Monday, 19 November 2012

Depression and Sport

I’ve never been so glad to finish a book as when I finally reached the end of A Life Too Short: The Tragedy of Robert Enke.  While on the one hand I couldn’t put the book down, reading it was, at the best of times, an upsetting and difficult process.

The book details the life and death of Robert Enke, a German national goalkeeper who suffered from depression, and who, in 2009, took his own life.

Robert is just one of a number of high performance athletes who have been affect by depression.  Multiple Olympic swimming champion Ian Thorpe, Celtic FC Manager Neil Lennon, and double Olympic Champion Dame Kelly Holmes are just some of the high profile athletes who have made their depression public.  Andrew Flintoff, Marcus Trescothick, Paul Gascoigne and Frank Bruno are just a few other who have been afflicted by the illness.

When exercise is a common treatment for depression, why do so many of the world’s most talented sportspeople suffer depression at some stage in their lives?  It may not be surprising that most athletes suffer some form of 'down' after a major Championship into which they have put their heart and soul, or after retirement, when the world they have been such an integral part of ceases to exist, but this is not normally the type of mood which would cause an individual to take their own lives.

While depression, described as feeling blue, sad, or miserable, may affect most individuals for short periods at some stage in their life, true clinical depression (or major depression) is a mood disorder resulting in feelings of sadness, anger, emptiness, frustration or loss which has a major impact on everyday life for weeks, months or years.

The causes of depression are not fully know or understood.  There is a common misconception that tragic event must occur for an individual to experience depression.  While trauma is one cause of depression, it can also be the result of genetic factors and underlying medical conditions.  Many researchers and medical professionals believe that chemical changes in the brain, caused by defective genes or triggered by stressful events, lead to depression.  While there are strong family links, individuals with no history of depression can suffer from the illness.  The onset of depression most often occurs between the ages of 20 and 30 years, with a second peak between 30 and 40 years of age, though it can affect individuals of any age, even young children.
Some of the factors which may be result in a depressed mood, but not always a psychiatric condition include:
  • Medical conditions including long-term pain, underactive thyroid, multiple sclerosis or cancer
  • Drug or alcohol abuse
  • Use of certain medications (e.g. steroids)
  • Stressful life events including divorce, bereavement, retirement, menopause, job loss, isolation, child abuse or failing an exam.
Depression alters or distorts the way in which the sufferer sees themselves, their life and their surroundings.  They usually have a negative outlook on situations, and find it difficult to see a positive solution for situations or problems.

Symptoms of depression include:
  • Difficulty concentrating
  • Becoming isolated or withdrawn
  • Irritability, agitation an restlessness
  • Fatigue and lack of energy
  • Difficulty sleeping
  • Dramatic appetite and weight changes
  • Feelings of guilt, self-hate or worthlessness
  • Feelings of helplessness or hopelessness
  • Difficulty sleeping or oversleeping
  • No longer finding pleasure in activities that once enjoyed
  • Thoughts of suicide or death
  • Delusions and hallucinations in extreme cases
  • Poor memory and concentration
  • Reduced sex drive
  • Physical symptoms such as fatigue, digestive problems and headaches
  • In the US about half of those with clinical depression also suffer lifetime anxiety
After testing for other underlying physical or medical conditions which may result in similar symptoms to depression, patients are treated with medication and /or councelling or psychotherapy.  Depression may appear no more than once in and individual’s lifetime, and last no more than a few weeks, or could last a lifetime with a number of major depressive episodes.

Tips for those working with athletes:
  • The thought of retirement from sport may be a major cause for anxiety among athletes.  Encourage athletes to lead a balanced lifestyle and to prepare early for retirement.
  • Ensure that athletes receive psychological support following major championships, during and after retirement, and while recovering from major injuries.
  • Avoid placing unnecessary pressure on athletes.  Athletes are often highly self-motivated, and any pressure should come from them, and be manageable.
  • Encourage athletes to deal well with problems.
  • Create an environment in which athletes always have someone to talk to in confidence (even if that is not you), and provide support where necessary.
  • If an athlete is suffering from depression, encourage athletes to seek professional medical help.
  • Understand that performance may decrease in athletes who are adjusting to anti-depressant medication.  Create a supportive environment in which they can continue to compete (if they wish), but with manageable pressure.
  • Try to understand the illness.
A Life Too Short is a well researched and beautiful account of Robert Enke’s life and death, documented by his friend Ronald Reng, with whom Robert had discussed writing his memoirs.  It details the difficult phases that Robert went through in his life, the changes of environment, the death of his daughter, the late development of his talent, and most importantly how Robert reacted to important transitions in his life.  The real tragedy is that, while Robert received successful treatment for this depression during the first dark phase of his life, it was the fear of his illness becoming public and the potential of loosing his place in the national team that stopped him receiving professional help and treatment at his darkest hour.  With the World Cup in South Africa just months away, Robert couldn’t cope with the thought of his depression becoming public.  In the end, he never made it to South Africa; he was already dead.

The real beauty of the book is that the author puts forward all the facts and details Robert's reactions to certain events, and his perceptions of those around him, but doesn’t try to give all the answers or lead the reader in any way.  In places, the book could not have been more autobiographical if Robert had written it himself, but Reng doesn’t try to fill the gaps that will always exist.  Nobody knows why depression affected Robert at the stages it did, and the author accepts his inability to answer this question. 

I would strongly recommend the book to anyone who thinks that depression only affects the weak or those who are unsuccessful; who thinks that depression doesn’t happen to people like them; who supports high performance athletes; or who would like to understand the disease a little bit more.

Just make sure that you have a box of tissues close to hand.

Some useful resources and reading material: - Loss, retirement and depression in sport
Cycling Weekly - Depression in Sport

Wednesday, 7 November 2012

Drug use versus training methods: EPO as an example

For some athletes, there is a fine line between modern training methods and the use of banned substances.  For me the difference is clear as day.  Below is my slightly tongue-in-cheek take on the differences between EPO use and altitude training which I wrote earlier this week for another blog.  I use it as an example of how training methods and drug use differ, and hope that it will have athletes confused by the differences between the two.   

In the interest of keeping things simple, when I refer to a drug’s secretion naturally in the body I give it it’s full name (e.g. erythropoietin), and when I’m referring to the drug in it’s synthetic, exogenous or administered form, I refer to it in abbreviations (e.g. EPO).

‘Legalise EPO’ they say, ‘because you can’t ban altitude training, and they’re essentially the same thing’.  ‘The only difference between EPO use and altitude training is that one is banned in sport and that the other isn’t’, I’ve recently heard people argue.  ‘They both increase red blood cells, so they must be the same thing’; a simplistic, and ignorant, statement which not only misinterprets how EPO and altitude training work, but completely ignores the ethos behind drug-free sport.
People’s arguments suggest that if there were different legislators in sport, altitude training might find itself on WADA’s prohibited list, or that one day we might see EPO legalised in sport.  As somebody who has strong anti-doping convictions, but has benefited from altitude training, for me, EPO use, and altitude training are worlds apart. 
To argue that EPO use and altitude training are the same thing because they have similar effects would be the same as saying that steroid use and weight training are similar (they both increase muscle size), and that taking an afternoon nap following training would be just as unethical as injecting HGH, as to do so would cause an increase in human growth hormone secretion and expose the body to it’s benefits.  In fact, hill training, endurance training, recovery runs, fartlek training, plyometrics, good nutrition, heat acclimatisation… and pretty much every other form of training, increases the body’s ability to perform through increased hormone secretion, increased tissue growth and/or increased neural adaptation, and it would be ridiculous to suggest that any of these are on the same moral footing as using banned performance-enhancing drugs.  Training is very much allowed!
The drug EPO is not only banned in sport, but it is a prescription-only drug, designed to help keep individuals with an inability to produce it naturally healthy.  It is not (or at least should not be) available for healthy individuals to purchase and use without medical reason.  Conversely, individuals around the world have the right to be born or live at any altitude at which human life is possible.
The use of EPO is extremely dangerous.  Prolonged or excessive use can have at least two fatal consequences in humans.  EPO increases red blood cell production, and the more red blood cells you have, the thicker your blood becomes.  Blood can in fact become so thick that your heart is no longer able to pump blood around the body.  If that happens, you die.  Additionally, EPO use can affect your body’s natural ability to produce erythropoietin.  Without erythropoietin you can’t produce red blood cells, and without red blood cells you can’t transport oxygen around the body.  Oxygen, I hear, is fundamental for human life (and not just in life involving sport), so that’s pretty crap.  Of course you don’t have to die, but you do become dependant on EPO.  Altitude exposure at or below 3,000m, even over a prolonged period of time, though not without it’s side effects (crazy dreams for example), is unlikely to kill you!
And now to the scientific bit, and the crux of my argument. Just because two things have the same end product, doesn’t mean that they are the same thing, physically, morally or legally.  We’ve already agreed (unless you’re the real argumentative type), that training in sport is allowed, and indeed encouraged if you want to be any good at sport, and call me an idealist, but I feel that injecting ourselves with any substance (when not medically required) to take a short-cut to enhanced performance is not in line with drug-free sport, irrespective of whether that substance is banned or not.
Now, I will agree that a large portion of the response to EPO use, and to altitude training, is the same, but there are some fundamental differences.  As we mentioned before, EPO use increases red blood cell production; increased red blood cells carry more oxygen around the body; and a greater oxygen carrying capacity increases endurance performance.  The main way in which altitude training is proposed to work is that the reduced atmospheric oxygen stimulates the body to increase erythropoietin synthesis, which in turn increases red blood cell production, increased red blood cells carry more oxygen around the body; and a greater oxygen carrying capacity increases endurance performance.  Taking EPO makes training easier.  It allows the body to recover quicker (because the body is not the one synthesising the EPO, which believe you me is stressful business for the body), and allows you to train hard day after day.  Altitude training on the other hand is a nightmare!  It’s impossible to breathe, you sleep 14 hours a day, simple tasks like walking to the shops can tire you out, you can’t run as hard or as long as you can at sea level, and think again if you think you’re going to do session after session after session.  Like lots of other beneficial training methods (e.g. weight training, hill reps), you need to recover.  Increased EPO increases red blood cell production.  More EPO creates more red blood cell production.  Altitude exposure increases erythropoietin, and subsequently red blood cell production, to respond to the reduced oxygen in the air, but once it’s adapted, it doesn’t keep on producing erythropoietin.  More altitude exposure doesn’t mean more erythropoietin.  And the real catch is that some people’s bodies are so against the whole erythropoietin synthesis lark that they don’t bother.  Yes, not everyone responds to altitude.  The good news though is that these people are usually the freaks that find altitude training easy.
For me altitude training and EPO use are as different from each other as helping old ladies cross the road and sticking needles in little babies’ eyes.  Other methods of increasing endurance such as altitude tents, altitude masks, iron injections, blood transfusions and blood doping may fall various degrees closer to the proverbial fine line, but training your ass off in difficult environments is not the same as injecting yourself with a drug, which you’ve acquired illegally, to make the route to the top easier for yourself.
Now, I don’t’ know if all of you, or in fact any of you, have managed to read through my waffle, but I have sure as hell enjoyed putting up my side of the argument.  If you’d like to agree or disagree, then please leave your comments below.
I've been Elizabeth Egan, and I'm for Drug-free sport (and for afternoon naps!).  Thanks for reading.