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Hard to express and how it tampers health

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Hard to express and how it tampers health

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34 seconds · Clipped by Wendy's 4For4 · Original video "Student Athletes Need to Talk About Mental Health | Mya Schnader | TEDxYouth@CarmelByTheSea" by TEDx ...

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Substance abuse Can Impact performance on and off the court

Less sleep can deteriorate memory of school and can negatively impact sport performance

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Multitasking both school and sports on top of health and other things leave little to no space for self and can be extremely difficult

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High expectations from family friends team members and fans all around can lead athletes to burnout which can impact health and performance on and off the court. The fear of letting others down trying to achieve unrealistic expectations

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Student-athletes might turn to substances as a coping mechanism or in hopes of increasing performance on the court. Which always ends out in a worse health state both mentally and physically all around bad. Can even effect the relationships with their families

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"Further, the non-athlete students demonstrated lower stress, higher life satisfaction, and better sleep quality in comparison to the athletes."

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INTRODUCTION

Sleep quality

The role of sleep is not without significance for athletes, for whom having good sleep quality is a desirable condition due to its role in recovery and athletic performance. The results of studies performed on athletes indicate that the group deals with decreased sleep quality.

Academic athletes, who need to combine the roles of a student and an athlete, may be more likely to suffer from sleep problems resulting from the fact that, in comparison to their peers, who are solely students, they bear more social roles. Study results, however, are ambiguous. Among the non-athlete students, the percentage indicating the occurrence of poor sleep quality is diversified and ranges from 50% to 60%. Research by Mah et al. and Sheehan et al. revealed that among student athletes, more than 40% in the former study and 30% in the latter study could be classified as poor sleepers. Further, Driller et al. compared athletes and the non-athletes regarding sleep behavior and sleep quality. Generally, the first group presented poorer sleep behaviors than their non-athlete peers, but their sleep quality, measured with the Pittsburgh Sleep Quality Index (PSQI), was higher. Recent study of Arbinaga et al. demonstrated that insufficiently physically active students scored higher in the PSQI than sufficiently physically active students, and among them the number of participants who can be identified as poor sleeper is greater. The opposite results were presented by Bender et al.. Their research revealed that, in comparison to a group of elite athletes, in a group of non-athletes there were more good sleepers.

Chronotype and sleep quality

One of the issues that have been discussed due to the interconnectedness with sleep is a chronotype. Even though it is defined as a continuum between extreme morningness and extreme eveningness, particular individuals can also be classified as different chronotypes: the morning ("larks", M-types [morning types]), the evening ("owls", E-types [evening types]), or the neither/intermediate type (N-/I-types [neither/intermediate types]). The M-type individuals, in contrast to the E-types, wake up and perform mentally and physically at their best in the earlier (morning) hours, but they find it difficult to stay awake at late-night hours.

It remains unclear whether sleep quality can be explained by chronotype. Bender et al. indicate that eveningness is positively correlated with poorer sleep quality in the group of athletes (in non-athlete controls, there is no such association). In turn, Lastella et al. and Monma et al. do not indicate the effect of the chronotype on athletes' sleep quality.

However, athletes who simultaneously hold the role of a student experience a lot of additional demands that may distort their natural circadian rhythm (e.g., early hours of lectures at the university or late hours of going to sleep due to their roommates' late-night activities). It may lead to the so-called social jet lag, understood as both the misalignment of biological and social time and the alterations between sleep patterns on free days and workdays.

Stress and sleep quality

Prior findings prove that the difficulty with sleep can be an effect of increased stress perceived by an athlete before an important performance. Juliff et al. suggest that poorer sleep quality prior to a competition constituted situational rather than a general problem with sleep. However, the results obtained by other researchers contradict this statement and indicate the existence of a negative relationship between sleep quality and general stress.

Apart from numerous burdens connected with training and competitions, student athletes are also exposed to the demands of everyday life resulting from various social roles, such as a student, a friend, a partner in a relationship, or an employee. Therefore, academic athletes may experience a higher level of stress and be particularly exposed to inappropriate sleep patterns consequently. In his review, Watson suggests that sleep restriction may not only worsen an individual's academic and sport performance, but also increase one's stress level, and secondarily result in further sleep disorders.

Life satisfaction and sleep quality

The relationship between sleep quality and life satisfaction, measured within non-clinical populations, is generally positive. Lower sleep quality is accompanied by lower satisfaction in the physical, psychological, social and environmental domains. Shin and Kim demonstrated that among students sleep quality has a direct positive effect on the level of life satisfaction. They indicate, though, that the relationship between these two variables can be bidirectional. Litwic-Kaminska and Kotyśko have presented similar conclusions in a study. In this study, however, only average life satisfaction results of academic athletes who obtained scores indicating good and poor sleep quality in the PSQI were compared. The athletes with decreased sleep quality, in comparison to the good sleepers, presented a lower level of life satisfaction. It should be noted that there is a lack of research among athletes in which the relationship between sleep quality and life satisfaction is analyzed.

Justification and objectives

Previous analyses have led us to the conclusion that student athletes with low sleep quality demonstrate a higher level of stress and declare lower life satisfaction than those with good sleep quality. The aim of this paper is to verify the relationships between the chronotype, perceived stress, life satisfaction and sleep quality. Along with this aim, we checked if stress and satisfaction with life are significant mediators in the relationship between chronotype and sleep quality.

MATERIALS AND METHODS

Participants

In the presented study, 349 students from one of Polish universities were surveyed. The participants consisted of two groups: student athletes (involved in sports, understood as training in sports clubs, as part of an academic sports association or having an individual training routine) and non-athletes (not engaged in sports activities and declaring a low level of physical activity). The first group consisted of 209 student athletes (aged M ± SD: 21.14 ± 1.77 yrs., 73% male). Due to the missing data in their questionnaires, two participants were excluded. The athletes represented individual (58.45%, e.g., athletics, swimming, combat sports) and team sports (41.55%, e.g., soccer, handball, volleyball, rowing), and their sports achievements were diverse. In the second group ( n=140), the level of physical activity was screened with the usage of the short form of the International Physical Activity Questionnaire (IPAQ). Twelve students whose physical activity levels were assessed as high, due to the data they provided, were excluded. Finally, the surveyed group included 128 non-active students (aged M ± SD: 21.52 ± 2.94 yrs., 23.4% male).

Measures

Chronotype: The Polish version of the Morningness-Eveningness Questionnaire (MEQ), prepared by Jankowski and Ciarkowska, is a one-dimensional measure that allows specifying a person's sleep-wake cycle and the preferred hours of functioning. It comprises 21 items, with usually four or five descriptive answers that are scored from one to four or five points. The higher the score, the more intense the morningness preference. The Polish adaptation of the MEQ has a satisfactory reliability level of 0.83.

Perceived stress: The Perceived Stress Scale (PSS-10) is a 10-item scale that evaluates the intensity of perceived stress during the previous month. The responses are given on a five- point Likert-type scale. The total scores range from 0 (no stress) to 40 points (extreme stress). The reliability of the Polish version was α=0.86.

Life satisfaction: The Satisfaction with Life Scale (SWLS) measures the cognitive component of well-being. It contains five statements (referring to one's life), to which the examined person responds by answering on a seven-point scale. The possible range of scores is 5-35. Cronbach's α coefficient of the version adapted to the Polish conditions is 0.81.

Sleep quality: The Pittsburgh Sleep Quality Index (PSQI) assesses sleep quality over a one-month time interval. The questionnaire includes 19 items (four of them are descriptive, and the remaining 15 are weighted on a 0-3 scale) that allow distinguishing seven components that are summed to produce a global score (range from 0 to 21, where higher scores indicate lower sleep quality). Results above 5 indicate "poor sleep". In this study, the cutoff criteria for low sleep quality were set at 5 or more points. The originally reported Cronbach's α in Buysse et al. was 0.83.

Physical activity level: The Polish version of the short IPAQ contains seven questions and gathers information about the time spent sitting or walking as well as the time devoted to intensive and moderate physical activity within the previous seven days. Only the activities that lasted continuously for at least 10 minutes without any significant breaks are taken into consideration. An examined person evaluates the number of days within a week devoted to their physical activity together with an average daily duration of that activity (in hours and minutes). By meeting particular criteria determined in the total weekly activity coefficient, calculated on the basis of metabolic equivalent of work (MET), with the units expressed in MET min/week, the subjects can be divided into three physical activity categories: high, moderate and low/insufficient. A short version of the IPAQ has acceptable measurement properties.

Procedure

Before the start of the activities, the participants of the study from both groups were familiarized with the aim of the research and asked to provide written informed consent for participation in the study. Following ethical principles of academic research, each participant was assured that he or she could resign from further participation at any stage of the study and that the collected data would be used for scientific purposes only. The participants individually filled out a set of questionnaires, and each received detailed feedback on the results obtained. The project of the study was approved by the Ethics Committee for Scientific Research of the Institute of Psychology (currently Faculty of Psychology), Kazimierz Wielki University in Bydgoszcz, Poland.

Statistical analyses

Statistical analyses were performed in SPSS v25 and AMOS v25. Data gathered in the study were normally distributed. The comparison between the student athletes and the physically inactive students in accordance with the PSQI, MEQ, PSS and SWLS was conducted by employing the t-Student test. The effect size for mean differences was interpreted using the Cohen's guidelines. The primary analysis was hierarchical regression analysis, where it was tested if the MEQ, PSS and SWLS are significant predictors of the PSQI. The next step was path analysis (with the use of multi-group analysis), which was conducted to verify the model and to determine the direct and indirect impacts of the chronotype, stress and life satisfaction on sleep quality. The multi-group analysis makes it possible to check if the model differs depending on the group, we are analyzing (in this study - student athlete or non-athlete). In the path analysis, the maximum likelihood (ML) estimation was used to obtain model parameters. In accordance to model verification the following model fit indices were evaluated: the χ ², the root mean square error of approximation (RMSEA), the comparative fit index (CFI), and the standardized root mean squared residual (SRMR). Following Hu and Bentler recommendations, in order to be able to speak of a good model fit, the fit indices should assume specific values, which are as follows: RMSEA < 0.06, CFI > 0.95, SRMR < 0.08.

With regard to the χ ² test, a non-significant test result is an indicator of a good fit. All parameters were calculated with the bootstrap of 5.000 samples and a confidence interval of 90%.

RESULTS

Differences between student athletes and non-athletes

The information about the means, standard deviations, and t-Student test results are presented in . The significant differences between the student athletes and their inactive peers were present in all studied variables. The non-athlete students had higher scores in the MEQ than the athletes. Further, the non-athlete students demonstrated lower stress, higher life satisfaction, and better sleep quality in comparison to the athletes. The effect size of the observed differences can be identified as generally low; the difference seems to be medium only in the case of perceived stress. Using the χ ², test it was checked whether the numbers of participants who can be called "bad sleepers" (a score of 5 or greater in the PSQI) and "good sleepers" (a score below 5 in the PSQI) are similar when taking into account the activity level (student athletes vs inactive students). Among the student athletes, more participants were classified as good sleepers ( n=123 vs n=44), unlike among the inactive students (χ ² =19.85; p<0.0001).

Table 1

Verification of the adopted model

To determine which variables are important predictors of sleep quality, and to what extent they explain the variance of this variable, a hierarchical regression analysis was performed with the control of sex (). According to the results, it can be stated that lower scores in chronotype (β=-0.241, p<0.001), a higher level of perceived stress (β=0.273, p<0.001), and lower scores in life satisfaction (β=-0.149, p=0.005) were significantly associated with lower sleep quality (higher scores in the PSQI indicate lower sleep quality). Sex were an insignificant predictor of PSQI scores when all variables were included in the model.

The hierarchical regression analysis became the basis for verifying the model of specific relationships between variables in which the main outcome was sleep quality; the chronotype was treated as the main predictor and perceived stress and life satisfaction as mediators ().

Using the multi-group analysis, we checked the fit indices of three models and compared them with the χ ² test. The comparison included Model 1 - unconstrained, and two constrained models (with fixed parameters); Model 2 - structural weights; and Model 3 - structural residuals (). Model 2 and Model 3 (both constrained) were not significantly worse than Model 1 (base model). Model 3 is not significantly worse than Model 2: χ ² =5.36, df=4, p=0.253. According to the mentioned results, we can assume that the models are equivalent, which means that the proposed theoretical model applies to the student athletes as well as to the non-athletes. In the proposed model (structural weights model was chosen), all but one path were statistically significant ().

Table 3

Based on the result of the mediation analysis, we can assume the perceived stress partially mediates the relationship between the chronotype and sleep quality ().

Table 4

DISCUSSION

The main purpose of the presented study was to examine how the chronotype, stress, life satisfaction, and sleep quality could be interrelated and whether stress and life satisfaction could modify the relationship between the chronotype and subjective sleep quality.

It was assumed that the chronotype directly affects the quality of sleep, but this relationship is mediated through the perceived stress, which results in a likely possibility of sleep quality being modified by satisfaction with life. The model parameters were tested in order to verify whether they apply to both analyzed student groups, the athletes and the non- athletes, to the same extent. Based on the obtained results, a solution was adopted assuming that the regression weights in both groups will be equal for the respective variable pairs, since the model with fixed parameters did not differ from the unconstrained one. This action allows for drawing simultaneous conclusions for both groups. In the model, all but one paths were significant. The chronotype has a negative influence on sleep quality score (but it needs to be emphasized that the higher the score, the worse the quality of sleep). This relation is in line with the findings of Roeser et al., but their study included female students only. Also, in Bender et al. research, it was noted that the athletes with the evening preference demonstrated poorer sleep quality. Yet, in the latter study, this relationship was only significant for the athletes; in the control group, it was inconsequential. A possible explanation could be that in the study by Bender et al. the control group consisted of the participants who could be classified as good sleepers; in our study, we included the students with low physical activity, and, as showed, their sleep quality was lower than the athletes'.

The chronotype significantly influences the perceived stress, as well. The presented results are consistent with the data obtained by Roeser et al., in which the chronotype had a significant impact on the level of the self-perceived stress response (this study procedure included an induction of acute stress to the participants via mental arithmetic task); however, this relationship became insignificant when sleep quality was included as a mediator. The model of relationship between the variables, developed as a part of our own study, included the reverse relationship among three variables, in comparison to the study by Roeser et al., for example, a given chronotype, sleep quality and perceived stress. We assumed that the chronotype could affect sleep quality directly as well as indirectly, via the perceived stress. This assumption was developed by the current research results indicating that stress affects the subjective quality of sleep.

Our findings from the mediation analysis suggest that the perceived stress (measured by a questionnaire and related to everyday life) is a significant mediator in the mentioned relation between the chronotype and sleep quality (partial mediation), which means that perceived stress can further aggravate sleep problems that arise from the chronotype of an individual. However, it should be mentioned that the chronotype itself, as a preference for functioning within selected times of the day, does not have to be a problem. Merely a discrepancy between the chronotype and the requirements of social functioning (i.e., social jet lag) may result in subjectively lower sleep quality.

The question about the possible two-way relationship between the mutual influence of stress and the quality of sleep has remained unresolved. In our proposed model, a path leading from stress to sleep quality was set; however, it is possible that reversing the model (the direct relation of the chronotype and stress, which is mediated by sleep quality, as proposed by Roeser et al.) and scrutinizing this relationship will give similar results.

Apart from the verification of the adopted model of relations between the variables, analysis of the differences between the studied groups of students was performed. The athlete students obtained higher results in the chronotype, were less stressed, and declared higher life satisfaction and sleep quality. We believe that this requires an extensive interpretation.

Primarily, note that higher scores on the MEQ indicate higher morningness preference, and conversely, lower scores indicate higher eveningness tendency. The mean results of both groups allow considering the participants as intermediate types, although the average result of the inactive students is near the limit score for E-type. Similarly, insufficiently physically active students in Arbinaga et al. study indicate a greater tendency towards the eveningness than those who presented sufficient physical activity. The obtained results in our study suggest that the athletes tend to choose earlier hours for work, learning or training. A possible explanation comes from the studies discussing physical activity as one of the health behaviors. It was confirmed that when compared to the M-types, the E-types were generally less active and spent more time sitting.

Another divergence between the athletes and the non-athletes was noted regarding perceived stress and satisfaction with life. Following Demirel, we presumed that the athletes would declare a higher level of stress and lower satisfaction with life. Other reports suggest that participation in a sport activity may become an additional stressor that non-athletes do not experience. The differences obtained in our study stand in contrast to these findings. The explanation here may be the fact that we did not examine acute stress connected with competitions or exam session periods (the time of conducting the research was chosen to limit the possibility of such situations), but we have taken into account stress experienced in everyday life. Second, physical activity undertaken by the examined students can act as a buffer against stress and the adverse effects of it. Such an effect was presented in Wunsch et al. study conducted among academic students who proved an influence of physical activity on the level of experienced stress, well-being, and sleep quality. Physical activity has a positive effect on an individual by improving his or her mood - via the release of endorphins, among other ways. Generally, in most cases athletes demonstrate better mental health when compared to non-athletes, except in the case of excessive exercise intensity, incompatible with one's possibilities at the time, and the persistent influence of stressors that an individual cannot effectively overcome.

Most of the athletes in our study can be considered good sleepers (the results measured with the PSQI at lower than 5 points), as opposed to the non-athletes, among which about two-thirds of the participants were qualified as bad sleepers. However, 40% of the athletes still declare problems with sleep. This indicates the significance of the undertaken subject.

The presented outcomes are consistent with the findings regarding decreased sleep quality among students in general. Analyzing the differences between the athletes and the non- athletes, it can be stated that the physically inactive students declare lower sleep quality. The previous studies have remained inconsistent in this respect. Our results are antithetical to some prior reports suggesting that athletes presented poorer sleep behaviors than the control groups, but closer to the scores according to which the non-athletes have a higher PSQI global score than the athletes or sufficiently physically active students present higher sleep quality than those insufficiently physically active.

Limitations

Although this study significantly fills the research gap in respect to the quality of sleep among academic athletes, it also has certain limitations that should be noted for carrying out future research in this field. First limitation applies to the sex ratio of the subjects. However, we controlled this variable in performed analyses, subsequent research should equate these proportions, in both the group of student athletes and the group of non-athletes, in order to analyze differences between males and females regarding psychological properties.

In this study, the PSQI was used to measure the quality of sleep, but there are other methods, for example, designed solely for athletes to describe their sleep and its properties. Our study included the measurement of the control group. Therefore, the PSQI was treated as a universal questionnaire. When planning further research including student athletes, it would be advisable to adapt to Polish conditions one of the methods addressed to athletes (e.g., The Athlete Sleep Behavior Questionnaire or the Athlete Sleep Screening Questionnaire) and measure sleep quality using several tools.

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Sleep quality of student athletes and non-athletes - the role of chronotype, stress and life satisfaction

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There are many internal and external factors that can affect sleep deterioration. The adopted model of the relationship between chronotype, stress, life satisfaction and sleep quality was veriﬁed in the study.In total, 335 healthy university students ...

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Abstract

Drug abuse occurs in all sports and at most levels of competition. Athletic life may lead to drug abuse for a number of reasons, including for performance enhancement, to self-treat otherwise untreated mental illness, and to deal with stressors, such as pressure to perform, injuries, physical pain, and retirement from sport. This review examines the history of doping in athletes, the effects of different classes of substances used for doping, side effects of doping, the role of anti-doping organizations, and treatment of affected athletes. Doping goes back to ancient times, prior to the development of organized sports. Performance-enhancing drugs have continued to evolve, with "advances" in doping strategies driven by improved drug testing detection methods and advances in scientific research that can lead to the discovery and use of substances that may later be banned. Many sports organizations have come to ban the use of performance-enhancing drugs and have very strict consequences for people caught using them. There is variable evidence for the performance-enhancing effects and side effects of the various substances that are used for doping. Drug abuse in athletes should be addressed with preventive measures, education, motivational interviewing, and, when indicated, pharmacologic interventions.

Keywords: doping, athletes, steroids, drug abuse, mental illness

Introduction

Doping, defined as use of drugs or other substances for performance enhancement, has become an important topic in virtually every sport 1 and has been discovered in athletes of all ages and at every level of competition. 2- 4 See Table 1 for rates of use of a variety of substances, whether doping agents or recreational substances, among different populations of athletes as reported in various recent research studies. 5- 10 Of note, self-reports are generally felt likely to yield under-reported figures. 5 Importantly, performance-enhancing drugs (PEDs) are not restricted to illegal drugs or prescription medications, such as anabolic steroids. 11 They include dietary supplements and a variety of compounds that are available at grocery and health food stores and online. 12

Table 1

Substance

Athlete population

Percentage of athletes using substance

Alcohol

College athletes (self report)

75%-93% for male athletes; 71%-93% for female athletes over past year 6
85% over past year 7

College athletes (self report)

0.2%-5% for males depending on sport; 0.0%-1.6% for females depending on sport over past year 7, 8

Professional football players (self report)

9% used at some point in career 8

Competitive power lifters (self report)

67% used at some point in career 8

College baseball players (self report)

40%-50% over past year 10

Professional baseball players (self report)

35%-40% over past year 10

Professional football players (self report)

20%-30% over past year 10

Drug abuse in the athlete population may involve doping in an effort to gain a competitive advantage. Alternatively, it may involve use of substances such as alcohol or marijuana without the intent of performance enhancement, since athletes may develop substance use disorders just as any nonathlete may.

Athletes may turn to substances to cope with numerous stressors, including pressure to perform, injuries, physical pain, and retirement from a life of sport (which happens much earlier than retirement from most other careers). 13 Additionally, athletes may be significantly less likely to receive treatment for underlying mental illnesses such as depression. 14 Athletes receive comprehensive treatment and rehabilitation for physical injuries, but this may be less often the case for mental illness, because of their sometimes viewing mental illness as a sign of weakness. 14 Untreated mental illness is often associated with substance use, perhaps in an effort to self-treat. Alternatively, substances of abuse may cause mental illness. 15

We will especially focus on doping in this review, which specifically aims to serve as a single paper that provides a broad overview of the history of doping in athletes, the effects of different classes of drugs used for doping, side effects of doping, the role of anti-doping organizations, and the treatment of affected athletes.

Materials and methods

For this review, we identified studies through a MEDLINE search. Search terms included the following, individually and in combination: "doping", "athletes", "steroids", "drug abuse", "mental illness", "drug testing", "anti-doping", "psychiatry", "sports", "depression", "substance abuse", "substance dependence", "addiction", "history", "side effects", "drug testing", "treatment", "androgens", "testosterone", "growth hormone", "growth factors", "stimulants", "supplements", "erythropoietin", "alcohol", "marijuana", "narcotics", "nicotine", "Beta agonists", "Beta blockers", "diuretics", "masking agents", "gene doping", "National Collegiate Athletic Association", and "World Anti-Doping Agency". We restricted results to the English language and used no date restrictions. We retrieved all papers discussing drug abuse in athletes. We reviewed the findings of each article, and reviewed the references of each paper for additional papers that had been missed in the initial search and that might include findings relevant to the scope of our review. Ultimately, 67 manuscripts or chapters were felt relevant and representative for inclusion among those referenced in this paper.

History of doping in athletes

The belief that doping is only a recent phenomenon that has arisen solely from increasing financial rewards offered to modern day elite athletes is incorrect. 16 In fact, doping is older than organized sports. Ancient Greek Olympic athletes dating back to the third century BC used various brandy and wine concoctions and ate hallucinogenic mushrooms and sesame seeds to enhance performance. Various plants were used to improve speed and endurance, while others were taken to mask pain, allowing injured athletes to continue competing. 17- 19 Yet, even in ancient times, doping was considered unethical. In ancient Greece, for example, identified cheaters were sold into slavery. 1

The modern era of doping dates to the early 1900s, with the illegal drugging of racehorses. Its use in the Olympics was first reported in 1904. Up until the 1920s, mixtures of strychnine, heroin, cocaine, and caffeine were not uncommonly used by higher level athletes. 16

By 1930, use of PEDs in the Tour de France was an accepted practice, and when the race changed to national teams that were to be paid by the organizers, the rule book distributed to riders by the organizer reminded them that drugs were not among items with which they would be provided. 20

In the 1950s, the Soviet Olympic team began experimenting with testosterone supplementation to increase strength and power. 16 This was part of a government-sponsored program of performance enhancement by national team trainers and sports medicine doctors without knowledge of the short-term or long-term negative consequences. Additionally, when the Berlin Wall fell, the East German government's program of giving PEDs to young elite athletes was made public. 1 Many in the sporting world had long questioned the remarkable success of the East German athletes, particularly the females, and their rapid rise to dominance in the Olympics. Young female athletes experienced more performance enhancement than did male athletes. Unfortunately, they also suffered significant and delayed side effects, including reports of early death in three athletes. 19

The specific substances used to illegally enhance performance have continued to evolve. 21 The "advances" in doping strategies have been driven, in part, by improved drug testing detection methods. 21 To avoid detection, various parties have developed ever more complicated doping techniques. 21 Further, new doping strategies may result from advances in scientific research that can lead to the discovery and use of substances that may later be banned. Over the past 150 years, no sport has had more high-profile doping allegations than cycling. 16 However, few sports have been without athletes found to be doping.

Many sports organizations have come to ban the use of PEDs and have very strict rules and consequences for people who are caught using them. The International Association of Athletics Federations was the first international governing body of sport to take the situation seriously. 22 In 1928, they banned participants from doping, 22 but with little in the way of testing available, they had to rely on the word of athletes that they were not doping. It was not until 1966 that the Federation Internationale de Football Association and Union Cycliste Internationale joined the International Association of Athletics Federations in the fight against drugs, closely followed by the International Olympic Committee (IOC) the following year. 23

The first actual drug testing of athletes occurred at the 1966 European Championships, and 2 years later the IOC implemented their first drug tests at both the Summer and Winter Olympics. 24 Anabolic steroids became even more prevalent during the 1970s, and after a method of detection was found, they were added to the IOC's prohibited substances list in 1976. This resulted in a marked increase in the number of doping-related disqualifications in the late 1970s, 24 notably in strength-related sports, such as throwing events and weightlifting.

While the fight against stimulants and steroids was producing results, 24 the main front in the anti-doping war was rapidly shifting to blood doping. 25 This removal and subsequent reinfusion of an athlete's blood in order to increase the level of oxygen-carrying hemoglobin has been practiced since the 1970s. 25 The IOC banned blood doping in 1986. 25 Other ways of increasing the level of hemoglobin were being tried, however. One of these was erythropoietin. 25 Erythropoietin was included in the IOC's list of prohibited substances in 1990, but the fight against erythropoietin was long hampered by the lack of a reliable testing method. An erythropoietin detection test was first implemented at the 2000 Olympic Games. 25

In the 1970s and 1980s, there were suspicions of state-sponsored doping practices in some countries. The former German Democratic Republic substantiated these suspicions. 25 The most prominent doping case of the 1980s concerned Ben Johnson, the 100 meter dash champion who tested positive for the anabolic steroid stanozolol at the 1988 Olympic Games in Seoul. 25 In the 1990s, there was a noticeable correlation between more effective test methods and a drop in top results in some sports. 25

In 1998, police found a large number of prohibited substances, including ampoules of erythropoietin, in a raid during the Tour de France. 25, 26 The scandal led to a major reappraisal of the role of public authorities in anti-doping affairs. As early as 1963, France had been the first country to enact anti-doping legislation. Other countries followed suit, but international cooperation in anti-doping affairs was long restricted to the Council of Europe. In the 1980s, there was a marked increase in cooperation between international sports authorities and various governmental agencies. Before 1998, debate was still taking place in several discrete forums (IOC, sports federations, individual governments), resulting in differing definitions, policies, and sanctions. Athletes who had received doping sanctions were sometimes taking these sanctions, with their lawyers, to civil courts and sometimes were successful in having the sanctions overturned. The Tour de France scandal highlighted the need for an independent, nonjudicial international agency that would set unified standards for anti-doping work and coordinate the efforts of sports organizations and public authorities. The IOC took the initiative and convened the First World Conference on Doping in Sport in Lausanne in February 1999. Following the proposal of the Conference, the World Anti-Doping Agency (WADA) was established later in 1999.

Performance-enhancing effects of substances used by athletes

There is a research base demonstrating that many doping agents are in fact performance-enhancing. However, some substances (eg, selective androgen receptor modulators, antiestrogens, and aromatase inhibitors), used in an effort to enhance performance, have little data to back up their effectiveness for such a purpose. Note that the studies cited in this paper are chosen as being historically important or representative of the bulk of the research on the topic, and the broad overview provided in this paper does not aim to cite all evidence on the effects of these substances. Additionally, research on this topic is limited by the difficulty in performing ethical studies due to the high doses of doping agents used, potential side effects, and lack of information on actual practice.

Androgens

Androgens include exogenous testosterone, synthetic androgens (eg, danazol, nandrolone, stanozolol), androgen precursors (eg, androstenedione, dehydroepiandrosterone), selective androgen receptor modulators, and other forms of androgen stimulation. The latter categories of substances have been used by athletes in an attempt to increase endogenous testosterone in a way that may circumvent the ban enforced on natural or synthetic androgens by WADA.

Amounts of testosterone above those normally found in the human body have been shown to increase muscle strength and mass. For example, a representative randomized, double-blind study involved 43 men being randomized to four different groups: testosterone enanthate 600 mg once per week with strength training exercise; placebo with strength training exercise; testosterone enanthate 600 mg once per week with no exercise; and placebo with no exercise. This was a critical study in demonstrating that administration of testosterone increased muscle strength and fat-free mass in all recipients, and even moreso in those who exercised. 27 A second study from the same investigators 5 years later further demonstrated a dose-response relationship between testosterone and strength. 28 Another double-blind trial of exogenous testosterone involved 61 males randomized to five different doses of testosterone enanthate, ranging from 25 mg to 600 mg, along with treatment with a gonadotropin-releasing hormone agonist to suppress endogenous testosterone secretion. That study demonstrated findings similar to the previous one, in showing a dose-dependent increase in leg power and leg press strength, which correlated with serum total testosterone concentrations. 29

Androgen precursors include androstenedione and dehydroepiandrosterone (DHEA). We found no evidence that androstenedione increases muscle strength. 30 DHEA is available as a nutritional supplement that is widely advertised in body building magazines as a substance that will improve strength. However, results from placebo-controlled studies of DHEA in males have been mixed. 30, 31 One study involved 40 trained males being given DHEA 100 mg per day, androstenedione, or placebo, with no resulting differences in muscle mass or fat-free mass between groups. 30 A second study involved nine males and ten females randomized to receive DHEA 100 mg daily or placebo for 6 months, who were then crossed over to the other group for a further 6 months. The males but not females showed increased knee and lumbar back strength during DHEA treatment. 31

Selective androgen receptor modulators are not approved for use in humans in any country, but athletes are able to obtain these substances on the Internet. 32 No studies were found looking at the effects of selective androgen receptor modulators on muscle strength or mass in humans.

Other forms of androgen stimulation include exogenous human chorionic gonadotropin, antiestrogens such as tamoxifen, clomiphene, and raloxifene, and aromatase inhibitors such as testolactone, letrozole, and anastrozole. These substances may result in increased serum testosterone. 33 However, we found minimal research demonstrating an effect on muscle strength. 34 While androgens of different forms have been shown to improve muscle strength and mass, they have not been shown to improve whole body endurance per se. 35

Growth hormone and growth factors

Growth hormone and growth factors are also banned by WADA. Research shows recombinant human growth hormone to increase muscle mass and decrease adipose tissue. One representative study randomized male recreational athletes to growth hormone 2 mg/day subcutaneously, testosterone 250 mg weekly intramuscularly, a combination of the two treatments, or placebo. 36 Female recreational athletes were randomized to growth hormone 2 mg daily or placebo. In both males and females, growth hormone was associated with significantly decreased fat mass, increased lean body mass, and improved sprint capacity (although with no change in strength, power, or endurance). Sprint capacity improvement was even greater when growth hormone and testosterone were coadministered to males.

Growth factors include insulin-like growth factor and insulin. They are presumed to have similar effects to growth hormone, but have not been studied in athletes. 37 Athletes use these substances because of their apparent anabolic effect on muscle. 37

Stimulants

Stimulants include amphetamine, D-methamphetamine, methylphenidate, ephedrine, pseudoephedrine, caffeine, dimethylamylamine, cocaine, fenfluramine, pemoline, selegiline, sibutramine, strychnine, and modafinil. Research has shown stimulants to improve endurance, increase anaerobic performance, decrease feelings of fatigue, improve reaction time, increase alertness, and cause weight loss. 38 Of note, while WADA bans stimulants as a class, it does allow use of caffeine. Energy beverages now often include a variety of stimulants and other additives including not only caffeine, but also the amino acids taurine and L-carnitine, glucuronolactone, ginkgo biloba, ginseng, and others. 39 Caffeine content can be up to 500 mg per can or bottle. The potential performance benefits of the other ingredients in energy beverages are unclear. For example, taurine may improve exercise capacity by attenuating exercise-induced DNA damage, but the amounts found in popular beverages are probably far below the amounts needed to be of performance-enhancing benefit. 39

Of note, the number of athletes, especially at top levels of competition, reported to be using stimulant medications has markedly increased in recent years. In the USA, the National Collegiate Athletic Association acknowledged that the number of student athletes testing positive for stimulant medications has increased three-fold in recent years. 40 There has also been concern about inappropriate use of stimulants in major league baseball in the USA. According to a report released in January 2009, 106 players representing 8% of major league baseline players obtained therapeutic use exemptions for stimulants in 2008, which was a large increase from 28 players in 2006. 41 Therapeutic use exemptions allow athletes to take otherwise banned and performance-enhancing substances if their physician attests that they should for medical reasons.

Nutritional supplements

Nutritional supplements include vitamins, minerals, herbs, extracts, and metabolites. 39 Importantly, the purity of these substances cannot be guaranteed, such that they may contain banned substances without the athlete or manufacturer being aware. Studies have shown that many nutritional supplements purchased online and in retail stores are contaminated with banned steroids and stimulants. 42 Thus, athletes could end up failing doping tests without intentionally having ingested banned substances. 42 Creatine is not currently on the WADA banned list and is the most popular nutritional supplement for performance enhancement. 3 Studies demonstrate increased maximum power output and lean body mass from creatine. 43, 44 As such, some allowable nutritional supplements may have ergogenic effects, but may have insufficient evidence supporting their ergogenic properties to rise to the level of being banned.

Methods to increase oxygen transport

Substances athletes use to increase oxygen transport include blood transfusions, erythropoiesis-stimulating agents such as recombinant human erythropoietin and darbepoetin alfa, hypoxia mimetics that stimulate endogenous erythropoietin production such as desferrioxamine and cobalt, and artificial oxygen carriers. Transfusions and erythropoiesis-stimulating agents have been shown to increase aerobic power and physical exercise tolerance. 45 However, the ergogenic effects of the other agents are debatable. 45

Other recreational drugs

Other recreational drugs that may be used in an attempt to enhance performance include alcohol, cannabinoids, narcotics, and nicotine. 13 WADA does not currently ban nicotine but bans cannabinoids and narcotics. Alcohol is banned in six sports during competition only. All of these substances may be used by athletes to reduce anxiety, which may be a form of performance enhancement, but we found little research looking at actual performance enhancement from these agents. Narcotics are used to decrease pain while practicing or playing. Nicotine may enhance weight loss and improve attention. 46

Beta agonists

There is debate as to whether beta-2 adrenergic agonists, for example, albuterol, formoterol, and salmeterol, are ergogenic. 47 There is anecdotal evidence of improvements in swimmers who use these substances prior to racing. 48 Additionally, oral beta agonists may increase skeletal muscle, inhibit breakdown of protein, and decrease body fat. 48 However, there is some evidence suggesting that swimmers may have a relatively high prevalence of airway hyperresponsiveness due to hours spent breathing byproducts of chlorine, such that beta agonists may be needed to restore normal, not enhanced, lung function. 49

Beta blockers

Beta blockers such as propranolol result in a decreased heart rate, reduction in hand tremor, and anxiolysis. These effects may be performance-enhancing in sports in which it is beneficial to have increased steadiness, such as archery, shooting, and billiards. 48

Other prescription drugs

Diuretics and other masking agents may be used as doping agents. 12 Diuretics can result in rapid weight loss such that they may be used for a performance advantage in sports with weight classes, such as wrestling and boxing. 12 Diuretics may also be used to hasten urinary excretion of other PEDs, thereby decreasing the chances that athletes will test positive for other banned substances that they may be using. 12 Masking agents in general conceal prohibited substances in urine or other body samples, and include diuretics, epitestosterone (to normalize urine testosterone to epitestosterone ratios), probenecid, 5-alpha reductase inhibitors, and plasma expanders (eg, glycerol, intravenous administration of albumin, dextra, and mannitol). 50

Glucocorticoids are sometimes used by athletes in an attempt to enhance performance because of their anti-inflammatory and analgesic properties. 12 However, there is minimal research to show any performance benefits of this class of drugs.

Athletes may also use phosphodiesterase-5 inhibitors in an attempt to attain increased oxygenation and exercise capacity, since they have vasodilatory effects. 51 However, again, little research exists to support a performance benefit from these substances.

Psychiatric medications, including antidepressants, anxiolytics, antipsychotics, and anticonvulsants, are generally not on the WADA banned list. 14 Bupropion is an antidepressant that is on the WADA 2014 monitoring list, meaning WADA is monitoring for any concerning trends of inappropriate use. One small study of nine males suggested that bupropion, when used acutely in warm environments, may allow athletes to push themselves to higher body temperature and heart rates without perceiving greater effort. 52 Otherwise, there is very minimal evidence that any of these classes of psychiatric medications enhance performance. 14

Nondrug performance-enhancing measures

Gene doping is a concerning potential method of nondrug performance enhancement and is banned by WADA. The potential to directly affect strength and endurance through gene manipulation has been demonstrated in laboratory mice, but no human athletes thus far have been found to be using this method. 16

Additionally, athletes may legally attempt to improve physical performance in a number of nondrug ways. 53 These have varying degrees of research into their effectiveness and safety, and include hypoxia induction techniques. 53 For example, athletes may train at high altitudes, which can result in erythrocytosis. Some studies suggest that a high-low method of sleeping at high altitude followed by training at low altitude is a better training strategy than training or sleeping at either high or low altitudes alone. 54 Some athletes have tried sleeping at simulated high altitude by using low oxygen tents. Athletes may also make dietary changes to try to increase hemoglobin levels. 55, 56

Side effects of substances used by athletes

It is presumed that most if not all doping agents have potential short-term and/or long-term side effects. Unfortunately, given the high doses of these agents used by athletes, it is difficult to confirm such effects. It would be unethical to give dosages as high as those used by athletes for performance enhancement effects to participants in research studies. 16 Knowledge about side effects may be gleaned from empirical observation, reports of admitted users, and effects in patients prescribed such agents for medical conditions. Table 2 lists the potential side effects of various forms of doping. 57- 59

Table 2

Substance/method

Potential side effects

Androgens (eg, testosterone, danazol, nandrolone, stanozolol)

* Reproductive: diminished spermatogenesis and gynecomastia in men, decreased fertility, decreased testicular size, possible benign prostatic hypertrophy or prostate cancer
* Cardiovascular: decreased high-density lipoprotein cholesterol, increased low-density lipoprotein cholesterol
* Hepatic: hepatotoxicity
* Neuropsychiatric: depression, mania, psychosis, aggression
* Other: hastened epiphyseal closure in adolescents, acne, hirsutism, temporal hair recession, clitoromegaly, voice deepening, and oligomenorrhea/amenorrhea in women, infections (abscesses at injection sites, septic arthritis, and hepatitis/human immunodeficiency virus from sharing needles), tendon rupture

Growth hormone and growth factors (eg, insulin-like growth factor, insulin)

* I nsulin resistance, hyperglycemia, diabetes mellitus, cardiomegaly, hastened epiphyseal closure in adolescents, myopathy, hypertension, edema, carpal tunnel syndrome

Stimulants (eg, amphetamine, D-methamphetamine, methylphenidate, ephedrine, pseudoephedrine, caffeine, cocaine)

* Hypertension, tachycardia, myocardial infarction, stroke, heat stroke, weight loss, rhabdomyolysis, headache, nausea, tremor, insomnia, anxiety/panic attacks, agitation, aggression, psychosis

Methods to increase oxygen transport (eg, blood transfusions, recombinant human erythropoietin, darbepoetin alfa)

* Myocardial infarction, stroke, deep vein thrombosis/pulmonary embolism, hypertension, antibody-mediated anemia

Nutritional supplements (eg, vitamins, minerals, herbs, extracts, metabolites)

* Depends on the components
* Creatine: acute interstitial nephritis, more rapid progression of chronic kidney disease 57, 58

Other recreational drugs

* Alcohol: sedation, decreased concentration and coordination
* Cannabinoids: reduced alertness, impaired short-term memory, psychomotor retardation, dysphoria, anxiety, psychosis 59
* Narcotics: physical dependence, nausea/vomiting, constipation, decreased concentration and coordination, fatigue
* Nicotine: chronic use associated with cardiovascular disease, chronic obstructive lung disease, and many types of cancer

Beta agonists (eg, albuterol, formoterol, salmeterol))

* Tachycardia, arrhythmias, hypokalemia, hyperglycemia, tremor

Beta blockers (eg, propranolol)

* Bradycardia, increased airway resistance, decreased endurance

Other prescription drugs

* Diuretics and other masking agents: dizziness, muscle cramps, rash, gout, renal insufficiency, electrolyte imbalances, gynecomastia (spironolactone)
* Glucocorticoids: hyperglycemia, fluid retention, depression, mania, psychosis, chronic use may result in reduced muscle mass/weakness, osteoporosis, diabetes mellitus, hypertension, weight gain, central obesity, and cataracts

Gene doping

* Unknown

Anti-doping organizations, drug testing in athletes, and rules

Drug testing typically occurs only in organized, competitive sports. At the college level, organizations such as the National Collegiate Athletic Association 60 and individual member institutions conduct standard drug testing programs and enforce penalties for positive tests.

Elite athletes competing at international and national levels are subject to standardized anti-doping guidelines under the auspices of WADA and related national organizations. WADA is the international independent agency that publishes the World Anti-Doping Code, which is the document harmonizing anti-doping policies in all sports and all countries. 61 The Code was first adopted in 2003 and became effective in 2004. The Code sets forth specific anti-doping rules and principles that are to be followed by the anti-doping organizations responsible for adopting, implementing, or enforcing anti-doping rules within their authority, including the IOC, International Paralympic Committee, international sport federations (for example, the International Cycling Union), major event organizations, and national anti-doping organizations (for example, the US Anti-Doping Agency).

WADA revises and publishes its list of banned substances approximately annually. It specifies those banned substances and methods that are prohibited at all times (both in-competition and out-of-competition) because of their potential to enhance performance in future competitions or their masking potential, and those substances and methods that are prohibited in-competition only. The list may be expanded by WADA for a particular sport.

WADA has also taken the lead in the development of the athlete biological passport concept. 61 WADA's athlete biological passport operating guidelines took effect in 2009. The fundamental principle of the athlete biological passport is based on the monitoring of selected parameters over time that indirectly reveal the effect of doping, as opposed to the traditional direct detection of doping by analytical means. This concept gained momentum as a result of questions raised during the 2006 Olympic Winter Games surrounding suspensions of athletes by their federations following health checks that reported high hemoglobin levels. An athlete's passport purports to establish individual baseline hormone/blood levels, which are monitored over time for significant changes. A positive test result would consist of too dramatic a change from the established individual baseline. This approach is intended to protect athletes from false-positive tests resulting from naturally occurring high levels of endogenous substances, while catching those attempting to cheat by using naturally occurring substances.

In the event that an athlete and his or her medical providers feel it necessary, for documented medical reasons, that he or she continue to take a banned substance, WADA may consider granting a therapeutic use exemption, a concept mentioned earlier. A therapeutic use exemption must be on file before an athlete tests positive for the substance allowed by that therapeutic use exemption.

Treatment of affected athletes, including counseling and psychiatric support

The first level of addressing the problem of drug abuse by athletes is prevention. 13 Drug screening is used in higher-level athletics both to deter athletes from using drugs and to punish and offer opportunities for rehabilitation to those who are found to have done so. Didactic education is another method aimed at prevention. 62 On the one hand, some authors and clinicians feel that among the most effective preventive strategies for drug abuse in sports is frequent, accurate, very closely observed, truly random urine drug testing. 13, 63 However, some view drug testing as ineffective at preventing use of PEDs. 64 The argument for the latter is that these interventions target doping behavior rather than athlete attitudes. Athletes ultimately focus on their performance, and thus may view doping as rational behavior. 63 Moreover, knowledge of the potentially dangerous consequences from doping imparted via didactic education does not necessarily dissuade athletes. For example, in 1997, Bamberger and Yaeger surveyed 198 Olympic athletes. When asked if they would use PEDs under the hypothetical conditions of knowing they would not be caught and knowing their use would result in victory, 195 of 198 responded "yes". Moreover, if the caveat was added that they would die within 5 years, 61% of the athletes still said they would use them. 65

There is little research available to guide counseling and psychiatric approaches to treatment of athletes who abuse drugs. 64 However, motivational interviewing approaches have been suggested for athletes with drug abuse or doping problems, since athletes may often present in the precontemplation stage of change. 13, 64 Important elements of motivational interviewing include: 64

1. Developing discrepancies between where the athlete wants to go in life after sport and the impact that continued use of the substance might have on those goals. During this process, the provider helps athletes to clarify conflict among their values, motives, interest, and behaviors.

2. Rolling with resistance. When resistance inevitably occurs, providers should avoid arguing with athletes, as that can exacerbate resistance to change. The provider may "agree to disagree" on certain points with some athletes. Providers may propose or "wonder about" certain alternative viewpoints or actions, but they do not impose or insist upon them.

3. Encouragement of self-efficacy. Athletes may need to shift their viewpoint from one of being willing to do whatever it takes to win, to acknowledging that they would use PEDs only if ultimately incapable of succeeding without them (with the hope that athletes will never get to that point). If an athlete is physically dependent on a drug, then additional strategies may be needed. These may include pharmacologic interventions such as naltrexone, acamprosate, or disulfiram for alcohol dependence, or buprenorphine for opiate dependence. 13 Additionally, providers should assess for comorbid mental illness, since co-occurrence of physical dependence and mental illness is commonplace. 13 Any underlying mental illness should be treated. 13 A recent review paper on the epidemiology of mental illness in athletes noted that some mental illnesses such as depression are probably as common in athletes as nonathletes. 14 Twelve-step facilitation, cognitive behavioral therapy, and network therapy are also approaches that may be helpful for athletes who are abusing drugs, although studies are preliminary. 10, 13, 66

Conclusion and suggestions

Drug abuse in athletes is a significant problem that has many potential underlying causes. The drive to be the best in sport dates to ancient times, as does the use of performance-enhancing substances. With the ever-mounting pressures faced by athletes, it is not surprising that drug abuse by athletes exists across essentially all sports and age groups.

Suggestions for those undertaking research and clinical work with athletes include:

1. If providers become aware of an athlete using PEDs, they should educate the athlete about the potential risks of continued use, regardless of any evidence that suggests this may not be influential for all athletes. Providers should encourage discontinuation of the abused substance(s).

2. There is great variance in drug testing programs in different sports and at different levels of competition. 13 More high-quality, prospective, randomized trials should be undertaken to determine the deterrent efficacy of various types of PED screening programs, and changes should be made to those types of screening programs found to be ineffective. 8

3. Physicians, trainers, coaches, parents, and others in the athlete entourage need to be well trained in recognizing the signs and symptoms of drug abuse, including changes in physical health and behaviors ( Table 3 ).

Table 3

Substance

Common signs and symptoms of use

Alcohol

Sedation, decreased concentration and coordination, disinhibition, slurred speech, vomiting

Anabolic steroids

Acne, rapid muscle gain, irritability, gynecomastia and hair loss in males, deepening of voice and facial hair in females, visible injection sites and cysts

Cannabinoids

Bloodshot eyes, increased appetite, slowed responses, cough, lack of motivation, paranoia

Opiates

Constricted pupils, sedation, slowed responses, slurred speech, constipation

Stimulants

Dilated pupils, anxiety, jitteriness, increased heart rate and blood pressure, loss of appetite, tics

4. The efficacy of education about PED use as a preventative measure needs further study. Early integration of well designed prevention curricula into sports programs may be beneficial. 8 However, as alluded to earlier, at least one preliminary study suggests that educational programs that solely emphasize the negative effects of PEDs may be ineffective for young athletes. 67

5. Mental health professionals should be included in the network of team doctors and other health care providers readily available to athletes. Psychiatrists are often helpful in developing strong drug prevention policies that emphasize education and treatment and not just sanctions. 13 Mental health care professionals should have a year-round presence with the athletes and teams with whom they are working so as to build trust. 13

6. Screening for and treatment of underlying mental illnesses such as depression that may contribute to self-treatment with drugs by athletes should be increased. The effectiveness of this screening should be studied.

7. Athletes who are using drugs are often skeptical of the medical field. This may be partly with good reason, as many health care professionals are unfamiliar with the mentality of athletes or common drug abuse patterns in this population. Accordingly, referral networks or team assistance programs consisting of health care professionals familiar with these issues should be established for athletes and teams. 62 The effectiveness of these models should be studied.

8. Research should examine differences in treatment approaches that may be needed for athletes who have been using drugs for a shorter versus longer period of time.

Trainers, coaches, and health care providers should provide evidence-based, safe alternatives to PED use, including optimal nutrition, weight-training strategies, and psychological approaches to improving performance, all of which may help with athletes' confidence in their natural abilities.

Footnotes

Disclosure
The authors report no conflicts of interest in this work.

References

46. Bailey JA, Averbuch RN, Gold MS. Cosmetic psychiatry: from Viagra to MPH. Directions in Psychiatry. 2009;29:1-13. [ Google Scholar]

64. Johnson MB, Sacks DN, Edmonds WA. Counseling athletes who use performance-enhancing drugs: a new conceptual framework linked to clinical practice. J Soc Behav Health Sci. 2010;4:1-29. [ Google Scholar]

Articles from Substance Abuse and Rehabilitation are provided here courtesy of Dove Press

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Drug abuse occurs in all sports and at most levels of competition. Athletic life may lead to drug abuse for a number of reasons, including for performance enhancement, to self-treat otherwise untreated mental illness, and to deal with stressors, such ...

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"34 percent indicated that sleep difficulties resulted in a lower grade on an exam or test, and an additional 13 percent reported that it resulted in a lower grade in the course."

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In 2011, more than 41 million U.S. adults over the age of 18 (about 18 percent) had a mental disorder, and nearly 9 million U.S. adults (4 percent) had a mental illness that greatly affected day-to-day living or resulted in serious functional impairment. Almost three-fourths of those who have been diagnosed with a mental disorder, such as anxiety, mood disorders, etc., have their first onset by age 24.

College students - including student-athletes - are not immune to struggles with mental well-being. About 30 percent of the 195,000 respondents to a recent American College Health Association (ACHA) survey reported having felt depressed in the last 12 months, and 50 percent reported having felt overwhelming anxiety during the same period.

One of the primary concerns regarding the prevalence of mental illness among student-athletes is that it may affect not only their success in academics and athletics but also their general well-being. While depression and anxiety have been found to be significant predictors of a lower grade-point average and poor athletics performance, they're also highly correlated with other risky behaviors, including suicide.

While it's not clear whether the source of challenges to student-athlete mental well-being is the same as those non-athletes face, collegiate athletes are known to encounter unique stressors that the general population doesn't have to deal with, such as time demands, relationships with coaches, and missed scheduled classes.

To help determine the prevalence and effects of anxiety and depression in the student-athlete population, we studied data from eight National College Health Assessment surveys the ACHA administered from 2008 through 2012. Those surveys cover issues including substance use, sexual behavior, physical health, weight, personal safety, violence, and mental health and well-being.

Varsity student-athletes were identified as those who answered "yes" to the question: "Within the last 12 months, have you participated in organized college athletics at any of the following levels...a) Varsity?" The others compose the non-athlete comparison group. In total, 19,733 student-athletes and 171,601 non-athletes were included in the analyses.

Both associated and demographic variables were included in the models. Demographic variables included sex, race, sexual orientation, transfer student status in the last 12 months and varsity athlete status in the last 12 months. The associated variables included perceptions of general health, perceptions of stress and substance use.

Additionally, a multi-part item asking whether a series of events or situations had been traumatic or difficult for one to handle was included in the model. These included:

Academics

Career-related issue

Death of a family member or friend

Family problem

Intimate relationship

Other social relationship

Finance

Health problem of a family member or partner

Personal appearance

Personal health issue

Sleep difficulty

After accounting for the demographics, nearly all of the associated variables were significant predictors for depression and anxiety, including student-athlete status, which was a negative predictor.

A few factors presented a comparatively strong relationship with depression and anxiety. Not surprisingly, the strongest was the perceived level of stress in the last 12 months. Stress can be associated with a number of the daily challenges college students face, including academics, interpersonal relationships, health concerns of a family member and financial concerns. Symptoms such as fatigue, hypertension, headaches, depression and anxiety can be attributed to stress.

The ACHA data show that sleep difficulties, and difficulties with intimate relationships and other social relationships also are strongly related to depression and anxiety.

Sleep difficulty was a self-reported measure asking if the respondent had experienced trouble sleeping in the last 12 months. Of those who reported yes, just 9 percent indicated that they had been diagnosed with insomnia in the last 12 months, and an additional 4 percent reported they had been diagnosed with another sleep disorder.

Fewer are being treated with medication for their diagnoses - just 7 percent in total. While few are reporting official diagnoses, a significantly greater percentage is reporting that difficulties with sleep are affecting them. Among those who said they are experiencing difficulty sleeping, 34 percent indicated that sleep difficulties resulted in a lower grade on an exam or test, and an additional 13 percent reported that it resulted in a lower grade in the course. (See Michael Grandner's article later in this chapter for more on sleeping disorders.)

The data also show that females and underclassmen were more likely to report difficulties with intimate relationships and other relationships. While reports of physical or sexual abuse in an intimate relationship are generally low (around 2 percent of all respondents), emotional abuse appears to be a greater concern, with 10 percent overall report having been in an emotionally abusive relationship. In all, 22 percent of those who claim having experienced difficulties in an intimate relationship report emotional abuse.

Loneliness is a common factor related to difficulties in relationships. Among those who reported relationship problems, 85 percent reported feeling very lonely in the last 12 months, compared with 50 percent of those who did not report problems with relationships. The data indicate that loneliness also is highly correlated with both anxiety and depression.

Anxiety also was strongly related to difficulties with academics. An additional factor with a significant relationship to both depression and anxiety was a catch-all category of "other" traumatic events. This may potentially include characteristics of collegiate student-athletes that were not covered in the survey. For example, poor athletics performance or loss of an athletics scholarship may be traumatic for student-athletes who are highly motivated athletically.

Seeking help. Most student-athletes and non-athletes in the study indicated a willingness to seek help for mental health concerns in the future (63 percent of student-athletes, compared with 68 percent of their non-athlete peers). However, the data indicate that student-athletes are less likely to report having received psychological or mental health services from a variety of providers, including counselors and psychiatrists. This could be due either to a reduced need among the student-athlete population or because they are less likely to report and seek treatment for these concerns.

Overall, while college student-athletes do struggle with depression and anxiety, the data indicate they are less likely than their non-athlete peers to report issues with either. Stress, interpersonal relationships and difficulty sleeping are strongly associated with depression and anxiety. Moreover, academic difficulties also are related to higher anxiety. Given the reluctance of student-athletes to report challenges with mental well-being, coaches, team physicians and athletic trainers are a good potential line of defense in encouraging their athletes to seek help when needed.
About the Authors
Ann Kearns Davoren joined the NCAA staff in 2004 and has focused primarily on student-athlete survey research. She has worked extensively with the NCAA Study of College Outcomes and Recent Experiences (SCORE) and the NCAA Growth, Opportunities, Aspirations and Learning of Students in college (GOALS) study. Ann also is involved in academic, governance and health and safety research across all three membership divisions. Before joining the NCAA, Ann was the assistant staff director at the Advisory Committee on Student Financial Assistance, a federal committee that advises Congress and the U.S. Department of Education on issues affecting student financial aid policy. Ann received her B.A. in speech communication from Saint Mary's College in Notre Dame, Indiana, and her M.P.A. with a focus on policy analysis and comparative international affairs from Indiana University in Bloomington. She currently is pursuing her Ph.D. in research methodology at Loyola University, Chicago.

Seunghyun Hwang is currently a researcher at the Korea Institute of Sport Science. He holds a dual Ph.D. from the College of Education at Michigan State University, where he specialized in the psychosocial aspects of sport and physical activity. He also has conducted research on student-athletes with respect to their academics and psychological well-being. He recently completed a Postdoctoral Research Fellowship in the Sport Science Institute at the NCAA national office in Indianapolis.

# data[].attributes.attachment_link.title
Mind, Body and Sport: Depression and anxiety prevalence in student-athletes

# data[].attributes.attachment_link.description
In 2011, more than 41 million U.S. adults over the age of 18 (about 18 percent) had a mental disorder, and nearly 9 million U.S. adults (4 percent) had a mental illness that greatly affected day-to-day living or resulted in serious functional impairment.

# data[].attributes.body
Injuries in an athlete can mean career suicide which can lead to depression and in some of the worst cases suicide.

Injuries can effect emotions and school performance as they cope it can even lead to substance abuse.

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Students can join support groups or even go to coach therapist to talk about their situations and reach out to others going through similar things

Step away from social media and focus on where your feet are

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Counseling Services is committed to the development of the whole person: intellectually, emotionally, spiritually, physically, and socially. As part of this commitment, Counseling Services recognizes the need for specific outreach, resources, and engagement of our student-athletes.

While not every student has the same experience, student-athletes may face unique stressors and struggles in their college experience that trigger emotional distress. The Counseling Services team is committed to providing a welcoming environment, where all identities, abilities, beliefs, and experiences are recognized and valued. Clinicians are available to provide counseling support to our student-athletes who may need a confidential space to explore distress, identify resources, and learn coping strategies. In addition to services we offer on-campus via counseling, case management, crisis intervention, groups, and outreach programming, we have collaborated with the JED Campus Team to compile resources here specific to the emotional and mental health needs of student-athletes.

Student-athletes are welcome to meet with Counseling Services for support and to learn more about any of the resources listed here:

The NCAA has a variety of resources related to athletes and mental health. Check out the NCAA Mental Health Sports Science Institute for Mental Health Education Resources including fact sheets on Anxiety, Depression, and Eating Disorders, as well as information on the Suicide Prevention.

HOPE HAPPENS HERE is a student-let movement that aims to promote mental health awareness and mental wellbeing on college campuses, and in particular for student-athletes. Follow Stonehill's HHH on Instagram! @stonehillhhh

Athletes for Hope: Whole Being Athlete|Mental Health Established in May 2021, the Whole being Athlete Program unites and empowers athletes of all levels and backgrounds to work together and end the stigma of mental health in and out of sports.

For student-athletes who may have experienced concussion, here's an article on how counseling can be helpful after concussion.

Looking to hear stories and perspectives from athletes regarding mental health? Check out:

Support for Sport is a site to help athletes find information about mental health referrals as well as how to have conversations with teammates when concerned about them.

LGBTQ+ Support: Athletes Share Coming Out Stories and Perspectives on Outsports.

Need additional resources? Check out this Resource List for athletes and mental health. Also consider checking out ULIFELINE, a great resource for a variety of college mental health topics. The Counseling Services Self-Help Resources page and the Health and Wellness Education site also provide helpful information.

We share resources on our site to offer information for interested students. However, it should be noted that Stonehill is not affiliated with these resources and they are independent platforms. It is a personal choice to utilize resources listed here and you may not find all the resources to be helpful for your needs. Please don't hesitate to call Counseling Services to schedule an appointment if you would benefit from discussing coping strategies and resources further. If you have any accessibility needs and cannot access resources listed here, please call the office and we will assist in any way we can.

In the event you are experiencing an emergency, please contact Campus Police at 508-565-5555 if on-campus or 911 if off-campus.

If you are in crisis and need to speak to a counselor urgently, please call our main line at 508-565-1331 and select Option 2 to be connected to the 24/7 Urgent Support Line.

If you would like to schedule a routine appointment such as an intake, or inquire further about our services, please call our main line at 508-565-1331 and select Option 1 to be connected to the front desk.

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Skip to Main Content Counseling Services is committed to the development of the whole person: intellectually, emotionally, spiritually, physically, and socially. As part of this commitment, Counseling Services recognizes the need for specific outreach, resources, and engagement of our student-athletes.