Athletic Trainers Miss the Mark on Mental Health Knowledge

Nancy A. Melville

June 06, 2013

INDIANAPOLIS, Indiana — There is a "striking discrepancy" between the perceived knowledge of college-level trainers and their competence in managing athletes with mental health disorders, according to new research.

The purpose of the study was to get a clearer picture of the extent of awareness and understanding of the mental health disorders that athletic trainers might encounter and to shed light on areas in need of improvement, said study author Andrew Krause, PhD, from the Ohio University Heritage College of Osteopathic Medicine in Athens.

"We wanted to identify the scope of specific diagnoses that athletic trainers have had experience with and what specific resources they use to manage these cases," he explained.

Dr. Krause presented the study results here at the American College of Sports Medicine 60th Annual Meeting.

The researchers surveyed 211 athletic trainers at National Collegiate Athletic Association member institutions with a median of 15.2 years of clinical practice about their experience managing athletes with mental health disorders. They were also asked to self-assess their understanding of the disorders.

Overall, 70% of the athletic trainers reported feeling competent to recognize the signs and symptoms of mental health disorders and make appropriate referrals. However, when competence in the use diagnostic criteria for mental health disorders was assessed, only 44.0% clearly understood the issues, and only 23.5% of respondents reported knowing Diagnostic and Statistical Manual of Mental Disorders (DSM) Fourth Edition, Text Revision norms.

Of the respondents, 75.9% reported that they had experience managing an athlete with a mental health disorder.

Table. Most Common Mental Health Disorders Encountered by Trainers

Disorder Percent
Attention-deficit hyperactivity disorder 86.7
Disordered eating 84.8
Depression 83.9
Anxiety 78.2
Substance use or abuse 75.8


Overall, 63.2% of the athletic trainers reported moderate confidence in their ability to manage mental health disorders acutely, and 43.9% reported moderate confidence in their ability to manage the disorders in the long term.

However, more than 70% reported a lack of knowledge about the medications prescribed to treat mental health disorders and the adverse reactions related to these drugs.

These findings are a concern, given that competitive sport can potentially exacerbate or even cause problems, ranging from depression and anxiety to eating disorders, and even suicidal ideation, said Antonia Baum, MD, a sports psychiatrist from Chevy Chase, Maryland, and vice president of the International Society of Sports Psychiatry (ISSP).

"For young athletes who may be at a high risk of depression or anxiety that is undiagnosed, their one opportunity to have their condition identified could be in their relationship with an athletic trainer and in the screening for sports," she said.

"It's a terrific opportunity to identify these cases, so should athletic trainers get better training? Absolutely. Are they getting the proper training? Evidently, no," said Dr. Baum.

"We hope that our data will be used to justify the need to develop a consensus for the care of mental health disorders," Dr. Krause said.

The National Athletic Trainers' Association (NATA) currently does not have a position on the management of mental health disorders; however, a consensus statement is in the works and is set to be released in September.

Tim Neal, MS, ATC, chair of the consensus statement committee for mental health disorders, said this study underscores precisely why such a statement is necessary.

Athletic trainers — and I think people in general — tend to overestimate their ability to effectively manage these issues.

"This study highlights the fact that athletic trainers — and I think people in general — tend to overestimate their ability to effectively manage these issues. That is why the NATA has decided to establish this consensus statement," said Neal, who is assistant director of athletics for sports medicine and head athletic trainer at Syracuse University in New York.

The statement is still a work in progress, but Neal reported the core components of the goals: to raise awareness about the prevalence of mental health disorders in college-aged students, particularly student athletes, which is estimated to be as high as 25% to 30%; to monitor behaviors, including taking note if an athlete's behavior shifts from his or her normal patterns; and to set up a referral system with the right mental health professionals.

"I can't stress enough that the athletic trainer or coach or anybody who is not a credentialed mental health professional should not be counseling student athletes," he said.

"As this study illustrates, too many people overestimate what they are capable of doing. We have to be aware of the scope of our practice and stay within it, identify potential problems, and establish a referral mechanism to get the athlete appropriate help," Neal explained.

Athletes can be even less likely to self-report potential mental problems than nonathletes, Ira Glick, MD, professor emeritus of psychiatry at the Stanford University School of Medicine in California and founder of the ISSP, told Medscape Medical News before the 2012 Summer Olympics. In part, this is because of a "gladiator" mentality of endurance and a perceived stigma related "to going to see psychologists or psychiatrists — or even nonpsychiatrists, internists, or general practitioners," he explained.

"If they go for help, it's a sign of weakness," he said.

According to Dr. Baum, that is precisely why the athletic trainer can be critical.

"When an athlete is feeling depressed or suicidal, chances are good that they aren't going to volunteer that information. Athletic trainers need to have the ability and perception to ask the questions that need to be asked and develop a relationship that will allow them to provide help when needed."

Because the role of the athletic trainer is to make the proper referrals, the failure to truly understand the details of the DSM might not be quite as important as the study suggests, she noted.

"There can be a whole constellation of symptoms involved in a mental health diagnosis — well beyond what's in the DSM. It would be far too much to expect an athletic trainer to fill that role," she explained.

"What is key is triage to a mental health professional, preferably a psychiatrist who can manage any medication and assess things like side effects."

Dr. Baum noted that "in an ideal world, a psychiatrist should be an integral part of every athletic department, just as we have orthopedic surgeons."

Dr. Krause, Dr. Baum, and Mr. Neal have disclosed no relevant financial relationships.

American College of Sports Medicine (ACSM) 60th Annual Meeting. Abstract 1814. Presented May 30, 2013.


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