Investigating the Attitudes of College Student

Athletes toward Mental Health Stigmas & Symptoms

 

Basketball next to books
 
Author’s Note:

Ever since joining my sports medicine internship, I have grown my passion for providing quality care for the student athlete community and ensuring their wellbeing on and off the field. Through the internship, I learned to take every opportunity as a learning experience, and this review was nothing short. I was prompted to choose a health-related topic for my UWP 104F class, Writing in the Health Professions, taught by Dr. Brendan Johnston. I chose this topic because I believe that more awareness should be brought toward holistic athlete wellbeing as these outcomes are often lost in the craze of sport culture and stigmas. I hope to bring more attention to the struggles of the student athlete community at the college level in order to improve overall mental health literacy and to mitigate mental health experiences for marginalized communities among student athletes. In reading this literature review, my hope is that the reader can understand that because there is an inconsistent relationship between student athletes’ likelihood of seeking treatment and mental health attitudes, improving attitudes toward treatment seeking takes precedence in achieving better mental health outcomes for college-aged student athletes.

 

Abstract 

Student-athletes are a niche population in which both sporting excellence and academic success are expected outcomes. Mental health is a critical topic in the student-athlete community because athletes are more at risk than nonathlete students for mental illness, and they often sacrifice mental health for sport success (Watson & Kissinger, 2007, as cited in Vickers, 2014). The purpose of this literature review is to investigate the attitudes of college-aged student-athletes toward stigmas and symptoms of mental health, in their college career and outside of their sport. Stigmas, attitudes, and intentions of student-athletes toward mental health were researched through studies from databases selected from EBSCO, PubMed, PsycInfo, BIOSIS Previews, and SPORTDiscus. Qualitative and quantitative research that concerned perceptions and treatment-seeking attitudes were analyzed and reviewed. It was determined that there is a clear disconnect between stigmas surrounding mental health and how athletes approach suspected mental health symptoms or seek treatment for mental health if indicated. Student-athletes have a general understanding of mental health literacy, but are still less likely to reach out for treatment. Student-athletes hold specific stigmas to a degree more than others in the community, and enough to significantly affect one’s intentions to seek treatment (Barnard, 2016; Bird et al., 2020; Edwards et al. 2022; Edwards & Froehle, 2021; Hilliard et al., 2020; Tabet et al., 2021). To improve the treatment-seeking attitudes of student-athletes and reduce stigmas around seeking treatment, mental health intervention programs catered to each school athlete population should be provided by the university. 

 

Introduction 

Two years ago, the number of current student-athletes in the National Collegiate Athletic Association (NCAA) topped 510,013, the association’s highest since 1982 (NCAA, 2021). About 10-15% experienced psychological issues in their career extreme enough to warrant professional counseling (Watson & Kissinger, 2007). Although it is proven that many athletes will find their athletic career fulfilling, the benefits may not always justify the emotional distress, mental illness, and physical wear that accompany it (Watson & Kissinger, 2007). The role of student-athletes among the college population is a unique one because they are expected to balance academic studies with sporting commitments and maintain a social life with success in their careers and studies as the ultimate goal. 

Despite not competing at the professional level, student-athletes still share distinct experiences, such as being scrutinized in the public eye and ensuring their body is in a healthy state for competition. The cumulative effect of these responsibilities produces added stressors and mental health symptoms and illnesses like anxiety, fatigue, difficulty sleeping, depression, and feelings of worthlessness (Vickers, 2014). Student-athletes are compelled to deal with the aforementioned symptoms in private and unhealthy ways due to their demanding schedule and the stigmas associated with symptoms of mental health in sports and reaching out for support. Being seen as “weak” if an athlete were to ask for mental health resources contradicts the mental toughness culture in sports. This culture is often enforced by fellow student-athletes and athletic staff to minimize psychological distress and mental illness indicators and to keep athletes in the game, at any cost (Mcquade, 2021). Oftentimes, feelings associated with mental health symptoms and illnesses negatively impact their careers, physical health, and academic performances, which can potentially exacerbate symptoms.

Research on student-athletes suggests that only 10% of athletes who are experiencing symptoms of anxiety or depression reach out for mental health services (Bird et al., 2020). Fewer student-athletes seek treatment, compared to nonathlete students. Although previous studies have acknowledged the statistics concerning mental health prevalence in college student-athletes, this review will examine the depths of causes, attitudes, and effects directly related to the mental health of student-athletes. Thus, the goal of this literature review is to investigate how college-aged student-athletes with mental health problems address the symptoms and stigmas regarding mental health in their college careers and outside of their sport. 

 

Methods 

Data for this literature review were acquired through health databases such SPORTDiscus, EBSCO, PubMed, PsycInfo, and BIOSIS Previews. Keywords used to search under the Boolean operator include “mental health,” “student-athlete,” “college,” and “performance”. Articles were examined based on relevancy, population demographics, the recency of findings, and research quality. To meet the inclusion criteria, selected studies had to discuss the attitudes of student-athletes toward general mental health or symptoms and/or illnesses such as anxiety, depression, and eating disorders. Other inclusion criteria concern the stigmas which prevent student-athletes from seeking treatment and common views shared by student-athletes regarding their mental health. 

Studies that discussed mental health literacy (MHL) were included to serve as baseline ideas of what student-athletes understand about mental health signs and symptoms and familiarity with common mental disorders. MHL was not a part of the inclusion criteria, but articles regarding MHL were examined based on population range and tools to measure MHL. Stigmas, such as social and personal stigma, served as variable measures for attitudes. Therefore, proper use of psychological assessments in data analysis operated as part of the inclusion criteria. Studies of student-athletes in NCAA Division I, Division II, and Division III athletic competitions were considered due to the variability in competition level, differences in funding for student-athlete resources, and the degree of mental health symptoms and illnesses experienced. Because many studies focused on student-athletes' attitudes toward mental health, performance effects were determined not to be inclusion or exclusion criteria. Still, if the study mentioned academic or sport-related performance concerning the mental health of college-aged student-athletes, the study was admissible. 

Exclusion criteria consisted of articles suggesting heavy confounding variables such as the COVID-19 pandemic. This phenomenon will draw bias to the reason student-athletes experience symptoms of mental illness. Studies with treatment-based approaches, samples of athletes less than 100, and studies with international populations or professional athletes were excluded. Studies with population samples outside the age range of 17-24 were also excluded. The Joanna Briggs critical appraisal tools—evaluative methods for determining the quality of research—were employed after selecting each study to establish validity. These guidelines also helped to establish personal critical appraisal criteria, such as ensuring method processes were free of bias and presented transparency about confounding variables. Eight studies remained after establishing criteria and critical appraisal, with six specifically addressing MHL and perceptions of student-athletes toward mental illness and symptoms. 

 

Results 

Attitudes toward symptoms and seeking treatment 

Student-athletes were less likely to report symptoms and seek treatment, and therefore reach out for a diagnosis/treatment. This was a theme derived across the studies that addressed attitudes toward help-seeking and symptoms defined as a result of mental health. The psychological assessment, Attitude Towards Seeking Professional Psychological Help Scale (ATSPPHS) was standard across the 5 main studies that discussed intentions to seek help and expressed responses on a scale. All except one successfully predicted that athletes would generally score lower on this scale or have a lower score in comparison to nonathletes. Barnard (2016) hypothesized that the nonathlete group would have a higher average mean than the athlete group, but there was insufficient data to support this hypothesis and no significant mean score difference was defined. 

Hilliard et al. (2020) used a different approach and sought to research the relationships between attitudes, intentions, public stigma, personal stigma, and social network stigma (SNS). These terms refer to the stigmas that are the most deterrent to student-athletes seeking treatment. For example, “public stigma refers to a belief that society perceives seeking help for mental health treatment as undesirable and individuals who seek help are socially unacceptable” (Hilliard et al., 2020, p. 1476). While public stigma is external, personal stigma refers to an internalization of the public stigma that operates within oneself (Hilliard et al., 2020). Data indicated that the strongest relationship was between attitudes and intentions and the weakest, SNS and intentions, indicating that one’s actions were dependent on feelings about anxiety or visiting a sports psychologist (Hilliard et al., 2020). Both Tabet et. al (2021) and Barnard (2016) used versions of the psychological assessment Perceived Devaluation Discrimination (PDD-A) to operate as a construct for personal bias and stigma toward individuals with mental illness. Despite using slightly different scales, both studies confirmed that student-athlete bias on mental illness was low, with Tabet et al. (2021) indicating that below-average mean scores using the PDD-A scale meant the amount of mental health stigma was not exaggerated. In conjunction, Barnard (2016) used statistical analysis to suggest that student-athletes had a significantly lower overall mean score, and are “less likely to devalue someone based on the presence of mental illness” (Tabet et al., 2021). 

Barnard (2016) found no evidence that student-athletes would score higher than student-nonathlete counterparts regarding social distance toward someone with mental illness. A second hypothesis regarding higher quantities of perceived discrimination toward someone with mental illness was also disproved, as statistical analysis revealed that student-nonathletes are more likely to discriminate, ultimately supporting that student-athletes extend less bias toward mental health (Barnard, 2016). A compelling takeaway is that student-athletes show impartial attitudes toward symptoms and seeking treatment. The phenomenon in which student-athletes reportedly face less mental health effects on performance than their nonathlete peers opposes this takeaway (Barnard, 2016; Hilliard et al., 2020; Tabet et. al, 2021).

Effects/manifestations on academic and athletic performance 

Evidence from two of three studies related to performance approved of the negative effects of mental health symptoms on academic and sports performance. Bird et al. (2020) was conducted using a mixed methodological approach, as it sought to understand mental health help-seeking concerns, under the Health Belief Model (HBM) framework, a theoretical framework consisting of questions regarding six independent factors, constructed to “capture an individual’s help-seeking behavior” (Bird, 2020, p. 61).  This allowed Bird et al. (2020) to collect qualitative and quantitative data to achieve a collective understanding of help-seeking behavior. This also helped to quantify and identify the primary factors that HBM produced. Under HBM, Bird et al. (2020) described six factors that would be used to guide participants’ experiences. One of those factors, perceived seriousness of mental illness, uncovered the influence of mental health on performance, in which most of the student-athletes believed issues regarding mental illness were in fact causing a negative effect on performance. One student-athlete indicated that mental health matters were preventing them from motivating their sports team and another reasoned that dealing with mental health matters was too much, alongside the factor of concentrating on their sport (Bird et al., 2020). Although Bird et al. (2020) offers a solid view of the relationship between mental illness and performance, it’s important to note that the sample population number totaled four student-athletes (the study consisted of six overall participants, but they were divided into groups after HBM surveys according to the sincerity of experienced mental health matters). Ultimately, this study was included in this review because it was one of the only studies to exemplify specific mental health factors barring student-athletes from their sport. Therefore, one must accept this relationship with caution, due to decreased ability to generalize findings to all student-athletes. 

Martens et al. (2006) infers that due to the mental and physical demands of a student-athlete’s sport and related commitments, stressors may present as excessive. In turn, this makes student-athletes more prone to symptoms like elevated anxiety levels and inducing unhealthy sport-related coping, like alcohol abuse. Research by Edwards & Froehle (2021) conversely suggests that mental illness does not serve as a significant impediment to academic performance. The data revealed that in comparison to club/intramural athletes and nonathletes, mental health impediments to student-athletes such as anxiety, eating disorders, and depression, demonstrated to have less of an impact on academic success. However, student-athletes and club/intramural athletes reported alcohol/drugs more frequently as an impediment to academic success than nonathletes (Edwards & Froehle, 2021). As mentioned by Martens et al. (2006), an impediment such as alcohol/drug abuse could exacerbate excessive stressors and lead to mental health issues. Therefore, the aforementioned finding is crucial to understanding the possible effects of academic performance that influence student-athletes more than nonathletes. 

Role of mental health literacy and its significance 

MHL is “defined as the knowledge and beliefs people have about mental health conditions, which helps in their recognition, management, and prevention” (Back to basics, 2022). According to Sullivan et al. (2021), a measurement of MHL is achieved through the Multi-Component Mental Health Literacy Measure (MMHLM). Consisting of a 3-factor model (knowledge-oriented MHL, beliefs-oriented MHL, and resource-oriented MHL), MMHLM combines one’s knowledge, recognition, and attitude to determine mental health behavioral predictions. Higher levels of MHL pertain to lower levels of stigma, and lower levels pertain to negative coping behaviors (Sullivan et al., 2021). MHL is important in student-athletes because it indicates how they might treat suspected symptoms of mental illness and reveal help-seeking behaviors. Sullivan et al. (2021) determined that in comparison to student trainers, student-athletes had higher levels of MHL related to the belief and knowledge factors, but not the resources factor. Higher levels of MHL constitute increased awareness of how mental illnesses present, increased likelihood of identifying appropriate services, and increased likelihood of accessing them (Sullivan et al., 2021). Comparisons were drawn between females and males, but no statistically significant factors were revealed, other than the belief factor (Sullivan et al. 2021). 

 

Discussion 

This literature review investigated the attitudes of college-aged student-athletes with mental health issues toward symptoms and stigmas in their careers and outside of their sport. All 6 studies regarding perceptions of college-aged student-athletes toward mental health agreed that there is an incoherent relationship between stigmas surrounding mental health and how athletes approach suspected symptoms or seek help for mental health if indicated (Barnard, 2016; Bird et al., 2020; Edwards et al. 2022; Edwards & Froehle, 2021; Hilliard et al., 2020; Tabet et al., 2021). 

Converse relationship between help-seeking behavior vs. attitude toward MH symptoms

A divergent relationship was established between student-athletes’ reasonable regard toward mental health and the likelihood of seeking treatment (Barnard, 2016; Bird et al., 2020; Edwards et al. 2022; Edwards & Froehle, 2021; Hilliard et al., 2020; Tabet et al., 2021). Subjectively, student-athletes experienced mental health issues that deterred them from academic and athletic performance but objectively issued less bias toward mental health (Barnard, 2016; Bird et al., 2020; Edwards & Froehle, 2021; Martens et al., 2006; Tabet et al., 2021). Student-athletes were less likely to discriminate against someone based on mental illness, indicating that positive attitudes toward mental health are becoming prevalent (Barnard, 2016; Tabet et al., 2021). This could be attributed to increased exposure to mental health resources in college. 

On the other hand, student-athletes were less likely to report anxiety and depression as impediments to academic performance, but Edwards et al. (2022) determined that low rates of student-athletes’ responses played a factor in the nature of these responses, due to possible fear of speaking out. Data from Sullivan et al. (2021) suggest that student-athletes are aware of how suspected symptoms present, or what to do in the case of a mental health issue, but are less likely to actually approach a resource. 

Assertive, negative perceptions toward student-athletes

It’s important to note that although student-athletes recognize the low-reporting/MH resource use phenomenon, negative attitudes still operate strongly not toward others with mental health issues, but toward their own intentions and stigmas, and this is why the relationship between attitudes toward mental health and the likelihood of seeking treatment is inconsistent (Hilliard et al., 2020). Fear of speaking out could be the cause of this issue, as well as public stigma. As mentioned in Tabet et al. (2021), the idea that student-athletes will be seen as weak or not tough enough, in sports culture, was identified as a possible motivation for not seeking treatment. Because it is evident that student-athletes are literate in mental health, the issue of seeking treatment lies strictly in the community, specifically the stigmas that operate in sport culture that dictate their actions and thoughts about mental health (Sullivan et al., 2021). 

Barnard (2016) mentioned how a study was conducted on undergraduate psychology students and their perceptions of a football player seeking psychological help, and how their evaluations were significantly negative (researchers dictated part of the negativity toward the rough nature of football). This study reinforces that public stigmas operate on most young people, not just student-athletes, but operate harder on student-athletes due to a combination of stigma and sports culture. 

Strengths and possible confounds

One strength of the aforementioned Barnard (2016) study is the assessments used to measure perceptions of symptoms and stigmas. Assessments such as the Perceived Devaluation-Discrimination Scale were utilized to measure attitudes toward someone experiencing mental health issues (Barnard, 2016; Tabet et. al, 2021). Interval evaluation of each assessment was concluded to ensure validity strong enough to infer an association between one’s response and the degree of said phenomenon. Although these quantitative variables were hard to measure, researchers certified that more than enough statistical analysis was done to ensure the validity of each response. To account for statistical human error in some cases, researchers extracted a sample within the population sample and ran through the procedure once more (Sullivan et al., 2021). Another strength of this study is that the consistency of results agrees with past research on mental health in relation to stigmas surrounding student-athletes and an overall decreased likelihood of help-seeking (Tabet et al., 2021). 

Although most studies provided significant evidence towards the relationship between increased MHL and positive attitudes toward mental health, a handful mentioned demographic confounds that affected the outcomes of the results (Barnard, 2016; Bird et al., 2020;  Martens, 2006; Watson & Kissinger, 2007). Differences in data were believed to be attributed to demographics such as race, gender, and sport type because in some cases, they actually served as predictors for the hypotheses (Barnard, 2016). Race, gender, and sport type each play a role within a student-athlete’s identity and experience; and attitudes toward mental health may vary based on this identity. Researchers suggested restricting these demographics so that studies include various student-athletes from all backgrounds and so that differences in data are more indicative of mental health attitudes (Barnard, 2016; Martens, 2006). 

Limitations and future research

Findings from this review can not be considered without limitations. A limitation of this review is that ethnographic research was not obtained. Ethnographic research provides raw, subjective data so that the researcher can explicitly record phenomena without bias. Most studies collected objective student-athlete responses as data, which leaves room for bias. Self-reporting tendencies, especially toward mental health in student-athletes, include stigmas that may operate on them, which may discourage student-athletes from speaking out. This, in turn, reduces the generalizability of the review, because it is unknown if the student-athletes self-reported truthfully. A direct implication of not obtaining ethnographic data is that specific attitudes toward symptoms of mental illness and seeking treatment were not included in the review. For example, a women’s basketball player with anxiety at Northwestern University could have offered insight into what it is like to manage her symptoms and what her teammates think about her going to therapy. Although objective data was obtained through psychological assessments, specific examples of attitudes would have served as stronger evidence. Extensively, avenues for further research include obtaining ethnographic research to determine specific stigmas that operate on specific student-athlete populations, and creating treatment programs catered to those populations. This also looks like using ethnographic research to focus on the effects of mental health on marginalized populations within the student-athlete community to improve equity.

 

Conclusion 

Mental health is important in the student-athlete community because athletes are more susceptible to mental illness, as they often sacrifice mental health for sport success (Watson & Kissinger, 2007, as cited in Vickers, 2014). The purpose of this literature review was to investigate the attitudes of college-aged student-athletes toward stigmas and symptoms of mental health, in their college career and outside of their sport. Although an incompatible relationship was revealed between the likelihood of seeking treatment and attitudes toward mental health, student-athletes remained consistent in their MHL and decreased bias toward others with mental health issues. Overall, student-athletes demonstrated positive attitudes toward mental health knowledge, but an absence of negative attitude toward treatment-seeking knowledge. In order to improve attitudes toward treatments, it’s important to recognize specific stigmas in the student-athlete community, and how they can be mitigated. It’s also essential to identify the different communities among student-athletes, in which mental health experiences can differ, such as Black student-athletes. Treatment programs catered to specific student-athlete groups are essential to understanding which stigmas operate in the student-athlete community so specific resources can be appropriated to encourage athletes to speak out and seek support and treatment for mental health issues.

 

 

 

References 

Back to basics: Understanding Mental Health Literacy. Mental Health America. (2022, May 4).  https://mhanational.org/events/back-basics-understanding-mental-health-literacy#:~:text=Mental%20health%20literacy%20has%20been,help%20and%20mental%20health%20outcomes.  

Barnard, J. D. (2016). Student-athletes’ perceptions of mental illness and attitudes toward help-seeking. Journal of College Student Psychotherapy, 30(3), 161-176. https://doi.org/10.1080/87568225.2016.1177421 

Bird, M.D., Chow, M. G., & Cooper, B. T. (2020) Student-Athletes’ Mental Health Help-Seeking Experiences: A Mixed Methodological Approach, Journal of College Student Psychotherapy, 34(1), 59-77. https://doi.org/10.1080/87568225.2018.1523699 

Edwards, B. & Froehle, A. (2021) Examining the incidence of reporting mental health diagnosis between college student athletes and non-athlete students and the impact on academic performance, Journal of American College Health, https://doi.org/10.1080/07448481.2021.1874387 

Edwards, B., Traylor, A., & Froehle, A. (2022). Mental Health Symptoms, Diagnoses, Treatment-Seeking, and Academic Impacts in Student-Athletes and Non-Athlete College Students Using the National College Health Assessment. Journal of Issues in Intercollegiate Athletics, 15, 75-93. http://csri-jiia.org/wp-content/uploads/2022/02/RA_2022_04.pdf 

Hilliard, R. C., Watson, J. C., & Zizzi, S. J. (2020). Stigma, attitudes, and intentions to seek mental health services in college student-athletes. Journal of American College Health, 70(5), 1476-1485. https://doi.org/10.1080/07448481.2020.1806851

Martens, M. P., Dams-o-Connor, K., & Beck N.C. (2006). A systematic review of college student-athlete drinking: Prevalence rates, sport-related factors, and interventions. Journal of Substance Abuse Treatment, 31(3), 305-316. https://doi.org/10.1016/j.jsat.2006.05.004 

Mcquade, L. (2021, August 30). College student-athlete health and well-being. TimelyMD. https://timely.md/blog/student-athlete-mental-health/ National Collegiate Athletic Association. (2021). NCAA Sports Sponsorship and Participation Rates Database. https://www.ncaa.org/sports/2018/10/10/ncaa-sports-sponsorship-and-participation-rates database.aspx 

Sullivan, P., Murphy, J., & Blacker, M. (2021). The Psychometric Properties of the Multicomponent Mental Health Literacy Measure with a Sample of Student Athletes and Student Athletic Therapists, Journal of Applied Sport Psychology33(3), 343-356. https://doi.org/10.1080/10413200.2019.1702119 

Tabet, M. S., Lambie, W. G., & Golubovic, N. (2021). An investigation of college student-athletes’ mental health stigma, help-seeking attitudes, depression, anxiety, and life stress scores using structural equation modeling, Journal for the Study of Sports and Athletes in Education, 15(3), 245-267. https://doi.org/10.1080/19357397.2021.1924562

Vickers, E. (2014, February 11). Mental Health in the Student Athlete. Believe Perform. https://believeperform.com/mental-health-in-the-student-athlete/ 

Watson, J.C. & Kissinger, D.B. (2007). Athletic Participation and Wellness: Implications for Counseling College Student-Athletes. Journal of College Counseling, 10, 153-162. https://doi.org/10.1002/j.2161-1882.2007.tb00015.x

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