Sports Medicine Research: In the Lab & In the Field: Many NCAA Clinicians Fail to Screen Mental Health (Sports Med Res)

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Monday, June 6, 2016

Many NCAA Clinicians Fail to Screen Mental Health

Variability in Institutional Screening Practices Related to Collegiate Student-Athlete Mental Health

Kroshus E. J Athl Train. 2016;51(5): ahead of print

Take Home Message: Only 39% of respondents indicated that they had a written mental health screening plan. There is a wide variability between mental health screening practices among NCAA institutions.

An athlete’s psychological response to injury or performance pressure may precipitate or exacerbate mental health vulnerabilities. The preparticipation examination (PPE) is an important opportunity to recognize health conditions, such as mental heath concerns, prior to the sport season. Unfortunately, we have no information about whether collegiate institutions are engaging in mental health screening or how they vary between institutions. Therefore, the author distributed a survey to 1076 NCAA supervising sport medicine clinicians to assess whether NCAA sports medicine departments have policies to identify student-athletes with mental health concerns and how these were instituted. A total of 365 clinicians (307 head athletic trainers, 54 physicians, 4 did not report credentials) completed a survey with 4 parts: sports medicine department policy, preparticipation screening, screening initiatives, and institutional characteristics. Only 39% of institutions had a written plan for identifying student-athletes with mental health concerns. Almost one-third of respondents (32%) failed to screen for any of the 6 mental health concerns (eating disorder, depression, anxiety, alcohol abuse, prescription drug abuse, illegal drug abuse). Only 20% of the respondents screened for all 6 mental heath concerns. Many of the respondents indicated that the PPE screened for history of diagnosis for eating disorders (85%), depression (79%), and anxiety (76%). However, less reported using specific screening instruments for symptoms of eating disorders (45%), depression (32%), anxiety (31%), alcohol abuse (57%), prescription drug abuse (52%), and illegal drug abuse (47%). A higher proportion of Division I institutions screened for eating disorders, depression, anxiety, and illegal drug abuse compared to Divisions II and III institutions.

Screening athletes for mental health issues could help limit their health burden, and negative effects on athletic performance. It was alarming to note that 32% of respondents failed to assess any of the 6 primary mental health concerns. The NATA PPE position statement contains 8 questions that broadly assess psychosocial functioning; however, the reliability and validity of these questions for screening for mental health concerns needs to be evaluated. Only 39% of the sports medicine professional respondents noted that they have a written plan for identifying student-athletes with mental health concerns. Division I institutions were more than twice as likely to have a policy than other institutions. This study is important since it highlights the need for more mental health screens among collegiate institutions, which could help improve health outcomes, understand athletes coping strategies, and enable referral of athletes for appropriate care. Screening for mental health vulnerabilities during the PPE seems like a viable opportunity to screen athletes for mental health concerns. Future research needs to be established in validating a screening instrument for use during the PPE, or we need to consult more frequently with  medical professionals who are skilled and trained to use currently established mental screening tools (e.g., sport psychologist).

Questions for Discussion: Do you screen for mental health? Do you think screening for mental health problems could improve health outcomes or coping strategies for patients later?

Written by: Jane McDevitt, PhD
Reviewed by: Jeff Driban

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Kroshus E (2016). Variability in Institutional Screening Practices Related to Collegiate Student-Athlete Mental Health. Journal of Athletic Training PMID: 27111587

9 comments:

EG said...

Having worked in a variety of settings, this article is spot on about mental health concerns. I think some settings have a way to identify them, but have no idea of how to handle it. Mental health concerns are a growing area in sports medicine, especially in the collegiate setting. Student-athletes with mental health conditions are less likely to ask for help than regular students; perhaps if we screened for this, we would be able to get them the health they need before the condition worsens. The NATA needs to come up with a way to screen for all of this; it would be completely reasonable to add this tool into PPEs.

Aleah Kirsch said...

Screening for mental health concerns is a topic that I think is overlooked more often than not. Based on my personal experience at the collegiate setting, I came in contact with some sports that took mental health very seriously and others that did not. I believe that it is extremely important to do so during PPEs. As a clinician I think it is vital that the athlete as a whole, meaning mind and body, are healthy. The statistics that were presented in this article are alarming. Only 20% of all respondents screened for all 6 mental concerns (eating disorder, depression, anxiety, alcohol abuse, prescription drug abuse, and illegal drug abuse) and 32% of respondents didn’t do any screenings. I think that if athletes were screened more thoroughly then they would have improved health outcomes. I think this because the clinician would better know how what helps each athlete personally and what they already may have going on before an injury.

Jane McDevitt said...

I agree with EG and Aleah,
Including a screen for all 6 mental heath concerns is important and seems most appropriate to do so during the PPE. I feel it is our job as athletic trainers to identify those who are at risk of these to prevent further harm and improve outcomes. I would be surprised if the NATA or other researchers are not working towards creating a PPE to include screening tools for these mental health concerns.

Catherine Hess said...

Mental health plays a huge role in overall health and wellness. The fact that mental health is overlooked during pre-participation examination leaves a lot of unknowns for the athletic trainers working with the athletes. I feel that it is not only important to evaluate mental health during PPEs, but also throughout the season, specifically following injury involving removal from play. PPEs already serve the purpose of gathering baseline information. I feel it is necessary to expand this in all settings to include mental health assessments. Coming from a Division 1 undergraduate program, the PPEs were extensive and included some aspect of mental health assessment. In addition, each team had an assigned sport psychologist whom they could meet with whenever needed. It is understandable that small schools may not include this, but I feel it is doing a disservice to the athletes. Gathering as much pertinent information as possible allows us as athletic trainers to do our job better. Keeping track of mental health status could help to improve rehabilitation and treatment compliance and outcomes and this is very important. In order for an athlete to perform at their best, they must be physically and mentally healthy, and there is an interplay between these two elements. Student-athletes with mental health conditions are statistically less likely to seek help and receive the help needed. By determining these individuals in need early, help can be arranged in order to intervene. Simply because mental health is not assessed or addressed does not mean that it is not a problem. Changes need to be made in order to provide the right information to allow athletic trainers to care for our athletes completely and as a whole.

Jane McDevitt said...

Catherine,

You bring up a great point. Mental health plays a role throughout the entire season. If we can identify an athlete with a mental health problem with the PPE, then if they get injured we can monitor their mental health better (e.g., using patient reported outcome measures to assess depression...), and provide better individualized care. For example, I probably would not give a depression PROM to an athlete throughout their rehab; however, if I know they are on anti-depressant medication or suggest in the PPE that they were depressed I would add that component to their rehab. Additionally, if we see changes in how they are performing that also may be related to their mental health that needs to be addressed. I also agree that no matter what division of high school or college the athlete participates in there should be a sport psychiatrist involved to help monitor mental health.

Lauren Krywy said...

This article relates closely to my thesis topic (the relationship of perceived social support on mental health) for the Master's program at Adrian College. Prior to Adrian College, I attended a NCAA Division I school where they did screen athletes for mental health conditions during PPE and there was also a sports psychologist on the campus as well that was very helpful and helped me overcome performance anxiety. I understand that not every campus can have the means for a sports psychologist, but regardless of NCAA division, mental health is something that should never be overlooked. It doesn't matter if the athlete is from a division II or division III school, they are still a branch of the NCAA and should be recognized at the same level as a division I school. Mental health conditions are not something that you can put a band-aid on and expect it to heal on its own. These conditions will be carried around in everyday life in and out of the athletic environment and long into their professional career once their collegiate life is done. The NATA position statement places an emphasis on psychosocial aspects, yet mental health in an area that most athletic trainers rarely experience for whatever the reason may be, but it is still important to recognize the signs and symptoms for the numerous mental health conditions. Having some type of screening tool allows you to better understand your athlete regardless of their academic year. As athletic trainers, we are supposed to be advocates for our athletes and how can we help provide care to them when it is an area most people do not want to get into. Athletes generally go to their athletic trainer first for everything before going somewhere else, so it is our responsibility to refer and recognize as needed. The athlete is more than the condition they are experiencing. We tailor things for orthopedic conditions so why should mental health be any different.

Jane McDevitt said...

Lauren,
That is nice that your school worked closely with a sports psychiatrist. There are several screening tools that I have seen used in the past. For example the hospital anxiety and depression scale (HADS) is a short survey that helps Its screen for athletes with depression and/or anxiety. It also has a validated cut offs so it make interpreting the information easier. For example, when should we make the call to refer to a sport psychiatrist if we do not have one on site. I do think these tools can be added into the PPE protocol like you suggested. It is just a matter of getting Its to recognize that there are helpful and quick tools out there that they can use to help screen for mental health. IT seems like everyone is on board with understanding this is an issue. Why do you think there is a disconnect understanding the importance and following through with a screening?

Lauren Krywy said...

Jane,
I think there is a disconnect in understanding the importance and following through with screening because even though mental health is more widely accepted, it is still a sensitive area. While working on my thesis, I found a stat that shocked me. At Columbia University, a study they conducted demonstrated that majority of individuals (less than 25%) never receive the appropriate mental health care. Mental health conditions are not a clear cut and dry matter. Many mental health conditions can mimic others and often times it takes a detailed and lengthy process to come to a conclusion. Because this is a sensitive topic, seeking appropriate care can be a challenge because of a number of factors such as social support and referral to the correct person. I think with the screening tools, it may be a simple item to hand out, but how many people truly know what to do with that information and refer the individual to the correct person. I think this can also be a disconnect in the importance and following through with screening.

Jane McDevitt said...

Lauren,
Nicely stated, I do think you hit one of the main problems, that we may not be providing enough education about mental health to our medical professionals. When I obtained my BS in AT I do not remember learning a lot about mental health. It was, if you think someone has a mental health problem, refer them. But, like you said, there is a wide spectrum of mental health conditions and without that knowledge you may not be sending them to the correct specialist. I think there is budding research (for example what you are doing) that will help direct medical professionals like ATs to target the appropriate support systems. I hope as more research comes out on this topic that mental health will not be as sensitive of a target and we address mental health concerns with the same vigor and knowledge base we approach musculoskeletal problems.

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