Thursday, August 2, 2018

Mental Health Series Part I: Depression

I'm going to really open up a can-of-worms right now and talk about probably the most brushed aside, or ignored, topic in today's society. No, not "sex", but mental health; the various diagnoses (or lack-there-of) and versions that exist that need not to be ignored but treated. There is a stigma we, as a society, need to conquer when discussing mental health. But for where we are now, guess what, most people ignore this topic because 1) we (coaches, therapists, doctors, etc.) don't know how to talk about it or don't like to talk about it, and 2) we don't know what to do about it if we do talk about it. I'm going to discuss some options for coaches, athletic trainers, and other medical professionals to both interpret, understand, and help provide treatment to those in need. This will focus more on an exercise based approach due to my field of study's inability to prescribe drugs and overall mantra of exercise and human happiness.

Disclaimer: I am in no way, shape, or form a mental health specialist. I am student physical therapist  relaying on knowledge garnered from experience, research journals, and professors during my undergrad and graduate career. I do, however, care about the well-being of others and feel mental health is an overlooked aspect in many aspec. If a case is encountered that you may presume to include a mental health disorder it is important to speak to the client/athlete/patient about this and consider including mental health professionals in the treatment plan.

The stress of sports, work, and life in general can heavily influence the quality of life of an athlete/individual. Among the many mental health disorders today, I'm going to focus on those that have had the largest impact on me, whether I've seen teammates, friends, classmates, or family struggle with or I think are the most occurring in today's world that we as health professions can help the most. These will include depression (mood disorders) and anxiety disorder broken up into 2 different posts.

The NCAA reports that 18% of those over 18 had a mental disorder diagnosed in 2011, with 9 million of those people having it affect their day to day living greatly. 75% of those diagnosed have their first onset by 24 y.o.. That brings us to college students (see image below). This data from the ACHA, indicates a slight decreased level of student athlete mental health involvement compared to non-student athletes. However, it was also discovered that student athletes are more reluctant to report mental health history and a decreased willingness to seek help of mental health professionals in the future. This is where it becomes important for those surrounding athletes (especially student-athletes) to be aware of mental health struggles of those athletes.

Part I: Depression 

Definition: A lump-sum, blanket term for disorders that cause an "experience prolonged times of sadness that interfere with the ability to function in daily life", "pervasive sadness causing difficulty for the individual suffering to imagine not feeling depressed", or "a sad, empty, or irritable mood that affects the individual's capacity to function".
Prevalence: 6.7% of US adults experience major depressive disorders in a calendar year; 18% of college-aged students
Cause: Interrelated, biopsychosocial factors such as genetic make up of the individual in combination with mindset and social factors. The direct cause can be linked to an imbalance in chemicals in the brain.
Signs and Symptoms (Normal Population): 
  • Low/sad moods
  • Irritability or anger
  • Feeling worthless, helpless, and hopeless
  • Eating/sleeping disturbances
  • Decreased energy, fatigue or tiredness
  • Decrease in concentration, interest, and motivation
  • Social withdrawal or avoidance
  • Negative thinking
  • Thoughts of death/suicide
  • Severe cases: suicide intent with plan
Signs and Symptoms (Athletes), above and possibly the following
  • Psychological response to injury
    • Being out for an extended period of time may result in a sense of failure for the athlete or loneliness from lack of participation 
  • Psychological response to the end of athletic career injury
    • It is important to keep the athlete involved with the team in any way as they may feel disconnected from their selves 
  • Over-training  
    • May induce depressive symptoms due to lack of rest/insomnia, recovery, and over-worked CNS
Our Role:
As a whole we need to be able to recognize and tell the difference between when an athlete, client, friend, family member, etc. is tired versus feeling depressed. It is important to have a meaningful conversation with the athlete and also those closest to them. Insert soap box. This is something that is I find really bothersome for me when I see healthcare personnel, coaches, etc. brushing through mental health history during paperwork, exam, or the "two questions to rule out depression" (insert link) like it is expected that they will be clean of mental health disorders. 43% of Division I college head athletic trainers admit they did not screen for mental health disorders at all. We can not assume just because the person is a high level athlete, a successful business person, or even just a 'normal' person, etc. that they are in the clear. Have a personal conversation about life, their a people person. Too many professionals think they know everything by the book but can't recognize it when it shows up in their face because they forgot how to be a person first. End Soap Box. 

Now, to switch gears, let's say we do have a presumed or clinically diagnosed depressed patient/athlete on our hands. What can we do? It depends! I bet you hate that answer. Each approach will be different, the hardest things to do are 1) have the subject open up to you about their struggles, and 2) get started on a routine. If we have someone that is in a rut and can't seem to get a normal physical activity schedule going we need to start small...

The Orange Theory: 
One of my favorite coaches in the world told me this story the very first time we met and it's stuck with me all this time, it goes something like this (synopsis): A doctor told an overweight man who wanted to lose weight to eat an orange a day for the next month and then come back to see him.  A month passes and the man comes back with numbers better than ever. The doctor asks what happened (fully knowing the response) and the man says, "I started eating an orange a day, then I began exercising, then I began eating healthier". Moral of the story: establish a routine with this person!!! 

What does exercise do for depression?
According to Mayo Clinic, exercise can release the endogenous opioids (feel good hormones) from the brain which can enhance the sense of well-being. Establishing an exercise routine can give them a place in their life to get away from the worries and negative thoughts. Realistic goals and small, incremental challenges can boost self-confidence and self-worth. Be aware of lofty goals as the failure to achieve can lose all progress the person had gained up to that point. 

A simple task can lead to a habit which can lead to more habits = a routine. Therefore, Step 1, help the person establish a simple routine. Start with relaxation techniques every morning such as diaphragmatic breathing, visualization, meditation, morning reading/journaling, or walking for simple cardiovascular exercise. Here's an example routine from Tim Ferriss (great author, internet guru, and just an overall overly-smart guy). I would not recommend throwing all of this at someone at one time, this is an end goal if they are up to it. Eventually help the person establish what they like to do, whether it's group exercise, strength training, or recreational sports, etc. Just be sure to provide the person with any knowledge and support they need. Harvard (yes, the world renowned Harvard) suggests that this is not a one-time fix (i.e. going for a 20 minute walk will not automatically cure one of depression), rather a long term lifestyle adjustment that should expect to see results in about a month. This further solidifies the effects of establishing a routine.

For athletes, it may not always be beneficial to withhold the person from a team sport or other events, as these may give the person a sense of identity or a self-esteem boost. This decision should be made along with other healthcare professionals involved. 

Overall, the athlete/client/patient NEEDS to be involved in the conversation at all times. Find out what works, what doesn't work, and what they think may work. If they think it would work, it doesn't need to be 100% evidence based, people. There's a thing called the placebo effect that makes healthcare more of an art than a science sometimes. This is an ongoing process, be patient!

To review, the prevalence of depression disorder is on the rise and affects all populations. It is a debilitating disease that 1) needs to be more scientifically researched and 2) needs to be more of a topic of conversation so healthcare professionals are more comfortable with treatment approaches. There are a multitude of symptoms that can be teased out with a conversation with the person and other close peers/teammates and it's not uncommon for athletes to try and hide it due to the social stigma. Treatment wise, start small, find out what works or doesn't work but don't take away from who the person is, especially athletes. Being essentially quarantined may be the worst thing for a person. I have posted links to various help-lines, links, etc. that one may find useful if they are struggling with tough times. 

For everyone: be an active listener to your friends, family, teammates, etc. and be true to yourself and don't try to 'tough it out', help is only one call away and it is NOT something to be ashamed about. 

National Suicide Prevention Lifeline: 1-800-273-TALK (8255)
Depression Clinics Help Line: 1-888-771-5166
UW-L Counseling Center608-785-8073

Note from Mayo Clinic: "If you exercise regularly but depression or anxiety symptoms still interfere with your daily living, see your doctor or mental health professional. Exercise and physical activity are great ways to ease symptoms of depression or anxiety, but they aren't a substitute for talk therapy (psychotherapy) or medications.

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