Depression in Endurance Athetes Part 2, Lets Talk About Suicide…

I woke up in tears, crying with a terrible combination of guilt, loss and sadness; I had learned that a patient of mine had committed suicide. He was young, suffered terribly from bipolar disorder and had recently reconnected to me after loosing access to his previous mental health clinic due to the complexity of our county mental health system and his aging out of a program for adolescents and young adults. I knew his parents well, an engaged warm couple, who were trying their best to keep their son from being institutionalized. When I evaluated him he was in the midst of a severe depressive episode but did not meet criteria for an involuntary hold. I restarted his medications ordered some labs and scheduled him to return in 2 weeks…that was the last time I saw him.  When one of my patients die, I usually offer to meet with the family, when I met with his family I was anxious because I felt that I let both the patient and them down and was still shocked. At the end of a tearful meeting reviewing what happened they invited me to his funeral. In my practice I take care of complex patients with severe medical, mental health and substance related problems, unfortunately my role sometimes involves being their provider to the end. I have found that, if invited, that attending the funeral helps me with closure but seems to be a positive experience for the friends and family. When I attended my patients funeral the family asked me to speak to and specifically asked me to talk about his condition, suicide risk and resources for mental health problems in the community.  When I spoke his parents passed out suicide hotline information to those in attendance. I had never experienced anything quite like that before.  It was very special in witnessing an amazing family trying to find a positive and transformative response to a horrible tragedy.

As a physician, I struggle with cognitive biases that affect my clinical judgment, all healthcare providers deal with this in some fashion because we are humans and not computers. Providers who take care of people with depression usually (and in my opinion should) have suicide risk as some part of the their assessment.  However, suicidal thought or thoughts of not wanting to live are much more common than actual suicide attempts. There is a nearly 10% lifetime risk of suicidal thoughts. Suicide as cause of death is in the top 10 in the United States; with white and native american males having the highest annual rates. Missing or failing to interrupt an attempt is a fear that weighs heavily in psychiatrists because it is very difficult to predict who will actually make an attempt.  In my experience, access to firearms significantly increase the lethality of attempts at self-harm and multiple studies support this with over 50% of suicides using firearms as the mechanism.  Studies found that the healthcare providers most likely to be seen before someone who has a suicide attempt are not in the mental health field, they are usually a primary care or general medical provider. Part of my work at UC Davis is educating primary care providers on mental health assessment and care with the goal of improving how mental health problems are treated by PCP’s.

Suicide Risk Factors:

  • History of previous suicide attempt
  • Diagnosis of mental illness, risk increases with severe mental illness (i.e. recurrent major depression, bipolar disorder, schizophrenia) and history of hospitalization for mental illness
  • Chronic Medical Conditions, such as HIV, hepatitis C, chronic lung disease, cancer, diabetes, stroke and heart disease.
  • Chronic Pain studies indicate cancer related pain but other types of chronic pain such as back pain also increase risk
  • Traumatic Brain Injury, with risk increasing with severity of the trauma
  • Childhood adverse experiences such as physical, verbal and or sexual abuse
  • Family history of suicide in first degree relatives
  • Severe Hopelessness, this symptom or emotional state is found to be a factor independently of other risk
  • Not being married or having a long-term legal partner, there are many studies that find this association and it maybe a marker for loneliness or social isolation. In epidemiologic studies, marital status is much easier to verify than other types of long-term relationships.
  • Certain types of employment or profession, military (especially combat experience) and physicians have been found to have much higher rates of suicide than other professions.
  • Unemployment and or financial strain
  • Living in a rural part of the country, rates of suicide are nearly double the rate of urban areas.

Suicide risk in endurance athletes are lacking data from large targeted studies but in, Baum AL. Suicide in Athletes: A Review and Commentary. Clinics in Sports Medicine, Volume 24, Issue 4 ,853-869. 2005, 71 cases were reviewed: composed of 66 completed suicides and 5 attempts or ideation. American Football was the sport in almost half the cases and may be related to football player’s higher rates of traumatic head injury and depression found in other studies. Track and field was the sport in 4 of the cases. Concussion and post concussive syndromes were identified by the author as one of the injuries most associated with suicide. Implied in the cases where other types of injury that were long-lasting, required surgery or derailed the career/success of the athlete as also being a risk factors for suicide or suicidal thought. Internal and external expectations for performance and results in their sport, social stressors and substance use also were found in the cases. As stated above having mental illness particularly mood disorders such as depression or bipolar disorder increases risk. There were some associations with anabolic steroid use and small studies support the potential risk. Being a gay athlete in a sport that may have a homophobic environment or attitudes also increases risk of depression and suicide.

All of these factors could be involved but there is a need to have more well-developed studies with a higher number and statistical validity to help better understand factors that are unique to athletes. Ultimately the reason for studying suicide is so athletes, coaches, managers, sports medicine professionals can identify and facilitate interventions earlier, stigma can be reduced, preventative strategies can be developed and governing organizations can better identify systematic factors that may inadvertently increase risk of depression and suicide in athletes. The reduction of repetitive head injury, more effective and standardized treatment of concussion and TBI that include depression and suicide screening (that are also repeated at intervals months to years after the injury) are the most obvious interventions needed. Additionally access to effective mental health professionals in a timely manner needs to be improved for athletes (and the general public).

Suicide Prevention:

Unfortunately there are few high quality randomized controlled trials, effectiveness trials or meta-analyses. However the following are recommended:

  1. Assessing recognized risk factors and treating underlying symptoms of depression along with identifying unrecognized mental illness
  2. Cognitive Behavioral Therapy and Dialectic Behavioral Therapy are structured forms of psychotherapy that have been found to reduce suicidal and or self-harm behaviors.
  3. Limiting access to firearms for those who are at risk for suicide; barriers on bridges and roof tops to inhibit jumping
  4. Family and social support networks such as religious organizations have been found to reduce risk.  Social isolation is a near universal risk factor for suicide across cultures.
  5. Appropriate use of psychiatric hospitalization and involuntary holds

The National Institute for Mental Health recommends the following approach for addressing a family member or friend in who may be at risk:

5 Action Steps for Helping Someone in Emotional Pain

  1. Ask: “Are you thinking about killing yourself?” It’s not an easy question but studies show that asking at-risk individuals if they are suicidal does not increase suicides or suicidal thoughts.
  2. Keep them safe: Reducing a suicidal person’s access to highly lethal items or places is an important part of suicide prevention. While this is not always easy, asking if the at-risk person has a plan and removing or disabling the lethal meanscan make a difference.
  3. Be there: Listen carefully and learn what the individual is thinking and feeling. Findings suggest acknowledging and talking about suicide may in fact reduce rather than increase suicidal thoughts.
  4. Help them connect: Save the National Suicide Prevention Lifeline’s number in your phone so it’s there when you need it: 1-800-273-TALK (8255). You can also help make a connection with a trusted individual like a family member, friend, spiritual advisor, or mental health professional.
  5. Stay Connected: Staying in touch after a crisis or after being discharged from care can make a difference. Studies have shown the number of suicide deaths goes down when someone follows up with the at-risk person.


This is a serious topic and I am barely scratching the surface on the literature and information available in this blog post. However I feel it is important to start a discussion because this is a major problem that we have not come to terms as a nation and society on how to discuss or describe the issues. In the context of depression in endurance athletes, I felt I could not write on the topic without taking sometime to address suicide. Readers will rightfully so take issue with the clinical approach to discussing this topic.  I am approaching it from a view that we should look for scientific evidence that can aid us in making the best decision.  I am by no means implying that the individual’s narrative, their life experiences, hopes, fears and values can be reduced to a collection of symptoms and statistical data. Hopefully the reader of this post will gain some knowledge and perhaps a way of describing a personal experience that will let them know that many people also experience similar feelings and that there are resources available.  Please let me know if you want more information or references.

There are conflicting feelings and misinformation about suicide risk assessment. One of the most dangerous, in my opinion, is that you can increase the risk for suicide by asking or accessing it (if you are a provider).  There is no evidence for this cognitive error but studies and surveys of providers have found this is a common concern and reason for not asking questions about suicide.  Even though screening tools, contracts and simple yes/no questions may not be effective by themselves, these interventions could keep suicidal thoughts as thoughts only and delay or prevent an attempt. There are also compelling philosophical and ethical discussion regarding freewill and self-determination on those who choose to end their lives, particularly at the end of life or in terminal illness.  Discussion of aid-in-dying laws such as the End of Life Options act in California is a topic for another post. In my experience educating and training primary care providers, the reluctance to access depression and suicidal risk factors comes in part of an irrational concern that you would give the idea of suicide to a patient, not having training on what to do and lack of resources or knowledge of resources.

I will end this post with another example from a patient. Several years ago when I first started at UC Davis, I saw a women who had fallen on very hard times because of the recession, they had lost their home, savings and had to move into the basement of one of their children.  Then 6 month later her husband was diagnosed with advanced cancer; on the way back from one of his appointments, she was driving and she had the strong urge to kill them both by driving into something at high-speed. Her husband talked her into driving to my clinic.  I placed her on an involuntary hold because she was still convinced she needed to die and was profoundly depressed and ashamed of her situation. I saw her a few weeks later after her discharge and she thanked me for saving her life….


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.

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