When I was the sports medicine doctor at the University of California,
Los Angeles (UCLA), I had a resident who came to us from Johns Hopkins
Medical School. He was a bright and dynamic young man who was also a competitive
marathoner. But he seemed to suffer from the hard lifestyle of a resident
even more than most. He struggled to understand that he was accepted.
One Saturday on grand rounds, everybody noticed that he was off, and we
referred him to a psychologist. He was diagnosed and put on lithium for
bipolar disorder. But just a few weeks later, he shot himself in the chest and died.
I've been thinking about that young man recently following the suicides
of Anthony Bourdain and Kate Spade. To me, these are not just news events.
A number of my patients have committed suicide over the decades, and 5
years ago two of my colleagues in the Santa Monica community, an ophthalmologist
and an anesthesiologist, killed themselves in the same year.
The prevalence of suicide increased by 25% from 1999 to 2016.[1] As sports physicians, we often encounter athletes at a point of extreme
pressure as they face sports competition. Physicians, too, face constant
stress as we struggle with limited time and resources to help people in
dire situations. My first day at medical school, the dean said to my class,
"Fifteen percent of you will see a psychiatrist before you graduate."
It's part of our practice, part of our community, and part of sports—what
I call the life of sports and the sport of life.
How can we best help our patients and our colleagues who are at risk for
suicide? The first step is figuring out who is likely to be affected.
Many athletes come to us for help. But in others, we must learn to recognize
the signs of a problem that they may not want to discuss.
Suicide can be particularly puzzling when it strikes someone like Bourdain,
who seemed to have so much going for him. "If I am an advocate for
anything, it is to move," he once said. "As far as you can,
as much as you can. Across the ocean, or simply across the river. Walk
in someone else's shoes or at least eat their food. It's a plus
for everybody." I'm still struggling to imagine how someone with
that attitude took his own life.
I'll never forget a dinner I had with the iconic comedian Robin Williams
when he came to a World Cup soccer game at Stanford Stadium in 1994. For
4 hours, I couldn't eat, I was laughing so hard. I felt a profound
shock when he died by his own hand two decades later.
In some cases, an underlying health problem can be discerned. Williams
suffered from diffuse Lewy body dementia, and earlier in his life he grappled
with substance abuse.[2] According to the Centers for Disease Control and Prevention (CDC), substance
abuse is a factor in 28% of suicides, while underlying physical conditions
are a factor in 22%.[3]
But more than half of people who die by suicide, like Bourdain, did not
have any known mental health disorder. If I have someone come in with
an open tibia fracture, an x-ray displays the fracture, and as an orthopedic
surgeon, I know how to fix it. But suicidal tendencies are often much
harder to diagnose and treat.
Here are the CDC's 12 warning signs:
- Feeling like a burden
- Being isolated
- Increased anxiety
- Feeling trapped or in unbearable pain
- Increased substance use
- Looking for a way to access lethal means
- Increased anger or rage
- Extreme mood swings
- Expressing hopelessness
- Sleeping too little or too much
- Talking or posting about wanting to die
- Making plans for suicide
More specific to athletes, a pamphlet from the National Collegiate Athletic
Association (NCAA) notes that a sudden decline in sports performance can
be a warning sign of a mental health problem. Conversely, poor sports
performance or fatigue can lead to depression.[4] One athlete who I have worked with who has been most public about his
depression is Landon Donovan, probably the greatest US soccer player ever.
His career was affected by his symptoms.
The NCAA pamphlet notes that depression can be hard to diagnose because
depressed people often withdraw. They may feel they don't merit your
attention, or feel embarrassed and seek to hide the problem by pretending
to be cheerful.[4]
One anesthesiologist I worked with chatted with me on a Friday afternoon
when we operated together. We talked about our children, about the schools
we had attended. All seemed well with her from what I could tell. But
that Monday morning she slit her wrist. Looking back, I keep wishing I
had been able to discern some warning sign in that conversation. Others
may use alcohol, drugs, or eating disorders in an attempt to manage their
depression.[4]
In other athletes, we have seen that chronic traumatic encephalopathy creates
behavior abnormalities in a spectrum. Although the most widely reported
cases have been in football, there have been a few reports in hockey,
soccer, and other sports. It manifests as behavioral symptoms: impulsiveness,
depression, and bipolar symptoms.[5]
The NCAA advises making an immediate referral if a student athlete makes
a suicide attempt or expresses a suicidal thought, intent, or plan. I've
been fortunate to work throughout most of my career with organizations
who have sports psychologists on staff. When I suspect that an athlete
is at risk, I don't hesitate to refer my patients to these experts.
Sports physicians working without these resources at their disposal and
limited or no insurance benefits must prepare in advance by identifying
the names and phone numbers of the experts to whom they can refer such
patients on an urgent basis. A good place to begin on college campuses
is the health or counseling center. When the moment comes that you identify
a suicidal patient, do not leave that person alone. Stay with them until
they are in the hands of someone else who can help them. If necessary,
escort them to a mental health expert.[4]
The National Suicide Prevention Lifeline is 1-800-273-TALK (1-800-273-8255). An
online crisis chat is available as well.
In working with an athlete who seems depressed, start by listening. Show
that you take the athlete's emotional disturbance as seriously as
a physical injury, and that you do not consider it a sign of weakness.
Stop what you are doing. Look at the athlete. Wait to speak until the
athlete has finished. Make a referral to a specific person.[4]
Treatment truly can help. A few years ago I was lecturing through the National
Association of Secondary School Principals, when I met Ross Szabo. He
was 6' 3", maybe 30 years old. "Look at me," he said.
"I'm good-looking, well-spoken, played high school football.
But I'm bipolar."
It was like an alarm going off 24/7 in his head, he said. The only way
he could deal with it was through alcohol and illegal drugs. But he finally
found a physician who put him on the proper medication and he came to
life, becoming an inspirational speaker.
Sports itself may help prevent suicide. Research on both high school[6] and college[7] students has shown that participation in sports teams and physical activity
are associated with a lower suicide risk.
In studying the evolution of human beings, Margaret Mead, the famous anthropologist,
found that the femur fractures she uncovered in Samoa never healed until
about 15,000 years ago. After that, she started to find femur fractures
that had healed. From that, she deduced that that was the moment when
compassion and caring for others in the human clan started, because it's
when we began taking care of each other.[8]
Perhaps that has something to do with the reason that people who participate
in sports teams are less likely to commit suicide. Beyond the well-documented
benefits of exercise for mental health,[9] teams provide a framework for caring. As sports physicians, we can do
our part to make sure that we are aware, caring, and compassionate for
those who need us most.
References
- Vital Signs: Trends in suicide rates and circumstances contributing to
suicide — United States, 1999–2016 and 27 states, 2015. MMWR
Morb Mortal Wkly Rep. 2018;67:617-624.
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Russian A. Robin Williams was 'snorting coke,' 'screwing everybody
in town' in early days, new book claims. People. 2018.
Source Accessed June 15, 2018.
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Centers for Disease Control and Prevention. More than a mental health problem.
CDC Vital Signs. 2018.
Source Accessed June 15, 2018.
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Thompson R, Sherman R. Managing student-athletes' mental health. NCAA. 2007.
Source Accessed June 15, 2018.
- Iverson G. Chronic traumatic encephalopathy and risk of suicide in former
athletes. Br J Sports Med. 2013;48:162-164.
- Brown D, Galuska D, Zhang J, et al. Physical activity, sport participation,
and suicidal behavior. Med Sci Sports Exerc. 2007;39:2248-2257. doi:10.1249/mss.0b013e31815793a3.
- Lester D. Participation in sports teams and suicidal behavior: an analysis
of the 1995 National College Health Risk Behavior Survey. Percept Mot
Skills. 2014;119:38-41. doi:10.2466/06.15.pms.119c13z5.
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Rowell EK.
1001 Quotes, Illustrations, and Humorous Stories. Grand Rapids, MI: Baker Books; 2006.
- Martinsen EW. Exercise and depression. Int J Sport Exerc Psychol. 2005;3:469-483.
Medscape Orthopedics © 2018 WebMD, LLC
Any views expressed above are the author's own and do not necessarily
reflect the views of WebMD or Medscape.
Cite this article: Sports Physicians Can Take Action Against Suicide -
Medscape
- Jul 26, 2018.