Suicide and the Athlete Population

By Julie Jardine, MD, FRCPC
Psychiatrist

As a psychiatrist, I regularly hear from people about their most painful life experiences and emotions. Despite this, some situations still hit like a gut punch. While a psychiatrist, sport or otherwise, will frequently work with patients experiencing suicidal ideation or who have engaged or are engaging in non-suicidal self harmful behaviours, having a patient complete suicide is a, thankfully, infrequent event. But when suicide does happen, the impact can be deep and lasting. It would be reassuring if athletes were fully protected from the risk of suicide, that somehow their relative super-humanness in the physical realm; their strong wills; their commitment and perseverance; their need to maintain a winning mind-set, could make this a path never chosen. But unfortunately, this is not the case, and a small number will make this desperate choice, one that leaves others grappling to understand why this seemed like the only option at the time; why the athlete didn’t feel they could turn to someone for help. And while suicides tend to have a wide impact, the unexpected death of a generally young, healthy, physically-talented person with a promising future can hit particularly hard.

Some Key Statistics

(Suicide in Canada, Government of Canada website)

• 4500 deaths per year by suicide in Canada
• Suicide rate among men 3 x higher than among women
• Females: highest rate of completed suicide in 2019 between ages 50-64 (rate 8.4/100,000)
• Males: rate of completed suicide among those between ages 20-34 in 2019 was 21.4/100,000; highest rate (25.9/100,000) was between ages 50-64
• 2^nd leading cause of death among youth and young adults (15-34 years)
• Hospitalization rate associated with self-inflicted injury per 100,000 population in 2020-2021 higher for women than for men until ages 65-79 when it becomes close to equal with rate higher for men than women 80 and older
• Hospitalization rate for girls and women between 10-19 and 20-34 much higher than for boys and men

Factors Associated with Increased Risk of Completed Suicide

(Suicide in Canada, Government of Canada website)

In Canada, people at increased risk of suicide include:

• Men and boys
• People serving federal sentences
• Survivors of suicide loss and survivors of a suicide attempt
• Some First Nation and Metis communities, especially among youth
• All Inuit regions in Canada
• Thoughts of suicide and suicide-related behaviours more frequent among LGBTQ+ youth (including lesbian, gay, bisexual, trans, Two Spirit, queer or queer/questioning youth) compared to non-LGBTQ+ peers

Risk Factors for Suicide

(from Centers for Disease Control and Prevention website)

Individual Risk Factors:
• Previous suicide attempt *
• History of depression and other mental illnesses
• Serious illness; chronic pain
• Criminal/legal problems
• Job/financial problems or loss
• Impulsive or aggressive tendencies
• Substance use
• Current or prior history of adverse childhood experiences
• Sense of hopelessness
• Violence victimization and/or perpetration

Relationship Risk Factors:
• Bullying
• Family/loved one’s history of suicide
• Loss of relationships
• High conflict or violent relationships
• Social isolation

Community Risk Factors:
• Lack of access to healthcare
• Suicide cluster in the community
• Stress of acculturation
• Community violence
• Historical trauma
• Discrimination

Societal Risk Factors:
• Stigma associated with help-seeking and mental illness
• Easy access to lethal means of suicide among people at risk
• Unsafe media portrayals of suicide

*Note that individuals with a history of a previous suicide attempt are more than 20 x as likely to eventually end up completing suicide than those without.

I would also add to the above that feelings of helplessness can tie in with hopelessness and strongly contribute to suicide risk. When the individual feels that they are in a situation that they don’t have the capacity to either tolerate or change, it can contribute to tunnel vision where suicide can seem like the only option. The individual’s assumptions, beliefs and emotional response to the stressor are more important than how severe the stressor might seem to others.

Athletes and Suicide Risk

The high performance athlete population includes individuals with some of the risk factors listed above. In addition, some characteristics and experiences may be found more commonly among this particular population. These can include the narrow focus that is generally required to reach the highest levels in a sport, one that often starts during childhood and continues through adolescence and into adulthood. When most of the athlete’s time, focus and energy goes into a singular pursuit, it can potentially interfere with some aspects of their psychological development. These aspects can include developing a broad and complete enough sense of identity that encompasses a number of different character traits, including strengths; interests; values; and roles.

The time and effort required to succeed at their sport may also make it more difficult for the athlete to incorporate “buffers” into their lives that can insulate them when they are feeling sad or depleted or when things aren’t going as hoped in the athletic realm. These “buffers” include friendships, ideally with some outside of their sport who can offer a different perspective and remind them of other aspects of themselves; hobbies which involve less scrutiny and focus on performance; and the ability to enjoy quiet time during which they can recoup physical, mental and emotional energy and practice being comfortable with themselves when they are not performing.

Athletes can also have personality characteristics that can increase their risk of suicidal ideation, attempts and completed suicide, including obsessiveness and perfectionism with intolerance of failure. Perfectionists don’t need to learn how to succeed, as it is ingrained within them. Being a perfectionist involves a willingness to put in a level of effort far beyond and to endure far more than what most others would be willing to do or bear. The perfectionist athlete can appear incredibly strong, and their grit and perseverance can be part of how they are perceived by others. But while trying to move toward their impressive goals, they may also be putting everything into avoiding the dreaded consequence of perceived failure, which can be unacceptable to them and highly threatening to their sense of self. Some athletes may also have borderline personality traits which include a tendency to experience intense emotions that the individual has difficulty tolerating and regulating; frequent suicidal ideation and engagement in self harm behaviours or suicide attempts; instability of interpersonal relationships; and fears of abandonment.

Body Dysmporphic Disorder which is included as part of Obsessive-Compulsive and Related Disorders in the American Psychiatric Associations DSM-5 can occur among athletes (including muscle dysmorphia) and tends to be associated with significant distress and an increased risk of suicidal ideation and attempts (a systematic review and meta-analysis involving 23 studies found a 35.2% lifetime suicide attempt rate which is the highest among the O-C and Related Disorders). The risk of suicide attempts is increased with co-morbid substance use disorders. Eating Disorders, also found at a significant rate among athletes, are another group of mental health disorders associated with an increased risk of suicide.

The athlete may experience frequent and/or extended periods away from important supports for training and competition with the potential for greater isolation during that time. While being part of a team or community of athletes can be protective, abrupt loss or disconnection from this community due to injury, deselection or retirement can increase risk of suicide for some.

Individuals involved in high performance/elite sport can be subjected to intense scrutiny due to being more frequently in the public eye. As part of this, they may be on the receiving end of critical or toxic social media posts that can be abusive, hateful, dehumanizing, racist, sexist, homophobic or even sometimes threatening. This can occur while the athlete may already be in a vulnerable state due to not performing up to expectations held by themselves and others. Being told that they have let a whole country down or that they don’t deserve to live because of this is a shocking and horrific burden for the athlete to have to bear. Even when commentary is not abusive, having embarrassing or shame-inducing experiences reported in the media can also make difficult moments even harder to get through. The risk of suicide should be considered after an athlete has been accused or sanctioned for a doping or other violation, as they are likely to receive negative exposure and be scrutinized in the media and elsewhere, and may experience deep shame and a number of significant losses, including of social supports; their ability to train and compete in their sport; prestige/respect; and, potentially, financial losses, such as loss of sponsorships or funding.

Athletes can experience concussions and sub-concussive blows at a higher rate than the general population (rate varies based on the sport), which can increase their risk of sleep impairment, cognitive impacts, anxiety and depressive disorders and suicide. Some may be reluctant to fully disclose their symptoms due to concern about being removed from training/play and the impact this may have on their opportunities in their sport.

Chronic pain related to MSK injuries can increase risk of suicide, as can Opiate Use Disorders that can occur in some individuals dealing with chronic pain (or following treatment of acute pain).

Athletes were also not immune to the challenging impacts of the pandemic. There was a notable increase in suicidal ideation and suicide attempts during the pandemic among the general population, particularly among adolescents (girls more than boys). Challenges that athletes faced included disruptions in training routines, including where and with whom they were able to train; social isolation; financial challenges; and uncertainty regarding when or if events they had been training for would occur (including the postponement of the 2020 Tokyo Olympics).

Another issue of note is that negative attitudes and discrimination against individuals who identify as LGBTQ+ (including lesbian, gay, bisexual, trans, Two Spirit, queer or queer/questioning) continue to occur within Canada where it is legally prohibited to discriminate based on sexual orientation and gender identity and expression (Canadian Human Rights Act, 1985). It can be even more difficult for athletes who identify as part of this group when they travel to train or compete in countries where such protections don’t exist; where expressions of hatred toward this group are more accepted; and where LGBTQ individuals can be at risk of arrest or worse. The potential impact of this reality on members of a demographic that is already at increased risk of thoughts of suicide and suicide-related behaviours should be kept in mind.

Suicide and Varsity Athletes

In 2015, Rao et al published a 9-year analysis of the NCAA Resolutions Database, which indicated that from 2003-2004 through 2011-2012 academic years, there were 35 incidents of suicide among 477 NCAA student-athlete deaths reviewed (7.3 % of all-cause mortality with an overall suicide rate of 0.93/100,000 per year). This annual suicide rate is lower than the rate in the general population between the ages of 18-22 of 11.6/100 000 according to the CDC, as well as in the overall collegiate population (7.5/100,000). Annual incidence among male athletes was found to be 1.35/100,000 and among female athletes, 0.37/100,000 (relative risk 3.7; P<0.01) with the highest rate among men’s football players (2.25/100,000 with a relative risk of 2.2 (P=0.03) compared with other male, non-football athletes). Male non-athletes were found to be 2.5 times and female non-athletes 1.67 times more likely to be suicidal than athlete peers.

I think it is important to humanize statistics, as the number 35 above represents 35 different NCAA athletes who didn’t have a chance to heal from whatever was going on with them and to go on with their lives.

There have been too many tragic stories in the media over the past year or so of suicides among varsity athletes. One of these was the suicide in March 2022 of Katie Meyer of Stanford University, a 22 year old varsity soccer keeper who was also team captain and part of the 2019 NCAA Championship team. Katie sounds to have been a highly driven, successful young woman who committed suicide on the same evening she received a “formal charge letter” by email from Stanford’s Office of Community Standards. During an interview in the days following her death, her parents stated that the incident prompting the potential disciplinary action related to Katie’s effort to defend a minor team-mate. In a Washington Post article written by Brittany Shammas and published December 1, 2022, there was a quote from Katie Meyer’s formal statement to the Stanford Office of Community Standards: “My whole life I’ve been terrified to make any mistakes. No alcohol, no speeding tickets, no A- marks on my report cards.”

Suicide and Olympians

While doing research online for this article, I found a fairly stark table on Olympedia: Olympians Who Committed Suicide (186). It includes a list of 186 Olympians who died of suspected suicide, from the ancient past up to the present. The earliest suicide listed was that of Nero, Emperor of Roma who competed in the 67 CE Ancient Olympics and who died 9 June 68 CE after being condemned to death as a public enemy.

The documentary The Weight of Gold directed by Brett Rapkin and narrated by Michael Phelps consists of a series of interviews with Olympics athletes, including Phelps, Bode Miller, Apolo Ohno, Sasha Cohen, Lolo Jones and Shaun White who speak out about their challenging experiences as Olympic athletes, which include, for some, mental health struggles. In the documentary, Phelps emphasized how difficult the period after an Olympic games can be, and he acknowledged his own experience of serious depression and thoughts of suicide. In an interview, Brett Rapkin explained that when he started making his film, he had intended to tell the positive story of Team USA bobsled pilot, Steven Holcomb’s successful experimental surgery for keratoconus after he had suffered significant vision loss to the point that he couldn’t drive. Brett Rapkin interviewed Steven Holcomb for the film during the spring of 2017. During the interview, Holcomb, who had won gold in the 4-man event at the 2010 Vancouver Olympics and double-bronze at the 2014 Sochi Olympics, spoke of his history of depression and the impact of his vision loss on his mood. He also spoke of making a suicide attempt in 2007 in which he overdosed on a combination of whisky and prescription medication. Rapkin changed the focus of the film when in May 2017, 12 days after the interview, Holcomb was found dead at age 37 at a training facility in Lake Placid with reported high quantities of alcohol and sleeping pills in his system (not confirmed to be a suicide; coroner’s report indicated that likely cause of death, pulmonary congestion).

At the Tokyo Olympics in 2021, Simone Biles withdrew from events she was to compete in, and was open about attributing this to her need to focus on her mental health. Biles was one of the hundreds of young members of the USA Gymnastics Team who had been victims of sexual abuse perpetrated by team physician, Larry Nassar. During an interview, she stated that she had previously started sleeping all the time to cope because sleeping was the closest thing to death. She had reportedly been reluctant to disclose the abuse she suffered, in part due to concern that others would start viewing her primarily as a sexual assault victim. It is important to assess for suicide risk in those who have been physically or sexually abused, as this is a known risk factor for suicide. It is also important to support the athlete’s efforts to maintain a complete sense of identity; one that recognizes the pain they have gone through, but continues to emphasize their amazing strength, perseverance, and talent without allowing the abuse that was perpetrated against them to diminish them in any way.

There are other hard-to-read stories of Olympians who have ended their lives, including following concussion; after being advised to discontinue their athletic careers due to health conditions; and after posting about the pressures of high-performance sport.

Suicide and Professional Athletes

Over the past few years, professional athletes, including tennis Grand Slam Champion, Naomi Osaka, have opened up about their mental health struggles. There have also been a number of suicides completed by former hockey enforcers, some of whom have been found post-mortem to have Chronic Traumatic Encephalopathy. Rick Rypien is one of these athletes, a professional hockey player who killed himself in 2011 at age 27 after dealing with depression for 10 years and signing with Winnipeg as a free agent after playing with Vancouver for 6 years.

What Can Be Done to Reduce the Risk of Athlete Suicide?

It is important for all people working with athletes to develop at least a basic understanding of warning signs of deteriorating mental health. It is also important that organizations working with athletes develop a culture in which discussing mental health is acceptable and encouraged and where concerns are taken seriously. Sport organizations should develop procedures to manage situations in which an athlete reports that they are experiencing mental health issues; is observed to be demonstrating changes potentially indicative of declining mental health (including in their appearance, attitude, performance, expressed thoughts or behaviour); or another athlete or person working with the athlete expresses concerns.

In situations where there are concerns an athlete might be at risk, asking whether the athlete is thinking of ending their life is encouraged. If yes, it can be important to know whether they have a plan and how close they are to carrying this out. These questions can convey to the athlete that suicidal ideation is a subject that can be discussed in the open. It also allows the situation to be managed with the urgency required, including connecting with emergency contacts identified by the athlete and ensuring that the athlete is connected to the most appropriate resources for further assessment and care (including a mental health professional, such as a sport psychiatrist; potentially, Mobile Crisis Teams when these are available; or hospital emergency departments).

It is important to ‘buy time’ for the individual so that they can undergo further assessment and appropriate treatment, including crisis intervention and potentially psychotherapy, medication management or treatment for alcohol or substance use disorders. Time also allows the individual to access their usual coping strategies (and learn new ones) and adjust to what has been overwhelming them and contributing to their despair. Sometimes voluntary or involuntary psychiatric admission may be needed to help to buy this time in a safer environment.

If a decision is made to continue with outpatient care, close follow up is important. Ideally, a support person or persons identified by the athlete can also be involved. Sometimes a team of providers can be helpful if the main provider is not available as frequently as required. It is important that support people and other health-care/mental health-care providers have a clear understanding of steps to take in case of escalation of suicide risk. A good therapeutic alliance can be protective for the individual, so it is essential for the clinical environment to be supportive and non-judgemental. It is also important to avoid putting more responsibility on supports than they can manage. If suicidal ideation is severe enough that the person requires constant monitoring, assessment in an emergency department recommended as psychiatric admission may be required.

It is also important when managing an athlete with suicidal ideation to avoid recommending plans that would leave them with a loss of structure and social contact. In many situations, it will be helpful for the athlete to not be fully removed from the team/training environment, though accommodations may be required.

Programs that assist athletes with adjusting to transition out of competing in their sport can be helpful (such as through Game Plan).

Psychotherapy can take time, but can help the person to change their framework for understanding themselves, others and the world around them. Increasing self-understanding and acceptance, including that they are more than their athletic performance, can enhance their resilience when dealing with life’s difficulties. They can also benefit from learning to identify, tolerate and regulate emotions, and from becoming more aware of which elements are most important for them to maintain mental wellness.

Medications can reduce suicidal ideation either by having direct anti-suicide effects (such as lithium for unipolar or bipolar depression) or by treating the underlying condition contributing to the thoughts of suicide (with antidepressants being an example). Medication choices need to be carefully considered due to the potential impact on athletic performance and following review of banned substances; however, in situations where the risk of suicide is high and not responding to other treatment approaches, medications with specific anti-suicide properties should be considered. Psychiatric consultation, ideally with a sport psychiatrist when one is available, is recommended in this situation.

Note that caution required with use of antidepressants, including SSRI’s and SNRI’s, in adolescents and young adults less than 25 years of age due to the potential risk of increased suicidal ideation and behaviour (but not completed suicide) in a minority of individuals taking these medications (Health Canada has asked drug companies to include a warning of this in their drug information). Despite this warning and while use of antidepressants is off label in Canada for children less than 18, antidepressants remain an important option for the management of moderately severe and severe mental health symptoms associated with conditions including Major Depressive Disorder, Anxiety Disorders and Obsessive-Compulsive Disorder.

If an antidepressant is used in an adolescent or young adult, careful monitoring is required (ideally with the involvement of supports) for increases in suicidal ideation or emergence or worsening of self harmful thoughts or behaviour, particularly following initiation of treatment and dose increases and during the first months of treatment. In addition, it is important for the individual and their supports to pay attention to symptoms, such as restlessness, racing thoughts, increased impulsivity, decreased need for sleep and grandiosity, potential adverse effects of the medication.

All suicidal behaviour should be taken seriously given the significantly increased risk of completed suicide in people who have made a previous attempt. The period following a suicide attempt can be a high risk time, as the individual may make modifications to their initial plan to increase the chance that they succeed in ending their life.

Engagement in high risk behaviours (dangerous driving; risky substance use; etc) without concern regarding the risk to themselves (or others) is also a warning sign that the person may be at risk of suicide.

Tools that can help in identifying people experiencing mental health symptoms and assist with assessment of suicide risk include:

SMHRT-1: The International Olympic Committee Sport Mental Health Recognition Tool 1 developed by IOC Mental Health Working Group “can be used by athletes, coaches, family members and other members of the athlete’s entourage to recognise mental health problems but not to diagnose them.”

SMHAT-1: The International Olympic Committee Sport Mental Health Assessment Tool is a standardized assessment tool that can be used by sports medicine physicians and other licensed/registered health professionals “to identity at an early stage elite athletes (defined as professional, Olympic, Paralympic and collegiate level, 16 and older) potentially at risk for or already experiencing mental health symptoms and disorders, in order to facilitate timely referral of those in need to adequate support and/or treatment. Also developed by IOC Mental Health Working Group.

Ask Suicide-Screening Questions (ASQ), a quick to complete National Institute of Mental Health suicide risk screening tool for adults and children 8 and over.

MHCC Suicide Risk Assessment Toolkit : https://mentalhealthcommission.ca/resource/suicide-risk-assessment-toolkit/

CAMH: https://www.camh.ca/en/professionals/treating-conditions-and-disorders/suicide-risk

Complicating factors in suicide prevention

• Many athletes are unaccustomed to acknowledging weakness and therefore, may not share their struggles;
• Concern about how their disclosure will be managed, including whether it will limit their athletic opportunities/career, may prevent athletes from coming forward. What happens after a person identifies their thoughts of suicide is very important;
• Concern about stigma can also influence willingness to disclose;
• Some individuals may have limited insight into their mental health deterioration and increased risk of suicide (such as when there are significant alcohol or substance use issues or in the case of psychotic symptoms);
• Concerning changes might not be as easily observed if the athlete at risk of suicide is more isolated due to injury or deselection;
• Risk factors for suicide have been identified; however, it can be very difficult to predict the particular window of time a person may be most at risk of carrying out a plan for suicide;
• Can be a short period of time between decision to commit suicide and carrying out suicide;
• In some instances, people intending to commit suicide may be relieved and appear happier and more relaxed in the period before they commit suicide.

Redefining Failure: Not Succeeding Well Takes Skills

There is a tendency to focus on teaching children and adolescents how to succeed. While this is a reasonable emphasis, there can be pit-falls when this objective is not balanced by also helping the athlete accept that they may not always succeed at their goals. And that this can be Ok, including that they remain intact, skilled and of value to themselves and others. And in high performance sport, this can be particularly important, as there are only so many spots on the team and so much room on the podium.

There are a significant number of skills involved in succeeding, but there are also important ones involved in not succeeding well. These include the athlete being able to self-compassionately support themselves through painful emotions, recognizing that these will eventually subside; to avoid going toward a quick fix in a losing effort to numb pain, such as alcohol or drug use, self-harm or suicide; to be able to acknowledge mental health struggles and to be willing to reach out to others; and to still be able to recognize their resilience which will assist them with figuring out a future direction even if they aren’t sure what next steps to take in the moment (same goal with different approach or new goal altogether). Not succeeding successfully also requires a recognition that their personal identity is comprised of much more than that one achievement, and that it remains intact, even if a goal is not attained. Having a set of skills to make it possible to not succeed and be ok can take a certain desperation out of their efforts to be the best at what they do, while also toppling some psychological barriers to succeeding. It some instances, this skill-set can be life-saving.

In Conclusion…

It is reasonably likely that the first professional the athlete sees when struggling won’t be a mental health care provider and it is also very possible that they won’t present to address mental health concerns. Awareness of risk factors for suicide in the general population and those that may be encountered in the athlete population more specifically is recommended for those working with athletes. It is crucial that, despite the strongest and most put-together of outward appearances, this vulnerability is kept in mind. By having available resources and clear systems in place to manage suicidal risk, non-mental health providers will be much better able to ask questions about suicide with confidence regarding the next step in the path if the athlete confirms that they are at risk. It is so important that we help the athlete slow things down and give themselves the benefit of time, as with support and appropriate care, they will very likely recognize within themselves the strengths that will allow them to get through whatever has brought them to that point. Then they can think about which star they might like to reach for next…

Key Clinical Points:

• There are some protective aspects to being an athlete; however, this group is not immune to mental health issues, suicidal thinking and completed suicide and some athletes will be at significant risk due to personal and situational factors;
• Being aware of risk factors for suicide in the general and athlete populations can help with recognizing when an athlete might be at increased risk;
• Personality characteristics, such as obsessiveness and perfectionism; having a narrow sense of identity with an emphasis on performance; time away from supports for training or competition; loss of connection to their sport due to deselection or injury; increased risk of concussions; exposure to negative scrutiny in the media are all issues that may increase the athlete’s risk of experiencing suicidal ideation;
• Asking the athlete questions about suicidal ideation can send a message that this is not an off-limit subject to discuss and may lead to the athlete being more open;
• Management of suicidal ideation involves careful evaluation to determine as well as possible the level of risk so that the most appropriate treatment plan can be developed, including the safest setting;
• There is value in balancing a focus on succeeding with learning how to manage not succeeding.
• Options for more immediate support include Talk Suicide Canada: 24 hrs per day 365 days per year for calls (1 833 456-4566) with communication by text (45645) available between 4pm-12am ET (languages English, French) and Kids Help Phone (text 686868 or phone 1800 668-6868); for carded athletes, access to counsellors through LifeWorks associated with Game Plan 24 hrs per day 365 days per year (1 844-240-2990)

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