All right. Hello, everyone. Thank you for joining us tonight. I'm going to be your moderator this evening, Dr. Devin McFadden, and I'm thrilled to be joined by Dr. Eugene Hong, who's going to be speaking to us about mental health and the athlete. Before we get started, I'm just going to go over some quick ground rules. So this is part of the National Fellow Online Lecture Series, which is sponsored by the Online Fellows Education Subcommittee, as well as the Education Committee and Fellowship Committee of AMSSM. The intent is to serve as an adjunct to your program's educational programming, to provide fellows with direct access to educational experiences with experienced AMSSM members. And at times, invited guests, experts in a variety of formats, but really the big purpose is to assist in CAQ exam prep as well. So this is something that you can certainly come back to online on YouTube later on as you prep for the boards. Just some ground rules. If I can figure out how to advance the slide. Mute your devices' microphones, please, so that the only person we hear is the speaker. I will be doing the same. If when I come back at the end to answer questions or ask the questions that you submit in the chat, you can't hear me, please just wave your hands and I'll figure it out. You can submit the questions throughout the presentation, I will monitor the chat section, and then at the end I will discuss those with Jean to get them answered for you. And then after the completion of the lecture, if you would please complete the evaluation form that there will be a link for. That just gives us good data to figure out how to make this better for you guys in the future. Again, we appreciate your attendance and hope you enjoy it. And from here I will turn it over to Dr. Eugene Hong. Actually, I won't because I need to read his intro. So Dr. Eugene Hong is the Chief Physician Executive for the Medical University of South Carolina Physicians and MUSC Health. In this role, Dr. Hong serves as a member of the MUSC Health Executive Leadership Team, and as an Executive Committee Officer for the Physician's Practice Plan. Prior to joining MUSC in March 2018, Dr. Hong spent 15 years at Drexel University College of Medicine in Philadelphia, Pennsylvania, where he held numerous roles to include Drexel University Physician Board Chair, Associate Dean for Primary Care and Community Health, Chief of the Division of Primary Care Sports Medicine, Fellowship Director of Drexel Sports Medicine, and Residency Director of the Drexel Family Medicine Program. Previously, he served as the Clinical Assistant Professor of Family Medicine and Sports Medicine for the Department of Family and Community Medicine at Jefferson Medical College, Thomas Jefferson University in Philadelphia, Pennsylvania, as well as Assistant Director of Primary Care Sports Medicine and Assistant Residency Director for Underwood Memorial Family Medicine Residency. Dr. Hong attended Phillips Exeter Academy, where he graduated with high honors, and also attended Columbia University in New York, where he was a member of the Sackhams Honor Society. He earned his medical degree from Tufts University School of Medicine in Boston, Massachusetts. His medical training included a surgical internship at the University of Connecticut, Connecticut Community Health Fellowship at the University of Massachusetts, and Family Medicine Residency and Sports Medicine Fellowship at Thomas Jefferson University. Dr. Hong's professional interests include the areas of concussions, tendinopathy and tendinosis, injury prevention, acute and chronic injury, and illness related to sports and exercise, exercise science, and the health and wellness of athletes of all ages and abilities. Dr. Hong has served as a team physician for several universities and colleges, two national U.S. lacrosse teams, and a number of high schools. He's treated athletes of all ages and abilities, including high school, college, professional, competitive, amateur, and weekend warriors. His research interests include the evaluation and management of sports-related concussions, treatment of tendon injuries, and mental health of athletes. Dr. Hong's scholarly work has been cited on ESPN and the New York Times, and he has received funding from the NIH, Department of Defense, and the NCAA. He currently serves on the NCAA Task Force on Mental Health and Athletes. He's received academic and professional awards and honors, including AOA, University Teaching Awards, Service Awards from the AMSSM, and the American College of Sports Medicine ACSM, and has been named a Top Doc in Philadelphia for several years running. So with that impressive intro, I will turn it over to Dr. Hong. Thanks, Devin, for the kind introduction. And thanks, everyone, for attending. Thank you, AMSSM and the subcommittee, for inviting me tonight to present to you. I will share my screen and see if that works. I can get a thumbs up from you, Devin. Is that working? All right. So, again, thanks, everyone, for attending, and appreciate the opportunity from AMSSM to speak to you about a topic and subject near and dear to my heart, certainly, but maybe as importantly, on your CAQ exam coming up at some point in the near future for all of you. So we'll try to make this talk interesting and practical at the same time. I do not have any disclosures of a financial nature to make. I wish I did, but I don't. Maybe I'll also mention, though, myself and Dr. Ashwin Rao from the University of Washington published a book on this topic just last year. We co-edited 22 chapters, and a number of AMSSM members contributed to that, and then also have given the CAQ prep talk on this area of mental health as well for a few years as well at AMSSM and ACSM. So with that, objectives are going to be modest. I do have about 60 slides, so I will be going through some of the slides fairly quickly and certainly not reading everything content-wise on every slide. I do understand that this is available to certainly everyone watching tonight afterwards on the AMSSM YouTube channel, so people can review some of the slides in more detail. But to be respectful of everyone's time, we'll be about 45 minutes or so, 40 minutes, and certainly time for questions and answers. So here's our objectives. We're going to focus on a few specific areas that I think are fair game for the CAQ prep exam. That is depression in athletes and injured athletes and mental health considerations there. So as I said, we'll make this as interesting as well as practical as possible. So 2006, the team physician consensus statement, if you haven't seen that from various sports medicine organizations, they get together and we had a writing group. And this was the conversation at lunch during a break in the writing effort for the 2006 psychological issues in the injured athlete statement. So these are true quotes that kind of have stuck with me the last 15 years. And for those of you who haven't started practicing yet or training, you will soon understand these quotes from two very experienced primary care sports medicine docs, because sometimes that's what our job feels like. This is a case study, a real case, and I'm going to come back to refer to it throughout the talk a couple of times just to kind of level set us in terms of the clinical applications of what we're going to talk about tonight. But a real case, a 21-year-old college basketball player, D1, with a complaint of insomnia. And doesn't necessarily talk about the sleeve on her knee, but while we're taking the exam and the history, just we start to talk about what the sleeve on her knee is there for and how it's affecting her. And I'll refer back to it. Gene, sorry to interrupt. We're still just seeing your title screen. If you could switch it to slideshow mode, I think we'll be able to see you advancing the slides. Gotcha. Sorry about that. Yeah, no, my bad here. So if you want to, I'm going to stop sharing, Devin, and I will restart, okay? Okay. Because somehow it paused. And I'm not sure why. So can you see a slide with bar graphs on it? Yeah. And I want to make sure I can advance the slides. There we go. I'll just quickly review so nobody saw anything besides the title slide. Here are the objectives. Fairly modest, but as I said, we have 60 slides or so. We're going to focus on talking about depression in athletes, the prevalence of risk factors, presentation and evaluation, and then also talk about the injured athlete and what you need to consider when it comes to mental health. All fair game topics, in my opinion, for the CAQ prep exam. And then I guess the joke didn't go so well when I was just talking and you couldn't see the slide, but these are actual quotes from primary care sports medicine doctors who everyone would recognize. And this was from a lunch break during the writing of the 2006 team physician consensus statement on psychological issues in the injured athlete. For those of you who aren't looking at the screen, one quote from a West Coast NFL team physician says, some days I feel like I'm an orthopsychiatrist. And a Pac-12 team physician responded at the same lunch table, then I must be an ortho-gyno-psychiatrist. Hopefully that joke went over better with the visual. Real case study, which I'll refer back to. So let's talk about depression prevalence. And those of you, everyone watching it, if you're through your primary residency training, already know some of these facts here, right? So these are just fundamental facts about what we know about depression prevalence in the U.S. So 12-month prevalence is 6.7%. And lifetime prevalence of depression, 16.5% in the U.S. adult population. And vary by age group. Here's a breakdown bit of that slide, too, of depression prevalence. And then if you weren't familiar, there's over 400,000 NCAA athletes participating each year. And millions of high school students, 5 to 7 million high school students, just involved in interscholastic sports alone. So my point in this slide is if you're practicing sports medicine and you think you've never seen an athlete who has depression, they've probably seen you. Even if you haven't seen them. But for those of you who are about to go out and practice in sports medicine, and we'll talk about this more on the slide, it's out there. There are athletes with depression. So it's part of our job to make sure we identify it and hopefully treat it appropriately. So let's talk about certain populations and depression. So depression, certainly prevalence is higher in young adults and in older adults. And I showed that bar graph slide. And many adults experience their first depressive symptoms actually in adolescence. So adolescence is an interesting time. Certainly we're encouraging athletic activity. Many folks in this age group are getting involved with organized sports and recreational sports. So a competitive adolescent athlete may have different expectations and pressures than their peers that are not involved in interscholastic sports. And we'll talk about what those differences may be. And then certainly in depression and adolescence, we worry about the increased risk for alcohol and drug abuse. And it's associated certainly with negative health consequences, including suicide in this population. So what about the college population? Well, most people on this call or watching this link will know that this has become an increasing problem in this population, certainly backed up by studies that showed increasing prevalence of depression in the college population. And then unfortunately, suicide is the second leading cause of death in the college population. So if you are taking care of college student athletes, you should be aware of some of these facts as well. What about retired NFL players? So this study has actually also been done. And I lost the actual references at the bottom when I was reformatting these slides, but I can certainly share that as well. So here's a study of retired NFL players. A pretty good response rate, almost 50%, mean age of a little over 50. But 14.7% scored in the moderate to severe category with their validated depression screening tool that was used in the study. And then I'll draw your attention to the bottom of this slide, actually. So the authors propose, actually, there may be an increased risk for suicide based on the results of the survey in this particular group of athletes, that is, retired NFL players. So I think, unfortunately, it's still a misconception out there of whether athletes are actually at increased or decreased risk for psychopathology. Again, in your primary residency training, we all understand that exercise can be used to treat some mental health conditions as well. It can be beneficial. So just wanted to have a slide acknowledging that and some further slides will discuss whether we think really you're at increased risk or decreased risk for psychopathology if you're an athlete. So some arguments that will propose decreased risk for psychopathology if you're an athlete. Things I think everyone would agree on, some of the benefits of exercise in sports and activity. But we'll talk more in this talk about what are some of the increased risks in an athlete for psychopathology, in particular depression. So athletes, by nature of their activity, are exposed to injury risk. Injury risk can increase that risk for an abnormal psychological response or a pathologic psychological response. And then, of course, athletes face some different pressures than non-athletes. You may know that a Division I varsity athlete might spend up to 40 hours a week at their sport, and that's on top of a full load of classes, is one example. So there are different triggers and or influences that potentially could affect an athlete's risk for depression that may be different from non-athlete peers. So how about studies so far in depression in college athletes? Well, they've been a little all over the place, and 15 to 21% prevalence. There's been some lack of consistency. We're getting better at this. And certainly from my perspective, someone who's kind of been struggling with this question for the last 15 to 20 years. And it is still a little bit in terms of actual numbers. So I don't think you'll get quizzed or asked a question exactly, is it 15 or 21%? I think that's not fair for the CAQ. But you might get something. Is it 5? Is it 10? Is it 20? Is it 50%? So this is kind of the studies to date. I'm actually going to present some of our own research, which we think is maybe more definitive in terms of what is the true prevalence of depression. Now, that's been published and peer reviewed. So are athletes at risk for depression? Here's a few studies that show, yes, that they actually may be at higher risk for depression. I'll read them to you all. But there's also studies that show maybe that athletes are at less risk for depression based on prevalence. So there's literature on both sides to support that question. But I think there's more and more agreement here. And this is based on the literature, certainly based on experience and based on ongoing research. And myself and colleagues are looking at this question, just kind of group risk factors into four areas. So injury seems to be a risk factor for depression in athletes. The end of a career, especially one that's involuntary, an unexpected injury that ends a career, for example, or other unexpected and unanticipated reason for a career ending could be a risk factor. Certainly performance expectations can apply some influence risk factors for depression. That's a little bit easier to understand after Michael Phelps and others have come forward with their struggles with depression. To understand, I think, when you talk to an athlete. So an athlete of any level will have performance expectations, right? And even at the highest level. And then loss of athletic identity seems to also be a risk factor for depression in athletes. And we'll talk more about what that actually is and how to screen for it. So let's talk about injuries and depression risk. So a number of states have looked at this and will present some actually also some further unpublished research that myself and a colleague have in this area. But we do think that having an injury actually increases the risk for depression in an athlete. There's some other kind of citations here where injured athletes may be up to six times more likely to experience depressive symptoms as non-injured athletes. And if you weren't aware, if you look at studies of Division One college athletes, a number of them have report being injured at least once. So injuries are very common in student athletes at the college level and probably at every level. A couple of interesting studies from Zachary and some colleagues. And I apologize again for the citations. They disappeared when I reported the format of these slides. But this is from AJSM. It's a well-known study that looked at the risk for depression, nine-year risk with self-reported concussion history in that same population, retired professional football players. Pretty well done study. If you haven't read it, you're interested in this, I would highly recommend you read it because it's well done. But it does show that there seems to be a linear trend towards if you report more concussions in this population that you have a higher risk of reporting a depression diagnosis. So in this population, and, you know, most of us are not treating many retired professional football players, but they may come across your patient panel. Hopefully this video works. This is a practice of a Division I lacrosse team. And that young man has just suffered, unfortunately, his fifth concussion. And just a little pause here and a little bit of video to get your attention to talk a little bit for a couple slides on, well, what about concussion? Is it a risk factor for depression in athletes, right? And this question actually is still a little unclear as well. So Lynn Manwaring, up in Canada, who has presented at AMSSM as one of our speakers in a mental health session, actually has done some interesting research that shows, well, actually ACL injured athletes may report more depressive symptoms for a longer period of time than a concussed athlete. And I'll show you some unpublished data in a few slides that we have that actually also pose an interesting twist to this question that there is no definitive answer as of at this moment. I think there's no universal consensus, but it's worthy of further exploration, I think. Let's talk about athletic career termination and depression risk factors. So again, I think it is important to point out if this athlete that you're looking at or treating or managing, was there a voluntary decision or an involuntary decision not made by the athlete to end the athletic career? So there does seem to be some differences in terms of risk for depression based on the literature. Athletic identity is also an important factor. So that's defined as degree to which an athlete defines herself or himself in terms of the athlete role. Maybe no surprising that if an athlete has a strong and exclusive athletic identity, exclusive to other ways to self-identify, they may experience more psychological distress at the end of their athletic career. Performance and depression risk. We've talked about this, as I mentioned earlier. This part of the conversation with an athlete for myself has become a little bit easier with some high profile athletes coming forward to talk about their struggles with depression, even though they've had success at very elite levels. I mentioned Michael Phelps earlier. Obviously this summer, we had a couple Olympic athletes come out and Olympic level athletes come out publicly in terms of their stress levels, perhaps if that's the right way to phrase it, and playing decisions like Naomi Osaka and Simone Biles. So we know that performance expectations may play a risk for depression in an athlete. So, you know, the best way to kind of evaluate this is just to talk to that athlete. So even if they think they did well, or you think they did well, an external observer or their coach or their parents thinks they did well, the best way to evaluate this is to talk to the athletes themselves and see how they feel about their performance, if that's relevant to what you are talking to them about or exploring. Are athletes accurately reporting depression symptoms? The citation for this study actually was a paper of myself and colleagues. The first author is Michael Gross, and it was in the Clinical Journal of Sports Psychology in 2017. And we studied something called depression management to see if athletes might be underreporting their symptoms, and lo and behold, maybe no surprise to folks on this call, we do think that athletes are underreporting their symptoms, still, in terms of depression symptoms. We're concerned about this question here about athletes not utilizing mental health services but don't have studies to support this. It's just a question I think that those of us who struggle and are interested in this area are concerned about. So are athletes underutilized in mental health services? Is there still a social stigma in sports out there that discourages appropriate utilization of resources available to them? So back to our case, just to reset ourselves, and we're going to pivot a little bit to talk about the evaluation of someone, an athlete, potentially with depression. So this diagram talks a bit about buckets, so to speak, of how an athlete could present, and no surprise, I'm sure, to folks on this call. So many symptoms of depression could be physical or somatic, could be cognitive in nature, certainly psychological, behavioral, as well as physical. So be on the lookout, have a broad differential, including mental health disorders such as depression, when you're evaluating almost any symptom that a student athlete might have, including the case study I presented with an athlete with insomnia. So some of the risk factors we've talked about, so has there been a recent injury, like in the case study I mentioned, with a recent grade two MCL sprain? Has there been a recent illness? Are you performing in terms of sports? Are you close to ending your career? Is there potentially a history of overtraining? Please assess for other ways that people cope besides exercise and sports, including some less potentially healthy ways to cope using substances or abusing substances. Screening tools, there is no kind of best athlete screening tool for depression, so refer to ones that are out there and validated in the literature used by many of folks watching this video or listening to this talk tonight. So PHQ-2, PHQ-9, many folks know the literature on that in terms of sensitivity and specificity are quite good. They haven't specifically been validated in the athletic population per se. So a good research tool maybe for some fellows out there, a research project that is, that maybe we should be developing a depression screening tool that fits in the athlete population. I'm going to talk about the BAVE tool on the next slide, a couple of slides from now, because I think that's one of my take home slides that I found useful in my 20 plus year career and want to pass on certainly in this talk in terms of how you screen for depression, a potential athlete who's potentially depressed. So a whole host of non-specific symptoms of depression that could be presenting. Don't forget some other risk factors for depression, including having a chronic medical illness and or other things like substance abuse, how they're doing in school and or their interpersonal relationships. So the BAVE tool, actually, I was introduced to this by a primary care physician who's retired, who's since retired. And so I believe he kind of coined this in some of his writings. But if you like mnemonics, and I like mnemonics, this is a really easy one. And I literally was going through this mnemonic as I was evaluating that 21-year-old basketball player complaining of insomnia. So B, background, what's going on in your life? A, how do you feel about this for affect? T, what's troubling you most about this? H, how are you handling this? And E for empathy, and just displaying some empathy to encourage further communication. So if you haven't heard of this tool before, it's widely used in primary care circles. I think for me, it's been very applicable in a sports medicine setting to ask some very simple questions. And then to go back to the case study I just referred to, I literally was applying the BAVE tool and asked about the sleeve on her knee, because she didn't say that she was recovering from a grade two MCL sprain. And talked about that. And I asked her, how do you feel about it? And she said, not great. And talked about how she felt isolated from her teammates. Those of you who are already practicing sports medicine are probably nodding your heads because this probably happens not infrequently. And what troubles you most about this? Actually, she was most frustrated because she was isolated from her teammates, even though she lived with them, but she wasn't part of the team as she was rehabbing. And then to this athlete's credit, she put it all together when I asked, how are you handling this? And she said, not well. And she put two and two together. I didn't do it. She did the work. But the BAVE tool was actually helpful for me to help her put the two and two together. That insomnia is tied to her recovery from the knee injury. The good news of the outcome of that story is not only did she have insight connected, it actually helped her recover from the injury physically, as well as performance-wise. And she was able to successfully recover from her insomnia and return to the court. If you're not aware, there's two team position consensus statements. Again, these are interdisciplinary statements. One was in 2006 and one was in 2017. I have the pleasure of being part of both writing groups. And these are going to be somewhat dense slides in terms of content, but I'm just going to read out the highlights. So this is actually the technical definition of stress, which is defined as the demands of a situation exceeding the resources to respond to those demands. So athletes who experience high levels of stress on or off the field may be at greater risk for being injured. So it's not that stress causes the depression, but actually, if you have a high level of stress as an athlete, you actually might be at greater risk for being injured, which is kind of an interesting take on stress in athletes. And then depression is a significant warning sign in the athlete. These are some take-home messages from two different consensus statements that have been put out by our professional societies. Let's pivot a little bit and talk about the injured athlete. So be aware that many athletes may feel pressure to play through psychological and physical pain. This is not an uncommon phenomenon at all, at any level really, unfortunately or fortunately, but that's the way it is. And survey after survey has actually supported that, that athletes do feel pressure to return to play, whether it could be internal or external, okay? And there may be any number of factors that are influencing that. And then injured athletes may under-report some of their mental health symptoms. Injury can lead to a loss of identity, even if we think it's a temporary injury and we know the prognosis is good, like the athlete I just talked about. We know clinically that that recovery was going to probably have a good prognosis and be uneventful, but for that athlete, it was pretty significant. So the injury can lead to identity loss because they are not participating in the things they normally would participate and identify themselves with. Be aware when you're evaluating that injured athlete about how they're coping. So, and again, the best way to address this is just ask them how they're doing and how they're handling it. Because we know they're injured, they don't need us to tell them that, but how are they handling it? So in whatever way you feel appropriate and are comfortable, please think about inquiring about how someone's coping, whether it's an ACL or a concussion they're recovering from. And certainly watch for any less healthy coping strategies like substance abuse. Again, we know college athletes use alcohol at higher rates than non-athletes in some studies. Some other thoughts about the injured athlete and mental health considerations. So see what their coping and support systems are, try and understand how important athletics is in that particular patient's life. And then just try and differentiate depression or adjustment disorders from overtraining as well. And we know many athletes like to train hard and some fall into overtraining, which is not exactly the same as depression and the treatment is different as well. So, and then see if there are alternate outlets while they're injured and they're not able to actually participate in everything they'd like to do, but what could they be doing? I'm gonna just maybe gloss over a few slides, but I just wanted to introduce and feel free to pull this article in the British Journal of Sports Medicine in 2016. But to date, as of that publication, that was the largest survey study of college athletes looking for depression symptoms. We had 465 that we published on. We continue to grow this study. Actually, we have over 800 Division I athletes now. So we haven't yet published a follow-up. So these things are in the literature. They're accepted. This is a pretty widely cited study for anybody looking at depression in athletes. Won't go through the details, but we did use a validated depression score that is used in NIH studies, et cetera. And then we found a clinically relevant depressive symptoms score reported in almost a quarter of the surveyed athletes. So a higher number that had been previously reported. And then just for interest sake, and I don't think you'll be tested on it, but in our study, females more than males reported that was statistically significant. They reported more depressive symptoms that were clinically relevant on the validated instrument tool that we used. We looked at sport, and track and field actually had a statistically significant difference. Lacrosse was the lowest, track and field was the highest and was statistically significant. And then we combined gender and interestingly female track and field athletes in our study had a relative risk of 2.2 reporting clinically relevant depressive symptoms scores. There might be a lot of differences. This is part of our paper and just some comments from us as researchers and authors of why we found differences there. These are just some tables from the article. I'm just gonna skip through because they're available in the article and they'll be available in the talk later. That talk a little bit about what I just went through and by sport and by sport and gender and the differences we've found. But I'll stop here because this is actually unpublished data from our study where we actually looked at concussion history. We actually, as well in the survey and our conclusion is really the last two or the last line in this table where while concussion history alone did not seem to play an increased relative risk factor for reporting of depressive symptoms. If we looked at where you injured in the last year multiple times and did you have a multiple concussion history the relative risk jumped up to 4.2 and the 95% confidence interval did not cross one. So that was a significant difference. Our conclusion, and we're still studying this and still collecting data may be that concussions alone are not a unique risk factor for depression but it may be the combination that is concussion is another type of injury that takes that athlete away from their sport and requires recovery time. But more to come, that's not a test. That's not a CAQ question just to be clear. So I wanna talk a little bit about a very well done consensus statement. It was published in 2017. So just four years ago, we met in 2016 and these are gonna be some content dense slides that I'm not gonna read all of but go over risk factors in the injured athlete. We talked a bit about them, go over signs and symptoms of stress in an injured athlete as well. And just list that out. It's a really useful document for sports medicine docs to refer to. If you're familiar with the team position consensus format there's always recommendations on the topic that are divided up into essential for team position student, understand and know and desirable for team position. So it's a very consistent format. And just to highlight a couple of things we've talked about recognizing that stress is a related athletic injury risk and it's desirable for the team position to certainly recognize signs and symptoms of stress and understand that stress may contribute to underlying mental health issues. More tables about problematic emotional responses, right? Injuries are common in athletes of any age and ability but what things to look for may be pain, perception and behaviors, excessive anger or rage, frequent crying and or emotional ability and certainly substance abuse could be warning signs for a problematic emotional response to the injury. And just some examples about what some of the things you might hear about in the training room or on the sidelines and or in your office. Again, a lot of content on here. I'm not gonna read the whole thing but essential that the team position understand that emotional responses will accompany injuries. That is very common. And sometimes they're normal, acceptable and not hampering that athlete's health and wellness and ability to recover but sometimes things will go off the rails there, so to speak. And then desirable at the team position promote monitoring for mental health status in an injured athlete. Certainly work to coordinate, facilitate appropriate referrals if necessary and educate and promote mental and physical health. You can think of several psychological factors that can affect injury treatment and outcomes because ultimately that athlete and maybe others involved wanna see that athlete successfully return to the field or the court or the pool or what have you. So these are some things you can monitor because they may affect actually how quickly the athlete recovers and returns to their sport. And so it actually, when you talk to coaches or talk to athletic trainers or certainly athletic administration, you can talk about why some of these things are important to actually evaluate because it can affect performance and affect return to play. So the tools to use are really not different than what you've learned in your primary residency training. So PHQs, GAD is an anxiety depression validated screening tool as well for anxiety. So there's not a need to reinvent the wheel there in terms of some of the screening tools available to you and look for poor recovery progression signs though. So irritability, emotional ability, withdrawal from their social relationships, some of these things listed here on the right. This is not a talk necessarily about how do you actually manage or help them manage, but here are some things. And this is where certainly myself as a team physician, as a sports medicine doc, I've engaged colleagues, right? That can help with CBT, that can help with understanding the various approaches. Mindfulness is one that's not on the table here from this statement too, but there's a number of different ways to actually help that athlete who seems to be struggling with their injury recovery and the stress associated with it, okay? So perhaps some of you listening are experts in these areas. I'm not, so I'm recognizing my limitations, encouraging you to think about identifying your mental health care team that can help you. Some treatment factors that I think are helpful in this document, we want to encourage specific stress coping skills, prepare people that are involved, whether it's coaches, athletic trainers, and parents at some levels to talk about the recovery process. Again, and you'll hear me say it probably in the take-home slides, is mental, look to your mental health network, your care team network, your partners. So it's essential that the team physician recognize that psychological factors may play a role in injury treatment, and that injury treatment should incorporate mental health techniques. We talked about the definition of stress, and again, stress doesn't necessarily cause depression, but it can put the athlete at risk for injury and complicate the recovery from return to play. So different categories of stress could be competitive in nature or organizational or certainly personal. So psychological issues in return to play. You know, I found this helpful to ask an athlete coming back from their ACL, any significant injury, but perhaps I should do it for less ones that I think medically are less significant, but are they ready to return to play? Just asking that question can be helpful, and often the answer is yes, and your assessment is yes, but occasionally there'll be some hint of concern. It's kind of hard not to be concerned. Especially, you know, based on whatever that athlete feels is important. So ask if they're ready to return to play. Just assess it. It may not change any of your medical management, but it'll help you help them better. Loss of social identity and social isolation feelings is really important when they're injured, and any increased pressure to return to play. Another reason, you know, to talk to student athletes wherever possible and where appropriate by themselves, right? Often the athletic trainer wants to be in the room. Sometimes the coach wants to be in the room, and we're not there to treat the coach or the athletic trainer. So based on your own assessment of the individual situation, make sure that you have that ability to have that communication with the athletes themselves and see if there's any pressure on them that they feel to return to play before they are ready. We've talked a bit about psychological responses that may be problematic. And I've also mentioned several times, just consider involving others in the mental health care of that athlete, especially one with a problematic response to injury or illness. And again, some essentials of the team position and some desirable comments. So we've talked about physical readiness to return to play does not necessarily correlate with that psychological readiness and that psychological factors are important in the successful return to play. I'm going to skip through this slide in the interest of time, because I do want to end at the 45 minute mark and leave time for questions and comments. But we've talked about the importance of a mental health care network and utilizing mental health providers where appropriate. All right, so I think I have three or four take home point slides. So, and these I think are fair test questions or related to test questions. So depression is not uncommon in athletes. It may be a similar prevalence of the general population. Okay, so that is a fair test question in my opinion. Recognize that risk factors for mood disorders can be unique to athletes. So there are some unique influences on athletes that maybe are the non-athlete peers do not have. And I think these are fair game test questions as well, including injury, retirement from sport, performance, identity. Please, as sports medicine physicians have a high index of suspicion from mood disorders, okay? Athletes are not immune from mood disorders or mental health disorders. Hopefully we've gone past that perception that was not that long ago that was common. Understand that the early diagnosis and appropriate management in an athlete of mental health issues can actually lead to better outcomes and more appropriate management. So we should be looking for these issues in all our student athletes and then work with an interdisciplinary team. So if you don't have that team, think about how you can start to build that team now because you will have athletes with mental health issues. Depression via increased stress may place athletes at higher risk for injury. Injury places the athlete at higher risk for depression. So it's a little bit cyclical there. But early identification of problematic responses to injury and appropriate management actually can help improve outcomes. And I'll end, Devin, with a quote here from Dr. Heinlein, who is our NCAA chief medical officer that I love. And so this is his quote. So mental health in athletes should be as accessible and approachable as an ACL injury. We need to transform society's approach to mental health in athletes. And that is my talk, Devin. Thank you everyone for attending and we'll stick around for questions and answers, Devin. Yeah, thank you very much, Gene. That was tremendous. So we do have some good questions here. So the first question, is there any research analyzing a link between socioeconomic status and mental health and injury risk? And then the person asking the question went on to comment that they work in a rural area and they've noted that players and teams from impoverished areas seem to take injuries, adversity and performance challenges a little bit harder than those from more affluent areas. Yeah, that's a great question. And to my knowledge, I have not seen good studies looking at that. What I'm thinking of though, is the general mental health and mood disorder literature on under-resourced we'll say communities, whether it's geography, like in a rural community or socioeconomic. So there is some literature there, but not necessarily in the athlete population. So that's an interesting observation. Would love that some fellow on listening to the call tonight picks that up as a research project because I would like to know the answer to that question. I would like to have data to that question. And I'm not sure I agree with that observation though, because having come from some both less privileged socioeconomic teams I've covered to more, I'm not sure in athletes I've seen that difference, but I'm sure there's different challenges, I would say. Another question, is there any data on the percentage of athletes requiring pharmacologic treatment for their depression? And have any medications been found to be more effective than others in the athletic population? Yeah, so great question. So maybe it's a two parter, right? So, and I anticipated this question coming up because it's very appropriate. First, I don't think you're gonna be tested on that in the CHQ, not based on the literature that I'm aware of. There are some opinions and I'll go over that. I did not have a slide obviously on that. So a couple thoughts on medication choice in athletes, right? So first you've got to be aware of if they're competing in NCAA or maybe perhaps you're competing in international competitions. So you have to be aware of restrictions on medication, right? So every year I check the same sites. I'm sure Devin does too and others doing this. So you have an athlete, you have a medication, particularly mental health medication or psychotropic, please, please check WADA, check other sites. These are all publicly available so you can check them. In athletes, so for example, and I'll reference my colleague and team members, so to speak, Claudia Reardon is a psychiatrist who likes the athlete population, has published several articles on medication choice in athletes. I'll refer you to Claudia Reardon's articles, but I'll summarize bupropion is something that is used by psychiatrists and in athletes. However, we should be careful because it is being looked at as a potential performance enhancer. So in the future, it might end up getting banned. And so you can look at that, but then there is the SSRIs and SSRIs in particularly fluoxetine actually has been looked at because we don't want to harm our athletes either, right? So much like we pick SSRIs or other medications for depression based on efficacy and side effect profile, right? For the particular case, fluoxetine in particular has been looked at in some of the other medications and fluoxetine in particular has been looked at in small studies in athletes without showing any decrease in their performance, for example. So it's not a fair test question, but it's a very good question. And the literature is still all over the place, but do NSSRIs, do they work any better? We don't know in the athletic population. But, and you also want to look at what's available as far as again, any negative impact on their performance, right? So, but those are just a couple of examples. Depression athletes, SSRIs certainly in bupropion have been looked at. There's some literature for their use. Bupropion, by the way, if there's a meeting disorder suspected that's a relative contraindication. So there's pros and cons to medication choices. So please pay attention to that. The first part of that question, Devin, I apologize. Yep. Any data on the numbers of treatment who actually require pharmacological management? Yeah, I would say anecdotal, not large well-done studies in terms of how many need pharmacological treatment. My sense without data to support it is it's going to be similar to the general population. That's my sense. As a sports medicine doc, I mean, don't be afraid to pull out the pharmacological tool you have as a physician. Again, just pick the right one based on that case and what you're treating. We didn't talk about anxiety a whole lot, but obviously beta blockers, we're all aware of their potential impact, but also be aware of their status as banned substances in certain sports. Be aware of in-competition versus out-of-competition banning because beta blockers can be a performance enhancer in things like riflery and other sports archery. So just think about your medication choice. That would be the only twist. So don't necessarily be afraid of medications, but don't necessarily jump to them without educating yourself as the prescribing provider. Great, thank you. Any recommendations on how to approach a patient athlete that is refusing to admit their diagnosis? So eating disorders, anxiety, depression, and they're just not ready to accept that diagnosis. Yeah, wow, great question also. It sounds like that person might have some experience and be thinking of a case. I'm certainly thinking of a case or two with that question. And the case for me that pops to mind, I'm not sure if this is gonna provide the insightful answer that the person asking the question wants, but young man with a concussion, recurrent concussions, but just was not getting better. And it literally took me several months finally where he opened up and at the time of his last concussion, which he hadn't recovered from, actually he lost his best friend to a violent episode. And so he was really suffering, whether you call it adjustment disorder or a grieving disorder, that's what it was. And that's why he wasn't getting better. His headache was getting better. His sleep disturbance wasn't getting better in addition to the concussion that he just had, right? So maybe for me, the take-home point was just persistence. I kept bringing them back, I kept asking them questions, but it was probably the 15th visit where he tells me this. And I don't know why, maybe I didn't ask the right questions, but persistence in terms of your clinical suspicion for what's going on. And just because they deny it or the parents deny it or the coaches deny it or what have you, if your clinical spider sense is tingling, you should listen to your clinical spider sense. A question I had, given that it's still earlier in the year for the new fellows, any recommendations on an emergency action plan for mental health emergencies and kind of the importance of rehearsing that? Yeah, Devin, thank you for that question because now I realize I didn't have that in my slides also, right? But the NCAA Mental Health Task Force, and I served on the second one. There was a first one, a second one, and there's been some statements. I actually have some subsequent slides after my end slide there, just listing resources. But NCAA has a number of resources. They're publicly available. There's the best mental health practices, for example, and that's what Devin is helping me refer to especially for fellows at the beginning of the year. So my first response to Devin's very good question, though, is ask if your team has an emergency action plan for mental health emergencies because many NCAA institutions will not. And we did this survey as part of the NCAA Mental Health Task Force work. Surprisingly, a lot don't. So that's a place to start. Does your team that you're covering, and if it's an NCAA team, there's documents there from the NCAA that you can pull mental health best practices as one of them, but there's several that are fully available. And a survey study that we did showed a number of NCAA institutions not having an emergency action plan. Now, if you're at a high school, I mean, there's no requirement for a MNFHSA or any other body that stipulates you have to have an emergency action plan that encompasses mental health. So it's still a fair question if you're covering a high school or a professional team. And then I'm sure Devin's been in the situation I have where there actually have been psychiatric emergencies in the weight room or in the training room or somewhere in the athletic facility, and you as a team doc will get that call. So-and-so is here, they're expressing suicidal intention. What do I do? And if you haven't practiced that, just like what do you do with that cervical spine injury? You got to practice it and you got to have the plan in place so then it becomes routine for you and athletic trainers and everybody else involved. But ask the questions that you can have at EAP. Great, thank you very much. Another question, when you start an athlete on SSRIs, what interval do you recommend follow-up? Do you stick with one to two weeks or is it individualized based on kind of case by case? And then when do you recommend starting pharmacology? So do you try therapy? Do you assess based on your perceived severity? How do you approach that? Yeah, so maybe another two-parter, right? So this is not gonna be, in my opinion, a fair board question either. So based on what I know of the literature and being a student of the literature and also my own experience, I don't think the recommendation for follow-up once you start that SSRI are any different than what you learned in your primary residency training. However, that being said, as a team physician, as a sports medicine doc, we may be more interested in following people a little more closely, right? And I'm just kind of admitting my own bias that I'll maybe see an injured athlete, maybe see a concussed athlete, depending on the injury or issue, a little more frequently than what's in the literature, because of what we do, right? And again, because of what we're aware of, and I said it probably a number of times, but just if they're injured, you better be looking for an abnormal emotional response that could lead to a mental health aspect to the recovery. So with the starting of an SSRI, I might see them in a week or two, but that's not based on evidence-based literature in the athlete, per se, it's because my own bias is to see them a little more frequently. The second part of that question- How do you decide when to start pharmacotherapy versus just start trying counseling? Yeah, so I fortunate in some of the teams and institutions, organizations I've worked with, there is that resource availability for professional mental health workers, whether it's the college counseling center and somebody who in particular has an interest and is good in dealing with the athletes, or a private practice person or what have you, or a fellow faculty member. So I've had that luxury, that privilege that I've been very fortunate to have. So my own bias, especially with an athlete, and most athletes will probably have told me over the years that they would prefer not to start a medication. And let's say, Devin, that this example that we're talking about hypothetically, so not anybody with a prior history of depression, with a prior history of taking psychopharmacologic agents, right? Because that's a different story, right? Yeah. And a different discussion. But somebody who's naive, so to speak, to pharmacologics of any sort and has depression, I would go with the non-pharmacologic methods first, if you have those resources available to you. Some of us at times may not have those resources. And as I think most folks on the call will know from their primary training, just psychopharmacologics can be very effective and be very helpful when used appropriately. So maybe the weight that I would think about that question is if you would think about it in a non-athlete, you should think about it in an athlete, the use of a pharmacologic agent. And then again, just with the particulars that I've mentioned with the prior questions, so just be aware of what's banned, what could affect performance, what could be helpful or harmful based on that particular medication choice as well to that patient. But that's probably from my standpoint, the most easiest way that I would think about it is if you're thinking about it in a non-athlete, you're gonna think about it in that athlete. All right. Well, that's all the questions I've got. And I think we're just right at about an hour. So I greatly appreciate your time and expertise tonight, Dr. Hong, that was phenomenal. And I appreciate the audience for attending. If you could, please fill out that survey that Andy posted just to give us some data on how we can improve this experience for you moving forward. And once again, thank you to everyone for coming. Thanks everyone.

3rd Edition, CASE 47

3rd Edition

Psychology

mental health

athletes

depression

injury

PHQ-9

interdisciplinary approach

emergency action plans

pharmacological treatments

Dr. Eugene Hong