Depression in Endurance Athletes Part 1

Depression is one of the most common mental health conditions in the world and is ranked in the top five causes of disability by the World Health Organization.  There is a nearly 20% lifetime prevalence in the adult population for having at least one episode of major depression. Depression increases mortality through suicide, co-occuring substance use and additionally through higher rates of cardiovascular disease and diabetes. While the exact cause of depression is certainly multi-factorial and include both environmental, genetic and epigenetic pathways there is no consensus on the exact cause and there are no diagnostic testing outside of controlled research centers that provide diagnostic testing such as fMRI or PET scans.  However there are consistent validated diagnostic criteria, screening questionnaires, patterns in a medical history and symptom clusters that are valid in identifying and studying effective treatments. Depression is at its core, profound unrelenting sadness and loss of the ability to experience joy or pleasure. In my clinical experience there are many ways depression expresses itself and the demographics, sex and stage of life can significantly affect the way depression is experienced and conveyed by those living with it.  Depression is a condition that is often silently endured and compartmentalized for months to years.  In high functioning professionals, depression can be insidious and may not be apparent to co-workers, friends and family. Athletes, somewhat ironically can turn to endurance training and physical activity as a way of self-treatment but still can become a victim to a debilitating exacerbation of the condition.

I had the great fortune to participate in presentations with ultra-endurance champions Rob Krar and Nikki Kimball. Both have eloquently presented their experience living and working through depression. They have found their own way of coming to terms with the condition and cultivating their own support network and professional support.  I recommend you take some time to check out these interviews and videos:

Ultrarunner Podcast-Nikki Kimball

Billy Yang Podcast-Rob Krar

Nikki Kimball Keynote Central California Psychiatric Society

Rob Krar-“Depressions”

Rob Krar-Movember Project Video

Depression is common in athletes but the rates greatly vary between types of sports.  The sports that have the highest rates of depression are those that have high rates of head injury: american football, soccer and boxing. Running is often lumped with other track and field sports in epidemiologic studies and have been found to have similar to slightly higher rates than the general population. In comparative meta-analysis (see references at end of this entry) and other studies of self-reporting depressive symptoms; high performance athletes defined broadly to include elite athletes in a range from high-performance youth development programs to Olympic or world championship level performance.  The studies found that there are risk factors specific to athletes for depression.

  • Injury: lasting >6 weeks or needing surgery
  • Age related loss of performance
  • Pregnancy interrupting training or competition
  • Retirement or loss of professional or elite affiliation
  • Over-training
  • Overly perfectionist personality traits
  • Recreational substance abuse
  • Anabolic steroid use

The risk factors can be lumped into more general categories. 1. Injury negatively impacting performance and or training. 2. Life or developmental milestones affecting the athlete. 3. Finally maladaptive approaches/attitude to training and or competition having unintended negative impact on performance.  It is my opinion that these risk factors should not be interpreted as an additive or causal relationship, meaning that if you acquire more of the above, like an aging type A personality-athlete with chronic injuries and difficulty attaining a sponsor, that you will definitely develop clinical depression; rather to recognize that these experiences, much like a fall on the trail, should indicate to the runner, coach, manager or sports med doc to perform a self-assessment or screening for depression.

1 and 2 are intuitive and make some sense, however there can be internal or external pressures to “tough it out” or like in the case of pregnancy feel that only positive feelings should be associated with the event. Over-training is often insidious and only recognized retrospectively or during a period of chronic injury.  There are probably as many opinions on how to access and deal with over-training as there are experts on the internet.  Perfectionist views when balanced can be adaptive and even effective particularly on the higher end of performance. I would say that some degree of perfectionism is inherent in any field that requires a great deal of training, precision and talent. However, when ones personal self-worth is consumed with perfection to the detriment of work, relationships, social interaction and even self-care an underlying depression may be occurring.  Performance enhancing substance use in sports with its potential ties to depression is worth an entire blog post but the evidence does seem to show using anabolic steroids independently increases risk for depression.

Major life changes or milestones can be stressful and traumatic and lead to depression.  If you have a family history of depression or other mental illness you may be more vulnerable to depression. Social isolation and lack of a support network can also increase the risk and exacerbate depression. Chronic medical conditions and financial stressors are also associated with depression. Most primary care doctors have access to the PHQ-2 or PHQ-9 depression screening tools. These are simple but effective tools in risk stratifying people who may need additional evaluation and help with depression. The PHQ-2 asks regarding the past 2 weeks how often you have been bothered by: 1. having little interest or pleasure in doing things and 2. feeling down depressed or hopeless. A positive score on either question should trigger the provider to have you complete the rest of the Patient Health Questionnaire-9 (a form that rates how often you have other symptoms of depression).  These tools have been found to be very helpful in identifying people who would benefit from additional help and also in rating the response to treatment.

The next step ideally would be a comprehensive and patient-centered evaluation. This could be done by a primary care provider, counselor, psychologist, social worker or psychiatrist.  While each profession may approach the evaluation differently all ideally should develop a time line of the problem/symptoms/feelings, gather a history of your developement and experiences, explore the severity and impact of the symptoms on functioning, previous treatments (and responses), past hospitalizations and suicidal thoughts or attempts. The evaluation should be able to rule out other causes such as hypothyroidism or other medical conditions that can have depression as a symptom. While a typical PCP or sports med doc do not have the time for such an interview, many clinics because of the ACA now employ or contract with mental health providers for these purposes. As healthcare consumers, it is your right to ask and if your problems are not being addressed do not hesitate to seek a second opinion. Sometimes bringing a friend or family member who can advocate will help connect you to the services you need.

Regardless on how you get to a mental health evaluation, this can be stressful and overwhelming in its own right. Unfortunately there is stigma and lots of bad experiences reported on the web that can create a sense of anticipation or even dread about the process. While I cannot speak for all providers, I can say that the majority of internists, family doctors, psychiatrists, nurse practitioners, physician assistants, psychologists, social workers and marriage & family therapists are people who care deeply about others and want to help to the best of their abilities. Most likely the evaluation will consist of a 45-90 minute conversation with the provider along with some diagnostic testing or signing releases for outside information. The national alliance for mental illness (NAMI) is also great local and national resource for support and to network with other consumers of mental health care.

Screening and evaluation is just one part of the comprehensive care of depression. Over the next 3 posts, I will write about treatment, stigma reduction and advocacy. Here are some additional resources:

Request for feedback: if you are reading this far down the post, thank you!! Please give me feedback on the content, style and approach of this blog. Also if you have topics or questions please take a little time to leave a comment.

References-I would not be an academic doc without these πŸ™‚

  • Kessler RC and Bromet EJ. The Epidemiology of Depression Across Cultures. Rev. Public Health 2013. 34:119–38
  • Gorczynski PF, et al. Depressive symptoms in high-performance athletes and non-athletes: a comparative meta-analysis. Br J Sports Med 2017;51:1348–1354
  • Hoffman MD and Krishnan E. Health and Exercise-Related Medical Issues among 1,212 Ultramarathon Runners: Baseline Findings from the Ultrarunners Longitudinal TRAcking (ULTRA) Study. PLOS ONE January 2014.Volume 9. Issue 1. e83867
  • Wolanin A, et al. Depression in Athletes: Prevalence and Risk Factors. Current Sports Medicine Reports: January 2015 – Volume 14 – Issue 1 – p 56–60
  • Stillman MA et al. Sport psychiatry and psychotherapeutic intervention, circa 2016, International Review of Psychiatry, 28:6, 614-622

The contents of this webpage and all blogs authored by John Onate, MD should not be interpreted or used as medical advice.  The information and views are for general information, advocacy, education and inspiration only. Specific medical questions and concerns should be addressed by the readers medical provider.  Reading this blog and any content contained within, including replies and comments authored by the writer in response to readers do not constitute a doctor patient relationship.


  1. Thanks for the thoughtful and timely post John. Easy read and I’m sure will be a valuable resource for many. Looking forward to next few posts! Rob Krar

    Liked by 1 person

  2. Thank you for the post and I also look forward to the ones still to come. As an individual who suffers from anxiety and depression I found exercise helpful in my battles with these illnesses and running being my favorite form of excercise has become a major tool I regularly employ. I’m heartened to see more frequent posts such as this and engagement by more prominent individuals such as Rob Krar and Nicki Kimball. Let’s keep it going. 😊
    I did notice a glitch when I clicked on your menu bar and went to your bio. I was unable to link back to this blog post.

    Liked by 1 person

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