Mood Disorders

The main mood disorders are major depressive disorder (MDD) and bipolar disorder. MDD is a period of at least 2 weeks during which there is either depressed mood or the loss of interest or pleasure in nearly all activities, accompanied by other symptoms such as insomnia and changes in appetite, energy and concentration. Any of three possible relationships between athletics and, in this case, the psychiatric disorder of depression could exist in depressed athletes. That is, athletes’ depression might have nothing to do with their athletic pursuits or the athletic pursuits could be their way of coping with depression, or it even could be caused by athletic participation.

These possibilities have not been studied per se. However, in the only textbook on sport psychiatry, Burton’ (…) concluded from the few epidemiological studies published that athletes experience psychiatric disorders, including mood disorders, at the same rate as the general population. The specific frequency of depression in athletic populations has been studied at a number of levels. At the high school level. Oler et al.(…) reported that athletic participation was a marker for decreased likelihood of depression and suicidal ideation. At the college level, Yang et al. .(…) studied 257 division 1 college athletes and found that athletes showed the same frequency of depressive symptoms as did a comparison group. However, athletes who were female, freshmen or who had pain were more likely to endorse depression.

Puffer and McShane’ .(…)  asserted that college athletes were generally well adjusted, and that overtraining (OT) seemed to be the most common cause of depression in this population. Donohue et al. .(…) compared 72 National Collegiate Athletic Association (NCAA) athletes and 64 recreational athletes at one university with data previously collected on 435 control students at another university. They found no difference in psychiatric symptoms, including those of depression, between the recreational and NCAA athletes, and between all athletes and the controls. We did not find any data in the literature on the prevalence of mood disorders in elite athletes.

Subtypes of depression (e.g. with seasonal onset, with melancholic or atypical features) in athletes have been little studied. Rosen et al. .(…) offered the only such study in their report of 68 division 1 college hockey players from the northern US. Eleven percent met criteria for seasonal affective disorder (SAD) and 39% exhibited subclinical seasonal affective disorders. While the 11% with SAD approximated the national average in northern latitudes, 39% exceeded the 13% average for the general population in northern latitudes. .(…)

While depression overall may be no more likely in athletes than non-athletes, when it does occur, précipitants may include OT, injury, competitive failure, aging, retirement from sport and the same psychosocial Stressors that can precipitate depression within the general population. OT in particular may either induce or be symptomatic of depression.(…) Indeed, it can be difficult to distinguish OT from primary MDD. Similarities between the two include fatigue, insomnia, appetite change, weight loss, amotivation and diminished concentration. .(…)

Armstrong and VanHeest’s .(…)  review showed that symptoms of OT appeared in >60% of distance runners during their athletic careers, >50% of professional soccer players during a 5-month competitive season and 33% of basketball players during a 6-week training camp. Morgan et al. .(…) studied 400 competitive collegiate swimmers over 11 years and found that mood-state disturbance increased in a dose-response manner as the training stimulus increased during the season, and then fell to baseline with reduction of training load.

Schwenk .(…) argued that there is a tendency for the same symptoms diagnosed as MDD in the average primary care patient to be diagnosed as OT in athletes, and that this was related to stigmatization of mental illness in athletes. He asserted that the two should not be distinguished, as there are numerous physiological similarities. Ultimately, he suggested that the primary difference between MDD and OT is the nature of the role dysfunction: athletic performance versus social, cognitive and work performance. On the other hand, evidence for the two being distinct conditions includes that some physiological symptoms of OT are not present in MDD. For example, athletes with OT often exhibit elevated heart rate and blood pressure, muscle soreness and changes in serum hormone levels. Moreover, in OT, a cessation of training often yields an improvement in mood, whereas depressed athletes who do not train or exercise often seem to experience worsened depressive symptoms.

Anecdotally, the transition to retirement seems to be a high-risk time for emotional distress in athletes. Parham’.(…) offered data on this in his study of college athletes and concluded that three factors predicted the degree of emotional distress experienced by athletes upon retirement from sport:

• extent of psychological attachment to sport;
• degree of devotion to sport to the exclusion of other activities; and (iii) level of success in sport.

There have been at least two reports on depression in former elite athletes during the years after retirement. Backmand et al.(…) studied 664 former eUte athletes and 500 controls and found that the best predictor of post-retirement depression was a low level of current physical activity. Schwenk et al. .(…) sent a survey to 3377 retired National Football League (NFL) players, with 14.7% of the 1617 respondents reporting moderate to severe depression and 47.6% reporting ‘quite’ or ‘very common’ difficulty with physical pain. The authors concluded that the level of depressive symptoms was similar to the general population but the impact of the symptoms was exacerbated by high levels of pain. They hypothesized that high levels of chronic pain with which many players leave the NFL (or other sports) contributed to a predisposition to depression.

Bipolar Disorder

Bipolar disorder is a mood disorder characterized by manic episodes consisting of an abnormally and persistently elevated, expansive or irritable mood, usually occurring separate from and in addition to episodes of major depression. In contrast to unipolar depression, very little has been written about bipolar disorder in athletes, with no known prevalence data.

Suicide

Suicide is a concern when considering mood disorders in any population. Baum’^^l reviewed the medical literature from 1960 to 2000 and the periodical literature from 1980 to 2000. She identified 71 cases of athletes who contemplated, attempted or completed suicide, including 66 completed suicides. This study had an obvious bias of anecdotal  reporting but may be informative nonetheless. The average age of the 71 cases was 22, including 61 men and 10 women. The rank order of sports from most to least suicides reported included football, basketball, swimming, track and field, and baseball. Risk factors included substance abuse, post-retirement, eating disorders, anabolic steroid use, family history of suicide, homosexuality and sexual abuse (including sexual abuse by coaches).

Smith and Milliner .(…) reported that, based on five cases of injured athletes who attempted suicide, risk factors in injured athletes may include success in sport pre-injury, injury requiring surgery, a lengthy rehabilitation process restricting athletic participation from 6 weeks to 1 year, inability to recapture pre-injury success, post-concussive syndrome and replacement by team mates. They note that the Emotional Responses of Athletes to Injury Questionnaire’.(…) can be administered to injured athletes to identify those who might be at risk for suicidal behaviour. Begel’ .(…) hypothesized that the catecholamine and endogenous opioid systems may be downregulated after athletic injury, thereby contributing to the dysphoria that commonly occurs following injury.