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Dr. Mandelbaum Explains to Medscape How Sports Physicians Can Take Action Against Suicide


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.


  1. 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.
  2. Russian A. Robin Williams was 'snorting coke,' 'screwing everybody in town' in early days, new book claims. People. 2018. Source Accessed June 15, 2018.
  3. Centers for Disease Control and Prevention. More than a mental health problem. CDC Vital Signs. 2018. Source Accessed June 15, 2018.
  4. Thompson R, Sherman R. Managing student-athletes' mental health. NCAA. 2007. Source Accessed June 15, 2018.
  5. Iverson G. Chronic traumatic encephalopathy and risk of suicide in former athletes. Br J Sports Med. 2013;48:162-164.
  6. 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.
  7. 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.
  8. Rowell EK. 1001 Quotes, Illustrations, and Humorous Stories. Grand Rapids, MI: Baker Books; 2006.
  9. Martinsen EW. Exercise and depression. Int J Sport Exerc Psychol. 2005;3:469-483.

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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.
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