Depression and the Endurance Athlete

by Mimi Winsberg, M.D.

Last month’s column looked at some of the potentially common biologic pathways in depression and athletic underperformance syndrome. To follow up on this, many athletes expressed interest in understanding more about depression; specifically how to recognize it, and what can be done if you observe symptoms in yourself or a friend.

First, it’s important to distinguish normal mood variability from clinical depression. While I referred last month to a promising blood test that appears to recognize depression with some accuracy, at present we are only able to diagnose depression by clinical symptoms.

Depression is defined and characterized by the presence of either a depressed mood or markedly diminished pleasure or interest in almost all activities for at least two weeks, and at least four of the following symptoms for at least two weeks:

• Significant weight loss or weight gain
• Insomnia or hypersomnia (excessive sleeping)
• Agitation and restlessness or slowed movements
• Fatigue or loss of energy
• Feelings of worthlessness or inappropriate guilt
• Impaired concentration, difficulty making decisions
• Recurring thoughts of death or suicide

We know that depression is influenced by both genetic factors as well as life circumstances. Major life events can trigger a depression, as can loss, illness, and substance abuse. Why a particular pattern triggers a depression in one individual and not another is not very well understood, but here are some general guidelines that have been found to be preventative:

1. Aerobic Exercise: 30 minutes a day reduces the risk of depression and anxiety, but 60 minutes a day is even more effective.
   
   
2. Brain Food: A Mediterranean diet -- a diet high in fruits, vegetables, nuts, whole grains, fish and unsaturated fat (olive and other plant oils) -- reduces the risk of depression.
   
   
3. Friends and Family: Social connectedness is also protective against depression. Note that this is not how many Facebook friends you have, but people with whom you actually spend time.
   
   
4. Coping Skills: Mature defense mechanisms such as altruism, finding humor in situations, anticipating stress, and using creative outlets to cope with stress are all helpful.

Though athletes exercise, lead a healthy lifestyle and may have mature coping skills and wide social circles, endurance athletes are by no means immune from depression. Certain habits and personality traits of endurance athletes may even predispose them to depression.

When we look at the characteristics that lend themselves to successful athletes we often see introverted perfectionists who adhere to rigid schedules and have much of their self-esteem invested in their performance. Of course not all successful athletes fit this description, but endurance sports do select for these traits and coaches may encourage them for success.

Healthy perfectionists set high standards for themselves and use their goals to squeeze the best that they can out of themselves. This is usually associated with high self-esteem and good social adjustment. Unhealthy perfectionists, however, set unattainably lofty goals and can feel that no level of achievement is enough. This latter form of perfectionism has a high rate of depression and hopelessness, as well as eating disorders. Elite athletes of both types can certainly be found, but there are plenty of driven endurance athletes who fall into the unhealthy perfectionist category.

Wondering which category you are in? There are scales to measure these traits, but start by asking yourself honestly:

• How do you measure your own success?
• How much is enough for you?

Unhealthy perfectionism and stress are both independently associated with depression, but when combined lead to an even higher risk for depression. So unhealthy perfectionists do poorly under stress and are much more likely to become depressed.

Social connectedness is nonetheless protective against depression even in this higher risk group, so encouraging more authentic social contact may have beneficial effects even in a very driven athlete. High performance goals can lead elite athletes to shun regular social commitments. Spending quality time with people is probably highly worthwhile if you feel you are at risk for depression.

The main pattern to worry about in the endurance athlete is the athlete who seeks to manage his mood swings and self-esteem with endurance exercise and then gets drawn into a destructive cycle of needing more and more exercise to feel good, while at the same time experiencing increased fatigue, diminishing performance, and a diminishing sense of self-worth.

If you observe such a pattern in a friend or family member, it can be valuable to take the time to talk, listen and suggest an appointment with a mental health professional. Sport psychiatry exists to address both superior mental performance in sport and also to address the clinical conditions that can arise from participation in competitive sport.

[For more on athletes and depression, listen to Mimi’s recent interview with Bevan and John from IMTalk.]

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