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'It was a life or death decision': Elite athletes face stigma, physiological challenges when taking antidepressants

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Content warning: This story discusses mental illness, eating disorders, suicidal ideation and self-harm.

When Tokyo Olympian Valerie Constien was prescribed antidepressant medication for the first time, she didn’t feel like she had much of a choice.

By the time she finally saw a doctor about her rapidly-worsening depression during her junior year of college, Constien had already considered ending her own life. If a teammate at the University of Colorado hadn’t brought a comment she made to the track and field coaching staff, Constien says she might have followed through on her darkest thoughts.

“It was kind of a life or death decision,” she said. “It was either take these medications that may or may not help, or continue down this path and potentially hurt myself. So for me, it wasn't really much of a decision; it was an ultimatum.”

Constien, who is now a professional long-distance runner, had grappled with untreated anxiety and anorexia for several years, but she first experienced symptoms of severe depression, including suicidal thoughts, after a stress fracture in her foot prevented her from training.

“When I got injured, I had to stop running, and I gained some weight,” she said. “Because of my anorexia, I just really hated the way my body looked and the way I felt about it. That kind of was the catalyst.”

After the Colorado athletic department got involved, Constien began regularly seeing a sports psychologist, and in coordination with team doctors, they determined that medication would be the best course of action to stabilize Constien’s mood.

“I was so deep in this hole of depression that seeing a psychologist and opening up to people I don't think would have been enough,” she said. “I think that I was sick. My brain chemistry was messed up.”

Valerie Constien reacts after competing in the women's 3,000-meter steeplechase Final at the 2020 U.S. Olympic Track & Field Team Trials at Hayward Field on June 24 in Eugene, Oregon.
Valerie Constien reacts after competing in the women's 3,000-meter steeplechase Final at the 2020 U.S. Olympic Track & Field Team Trials at Hayward Field on June 24 in Eugene, Oregon.

How antidepressants impact athletes

The Tokyo Olympics were a breakthrough in the discussion that has been building for years around athletes’ mental health.

Simone Biles, the anticipated star of the Games, was the impetus. She withdrew from nearly all of her events after she began struggling with her mental health, specifically a condition known as the twisties that causes gymnasts to lose their body awareness in the air during twisting skills.

Dozens of other athletes took advantage of the opening to speak frankly about their mental health. American sprinter Noah Lyles told reporters about his depression after winning bronze in the 200 meters. Russian pole vaulter Anzhelika Sidorova, who won a silver medal, admitted she sees a therapist. U.S. weightlifter Mattie Rogers discussed struggling with the lack of family support in Tokyo due to COVID-19 restrictions.

However, of the many competitors who did speak out about mental health, very few delved into the topic beyond its relation to sport. Two who did were Biles and Lyles. Biles, in her first statements to media after withdrawing from the all-around team final, said medicine has helped her manage her mental health in addition to therapy in the past. Lyles spoke publicly about how sertraline, a common antidepressant, helped with his depression.

“Recently I decided to get on antidepressant medication,” Lyles wrote on Twitter last August. “That was one of the best decisions I have made in a while. Since then I have been able to think without the dark undertone in mind of nothing matters. Thank you God for mental health.”

However for Lyles and many other athletes, taking antidepressants is anything but straightforward. Sertraline, the medication that Lyles took, is a selective serotonin reuptake inhibitor (SSRI), and the side effects from medications in this class can have a negative impact on athletic performance.

For Lyles, the emotional regulation that the medication provided also made it difficult for him to reach the emotional high that made him explosive during short sprint races.

“It got me out of the darker areas of my mind, but when I tried to reach higher than normal, it would always keep me buffered at what it considered a normal, calm behavior,” he told Sports Illustrated. “It was very hard for me to get up to that excitement level. Say if 50% is normal. I’m stuck in between 40-60%, and I’m trying to get that to 90%.”

Because he lost his “spark,” Lyles weaned off of the antidepressant in the leadup to the U.S. Olympic Trials and Tokyo Olympics, even though he still needed them to manage his depression.

American track athlete Tianna Bartoletta, who is a world record holder in the women’s 4x100-meter relay, said she went through a similar experience when she was taking antidepressant medication and competing at her peak.

“[I] was on them indoor 2016, didn’t make the indoor world team in the 60, couldn’t react to the gun, couldn’t get up for the competition,” Bartoletta wrote on Twitter. “[I] gambled with my depression and suicidal thoughts with the hopes that winning again would keep those two at bay.”

Claudia Reardon, a sports psychiatrist at the University of Wisconsin, said it is fairly common for athletes to experience negative impacts on their performance when taking certain antidepressant medications.

“Athletes are so exquisitely tuned into their bodies and how their bodies feel, so they perceive side effects that you or I probably don't perceive,” Reardon told USA TODAY Sports. “If their 100-meter dash is 1/100th of a second slower, they can tell. The kinds of side effects that may impact sports performance include things like sleepiness, reaction time, tremors, weight and appetite changes, heart rate changes and dizziness, just to name a few.”

Constien was not competing during the six-month period when she took antidepressants, but she said she still noticed certain side effects that would make her hesitant about using that drug if she were to need antidepressants again in the future.

“I gained more weight from taking the antidepressants, which didn't help because I was attempting to recover from anorexia, so that was really hard,” she told USA TODAY Sports. “I was also a little bit more emotional while I was taking the antidepressants. I think I took things too personally, but I was also coming out of severe depression too, so I don't know if it was the medication or if it was me just like, learning to feel again. Even though the side effects were not great, it was so much better than the alternative for me at the time.”

Amanda Beard qualified for her first Olympic Games when she was just 14 years old and formerly held the world record in the 200-meter breaststroke. The American swimming legend also grappled with severe depression and body dysmorphia, which led her to self-harm through cutting and caused suicidal thoughts.

When she started taking medication in 2004, Beard said she didn’t experience negative side effects from the medication itself. The antidepressants helped her enjoy swimming again, but she said she had a horrible physical reaction when she accidentally missed doses.

“I remember I was heading to a swim meet one time in southern California and I forgot to take my medication, I think for one or two days in a row or something like that, and I felt awful,” Beard told USA TODAY Sports. “I felt almost, I don't want to say drunk, but like in a dizzy state, almost. I was like, ‘Well, this is gonna be a really great swim meet.’”

While certain side effects are common with antidepressant medication, individuals often react very differently depending on the specific drug. Reardon said it is almost always possible to find a medicine or combination of medicines that will help stabilize an athletes’ mental health without impacting their performance negatively.

However, finding the right medication can be a lengthy process and the time commitment poses additional concerns for athletes who have predefined competitive seasons during which they need to be at peak health both mentally and physically.

“It can take up to a month or more to see the full effect of a medication, and that can be a significant portion of an athlete's given season,” Reardon said. “If the first med you try works, that's one month, but what if it's the third medication?”

“If someone's really in the heart of their season, and they're functioning OK, and they really want to push through until the offseason when they have six months to work on figuring out a medication that's going to work for them, sometimes we can get them through with other supportive treatments. But if someone is really experiencing a lot of distress or dysfunction, then we want to start treatment right away.”

Like Lyles and Bartoletta, Constien only took antidepressants for a brief period of time — approximately six months — during the spring of and summer after her junior year of college. She said she was largely uninformed about how to manage her antidepressant use, and when her prescription ran out, she simply stopped taking the medication.

Stopping antidepressants cold turkey can be dangerous and is never recommended by licensed psychiatrists. The sudden change can cause a drastic chemical imbalance and withdrawal symptoms that often exacerbate the mental health concerns that the medication was treating.

“I experienced withdrawals, and they were very uncomfortable,” Constien said. “I was dizzy and lightheaded all the time, I couldn't really focus very well and I was even more emotional than I was when I was taking the medication. Then later, I found out you're supposed to phase out of taking them, and apparently phasing off takes a month to two months, depending on the side effects. I think that the reason why that's not known is because people just don't talk about it.”

Anti-doping challenges

In September 2020, American middle-distance runner Brenda Martinez failed an anti-doping screening, testing positive for a banned diuretic called hydrochlorothiazide. However, Martinez hadn’t taken the drug willingly; it had accidentally contaminated her antidepressants.

“I hope that, moving forward, not one more of us clean athletes will have to go through what I did,” Martinez told the New York Times. “It was too traumatic to take a medicine I needed, only to get punished.”

Positive doping tests because of unintentional contamination are not uncommon, and the threat of an anti-doping investigation can contribute to athletes’ hesitation to put anything unfamiliar in their bodies, including antidepressants. According to the U.S. Anti-Doping Agency’s database, there have been 28 cases of positive tests that were concluded to have “no fault/negligence” on the part of the athlete since 2001. Eight of those cases involved the same diuretic that Martinez tested positive for.

The World Anti-Doping Agency (WADA) has since updated its minimum reporting levels for diuretics and certain growth promoters to reduce an athletes’ likelihood of testing positive due to cross-contamination in medications or foods.

Reardon also said that certain psychiatric medications are banned by WADA or the NCAA. This is primarily an issue for stimulants, which are often used to treat ADHD, or certain blood pressure medications that can be used to treat anxiety.

“There's a class of blood pressure medicines called beta blockers that slow down your heart rate,” she said. “For sports where you have to take aim, like archery or rifle, if they slow down your heart rate, that means you have a longer time in between heartbeats to take aim without having this natural physiological tremor that we all have, so they're prohibited in those kinds of sports.”

Fighting against stigma

“I didn’t tell a single soul,” Beard said of her mental health treatment. “Absolutely everything that I was doing was very hush hush.”

Beard began taking antidepressants near the end of 2004, and conversations around mental healthcare were far less open then than they are today, but the stigma around psychiatric medication is still very present, especially among athletes.

Constien started treating her depression more than a decade later in 2017, but she, like Beard, described a desire to hide what she was going through from her teammates and friends.

“I was so self-conscious about having depression and taking medication that I didn't talk about it, and after years and years of space in between that point in my life and now, I finally realize how important it is for athletes who have a platform like me to talk about it, and to destigmatize it,” Constien said. “Because for so many people, they don't realize what direction they're headed in until they're too late.”

LOOKING AHEAD: Will Tokyo Olympics be a game-changer in how we view athletes' mental health?

ARMOUR: Opinion: Simone Biles didn't win any golds in Tokyo but still enhanced her legacy

Beard has been open about her mental health for many years, writing a memoir detailing her experiences titled In the Water, They Can’t See You Cry. She believes that athletes sharing their struggles and being honest about all aspects of mental healthcare is the best way to combat stigmatization both in and out of sports.

“I feel like all these athletes that are coming out and talking about what they're dealing with and struggling with, they're doing so much help for so many young athletes, obviously, but for everyone, because it's not just athletes who’ve had these experiences it's everybody,” she said.

Reardon also said most athletes are far more comfortable seeing a sports psychologist to discuss topics like goal setting and performance anxiety than they are seeing a licensed therapist or psychiatrist. She said having more mental healthcare professionals with expertise in sports could help make athletes more comfortable with seeking mental health treatment.

“Those of us that work in sport realize how much it means to them,” Reardon said. “If you're working in athlete mental health, you really do need the appreciation that it really does matter if I slow down your 100-meter dash by 1/100th of a second. If I make you the slightest bit sleepy on the basketball court, that all matters, and I think the average non-sport mental health provider doesn't necessarily appreciate what a big deal that is.”

Today, Constien said she is generally very happy. She lives in Boulder, Colorado with her boyfriend and still trains with her college coaches. She placed 10th in the 3,000-meter steeplechase final at her first Olympic Games. She also works a full-time job in customer service with STRYD, a tech company that creates devices for runners to track and analyze their training.

Constien is open about her mental health journey because she is proud of how far she has come, and she knows that her voice has the power to change someone else’s path for the better.

“It takes a lot of humility and self-confidence to be able to admit that there was a point in your life where you were dealing with something really, really tough,” she said. “It just makes me so happy to think that the kids who go to elementary school across the street, or my coworkers’ kids, they have a really positive person to potentially look up to talking about how they were struggling with something, but they reached out to someone, and then they got better.”

Contact Emily Adams at eaadams@gannett.com or on Twitter @eaadams6.

This article originally appeared on USA TODAY: Elite athletes struggle with stigma, side effects of antidepressants