Depression and Associated Negative Stressors: The Collegiate Athlete vs. Non-Athlete
Tabitha A. Maurer & Dr. Joni L. Cramer Roh*
California University of Pennsylvania
Depression is a major medical concern among college students, and has recently become a crucial component in assessing and treating athletic-related injuries. The purpose of this literature review is to evaluate the current literature whether athletes or non-athletes experienced more depression symptoms, and what negative stressors lead to depression. The current research demonstrates that student-athletes suffer more psychological problems (anxiety, fear of failure in competition, lack of sleep, alcohol use and abuse, disordered eating, overtraining, and feelings of exhaustion) than their non-athlete peers due to the combination of stressful athletic and academic schedules. Female athletes, and athletes following a severe injury, had significantly higher levels of depression, yet athletes overall had a lower incidence of depression when compared to non-athletes.
College is a four year passage to strategize the rest of one's adult life. These four years are filled with both positive and negative influences that students must face while obtaining a degree to prepare for a desired profession. Unfortunately, mental disorders frequently develop in response to the amount of stress being placed upon the student, and the inability to properly cope with that stress. Depressive disorders are the most prevalent psychological disorder. Around 17.7 % of the population will acquire this condition at a period in their life, and depression is the leading cause of a disabled life following participation in athletics (Hammond, Gialloreto, Kubas, & Davis, 2013; Yang et al., 2007).
Academics alone are rigorous, but athletics participation can add a great deal of stress. Some stressors in the collegiate athlete's life are physical and psychological in nature and include: managing academics, maintaining health, recovering from injury, coping with success, managing performance expectations, anxiety, failure in competition, alcohol use and abuse, disordered eating, overtraining, lack of sleep, and feelings of exhaustion (Armstrong & Oomen-Early, 2009; Hammond et al., 2013). If this stress is negative, it may lead to the development of depression symptoms, including: decreased motivation, decreased interest in once enjoyable activities (anhedonia), low energy, loss of pleasure, impaired concentration, changes in sleep and/or appetite, and feelings of worthlessness and hopelessness (APA, 2000).
Depression is a major medical concern on college campuses (Armstrong & Oomen-Early, 2009). Involvement with athletics, along with accompanying athletic injuries, intensifies negative stressors in the lives of student-athletes. These additional negative stressors increase the risk of developing depression symptoms in the collegiate athlete when compared to collegiate non-athletes. Collegiate athletes have a higher tendency to develop this mood disorder as a result of negative stressors impacting them daily due to the combination of academics and athletics (Proctor & Boan-Lenzo, 2010).
Both psychological well-being and mental disorders have become topics of increasing public and scientific interest, but previously collected data on the matter is flawed (Nixdorf, Hautzinger, & Beckmann, 2013; Weigand, Cohen, Merenstein, 2013). Therefore, more research needs to be performed comparing collegiate student-athletes to non-athletes to better aid in caring for the psychological well-being of both populations. The purpose of this research paper is to review the current literature on depression among college students and college student-athletes.
Statement of the Problem
Depression is a disabling mental disorder that has the ability to affect both collegiate athletes and non-athletes. However, it is a commonly avoided topic in sports due to the negative stigma surrounding it, along with a lack of training to understand and treat this mental illness (Weigand et al., 2013). The purpose of this research is to determine whether athletes or non-athletes experience more depression symptoms, and to identify the negative stressors that lead to depression.
Depression can be a severely disabling mental illness that presents with alarming symptoms that interfere with activities of daily living. These symptoms include, but are not limited to: sadness, anger, and anhedonia (APA, 2000; Weigand, et al., 2013). Common causes for depression include: brain chemistry, personality variables, social relations, cognitive processes, and behavior patterns (Nieuwsma & Pepper, 2010). The two categories of etiological explanations for the development of mental illnesses are biological and psychosocial. Biological explanations include genetics and neurotransmitter concentrations, and the psychosocial category references the individual's past experience, relationships, current situation, thoughts, feelings, and behavior (Nieuwsma & Pepper, 2010).
Cognitive behavioral stress management (CBSM) is a well-known treatment in decreasing fatigue, depression, and cortisol levels due to heavy exercise training (Perna, Antoni, Baum, Gordon, & Schneiderman, 2003). Similar in treatment, CBSM is used to treat depression as well as orthopedic surgery recovery. In both instances, participants find significant declines in illness and injury rates. Cognitive behavioral stress management alters both behavioral and psychological effects, which in turn speeds up skeletal muscle recovery and shortens the amount of time the athlete is unable to participate in sport. Perna et al. (2003) found that cortisol levels are not affected by intervention-induced effects, but rather by negative effects, thus allowing decreased illness and injury rates.
Adding to the merit of cognitive behavioral stress management as a treatment for depression of athletes by Perna et al. (2003), Maddison & Prapavessis (2005) found CBSM intervention to be successful in decreasing the number of athletic injuries with at-risk psychological profiles. These profiles include depression, anxiety, and other psychological disorders frequently found on a college campus.
Other common interventions for treating depression include cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT). These are both considered evidence-based treatments (EBTs). Cognitive-based therapy works by aiding the individual to learn application skills useful in situations where they will be on their own (Lusk & Melnyk, 2013). Overall, cognitive behavioral therapy instructs patients, in a safe environmentto identify, evaluate, and respond to their psychologically dysfunctional views in ways that can be later used when they are on their own. For example, deep breathing is a coping skill taught in CBT as an intervention when feeling overcome with depression symptoms. Lusk et al. (2013) found that CBT is a very straightforward and successful approach in treating depression and anxiety in teens.
Interpersonal therapy (IPT) focuses one clinician showing the patient that their depression feelings of self-blame, hopelessness, and dependency are, in fact, caused by the disease as opposed to reality-based (Bernecker, Constantino, Pazzaglia, Ravitz, & McBride, 2014). Patient functioning was shown as improving once exposed to IPT both interpersonally and cognitively, and patients also experienced a decreased dyadic adjustment. Minorities, specifically African Americans, have been shown to respond effectively to IPT treatment for depression (Kalibatseva & Leong, 2014).
Specific to athletes, the way treatment methods are handled by professionals can vary significantly due to the patient's athletic mindset (Maniar, Curry, Sommers-Flanagan, & Walsh, 2001). The lifestyle of an athlete is different from that of a non-athlete, and therefore so is their mentality of psychological treatment. For example, an athlete has been shown to be more adaptive to treatment of depression if they are referred to a sport psychologist with a title such as "performance enhancement specialist". Furthermore, treatments that are simpler to understand and better explained should be preferred over the complex, and a psychologist who is empathetic to an athletic lifestyle will provide positive results.
Two approaches have been shown to aid in preventing depression: the population approach and the high-risk approach (Hardy, 2013). The population approach focuses on the risk factors affecting an entire population, whereas the high-risk approach identifies and treats individuals at a high-risk of developing depression. It is shown that those with diabetes and those with coronary heart disease are at a high-risk for succumbing to depression. Once the high-risk patient has been treated for depression, a further prevention measure will be enacted in order to reduce the effect of the condition on patient function and overall quality of life. Due to the extreme impact these diseases have on the lives of the affected patients, treatment for depression focuses on living day-by-day with the disorder, and on coping with the physiological disease.
Exercise is also an established method of preventing or reducing the formation of depression symptoms. The frequency of exercise, rather than the duration and intensity should be the target focus in increasing positive mood outcomes (Craft & Perna, 2004). Exercise is an effective antidepressant, regardless of a clinic-based or home-based exercise intervention plan implementation (Craft, Freund, Culpepper, & Perna, 2007)
Overall, female athletes have higher depression scores when compared with both male athletes and non-athletes (Appaneal, Levine, Perna, & Roh, 2009; Nixdorf et al., 2013; Storch, Storch, Killiany, & Roberti, 2005). This is also true of females and depression scores regardless of injury status. Female athletes reported greater mean scores on measures of social anxiety and depression symptoms, but lower mean scores on levels of social support in contrast to male athletes and both male and female non-athletes (Storch et al., 2005). According to Dishman, et al. (2006), physical activity and sport participation might reduce depression risk among adolescent girls. Thus, explaining the aforementioned results. Physical activity creates a positive influence on physical self-concept, separate from fitness, body mass index, and perception of sports competence, body fat, and appearance (Dishman et al., 2006).
The Collegiate Student-Athlete
There are abundant advantages to being involved in competitive athletics while enrolled in college. These positive benefits include feelings of improved self-esteem and overall general mental health (Proctor & Boan-Lenzo, 2010). Furthermore, athletes have been shown to have decreased levels of social anxiety, neuroticism, and stress. Additional advantages include accessibility of academic support services and some form(s) of medical care. Specifically, cross-sectional studies show that people who are physically active are 3 times less likely to suffer from depression than are inactive individuals, leading to the conclusion that depressive symptoms decrease with increasing levels of physical activity (Armstrong & Oomen-Early, 2009; Craft et al., 2007; Craft & Perna, 2004).
Psychologically speaking, a rise in exercise increases serotonin levels in the brain, therefore increasing the individual's overall mood. Athletic participation also provides an immediate outlet for release, which is useful after a stressful day/week (Proctor & Boan-Lenzo, 2010). Additionally, athletes on a structured team have a much more readily available social support network when compared with non-athletes. Furthermore, athletic participation on an intercollegiate sports team is directly related to lower levels of depression (Proctor & Boan-Lenzo, 2010).
However, academics combined with athletics can be demanding, and are often accompanied by emotional stress. Some stressors in the collegiate athlete's life include: managing academics, maintaining health, recovering from injury, coping with success, managing performance expectations, anxiety, failure in competition, alcohol use and abuse, disordered eating, overtraining, lack of sleep, and feelings of exhaustion (Armstrong & Oomen-Early, 2009; Hammond et al., 2013). These are all situations that athletes competing at the collegiate level will face, and hopefully be able to overcome. If this stress is negative, it may lead to the development of depression symptoms.
Injurys been shown to play a large role in the development of depression symptoms in the collegiate athlete. Around 40%-50% of collegiate athletes sustain at least one athletic injury that results in one or more sessions of time loss during their years of eligibility. The seclusion from one's team following an athletic injury adds additional negative stressors, such as psychological disturbance that can evoke anger, depression, anxiety, or a decrease in self-esteem (Yang et al., 2007).
Although research shows that exercise and participation in sports can be positive for mental health (Craft et al., 2008; Craft & Perna, 2004; Dishman et al., 2006), there is nearly a 50% chance that one can become injured, and once one is injured there is a greater likelihood of developing depression symptoms (Appaneal et al., 2009; Newcomer & Penna, 2003; Roh & Perna, 2000; Yang et al., 2009). Furthermore, the more severe the injury the higher the levels of depression (Appaneal et al., 2009),he longer the depression lingers (Roh & Perna, 2000).
Proctor and Boan-Lenzo (2010) reported a higher prevalence of depression symptoms in intercollegiate non-athletes when compared to athletes. The data collected showed a 15.6% risk of athletes developing major depressive disorder, and 29.4% risk for non-athletes. In contrast, Armstrong and Oomen-Early (2009) concluded that athletes had significantly greater levels of self-esteem and social connectedness, along with lower levels of depression when compared to non-athletes. Statistically, the strongest predictors of depression were gender, self-esteem, social connectedness, and sleep. Roh and Perna's (2000) evidence suggests that depressive distress has an association with athletics post-injury, and also that this distress may linger after physical recovery has finished. In comparison, research indicates that there is as much as a 40% decrease in healing following injury when there are elevated levels of stress (Kiecolt-Glaser, Page, Marucha, MacCallum, Glaser; Marucha, Kiecolt-Glaser, & Favagehi, 1998). Although these findings were not specific to college athletes with injuries, they can be compared to students exposed to stress prior to taking an exam. (Kiecolt-Glaser, Page, Marucha, MacCallum, Glaser, 1998; Marucha, Kiecolt-Glaser, Favagehi, 1998). Specific to high school and college athletes, Newcomer and Penna (2003) identified intrusive thoughts and avoidance behaviors as lingering depressive symptoms among injured college athletes.
It was noted by Appaneal et al. (2009) that self-rated depression symptoms in student-athletes ages 14-24 years old differed when compared to clinician-based ratings in both males and females. For example, Appaneal et al. (2009) found that the clinician interview detected the direct elevation in depression symptoms following a severe sport injury, lasting up to one month, that was not detected by the paper and pencil self-rated depression checklist. In regards to stress, increased intensities of chronic stress foreshadow a high level of acute stress (Hammen, Kim, Eberhart, & Brennan, 2009). These results show a trend in the effects of chronic stress in the stress-depression relationship, and should be taken into account when surveying for a depression diagnosis.
O'Hara, Armeli, Boynton, Tennen, and Farmington (2014) evaluated the data using a correlation between a history of depression and strong stress-reactivity in college non-athlete students. Out of 1,549 participants, the researchers found 18% with remitted depression and 13% with recent depression. Students with a history of depression did have increased levels of stress-reactivity when compared to those without a history of depression. However, it is important to note that there was no significant difference between recent and recurrent depression and stress-reactivity levels.
There have been studies previously performed on collegiate athletes regarding depression symptoms, but this data has brought forth contrasting results, as viewed in the above sections. Based on the negative stigma surrounding the term "depression," the illness often goes underdiagnosed in college athletes who attempt to ignore or even cover up the problem (Weigand et al., 2013). The intercollegiate atmosphere may also be an influence in the underreporting of symptoms. Athletes have an opportunity to reach the intercollegiate level, and achieve success (Proctor & Boan-Lenzo, 2010). However, appropriate terminology and empathy given to athletes are more likely to treat this illness when presented and reported to a mental health professional (Maniar et al., 2001).
As previously mentioned, depression is a disabling mental disorder (APA, 2000; Weigand et al., 2013). This mental disorder has the ability to affect both collegiate athletes and non-athletes (Armstrong & Oomen-Early, 2009; Proctor & Boan-Lenzo, 2010; Storch et al., 2005; Weigand et al., 2013).Psychological well-being and mental disorders have become topics of increasing public and scientific interest (Appaneal et al., 2009; Newcomer & Penna, 2003; Roh & Perna, 2000; Nixdorf et al., 2013). Overall, research performed on adjustment to college concluded that college students' physical and psychological states declined within a year following admittance into the university (Proctor & Boan-Lenzo, 2010). This is regardless of athletic participation.
The purpose of this research was to determine whether student-athletes or non-athletes experience more depression symptoms, and what negative stressors lead to the conclusion. Student-athletes on average have been found to experience more psychological problems than their non-athlete peers due to the combination of stressful athletic and academic schedules, yet have a lower percentage of depression (Armstrong & Oomen-Early, 2009; Storch et al., 2005). The problematic area with this is that athletes greatly underutilize school counseling and mental health services (Storch et al., 2005). Therefore, more research needs to be performed comparing both collegiate athletes and non-athletes in order to better aid in caring for the psychological well-being of the student-athlete.
Due to the lack of epidemiological data on the mental health status of collegiate student-athletes, it is difficult to set up mental health interventions (Yang et al., 2007). Without current and non-contrasting research results on depression in collegiate athletics, a protocol to handle situations with such a negative stigma surrounding it cannot be put into place (Maniar et al., 2001). An increase in consistent research on depression in collegiate athletes will enable counseling services to be put in place, and more easily accessible to all student-athletes.
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