All right. Thank you guys all for being here. I appreciate the chance to speak on a topic. My name is Ashwin Rao. I'm a professor in the Department of Family Medicine in the section of sports medicine at the University of Washington. I'm a team physician for UW Husky Athletics. For 12 years, I took care of the Seattle Seahawks as well. And I take care of a number of professional runners. And I bring those things up just because the topic that I'm going to be talking about, overcoming the stigma of mental health and athletics, came out of this time spent with the care of the competitive and elite athlete, and really across all levels of sport. And so I wanted to talk about that. I wanted to talk about some of the research and some of the context related to the care of the athlete at that level. And hopefully bring you guys some information that might be helpful to you. I know the last talk that I sat in on, there was a lot of talk about the mental aspect of the care that you as a physiatrist and rehab specialists give. And that's very much true in the athletic setting as a primary care doctor who functions a lot like a physiatrist in my private practice. I was talking to Ellie Gelsing about all the interventional procedures I do. I find that the care that I deliver really is impacted by my attention or lack thereof to the mental health of the person in front of me. So we'll be talking a little bit about some of that and talking about it in the context of athletics. So I hope you find this entertaining and hopefully useful as you take that into account in your own practice. So let's see here, there we go. So I have no disclosures. So this is sort of a show of hands question. It's totally fine. Feel free to answer or not. How many of you in this room feel comfortable discussing mental health? Okay, so about a half to two thirds. That's actually better than most rooms that I've asked that question in. How many of you have had formal training in identifying mental health concerns? Less, myself included. Didn't have formal training until very recently. How many of you then have had formal training in caring for mental health concerns? Even, yeah, a couple. But many of us are taking care of student athletes or people who are dealing with these issues and trying to understand it a little bit better. I think hopefully we'll be a place where you guys can start from. So I wanted to bring up the sobering losses that have clearly painted a picture in the media in terms of athletes dying by suicide. Junior Seau, decorated NFL veteran, Dave Mira, famous BMX cyclist who died by suicide, Julia Albini, famous handball player in Europe, Rashaan Salaam, a former Heisman Trophy winner at the University of Colorado, Maddie Halloran, who was a student athlete at the University of Pennsylvania who documented her passing through social media, one of the very first sort of step-by-step documentations, very, very tragic. Tyler Helinski over in my corner of the woods in Washington, starting quarterback at the University of Washington. And most recently, Katie Meyer, starting goalie for four years at Stanford University. These are people who you might see in your clinic who might be struggling and have a smile on their face. So be aware of that. And I think that as COVID has come along, as attentions shift, as our media churns through whatever they're interested in, these issues can sort of fall by the wayside, but they remain an issue. So just between March and May, five student athletes at NCAA institutions died by suicide in less than two months. So this is an issue that is in front of us. So I wanted to talk a little bit about the scope of the problem in the U.S., how prevalent this is, so you can start to entertain and get your minds around what's going on here. And so as of 2020, about 8% of the entire U.S. population has had at least one episode of major depression. 10.5% of females report, and 6.2% of males report that. I state report because women are more likely to report depressive symptoms to a primary care provider or a physician than males do. So some of this might be reporting bias, but that has been demonstrated over and over. 6% of those individuals have had one major episode with severe impairment, meaning they can't participate in their job, their sport, maybe their classroom studies, they're debilitated. When you look at younger people, people who are in the athletic spectrum, age 12 to say 30, you're starting to see even higher rates. And in people with multiracial ethnicity, higher rates again, here's a graph from 2020 through the CDC that demonstrates this. You can see individuals aged 18 to 25, which is the wheelhouse of who I take care of, 17% with a major depressive episode. And those with multiracial ethnicity, certainly relevant to a city like Seattle, but really increasingly so, high rates of mental health in this group. Well, what about suicide? Now, suicide's an area that I've actually looked at through scholarship, and we'll talk a little bit about some of that. But the 10th leading cause of death overall in the United States. But if you look at individuals aged 15 to 34, suicide trails only accidents as the leading cause of death. And many accidents also are related to mental health issues like substance abuse, alcohol misuse. So keep in mind that suicide is a pretty large factor in this age group. And suicide rates for unclear reasons have actually been gradually increasing over the past 15 years. Although we've seen a drop since 2019, you can see a graph here that shows that gradual upward trend, both by gender as well as overall. And then a slight drop off. And this is data that just led up to the pandemic. So who knows where we are with the pandemic and the mental health impacts that this has. So just something to factor in. Again, though, if you cone in on athletes or individuals age 15 to 24, or 25 to 34, and look at those graphs, that bottom blue line and then the yellow line above it, you can see that those rates continue to rise as of 2020. So in our young athletic population, some whom you may be taking care of, these rates are in the range of 15 to 100,000 passing by suicide. And again, if we take a look at rates of death across age range and rank them out, suicide tends to be between the second and fourth leading cause of death for individuals between the ages of 10 and 44. So this is a real issue in the United States. This is something that comes up quite a bit. And my question for this talk, are our athletes at greater risk? We certainly see all the media reports, we see all these stories that are very poignant, but are they at greater risk? And I think the question is, are they at greater risk of depression? Are they at greater risk of suicide? How do we understand that problem? So as you all know, athletes are often seen as pillars of health and wellness in our communities. The perception of that often excludes the possibility of vulnerability or weakness. This is prevalent in athletic culture as well. I've had conversations with some of our Seahawks, some of our Husky athletes over the years, who simply said, I cannot disclose a mental health issue because I'm gonna lose my spot as a starter. The coach doesn't believe in it. And I've had that conversation multiple times. And it's really daunting when you're trying to take care of somebody and they simply don't want to be cared for because it has major repercussions to their life and career. Some athletes, as I mentioned, just concern mental health as a sign of weakness and they never disclose, they simply don't. I had a athlete on our Super Bowl team with the Seahawks back in 2013, who I had discussions about anxiety about. He was coming in for IV fluid hydration as a player who basically never played. And we came to this discussion that really what he needed to do was relax for a few minutes before the game. He took that into account and sort of factored it in. We only got our discussion going so far. And then after his career, he would talk about how on the way to the practice facility, he would think about jumping out of his car every day as a way of taking his life. And so very disturbing to hear these stories both in the moment and after the fact and try to come to grips with it. And so it really got me thinking to, how do we de-stigmatize this issue? How do we make it more relevant for people to be willing to disclose without the fear of some form of repercussion or shame? So our athletes have started doing this for us, which is actually really great. Naomi Osaka, who I'm sure all of you know, former number one overall in the world tennis player, after her stepping away from tennis for a period of time said that she felt under great amounts of pressure to disclose my mental health symptoms, frankly, because the press and the tournament did not believe me. I do not wish that on anyone and hope that we can enact measures to protect athletes, especially the fragile ones. Simone Biles, I'm sure some of you have heard of her. At one point I slept so much because for me, it was the closest thing to death without harming myself. It was an escape from all of my thoughts, from the world, from what I was dealing with, and it was a really dark time. Kevin Love, multi-time NBA all-star, currently still playing in the league, talking about mental illness and your quote unquote problems was a form of weakness that could derail my success in sports or make me seem weird or different. Michael Phelps, the most decorated Olympian of all time. It was a long, long, long road, and I just never wanted to deal with it. And for me, that sent me down a spiral real quick. So this is pretty heavy stuff, hearing this from some of our most well-regarded athletes. Kevin Love again, for 29 years, I thought of mental health as someone else's problem. Didn't want to deal with it. How do we change that culture? So life as an athlete, you're living the athlete lifestyle often as a public persona. Most people think of that for our professional athletes, but on any college campus, even a Division III college campus that you might be taking care of, those athletes are often seen as a pillar in their community, somebody to look forward to, somebody to look up to. Wow, they can be a student athlete and a student at the same time and have a social life, but we don't really know what they're going through. And what I would say is this quote by Kate Fagan, who wrote a book about Maddie Halloran, who documented her demise and passing, describes transitioning to college life as walking through an obstacle course with a blindfold on. And I think that that's fair. I've talked to numerous student athletes over the years because I have an interest in this area, and just check in with them. Try to ask how they're doing, because it is very chaotic to make that transition from being someone's child to suddenly being thrust into being an adult at age 18, let alone trying to make their scholarship work, trying to get all their paperwork done, trying to be competitive on their team, try to make friends, maybe somewhere far from home. So a lot of challenges there. And a fear of loss of social, coaching, financial, or family supports is on their mind. Further, athletes are not always sophisticated enough in a specific area, certainly I wasn't for a long time, to even recognize maladaptive patterns. Drinking, hazing, bullying could all be forms of mental health disturbance. And so not only for the person receiving it, but for the person giving it. So it takes a lot of empathy to try to address somebody on their level and try to understand what's going on. Say the person who is bullying another individual, what is going on there? And try to understand what the circumstance is, let alone the person who's the target of that, who we would likely be more empathetic with. And as physicians, I would hasten to say that many of us are uncomfortable discussing mental health. I think we are. I certainly was for a long period of time. I actually had to go through my own stuff to kind of find a way to have a better way of connecting. And we all have parts of our life that are weaker, our parts that are struggles for us, things that we can reflect on that may make this more tangible in those moments where we just don't feel like we have enough time. We're taking somebody care of somebody's, you know, whatever it is, whatever their issue is. And the mental health aspect is not a priority in that moment. And I would just ask that you think a little bit about that. I remember being at a clinic, an orthopedic clinic as a resident, and this really struck me. It was a person who was dealing with knee pain, arthritic knee pain, just came into the room, was wondering about their injection, and everything had failed. And they were basically on their route to have surgery, basically a knee replacement. And it was a woman, and she was looking down, and she basically, with her head down, said, hey, I don't know if I can live any further with this pain. And in that moment, I was looking, and her husband's head popped up, and then popped right back down. And the physician in the room did not recognize that moment for what it was. And it was a moment where that person was really struggling with their mental health, and just was assuming it was a knee issue. And gosh, their knee hurts. You know, we'll get them better. And I think there's a lot to the physical ailments that we're managing that are mental. So just keep that in mind. Our athletes are in a very complex environment. I think you all kind of understand this. But when it's trying to figure out, okay, how supported or how much of a struggle is an athlete dealing with in any given moment, keep in mind that their lives are fairly complex, just like ours are. They have team structure. They have the social connectedness, which can be a good or a bad thing, depending on what team, and what your teammates look like. They have established identity measures that they're supposed to live up to. Is that a good or a bad thing? They have many support mechanisms. The administrators, the team physicians, the athletic trainers, their sports psychologists, their dietitians, all of these individuals at at least a Division I setting that are gonna be paying attention to them. As those resources go down, depending on which level you're caring for, it might fall upon you or maybe the coaches to be the person to identify something. But they have an incredible amount of stress, the scholarship and financial obligations. Nowadays, Division I student athletes can lose their scholarship if they don't perform to a standard, and it's a coach's prerogative after a year. It can be a challenge when somebody's looking at their financial issues in the middle of trying to be a student athlete and trying to graduate. And most, as you know, who are at that Division I or high level of competition are not gonna do this professionally. So maybe this is their road to their scholarship and their education that is on the line. Performance and participation expectations, let alone injury that you all deal with regularly, how's that gonna factor into somebody's identity? Does their identity become their injury? Does their injury affect their identity enough to make them depressed? Team dynamics, we already alluded to the bullying and hazing and all the different pressures that come with being an athlete. So I would just say, it's not so simple. This is just a graph that tells you all of the different factors, kind of in a quick snapshot from the mental and physical problems to the high-risk cognitive states to the life stressors, let alone the genetic things that might factor into that. And so what we do know is that 80% of athletes coming to treatment for a physical injury also wish to discuss the psychological impacts of that injury. That is a study that's been done that suggests this. So again, it behooves us, as people taking care of those who might be injured, to check in on their mental health. And those who are in the athletic sphere who are seeing a sports psychologist, at least 40% of them are actually hoping to talk about a clinical concern they have, a mental health and mental illness concern, not just a performance concern, which is what many sports psychologists would prefer to take care of in that setting. And many physicians, as I mentioned, I would say many of us are not prepared or informed or even comfortable at discussing this. So another story, Jonathan Martin. How many of you are familiar with Jonathan Martin? Does that name sound familiar? A few of you. So Jonathan Martin was an offensive lineman in the mid-2000 teens. He played at Stanford University. Highly educated, highly decorated, coming out of high school, offensive lineman. Was drafted in the second round by the Miami Dolphins. During his rookie year, it became apparent after the fact that he was the target of bullying and hazing incessantly by some of his teammates. There was a player by the name of Richie Incognito who became kind of known as the bullier who was targeting him as well as one of the athletic trainers of Asian descent. And this is how he described that situation in that moment. You see football as the only thing that you are good at. Your only avenue to make the shy, depressed, weird kid from high school quote unquote cool. Your job leads you to attempt to kill yourself on multiple occasions. Your self-perceived social inadequacy dominates every waking moment in thought. You're petrified of going to work, playing the sport that you grew up obsessed with. So this is somebody who's made it. Somebody in his world said you became an NFL second round pick. You're playing as a starter in your rookie year. Years later after having struggled with leaving the league, seeming to become an advocate for against bullying and hazing, you know, he continued to struggle. And this was a post on social media that was published a couple years after this is that when you're a bully victim and a coward, self-admitted in his case, your opinions, your options are suicide or revenge. And so you can see the powerful emotions that play if we don't have the ability to take care of this. So depression. I wanted to talk a little bit about depression and we're going to talk a little bit about suicide and get into this further. Depression is a very prevalent issue among student athletes. 17% of high school football athletes report being diagnosed with depression. And in certain studies that's no different than the general population. And it does seem that in general when we look at different subpopulations and different groups of athletes across spectrum of competition, that could be college, professional, high school, clinically significant depression symptoms are about as common in our general population as our athletic population. So we're talking about 20% or so of student athletes or professional athletes or those in the community are likely to be suffering from depression. So one out of every five people you might be seeing for injury check. And the prevalence of depression amongst college students, again, similar, 15 to 20%. What is also you should be aware of as people who are taking care of injuries in many instances is that failure following a competitive cycle, maybe due to injury, can produce more depressive symptoms. So to be aware of that, depression being more common in athletes who are injured approaching retirement, so being aware of transitions in time, be it entrance to college, ending college, retiring from a professional sport or competitive sport, or if they're just performing poorly. What you see here, again, are more data that just supports that about 15 to 20% of individuals who have a competitive sport have been diagnosed with depression or are concerned about their depressive symptoms. Further, there's just other studies that suggest that it's not so simple. For example, in rugby, there's a higher risk of depression in people who have had multiple concussions. And we're going to talk a little bit about some of the concussive studies, studies around concussion, because there's a lot of controversy that I'm sure you guys are all aware of, of how do you think about chronic traumatic encephalopathy, head injury in sport, and how does depression and suicidality factor into that? We're going to get into that as well. So let's talk about suicide. That's sort of what I led with and part of where I'm interested in studying this a little bit more. It's the 10th leading cause of death in the U.S. in the general population, but if we look among those of collegiate age, our 18 to 23-year-old cohort, it's the third leading cause of death. And when we look at college students specifically, it is the second leading cause of death. So framing the context there, in the high school group, there was a study done in 2005 that actually hasn't been repeated, that looked at 8,000 student-athletes, and in that group, student-athletes at the high school level did not differ substantially from their non-athletes in reporting suicide or suicide attempts. Similarly, when we look at high school athletes in different studies, it appears that female athletes are significantly less likely to consider or plan suicide than non-athletes. So we're starting to wonder, hey, if somebody's involved in a sport, are they actually, even though the depressive symptoms are similar, are they less likely to consider or plan suicide than their non-athlete peers? Similarly, male and female athletes report lower suicidal ideation and behavior than non-athletes, and those who are highly involved, that is like your varsity student-athlete or others similarly in a competitive sport, were substantially less likely than their non-athlete peers of contemplating suicide. Similarly, at the college and university levels, athletes report higher self-esteem, social connectedness, so there seems to be something about participating in a sport that is maybe protective. Male athletes seem two times as less likely to be suicidal than their non-athlete peers, while female athletes are about one and a half times less likely. So it seems that participation on a college sports team reduces the likelihood of considering planning or attempting suicide. But what about actually completing that event? What about dying by suicide? And so I started getting interested in this research because I was looking at the time at sudden cardiac arrest amongst our student-athletes. And as I was piling through the different databases, including the one that we used in this study, I was finding that suicide and homicide were the third and fourth leading causes of death amongst our student-athletes, and I started saying, hey, we need to think a little bit about this because it's a real thing. So we did a nine-year retrospective study focusing on the years 2003 to 2012, and amongst the 477 individuals we identified having died as student-athletes during that time, there were 35 cases of suicide in that group, and we calculated this suicide rate of 0.93 in 100,000. We also looked a little bit more and did some subgroup analysis, and it appeared that the relative risk of suicide in males, which is demonstrated in other populations outside of athletics, was about 3.7. So males were more likely by a factor of 3.5 to die by suicide than females. Football was one of the data points that was actually interesting to look at. Football athletes were about two times as likely, compared to other male sports, to die by suicide. And in this group, suicide was the fourth leading cause of death. But when you step outside of that group itself and start to look and compare to peers that are outside of athletics, say college students or people of collegiate age, you can see here that NCAA student-athletes are much less likely to die by suicide than their athletic or similarly aged peers. So interesting that maybe college students, with all of the resources available to them, are protected by suicide, even though their depression rates are comparable. When we look at professional studies, there's more of an even distribution there. It seems that the rates of suicide amongst retired soccer athletes is similar to the general population when studies were done in Italy. Similarly, in 2007 through 2013, suicide was found to be the third leading cause of death in retired soccer athletes coming out of Northern Europe. We do see some increases in power athletes. And there's some debate about the confounder of performance-enhancing drugs in power athletes as being a precipitant of suicide in certain male power athletes. What we do know is that one in six international elite track and field athletes is also suicidal, and that's pretty recent data. So one of the key points of suicidal behavior has been the NFL. We're going to talk a little bit about that now. So there's been a narrative that NFL athletes are more likely to die by suicide due to the risks of chronic traumatic encephalopathy, or CTE. And I would say that we should pause because of the studies we're going to talk a little bit about, and we'll get into that in a second. So a group led by Lehman evaluated a cohort of almost 3,500 retired NFL players, credited with at least five seasons of playing in the league. And in that group, there were 12 deaths from suicide. And when you take a comparable group and study them outside of football, the rate was about 25.6 for a comparable general U.S. population sample. So there also appeared to be a disproportionate number of deaths in this group from 1980s forward that they said they needed to understand a little bit better, partly maybe due to reporting and who knows what other factors. But the authors concluded that football players are actually not at higher risk of suicide than the general population. So a narrative that has been sort of discussed from all the different cases that are out there that are all prominent. And then this study by Ann McKee and her colleagues, which looked at essentially a selected group of 100 NFL athletes whose brains were donated with identified clinical pathologic findings of chronic traumatic encephalopathy. So this is a convenient sample. I don't mean it convenient in the way that, you know, it's sort of, it's an odd word to use when people are donating their brains when they have died by suicide. But these were individuals who had, or their families had donated their brains for evaluation. And in that group, 99 of 100 individuals had pathologic findings of chronic traumatic encephalopathy. And so the group also did this retrospective review of a wide range of other issues that these people were experiencing as reported by close connections. Either family members or next of kin, other individuals saying, hey, did this person exhibit depressive symptoms? Did they exhibit substance abuse behavior? What else was going on? And so unfortunately, what they did in doing that was confer some causality saying, okay, if they had chronic traumatic encephalopathy, then they by definition now have mental health concerns due to the chronic traumatic encephalopathy. And I think that that's a mistake. Because you are conferring causality in the absence of scientific impact there. And so the evidence would suggest, okay, this group that has chronic traumatic encephalopathy largely has mental health or substance abuse problems, but we're really not looking at a comparable group of other individuals because we don't have access to their brains. What if the entire population of NFL athletes who's been competing has some evidence of chronic traumatic encephalopathy, but they're not donating their brains to science to be evaluated? And so there's a much larger group of individuals who never have symptoms that would lead them to want to deliver their brains to be studied. And so this is a challenge of the narrative of chronic traumatic encephalopathy. And what I worry about is that it magnifies the concern related to the safety of football. Because it is something that's easy to talk about and discuss in the media. It really disregards some of the other studies I talked about that said that, hey, there seems to be a likely lower lifetime risk of mental illness in this group. And it disregards other life stressors such as substance abuse, life stress, financial hardship, chronic pain as potential sources of distress that might lead to suicide. And it fails to embrace that mental health should really have its own stage in our athletic population. And it's the struggle of like, yes, I have chronic traumatic encephalopathy, I have a lot of concussions, I don't want to talk about my mental health because it's due to this other problem. And that's a challenge. And I would hasten to say, regardless of the outcome, regardless of the reason, we still need to be dealing with mental health. It doesn't, to me, matter so much other than trying to figure out how best to take care of the person in front of me and understand that. More data that was published more recently by Grant Iverson, who's been pretty prominent in this area, saying again that when looked at between 1928 and 2018 and doing a systematic review, retired athletes in the NFL are not at greater risk of suicide. And Bob Cantu, who's a very prominent researcher, neurologist in this area, says that I think it's appropriate that suicide is a multifactorial situation. And we're not precisely clear what factors contribute to the problem. So I wanted to talk about a few other things that factor into the athletic lifestyle, things that you might want to consider. Sleep is one of those issues that are important to consider. What we know is that insufficient sleep duration can impact metabolism, endocrine function, athletic and cognitive performance. So you might imagine that that could translate into athletics. Certainly most of my student athletes at the college level are sleep deprived. And athletes tend to sleep less than their non-athletic peers, partly because they have rigorous schedules to maintain and they're often trying to balance that against everything else in life. Poor sleep quality and short duration of sleep are also associated with stress the following day. I certainly can tell you all about that. I'm sure many of you guys feel that as well. And 21% of athletes report anxiety as a primary reason for them getting up at night or having a sleep disturbance. And numerous studies show that there's essentially insufficient sleep drives higher levels of anxiety. So these are kind of vicious cycles that I showed you before, where worsening anxiety interrupts sleep, that worsens anxiety. And trying to deal with this as a student athlete or somebody who's competing and trying to perform at a high level becomes even more challenging. So I think we need to deal with this. Again, I think it's important to ask, because if we don't ask, we're not going to know. And I think the biggest challenge for anyone in this room is finding the time to do that. I'm in an academic medical center, so I have a little bit more time to spend with my patients. So maybe I have that as a benefit. But it doesn't take long to ask or to hand them a validated questionnaire. So there is many numerous sleep validated questionnaires to screen for sleep disturbance. For athletes, the ASSQ is a good test. And then ultimately, to treat. We even have medications, biofeedback. If any of you have seen the app Headspace, it's one of my favorite apps. That's sort of a mindfulness app that can help people with sleep. So something as simple as an app can help somebody get back to bed. Why not use that as a tool and say, hey, you might want to think about this. Take a look at this. This might be something to consider. I think it's important to promote a culture of healthy sleep and prioritize that as part of performance. I've noticed this actually in my coaches at the collegiate level are more and more emphasizing and promoting sleep. So there is something in the coaching atmosphere that is talking about sleep a little bit more. And I know that my coaches, at least the recent batch of coaches, have prioritized sleep amongst their student-athletes. And suggesting to them if they're not prioritizing that, that sleep can help with recovery and performance. And so that also can include managing training and traveling schedules. I'm actually quite concerned about how collegiate athletics is seeming to silo out between like the SEC, the Big Ten, and I'm in a Pac-12 school, and two of our schools, USC and UCLA, will now be playing in the Big Ten across country with teams mainly from the Midwest and East Coast. What's that going to do to the travel training schedules and the academic rigors of those student-athletes who are expected to be students, but they're going to be traveling every weekend starting Thursday, coming back Sunday on a sleep deficit? Nobody's really talked about that. Substance abuse. We're going to touch on this briefly, but I wanted to bring it up just because I think it's relevant when you're talking to student-athletes at all levels, because it's something we don't like to talk about either. Who wants to ask a student if they're taking substances or drinking alcohol or doing anything that might be considered maladaptive? But I think it's important to ask. The NCAA in 2017 showed that 77% of athletes report alcohol use. I think that's pretty fair. 36% of those athletes drink weekly, 2% daily. Even more concerning to me is binge drinking, which is, this is a real problem amongst college students and certainly in the professional setting. Binge drinking occurs in 42% of student-athletes at the NCAA across divisions. You can imagine the individual who's binge drinking may make not the best decisions, and unless they have somebody to help them make proper decisions in that moment, they're the individuals in some cases who might be having accidents, which is the leading cause of death amongst student-athletes. Just being aware that these are factors that play against each other. Recreational drug use, specifically marijuana, has grown over the years. Marijuana has recently replaced tobacco as the second most used drug after alcohol. In Seattle, where it is illegal to use marijuana, it becomes an issue because that can stand against NCA bans of the product. And so trying to figure out how to navigate that tactfully, again, using empathetic discussion to say, hey, I'm not judging you for your marijuana use, but at the same time, I need to understand how that might be playing a role. One of the challenges with marijuana is that it's, up until recently, being considered a CNS depressant, but that's at lower doses. And many of the vendors of marijuana are selling very, very potent concentrations of marijuana, which actually becomes a psychoactive stimulant, and so psychosis, other types of symptoms. So these are on a U-shaped curve, and if somebody is using marijuana from a dispensary that's at a 40% concentration, they may be more prone to agitation and psychosis than otherwise. So keeping those things in mind is something to factor in. Another study shows that 21% of college students use alcohol highly, which kind of fits with the binge drinking group. And those with severe depression or psychiatric burdens were likely to be using alcohol and other substances as well. So just be aware that when we're talking about substances, we're often talking about mental health for a variety of reasons. I'm not talking about performance enhancing drugs. I have other talks on that available, but it's just too much to cover. And hold your attention for the entire time. So I'll hold off on that. I did want to talk about COVID because I think it's quite relevant. This is the first, it's actually the second conference I've been at where we kind of are kind of moving past it. Not many masks, including me anymore, which is both great and interesting in a different time. So, you know, I wanted to ask you again a few questions and maybe reflect on athletic life as part of this. So how many of you felt stressed during the COVID pandemic? Cool, that's kind of like a stretch now. How many of you have struggled with anxious or depressed thoughts? Only feel comfortable to answer if you did, but I certainly did. How many of you have considered how your future and careers may be affected by COVID? I did too. How many would you say your way of life was disrupted during that time? I would say pretty much all of us. Now, you know, consider that you're a student athlete and how they may feel. I currently have 24 and 25 year old student athletes who are still in college because they have extra years of eligibility. How does taking a year or two off of your competitive cycle impact your ability to play, your potential for professional career? All of those things are things that we're having to factor in now. Just not being able to play or exercise can be a real challenge. So we've seen a pretty substantial rise in depression amongst our young people across the country, and we'll get to student athletes, but the CDC in 2020 showed during the pandemic a tripling of anxiety and a quadrupling of depression symptoms. I think you all intuitively know this, but 40.9% of individuals reported adverse mental or behavioral health conditions, 75% for those aged 25 to 44, about 10% a little higher than baseline where had contemplated suicide. And these numbers are higher amongst our vulnerable populations, essential workers, people of Hispanic ethnicity, those with high school diplomas are more vulnerable. So our vulnerable populations are more likely to have this struggle. So we have to be aware of that. Student athletes have been talked about in the lay press as having had a massive toll imparted upon them by mental health and otherwise from COVID. The stoppage of your sports. I actually had a colleague who took care of the athletes in the WNBA bubble where they all went and played together for six weeks. And that was incredibly stressful for athletes at the WNBA level. There was a substantial amount of severe mental health and anxiety and depression from being separated from your families during that time. And unless you're aware to talk about it and address it and identify it, it's something that could easily go missed and then lead to all kinds of behavioral challenges. I know student athletes who are worried that they didn't want to spread COVID to their loved ones and trying to figure out how to see family members. I'm sure we all have felt that. And then it's interestingly long-term health risks. I have had several professional runners who've had COVID who've not been able to return to their pre-performance levels because of cardiopulmonary disruptions that are unclear and tangible and noticeable. And so what's going on there in terms of their physical health? How is that affecting their mental health? What part of their mental health is contributing to this are all open-ended questions. And so you take this really complicated momentally you and throw COVID on top of it, good luck. And so Stanford did a study looking more at specific athlete concerns. And what we saw was a 477% increase in feeling down or depressed more than half of the days of the week compared to previous to the pandemic in our student athletes at the college level. 20% at that time reported difficulty exercising related to their mental health. 11% felt preoccupied with their futures and being concerned about that. Endurance athletes, interestingly, I didn't predict this but endurance athletes were six times more likely to ascribe to anxiety symptoms more than half days of the week and seven times more likely to be not interested in doing their activities. So interesting to see how different subpopulations of athletes, every athletic team has different cultures. So just being aware of like, hey, my runner might be different than my football player in managing their concerns and how they deal with this. That's what this told me. And the study was actually repeated just recently in 2022 trying to understand, okay, now that we're emerging from the pandemic, where are our student athletes right now? And I thought this data was quite interesting. Nearly 10,000 students were included in this study across NCAA divisions, across all four years of college. And the majority reported higher rates of mental distress compared to before the pandemic. There was a slight decrease in feelings of hopelessness and a few other things. We're gonna show you a few graphs compared to 2020 when we were entering the pandemic. And obviously there was higher relative concerns amongst women, people of color, LGBTQ, BIPOC communities all had higher risks of mental health concerns than they did prior to the pandemic. And you might say, well, gosh, we're improving, but we're still far behind in our mental health compared to where we were during the pandemic. And I don't know if any of you guys have reflected on this for your own lives, but I think that's kind of the case for a lot of us is that we're still struggling even though we're emerging from this different time. So here's some data that reflects that. This was done in 2022 as well and looked at 2021 data. The table above is male athletes and the table below is female athletes basically asking within the past month, have you had mental health concerns? And then they looked at data from 2019 through the fall of 2021. The green bars are improvements, yellow bars are worsening and everything else is not statistically significant from the year before. And you can see the numbers are pretty consistent even as we're emerging from the pandemic in the fall of 2021, even though that, I don't know if we were truly emerging at that point, but you can see that people are feeling more mentally exhausted in large part, but still feeling lonely, still feeling hopeless. And if you compare it to the 2019 data, which is in that most left bar, the numbers are still pretty starkly different than they were in 2019, pre the pandemic. You're seeing numbers that are almost double the rates of those depressive measures compared to before. And this is across all athletes. Now, if we look at men's and women's sports and looking at people who are of more disadvantaged background or underrepresented backgrounds, are black athletes, are Latinx athletes. We see that those athletes are more likely to struggle with hopelessness, exhaustion, sleep difficulty, and depression compared to our white athletes. Similarly, our queer athletes, those who are asked constantly or most every day, are they struggling with their mental health? Are at least twice as likely across those parameters to feel depressed, anxious, lonely, and all of the parameters listed here. So being aware of your vulnerable populations, I think very important to kind of factor in. So where are we with some of this stuff? Where are we in terms of progress? Well, I think we're making progress. This is a different time than it was five to 10 years ago when I started doing a lot of the research in this area. We have many more multidisciplinary care teams. Are any of you taking care of collegiate athletes at college level? So some of you, not all of you. Well, at the college level, many institutions now are employing a team of physicians, athletic trainers, dieticians, sports psychologists. We are very well resourced in this setting. And even so, we're still struggling with the mental health care, partly because we've opened the door to talking about it, and we're getting a lot of attention to it. And thankfully, people are coming, but it also is overwhelming in some way. NCAA has published a number of different publications, including the Mind, Body, Sport document. I wrote a textbook on mental health concepts, trying to inform providers who are interested in caring for certainly athletes about how to think about that. And there's research that's ongoing. And what's nice is that some of the Big Ten, Pac-12, and other institutions are putting money towards grants to look specifically at mental health as part of their request for research funding to look closely at mental health amongst the student athlete populations. So we're coming better there. I think ultimately, to overcome stigma, we need to have better bidirectional communication. You have to be willing to ask. You have to listen empathetically, be willing to give the time to it, and ask for help from your student athletes or otherwise, your patients, whoever else you're taking care of, to say, hey, how can I help you? Or where are your questions? And that takes time and effort, stuff that we don't always have. Our athletes are helping, as I mentioned. DeMar DeRozan, NBA All-Star for the San Antonio Spurs, previously was on the Raptors, said, depression is nothing I'm ashamed or against. Kevin Love, mental health isn't just an athlete thing. No matter what our circumstances, we are all carrying around things that hurt, and they can hurt us if we keep them buried inside. Simone Biles, I thought I could figure it out on my own, but that's sometimes not the case. And that's not something you should feel guilty or ashamed of. Once I got over that, I actually enjoyed it and look forward to going to therapy. It's a safe space. You can imagine how de-stigmatizing that is to hearing Simone Biles say that in a public forum. And Naomi Osaka, cover of Time, it's okay to not be okay. I think that's a very powerful message, at least one for me, to hear somebody at her level say that. She even said, Michael Phelps told me that by speaking up, I may have saved a life, and if that's true, it was worth it. And Michael Phelps, one of the first very prominent athletes to really take a stand, talking about mental health even before the end of his career, said that since the day that I opened up about depression, it's just been so much easier to live life and so much easier to enjoy life, and it's something I'm very thankful for. And again, that message, it's okay to not be okay. So a few research gaps, recommendations. Most of the publications that I talked about were retrospective analyses. We really need prospective data to make better conclusions about incidents of suicide, risk factors, suicidality, and depression. We don't have any mandatory databases to report into, and so that's a challenge across the spectrum. I think our medical records do pose an opportunity, depending on how we wish to use them. Epic seems to be everywhere these days and has some interesting tools that allow us to track, so trying to come to some comprehensive approach there. We need better prospective screening studies to look using validated tools. A lot of the tools that have been used are not validated, and it makes it harder to draw conclusions when you're using a tool that's not really been shown to test the thing you're looking for. So using validated tools are gonna be important. And trying to understand what our interventions are accomplishing. Trying to do these tests to look at proactive prevention strategies and see which ones work, because they don't all work. We think that these strategies might be helpful, but they don't always help. And we need to understand the confounders, the separation of CTE, substance abuse, the impact of injury, and other things from risk-taking to better understand it better. So I think it takes awareness at all levels. That NCA study that I talked about before, as much as we would like to think that we are the bastions of mental health or any sort of physical health or support for our student-athletes, it's actually the coaches. So if you're taking care of student-athletes, try to educate your coaches, because they're gonna be the ones who get it first. I mentioned online and app-based platforms that track wellness. They're widely available, often free, and easily accessible if you can get buy-in, and that's always a challenge. We just need to understand things a little bit better. The University of Washington actually created this Forefront Suicide Prevention Center, and they promoted this LEARN method. This is actually a module that everybody in the state of Washington has to go through to maintain their board certification as providers in medicine. So MD, DO, as well as athletic trainers and physical therapists have to go through this training in order to maintain their certification. And it promotes this method of, which is probably an easy summary on steps you can take. Look for warning signs in your patients. Look for signs that they might be off. So looking at that patient whose head is down, seeing that they can live their life, I think is important to factor in. It may not just be their pain or their immediate issue. Being able to empathize, being able to listen actively, and to ask and assess. Ask if they are dealing with depression. I talk about depression like I talk about an ACL injury. I don't really differentiate the two anymore. And I said they're both issues that you're gonna have to manage that will affect your ability to return to play. So I'd like to talk about both of them. And do it in a way that is non-judgmental to them, and they're gonna be more willing over time to respond to you, regardless of where they come from as a patient, be it somebody who's not competitive, competitive, or whatnot. I think it's also important to remove dangers and restrict access to lethal means. Men are much more likely to commit, to complete suicide than women, because they are more likely to use a lethal means, such as a gun. So that's one of the factors that is important to identify. And then also identify next steps for your athlete. If you're gonna talk to them, make sure you have a game plan for them. Like, hey, I'm gonna see you back in two weeks, or I'm gonna send you to our sports psychologist, or I'm gonna support you in this different set of ways, and that's gonna be helpful for them as well, to give people who are vulnerable some direction. One of the most recent developments that just came out this past year was the 988 Suicide and Crisis Hotline. This is akin to 911, but for mental health issues. So if you're not aware of it, certainly just tell your patients, this is a resource. If you're struggling with your mental health and don't have anybody to talk to, just dial 988, and that's like dialing 911. And there's a few other resources, crisischat.org, and texting hello to 741741. I actually have these on my phone, so I share them with my student athletes, or my NFL athletes when I took care of them, just to make sure that they have resources if they want a no-strings-attached approach. So take-home points. We're wrapping up a little early, hopefully. Yeah, actually, quite a bit early. Current research suggests that depression is at least as common amongst our athletes compared to our non-athletic peers, but the research does not support that athletes are at greater risk of suicide. So we think that athletic participation is probably protective. Athletes are, as you know, presented with a unique risk and support environment, and that obviously sleep, substance abuse, and COVID are all additional stressors upon all our lives that also impact competitive athletes. And we definitely need more research, and we need to make sure to ask, acknowledge, and screen for mental health and promote discourse. I think those are all important steps that we can take. And so I did wrap up early, and if you guys have questions, I would love to entertain them. Thank you. I saw a hand. Yeah. Hi. Hi. We talked a little bit about this. We did. Thank you for sharing. I know I fully concur. I think it's It's part of the reason I've tried to take on more Of responsibility for this myself is because there are very limited resources and even in our over resourced or highly resourced university setting There's still not enough mental health Clinic slots available for our student-athletes to be seen in a timely manner. And this isn't a very well resourced setting And so trying to find resources for people who might not have that and the cost is incredible So I know providers including myself who've learned cognitive behavioral therapy and started to say, you know what, let's at least take a few steps and and give the person a textbook and some homework to do to start working on their emotional well-being because You know, it's better than nothing Even though it's not perfect Yeah Yes, we do. Eating, disordered eating, eating disorders are common across female competitive athletics at a pretty high level. I think it's in the range of up to 20% depending on which subgroups you're looking at. In some of the more aesthetic sports, sports that, endurance sports like track and field and cross country, for example, the rates can be even substantially higher than that. There's a number of different factors that go into that as well. Then you're dealing with that plus depression, anxiety, and all the other things that circle through that. The rates are quite high. We're becoming more and more aware of disordered eating amongst male athletes as well. That's been largely disregarded for many years, but there's more and more research now, especially in the endurance sports for male athletes and disordered eating or eating disorders. What's a good point you ask? That's an area that needs to be studied. I think sort of looking at it two ways. I did with one of my resident physicians, we did a meta-analysis, or sort of a, sorry, not really a meta-analysis, a systematic review on looking at concussion and other mental health issues as a proxy. And what we identified was a much higher risk of mental health burden in people who are long-term concussion sufferers, who basically had prolonged concussions. And that data seemed to be demonstrated despite the quality of the data being iffy on a regular basis. And I think the question is very valid. Hey, is somebody who is struggling with mental health have an injury that's going unpredictably and taking a longer time, or vice versa? What is the impact of the mental health on somebody's mental health for being injured? And so, yeah. I was curious, is that younger athletes that don't get better keep coming back to clinic? Yes. Many of them have issues, anxiety, mental pressure, and the others, and they never get better, they keep coming back to clinic. I think that's huge, actually, is that we see this very much with concussion because there's so much overlap between symptoms of depression and post-concussive symptoms that it becomes very difficult to tease those two apart, which is what changes. And it's hard, again, for somebody who's struggling with concussion, for example, to admit to feeling that this might be depression instead, or anxiety, or another mental health issue when you have something tangible in front of you. And certainly with other injuries, yeah. Honestly, I think that 50 to 60% or more of what I take care of in clinic, and I see a lot of chronic tendinopathy, I do tendon debridements, and peripheral nerve hydrodissections, and all of these things that I do interventionally, but a large part of that pain response is mental health. And I think I get along well with my patients because I relate to them pretty well for whatever reason, and it largely is because we are on the same wavelength with regards to some of the mental health factors. It's a great question. You know, the SCAT-5 is really challenged in some ways by an athlete's willingness to disclose those symptoms, so if they are bringing it up, I take it very seriously and try to factor that in. When we're looking at somebody with concussion, the SCAT-5 is sort of the clinical tool that most of us are using, in case you guys are not all aware of it, but the issue is almost a converse, when somebody is basically circling all zeros and struggling to return and trying to find ways to objectify and identify somebody. I think it's really important, especially if you're taking care of teams, to know your student-athletes before their concussion, because it can really predict how they might do after the fact, and it's part of being a team physician that I think is challenging, so yeah. But I take it seriously. It's the quick start, quick answer. talk to them by themselves, have that one-on-one, are you sexually active, that kind of thing. Are you doing that? that would be minors? Yeah, I do. I see this, I take care of that sort of transitional young adult youth athlete, the 10 to 14 year old quite often, and I try to do that. It may not always be at the first visit, so sometimes it's building that relationship and trying to make them feel comfortable. I often worry about that overbearing parent, and I am a overbearing parent, so I'm self-incriminating, I think, but as a potential challenge to disclosure. And so if the conversation's going well and things are going well, I'll be like, at a certain point, I do want to speak with your child alone, because I think it's important for me to get a true understanding of what's going on from them, especially when, for example, people have injuries that don't make sense. It's an athlete who is injured, but they're not really injured, and you're trying to figure out what's going on, and it's often they have stopped being interested in their sport, but their family is really invested in it. And it's something that I certainly have taken very seriously, and it takes building that relationship sometimes. It's hard to do on a one-off situation, but even if it's hard, sometimes if I get a sense in the room that it's an opportunity, then I will take it. I mean, just kind of anecdotally speaking, I was with the same team, and just following up on what's going on with them, how are you doing from a mental standpoint, and all of them say not well. Like, acute injury, chronic injury, nobody's doing well. Can you just open it up? And I'm wondering, from a, I guess, a validated medical standpoint, do you have any suggestions? Yeah. Nobody wants to answer a lot of questions, so I tend to use the PHQ-4, which is just four questions, two for anxiety, two for depression. There is some data. I was part of, or I am part of the NCAA Student Athlete Mental Health Task Force, and in that task force, and in the Diverse Student Athlete Mental Health Task Force that I was part of as well, it became clear that we also need to ask separately about suicide, because being depressed, being anxious does not always equal being suicidal, at least the way we ask the questions. And so, I think it's important to ask quickly, and honestly, again, setting up that environment where somebody's going to be willing to have those discussions. And we do a PHQ-4 for every returning student athlete, and every incomer as well. I usually wait until one or two weeks after they've already entered, because a lot of them will be super anxious just showing up to campus after being away for a while, and if they're answering honestly, they'll just circle a lot of positives. So after a couple weeks of adjusting, we'll have our athletic trainers give everybody those measures, and then anybody who scores a three or above, we will have the athletic trainers and them circle together and then have a visit with me so we can discuss. And oftentimes, it's a nothing. It's not too concerning, but every once in a while, I can think of two people today who are struggling with chronic injury who flagged positive, and it turns out that they are struggling kind of mightily with their mental health and are now in services, which has been good. So I find it to be valuable to screen. If you have somebody who's more invested and willing to, the PHQ-9 and the GAD-7 are my sort of two go-tos, just because they are so broadly used and validated. The ASQ is a suicide questionnaire that's also valuable to ask that's relatively short, but again, you're starting to get into lots of questions, and whether somebody's willing to do that on top of every other piece of paperwork they have to fill out is challenging. So for me, the PHQ-4 has been the tool to use from an ease and practicality standpoint. Yeah, that's a, I think that's a double-edged sword to be honest with you. I'm not aware of that data yet. I think it's just so new that nobody's really looked at it. It is something definitely worth looking at though. One of the challenges, you know, it's interesting because not everybody on a given team will have access to or be interesting to people who might be willing to give money to, you know, sort of allow them to profit from the NIL stuff, name and image likeness. I would say at the University of Washington, which is, you know, a Pac-12 Division I program, probably about currently a fifth of our student athletes are in some sort of NIL contract. The challenge is that they're often the only person vetting that contract and they often have many impositions upon their time to fulfill the contract, which adds to a lot of their sort of mental stress of like, oh, I have to make this appearance or I have to sign 500 jerseys or I have to be at this place to like help, you know, promote some brand. And I've seen that amongst my student athletes and I've asked a few of them who've been more involved. I, for example, just saw a baseball athlete who's actually got a pretty big social media following and has like probably 20 or 30,000 followers and as a result has a NIL deal. And he told me that that summer, instead of playing baseball, which was going to be his plan, he decided to go to Los Angeles, spent the entire summer living out of a car because he had no money yet, and basically went, doubled up his ADHD medications, which is why he routinely sees me, so he could stay focused the entire time and now was coming off of the ADHD medications and crashing. And I was like, wow. And then he's like, I had to meet all these people. I was partying a lot. I was drinking a lot. You know, I was trying to always, and he's like, I'm completely kind of strung out right now coming back onto campus. And I was like, wow, wow. And that was because of NIL deals. And so, I mean, that's a one-off story, but there is a lot of that trying to, young people trying to figure out how to navigate this and the finances of it when they're 18 to 23 years old. It's challenging. Yeah, I have not seen any data on it yet, but it is definitely something that I know some people are definitely starting to think about. Great question, though. Well, awesome. I'll get you guys out early. Thank you so much. Appreciate it.

mental health stigma

athletes

depression

athletic culture

seeking help

psychological impacts of injuries

sleep habits

comprehensive healthcare

substance abuse

mental health resources