Who is coaching the coach? Knowledge of depression and attitudes toward continuing education in coaches

Participants

All current Division I cross-country and track and field coaches with valid email addresses were invited to participate in this survey study. Email addresses were obtained through the National Association of Collegiate Directors of Athletic Directory. Once email addresses were collected, a link to the survey was emailed to each coach using Qualtrics Survey Software. One thousand three hundred and fifty-three valid email addresses were sent links to the survey. Coaches were given 8 days to complete the survey before a follow-up email was sent to coaches who had not completed the survey. Data collection was concluded 21 days following the initial email invitation to participate, at which point the survey was closed and no longer accessible to email recipients. Coaches provided consent by participating in the survey. Responses were kept anonymous, and no incentives to participate were given. The response rate was approximately 18% (n=253), which is typical for this difficult-to-reach demographic. The sample was fairly representative of the population (discussed within results), providing support for the ability for the sample to satisfactorily represent the population.

Survey methods

An adapted version of the Adolescent Depression Knowledge Questionnaire (ADKQ) was used to determine basic knowledge of depression. The ADKQ was chosen because it has demonstrated reliability in measuring the knowledge of depression at a level expected of individuals without formal training or education. The ADKQ consists of 13 true-or-false statements, 8 of which were included directly in this survey. The remaining five statements were replaced or altered with statements more relevant to the college athlete population. Specifically, a true or false statement about the prevalence of depression among teenagers was replaced with a statement on the prevalence of depression among athletes; two statements regarding bipolar disorder were replaced with statements regarding depression and injury risk; and a statement saying that all adolescents whose parents go through divorce will develop depression was replaced with a statement comparing the likelihood of athletes and non-athletes to seek help for depression. Participating coaches were asked to list symptoms of depression. In addition, coaches were asked to describe how they dealt with a depressed athlete most recently and to estimate the percentage of the athletes they have coached who have struggled with depression.

In order to determine coaches’ level of interest in continuing education, a 4-point Likert scale ranging from ‘no interest’ to ‘strong interest’ was used. Coaches were also asked to indicate the two methods they would most prefer for receiving education. Lastly, demographic information was collected, including gender and race/ethnicity, length of coaching experience, event specialty and certification completion. The complete instrument is available in online supplementary appendix A.

Data analysis

One-way analyses of variance were performed using SPSS V.23 to determine whether differences on mean depression questionnaire scores existed between event specialties, gender, coaching title (head vs assistant), certification completion and length of coaching career. An alpha level of 0.05 was used to determine significance.

χ² tests of independence were run in order to determine whether a relationship exists between the level of interest in continuing education and coach gender, length of college coaching experience, event specialty, coaching title (head vs assistant) and certification ownership. Alpha level was set to 0.05 a priori. Responses to an open-ended question asking coaches how they responded to an athlete with depression were coded, and themes were identified and organised into emergent categories. On initial independent analysis, the comparison revealed a per cent agreement of 97.4% and an adjusted Scott’s Pi of 0.936, which is above the generally accepted level for intercoder reliability.

Demographics

The sample consisted of 253 participants, of whom 56 (25%) identified themselves as female and 170 (75%) as male. All participants were current cross-country and/or track coaches at an NCAA Division I university. With regard to ethnicity, 179 (78%) (n=179) self-identified as white, 35 (15%) as black and 7 (3%) as Hispanic or Latino. The remaining 4% of respondents fell into another category of race and ethnicity. Four individuals selected one or more races. These sample demographics are fairly representative of the population, as each of the sample percentages fall within 10% of the Division I track coach gender and race statistics for women’s teams and within 15% for men’s teams.42 For complete demographic information of respondents, see table 1.

The mean percentage of correct answers on the depression questionnaire portion of the survey was 83% (see table 2). The lowest score was 50%, while the highest score (achieved by 24 (10%) of the coaches) was 100%. The majority (>50%) of coaches answered 10 of the 12 statements correctly. Two of the statements—‘the prevalence of depression is equal among men and women’ and ‘Major Depression is a curable medical illness’—were correctly identified as false by less than 45% of respondents.

Common themes identified in how coaches have responded to an athlete struggling with depression are included in table 3. These themes include meeting one-on-one with the athlete (39%) and referring the athlete to campus resources (33%). Only 4% (n=9) mentioned adapting their athletes’ training plan. Coaches estimated that 11% of the athletes they currently coach or have coached in the past have suffered from depression, which falls below reported rates in previous research.

The vast majority of coaches (98%) indicated slight to moderate interest in receiving continuing education on at least one topic, and 64% indicated a strong interest in continuing education on at least one topic (see table 4). The topics that received the greatest interest were injury prevention (60% strong interest) and nutrition (59% strong interest). Just over half of coaches (52%) indicated strong interest in mental health education. Coaches indicated they would most prefer to receive the education via face-to-face instruction (27%) or video modules (24%) as listed in table 5.

No significant differences in mean score on the depression questionnaire were observed between coaches of different genders, ages, years of coaching experience or certification history.

A significant difference in mean score between coaches specialising in distance/mid-distance/cross-country events and coaches of sprints/hurdles events (F (3,221)=3.54, p=0.009) was observed. Distance/mid-distance/cross-country coaches scored, on average, about six percentage points higher on the ADKQ than sprints/hurdles coaches. Interestingly, a significant difference χ² (18, N=235)=48.71, p<0.001 was observed in the mean scores of coaches based on how well they estimated they understand depression. Percentage of coaches who felt they understand depression only moderately well still achieved a perfect score on the depression questionnaire.

No significant differences in interest in continuing education topics or methods were observed based on age, gender, years of coaching experience or event specialty. However, a significant difference χ² (3, N=257)=13.07, p=0.004 was observed between coaches with differing numbers of certifications. Coaches with no certifications were significantly less likely to express interest in continuing education.

Understanding of depression

The findings of this study indicate the participating coaches have a good knowledge of depression for individuals without formal education on the topic. The average score on the ADKQ was 83%, which demonstrates ‘depression literacy’ as defined by the Adolescent Depression Awareness Program.43 This performance demonstrates these coaches have adequate knowledge of the symptoms and characteristics of depression.

When looking at the individual statements, the majority (>50%) of coaches identified 10 of the 12 true or false statements correctly. There were two statements that were answered correctly only by the minority of coaches. Fifty-eight per cent of coaches identified the statement ‘Major Depression is a curable medical illness’ as true, when in fact it is false. According to ADAP, major depression is treatable, not curable.44 Although the difference in wording is slight, it is an important one; it is important to understand that an athlete with depression may struggle with the illness for the rest of his or her life, if not given the proper treatment and attention to minimise the condition, or that it may ‘flare up’ when life circumstances change. Similarly, 55% of coaches incorrectly identified the statement that the prevalence of depression is equal between men and women as true, when it is false; studies in multiple countries all over the world have found women to be at a higher risk of depression than men.14 45–49It may be important, especially for coaches who work with both men’s and women’s teams, to know that their female athletes are more susceptible to depression.

Distance/cross-country coaches performed significantly better on the depression questionnaire than sprints/hurdles coaches. One possible explanation for this is that distance coaches have more previous experience with depressed athletes than sprints coaches, although there was not a significant difference in sprints coaches’ and distance coaches’ estimates of depression among their athletes. However, it could be that distance athletes are at a greater risk of depression than their sprinter teammates. It is known that athletes who participate in sports that emphasise leanness are at a greater risk of developing an eating disorder,50–52 which are often accompanied by depression.53 54 While being lean is an advantage in both the sprint and distance events, there may be a greater emphasis on being light among distance athletes given that endurance is more important than explosive power in their events. Another potential reason distance athletes may be at a higher risk of depression is the racial/ethnic breakdown of those participating: a much greater percentage of collegiate cross-country runners (who often participate in distance track events) are white than are African-American, whereas the discrepancy between the two races is much smaller in track and field.38 This is significant because whites have been found to be at a higher risk of depression than African-Americans.55 If this explanation is in fact true, distance coaches may have had to deal with depression in their athletes more frequently than sprints coaches, which could help explain why distance coaches demonstrated significantly better scores on the depression questionnaire. Another explanation is that the culture of the sprinting events is different than that of distance events. Perhaps, ‘being tough’ (and thus failing recognise depression as more than mental weakness) is embraced to a greater degree among sprinters and their coaches or conversely that mental disease is less taboo among distance runners and their coaches. Each of these potential explanations for the findings warrant future study.

An unexpected noteworthy finding from the study was the discrepancy between coaches’ estimated rate of athlete depression and athlete reported rates found in previous studies. Across all sports, studies have found rates between 15.6% and 23.7%.13–15 Wolanin et al 14 reported the rate of depression among track and field to be as high as 34%, three times higher than the 11% rate reported by coaches in this study. A potential hypothesis for this discrepancy between participants’ estimates and previous research is that coaches may not realise how much their athletes are struggling with depression symptoms. If this is the case, then the problem may not be a lack of depression knowledge among coaches but rather a lack of depression awareness. It is likely much easier to take a 13-question test, with only two answer choices (and thus a 50% chance of being correct), than to actually identify symptoms in a living, breathing human being. This is supported by Mentink,35 who found that coaches struggle to recognise when their players displayed signs of depression.

This hypothesis is supported by the finding that coaches in the sample found out an athlete was suffering from depression most often by the athlete self-reporting. Athletes may be reluctant to share symptoms with their coach because they are worried it will be perceived as mental weakness,36 it will disrupt the relationship dynamic they have with their coach38 or it will affect their training and/or athletic performance. Because of this, athletes may suffer in silence or turn to the department’s sport psychologist, on campus counselling service, or their athletic trainer, each of whom may be obligated to keep their conversations confidential.

A lack of coach knowledge about their athlete’s depression symptoms has important consequences. Athletes suffering from depression are at a greater risk of injury26–28 because some of the chief symptoms of depression include fatigue, difficulty sleeping and loss of appetite, none of which provide athletes with a good foundation for intense training. Furthermore, athletes may be less likely to disclose their depression during peak competition periods, the time that they need help the most, as these parts of the season are often accompanied by stress over the pressure to perform.

In addition, it may also be beneficial for a coach to know his or her athlete has depression because it may change the way they need to relate to the athlete. For example, feelings of guilt and worthlessness are associated with depression.56 Coaches who are aware of their athlete’s depression may tailor their feedback after a training session to make sure it is not hypercritical, so that they are not unintentionally adding to the athlete’s perceived lack of worth. Thus, it is important to work with both athletes and coaches to reduce the discomfort and stigma surrounding mental illness that is prevalent in our society.57

Continuing education

Coaches indicated a strong interest in continuing education. Seventy-seven per cent specified a strong interest in at least one topic, with the two highest preferred methods of receiving education being video modules (27%) and face-to-face instruction (24%) with topics with the highest degree of strong interest being injury prevention (60%), nutrition (59%) and sport psychology (58%). A lack of opportunity for education was implied by the results: 16% of coaches said they had no training regarding depression, yet 98% of coaches expressed a slight interest or greater in mental health and 52% of coaches expressed a strong interest in receiving education on mental health. Considering that 74% of coaches already hold or are currently pursuing certification, it does not seem likely that the discrepancy between desire for education and actually receiving education is due to lack of coaches’ ambition or follow-through. This discrepancy indicates that there may not be enough opportunity for education or there may be barriers preventing them from taking advantage of educational opportunities. Future research should explore what barriers for educational opportunities exist.