Authors: Matt Moore, Ph. D, MSW 1, Anne M. W. Kelly, Ph. D 2, Lana Loken, Ed. D. ATC 2, Mastano N. Dzimbiri, MS 1, Payton Bennett, student

Corresponding Author:

Matt Moore, Ph. D, MSW
Chair and Faculty, Family Science and Social Work Department
Miami University
501 E. High Street

Coaches’ Perspectives of the Influence of Safe Sport-Related Education 


Purpose: An increase in mental health concerns and suicide among young adults led to a sharpened research focus on suicide and college athletes. In this study, we investigated the relationship between college athletes’ risk of depression, suicidality, and their support system and whether preventing suicide deaths requires identification of commonly cited risk factors. Methods: Voluntary college athletes aged 18-years-old or older and attending an NAIA member institution participated in the study (n = 361). They completed a web-based instrument that consisted of the following: (1) demographic questionnaire, (2) Patient Health Questionnaire (PHQ-9), (3) Berlin Social Support Scale, and (4) Columbia Suicide Severity Rating Scale. Results: Between 5-18% of college athletes responded affirmatively to one of the questions asking about suicidality. There was a significant moderate negative correlation between the suicide predictor and the PHQ-9 score and significant weak positive correlations between the suicide predictor and perceived emotional support and between the suicide predictor and perceived instrumental support. Conclusion: This study identified findings that might be useful to practitioners and opened new lines for future research. Applications in Sport: College athletic programs and university counseling centers are poised to enhance our understanding of student-athletes’ suicidal distress and how to respond by making use of qualitative research methods. We strongly recommend adopting this strategy to address depression and suicidal ideation.

Keywords: prevention, student-athletes, mental health, risk factors

Despite growing openness about mental health struggles, a disparity still exists between physical and mental health (Gorczynski et al., 2023; Moore et al., 2022), fostering stigma and hindering help-seeking behavior (Moore, 2017), particularly among college students (Centers for Disease Control and Prevention [CDC], 2021). While mental health diagnoses in the college student population is a longstanding challenge, the COVID-19 pandemic increased stressors placed on the college student population leading to increased risks (Gupta & Agrawal, 2021; MacDonald & Neville, 2023).

According to the CDC (2021), mental health concerns and suicidal thoughts are increasing for youth and young adults. Forty percent of those surveyed showed signs and symptoms of depression and 20% said they had thoughts of suicide. These trends are similar to studies on college student mental health and suicidality (Barclay et al., 2023; Schmiedehaus et al., 2023). According to the Substance Abuse and Mental Health Services Administration (SAMHSA, 2017) individuals aged 18-25 reported a 3% increase in major depressive episodes from 2015-2017. Additionally,18.9% of individuals 18 and above reported experiencing a mental illness in the past year, with 7.5% reporting a serious mental health illness (SAMHSA, 2017). A second SAMHSA (2021) study found 33.7% of individuals aged 18-25 reported a mental illness and 11.4% reported a serious mental illness.
In addition to concerns about serious mental health illness, SAMHSA (2021) found an increase in rates of suicidal behavior. Specifically, 10.5% reported having serious thoughts of suicide, 3.7% created a suicide plan, and 1.9% attempted suicide. Research by Rosenthal et al. (2023) found higher rates with 13.7% of college students reporting suicide ideation, 7.6% making a suicide plan, and 3.2% reporting at least one suicide attempt. In 2021 suicide became the leading cause of death for those aged 20-24 (CDC, 2023).
One subset of the college student population is college athletes. Recently, discussion of their mental health increased. Researchers attempted to explore the intersectional identity of student athletes and the effect that this role strain may have on mental health (Gorczynski et al., 2023; Moore et al., 2022). Quantifying mental health and suicide risk in this group is challenging, with conflicting results on the link between depression, support systems, and suicide. Many researchers see sport participation as a protective factor for mental health risk due to the social support provided by the team (Hui et al., 2023; Sullivan et al., 2020). But additional pressures like failure to successfully compete or live up to expectations, loss of social structure due to injury or retirement from sport, or time demands of the sport in addition to being a college student can increase the risk (Moore, 2017; Moore et al., 2022). This study builds upon existing research by looking more closely at the relationship between a college athletes’ risk of depression, suicidality, and their support system.

College Athletes and Depression
According to the American Psychological Association (2020), depression is one of the most common mental health disorders in the United States. Depression might include emotional, cognitive, physical, and/or behavioral symptoms and is best understood on a continuum of severity, rather than either present or not present. Findings amongst college athletes demonstrate that depression rates align with rates of the general population of college students (hovering around 25%) (Prinz et al., 2016; Wolanin et al., 2016), and some revealed that athletes have higher rates of depression (over 30%) than the general population (Cox, 2015). While many studies find similar rates between college athletes and their non-athlete peers, others show participation in college athletics can decrease one’s risk for depression (Banu, 2019; Salehioan et al., 2012).
Although some research shows athletic participation may protect against mental illness, there is still reason for concern for college athletes. A current study by the National Collegiate Athletic Association (NCAA, 2022) surveyed almost 10,000 NCAA athletes from all three competitive division levels. Results showed athletes of all competition levels demonstrated elevated levels of mental exhaustion, anxiety, and depression. These levels were nearly two times higher than pre-pandemic levels. The top three factors negatively affecting mental health were academic worries (44%), planning for the future (37%), and financial worries (26%). Only 50% of college athletes believed mental health was a priority for their athletic department, 33% of college athletes did not know where to go to seek mental health services, and as many as 17% of college athletes reported feeling hopeless.

College Athletes and Suicide
Suicide risk in athletes is difficult to determine due to underreporting and misclassification of many sudden deaths. Over the past two decades the NCAA attempted to determine the risk of suicide specific to college athletes. Rao et al. (2015) reported that 7.3% of all athlete deaths were suicides, making suicide the fourth leading cause of death for college athletes. Previously, Miller and Hoffman (2009) found approximately 5% of student-athletes contemplated suicide. Much like research on college athlete depression, some research demonstrates sport protects against suicidality (Maron et al., 2014). This study’s findings highlight the importance of promoting participation in diverse sporting activities among college students given that engaging in such activities safeguards against depression and suicidal ideation by nurturing self-esteem and bolstering social support.

College Athletes and Social Support
The discrepancy in the literature may be accounted for by the supports that are available to college athletes and their willingness to seek such supports (Sullivan et al., 2020). One of the most discussed supports is the team environment. Sullivan et al. (2020) analyzed the effects of social supports on depressive symptoms in college athletes. They found emotional support from teammates, family, and friends was correlated with a decrease in depressive symptoms. Other more formal or instrumental supports that reduced depression included the availability of tutoring and health services, including mental health providers with specialization with athletes.
Social support has not been as extensively studied in the college athlete population. Studies show links between social support and burnout as well as social support and overall wellbeing in college athletes (Defreese & Smith, 2014). Research identified social support as an important component in allowing athletes to balance school and athletics (Carter-Francique, 2015). Many college athletes have strong social support networks naturally, such as relationships with teammates, coaches, medical staff, and other resources provided by the athletic department (Armstrong & Oomen-Early, 2009). They also have supportive relationships, such as family and friends, outside of athletics.
Despite knowledge of these available supports and benefits they offer college athletes, exploring the utilization of built-in athletic supports and personal supports unique to an individual athlete remains understudied. Much of the research tends to oversimplify social support. Due to its dynamic and complex nature, social support among college athletes merits further investigation. Research has not examined the differences in the type of perceived social support in collegiate athletics as it relates to levels of depressive symptoms and suicidality.

Present Study
Overall, the research on mental health issues, including depression and suicide in collegiate athletes is inconclusive. More research is needed to determine what factors put athletes at risk for severe mental health concerns and suicide. The purpose of this study was to investigate whether there is a relationship between levels of depression and suicide risk and levels of social support among National Association of Intercollegiate Athletics (NAIA) college athletes. The NAIA does not have data available on connectedness between depression, social support, and suicide.



Research Design
The current exploratory study utilized a cross-sectional, web-based survey design to gather data from NAIA college athletes. Considering the size of the NAIA student-athlete population, confidence level, confidence intervals, statistical test, and statistical power, the minimum sample for this study was 47 college athletes (Faul et al., 2007). Researchers identified athletic trainers through the NAIA database to establish contact information. Athletic trainers provided survey information to their assigned college athletes. This approach was successful in other NAIA research efforts (Moore & Abbe, 2021).

The exploratory study utilized a stratified random sampling procedure to identify college athlete participants. Researchers divided the NAIA college athlete population into subgroups, or strata, based on sports available throughout the NAIA. This included a stratum for each of the 17 sports with separate stratum for each gender that participates in a sport. Next, researchers identified NAIA member institutions that participated in each of the 17 sports. Each institution participating in a sport received a random number. Researchers selected random numbers to identify the member institutions that would participate in the survey from each sport. This approach ensured all member institutions participating in various sports had an equal opportunity for inclusion.

Voluntary college athletes aged 18-years-old or older and attending an NAIA member institution participated in the study (n = 361). Most participants were 18-21 years old (53.5%, 46.5% indicated being over the age of 21). Survey participants were primarily juniors (30.7%, 23.8% sophomores, 23.1% first years, 22.1% seniors of graduate students). More women completed the survey (59.8%, 40.2% men). Most participants who reported race/ethnicity were White/Caucasian (55.4%, 21.9% Hispanic or Latino, 14.9% Black or African American, 6.6% multiracial, 1.2% from other groups).

Table 1.

NAIA Institutional Demographic Information

University Demographic%
Faith Based62.9%
Non-Faith Based37.1%

Participants recorded which NAIA athletic team they were primarily affiliated with (20.2% baseball, 19.9% soccer, 12.5% track volleyball, 8.0% softball, 6.4% cross country, 6.1% basketball, with all other sports being under 5% each [e.g., football, bowling, cheer, dance, track and field, swimming and diving, golf, tennis, and lacrosse]). Participants were further examined regarding NAIA college/university demographics (See Table 1). Participants also responded to whether or not they receiving mental health training from their college of university before participating in sport. The largest majority (n = 229, 63.7%) indicated they did not receive such training. The other 36.3% (n= 132) indicated they did receive some form of training.
[Insert Table One]

Measures and Instruments

College athletes completed a web-based instrument that consisted of the following: (1) demographic questionnaire (see above demographics), (2) Patient Health Questionnaire (PHQ-9; Kroenke et al., 1999), (3) Berlin Social Support Scale (BSSS; Shulz & Schwarzer, 2003), and (4) the Columbia Suicide Severity Rating Scale (C-SSRS; Posner et al., 2011). 

Patient Health Questionnaire (PHQ-9)
The PHQ-9 is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders (Kroenke et al., 2001). It is used to make criteria-based diagnoses of depressive and other mental disorders commonly encountered in primary care. This is a 9-item depression module upon which the diagnosis of Diagnostic and Statistical Manual (DSM) depressive disorders is based. Reliability and validity of the tool have indicated it has sound psychometric properties. Internal consistency of the PHQ-9 has been shown to be high (American Psychological Association, 2020). There is precedent for using the PHQ-9 in research with college athletes (DaCosta et al., 2020; LoGalbo et al., 2022).

Berlin Social Support Scale (BSSS)
The researchers measured the degree of emotional and tangible support using the BSSS (Schulz & Schwarzer, 2003). This scale measured perceived emotional and instrumental supports, need for support, and support seeking. There are 17 items on the BSSS that are answered using a five-point Likert scale with endpoints “1 = Strongly Disagree” and “4 = Strongly Agree.” The researchers used a mean score for each of the subscales (perceived emotional support, perceived instrumental support, need for support, and support seeking). The scale has a Cronbach’s alpha of 0.83 for perceived social support, 0.63 for need for support, and 0.83 for support seeking (DiMillo et al., 2017). The scale has a prior history of use within college athletics (Sullivan et al., 2020)

Columbia Suicide Severity Rating Scale (C-SSRS)
The C-SSRS was developed by researchers from Columbia, Pennsylvania, and Pittsburgh Universities to evaluate suicidal ideation and behavior (Posner et al., 2011). The scale provides a brief assessment of severity and intensity of suicidal ideation, suicidal behavior, and lethality (Syndergaard et al., 2023). The screener version used in this study consisted of six “yes” or “no” questions. Based on participant responses to the six questions, participants were considered low, moderate, or high risk. The C-SSRS has excellent internal consistency (α = 0.95). Principal components analysis revealed a two-factor solution, accounting for 65.3% of the variance across items (Madan et al., 2016). There is limited research on the use of the C-SSRS with the athlete population (Costanza et al., 2021).

Data Collection
Researchers contacted the athletic training staff at all sampled NAIA member institutions. Athletic training staff received the list of teams from their institution for inclusion in data collection. Researchers provided athletic training staff detailed instructions for data collection and a copy of the informed consent. Athletic training staff distributed the electronic survey to their college athletes. College athletes were able to opt-out of the survey at any time. The survey took approximately 15-20 minutes to complete. Researchers recorded survey results into a statistical software program (SPSS 28) on a secure, private platform.

Data Analysis
Researchers utilized descriptive statistics to provide details about the sample and overall survey results. Researchers used inferential statistics to infer information from the sample data to the overall NAIA student-athlete population.

To investigate the first research objective, an initial correlation analysis was conducted to examine whether having any safe sport training was related to increases in coaching outcomes. The safe sport training variable was transformed so that coaches who answered “yes” to completing any of the safe sport training courses were coded as 1 and coaches who had answered “no” to completing all the safe sport training courses were coded as 0 (i.e., no SS training=0, any SS training=1). This variable was included in a correlation analysis with all coaching outcomes: knowledge & confidence, safe sport stress, stress over athlete well-being, and efficacy to support others. To investigate the second research objective, four separate linear regression models were constructed with the sum of completed safe sport training courses (range =1-12) as the independent variable, and the following coaching outcomes as respective dependent variables: knowledge & confidence, safe sport stress, stress about athlete well-being, and efficacy to support others. In all four models, the coaching context, whether training was required (0=no, 1=yes), and whether training was free (0=no, 1=yes) were included as covariates. To address the third research objective, ANOVAs were conducted with individual safe sport courses as independent variables, and the following coaching outcomes as dependent variables: knowledge & confidence, efficacy to support others, safe sport stress, stress about athlete well-being and efficacy to support others. All analyses were conducted using IBM SPSS Statistics (Version 28) (20).


Descriptive Statistics
College athletes answered each item from the C-SSRS. Descriptive findings from this scale indicated that 18.3% of participants wished to be dead, 18,3% had non-specific active suicidal thoughts, 13.6% had active suicidal ideation without intent to act, 6.1% had active suicidal ideation with some intent to act, and 5.0% had active suicidal ideation with a specific plan and intent to act. Of the 361 college athlete respondents, 25.8% answers “yes” to at least one of the questions on the scale.

College athletes completed the PHQ-9 as a brief screening tool for potential depressive symptoms. Results of the PHQ-9 and the percent of athletes at risk of depression for each item can be found in Table 2.

Table 2. PHQ-9 Scores for NAIA College Athletes

QuestionMean (SD) (% At Risk)
Little interest or pleasure in doing things?1.81 (0.91) (22.1%)
Feeling down, depressed, or hopeless?1.68 (0.81) (14.1%)
Trouble falling asleep or sleeping too much?2.06 (1.05) (30.2%)
Feeling tired or having little energy?2.17 (0.92) (29.1%)
Poor appetite or overeating?1.81 (0.96) (21.3%)
Feeling bad about yourself?1.75 (0.93) (18.6%)
Trouble concentrating on things?1.69 (0.96) (17.2%)
Moving or speaking so slowly that people could have notice? Or more fidgety and restless than usual?1.34 (0.69) (7.8%)
Thoughts that you would be better off dead?1.21 (0.53) (4.1%)

Evaluation of Assumptions

College athletes also completed the BSSS. Results of the BSSS and the percent of athletes at risk of limited social support in various areas can be found in Table 3. These are only the scale items where there were significant concerns about perceived emotional support, perceived instrumental support, need for support, and support seeking.

BSSS Scores for NAIA College Athletes

QuestionMean (SD) (% At Risk)
Whenever I am not feeling well, other people show me that they are fond of me? 3.14 (0.82) (17.2%)
When everything becomes too much for me to handle, others are there to help me?3.21 (0.83) (18.3%)
I get along best without any outside help?2.48 (0.81) (48.7%)
In critical situations, I prefer to ask others for their advice?3.00 (0.79) (23.0%)
Whenever I am down, I look for someone to cheer me up again?2.51 (0.89) (49.6%)
When I am worried, I reach out to someone to talk to?2.69 (0.93) (38.2%)
Whenever I need help, I ask for it.2.70 (0.96) (39%)

Researchers used correlation analysis to assess the relationship between a college student-athletes predictor of suicide with their score on the PHQ-9, perceived emotional support, perceived instrumental support, level of needed support, level of support sought, and mental health training.

Prior to conducting the analysis, researchers generated several statistics and graphs to examine the tests of assumption, including level of measurement, related pairs, absence of outliers, and linearity.

Results of the Correlational Analysis
Researchers computed a Pearson product-moment correlation coefficient to assess the relationship between a college student-athletes suicide predictor and their PHQ-9 score, perceived emotional support, perceived instrumental support, level of needed support, and level of support sought. There was a significant (p < 0.001) moderate negative correlation, r = -.462, N = 361 between the suicide predictor and score on the PHQ-9. There was a significant (p < 0.001) weak positive correlation, r = .236, N = 361 between the suicide predictor and perceived emotional support. A similar significant (p < 0.001) weak positive correlation, r = .255, N = 361 between suicide predictor and perceived instrumental support. A college student-athlete’s exposure to mental health training, perceived level of needed support, and level of support sought did not appear to be suicide predictors.


In this study, we investigated whether preventing suicide deaths requires the identification of factors that are associated with people’s risk of suicidal behavior. Commonly cited risk factors for suicidal thoughts and behaviors are depression and inadequate support. Association between major depressive disorder (MDD) and suicide attempts or ideation has been well-documented. Accordingly, depression has been considered a necessary or sufficient cause of suicidal thoughts. But much is unknown about the characteristics that increase suicide risk among people living with depression (Bradvik, 2018). Many mechanisms could play a role in suicidal behavior among people with MDD, and, although suicidal behavior occurs among people with major depressive disorder, depression is not necessarily a useful tool for understanding the complexity of suicide (Orsolini et al., 2020).

Most people with depression do not attempt suicide. Diagnosis of MDD requires a simultaneous presentation of several specific symptoms. Approximately, 17 million American adults will have symptoms of MDD each year, but only around 45,000-50,000 Americans will die by suicide during that same time. Considered independently of other risk factors, MDD may put one at greater risk, meaning that those with this disorder are more likely than those without it to die by suicide. But still very few of those with MDD will go on to die by suicide; reliance on depression to predict suicidality is inadvisable. This is supported by Ribeiro et al. (2018), who reviewed existing literature on the subject and showed that although depressive symptoms were reported to confer risk of suicidality, the effects were weaker than expected.

Melhem et al. (2019) demonstrated that the most severe depressive symptoms and variability over time were the only predictors of suicide attempt in young adults, especially when combined with other factors (e.g., childhood abuse, history of attempt, substance use disorder, and parental attempt). But prediction was marginally better than chance, perhaps because suicidal risk varies during a psychiatric illness and may be linked to other factors that appear during depressive episodes. Orsolini et al. (2020) showed that anxiety disorders co-occurring with MDD are among the main predictors of attempts. Several factors interact and contribute to suicidal behavior and death by suicide. These may include major depressive disorder, but interactions with other factors, such as genetic vulnerability, stress, psychiatric comorbidities, and social aspects need to be evaluated to improve prevention (Orsolini et al., 2020).
Results from our research showed a moderate negative correlation between the suicide predictor and score on the PHQ-9, challenging the assumption that depression is a necessary or sufficient cause of suicidal thoughts. This lends support to the idea that traditional risk factors can be problematic and that their predictive value has not improved over the past 50 years (Franklin et al., 2017; Fortune & Hetrick, 2022).

Bradvik (2018) also acknowledged that depression is related to suicidal ideation and attempt but is not a good predictor. Bradvik (2018) pointed to results from the Australian Rural Mental Health Study in which only 364 out of 1051 respondents reported life-time depression. Of those 364 respondents, 48% reported life-time suicidal ideation and 16% reported a suicide attempt. Gender, age of depression onset, and possibly psychiatric comorbidities were somewhat predictive of suicide behavior, but no other predictive factors were revealed. These results were echoed by Melhem et al. (2019).

The limits of risk factors to accurately predict suicide is further strengthened by our finding that an increase in emotional social support was weakly associated with an increase in suicide risk, contradicting earlier research that showed suicidal distress was worse when emotional social support was low (Ayub, 2015; Otsuki et al., 2019). Similarly, instrumental social support (i.e., support that helps people with practical tasks) was weakly associated with suicide risk, contradicting findings from Otsuki et al. (2019).
After a concussion, athletes experience a range of psychological symptoms, with depression and anxiety being among the most reported (Kontos et al., 2012). Symptoms can include loss of interest in activities that were once enjoyable, persistent sadness, physical and mental fatigue, and changes in sleep patterns. These negative outcomes may be more pronounced in athletes who attach a great degree of importance to the athlete’s role in relation to other activities (Brewer et al., 1993; Raedeke & Smith, 2001) and can be made worse by changes in lifestyle, the loss of social support that team members provided, and even personality traits. One such trait is maladaptive perfectionism.
Maladaptive perfectionists are overly critical of mistakes. They strive for excessively high and ultimately unobtainable goals. This usually results in failure, which can be painful, especially for athletes with maladaptive perfectionism, who may lack resilience to bounce back from stressful experiences. This unhealthy perfectionism is associated with higher levels of depressive symptoms (Egan et al., 2011; Olmedilla et al., 2022). Additionally, perfectionists can struggle with time management, not setting realistic timelines for getting things done or because they are paralyzed by the prospect of failure. Time management is one of the most difficult aspects of participating in college sports (Rothschild-Checroune et al., 2013).

Taken together, injury and concussion, personality traits (e.g., maladaptive perfectionism), and external factors (e.g., time constraints) can contribute to negative mental health outcomes among student-athletes and may increase suicidal distress. College athletic programs and university counseling centers are poised to improve our understanding of the nature of suicidal distress among student-athletes face and how to respond by making use of qualitative research methods, which we recommend. We urge university administrators to dedicate more resources to building and integrating academic and co-curricular resilience programs into their campuses and rely less on risk assessment that focuses on commonly cited factors (e.g., depression) to predict suicide.

Study Limitations
While efforts were made to decrease discomfort with the survey, it is possible college athletes felt pressure to respond in particular ways out of personal and/or athletic concerns. This study also relied upon self-reported data. Without having the ability to verify participant responses, there was no way of knowing the legitimacy or honesty of participants’ responses. The study was unable to control the multiple covariates or confounding variables that influence a college suicidality and mental health. Finally, our study lacked a detailed exploration of how specific socio-demographic characteristics, such as race, gender, and class status, might influence suicidal ideation and other risk behaviors among college athletes.

Future Research
The complex interplay between core risk factors in individuals and heightened suicide risk among athletes necessitates further exploration. Future research should focus on understanding the repercussions of escalated demands on athletes’ mental well-being, particularly the impact of significant situational factors such as career-ending injuries on their mental health and suicide vulnerability. Additionally, there is a need to delve into the connection between suicide rates, race, and gender among collegiate students for a more comprehensive understanding of these dynamics.

This study examined the relationship between college athletes’ risk of depression, suicidality, and their support system and whether preventing suicide deaths requires identification of commonly cited risk factor. The results are quite different from previous research findings, revealing a moderate negative correlation between the suicide predictor and scores on the PHQ-9, adding nuance to the presumption that depression is either a necessary or sufficient factor for the emergence of suicidal thoughts. College athletic programs and university counseling centers are poised to enhance our understanding of student-athletes’ suicidal distress and how to respond by making use of qualitative research methods. We strongly recommend adopting this strategy to address depression and suicidal ideation.

Applications in Sport
Studying suicide in college sports has practical applications that can help improve the well-being and safety of college athletes. By examining the factors that contribute to suicidal ideation and behavior in college sports, researchers and practitioners can develop targeted interventions and support systems to address mental health challenges. For instance, such studies may lead to the creation of tailored mental health resources for student-athletes, including counseling services and peer support networks. Furthermore, understanding the unique stressors faced by student-athletes, such as performance pressure and balancing academics with athletics, can inform the design of preventative measures such as stress management and resilience training programs. Additionally, awareness campaigns can be created to destigmatize mental health struggles in sports, encouraging athletes to seek help when needed. Overall, studying suicide in college sports can lead to a safer and more supportive environment for student-athletes, promoting their overall health and success.


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