Building a Mental Health Dream Team for Athletes (How Sleep Screening a Team Can Save Lives)

By Brendan Duffy, CCSH, RPSGT

From the song and album “The Stranger” (1977)….Billy Joel

Jeret Peterson, known to most as “Speedy” Peterson, was an American three-time Olympian and silver medal aerial skier. He tragically took his own life in 2011 via a self-inflicted gunshot wound. Just a year after his celebrated Olympic success, he was gone. Just like that. Age 29. He succumbed to his demons, the alcohol abuse, and his inner loneliness and hopelessness. In the end, he made the irreversible momentary decision to end his life. Could we have changed his heartbreaking fate?

Michael Phelps, the highly decorated world-famous Olympian was almost another casualty of what too often lies beneath the surface but is hidden from friends, teammates, and the public. In a recent HBO documentary entitled The Weight of Gold, Michael spoke about the various fears that impact athletes on and off the playing field and how they can lead to hopelessness and despair. Per this compelling documentary, Michael’s biggest question after retiring from the Olympics was, “Who am I?” Much like Speedy Peterson, Phelps had several run-ins with self-medicating via alcohol, perhaps in an effort to escape this question that he faced after his career ended.

He stated in an interview in 2018, “Drugs were a way of running from ‘whatever it was I wanted to run from…. It would be just me self-medicating myself, basically daily, to try to fix whatever it was that I was trying to run from.” 1

He has also spoken about how he had considered ending his life via overdose in a hotel room at one time―and was grateful to find there was only one Ambien pill left in the bottle.

Phelps’s mindset during this dark period in his life was related in a Washington Post article: “After the 2012 Olympics, Phelps said, he became suicidal after ‘doing the bare minimum’ to compete and wanting to get away from the sport. By 2014, when he got his second DUI, he admitted he was ‘running from something,’ adding, ‘I wanted to die. I straight wanted to die. We were prescribed Ambien because we were traveling the world, and I actually looked back and I had one Ambien left,’ he said. ‘And I’m actually happy I only had one.… that scares the living hell out of me’.”2

There are so many others out there. They seem to have everything anyone could want in this world, yet they feel they are carrying the world on their shoulders. And for some, it crushes them. They are not only Olympic-level athletes but athletes at all levels of sports. Others who have come forward to talk about their mental health battles include players such as Robin Lehner, NHL goalie with the Vegas Golden Knights, who spoke about his insomnia and excessive drinking during his season in Buffalo―unable to get to sleep prior to getting help. Imagine facing 100-mile-per-hour slap shots while sleep-deprived! Fortunately, he was later diagnosed with bipolar disorder and is on the mend. His story could have had a tragic ending had he remained in the shadows.

Another player with a disturbing story is former NFL star, Keith O’Neil. As a story in the Washington Herald-Tribune relates, O’Neil “hadn’t slept in four nights when he walked into the office of head football coach Tony Dungy. Just acquired off waivers, O’Neil opened up to Dungy about his insomnia and issues with anxiety.” 3

It was an O’Neil quote that made me realize that we may be missing some of the signs of what is lurking below the surface. Why aren’t we picking up some of these warning signs by asking our athletes of all ages how they are sleeping? It’s simple, yet we are not asking.

O’Neil noted as much in the above-referenced article: “I knew I had anxiety, I knew I was moody, I knew I had sleeping problems…. I just thought it was who I was. We didn’t have a mental-health month at school.”

Let that sink in a moment. O’Neil knew he had issues to address but felt alone because nobody asked. Nobody asked about his mood. Nobody asked about his anxieties. Nobody even asked about his sleep problems!

Sleep issues and mental health are very much intertwined. There are few if any mental health issues that do not have a sleep component. Dr. Meeta Singh, a board-certified sleep physician and prominent sleep coach for teams in the MLB, NFL, and NBA told me, “You cannot talk about mental health without giving sleep health a seat at the table.”

So it’s time we asked. Michael Phelps has stated that he just can’t see any more suicides. We need to speak up and take action.

Suicide is the second leading cause of death for people ages 10–34, and according to the National Alliance on Mental Illness (NAMI), suicide has increased 31% since 2001. It is the tenth leading cause of death in the US. It is beyond time that we used sleep screening with athletes not only as a valuable tool for performance and recovery but also as a way to possibly open a window to mental difficulties that may lay under the surface for these players. It’s time to reach out to the strangers in the locker room and extend our expertise and knowledge via methods such as sleep screening.

As sleep professionals, as coaches, and as certified athletic trainers, we need to educate ourselves on how we can ask these athletes about their sleep so that we can hopefully in some instances tease out mental issues, deter bad choices, and save lives. We need a better mental health game plan! And sleep screening should be part of that plan.

According to the NAMI website, “approximately 50% of insomnia cases are related to depression, anxiety or psychological stress. Often the qualities of a person’s insomnia and their other symptoms can be helpful in determining the role of mental illness in a person’s inability to sleep. Early morning wakefulness can be a sign of depression, along with low energy, inability to concentrate, sadness and a change in appetite or weight. On the other hand, a sudden dramatic decrease in sleep which is accompanied by increase in energy, or the lack of need for sleep may be a sign of mania”. 4

In any locker room, it is entirely conceivable that there are one or two players suffering in silence, as it often takes a decade or more from symptom onset to treatment, according to NAMI.

In an effort to start this conversation about assisting our athletes, I assembled my own dream team of sleep professionals who work with elite Olympic athletes, professional athletes, and high school and NCAA college athletes. They were gracious enough to take the time to answer eight questions I posed to them about athletes, sleep, and mental health. I am so thankful for their willingness to share their thoughts and their vast knowledge in this field.

They are:

1-   Mr. Pat Byrne – Pat Byrne is a sleep scientist, co-author with Suzanne Byrne of the book Inconvenient Sleep: Why Teams Win and Lose (2020), and sleep coach for teams in the NHL and NFL as well as several others since 2008. Byrne pioneered much of the information now utilized in working with players in regard to sleep and fatigue issues.

2-   Dr. Ian Dunican – Ian Dunican has twenty-three years of international professional experience in health, safety, research, and operations within the military, high-risk industry, and elite athletes. Combining scientific research and operational leadership with his business and engineering knowledge, Dunican supports organizations in reducing risk, lowering costs, and optimizing productivity and performance. He is currently the director/chief adviser at Melius Consulting, adjunct senior research fellow, UWA & adjunct associate professor, ECU.

3-   Dr. Amy Bender – Amy Bender holds a PhD and MSc in experimental psychology from the Washington State University, specializing in sleep EEG. Bender has developed sleep intervention protocols for numerous Canadian National Olympic sport teams.

4-   Dr. Michael Grandner – Michael Grandner is director of the Sleep and Health Research Program at the University of Arizona and director of the Behavioral Sleep Medicine Program at the Banner-University Medical Center in Tucson, AZ. He is associate professor of psychiatry, with appointments in psychology, medicine, nutritional sciences, and clinical and translational sciences. His research focuses on real-world implications of sleep in the context of health and society. He also works with companies and organizations interested in sleep health, sleep technology, and impacts of sleep on performance. He is the author of the book Sleep and Health (2019).

Q&A

  1. How can asking about sleep help a team unveil mental health issues of athletes?

Pat Byrne – While there have been great gains by compartmentalizing modern medicine into the various specialties, we should not forget that humans are an integrated system. It is hard to look at sleep or mental health in isolation. It turns out that sleep and mental health are two sides of the same coin.

Poor sleep is not a disease; poor sleep is a symptom. Poor sleep can result from, amongst other things, biological sleep disorders, organic diseases, lifestyle issues, and mental health issues. In our book, we quote Dr. Daniel Freeman, a psychiatrist at Oxford:

“Sleep problems are a common occurrence in patients with mental health disorders.… The traditional view is that disrupted sleep is a symptom” of the mental health disorder, but another perspective is that disturbed sleep is a cause of the mental health disorder.

Asking athletes about their sleep is a first step in recognizing and diagnosing the cause(s) of poor sleep, including mental health disorders.

Ian Dunican – As there is a link between poor sleep and mental health, I think asking athletes how they are sleeping can kick-start a conversation about mental health. Questions related to sleep may uncover issues. For example, those people with depression tend to spend a lot of time in bed but have low sleep efficiency as they spend a lot of time awake. Additionally, variation in time at sleep onset over time may be due to an underlying issue such as bipolar, whereby sleep patterns are linked to bipolar events.

Amy Bender – New research has shown that disturbed sleep can lead to mental health problems, so by assessing and fixing broken sleep, you may be able to prevent mental health problems or identify those who may have mental health issues.

Michael Grandner – Mental health problems often come with stigma, especially in athletes who are taught to be “tough.” Sleep problems, though, are much less threatening to talk about. Not only that, but by talking about sleep, that may be a way to talk about what is keeping them awake at night. This often includes worries, fears, and other mental health issues. Another issue is that sleep therapies are often effective, and this may serve as a good experience with a therapist that can be built upon for additional work in more complex areas.

  1. What are some of the conditions that cause stress for athletes and can overwhelm them?

Pat Byrne – It turns out that athletes are also human beings and subject to the same frailties as the rest of us. They can suffer from cancer or physical injuries and all of the other human ailments. Athletes tend to be younger and healthier, but that does not exempt them from such conditions. However, depending on the sport and the level of competition, athletes can find themselves somewhat isolated and under constant pressure to perform. For example, student-athletes have to juggle their time and energy between their family and peer demands, their academic pressures, and their athletic pressures to perform. However, it is rare that these groups that compete for the athletes’ time communicate with each other. It is left to the athlete to try to juggle these pressures, often resulting in destructive anxiety. In 2018, the NCAA reported that over 30% of student-athletes have experienced “overwhelming anxiety.”

Professional athletes can also suffer from such destructive anxiety, particularly before a major competition. Performing well for them is not just a matter of pride but can influence their career and their livelihood. For every professional athlete, there are thousands of other athletes competing to take their jobs.

Ian Dunican – The main issue for athletes is pre-competition stress. In individual athletes compared to team-based sports, sleep and stress is higher the night before a competition. Another area that does not get discussed is contract negotiations, an aging athlete who is fighting for a position in the team and trying to increase their longevity as an athlete. In addition to all of this is family, children, study for college, and for those at the top of their game, sponsorship activities and travel.

Amy Bender – Balancing work, school, social life, and family, along with high demands for the sport can be quite challenging. I was working with the Canadian National Curling teams and it was unreal how little time some of the athletes had because of full-time jobs and a family to take care of. All of these can lead to overwhelming stress and a lack of sleep because of the difficulty to prioritize sleep.

Michael Grandner – Many athletes worry about their future, they struggle with feeling overwhelmed, and suffer from exhaustion. Anxiety and depression symptoms are common in athletes because they are common in everybody. Especially young adults under constant pressure!

  1. Do you believe Ambien and melatonin are overprescribed for athletes, and what would you do if you worked with a team to resolve this issue?

Pat Byrne – That is difficult to judge. Ambien and other sleep medications are normally available by prescription through a physician. Athletes have access to such drugs from many sources, not just the team physician. Most of the information about the use of sleep medications for athletes is kept private. It is worth noting that Australian Olympic athletes are banned from using these medications as a result of abuse of the products. So, certainly, if teams and leagues wanted to look into the use of sleep medications amongst athletes, they might not like what they see.

Melatonin is a bit different. In North America, it is largely unregulated and can be obtained over-the-counter by anyone. It is also controversial. We discuss this at length in our book. While melatonin is widely used and sometimes handed out like candy to athletes, there is little scientific evidence that it helps with sleep. In addition, the long-term effects of its use have not been thoroughly studied.

Ian Dunican – I’m not sure if they are overprescribed, as the use varies from country to country depending on regulations. However, I do think that athletes and non-athletes believe that melatonin will solve all their problems related to sleep. In some cases, the use of melatonin, if not timed correctly, may cause more harm than good.

Amy Bender – Potentially, these drugs may be overused. I gave a talk to some elite adolescent athletes, and they were using the term “mellies” to talk about melatonin, which signified to me that this was an issue. I think both of these drugs have a place for athletes, but there has to be strategic use and rules related to them. If an athlete has been really struggling with insomnia in certain situations (e.g., can’t sleep on a plane on an overseas trip, jet lag problems in a new time zone), these can be effective. But ideally used only acutely, as there are potentially more effective treatments out there (e.g., CBTI) for long-term management.

Michael Grandner – I am not sure how overprescribed they are. However, I usually find that CBTI is extremely effective in athletes, and therefore substances like Ambien and melatonin―and the potential side effects―are not necessary.

  1. Do teams do enough to monitor the interaction of sleep meds, especially when dealing with athletes after concussion or who are prescribed pain meds also? Are we educating the team docs and the athletes sufficiently?

Pat Byrne – Teams largely rely on their team physicians to monitor the use of all medications for athletes. However, athletes can get access to prescription medications from many other sources. For example, I worked with an athlete who was from Eastern Europe. He was taking a doctor-prescribed sleep medication from there, and we never really knew what he was taking.

In addition, while the American College of Sports Medicine sets out the roles and responsibilities of sports physicians, including “substance abuse,” they do not describe responsibilities for sleep or circadian rhythm disruptions.

Ian Dunican – No, we are not educating staff, medical staff, and athletes enough. This is the fault of the clubs/teams themselves. They are not prepared to invest in research or pay for expertise to support them. If you look at the recovery pyramid in athlete recovery, sleep is at the base of this, but teams are more interested in spending money on massage, cryotherapy, buying pajamas instead of scheduling for optimal sleep during training periods of travel and competition. More has to be done by the teams themselves….

Amy Bender – I actually don’t have enough information/experience with this specific med interaction scenario to comment on this question.

Michael Grandner – In my experience, a lot of team docs don’t have a lot of education about sleep medications. It just isn’t their training. So they end up either prescribing things ineffectively, or they become shy about prescribing medications that may be beneficial.

  1. Do you feel athletes have enough resources or lifelines when they are having mental health issues? What barriers do they face?

Pat Byrne – I would say that in the past this has been a problem, but it is changing as more high-profile professional athletes are coming forward to talk about mental health issues. In my view, the issue is less about mental health resources for the athletes than about diagnosis and convincing athletes that there are successful interventions that will not affect their careers. The challenge is that many athletes see mental health as a weakness that may affect their careers, resulting in a reluctance to come forward. In my experience, it is not uncommon for athletes to even hide some physical injuries in order to not affect their playing time. Those same difficulties apply to mental health issues.

Ian Dunican – No, the material that is out there is generic in nature, and whilst it may be helpful in certain cases, it does not address specific issues that athletes face.

Amy Bender – I don’t believe we are to the point of having enough resources for mental health. There are always ways to improve.

Michael Grandner – Many athletes are surrounded by support systems, but often those are not well-equipped to handle mental health issues. Dedicated mental health resources―or at least people with mental health training―should be made available.

  1. How can team staff differentiate the insomnia that is due to game anxiety issues versus mental issues or depression?

Pat Byrne – Team staff likely cannot normally make those determinations. The term “insomnia” is often used as a catch-all for poor sleep. Athletes need to be properly screened (and diagnosed) for sleep and mental health disorders. That is the only way these issues can be differentiated from game-time anxiety.

Ian Dunican – First thing to do is objectively measure it. Many athletes I know say they have insomnia, but after PSG, actigraphy, and diary measurements, they actually don’t.

Amy Bender – I would say a good way would be to assess whether it is happening more frequently even on rest days vs. the night before a competition, which is pretty common.

Michael Grandner – Asking some basic questions about whether sleep problems are more persistent, not only timed to competitions, would help. But team staff are not mental health experts. If athletes are reporting sleep problems, refer them to a validated screening tool or a trained professional who can determine these things. That way, they get the care they need if they need it, but normal issues are not blown out of proportion.

  1. What dangerous coping methods have you seen for athletes trying to sleep and deal with depression?

Pat Byrne – The way athletes cope with depression or other mental health issues is often hidden. I do know athletes can abuse alcohol and recreational drugs.

Ian Dunican – I haven’t witnessed anything dangerous, but I do know that some athletes use alcohol and sleep meds to get to and stay asleep.

Amy Bender – Haven’t really worked with athletes and depression extensively.

Michael Grandner – Athletes don’t always know the best strategies for dealing with their mental health issues and insomnia. Problematic substance use is common, whether it’s stimulating substances to promote alertness or sedating substances to get to sleep or both. Also, they can sometimes be distracted by unproven “quick-fix” strategies, supplements, and technology that end up just frustrating them even more.

  1. With Michael Phelps and others speaking out about mental illness, do you see changes happening with team players being more open in disclosing their troubles?

Pat Byrne – I think I answered this in #5. Having high-profile athletes discuss mental health issues is an important first step. However, there is still a long way to go to convince athletes to admit to any frailties when their careers are on the line.

Ian Dunican – I hope so, but again, like sleep, we need more funding, more ownership, and more teams driving this and not reacting to comments.

Amy Bender – I would think it would reduce the stigma around mental health issues and make it easier for athletes to talk about.

Michael Grandner – Michael Phelps and Dr. Brian Hainline (NCAA chief medical officer) have both made incredible progress in getting athletics organizations to take mental health seriously. The NCAA released their Mental Health Best Practices in 2015, and their position statement on sleep guidelines in 2019. The International Olympic Committee also released their mental health position statement (which heavily featured sleep) this past year. Another international consensus guideline document is set to be published this year as well. And the NCAA, IOC, and other organizations are following up these guidelines with educational materials, guides, and other resources for addressing mental health and sleep problems.

Sources

1- Scutti, Susan. “Michael Phelps: ‘I Am Extremely Thankful I Did Not Take My Life.” CNN. Jan. 20, 2018. Retrieved from https://www.cnn.com/2018/01/19/health/michael-phelps-depression/index.html

2- Boren, Cindy. “‘I Straight Wanted to Die’: Michael Phelps Wants USOC to Help Athletes Cope with Depression.” Washington Post. Mar. 28, 2018. Retrieved from https://www.washingtonpost.com/news/early-lead/wp/2018/03/28/i-straight-wanted-to-die-michael-phelps-wants-usoc-to-help-athletes-cope-with-depression/

3- Fernandes, Doug. “O’Neil’s Journey in NFL with Bipolar Disorder.” Sarasota Herald Tribune. Apr. 6, 2018. Retrieved from https://www.heraldtribune.com/sports/20180406/oneils-journey-in-nfl-with-bipolar-disorder

4- “Sleep Disorder.” National Alliance on Mental Illness. Retrieved from https://www.nami.org/About-Mental-Illness/Common-with-Mental-Illness/Sleep-Disorders

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Brendan Duffy is the Director of Sleep Services for Catholic Health Hospitals on Long Island. He has worked with professional, college, and high school athletes with regard to sleep and its impact on performance and recovery.

A message from Brendan Duffy: I would like to thank all of my sleep colleagues who took the time to provide their thoughts for this important discussion. It is our hope that we have provided some thought-provoking information for coaches, certified athletic trainers, and team medical staff as they work with these athletes. Let’s remember that athletes are humans too. By inquiring about sleep difficulties, you just may unmask the stranger, start a dialogue, and save a life. That would be your greatest win!

(If you or someone you know needs assistance, please call the National Suicide Prevention Hotline at 1-800-273-8255.)

 

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