Authors: Peter J Economou, Victoria Glascock, Mark Louie, Polina Poliakova, William Zuckerberg

Graduate School of Applied and Professional Psychology, Rutgers University, USA

Corresponding Author:

Peter Economou
1 Scarlet Knight Way
Piscataway, NJ 08854
[email protected]

Dr. Peter Economou, the Principal Investigator holds a Ph.D in counseling psychology with a concentration in neuropsychology. He conducts research on mindfulness and meditation in sports.

Dr. Mark Louie, a research assistant and Postdoc to the PI, holds an Ed.D in Applied Exercise Physiology, and a Masters in Psychological Counseling from Teachers College, Columbia University. He is a licensed counselor in both New Jersey and New York.

Victoria Glascock, Polina Poliakova, and William Zuckerberg are research assistants for the GSAPP Performance Psychology Center.

COVID-19 and its Impact on Student-Athlete Depression and Anxiety: The Return to Campus

ABSTRACT

The COVID-19 pandemic prompted the NCAA to abruptly cancel all sporting events, to help slow the spread of the virus. As such, measures such as social-distancing and work from home orders, were implemented nationwide. While effective, both safety measures are socially disruptive with the potential to cause psychological disturbances such as post-traumatic stress disorder (PTSD), depression, anxiety, and other behavioral disorders. To date, there is no literature that examines the consequences of abrupt mid-season cancellation for student-athletes, and the subsequent return to campus in Fall of 2020 brought on by a global crisis like the COVID-19 pandemic. To explore the mental health consequences of such termination and subsequent return to campus, student-athletes were surveyed on their experience with returning to campus amidst a global pandemic. Our results indicate that there were increased feelings of depression and anxiety upon returning to campus in Fall 2020.

Key Words: COVID-19, Student-athlete, mental health, termination, mid-season, pandemic, trauma

INTRODUCTION

The World Health Organization (WHO) declared the outbreak of a new coronavirus disease, COVID-19, in January of 2020 to be a public health emergency (4). COVID-19 was characterized as a pandemic by WHO in March 2020. Due to the stress that the crisis generated throughout the world, the WHO Department of Mental Health and Substance Use developed messages and tools to support communities through this trying time. Highlighting the toll on mental health that this pandemic can have on people from all walks of life, addressing mental health needs and mitigating chronic stress and anxiety can be achieved by using healthy coping skills (e.g., exercise). Integrating mental health and psychosocial support (MHPSS) into the COVID-19 response is a key pillar of the WHO’s effort to combat negative effects on mental health as a result of the pandemic (10).

States across the United States issued “Stay at Home Orders” directing residents to shelter in place and leave their homes for essential needs only (21). Schools closed, work transitioned to work from home, and life as we knew it dissipated. While the shutdowns helped to flatten the curve, the economic effects of COVID-19 were far-reaching. Twenty-two million workers filed for unemployment in a four-week period, which is about equal to the number of jobs created over a 9-and-a-half-year upswing (5). Financial markets fell sharply, and the volatility levels resembled those of the financial crisis of 2008/9 (8). People were experiencing a disruption in their work-life, families were navigating a new normal, children were being homeschooled, and college students were not on campuses. Not to be overlooked are the collegiate student-athletes that had their seasons cut short due to the COVID-19 pandemic.

The COVID-19 pandemic represents a sizable global event presenting the likelihood of delayed onset trauma for many personally affected on both the disease and economic fronts. A study that examined post-traumatic stress disorder (PTSD) in residents affected by Hurricane Katrina, one of the most devastating natural disasters in United States history, found that nearly half of the respondents experienced delayed-onset PTSD (more than six months after the hurricane) (20). The stressors of death, risk of death, economic distress, and future uncertainty experienced in the aftermath of Hurricane Katrina are similar to the disruptions caused by COVID-19. Further highlighting the potential for delayed onset trauma caused by the COVID-19 pandemic is a meta-analysis of 39 studies that concluded PTSD may manifest six months after the trauma occurred, with professional groups being at greater risk (38). The long-term mental health implications of the pandemic are still to be seen.

There are over 460,000 student-athletes across NCAA collegiate sports and many who had their season ended abruptly while trying to navigate new schedules and the intricacies that accompany life after sport. College student-athletes represent a high-risk group due to the intense demands of being a student and an athlete, and literature shows in normal circumstances, student-athletes report higher levels of anxiety and depression when compared to the general college student population (7). Barriers to seeking mental health treatment in the student-athlete population include seeing it as a sign of weakness, feeling like they should be able to push through psychological distress as they do physical distress, and a lack of healthy coping behaviors (32). The recent, abrupt, and decisive cancellation of all sports in an effort to mitigate the spread of COVID-19, presented a unique circumstance that accelerated retirement for many student-athletes in their final year of competition.

While closely tracking the COVID-19 situation, the NCAA made the decision to cancel the remaining NCAA championships and related events for the winter and spring seasons (34). Individual athletic conferences, such as the Ivy League and the New England Small Athletic Conference (NESCAC), to name a few, quickly followed suit (18). The abrupt cancellations represented an unexpected and instantaneous career termination for student-athletes in their final year. This created a scenario of complete termination, unlike any other event.  The necessary cancellations effectively ended the spring season abruptly and accelerated the retirement and transition of several student-athletes without the possibility of competing and experiencing the typical closure competition and tournaments provide.

The COVID-19 pandemic has been recognized as a psychologically stressful event in itself and may compound pre-existing negative emotional responses to the season being terminated early. There is limited literature that addresses the impact that COVID-19 has had on collegiate student-athlete mental health. Nonetheless, previous research does identify collegiate student-athletes as a vulnerable population who have mental health needs that differ from their non-athlete peers. A study that examined 465 NCAA Division 1 student-athletes over three years found that one-quarter of the athletes had clinically relevant levels of depressive symptoms (43). Circumstances such as career-ending injuries have been shown to cause complicated reactions that need to be addressed by their support systems (45).

Unique to this study is its focus on the return to campus after COVID-19 restrictions and lockdowns were put into place in the fall of 2020. Ultimately, our research on the impact of COVID-19 on student-athlete mental health seeks to fill the void in the literature that does not address the mental health consequences of an abrupt midseason termination and subsequent return to campus in addition to a stressful global event, such as the COVID-19 pandemic, for collegiate student-athletes.

STUDENT-ATHLETE MENTAL HEALTH

The Fall 2020 NCAA Student-Athlete Well-Being Survey indicated that 19% of fully in-person student-athletes felt overwhelming anxiety and 6% of student-athletes were so depressed that it was difficult to function (24). In 2016, nearly a quarter of student-athletes reported being exhausted from the mental demands of their sport (23) and stressors that student-athletes contend with are linked to mental health issues include increased academic pressures, long athletic seasons, the pressure to perform in sport and in the classroom, and the commercialization of college athletics (3). Literature shows collegiate student-athletes are more likely to have high levels of depression and anxiety than their peers, highlighting the need for adequate psychological services accessible to them. (42). One study found that student-athletes felt that feelings of depression and anxiety could result from poor performance and injuries also increased the likelihood of depressive symptoms (11). Over 85% of athletic trainers found anxiety to be an issue among student-athletes on their campuses (3). In addition to general anxiety, student-athletes can suffer from competition or performance anxiety, where anxiety symptoms are related to competition or performance (35).

Injury heightens the risk for depressive symptoms, especially if self-esteem is directly tied to their identity as a student-athlete (1). A study of 343 male student-athletes revealed that injured athletes experience depression, anxiety, and lower self-esteem than controls immediately following injury and up to two months post-injury (16). Injury can unmask mental health issues including depression and suicidal ideation, anxiety, disordered eating, and substance use/abuse. Collegiate student-athletes are also at risk for eating disorders, substance abuse, gambling addictions, sleep disturbances, mood disorders, and elevated suicide risk (22). The convergence of managing academic and athletic demands, possible injury, social relationships, and transitive periods such as leaving sports, can manifest into emotional difficulties for student-athletes (40).

Another aspect of the student-athlete experience that contributes significantly to their mental health is associated with retiring or other career-ending issues. The COVID-19 pandemic ultimately provides most athletes with an opportunity to play again, however, there are large numbers of spring 2020 student-athletes that were not given that opportunity for their final season. A qualitative study consisting of seven semi-structured interviews with athletes explored how they dealt with involuntary sport termination (9). These interviews revealed that the athletes all had a powerful connection to sport and that the retirement process was sequential in nature. Specifically, athletes described sport as becoming part of who they are, having intense emotional involvement in their sport, and feeling a deep sense of dedication. The athletes said that being on a team felt like being part of a family (9).

After the abrupt loss of sport for student-athletes, feelings of uncertainty related to their future and the lack of control, as well as experiences of frustration, anger, and depression arise (9). The sense of loss felt is akin to the loss of sport and identity that many NCAA athletes are feeling today subsequent to COVID-19’s impact on sport performance. To conceptualize this loss amidst the pandemic, we turn to the Kübler-Ross stage model for grief (1969) which has been used to explain post-injury and career termination responses in athletes. The model consists of five stages: disbelief, anger, bargaining, depression, and acceptance (15). A study of 21 athletes who could not participate in sport for a minimum of two months identified post-injury responses similar to Kübler-Ross’s grief responses (31). Athletes grieve the loss of sport and athletic identity similar to the grief process that one goes through when losing a loved one. It is vital that adequate resources be in place for student-athletes during these traumatic times.

Regarding the COVID-19 impact on mental health, in the spring of 2020, 9% of female student-athletes and 7% of male student-athletes felt so depressed that it was difficult to function (25). The NCAA also found that 27% of female student-athletes and 14% of male student-athletes felt overwhelming anxiety. Female student-athletes are more likely to report high levels of depressive and anxiety symptoms and lower levels of social support than their non-athlete peers (14).

METHODS

To evaluate the impact of the COVID-19 pandemic on the mental health of Division I NCAA collegiate student-athletes as they returned to campus in fall 2020, we conducted an online survey study using Qualtrics. The study was approved by the IRB prior to data collection and a recruitment email was sent out to athletic directors, coaches, and trainers, who were asked to distribute the survey link to athletes who fit our inclusion criteria of being an active NCAA student-athlete. The online survey consisted of the Beck Depression Inventory (BDI), the Athlete Identity Measurement Scale (AIMS), and the Generalized Anxiety Disorder 7-item (GAD 7). Student-athletes completed the informed consent, did not receive payment, could end the survey at any time, and completed the online survey during the fall 2020 semester as they returned to campus during the COVID-19 pandemic. Following completion of the survey, student-athletes were provided with referral information for mental health resources.

Beck Depression Inventory (BDI)

The Beck Depression Inventory (BDI) has been shown to be a reliable questionnaire for detecting depressive symptoms and is widely used. Wang & Gorenstein (2013) found that the BDI shows high reliability and good correlation with measures of depression and anxiety (39). The BDI has high internal consistency, high content validity, and validity in differentiating between depressed and non-depressed subjects (33).

Athlete Identity Measurement Scale (AIMS)

The Athlete Identity Measurement Scale (AIMS) that we will be using has been proven to be utilized across dimensions. This is a ten-item questionnaire where athletes are asked to rate the level to which they identify as an athlete. Martin et al. (1997) proved that the scale is valid across different populations (19). The AIMS has high test-retest reliability and internal consistency (2). AIMS scores are significantly correlated with perceived importance of sports. The questions are rated on a scale from 1-7 (7=strongly agrees, 1=strongly disagree)

Generalized Anxiety Disorder (GAD-7)

The Generalized Anxiety Disorder (GAD-7) questionnaire is a self-report anxiety questionnaire that has been proven to be reliable and valid in the general population (17). The GAD-7 has good reliability, and criterion, construct, factorial, and procedural validity (37).

RESULTS

A total of 178 student athletes completed the survey, but not all data for each participant was completed and therefore a few respondents’ data were not included in the analysis. Fifty-nine percent of respondents were NCAA Division 1 student-athletes, and 24.2% were Division II student-athletes, with 16.9% of respondents did not answer this question. One hundred and sixteen student-athletes identified as female and 39 identified as male. Twenty percent of the respondents were eighteen years old (n=36) at the time of the survey, 14% were nineteen years old (n=25), 17.4% were twenty years old (n=31), 16.9% were twenty-one years old (n=30), and the remaining participants ranged from twenty-two to thirty years old. A major limitation of this sample is that 75% of participants identified as White, while only 4.5% identified as Black, 1.1% identified as American Indian or Alaska Native, 3.9% identified as Asian, .6% identified as Hawaiian or Pacific Islander, and 6.7% identified as other.

During data analysis it became apparent that the AIMS questionnaire was skewed and could not be appropriately used, therefore for the purposes of data analysis, the scores from the BDI and GAD-7 were analyzed and then compared to the data reported by the NCAA reports. It is also important to note that our sample was skewed to the northeast where the COVID-19 pandemic hit hard and first (i.e., New York area). It is possible that student-athletes living in this region were affected by the stress of COVID-19 in a unique manner, hence, reporting higher levels of depression and anxiety.

BDI

The Beck Depression Inventory was completed (n=146) and responses were categorized into the corresponding classifications. Respondents with scores in the range of 0-13 were classified as “0” equaled minimal depression, scores between 14-19 were classified as “1” equating to mild to moderate depression, scores between 20-28 were classified as “2” for moderate depression, and those scoring between 29-63 received a classification of “3” for severe depression. The frequencies can be seen in Table 1 whereby 50% of the respondents endorsed mild to moderate depression as they returned to campus fall 2020.

TABLE 1

BDI ClassificationNumber of Student Athletes
0 Minimal Depression62 (42%)
1 Mild Depression42 (28%)
2 Moderate Depression32 (22%)
3 Severe Depression10 (.07%)
Table 1 BDI Classifications

GAD-7

The Generalized Anxiety Disorder questionnaire was analyzed (n=142) according to a classification 0-3, however, none of the respondents endorsed “0” or no anxiety. Scores that ranged between 5-9 were classified as “1” for minimal anxiety. Scores between 10-14 were classified as “2” for moderate anxiety, and respondents that scored between 15-21 were classified as “3” indicating severe anxiety. There was nearly an equal distribution between the three classifications whereby 28% endorsed minimal anxiety, 35% endorsed moderate anxiety, and 37% endorsed severe anxiety as they returned to campus during the fall 2020 semester amidst the COVID-19 pandemic as shown in Table 2.

TABLE 2

GAD-7 ClassificationNumber of Student-Athletes
1 Minimal Anxiety40 (28%)
2 Moderate Anxiety49 (35%)
3 Severe Anxiety53 (37%)
Table 2 GAD-7 Classifications

Open-ended Responses

At the end of the survey, respondents were provided an open-ended opportunity to submit descriptions related to the COVID-19 pandemic and the way it has affected their return to campus following the abrupt end to the spring 2020 semester. Three main themes emerged from the responses, including: 1. worsening of mental health, 2. anxiety related to the pandemic, and 3. positive experiences after returning to campus.

For the first theme, worsening mental health, the authors share a few of the responses:

“It’s mentally harder than I think people can understand unless you are an athlete actually going through it. The sport keeps us feeling some type of normal.”

“It was the hardest time of my entire life and my mental health has never been worse and continues to get worse.”

“By the end of the semester, you feel like it is never going to end. You feel really overwhelmed and tired about classes but mostly about sport.”

Student-athletes expressed anxiety related to COVID-19:

“I think that it is really tough not being able to live life regularly. Anything I do, I feel like I am at risk of getting sick and risking other people. This creates more self isolation than I am used to which leaves me with too much time to think and worry about many different things.”

“I am really hoping school stays online, it has been much easier to accommodate practices and saves a lot of time, it worries me that we might have in person classes next semester, what if I catch it from class and spread it to the other athletes.”

“The unknown with no answers on the future is depressing and being tested weekly is nerve racking when waiting on results. Being testing every week is also over the top.  Having to be virtual is very difficult and makes it harder to build relationships with other students and professors which does not allow me to gain a full college experience.”

The return to campus was a positive experience for some:

“It is difficult not playing in games, but it is nice to be back together with my team. It is hard to get through months/weeks without being able to see anyone else besides my teammates.”

“Before our season was cancelled. We were in a bubble for 3 weeks and it took a huge toll on my mental health. My mental health has since improved. Being able to hang out with other athletes and make friends was very important for me mentally.”

DISCUSSION AND FUTURE CONSIDERATIONS

The Spring 2020 Student-Athlete COVID-19 Well-being Survey conducted by the NCAA indicated that 9% of female and 7% of male student-athletes felt so depressed that it was difficult to function (25). Our results suggested an increase in levels of depression upon returning to campus, with 22% of student-athletes reporting moderate to severe depression. The NCAA also found that 27% of female and 14% of male student-athletes felt “overwhelming anxiety” in the Spring of 2020 following COVID restrictions (25). Again, our results indicated an increase in levels of anxiety, with 37% of student-athletes endorsing severe anxiety. Increases in depression and anxiety were seen amongst NCAA student-athletes following the return to campus in Fall 2020. Open-ended responses revealed that the return to campus was welcomed and the reunion with teammates alleviated feelings of anxiety and depression. As would be expected during a global pandemic where the general student body was likely not present physically on campus (i.e., especially in the northeast region), many student-athletes endorsed they were aware of the decline of their mental health. This seemed to demonstrate that the return to campus amidst the pandemic exacerbated mental health struggles, and support for student-athlete mental health was critical.

Collegiate student-athletes represent a vulnerable population with increased levels of depression and anxiety. The additional stressors that student-athletes contend with are linked to mental health issues and can increase during times of stress. Further, previous research informs us that abrupt termination of athletic careers can result in a complex grief reaction that athletes grapple with (45). High levels of stress are experienced before and after retirement and the loss of athletic identity can leave athletes yearning for a life they once knew (2, 12). Taking these variables into consideration, coupled with the trauma of a global pandemic, the NCAA, athletic departments, coaches, and other support systems for athletes should be prepared for an increased need in mental health support for student-athletes.

The trauma being caused in the general population, not just student-athletes, by the COVID-19 pandemic can be compared to past historical events that brought about mass trauma and left people psychologically hurt (eg. 9/11, Hurricane Katrina, 1980 US boycott of Olympic games). A longitudinal study of the health impact of the September 11, 2001, terrorist attacks on the United States found that physician-diagnosed health problems increased by 18% over the three-year post 9/11 period (13). Similar to how the COVID-19 pandemic is having an impact on both individuals as well as the broader community, the 9/11 attacks were experienced directly as individual trauma and a collective cultural upheaval for the whole American population (41). An impact on mental health was seen around the country, and stress responses of people who were indirectly exposed to the event mirrored responses typical of people directly exposed to the event (13). A meta-analysis of 2,647 studies found that peritraumatic psychological processes are the strongest predictors for psychological disorders such as PTSD (28). Importantly, a link between psychological stress and the impact that it has on physical health became clear after the 9/11 attacks. Comparable to 9/11, COVID-19 is a large-scale collective event that comes with personal loss, economic hardship, and fears about the future. A review of mental health services provided in New York City following the attacks concluded that outreach is an important strategy to reach people who may be in need of psychiatric support (30).

The U.S. boycott of the 1980 Olympic games in Moscow, Russia caused similar disruption to athletic journeys that we are seeing as a result of the pandemic. Athletes and coaches alike responded to this boycott with feelings of disappointment, frustration, and anger (6). For many people, the stress response to these obstacles deepens over time and places their physical health at risk (13). Long term exposure to cortisol and other stress hormones can have negative impacts on bone density, blood pressure, plaque build-up in the arteries, and increase the risk of myocardial infarction (3). Four main takeaways from disaster are that 1) trauma exposure is important in conceptualizing mental health outcomes within affected populations; 2) valid and accurate measurement of mental health outcomes are essential for properly informed interventions; 3) psychiatric disorders must be distinguished from normative distress; and 4) different types of interventions will be needed depending on psychiatric illness versus normative emotional distress (27). Using these takeaways as a guide, informed protocols can be implemented to best support student-athletes as they navigate life after COVID-19.

CONCLUSIONS

The convergence of the trauma that a global pandemic can bring, and the traumatic termination of athletic seasons places an already vulnerable group at a higher risk for mental health distress. Student-athletes need to be supported by their athletic departments, the NCAA, and their social support circles during this time. Through establishing a group with the goal of developing a plan for recognizing and referring collegiate student-athletes with psychological concerns, the National Trainers’ Association has identified important factors in helping student-athletes: athletic trainers and team physicians should monitor sub-clinical changes in mood and mental state, specifically following incidents like injury or termination (26). Concerns about mental well-being should be addressed immediately in an effort to minimize the negative impact. Adequate psychoeducation about resources available to student-athletes and signs and symptoms of mental distress are vital to the student-athletes well-being. Ideally, campuses will find themselves being proactive more often than reactive. Having a strong support system in place that is able to handle the trauma that events like a COVID-19 pandemic bring on will benefit the athletes in the long run. Looking at past traumatic events, and research on early career termination is indicative that there will be mental health repercussions. We hope that research can guide organizations like the NCAA in directions that better prepare them to support the well-being of their student-athletes.

APPLICATIONS IN SPORT

Further research should include exploration on the lasting effects that the COVID-19 pandemic has had on NCAA student-athletes. Athletic departments and campus cultures should be evaluated for efforts pertaining to supporting the mental health of student-athletes with continued growth and resources given to the sport health units to ensure that behavioral health is prioritized.

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