1. Running head: Major Depressive Disorder and Athletes
Sport and Depression: A Review of Major Depressive Disorder in the Lives of Athletes
Mathieu de Moissac
City University of Seattle
CPC 524: Psychopathology and Psychopharmacology

2. MAJOR DEPRESSIVE DISORDER AND ATHLETES 1
Sport and Depression: A review of Major Depressive Disorder in the lives of athletes
Introduction
With the release of the DSM-5 in 2013, depressive disorders have received a lot of
attention regarding the changes that were made from the DSM-4. Amidst these recent
changes, the world of sports has continued to remain disconnected as a culture that has yet to
embrace mental health as a normative reality. This cultural stigma, as Markser (2011)
explained, views only the mentally strong as being able to achieve success, leaving no room
for mental disorders in high performance sport where the mentally weak are seen as failures.
He notes that as a result of this stigma, there has been an underwhelming amount of academic
papers and research done in this field (pg. 182). Major Depressive Disorder (MDD) has
been studied and researched for years in regards to the efficacy of psychotherapy and
psychopharmacology interventions with recovery from this disorder being amongst the
highest of all mental disorders; however, this paper will examine whether these treatments
have been, or can be as effective for high performance athletes.
Diagnostic Criteria and Statistics
MDD is distinguished from other depressive disorders by its symptoms needing to be
present for just 2 weeks. Five or more of the following symptoms need to be fully present for
2 weeks with at least one of the symptoms being either depressed mood or loss of interest: (a)
depressed mood (subjective or observed); (b) loss of interest or pleasure; (c) change in weight
or appetite; (d) insomnia or hypersomnia; (e) psychomotor retardation or agitation
(observed); (f) loss of energy or fatigue; (g) worthlessness of guilt; (h) impaired
concentration or indecisiveness; and (i) thoughts of death or suicidal ideation or attempt (The
Diagnostic and Statistical Manual of Mental Disorders 5th ed.; DSM–5; American
Psychiatric Association [APA], 2013; Uher, R., Payne, J., Pavolva, B., and Perlis, R., 2013,
pg. 466). Lifetime prevalence for any form of depressive disorder is 17%, with MDD making

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up 7%. There is a large difference in prevalence between men and women at a ratio of 1.5-3
times more women than men experiencing depression and a large difference within age
groups such that 18-29 year olds have a threefold higher rate of prevalence than individuals
who are 60 or older (DSM-5, APA, 2013; Preston, J., O’Neal, J., and Talaga, 2010, pg. 73).
Similar numbers are found in the athletic population and it should be noted that the most at
risk age group for MDD is the most represented age group in high performance athletes.
In a French study that researched the prevalence of psychopathology in its national
federation athletes, they found that 8.7% of men and 16.3% of women had recent or ongoing
depression (Schaal, et al., 2011, pg. 3-4). Weigamd, S., Cohen, B., and Merenstein, D.,
(2013) studied current depression levels of collegiate athletes and discovered that 16.77%
(n=27) had scores consistent with depression, and 8.03% (n = 9) of former athletes showed
levels of depression (pg. 264). A correlation study done by Armstrong, S., & Oomen-Early,
J. (2009) of collegiate athletes found similar numbers of 16.69% of women and 13.41% of
men having experienced at least one episode of depression (pg. 522). One study that found a
significant increase in prevalence was done by Hammond, T., Gialloreto, C., Kubas, H., and
Davis IV, H. (2013) using a sample of Canadian swimmers who were qualifying for Olympic
positions. 64% of athletes met criteria for major depressive disorder in the previous 36
months and 34% of all athletes met criteria for MDD immediately following the trials. This
significant difference will be discussed at length later in this paper.
Changes from DSM-4 to DSM-5
There have been three main changes to the diagnostic criteria of MDD in the DSM-5:
(a) not counting mood-incongruent delusions and hallucinations was removed; (b) a
depressive mood, formerly described as “sad or empty”, is now “sad, empty, or hopeless”; (c)
the bereavement exclusion, which stated that MDD should not be diagnosed if depressive
symptoms occurred within 2 months of the death of a loved one, has been removed (DSM-5,

4. MAJOR DEPRESSIVE DISORDER AND ATHLETES 3
APA, 2013; Uher et al. 2013, pg. 460-461). The bereavement exclusion has been
controversial because “Critics of removing the bereavement exclusion are primarily
concerned that individuals who exhibit normative responses to loss … would unnecessarily
be diagnosed with MDD according to DSM-5” (Gotlib, I., & Lemoult, J., 2014, pg. 199).
Whereas a diagnosis of MDD after the death of a loved one could potentially stigmatize and
pathologize their grief, others argue that people might receive immediate and appropriate
treatment with insurance coverage providing them, instead, with a sense of relief (pg. 200).
One other small change between versions worth noting is the addition of 2 new
specifiers: “with mixed features” and ”with anxious distress”. “With mixed features” allows
for a specifier diagnosis that does not fulfill the criteria for manic or hypomanic episode and a
“with anxious distress” specifier allows information on anxiety to be recorded and accounted
for, even if a client does not meet criteria for General Anxiety Disorder (GAD) (Uher, et al.
2013). The addition of the anxious distress specifier could be beneficial for diagnosing MDD
in high performance athletes as comorbidity between MDD and GAD are highly correlated.
This comorbidity for high performance athletes is logical because the anxiety caused by
attempting to meet the expectations of teammates, coaches, fans, and oneself can often lead
to disappointment if those expectations are not met (Schaal, et al. 2011).
Mediating Factors
In the DSM-5 the highlighted mediating factors for developing MDD are: (a)
pessimistic or a neurotic temperament (this undoubtedly results in low resilience); (b)
stressful environments or events; (c) genetic or physiological predisposition to depressive
symptoms; and (d) comorbidity with other disorders (APA, 2013, pg. 166). The assumption
for years has been that high performance athletes are extremely resilient and are therefore far
less vulnerable to depressive episodes; however, it could be just as likely that they are at a
greater risk of developing MDD due to their position in society and the accompanying

5. MAJOR DEPRESSIVE DISORDER AND ATHLETES 4
pressure and stress of such a lifestyle. This athletic paradox has yet to be empirically tested
due to a lack of sport psychologists available who understand how to assess and treat this
population (Nixdorf, F., and Beckmann, J., 2015, pg. 1).
Weigand et al. and their work with former and current collegiate athletes provides
some insight into this paradox. They hypothesized that former collegiate athletes would
present with more depressive symptoms on the Wakefield Depression Scale than current
athletes due to loss of physical routine, like minded community, and identity. Their
hypothesis was disproven and instead, hypothesized that stressors such as overtraining,
injury, pressure to perform, lack of free time, and stress from school work contributed to an
increased susceptibility of depression (2013). Markser (2011) provides a developmental
explanation to this paradox by breaking down the adolescent's social role within sport. He
noted that expectations are contradictory and rapidly changing, not allowing for many young
athletes to handle the pressure. Their image as heroes or role models can change overnight
into that of failure or losers. Also, athletes’ careers can peak during adolescence in many
sports, meaning intense and systematic training is occurring at a volatile stage of
development (pg. 183). These studies all inferred that the pressure of athletic performance
could be a major potential risk factor for the development of MDD.
Hammond et al. found statistically significant results supporting this risk factor by
assessing athletes during the Olympic trials, the most high-pressure and competitive of
athletic events. Out of the 34% that met diagnostic criteria for MDD after the trials, 66% of
them were within the top 25% of all athletes, showing that higher expectations of success
result in greater vulnerability for depression. They summarized that “Aspiring to compete
among the world’s best athletes may increase an athlete’s susceptibility to depression,
particularly in relation to failed performance” (2013, pg. 277).

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Treatment
Cognitive Behavioural Therapy (CBT) is the most widely researched and practiced
psychotherapeutic method used to treat people with depression. In Barth et al.’s network
meta-analysis of 7 psychotherapeutic interventions for patients with depression, 51% of the
271 studies compared were of CBT origin (2013) and Hofmann et al’s meta-analysis review
found a total of 269 CBT based meta-analytic reviews within several databases (2012).
Studies have shown that there are a number of other psychotherapies that treat depression
with the same levels of success, such as interpersonal therapy, behavioural activation therapy,
problem solving therapy, social skills training, psychodynamic therapy, and supportive
counselling; however, the large number of studies measuring CBT outcomes is an example of
both its cost effectiveness and easily measurable treatment outcomes (Barth et al., 2013, pg.
6; Hofmann et al., 2012, pg. 436).
It has been mentioned that research in the field of athletic mental health is
underwhelming but it becomes even more scarce with sport specific treatment methods of
depression. Baron, D., Baron, S., and Foley, T. have conducted one of the only studies that
examined the effects of a specific treatment method on depressed athletes. This small study
measured the effects of CBT with only 3 case studies and measured success based on a semi-
structured interview and client self-reporting. They argued that CBT parallels well with
athletes because it challenges negative self-talk and provides homework (similar to an athlete
being responsible for health and fitness outside of their structured training and being used to
accepting directions from coaches). They concluded that CBT was a proven effective
treatment for depression, although the sample size may be too small to state this with
confidence (2009).
One last treatment consideration is the use of psychopharmacology. There are many
kinds of antidepressant medications such as MAOI’s, TCA’s, TeCA’s, SSRI’s, SNRI’s, that

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make it difficult to know which one will provide the least amount of side effects for a client.
For MDD, SSRI’s and SNRI’s are more commonly used now due to less severe side effects;
however, it is the consensus that combining therapy such as CBT with medication lowers the
rate of antidepressant discontinuation, therefore reducing the risk for relapse and recurrence
of depression (Maddux & Winstead, 2012, Psychopathology: Foundations for a
Contemporary Understanding, pg. 227).
Discussion
The studies mentioned above, all using different assessment tools, studied athletes
from a variety of sports and measured depression levels at different points of the competitive
season. Although many depressive symptom assessment checklists such as the Wakefield
Depression Scale, Beck Depression Inventory I-II, or Center for Epidemiologic Studies
Depression Scale are simple to use and yield consistent results, the vast complexity of this
population needs rigorous research. Appaneal, Levine, Perna, and Roh have suggested that a
useful assessment strategy for athletes who experience injury may include depression
symptom checklists during preseason physicals and again when an athlete experiences an
injury (2009, pg. 72). This same strategy could be used regardless of injury. Having a sport
psychologist apply depression checklists prior, during, and after the competitive season
would yield more comprehensive data.
Even if a diagnosis of MDD was found in an athlete, there are a number of treatment
limitations for athletes that need to be considered. First, there is rarely time for appropriate
psychotherapeutic treatment. Second, athletes tend to avoid seeking long term professional
help due to negative stigma. Lastly, many athletes cannot be prescribed antidepressants due
to doping regulations and potential side effects to their training regiment (Markser, 2011, pg.
184). Other characteristics of high performance athletes that make treatment difficult are the
way in which symptoms present. It is important to be able to recognize that “Their mood

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symptoms may manifest in the form of increased irritability, poor performance in practice or
competition, lack of enjoyment in competing, over-training, or drug and alcohol use” (Baron
et al. 2009, pg. 73). The fact is, there are incredible amounts of physical, social, and mental
stress within high level sport that come very close to disorder (Markser, 2011, pg.184).
Conclusion
What we know from these studies is that depression and MDD are just as prevalent
for high performance athletes as with the general population. The assumption that athletes
have stronger mental resilience than the general public to prevent depressive symptoms is a
damaging stigma that makes the acceptance and treatment of MDD complicated and difficult.
Competition as a career fosters the creation of an identity that can be bombarded with
conflicting expectations and repeated failure. These identities begin forming in an adolescent
development stage that demands the positive support systems of friends, family, coaches, and
trainers. The rewards of athletic aspiration and achievement can overshadow the many
unique MDD risk factors of this population. With this in mind, it is evident that greater
attention needs to be given to this field by qualified sport psychologists to ascertain more
effective preventative measures and treatment plans; however, it is likely that this kind of
research is contingent upon the acceptance and open communication of coaches, trainers,
sporting organizations, and mental health professionals.

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References:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Appaneal, R. N., Levine, B. R., Perna, F. M., & Roh, J. L. (2009). Measuring postinjury
depression among male and female competitive athletes. Journal of Sport & Exercise
Psychology, 31(1), 60-76. Retrieved from http://researchgate.net
Armstrong, S., & Oomen-Early, J. (2009). Social connectedness, self-esteem, and depression
symptomatology among collegiate athletes versus nonathletes. Journal of
American College Health, 57(5), 521-526. doi: 10.3200/JACH.57.5.521-526
Baron, D. A., Baron, S. H., & Foley, T. (2009). Cognitive and Behavioral Therapy in
Depressed Athletes. Advances in Psychiatry, 3. Retrieved from http://researchgate.net
Barth, J., Munder, T., Gerger, H., Nüesch, E., Trelle, S., Znoj, H., . . . Tsai, A. (2013).
Comparative Efficacy of Seven Psychotherapeutic Interventions for Patients with
Depression: A Network Meta-Analysis (Network Meta-Analysis Depression). PLoS
Med, 10(5), E1001454. doi:10.1371/journal.pmed.1001454
Gotlib, I. H., & LeMoult, J. (2014). The “Ins” and “Outs” of the Depressive Disorders
Section of DSM‐ 5. Clinical Psychology: Science and Practice, 21(3), 193-207.
doi: 10.1111/cpsp.12072
Hammond, T., Gialloreto, C., Kubas, H., & Davis IV, H. H. (2013). The prevalence of
failure-based depression among elite athletes. Clinical Journal of Sport Medicine,
23(4), 273-277. doi: 10.1097/JSM.0b013e318287b870
Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of
cognitive behavioral therapy: a review of meta-analyses. Cognitive therapy and
research, 36(5), 427-440. doi: 10.1007/s10608-012-9476-1

10. MAJOR DEPRESSIVE DISORDER AND ATHLETES 9
Maddux, J., & Winstead, Barbara A. (2012). Psychopathology foundations for a
contemporary understanding (3rd ed.). London; New York: Routledge.
Markser, V. Z. (2011). Sport psychiatry and psychotherapy. Mental strains and disorders in
professional sports. Challenge and answer to societal changes. European archives of
psychiatry and clinical neuroscience, 261(2),
doi: 182-185.10.1007/s00406-011-0239-x
Nixdorf, F. R., & Beckmann, J. (2015). Depression among Elite Athletes: Prevalence and
Psychological Factors. Deutsche Zeitschrift Fur Sportmedizin. Retrieved from
http://www.zeitschrift-sportmedizin.de
Schaal K, Tafflet M, Nassif H, Thibault V, Pichard C, Alcotte M, et al. (2011) Psychological
Balance in High Level Athletes: Gender-Based Differences and Sport-Specific
Patterns. PLoS ONE 6(5): e19007. doi:10.1371/journal.pone.0019007
Uher, R., Payne, J. L., Pavlova, B., & Perlis, R. H. (2014). Major depressive disorder in
dsm‐ 5: implications for clinical practice and research of changes from DSM‐ IV.
Depression and anxiety, 31(6), 459-471. doi: 10.1002/da.22217
Weigand, S., Cohen, J., & Merenstein, D. (2013). Susceptibility for Depression in Current
and Retired Student Athletes. Sports Health, 5(3), 263–266.
doi:10.1177/1941738113480464