Depression/Suicide: Athletes are not Immune Leonard Zaichkowsky, - - PowerPoint PPT Presentation

Depression/Suicide: Athletes are not Immune

Leonard Zaichkowsky, PhD Frank Perna, Ed.D, Ph.D Boston University & John Sullivan, PsyD University of Rhode Island

What is depression?

• Depressed mood
• Diminished interest or pleasure in most activities most of the time
• Significance weight loss or weight gain or decrease or increase in appetite
• Sleep disturbances
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness or excessive guilt
• Diminished ability to concentrate
• Recurrent thoughts of death or suicide ideation

Prevalence of symptoms

At least five of the symptoms must be

present during a two-week period

At least one symptom must be either

– Depressed mood – Loss on interest or pleasure

Depression in the community: Some Stats

The lifetime prevalence risk for major depressive

disorder in the community it estimated to be 17%

– 21% Females – 13% Males – Nearly 2x for females

Only half of subjects suffering from depression

seek treatment, and out of these only one half get a correct diagnosis

Depression and adolescents: More Stats

Approximately one-third of adolescents who go to

a mental health clinic suffer from depression. (Fleming, Boyle, & Offord, 1993)

Depression is more common in the adolescent

years than the elementary years

By age 15, adolescent girls have a rate of

depression that is twice that of males

Athletes vs. Non-Athletes

What do we know?

Some Publicized Cases

Terry Bradshaw Picabo Street Barret Robbins (bipolar disorder) Mike Tyson Jimmy Piersall Pat LaFontaine Pete Harnisch Vin Baker Jim Shea

Heredity & Stress

The big predictors of depression The “stress” of injury

Clinical Depressive Disorders

DSM-IV Diagnostic Categories Symptom Criteria Injured vs. Non-injured

Depressed Mood X Major Depressive Episode Anhedonia X Loss of Appetite/Weight Depressive Disorder NOS Impaired Sleep X Psychomotor Disturbance X Fatigue/Energy Loss Differential Diagnosis: Guilt/Worthlessness Adjustment Disorder Impaired Concentration Suicidal Ideation Anxiety/Hypochondriasis X

Athletic Injury

?

Psychological Stress

Psychological Stress Injury

How does this happen? (Mechanisms)

– Cognitive: Peripheral Narrowing – Physiological: Neuroendocrine Response

Immunosuppression “Window of Susceptibility”

Health & Healing Implications

PSYCHOLOGICAL DISTRESS NEGATIVE AFFECT COGNITION

Worry Attention

BEHAVIOR

Sleep Self Medication Coping Strategy

NEUROENDOCRINE RESPONSE

Catecholamines Cortisol & ACTH Neuropeptides

IMMUNE SYSTEM Immune Cells Cytokines Post-operative Infection MUSCLE REPAIR WOUND HEALING

Blood Flow Satellite Cells IL-I & IL-II Growth Hormone

Injury Psychological Stress

Cognitive-Affective Responses

– Negative Affect – Clinical Depression – Posttraumatic Distress *

Behavioral Responses

– Rehabilitation Noncompliance – Posttraumatic Distress *

Physiological Responses

– Heightened ANS activation – Posttraumatic Distress *

Negative Affect: Depressed Mood

3 6 9 12

1-Week 1-Month POMS-D

Injured Non-injured

Clinical Depression

5 10 15 20 25

1Week 1 Month %

Injured Non-Injured

FYI: Post-Injury Psychological Distress

Negative Affect (Smith et al, 1990)

– Depression/Anger * – Tension, Fatigue, and Confusion

Depressed Mood (Roh et al., 1998)

– Significant elevation from pre- to post-injury – Greater among injured vs. non-injured athletes

at 1-week & 1-month post-injury

FYI: Post-Injury Psychological Distress

Clinical Depression (Perna et al., 1998; Brewer et al., 1995)

– Injured (26%) vs. non-injured (4.4%) athletes

at 1-week post-injury

– Symptom endorsement (Newcomer et al, 1999)

Depressed mood, Anhedonia, Insomnia (early/late),

Psychomotor agitation, Anxiety, & Hypochondriasis

Intrusive Thoughts (Newcomer et al, 1998)

– Elevated at 1-week & 1-month post-injury – Remain elevated after physical recovery – Scores comparable to other trauma populations

(e.g., MVAs)

Implications: “So What?”

Physiological

Delayed surgical recovery Post-operative infections Delayed Wound Healing Decreased pain tolerance

Behavioral

Increased Self Medication Disrupted Sleep Quality Loss of /Change in Appetite Impaired Social/Occup. Fx

(Anhedonia)

Rehabilitation Noncompliance

Indications of Psychological Distress

Prior History of Stress & Coping: E.g.,

– Negative Life Events – Chronic a/o Recurring Problems – Change in Self-esteem a/o Significant Relationships – Maladaptive Coping Behaviors

Current Symptoms (intensity & duration): E.g.,

– Depression a/o Intrusive Thoughts – Sleep a/o Appetite Disruptions – Diffuse Pain Reports a/o Physical Complaints

Your Observations: E.g.,

– Changes in Usual Patterns of Behavior – Unable to Focus or Follow Instructions – Improper Medication Use

What to do...

Assessment

– Observation – Communication

Evaluation

– Severity – Duration

Referral

– Established Resources – Collaboration

Assessment Areas

Psychological Symptoms

–

Depressed mood (irritability, argumentative, etc.)

–

Difficulty thinking, concentrating, or making decisions

–

Decrease social interactions (anhedonia)

–

Intrusive thoughts (avoidance behavior)

–

Feelings of worthlessness, guilt, hopelessness

–

Recurrent thoughts of death a/o suicidal ideation, plans, or attempt Physical Symptoms

–

Changes in sleep quality & appetite

–

Changes in psychomotor activity

–

Pain tolerance Coping & Social Support

Sample Questions

Depression

– How has this injury affected you emotionally? – How have you been sleeping? (probe: sleep onset, early

morning awakenings, get up a lot in the middle of the night)

– What have you been doing during the day? (probe: going to

class, studying, hang out with your friends)

– Have you been irritable or tense? (probe: edgy, fights with

roommate, teacher, significant others, family members)

– Have you been able to concentrate or remember things?

(probe: focus)

Sample Questions

Intrusive Thought & Avoidance Behavior:

– Have you thought about your injury when you didn’t mean to?

(probe: thought suppression or flooded with thoughts, dreams, nightmares)

– Have you avoided talking about your injury? (probe: staying away

from reminders)

Social Support & Coping:

– Is there anyone that you can confide in about how you’ve been

feeling? (note: access and utilization of social support)

– Have you talked to anyone about your emotional reaction (e.g. fears)

to this injury? (note: quality of emotional expression, satisfaction)

– Have you noticed a change in the frequency or intensity of your

drinking? (note: inquire about other substances)

Therapeutic Interventions

Providing a Supportive Environment

– Communication Behaviors

Changes in Cognitive-Appraisals

– Primary (threat): How bad is this? – Secondary (coping): How will I deal with this?

Goal Setting

– Collaborative, Realistic, Specific, Re-evaluation

Physical Conditioning

– Maintenance of Physical Functioning – Stress-buffering Effects of Exercise

Effects of Psychological Interventions

Decreased incidence of injury/illness Decreased pre- & post-injury emotional distress Decreased post-injury pain Improvement on tests of physical functioning

(e.g., CYBEX strength)

Faster return to competition

Selected References

• American Psychiatric Association (1994) Diagnostic and Statistical Manual for Mental Disorders (DSM-IV), American Psychiatric Association, Washington,

D.C.

• Angst, J., Gamma, A., Gastpar, M., Lepine, J., Mendlewicz, J., Tylee, A., Gender Differences in depression. European Psychiatry Clinical Neuroscience,

(2001) 252:201-209.

• Farmer, M., Locke, B., Moscicki, E., Dannenberg, A., Larson, D., Radloff, L., Physical Activity and depressive symptoms: The NHANES I Epidemiologic

Follow up study. American Journal off Epidemiology. 1988, 128:1340

• Fleming, J.E.; Boyle, M.; & Offord, D.R.; The outcome of adolescent depression in the Ontario child health study follow up. Journal of the American

Academy of Child and Adolescent Psychiatry, 32, 28-29.

• Gore, S., Farrell, F., Gordon, J., Sports Involvement as protection against depressed mood. Journal of Research on Adolescence, 11(1), 119-130. 2001
• McCann, I., Holmes, D., Influence of Aerobic Exercise on Depression. Journal of Personality and Social Psychology, 1984, Vol. 46. No. 5, 1142-1147.
• NIMH: National Institute of Mental Health (2000). Depression research at the National Institutes of Mental Health. Publication no. 00 – 4501. Accessed on

June 23 2006 from http://www.nimh.nih.gov/publicat/depresfact.cfm.

• NIMH: National Institute of Mental Health (2001). The invisible disease: Depression. Publication no. 01 – 4591. Accessed on June 23 2006 from

http://www.nimh.nih.gov/publicat/invisible.cfm.

• Patten, C., Choi, S., Vickers, K., Pierce, J.; Persistence of depressive Symptoms in Adolescents. Neuropsychopharmacology 2001 Vol. 25, no. s5
• Perna, F. M., Ahlgren, R. L. & Zaichkowsky, L. (1999). The influence of career planning, race, and athletic injury on life satisfaction among recently retired

collegiate male athletes. The Sport Psychologist, 13(2), 144-157.

• Wyshak, G., Women’s College Physical Activity and Self-Reports of Physician-Diagnosed Depression and of Current Symptoms of Psychiatric Distress.

Journal of Women’s Health & Gender based medicine. Vol. 10, No. 4, 2001.

• Maton, K., Meaningful involvement in instrumental activity and well being. American Journal of Community Psychology, 18. 297-320