There has been an increase during the past several years in the extent and severity of mental-health problems for which students seek psychological counseling.

In a study of 13,257 Kansas State University students between 1989 and 2001, there was an increase in the complexity of mental-health issues, including areas that one might expect in a college population (such as relationship difficulties and developmental issues), as well as more severe problems, including anxiety, depression, suicidal ideation, sexual assault and personality disorders.

During that time period, the number of students seen for depression doubled, and the number of students with suicidal ideation tripled. These issues are not isolated to any one school, and several schools have noted similar increases in psychological demands and needs of students.

It is unclear why these increases in mental health problems have occurred, and most experts feel it may be that as the world has become more complex, more students are not equipped to handle the "stressors."

Robert Portnoy, director of the University of Nebraska, Lincoln's, counseling and psychological services center, stated in a February 3, 2003, article in The New York Times that "people just don't seem to have the resources to draw upon emotionally to the degree that they used to. What would once have been a difficult patch for someone in the past is now a full-blown crisis."

What about student-athletes?

Some might assume or expect that athletes might be better adjusted, have higher self-esteem or confidence, and therefore are at a lower risk for experiencing mental health issues. Though this question has not been answered, it may very well be that this assumption is not at all true; maybe athletes are at higher risk.

When it comes to mental health, the full range of issues found in the general student population can also be found in the life of student-athletes. Mental health is challenged by any number of factors in student life. Students may experience depression because of genetic predisposition, developmental challenges of college transitions, academic stress, financial pressures, interpersonal difficulties and grief over loss/failure.

Participation in athletics does not provide student-athletes any immunity to these stresses, and it has the potential to pose additional demands. Student-athletes must balance all of the demands of being a college student along with athletics demands. This includes the physical demands of their sport, along with the time commitment of participation as well as strength and conditioning and skill instruction.

Most athletes participate almost year-round, often missing holidays, school and summer breaks, as well as classes and even graduation. In addition, if they struggle in their performance, have difficulty interacting with the coach or teammates, or if they lose their passion for their sport, it can be very difficult to handle.

On the other hand, for many athletes who define themselves by their role as an athlete, an injury can be devastating.

Some attributes of athletics and competition can make it extremely difficult for student-athletes to obtain help. They are taught to "play through the pain," struggle through adversity, handle problems on their own, and "never let your enemies see you cry." Seeking help is seen as a sign of weakness, when it likely should be recognized as a sign of strength.

Team dynamics also may be a factor: problems often are kept "in the family," and it is common for teams to try to solve problems by themselves, often ignoring signs or symptoms of more serious issues.

Depression affects approximately 19 million Americans, and for many, the symptoms first appear before or during college.

Early identification and intervention (referral/treatment) for depression or other mental illness is extremely important, yet may be inhibited within the athletics culture for the following reasons:

• Physical illness or injury is more readily measured and treated within sports medicine, and often there is less comfort in addressing mental illness.

• Mental wellness is not always perceived as necessary for athletic performance.

• The high profile of student-athletes may magnify the attention paid on campus and in the surrounding community when an athlete seeks help.

• History and tradition drive athletics, and can stand as barriers to change.

• The athletics department may be in denial, or desire to disassociate mental illness in any way with athletic participation.

But in these times of increasing awareness, an athletics department can no longer afford in human terms to remain unaware of problems. The ultimate failure of a system that does not attend to these issues is counted in drop-outs, substance abuse, violence and even death, either by homicide or suicide. These serious issues bring clarity to the urgency of attending to mental health, but the signs and symptoms that may lead to them are not always clear.

What should we be doing?

One way to ensure an athletics department is in tune with student-athletes' mental well-being is to systematically include mental health checkups.

A number of programs exist that provide an easy way to incorporate these checkups. Three such programs are QPR (Question, Persuade, Refer) Gatekeeper training; the Jed Foundation U Lifeline; and the Screening for Mental Health Depression and Anxiety Screenings. Information about these programs, and ways to incorporate them into student-athlete physicals, can be found at www.ncaa.org/health-safety, via the Hot Topics link.

Also available at the Web site is a short video from the parents of one student-athlete who committed suicide. The video may be used to raise awareness within an institution about the issue of mental health/depression and suicide.

One important preparation is to gain confidence in sources for assistance where athletics departments may refer student-athletes. It is useful to become familiar with the campus counseling center, and to discuss whether it is an appropriate referral for student-athletes or if that center recommends another resource.

It is important that the referral system accommodate the special needs that student-athletes face. Their resistance to seeking help, along with pre-set suspicions about what counseling entails and the overwhelming sense that they should be "strong" enough to handle their problems on their own, often make athletes a tougher crowd to guide into seeking counseling. It is also important to ensure that the psychological staff has an understanding of the life of a student-athlete, the coping mechanisms that athletes have, and the role athletics has in the life of the athlete, as well as the psychological issues that they are facing.

A recent survey of NCAA coaches provided positive information about satisfaction with services provided by mental-health professionals. Responding to a general referral to a mental-health professional, 72 percent of coaches surveyed found the services to be good or excellent.

Student-athletes are amazing people -- they manage so much in a 24-hour period. But they also are prone to overbooking themselves, giving all for the team and others, and sometimes ignoring their personal needs.

The whole team, the athletics department and indeed the entire campus will thrive when mental health is considered as important to student-athlete well-being as all the other important student development issues we currently address. Athletic performance, academic performance, interpersonal behaviors and future success all depend on keeping our mental and emotional lives functioning at peak performance.

Nathan's story: Awareness, training saves lives

The case of Nathan Eisert may help demonstrate the dilemma faced by athletics departments in identifying athletes who would benefit from intervention. Here's Nathan's story, told by his mother, Jan Ulrich.

As a mother, I was so excited when my son Nathan Eisert was asked to walk-on to an NCAA Division I basketball team in 2000-01. I envisioned all of the wonderful opportunities that lay ahead of him, not just as a basketball player, but as a person. And I believed that as a student-athlete he would be surrounded by a safety net of coaches, trainers and teammates. I could never have imagined that two years later he would be found dead in his dorm room from a self-inflicted gunshot wound.

Nathan worked very hard his first year, had some opportunities to get in some games and score some three-pointers. He made honor roll. He wanted so badly to improve his game that he would seldom stray far from the gym, even during his summer break. In the summer of 2001, he was awarded a one-year scholarship. That same night, during a pick-up game, he badly re-injured an ankle that he had broken two years before during a basketball camp. The doctor at the hospital told him that he would have been better off if he had broken his ankle and that it would take at least a year to heal.

His sophomore year was very different from his freshman year. He got very little playing time and his grades dropped. But when I would ask him if he still wanted to be on the ball team he would say "Mom, I'm okay. You don't have to worry about me."

But he wasn't okay. He still struggled with the pain from his injury and the feeling that he was no longer a benefit to his team. We did not know it then, but he was suffering from undiagnosed and untreated depression. In May 2002, he was dismissed from the team. No one told me or his stepdad that he had been released from the team. The coach did contact his natural father, who lives near the university. About five weeks after his release from the team, on June 8, 2002, Nathan was dead.

Nathan did not talk to us about his depression. But in the weeks before his death, he talked about the depression he saw in several of his teammates. He expressed concern about another high-profile player that had also experienced a devastating injury. Maybe this was Nathan's way of trying to talk about his own feelings.

Several months after his death, another athlete at the school struggling with grief over Nathan's death and other life circumstances attempted suicide. College athletes have since told me that the reason they didn't ask for help was because "They tell us every day we have to be mentally tough. To ask for help would mean getting kicked off the team."

Nathan's former coach left the university about a year after Nathan's death to coach at another school. Nathan's teammate and sophomore-year roommate transferred to another institution. While I have received very little communications from his former teammates, coaches or trainers, I can only imagine that they too, still struggle with the grief, loss and guilt that accompanies any suicide death.

As a parent and a suicide awareness and prevention advocate, I am convinced that my son's life could have been saved. There are predictable events in the life of a college-athlete when they are more susceptible to depression and/or substance abuse problems. I have witnessed lives saved because of better awareness, training and education. These young women and men who step up to offer their hearts and souls to "the game" deserve no less.

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