GENERAL MEDICAL CONDITIONS

Depression in Athletes: Prevalence and

Risk Factors
Andrew Wolanin, PsyD1; Michael Gross, MA1; and Eugene Hong, MD2

understudied, initial data suggest that

Abstract
athletes are far from immune to de-
Depression affects an estimated 6.7% of today’s adult population in
pression. In fact, empirical studies in-
a 12-month period. The prevalence rates for certain age groups, such
dicate that athletes are just as likely
as young adults and older adults, are higher. There are approximately
to experience depression as the general
400,000 National Collegiate Athletic Association student athletes
population (26). The purpose of this
competing each year and 5 to 7 million high school student athletes in-
article was to review the current re-
volved in competitive interscholastic sports. Given such a high preva-
search on athletes and depression and
lence rate in certain age groups and a large denominator pool of athletes,
to highlight that this is an issue in much
past notions that athletes are devoid of mental health issues have come
need of further study and inquiry. In
under scrutiny by sports medicine providers. Initial data suggest that
particular, this article will provide an
athletes are far from immune to depression. The purpose of this article
overview of studies, which have inves-
was to review the current research on athletes and depression; particu-
tigated the rate of depression among
larly this article will provide an overview of studies, which have investi-
athletes, discuss relevant factors (e.g.,
gated the rate of depression among athletes, and discuss relevant risk
injury), which may contribute to depres-
factors, which may contribute to depression among athletes.
sion among athletes, and consider how
an integrative approach involving sports
Introduction medicine and sports psychology can best serve athletes.
Depression affects an estimated 6.7% of today’s adult
population in a 12-month period (21). According to the U.S.
Department of Health and Human Services, the prevalence Depression Prevalence and Athletes
rates for certain age groups, such as young adults and older To date, the majority of studies investigating the preva-
adults, are higher V for example, for the 18-to-25 age group, lence rate of depression among athletes have been conducted
the 12-month depression prevalence rate was 8.7% in 2008. with college athletes. Findings from these studies suggest that
There are approximately 400,000 National Collegiate Ath- the prevalence rate of depression among college athletes
letic Association (NCAA) student athletes competing each ranges from as low as 15.6% to as high as 21% (25,35). On
year and 5 to 7 million high school student athletes involved the basis of these prevalence rates, as many as one in five
in competitive interscholastic sports. Given such a high prev- athletes may be depressed. However, there has been a general
alence rate in certain age groups and a large denominator lack of consistency thus far in the findings.
pool of athletes in these age groups, it is reasonable to sur- Storch et al. (29) were the first investigators to compare
mise that there are thousands of athletes with depression rates of depression symptoms between athletes and non-
participating at the high school and college levels. Recently, athletes. This study hypothesized that because athletes deal
sports medicine and sports psychology practitioners and with more stress than nonathletes, they would report higher
researchers have turned their attention to this important levels of alcohol use, depression symptoms, and social anxi-
issue, as past notions that athletes have reduced mental ety. The study also hypothesized that athletes would report
health issues due to increased levels of exercise have come having less social support than nonathletes. There was partial
under scrutiny in the popular media (24). Although vastly support for these hypotheses, as female athletes reported
experiencing depression symptoms, social anxiety, and non-
1
Kean University; and 2Drexel University support to a greater extent than male athletes and male and
female nonathletes. In another study, Yang et al. (35) dem-
Address for correspondence: Eugene Hong, MD, Drexel University; onstrated similar findings regarding gender, as female ath-
E-mail: [email protected]. letes reported the highest levels of depression among a
1537-890X/1401/56Y60
sample of 257 Division I college athletes. These findings
Current Sports Medicine Reports are consistent with data from the general population, which
Copyright * 2015 by the American College of Sports Medicine repeatedly have found women to report higher rates of

56 Volume 14 & Number 1 & January/February 2015 Depression in Athletes

Copyright © 2014 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
depression than men. In total, 21% of the athletes surveyed the athletes (51%) who sustained an injury during the course
reported symptoms of depression. Freshman athletes and of the study endorsed mild-to-severe depression symptoms,
those who endorsed pain reported more depression symp- as measured by the Beck Depression Inventory (BDI). Thus
toms in this study. far, a limitation in the research has been sole reliance on self-
According to Yang et al. (35), athletes in their sample report measures to assess depression. However, Appaneal
experienced depression at approximately the same rate as et al. (2) sought to address this issue by including two mea-
that of a comparison group of nonathletes who participated sures (semistructured interview and self-report) of depression
in the study. However, Armstrong and Oomen-Early (3) in their study examining athlete’s postinjury depression symp-
found that college athletes reported lower levels of depres- toms. In this study, the researchers used a sample of 164 ath-
sion than those reported by nonathletes. This study used a letes competing at the NCAA Division I, NCAA Division II,
sample consisting of 227 participants, 104 of which were and high school levels. Athletes in the study were assessed
male and female athletes from various sports. Overall it was using the CES-D and the semistructured interview guide for the
found that 33.5% of the sample reported clinically signifi- Hamilton Rating Scale for Depression (SIGH-D). In this study,
cant levels of depression. The percentage of athletes endors- it was found that depression symptoms of athletes with injury
ing clinically significant levels of depression was reported to were elevated 1 wk after injury and remained this way 1 month
be ‘‘significantly lower’’ than that of nonathletes. This study after injury when compared with healthy controls, as mea-
also found that athletic status was not a statistically signifi- sured by the SIGH-D. No significant differences between
cant predictor of depression when compared with other var- groups were found in this study, as measured by the CES-D.
iables investigated in the study including gender, self-esteem There has been a recent surge of evidence suggesting that
levels, social connectedness, and rested sleep. Armstrong and sports concussions can lead to changes in emotional state
Oomen-Early (3) contended that having a social network and (14,17). Furthermore there is recent evidence to suggest that
team support are two factors that most strongly protect col- sports concussions can have long-lasting emotional impact.
lege athletes from developing depression. In a recent survey of 1,044 retired National Football League
Proctor and Boan-Lenzo (25) conducted another recent (NFL) players, it was found that the 9-year risk of a depres-
college athlete and depression prevalence study. This study sion diagnosis increased with the number of self-reported
investigated depression symptoms among a group of 61 Di- concussions (15). According to the survey, retired athletes
vision I male baseball players and 51 male nonathlete col- reporting three or more concussions were three times more
lege students. Proctor and Boan-Lenzo (25) found that male likely to report being diagnosed with depression when
athletes reported fewer depression symptoms than those compared with athletes with no history of concussions.
reported by male nonathletes. Although nonathletes reported Strain et al. (30) conducted a study with 26 retired NFL
higher levels of depression (29.4%), 15.6% of the athletes athletes who underwent a magnetic resonance imaging tech-
met criteria for a possible diagnosis of clinical depression. nique identified as diffusion tensor imaging scanning. They
With consideration for the mixed epidemiological data, reported that certain voxels negatively correlated with BDI-II
taking a more nuanced look at the factors that may con- scores and that specific brain areas of the forceps minor, right
tribute to depression among athletes is particularly relevant. frontal aslant tract, right uncinate fasciculus, and left su-
To date, one of the most widely studied risk factors for perior longitudinal fasciculus negatively correlated (P G 0.01)
psychological distress among athletes has been sports injury. with total BDI-II scores. Fractional anisotropy maps, which
In a recent survey of sports medicine physicians, it was reflect fiber density, axonal diameter, and myelination in white
found that 80% of the time, athletes coming to treatment matter of the forceps minor differentiated depressed from
for an injury also discuss psychological issues related to the nondepressed athletes with 100% sensitivity and 95% spec-
injury (19). However, there only have been a handful of ificity, from which the authors conclude that diffusion tensor
studies, which have investigated depression symptoms di- imaging is a promising biomarker predictor of depression
rectly among athletes following sports injury. symptoms. Additionally Hart et al. (13) conducted a neuro-
imaging study measuring cognitive impairment and depres-
Sports Injuries and Depression sion in a sample of 34 retired NFL players and found a 23.5%
Brewer and Petrie (7) were among the first researchers to prevalence of depression and a high rate of cognitive deficits
compare depression symptoms between athletes who had compared with those of a control group. They concluded that
and had not experienced injuries. In this retrospective study, cognitive deficits and depression symptoms appear to be
it was found that athletes who experienced an injury during more prevalent in retired NFL players when compared with
the previous year reported significantly higher depression those in a healthy control group.
symptom scores than those reported by noninjured athletes, While the relationship between concussion and depres-
as measured by the validated Center for Epidemiological sion may be significant, there is also evidence to suggest that
Studies Depression (CES-D) scale. The sample in this study a concussion may have the same effect as other injuries on
consisted of 916 NCAA Division I college football players. mental health. For example, Mainwaring et al. (18) conducted
Brewer and Petrie (7) also found that both groups of athletes a study to examine the differences between emotional re-
in their study reported high levels of depression symptoms, as sponses in athletes who had a concussion compared with an-
33% of athletes with injury and 27% of noninjured athletes terior cruciate ligament (ACL) injury. They found that athletes
could be classified as depressed on the basis of the CES-D with ACL injuries had more severe levels of depression and
results. In another study, Leddy et al. (16) used a prospective longer duration of depression compared with those of athletes
design to examine depression symptoms in athletes following with concussion. The authors concluded that ACL injuries
injury. The results from this study indicated that over half of have a higher level of emotional disturbance compared with

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Copyright © 2014 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
that of athletes with concussion and that screening and inter- reactions (including sadness) when compared with unplanned
vention should be focused on athletes with ACL injuries and retirement.
concussions. While the sample size of this particular study was Whereas voluntary versus involuntary career termination
small, it does illustrate that there is increased risk of maladap- has been the most well-studied situational factor related to
tive psychological response to various types of injuries and the end of athlete’s career, athletic identity has received the
that concussion may or may not be an increased risk factor most attention as a potential individual factor that can im-
for depression over other types of sports-related injuries. pact the process of transitioning out of sports. Athletic
Although not due to the result of an acute injury, over- identity is defined as the degree to which an athlete defines
training syndrome (OTS) also can threaten the overall mental himself or herself in terms of the athletic role (8). Baillie and
and physical well-being of an athlete. OTS is characterized Danish (4) found that athletes rating high in athletic identity
by psychological and physiological disturbances, along with were prone to experience emotional and social adjustment
decreases in performance (20). There is much debate about issues after they ended their sports career. Strong and ex-
the causes and consequences of OTS, but the research does clusive athletic identity also has been associated with height-
indicate that the symptoms of major depression and OTS can ened stress and anxiety following sports career termination
appear similar (23). As such, those professionals working with (11). Brewer (6) found that athletes scoring high on the Ath-
athletes should be mindful of not mistaking depression for letic Identity Measurement Scale responded to hypothetical
OTS and vice versa. However, they also should be aware that career-ending injuries with depression reactions. In summary,
the two conditions are not necessarily mutually exclusive and research findings consistently suggest that individuals with a
can co-occur. strong and exclusive athletic identity experience more intense
and frequent psychological and emotional difficulties fol-
Career Termination lowing retirement from sports (1,4,11,21).
The end of an athlete’s career marks a major life transi- The potential for loss of an athlete’s identity following
tion that can result in changes to an athlete’s interpersonal sports career termination was the primary reason, as hy-
relationships, roles, and daily routines (28). Although sports pothesized by a recent investigation, why former college
career termination represents a significant life transition for athletes would report greater depression symptoms than
athletes, this necessarily does not mean that it results in current college athletes (32). However, the opposite was
psychological distress. For some athletes, the transition from true, as depression was significantly higher among current
competitive athletics to sports retirement is done with ease, athletes when compared with that among former athletes.
allowing them to pursue new career paths and opportuni- On the basis of the results, 17% of current college athletes
ties. For others, this transition is a difficult process that has met the criteria for depression whereas 8% of former col-
been correlated with behavioral difficulties and emotional lege athletes had levels of depression consistent with a di-
distress (21). For example, sports career termination has been agnosis for the disorder. Weigand et al. (32) concluded that
associated with maladaptive coping strategies, depression, these findings suggest that voluntary sports career termi-
anxiety, increased hostility and anger, and substance abuse nation for the college athlete V i.e., the end of their college
(11,28,33,34). athletic career V necessarily does not put the athlete at higher
It is likely that several moderating and mediating vari- risk for the long-term development of depression. These find-
ables impact an athlete’s response to career termination. ings may or may not be applicable to the athlete whose career
One particular variable that has received considerable at- is ended or interrupted by injury or who is cut from the team
tention is voluntary (i.e., personal decision to retire) versus or sports, especially if the athlete’s identity and self-worth are
involuntary (i.e., injury, getting cut from team) career ter- related intricately to continuation in sports.
mination. It has been hypothesized that involuntary career
termination is more likely than voluntary career termina- Performance and Depression
tion to impact an athlete’s mental health negatively (9). From a psychological perspective, athletes may be prone
Wippert and Wippert (34) garnered additional support to experience depression symptoms when they face declines
for this contention in a study that found that involuntary in their athletic performance or a catastrophic (‘‘choking’’)
career termination was associated with significantly greater athletic performance. Conceptually poor athletic performance
psychological symptoms, including depression symptom- may result in lack of external reinforcement, behavioral de-
atology, as measured by the Symptom Checklist-90-R, than activation, negative self-perceptions and evaluations, and
voluntary career termination among a sample of skiers. feeling of helplessness or hopelessness, which are consistent
However, it also was found that symptoms of psychological with depression symptoms. When viewed in an objective
distress for those athletes dealing with involuntary career context, the nature of athletic competition can yield higher
termination decreased over time. This finding may indi- rates of loss throughout the year and ultimately only one
cate that, initially, athletes have a difficult time adjusting to team or athlete may achieve the pinnacle while all others end
involuntary career termination but experience overall re- their season or career with a competitive loss. Hammond
duction in psychological distress the farther removed they et al. (12) conducted a study to examine the relationship be-
are from the event. Alfermann et al. (1) demonstrated sim- tween the prevalence of diagnosed failure-based depression
ilar findings in their investigation of the cognitive, behav- and self-reported symptoms of depression within a sample of
ioral, and emotional consequences associated with career 50 elite swimmers. Of note in this study was a 68% lifetime
termination among a sample of 256 amateur European prevalence of depression episodes among the participants, with
athletes. Alfermann et al. (1) found that planned retirement significantly more females endorsing history of depression.
from sports was associated with fewer negative emotional The authors found that after an athletic competition, 34% of

58 Volume 14 & Number 1 & January/February 2015 Depression in Athletes

Copyright © 2014 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
the athletes had clinically elevated depression scores on the represent the group with the highest risk of committing
BDI-II but the top quartile of elite performance had 2 times suicide. Although suicide in athletes continues to occur and
higher rate of elevated depression scores. Considering the fact there are aspects to athletic participation that may lead to
that the Olympics only occur every 4 years may account for increased rates of depression and potential suicide risk,
this effect, it is still important to note that within this elite there is paucity of research identifying risk factors for sui-
performer group, there was a significant relationship between cidal behaviors in athletes and a lack of information on
the athlete’s performance and depression symptoms. This guidelines to assess suicidal potential in athletes. Smith and
study illustrates that some high-performing athletes actually Milliner (27) and Baum (5) report case studies of athletes
may be more susceptible to depression when faced with per- who committed suicide and make inferences to the manner
formance outcomes that are below expectation and that sports in which athletic trainers and other professionals may assess
medicine personnel need to be aware of the psychological suicidal risk. For example, on the basis of five case studies of
consequences of losing or personally failing during compe- athletes with injury seen in their clinical practice, Smith and
tition. Those providing comprehensive care for the athlete Milliner (27) contend that a serious injury necessitating
should understand that the expectations for athletic perfor- surgery, an extended rehabilitation process (6 wk to 1 year),
mance have a number of influences and may include not only reduced athletic skills despite adherence to rehabilitation, a
the athlete’s viewpoint but also the perception of teammates, perceived lack of competence upon returning to sports
coaches, and family. when compared with preinjury levels, and being replaced by
a teammate at their given position all may contribute to
Concerns With Underreporting suicidal behavior among athletes with injury.
As noted by Proctor and Boan-Lenzo (10), one reason for While the previous research and discussion are worth-
the difference in depression rates in their study may be be- while, the small sample sizes of these studies elicit caution
cause athletes were underreporting depression symptoms in against making clinical decisions without more quantitative
an attempt to portray themselves in a favorable light. In findings. Drawing from clinical practice guidelines may be
contrast to nonathletes, athletes may have some reserva- the most effective manner at implementing strategies to as-
tions when filling out a depression measure, such as coaches sess and manage suicide risk with athletes. Fowler (10)
discovering their scores or concerns over imagined reactions completed a practice review of suicide risk assessment in
to admitting being depressed. The question of how responding clinical practice that illustrates the poor predictability of
impacts reporting on self-report questionnaires is always an suicide and suicide attempts and the complex interactive
important question for researchers and may be particularly nature of variables associated with suicide. Overall, much
critical in measuring depression among college athletes. An- still remains to be understood about the identification and
ecdotally, athletes tend to portray a picture of psychological assessment of athletes at risk, as it relates to suicide and
strength when assessed for depression symptoms. There ap- suicide risk reduction.
pears to be a tendency to put considerable effort into appearing
‘‘fine’’ or ‘‘okay’’ and ready for the next competition or chal- Conclusions and Discussion
lenge. This is inherent to the culture of athletics, as confidence Review of the literature reveals that depression does oc-
often is regarded as a necessary state of mind for completion. cur in athletes and that athletes are not somehow immune
However, it creates significant difficulty for sports medicine or resistant to depression. In fact, it is hypothesized that
professionals attempting to access an athlete’s state of mind there are risk factors that are more unique to an athletic
accurately. Further research into depression in athletes ideally population (i.e., injury, involuntary career termination, per-
should take into account the concern for underreporting of formance expectations, and possibly overtraining) that may
depression symptoms, especially if the study relies on self- increase the risk of depression compared with the general
reported data. We currently are involved in such a study of population. In certain subpopulations of athletes, there may
college athletes that not only employs a validated depression be a higher rate of depression than nonathletes. Clearly de-
survey tool but also includes an additional validated reporting pression in athletes exists. Suicide in athletes, a tragic out-
tool that helps in determining whether symptoms are being come that can be associated with depression, exists.
underreported. At this time, there is limited knowledge regarding optimal
assessment of depression in athletes and there is paucity of
Suicide evidence-based interventions that have been shown to be
A number of recent suicides of current or former athletes effective for treating athletes with clinical levels of depres-
and related media attention have resulted in heightened fo- sion. Future studies in depression and athletes should ex-
cus and discussion on potential risk factors for suicidal be- plore how assessment and management of depression may
havior in athletes. Athletes, similar to the general population, be different in athletes and nonathletes; for example, is
in fact do contemplate and commit suicide. In a review of the evidenced-based therapy more or less effective in athletes or
medical and periodical literature, Baum (5) found 71 cases of what class of medications may be more helpful to the ath-
athletes who contemplated, attempted, or completed suicide. lete? It is hypothesized that mental health treatment services
Of these 71 identified cases, 66 were completed suicides. The may be underutilized by individuals participating in athlet-
vast majority of these cases were male athletes (61 cases) ics due to a myriad of variables such as time constraints and
with an average of 22 years old for the entire sample. This social stigma (34), which is concerning, considering the high
is consistent with the empirical literature, which indicates rates of depression among athletes that have been found
that males are more likely than females to commit suicide in some studies. Primary contact regarding depression and
and that individuals between the ages of 15 and 24 years mental health issues may occur with sports medicine teams.

www.acsm-csmr.org Current Sports Medicine Reports 59

Copyright © 2014 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Therefore, it is essential that these health care professionals 14. Hutchinson M, Mainwaring LM, Comper P, et al. Differential emotional
responses of varsity athletes to concussion and musculoskeletal injuries. Clin.
are able to identify the signs and symptoms of depression J. Sport Med. 2009; 19:13Y9.
among athletes and offer appropriate referrals when neces- 15. Kerr ZY, Marshall SW, Harding HP, Guskiewicz KM. Nine-year risk of de-
sary. Athletes may present with atypical signs and symp- pression diagnosis increases with increasing self-reported cncussions in re-
tired football players. Am. J. Sports Med. 2012; 40:2206Y12.
toms, such as anger and irritability, and engage in healthy or
16. Leddy MH, Lambert MJ, Ogles BM. Psychological consequences of athletic
less healthy coping mechanisms, such as substance abuse or injury among high-level competitors. Res. Q. Exerc. Sport. 1994; 65:347Y54.
overtraining. Beyond the traditional indicators of depres- 17. Mainwaring LM, Bisschop SM, Green RA, et al. Emotional reaction of var-
sion, athletic trainers and sports medicine teams should sity athletes to sport-related concussion. J. Sport Exerc. Psychol. 2004;
maintain increased awareness that (given the nature of the 26:139Y5.
athletic culture) athletes may be likely to deny depression 18. Mainwaring LM, Hutchison M, Bisschop SM, et al. Emotional response to
sport concussion compared to ACL injury. Brain Inj. 2010; 24:589Y97.
symptoms. Education of sports medicine professionals and
19. Mann BJ, Grana WA, Indelicato PA, et al. A survey of sports medicine phy-
the athletic care network is key to the optimal evaluation, sicians regarding psychological issues in patient-athletes. Am. J. Sports Med.
management, and outcome of depression in athletes. 2007; 35:2140Y7.
20. Meehan HL, Bull SJ, Wood DM, James DVB. The overtraining syndrome: a
multicultural assessment. The Sport Psychol. 2004; 18:154Y71.
The authors declare no conflicts of interest and do not 21. Murphy S. Transitions in competitive sport: maximizing individual potential.
have any financial disclosures. In: Murphy SM, ed. Sport Psychology Interventions. Champaign (IL): Hu-
man Kinetics; 1995, pp. 331Y46.
22. National Institute of Mental Health. The NIMH Depression Page. Available
from: http://www.nimh.nih.gov/health/topics/depression/index.shtml. Accessed
June 6, 2013.
References
1. Alfermann D, Stambulova N, Zemaityte A. Reactions to sport career ter- 23. Nederhof E, Lemmink KAPM, Visscher C, Mulder T. Psychomotor speed:
mination: a cross national comparison of German, Lithuanian, and Russian possibly a new marker for overtraining syndrome. Sports Med. 2006;
athletes. Psychol. Sport Exerc. 2004; 5:61Y75. 36:817Y28.
2. Appaneal RN, Rockhill-Levine BR, Perna FM, Roh JL. Measuring postinjury 24. Paluska SA, Schwenk TL. Physical activity and mental health: current con-
depression among male and female competitive athletes. J. Sport Exerc. cepts. Sports Med. 2000; 29:167Y80.
Psychol. 2009; 31:60Y76. 25. Proctor SL, Boan-Lenzo C. Prevalence of depressive symptoms in male in-
3. Armstrong S, Oomen-Early J. Social connectedness, self-esteem, and depres- tercollegiate student-athletes and nonathletes. J. Clin. Sport Psychol. 2010;
sion symptomatology among collegiate athletes versus nonathletes. J. Am. 4:204Y20.
Coll. Health. 2009; 57:521Y6. 26. Reardon CL, Factor RM. Sports psychiatry. Sports Med. 2010; 40:961Y80.
4. Baillie PHF, Danish SJ. Understanding the career transitions of athletes. Sport 27. Smith AM, Millner EK. Injured athletes and the risk of suicide. J. Athl. Train.
Psychol. 1992; 6:77Y98. 1994; 29:337Y41.
5. Baum AL. Suicide in athletes: a review and commentary. Clin. Sports Med. 28. Stephan Y, Bilard J, Ninot G, Delignieres D. Repercussions of transition out
2005; 24:853Y69. of elite sport on subjective well-being: a one-year study. J. Appl. Sport
Psychol. 2003; 15:354Y71.
6. Brewer BW. Self-identity and specific vulnerability to depressed mood. J. Pers.
1993; 61:343Y64. 29. Storch EA, Storch JB, Killiany EM, Roberti JW. Self-reported psychopa-
thology in athletes: a comparison of intercollegiate student-athletes and non-
7. Brewer BW, Petrie TA. A comparison between injured and uninjured football
athletes. J. Sport Behav. 2005; 28:86Y98.
players on selected psychosocial variables. Acad. Athl. J. 1995; 10:11Y8.
30. Strain J, Didehbani N, Cullum CM, et al. Depressive symptoms and white
8. Brewer BW, Van Raalte JL, Linder DE. Athletic identity: Hercules’ muscles matter dysfunction in retired NFL players with concussion history. Neurol-
or Achilles’ heel? Int. J. Sport Psychol. 1993; 24:237Y54. ogy. 2013; 81:25Y32.
9. Erpic SC, Wylleman P, Zupancic M. The effect of athletic and non-athletic 31. Watson JC. Student-athletes and counseling: factors influencing the decision
factors on sports career termination process. Psychol. Sport Exerc. 2004; to seek counseling services. Coll. Student J. 2006; 40:35Y42.
5:45Y59.
32. Weigand S, Cohen J, Merenstein D. Susceptibility for depression in current
10. Fowler JC. Suicide risk assessment in clinical practice: pragmatic guidelines and retired student athletes. Sports Health. 2013; 5:263Y6.
for imperfect assessments. Psychotherapy (Chic.). 2012; 49:81Y90.
33. Wippert PM, Wippert J. Perceived stress and prevalence of traumatic stress
11. Grove JR, Lavallee D, Gordon S. Coping with retirement from sport: the symptoms following athletic career termination. J. Clin. Sport Psychol.
influence of athletic identity. J. Appl. Sport Psychol. 1997; 9:191Y203. 2008; 2:1Y16.
12. Hammond T, Gialloreto C, Kubas H, Davis H. The prevalence of failure- 34. Wippert PM, Wippert J. The effects of involuntary athletic career termina-
based depression among elite athletes. Clin. J. Sport Med. 2013; 23:273Y7. tion on psychological distress. J. Clin. Sport Psychol. 2010; 4:133Y49.
13. Hart J Jr, Kraut MA, Womack KB, et al. Neuroimaging of cognitive dys- 35. Yang J, Peek-Asa C, Corlette JD, et al. Prevalence of and risk factors asso-
function and depression in aging retired National Football League players: a ciated with symptoms of depression in competitive collegiate student ath-
cross-sectional study. JAMA Neurol. 2013; 70:326Y35. letes. Clin. J. Sports Med. 2007; 17:481Y7.

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