Motivation and emotion/Book/2014/Depression in athletes

Depression in athletes:
Why are athletes vulnerable to depression
and what can be done about it?

Multimedia presentation (5 min)

Overview

The psychology of mental functioning and its relationship with athletic performance has received increasing research attention since the 1990s. From the research findings, it is understood that an athlete’s mental state plays a crucial role in their ability to perform.

This chapter gives a brief overview of depression, how depression affects athletes, and provides a theoretical framework from which to examine depression in athletes which includes positive psychology, cognitive behavioural theory, and self-efficacy. A case study illustrating the explained theoretical framework is presented. Following this, depression in athletes is discussed in relation to the prominent research surrounding the topic. This research suggests that factors including injury, overtraining and burnout, retirement and loss/lacking social support, leave the athlete vulnerable for developing a major depressive disorder. The reasoning for this, suggested in current research is explained. Finally, some practical skills to minimise athlete vulnerability to depression are suggested.

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Depression

A depressive mood disorder is a disabling mental disorder that can interfere with all aspects of daily life functioning. This includes loss of interest in once enjoyable activities; this is something that is detrimental to sporting participation (Armstrong & Oomen-Early, 2009). This illustrates how depression and motivation are closely linked.

Major depressive disorder (MDD) is the most common and severe expression of a depressive disorder and is diagnosed with the presence of a major depressive episode which is established when the individual exhibits five or more of the required symptoms. These include, but are not limited to, a pervasive sense of hopelessness, worthlessness, decreased motivation, energy, and pleasure, as well as impaired sleep, concentration and appetite changes (APA, 2014).

Depression in athletes

Athletes are considered a high-risk subculture for a variety of health hindering behaviours including substance abuse, disordered eating, high stress, coping with injury, overtraining and fatigue, many of which correlate directly with depressive symptomology (Armstrong & Oomen-Early, 2009). Data positively suggests that individuals who are physically active are three times less likely to suffer from depression than inactive individuals. However, evidence indicates that the intense pressure that athletes face to perform at their peak can reduce the positive effects of exercise (see Figure 1; Armstrong & Oomen-Early, 2009). According to the American Psychiatric Association (APA), the most common time for depression onset is between 20 to 30 years which correlates with the age of peak athletic performance (Weigand, Cohen & Merenstein, 2013). This underlines why theory and research surrounding MDD in athletes is important for understanding why athletes are vulnerable to depression and what can be done about it.

Figure 1. Pressure to perform can undermine the beneficial effects of participation in sport

Theory

Participation in athletic activity is an integral component of society. Recognition of this has spurred increasing interest into research surrounding the psychological well-being of elite athletes (Storch, Storch, Killiany, & Roberti, 2005). It is generally understood that participation in recreational sports has a range of physical and mental health benefits (as cited in Storch et al., 2005). However, literature suggests that when athletes enter elite levels of sporting commitment that the stressors due to these commitment levels can outweigh the associated mental and physical health benefits (Storch et al., 2005).

Positive psychology

There are many known benefits of physical activity. Exercise has been proven effective to improve depression and has been able to prevent it all together (Salehian, Gursoy, Aftabi, & Taghizadeh, 2012). It is argued that exercise increases one's self-confidence and provides a feeling of accomplishment and mastery, which can raise an individual’s overall outlook (Salehian et al., 2012).

A generally optimistic theorisation of the effects of physical activity on mental health is derived from the perspective of positive psychology. Positive psychologists theorise that athletes who participate in regular physical activity should be generally happy. This is because physical activity incorporates all five components that are found to make individuals the happiest. These five components proposed by Seligman (as cited in Mostafai, 2012) include pleasure, flow (described as the absorption of an enjoyed activity), social ties, meaning, and accomplishment. Furthermore, the concept of happiness is suggested to include positive excitement, life satisfaction and lower expressions of negative emotionality such as depression and stress (Mostafai, 2012). The criticisms of this perspective is that it is one-sided does not account for times in which the athlete does experience cognitive distress.

Cognitive behavioural theory

Cognitive behavioural theory, from which Cognitive behavioral therapy (CBT) is derived posits that psychological problems begin, and are maintained by cognitive processes and the way in which the individual interprets and responds to their environment (Lindvall, & Moharer, 2011). Therefore, from the perspective of CBT, distress results form a negative cognitive interpretation and understanding of the self, current experience, and the future (see Figure 2; Storch, Storch, Killany, & Roberti, 2005). Alternatively, CBT suggests that if an athlete has a positive and more realistic view which incorporates their successes, failures, and abilities, they would not experience the same distress (Storch et al., 2005). From the perspective of CBT, it is theorised that these beliefs about the self, experience and future develop through internalisation of others' feedback (Storch et al., 2005). This is particularly relevant for athletes, as performance in a social setting enables constant scrutiny about their performance by others.

Figure 2. If an athlete has a negative view of their failures and abilities s/he is more likely to develop cognitive distress.

Social cognitive theory: Self-efficacy

Bandura’s (1977) theory of self-efficacy was developed within the framework of social cognitive theory (Feltz & Lirgg, 2001). Self-efficacy is defined as the self-belief that one has that they are able to execute a specific task successfully to obtain a certain outcome (Feltz & Lirgg, 2001).

Self-efficacious beliefs are an individual’s judgements about what s/he can accomplish with his/her skills, and these beliefs rely on cognitive processing from diverse sources of efficacy information. Bandura (1977) suggested that these sources include performance accomplishments, vicarious experience, verbal persuasion, and physiological states (Feltz & Lirgg, 2001). Performance accomplishments are suggested the most influential source of efficacy information because they are based on an individual’s mastery experiences (Feltz & Lirgg, 2001).

The concept of self-efficacy is suggested to be one of the most influential psychological constructs to effect achievement in sport (Feltz & Lirgg, 2001). So, according to the concept of self-efficacy, if an athlete places negative attributions on their sport, believing that they cannot effectively compete or improve their performance they will experience distress (Storch et al., 2005).

Theory integration

By combining perspectives from positive psychology, cognitive behavioural theory, and Bandura’s concept of self-efficacy, we are able to generate an understanding of how to improve and even prevent depression in athletes. Findings from the perspective of positive psychology understand that physical activity has positive effects on both body and mind, increases self-confidence, and provides a feeling of accomplishment and mastery (Salehian et al., 2012). However, at the elite athletic level an individual’s sporting performance is graded which incorporates perceived successes and failures. From the perspective of CBT, it is understood that a positive and realistic view of an individual’s ability to achieve both successes and to recognize his/her failures is needed to ensure the individual does not experience cognitive distress (Storch et al., 2005). This view can be theorised as self-efficacy, which is the belief that a person has as to what they can successfully accomplish with their skills. So, a focus on generating and maintaining realistic self-efficacy beliefs in athletes is necessary to minimise negative emotional outcomes such as depression.

Case illustration

A particularly interesting review into eight former Olympic athlete’s mental dispositions throughout and after their sporting career was conducted in 2011 (Barker-Ruchti, Barker, Lee, & Rynne, 2011). Michelle* (name changed) was one of the athletes interviewed; she believed that she managed to keep her sporting career in perspective. In an interview conducted with Michelle, she stated that her coaches did not like it when she suggested that the sport was ‘just a game’. So, Michelle’s suggested self-efficacious beliefs surrounding the sport, and her beliefs about her general life skills would be assumed positive and accurate. Sadly however, Michelle experienced acute tension and suffered from what she states as ‘debilitating’ depression for over a year after retirement from sport (Barker-Ruchti et al., 2011). From the perspective of social cognitive theory this could have been due to the high amount of pressure that her coaches placed on her to take her sporting commitments seriously. It turns out that Michelle’s actual disposition towards participation in sport, was very rigid, as she stated that a perfectionist approach was critical for her own success (Barker-Ruchti et al., 2011). Michelle stated in an interview that "you would be training for some intricate little skill you want to improve or perfect…[with] constant goals and reassurances that you were doing the right thing" (Barker-Ruchti et al., 2011, p.24). Showing that Michelle’s actions were constantly monitored by those around her, and in her mind, that they needed to be perfectly executed or there would be ramifications. Startlingly, Michelle stated that she enjoyed this constant scrutiny in saying, "I don’t care if I’m needy – tell me I’m sh*t hot?, [As] if that’s going to make me play better"(Barker-Ruchti et al., 2011, p.24). This suggests that the constant social scrutiny and pressure to perform had negative effects on Michelle’s disposition and could have led to her depression following retirement. Following the theoretical underpinnings explained above, (See Theory), Michelle no longer could define herself through her sport after retirement. This had a negative effect on her self-efficacious beliefs. Furthermore, she no longer had the strong and constant social support around her, and she was no longer receiving the benefits of psychical activity. All of these factors increased her vulnerability and contributed to her depression.

If you would like to learn about some other athletes who have suffered from depression, go to External links for some great resources.

Research

Moderate to vigorous aerobic activity is important in the prevention of mental and physical health problems. But when performed at higher intensity, at the elite athletic level, physical activity can compromise health (Appaneal, Levine, Perna, & Roh, 2009). The negative effects of elite sporting participation include injury, overtraining and burnout, retirement and loss/lacking social support (Appaneal et al., 2009). These factors are suggested to leave the athlete in a highly vulnerable state for a major depressive disorder.

Figure 3. Strong social support is incredibly beneficial to the athlete mentally and physically.

Injury

It has been well documented in research regarding athletic injury that athletes with injuries experience greater levels of psychological distress than non-injured athletes (Appaneal et al., 2009). Also, that depression emerges as the most common emotional reaction to injury (Appaneal et al., 2009). Depression is suggested as an emotional reaction to injury in athletes because the athlete perceives a loss in either mobility, playing time, or career (Green & Weinberg, 2001). Injury is also preventative in allowing the individual to pursue their self-defining activity (Green & Weinberg, 2001).

Damage to self-esteem is another potential consequence of athletic injury that could heighten an athlete’s risk of depression. Research indicates that injured athletes report significantly lower total and physical self-esteem than non-injured athletes (Green & Weinberg, 2001). From this understanding Green and Weinberg (2001) suggest that injury can lead to negative changes in how the athlete views themselves with regard to certain components of their self-esteem, such as physical self-efficacy and perceived physical confidence.

Overtraining/burnout

Athlete burnout is suggested to be one of the factors influencing depression in athletes (Lemyre, Hall, & Roberts, 2008). Burnout is the most extreme manifestation of overtraining (Appaneal, Levine, Perna, & Roh, 2009). Overtraining relates to prolonged fatigue and underperformance typically following a period of heavy training or competition (Budgett, 1990). Burnout is a syndrome that results from chronic increased physical activity and in turn mental stress resulting in reduced accomplishment, sport devaluation, and physical and emotional exhaustion (Cresswell & Eklund, 2004).

Physiologically the stress of training is a major factor in prolonged fatigue in athletes; this stress weakens immune function and produces increased vulnerability to infection (Budgett, 1990). Psychologically, burnout syndrome can impair all aspects of daily life for the athlete due to decreased concentration, increased anger, slowed mental functioning, and lower self-esteem (Hollander, Meyers, & LeUnes, 1995).

Hill, Hall, and Appleton (2010) suggest that socially prescribed perfectionism from individuals close within the athletes support network further increase their risk of burnout. A social-cognitive study conducted by Lemyre, Hall, and Roberts (2008) supported these findings, with results suggesting that maladaptive motivational thoughts and a want for perfectionism (as seen in Michelle’s case) were significantly associated with burnout.

Retirement

Retirement is suggested as a factor that can lead to depression in all individuals because the activity that the person once used to define themselves is no longer a defining characteristic (Green & Weinberg, 2001). Research suggests that retired athletes may no longer workout as often as they once had and this loss of peak physical condition is an associative factor for depression (Green & Weinberg, 2001). The transition for an athlete out of their career can be highly distressing, and marks a need for an identity change (Cosh, Crabb, & LeCouteur, 2013). Elite athletes' career lives are dedicated to sport, organized around competition and training, and are socially regulated (Cosh, Crabb, & LeCouteur, 2013).

Retirement requires a shift to independent management and life structure and research suggests that this leaves the athlete vulnerable to mental illness if they do not have the appropriate skills to cope with this change (Cosh, Crabb, & LeCouteur, 2013). There are three types of athletic retirement: retirement due to age, injury, or one that is actively chosen (as cited in Cosh, Crabb, & LeCouteur, 2013). Research suggests that retiring due to injury or age results in a conflict between internal desire to continue and external physical limitation (Cosh, Crabb, & LeCouteur, 2013). This conflict creates an unfavourable mental space for the athlete and is suggested as an influential factor for the development of depression. This explanation follows the same reasoning as to why injury leaves an athlete vulnerable to depression (see Injury) Suggesting that the individual perceives a loss in career which disallows them to pursue their self-defining activity (Green & Weinberg, 2001).

Lacking/loss of social support

Depression in athletes is more likely when there is perceived external pressures to succeed (Appaneal, Levine, Perna, & Roh, 2009). Literature suggests that socially prescribed perfectionism is closely correlated to depressive disorders (Stirling, & Kerr, 2014). Research indicates that expectations of perfectionism from the athletes' social network including coaches, other athletes, and significant others, correlates closely with mood state scores. In that the higher the level of expected perfectionism, the higher the level of negative mood state reported by the athlete (Stirling, & Kerr, 2014). Green and Weinberg (2001) conducted a study of athletes with injury that prohibited physical activity. The authors found that the higher an individual’s satisfaction with his/her social support networks, the less mood disturbance that s/he experienced (see Figure 3).

It has been found that athletes who report low levels of social connectedness report higher levels of psychological distress, including depression and low self-efficacy (Armstrong, & Oomen-Early, 2009). Specifically, the coach-athlete relationship has been suggested to be one of the most influential to the athlete’s mental function. The authority of the coach has been found to override the athlete’s ability to think critically about the relationship (Stirling, & Kerr, 2009). In situations where this power is abused, research suggests that this will negatively influence an athlete’s self-efficacious beliefs, emotionality, and general mood state (Stirling, & Kerr, 2009). This abuse of power is argued due the culture of elite sport, where athletic performance is prioritised above the interests and well-being of the athlete (Stirling, & Kerr, 2009).

Critical integration with theory

By relating these research findings to the theories discussed, we are able to generate an understanding of how to improve and even prevent depression in athletes. By following the theoretical underpinnings of positive psychology, which understand that physical activity has positive effects on both body and mind. CBT, which proposes that healthy cognitive functioning requires a positive and realistic view of one’s ability to achieve success and to recognise their failures. Finally, by following the concept of self-efficacy; which is the belief that a person has as to what they can successfully accomplish with their skills, practical and effective skills and strategies can be suggested to minimise the athlete’s risk of developing depression.

Conclusion

This chapter summarises the evidence of suggested factors that can lead to depression in athletes. It is important to address these significant factors as mental illness, specifically depression, is understood to impact heavily upon all aspects of daily life functioning. From the evidence found through the research and theoretical underpinnings discussed, some practical treatment options and skills to reduce, and even prevent depression in athletes are suggested and outlined in the box below.

Cognitive Behavioural Theory- Cognitive Restructuring: Interventions that educate the athlete with practical skills to cope with their negative emotions and thoughts through; Cognitive restructuring, behavioural experiments, and mindfulness techniques are found to restructure the individuals' cognitive processes to shape a more positive and realistic understanding of their strengths and weaknesses (Lindvall, & Moharer, 2011). Cognitive Behavioural Theory- Goal setting: Evidence suggests that encouraging task-based goals rather than outcome-based goals influence the athlete to seek challenge, put in effort and maintain high intrinsic interest and have an overall more positive emotionality towards their sport than if outcome-based goals are recommended (Hill, Hall,& Appleton, 2010). Social Cognitive Theory- Perfectionism: The strong correlation found between mood disturbance and socially prescribed perfectionism suggests that coaches should foster independence; encouraging athletes to set their own goals, and refrain from encouraging perfection, rather encourage progress. Cognitive behavioural coaching following CBT principles has been found to reduce perfectionist qualities in athletes (Kearns, Forbes & Gardiner, 2007). Social Cognitive Theory- Self-efficacy: Persuasive techniques which attempt to positively influence an athlete’s self-perception of efficacy including; verbal persuasion and feedback, positive self-talk and imagery and other cognitive strategies would be useful in attempt to improve an individual’s self-efficacy perceptions. Positive Psychology- Stress management: Chronic stress commonly indicated by elite level athletes is suggested as a highly influential factor for depression. Suggested stress management techniques include relaxation, self-affirmations and positive feedback (Storch et al., 2005). Positive Psychology- Mindfulness: Mindfulness is the acceptance of ones internal emotions, thoughts and sensations and focusing these in a non-judgemental way, which is suggested as an effective tool to address and understand negative congitive and mood states.

Quiz

Point added for a correct answer:
Points for an incorrect answer:
Ignore the questions' coefficients:

1 A depressive mood disorder is ?

	A enabling mental disorder that will increase all aspects of daily life
	A disabling mental disorder that can interfere with all aspects of daily life functioning
	When someone is sad around you, and that starts to depress you
	A mental disorder where someone is unplesant to be around

2 The most common expression of a depressive disorder is?

	MND
	MMD
	MMA
	MDD

3 The theory that argues that exercise increases one's self-confidence, provides a feeling of mastery, and can raise an individual’s overall outlook is ?

	CBT
	Positive Psychology
	Self-efficacy
	Social Cognitive Theory

4 It has been found that athletes who report high levels of social connectedness report higher levels of psychological distress. True, or false?

	False
	True

5 Following social cognitive theory, it is suggested that coaches should foster dependence; encouraging athletes to follow set goals. True, or false?

	True
	False

See also

• Depression and motivation (Book chapter, 2014)
• Exercise and mood (Book chapter, 2014)

References

American Psychiatric Association (2014). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition. American Psychiatric Association. Retrieved from http://www.psychiatry.org/dsm5

Appaneal, R., Levine, B., Perna, F. M., & Roh, J. L. (2009). Measuring Postinjury Depression Among Male and Female Competitive Athletes. Journal Of Sport & Exercise Psychology, 31(1), 60-76. doi: 10.1192/bjp.bp.111.095976

Armstrong, S., & Oomen-Early, J. (2009). Social Connectedness, Self-Esteem, and Depression Symptomatology Among Collegiate Athletes Versus Nonathletes. Journal Of American College Health, 57(5), 521-526. doi:10.3200/JACH.57.5.521-526

Barker-Ruchti, N., Barker, D., Lee, J., & Rynne, S. (2011). Preparing Olympic Athletes for Lives Outside of Elite Sport: Towards Best Practice [Research Grant]. IOC Postgraduate Research Grant 2011, 1-51. Retrieved from https://doc.rero.ch/record/28952/files/Barker-Ruchti_et_al_Final_Report_2011.pdf

Budgett, R. (1990). Overtraining syndrome. British Journal of Sports Medicine, 24(4), 231-236. Doi: 0306-3674/90/040231-06 Cosh, S., Crabb, S., & LeCouteur, A. (2013). Elite athletes and retirement: Identity, choice, and agency. Australian Journal of Psychology, 65(2), 89. DOI: 10.1111/j.1742-9536.2012.00060.x

Cresswell, S., & Eklund, R. (2004). The athlete burnout syndrome: Possible early signs. Journal Of Science And Medicine In Sport, 7(4), 481-487. Retrieved from ezproxy.canberra.edu.au

Feltz, D., & Lirgg, C. (2001). Self-efficacy beliefs of athletes, teams, and coaches. Handbook Of Sport Psychology, 2(2001), 340--361. Retrieved from http://www.upo.es/psicologiadeldeporte/doc/articulo_deborah_feltz.pdf

Ferrari, A. J., Somerville, A. J., Baxter, A. J., Norman, R., Patten, S. B., Vos, T., & Whiteford, H. A. (2013). Global variation in the prevalence and incidence of major depressive disorder: a systematic review of the epidemiological literature. Psychological medicine, 43(03), 471-481. Doi: 10.1017/S0033291712001511

Green, S. L., & Weinberg, R. S. (2001). Relationships among athletic identity, coping skills, social support, and the psychological impact of injury in recreational participants. Journal of Applied Sport Psychology, 13(1), 40-59. Retrieved from Taylor & Francis online.

Hill, A. P., Hall, H. K., & Appleton, P. R. (2010). Perfectionism and athlete burnout in junior elite athletes: The mediating role of coping tendencies. Anxiety, Stress, and Coping, 23(4), 415-430. doi:10.1080/10615800903330966 Hollander, D. B., Meyers, M. C., & LeUnes, A. (1995). Psychological factors associated with overtraining: Implications for youth sport coaches. Journal of Sport Behavior, 18(1), 3. Retrieved from SPORTDiscus with Full Text

Kearns, H., Forbes, A., & Gardiner, M. (2007). A cognitive behavioural coaching intervention for the treatment of perfectionism and self-handicapping in a nonclinical population. Behaviour Change, 24(03), 157-172. doi: http://dx.doi.org/10.1375/bech.24.3.157

Lemyre, P. N., Hall, H. K., & Roberts, G. C. (2008). A social cognitive approach to burnout in elite athletes. Scandinavian Journal Of Medicine & Science In Sports, 18(2), 221-234. DOI: 10.1111/j.1600-0838.2007.00671.x

Lindvall, S., & Moharer, A. (2011). Effects of an internet-based CBT programme on coactive elite athletes psychological skills: a randomized controlled study [Unpublished Thesis]. Umea University. Retrieved from http://www.diva-portal.org/smash/get/diva2:421467/FULLTEXT01.pdf

Mostafai, A. (2012). The Comparison between athlete women and non athlete women regarding to mental health and happiness. Annals of Biological research, 3(5), 2144-2147.

Salehian, M., Gursoy, R., Aftabi, G., & Taghizadeh, M. (2012). Comparison of depression between university athletes and non-athletes. European Journal Of Experimental Biology, 2(4), 1008--1011. Retrieved from scholarsresearchlibrary.com Stirling, A. E., & Kerr, G. A. (2009). Abused athletes' perceptions of the coach-athlete relationship. Sport in Society, 12(2), 227-239. doi:10.1080/17430430802591019

Stirling, A., & Kerr, G. (2014). Athletic Insight - Perfectionism and Mood States among Recreational and Elite Athletes. Athleticinsight.com. Retrieved from http://www.athleticinsight.com/Vol8Iss4/Perfectionism.htm

Storch, E., Storch, J., Killiany, E., & Roberti, J. (2005). Self-reported psychopathology in athletes: A comparison of intercollegiate student-athletes and non-athletes. Journal of Sport Behavior, 28(1), 86.

Weigand, S., Cohen, J., & Merenstein, D. (2013). Susceptibility for depression in current and retired student athletes. Sports Health, 5(3), 263-266. doi:10.1177/1941738113480464

Yavuz, H., & Oktem, F. (2012). The relationship between depression, anxiety and visual reaction times in athletes. Biology of sport, 29(3), 205-209. doi:10.5604/20831862.1003444

External links

• VIDEO: Grant Hackett Discusses - Athletes vulnerable to Depression
• ARTICLE: Setting the bar: athletes and vulnerability to mental illness
• Q+A: Ian Thorpe's Battle with Depression