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Addressing psychological concerns to practice whole-person health care.

As the director of a postprofessional athletic training program affiliated with the founding school of osteopathy, I am keenly aware of the osteopathic profession's tenet that the body is a unit and that we should treat the body, mind, and spirit, a philosophy that serves as the foundation for the practice of whole-person health care. As athletic trainers, our emphasis has primarily been on the physical nature of an injury and the need to return our patients to physical activity and sport, which often neglects the psychological effects of injury. In recent years, however, there has been a push across all areas of health care to recognize mental health as an important aspect of well-being and for clinicians to better understand the various psychological conditions that may affect patients. In the patient population treated by athletic trainers, these conditions may present on their own or may be a consequence of physical injury. 
 
In our own body of literature, growing evidence indicates that sport-related injury can influence aspects beyond pain and function, including health-related quality of life.1–4 Much of a patient's identity is tied to his or her sport. A season-ending or career-ending injury can result in feelings of isolation, which can lead to depression or other psychological conditions. Patients returning from an injury may experience fear of reinjury and have difficulty returning to full play. Even athletes who seem otherwise healthy may be at risk for disordered eating, substance abuse, anxiety, or bullying. 
 
Sport-related concussion can result in comorbid or subsequent psychological conditions, a fact that is important for athletic trainers to recognize. Concussion is often described as an invisible injury, with limited outward signs and symptoms. To teammates and others, the patient may seem fine, even though he or she is dealing with numerous symptoms and cognitive problems. Some authors2–4 have described an emotional response to concussion that includes overall mood disturbance, increased fatigue, decreased vigor, and depression. Further, some evidence suggests that psychological conditions, such as attention-deficit hyperactivity disorder, may be a risk factor for prolonged recovery after concussion. In this issue, Vargas et al (“Predictors and Prevalence of Postconcussion Depression Symptoms in Collegiate Athletes,” pages 250–255) show that patients with concussion reported mild levels of depression and were more likely than the control group to experience clinically significant symptoms of depression compared with their baseline. In addition, postconcussion depression symptoms were predicted by more baseline depression symptoms, postinjury concussion symptoms, and age when the patient first participated in organized sport. These findings may support the need to obtain a better psychological health history and perhaps even a baseline depression symptom inventory. 
 
The question then becomes this: How does an athletic training staff, especially at the secondary school level, obtain this type of information that is so important to patient care? Recommendations made in the “Summary Statement: Appropriate Medical Care for the Secondary School-Aged Athlete”5 suggest that members of the athletic health care team should be able to identify potential psychosocial concerns and that medical care should provide for psychosocial consultation and referral to appropriate medical providers for diagnosis and treatment. However, the statement is limited in discussing the preparticipation examination as the means to obtain a psychosocial history. 
 
In this issue, Neal et al present the “Interassociation Recommendations for Developing a Plan to Recognize and Refer Student-Athletes With Psychological Concerns at the Secondary School Level: A Consensus Statement” (pages 231–249), which are designed as a blueprint for athletic trainers and secondary school administrators to develop sound plans to recognize and refer student-athletes with psychological concerns. This timely consensus statement, written by experts in athletic training, pediatrics, psychology, counseling, and law, highlights numerous psychological concerns and provides suggestions for developing a management team to identify and refer student-athletes for proper diagnosis and treatment. The statement provides a nice review of various psychological conditions and is applicable to all athletic trainers, not just those practicing in a secondary school setting. 
 
As mental health issues are discussed more frequently across all areas of health care and we broaden our approach to incorporate whole-person health care, we must understand how injury affects our patients' psychological health. Athletic trainers can use educational resources such as the National Collegiate Athletic Association's Mental Health site (http://www.ncaa.org/health-and-safety/medical-conditions/mental-health), which provides publications, guidelines, and links. Lastly, athletic trainers should be well versed in these conditions and look to establish collaborative relationships with mental health experts to whom they can refer patients.