Expert: NHL must be involved in mental health

ANN ARBOR, Mich. – We have to talk. Something must be done.

Three times in 3½ months, an NHL enforcer has died. Derek Boogaard(notes) was found dead May 13 due to what was called an accidental mix of alcohol and the painkiller oxycodone. Rick Rypien(notes) was found dead Aug. 16, the recently retired Wade Belak(notes) on Wednesday, both reportedly of suicide.

Research has shown that depression is more common among elite athletes than the general population and even more common among elite athletes after retirement, according to a leading sports neurologist. NHL enforcers face a unique set of stressors.

But this is a more complicated issue than many are making it out to be, we don't know the specific circumstances of these recent incidents, and jumping to conclusions about concussions or repetitive head trauma or other factors could make the situation even worse.

"What I am most concerned about is, take somebody who is depressed, has a problem with depression, has admitted it, is trying to find help, and they are inundated with messages from the media that they are going to have a dementing illness and they're doomed to a terrible fate," Jeffrey Kutcher said Thursday near his office at the University of Michigan. "What do you think is going to happen to people who are depressed? They're going to be more likely to take their life."

Kutcher is a consultant for the NHL Players' Association, the director of Michigan NeuroSport and the chair of the Sports Neurology Section of the American Academy of Neurology. He is an expert on concussions and return-to-play protocol, and he is beginning to study the long-term effects of repetitive brain trauma on athletes.

When it comes to cases like those of Boogaard, Rypien and Belak, Kutcher is less concerned with cause than effect. Cause takes years of scientific study to determine. Cause can vary depending on individual circumstances. Kutcher wants to focus on effect – the substance abuse or the depression itself.

"That's the big message," Kutcher said. "The cause is debatable and arguable, and we're doing research here. I hope in 10 and 12 years I can tell you, 'Here's the risk of your average 10-year-old starting football getting depressed or having problems.' I can't tell you that now. In the meantime, let's not make assumptions we don't know about and let's treat the problem."

So how do we do that?

NHLPA executive director Donald Fehr and NHL commissioner Gary Bettman released a joint statement Thursday in which they pledged to evaluate their existing assistance program and determine "whether concrete steps can be taken to enhance player welfare and minimize the likelihood of such events taking place."

Kutcher emphasized education, screening, diagnosis and treatment. If a player becomes depressed, it doesn't matter how he became depressed. The bottom line is his depression.

"We've got to deal with that," Kutcher said. "We've got to be better at monitoring for it, diagnosing it, treating it. … It's psychological counseling on a routine basis in certain cases, and I think that's kind of the message that I want to get out, is that it has to be more involved – far more involved – than what we've made it so far."

The early symptoms of depression include trouble sleeping, trouble concentrating, loss of desire, aches and pains. They can descend into loss of self-worth and worse. Even a person who seems happy on the outside, as Belak apparently did, can be tormented on the inside and unable to cope.

"And so the only avenue starts coming around to hopelessness, which ends up saying, 'People will be better off without me. I'm in the way. I'm not doing my job. I'm not good,' " said Eric Hipple, an outreach coordinator at the University of Michigan Depression Center. "And so death becomes an answer."

Hipple played quarterback for the Detroit Lions from 1980-86 and '88-89. He lost his 15-year-old son, Jeff, to suicide in 2000 and suffered from depression himself. He shared his story in the book "Real Men Do Cry" and now works with groups ranging from children to the military.

"People are people," Hipple said. "You have to look across the board. It doesn't go by socioeconomic. It doesn't go by gender. It's a pretty equal-opportunity illness, and a lot of it has to do with genetics and how we're put together and our environment and all the stresses we go through. A lot of us are predisposed to the illness of depression."

Elite athletes face the pressure to perform and the constant evaluation from peers, superiors and the public – pressure they have often experienced since a young age. They experience pain – physical pain that leads to mental pain. "You take anybody off the street and give them 10 years of chronic pain," Kutcher said. "Ask them if they're depressed."

That leads to more drug use than the general population, in the form of pain killers. Mix in a lifestyle that includes lonely life on the road. Add alcohol and recreational drugs. Now consider the culture of machismo. "In the sporting community, you don't talk about anything that can be perceived as a weakness," Hipple said. "And so when things are happening … you just suppress all that stuff, because nothing gets in the way of the mission, which is to be on the field of play."

Then there is retirement. Hipple said it can be "devastating" – loss of identity, loss of connections to teammates, loss of support network. Said Kutcher: "If you define your self-worth based on statistics and playing sports, and you've been doing that your whole life, and that's taken away from you, you either have to be able to adjust to that or be able to replace that in some way." The roar of the crowd is difficult to replace.

All of this is amplified for NHL enforcers. Their anguish is well-documented – the feeling in the pits of their stomachs before a fight, that they aren't valued as much as skill players, that they have to fight to stay in the game. Enforcers are expected to be even tougher than usual, and indeed they are often clinging to their jobs. That can make it easier to slip into depression and harder to seek help.

"It's a tremendous burden, for sure," Kutcher said. "That alone is going to cause significant depression at a much higher rate than people who don't do that job. … Obviously the big stars are more able to be injured than the guys who might be on the cusp. It's that chunk of people, the ones that are on the cusp, on the fringe, that probably need a little more attention."

Eliminating or reducing fighting has been – and should be – a point of debate. But we don't know what role fighting actually played in the deaths of Boogaard, Rypien and Belak, and even without fighting depression would continue to be an issue in hockey, as it is elsewhere.elsewhere.

Suicide has struck all over sports in recent months, claiming several current and former elite athletes, including former Baltimore Orioles pitcher Mike Flanagan, U.S. Olympic aerial skier Jeret "Speedy" Peterson, former New York Yankees pitcher Hideki Irabu, former Duke basketball captain Thomas Emma; Austrian Olympic judoka Claudia Heill, former Pro Bowl safety Dave Duerson and former San Jose Sharks farmhand Tom Cavanagh(notes).

Different sports, different individuals, different cases – same conclusion: Mental health must be monitored more like physical health.

"The message isn't, 'Don't be afraid to seek help,' " Hipple said. "The message is, 'Be proactive in being mentally healthy.' … The professional knows what it's like to get their body in shape to get ready to play. Well, there's things that we can do to learn how to be mentally healthy as well – how to overcome certain things, how to be more resilient, how to utilize more tools than just the ones we end up with when things don't go right."

Kutcher cautioned that monitoring the brain is more complicated than monitoring the body and that there is the lingering stigma of mental illness. Hipple said the approach has to change. Tell an athlete he needs help, and he might take it as a personal attack. Tell him someone can help him improve his performance, and he might be open to the idea.

NHL teams have psychologists. The league and union have a substance abuse and behavioral health program, and it covers players up to two years after they leave the game. The union has a program to help players find careers after hockey. (Note that Fehr's son Mark is a neurologist. He did a fellowship at the University of Michigan last year.)

"The NHLPA is very progressive on health issues, period," Kutcher said. "[The union has been proactive in] understanding the complexity of the issue, understanding that the real crime is not to report symptoms when you're having problems, that teammates need to look out for each other in the offseason maybe even more so than the regular season. Really the whole spectrum of mental health, drug use, depression, head injuries – all of that is being addressed and very aggressively."

The answers aren't easy. Why Boogaard mixed alcohol and pain killers is unknown. Rypien's depression was well-known. He took two leaves of absence from the NHL, saw multiple experts and still took his own life. Belak's situation seemed well-hidden. By all accounts, he seemed to be the happy-go-lucky guy he had always been right to the end, and he had a vibrant post-playing career set up.

But more can be done. More must be done. Major League Baseball has taken the step of considering emotional disorders injuries, creating a "Mental DL." Hipple works with a NFL Players Association program that evaluates retired players and assists those who are struggling. Those are just two examples.

"We've got to treat the first symptoms starting out instead of waiting until the symptoms are so bad this is the decision they make," Hipple said. "These things are normal. There are ups and downs. People do suffer from mood disorders, and if you do, they're easily treatable. So let's get the treatment and let's work with it."

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