Depression and Performance Enhancing Drugs – Are we willing to understand this relationship?

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The development of depression during retirement from professional sport has been highlighted by many athletes and most recently by swimming legend Ian Thorpe.  James Cracknell has spoken about his tunnel vision of sport performance and subsequent inability to broaden his horizons in retirement. Alternatively sports stars have often quit a major competition or retired from the sport due to their inability to cope with their depression. This includes Michael Yardy and Jonathan Trott who quit cricket tours in 2011 and 2013 respectively to deal with stress related issues and depression. The examples are endless upon a simple Google search.

With this in mind consider a question. What is your opinion of an athlete caught taking performance-enhancing drugs in an attempt not to increase performance but to escape from his depression?

This article is a reflection on one such athlete. Depression it seems is a prominent feature in this athlete’s road to drugs and resulting public backlash. Martin Fagan was formally an Irish international track athlete who specialised in distances of the half marathon and the marathon. Among many exemplary achievements spanning road racing, cross country and track racing, he qualified for the Beijing Olympic marathon from which he set his sights on the Irish national record.

Important to note for readers is the next string of events, which are detailed in an in-depth personal interview with Fagan in the Irish Times by Ian O’Riordan (available at: http://www.irishtimes.com/sport/relief-to-fore-as-athlete-admits-his-race-is-run-1.445871?page=3). This reflection on Fagan is solely based on the Irish Times article, as it seems to be the only publically available explanation for his choice to take performance-enhancing drugs.

According to the article, during the qualification for the Olympics Fagan suffered a triple stress fracture to his pelvis. Despite overcoming this he was forced to drop out in the middle of the Olympic marathon in Beijing 2008 due to an Achilles injury. This developed into a serious injury known as Haglunds Syndrome, which required surgery. After Beijing he failed to complete three consecutive marathons and began to struggle financially as he did not qualify for funding from the Irish Sports Council. As a result of these events invites to further high profile races in which to earn money reduced. Furthermore, USA visa issues prevented him from working exasperating his monetary issues. Yet in 2009 he broke Irish Olympic silver medallist John Treacy’s 21-year-old national half-marathon record only to exasperate his previous Achilles tendon injury (O’Riordan, 2012). However his refusal to compete in the European Championship Trials in July 2010 culminated in his non-selection for the Irish team. Fagan wrote to his national governing body (NGB) a year before the 2012 Olympics after breaking the national record in the hope of receiving funding. However he had not reached any standards for funding for racing distances that featured in the Olympics. As a result Fagan states in the newspaper article that he stopped taking his prescribed anti-depressant drugs (O’Riordan, 2012). So it seems he already had a dispensation of depressive feelings and behaviour, which to our eyes seems to be lacking logic.

As such Fagan reported a serious deterioration of his mental state with repeated lies to his coach and family as he did not feel emotional problems were significant enough to highlight on the backdrop of so many injuries (O’Riordan, 2012). According to Fagan this resulted in the purchase and use of the performance-enhancing drug EPO, in November 2011, in an attempt to escape the depression and isolation of living and training in the US.

Understandably for many, this gives the impression of a sad story accompanied by a very lonely violinist playing a melodramatic tune. In no way do I advocate Fagan’s behaviour of the use of EPO as an escape. However I do urge you to examine the psychological impact his circumstances had on him within the concepts of depression.

Basic Concepts of Depression

The Cognitive Model of Depression may help to explain the aspects that developed and maintained Fagan’s depression. The model includes elements such as the Cognitive Triad, schemas, and cognitive errors (errors in mental processes). According to the model’s creator these combine in the development of depression (Beck, 1979).

Cognitive Triad

In Fagan’s case, he predominantly portrays the Cognitive Triad, which involves three schemas or mental concepts,

  1. A negative view of himself,
  2. A negative view of his interpersonal world,
  3. A negative view of the future.

However, as there is only one primary source of information via the Irish Times interview, Fagan could be presenting a persona that is not truthfully himself in the dimensions of his depression due to the intense scrutiny of the media.

Nonetheless, the interpretation of repeated ‘did not finish’ results in marathons and repeated injury, resulting in financial worry, may have created the assumption that the world is presenting over-reaching demands on Fagan (Beck, 1979). This could have further degraded his perceived ability to achieve his sporting goals and thus happiness (Beck, 1979). Therefore a negative view of himself and the world in which he is situated could have developed. Subsequently in line with Beck’s (1979) final component of the cognitive triad, it seems he interpreted an indefinite continuance of his troubles in the future as he was experiencing continual hardship and frustration with performance and money.

These could have been a determinant in Fagan’s decision to take EPO. This is conceptualised by his irrational beliefs. Specifically he felt that he was trapped within himself, unable to voice any worries to his family or coach (O’Riordan, 2012). More so he felt his emotional problems did not satisfy the requirements to be voiced in the face of previous physical injury. These decisions could be perceived by his critics to be void of logic, which is true. However, importantly research has stated that evidence of the cognitive triad in a person can lead to negative emotional and behavioural consequences (Wong, 2008; Ellis, 1991), which are eminently portrayed by Fagan. Furthermore the final element of the cognitive triad is dependent upon the weight in which future judgments are made, from which Fagan’s depression severed any optimistic views (Pacini, Muir & Epistein, 1998). Therefore without optimism one may consider the need to escape via irrational behaviour. In looking at Fagan’s reported experiences and emotional turmoil within the framework of depression his behaviours and actions may be understandable within this framework only.

So one could ask, why didn’t he return home to Ireland like the cricket athletes cited at the start of this article? Only Fagan knows for sure however the analysis of the Irish Times interview (O’Riordan, 2012) may shed some light on the matter. According to research, Fagan’s increase in pessimistic beliefs regarding a negative view of himself and an inability to cope with negative life events could have resulted in a refusal to acknowledge his struggles (Strunk & Adler, 2009). This is probably best seen through the cessation of his anti-depression medication and a refusal to acknowledge his struggles with his coach, family and friends. Further, he continued his training in the US despite financial and emotional difficulties. So specific life events are important here, for example, collapsing one mile away from the finish at the Chicago marathon is definitive for Fagan. Here he was on target to achieve the London 2012 Olympic qualifying time, his only hope of regaining financial and thus emotional stability. This can be defined as a specific life event in which a state of hopelessness may have instigated the use of EPO. Therefore it is possible that his depression elevated a random bad performance in the 2008 Beijing Olympics to what those in the psychology profession call a continued dysfunctional schema (Beck, 1979). So he portrayed continued and repeated behaviour and emotions which we can call dysfunctional or without logic. Thus illustrating the advanced state of Fagan’s depression as opposed to any other psychiatric disorder such as anxiety (Beck, Wenzel, Riskind, Brown & Steer, 2006).

Cognitive Errors

So consider this. As a result of elements discussed above, the cognitive triad is exemplified in his continued poor athletic performance and repeated injury due to his refusal to take rest and recovery as stated by Fagan in O’Riordan (2012). This is also evident in his inability to accept the diagnosis of Hagalunds Syndrome and the prognosis of a year-long rehabilitation programme. Subsequently it can be said that a concept of what is called ‘cognitive errors’ could have induced a paralysis of Fagan’s will whereby he unrealistically overestimated the difficulty of normal tasks such as executing marathon races, conversing with his coach, and training without pain (Beck 1976), stating,

“I didn’t want to tell him I couldn’t run because my head wasn’t right. So I would lie to him, tell him training was going well, that I was doing the work-outs he was sending me, no problem. But I was in pain most of the day. My whole body.”

Cognitive errors in research on depression (Beck, 1979) are evident in the Irish Times interview. These include:

Cognitive Error

Explanation

Quote

Catastrophising -Involves assuming the worst possible outcome in a given situation.-This is shown in his suicidal inclinations resulting in taking EPO, a very traceable drug” -“In my head I had already packed up my stuff, packed up my running. I was leaving America, I had to come home.”
Arbitrary inference -Involves drawing a specific conclusion from a situation to support negative emotions despite a lack of evidence or evidence to the contrary.-This is best seen in his inability to cope with set backs or poor performances in races. -“That just broke me, physically and mentally. So near and yet so far. If I’d finished that race I could have taken two months off, to completely recover, maybe get myself right.”
Selective abstraction -Involves focusing solely the negative aspects of an event.-This is evident in Fagan when he focused solely on the negative aspects of races such as failing to complete the Chicago marathon despite being relatively unfit to do so. -“If I’d only got to the line I could have run sub-2:12, and a London qualifier. Instead I got nothing out. No money. A DNF [did not finish] next to my name. And no one cared. That really broke me. The final nail in the coffin, really”.
Magnification -Involves the evaluation of errors in an event which if observed to be large may continue maladaptive or destructive thoughts and behaviours.-This is viewed through Fagan’s repeated negative outcomes from races and injury, leading to his refusal to rest and thus recover post races, training and injury -“That just broke me, physically and mentally. So near yet so far.”-“I’m not a doctor. But I was already in meltdown.”
Dichotomous Thinking -Involves the placement of the self in one of two opposing categories, being positive or negative.-This is seen through placing himself in the category that he has nobody to speak to and is trapped within himself causing him to search for an escape. “I got myself into a position where I should have talked with someone, but I just kept it all inside. I think some runners just do that, put on this brave front, look at the next race and think everything will be okay, once I get through that.”
Personalisation -Involves the evaluation of the outcome of previous negative events and attributing this to internal causes or lack of ability, despite evidence to the contrary.-Seen in Fagan’s repeated failure to complete marathons despite being unfit/injured -If I’d finished that race I could have taken two months off, to completelyrecover, maybe get myself right.”

 

Fagan’s most evident cognitive error is selective abstraction. As a result he could have been unable to contemplate his potential to recover from injury and races, thus reducing his perceived ability to qualify again for the London Olympics. Therefore his judgement may have been shrouded when refusing to complete the full of rest and recovery period after marathon races and injury, leading to repeated failures and subsequent episodes of depression. Another cognitive error, over-generalisation, may have normalised negative events leading Fagan to believe that these were due to a lack of ability. Furthermore Fagan’s perceived failures, with each negative outcome, may have been amplified through another cognitive error of magnification. Subsequently personalisation could have induced the internalisation of the cognitive errors from which he felt that he was solely responsible for negative events (Weems et al., 2001).

Fagan’s behaviour, in line with the cognitive triad and cognitive errors, indicates a major depressive disorder (Reardon & Factor, 2010). According to research this can lead to maladaptive or destructive behaviour.  So do we accept Fagan’s behaviour of taking EPO to escape the sport which created so much emotional turmoil? Or do me maintain the stance that one must just ‘get over feeling down’? For example is it acceptable for a long retired sports pundit to acknowledge only his own anger and disgust of Fagan in a distinctively aggressive rebuke of Fagan’s actions (easily searched on youtube)? Upon deciding your opinion of Fagan’s behaviour and reported depression contemplate some more sports specific literature regarding his maladaptive coping mechanisms.

Sport Specific Concepts of Depression

It is evident that Fagan was unable to balance life-stressors with the psychological and physical requirements of athletic training and performance (Proctor & Boan-Lenzo, 2010). This could have compounded his emotional distress and subsequent depression (Proctor & Boan-Lenzo, 2010). Moreover, he portrayed a social and cultural stigmatisation of depression in sport through his denial of a psychological impairment compared to physical impairment (Reardon & Factor, 2010), stating

“I think [it] can happen in any sport, because of the pressures that can be there. And that I think the stigma is also there, that it’s hard for any athlete to come out and say they’re suffering from depression”

So, many people when reading this quote in the Irish Times article (Riordan, 2012) may have reacted with mixed emotions and mixed judgement, which are fair. Consider research on this matter. For Fagan there was pressure to excel in sport and survive financially. These may have created a discrepancy between his desired goals and actual potential performance (Schaal et al., 2011), particularly in light of his many injuries and refusal to rest. This can be observed in his failure to complete one marathon and subsequent refusing to rest in order to do another marathon in quick succession. Furthermore, a sense of powerlessness throughout his repeated injuries may have substantiated a decrease of self-worth and an increase of depression in line with previous research in sport (Kerr & Goss, 1997). This is evident in the Irish Times interview through avoidance behaviours. Here, in line with research, Fagan sought to disengage in the processes of training and competition (Proctor & Boan-Lenzo, 2010).

Fagan’s psychological responses to his repeated injuries comprise of cognitive (mental processes, emotional and behavioural reactions, which negatively influenced his recovery and coping mechanisms (Tripp et al., 2007; Wiese-Bjornstal, 2010). Furthermore, his psychological recovery from his first injury, a triple stress fracture, was hampered the suppression of negative emotions and re-injury fears, which are common in athletes (Mankad et al., 2009). With limited sources, this is further apparent through his refusal to treat the Hagalunds Syndrome and his refusal to rest after the failed attempt to qualify for London 2012. Therefore in line with research he was unable to identify and release injury anxieties and fears culminating in depression (Woodman & Hardy, 2003).

Furthermore, research shows that repeated injury and minor depression responses increase the risk of major depression through a lack rehabilitation compliance, thus resulting in re-injury  (Wiese-Bjornstal, 2010; DiMatteo et al., 2000). Therefore Fagans’s suicidal inclinations can be observed to develop through hopelessness (Appeneal et al., 2009), which manifested itself in avoidance coping behaviours and taking EPO.

Nonetheless, this article does not support the use of performance enhancing drugs as an option to escape major depression. However I hope it educates the reader in the various aspects of major depression. Hopefully aligning these with Fagan’s statements and experiences will help the reader understand that depression is a dangerous illness resulting in behaviour, which non-sufferers would question and criticise. Furthermore, competing in professional or high level sport does not protect a person from depression.

Numerous athletes have publicised their depression. Recently Great Britain Olympic 400 meter hurdler, Jack Green, took a break from the sport stating,

“Those close to me and working with me know I have been suffering with depression over the last year and, despite a full recovery, I believe a break is necessary for my mental health,” – (Hart, 2013).

Many could say Fagan should have done the same, however with his cessation of medication, it is evident that he could not contemplate logic in favour of maladaptive coping mechanisms. Alternatively consider the case of footballer Gary Speed who committed suicide in 2011 in an attempt to escape depression. Would Fagan’s critics be so quick to judge if he chose this path or would they join a tide of empathy?

References

Appeneal, N. M., Levine, B. R. Perna, F. M. & Roh, J. L. (2009). Measuring

postinjury depression among male and female competitive athletes. Journal of Sport & Exercise Psychology, 31, 60-76

Beck, J. S. (1979). Cognitive Therapy of Depression. New York, N.Y: Guilford.

O’Riordan, I. (2012). Relief to fore as athlete admits his race is run. Retrieved from http://www.irishtimes.com/sport/relief-to-fore-as-athlete-admits-his-race-is-run-1.445871?page=3.

DiMatteo M.R., Lepper, H.S. & Croghan, T.W. (2000). Depression is a risk factor for

noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Archives of Internal Medicine, 160, 2101–2107.

Ellis, A. (1991). Reason and emotion in psychotherapy. New York, N.Y.: Citadel.

Hart, S. (2003). Champion hurdler Jack Green to take a break from athletics in 2014 after revealing battle with depression. Retrieved from, http://www.telegraph.co.uk/sport/othersports/athletics/10508020/Champion-hurdler-Jack-Green-to-take-break-from-athletics-in-2014-after-revealing-battle-with-depression.html.

Kerr, G. & Goss, J. (1997) Personal control in elite gymnasts: the relationships

between locus of control, self-esteem and trait anxiety. Journal of Sport Behavior 20: 69–82.

Mankad A, Gordon S. & Wallman K. (2009). Perceptions of emotional climate

among injured athletes. Journal Clinical Sport Psychology, 3, 1–14.

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cognitive experiential self-theory. Journal of Personality and Social Psychology, 74,1056–106

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Berthelot, G., Simon, S. & Toussant, J. (2011). The balance in high level athletes: Gender-based differences and sport specific parrterns. PLos One, 6, 1-9.

Strunk, D. R. & Adler, A. D. (2009). Cognitive biases in three prediction

tasks: A test of the cognitive model of depression. Behaviour Research and Therapy 47, 34–40.

Tripp, D. A., Ebel-Lam, A., Stanish, W., Brewer, B. W. & Birchard, J. (2007). Fear of

re-injury, negative effect, and predicting return to sport in recreational athletes with anterior cruciate ligament injuries at 1 year post surgery. Rehabilitation Psychology, 52, 74-81

Weems, C. F., Berman, S. L., Silverman, W. K. & Saveereda, L. M. (2001). Cognitive

errors in youth with anxiety disorders: The linkages between negative cognitive erros and anxious symptoms. Cognitive Therapy and Research, 25,. 559–575.

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thoughts, and irrational beliefs and test anxiety. Current Psychology, 27:177–191.

 

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