE Cortisol & ACTH AFFECT Neuropeptides COGNITION MUSCLE IMMUNE SYSTEM Worry REPAIR Immune Cells Attention Cytokines WOUND Post-operative Infection HEALING Blood Flow BEHAVIOR Satellite Cells Sleep IL-I & IL-II Self Medication Growth Hormone Coping Strategy
Injury Psychological Stress � Cognitive-Affective Responses – Negative Affect – Clinical Depression – Posttraumatic Distress * � Behavioral Responses – Rehabilitation Noncompliance – Posttraumatic Distress * � Physiological Responses – Heightened ANS activation – Posttraumatic Distress *
Negative Affect: Depressed Mood Non-injured Injured 1-Month 1-Week 12 9 6 3 0 POMS-D
Clinical Depression 25 Injured 20 Non-Injured 15 % 10 5 0 1Week 1 Month
FYI: Post-Injury Psychological Distress � Negative Affect (Smith et al, 1990) – Depression/Anger * – Tension, Fatigue, and Confusion � Depressed Mood (Roh et al., 1998) – Significant elevation from pre- to post-injury – Greater among injured vs. non-injured athletes at 1-week & 1-month post-injury
FYI: Post-Injury Psychological Distress � Clinical Depression (Perna et al., 1998; Brewer et al., 1995) – Injured (26%) vs. non-injured (4.4%) athletes at 1-week post-injury – Symptom endorsement (Newcomer et al, 1999) � Depressed mood, Anhedonia, Insomnia (early/late), Psychomotor agitation, Anxiety, & Hypochondriasis � Intrusive Thoughts (Newcomer et al, 1998) – Elevated at 1-week & 1-month post-injury – Remain elevated after physical recovery – Scores comparable to other trauma populations (e.g., MVAs)
Implications: “So What?” Behavioral Physiological � Increased Self Medication � Delayed surgical recovery � Disrupted Sleep Quality � Post-operative infections � Loss of /Change in Appetite � Delayed Wound Healing � Impaired Social/Occup. Fx � Decreased pain tolerance (Anhedonia) � Rehabilitation Noncompliance
Indications of Psychological Distress � Prior History of Stress & Coping: E.g., – Negative Life Events – Chronic a/o Recurring Problems – Change in Self-esteem a/o Significant Relationships – Maladaptive Coping Behaviors � Current Symptoms (intensity & duration): E.g., – Depression a/o Intrusive Thoughts – Sleep a/o Appetite Disruptions – Diffuse Pain Reports a/o Physical Complaints � Your Observations: E.g., – Changes in Usual Patterns of Behavior – Unable to Focus or Follow Instructions – Improper Medication Use
What to do... � Assessment – Observation – Communication � Evaluation – Severity – Duration � Referral – Established Resources – Collaboration
Assessment Areas � Psychological Symptoms Depressed mood (irritability, argumentative, etc.) – Difficulty thinking, concentrating, or making decisions – Decrease social interactions (anhedonia) – Intrusive thoughts (avoidance behavior) – Feelings of worthlessness, guilt, hopelessness – Recurrent thoughts of death a/o suicidal ideation, plans, or attempt – � Physical Symptoms Changes in sleep quality & appetite – Changes in psychomotor activity – Pain tolerance – � Coping & Social Support
Sample Questions � Depression – How has this injury affected you emotionally? – How have you been sleeping? (probe: sleep onset, early morning awakenings, get up a lot in the middle of the night) – What have you been doing during the day? (probe: going to class, studying, hang out with your friends) – Have you been irritable or tense? (probe: edgy, fights with roommate, teacher, significant others, family members) – Have you been able to concentrate or remember things? (probe: focus)
Sample Questions � Intrusive Thought & Avoidance Behavior: – Have you thought about your injury when you didn’t mean to? (probe: thought suppression or flooded with thoughts, dreams, nightmares) – Have you avoided talking about your injury? (probe: staying away from reminders) � Social Support & Coping: – Is there anyone that you can confide in about how you’ve been feeling? (note: access and utilization of social support) – Have you talked to anyone about your emotional reaction (e.g. fears) to this injury? (note: quality of emotional expression, satisfaction) – Have you noticed a change in the frequency or intensity of your drinking? (note: inquire about other substances)
Therapeutic Interventions � Providing a Supportive Environment – Communication Behaviors � Changes in Cognitive-Appraisals – Primary (threat): How bad is this? – Secondary (coping): How will I deal with this? � Goal Setting – Collaborative, Realistic, Specific, Re-evaluation � Physical Conditioning – Maintenance of Physical Functioning – Stress-buffering Effects of Exercise
Effects of Psychological Interventions � Decreased incidence of injury/illness � Decreased pre- & post-injury emotional distress � Decreased post-injury pain � Improvement on tests of physical functioning (e.g., CYBEX strength) � Faster return to competition
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