Four-time Academic All-Big 10 honoree and defensive tackle Will Heininger's biggest battle was not waged in the classroom or on the football field.
"I had emotional pain that was overwhelming; I would wake up, and from morning until I feel asleep -- when I was able sleep -- I had troubling thoughts that were utterly consuming," said the 2011 Michigan honors graduate. "Not a minute would go by in a day, without my depression on my mind … this, this felt impossible."
When Heininger tore the ACL in his right knee in 2010, most every Michigan football fan, coach and opponent knew about it. But suffering with a mental health crisis, like former Missouri swimmer Sasha Menu Courey did, is far more personal and less obvious. Such issues can lead to devastating results.
According to the most recent data compiled by the NCAA, suicide was the third-leading cause of death of student-athletes from 2004-08, after accidents and cardiac causes.
"Mental illness is probably one of the greatest silent epidemics in our country. It's a public health issue and now we're seeing it more and more in our student-athletes," said Timothy Neal, assistant athletic director for sports medicine at Syracuse University. "One in every four to five young adults has mental health issues, but what is unique about the student-athlete is they have stressors and expectations of them unlike the other students that could either trigger a psychological concern or exacerbate an existing mental health issue."
For years, policies and procedures have been in place for college athletes to seek mental health help just as they do with their physical health. They can do so without losing their scholarships or having to drop out of school. But though those procedures and policies provide equal treatment to mental and physical health issues, how each is dealt with is starkly different.
• Physical injuries such as concussions and knee injuries draw routine and widespread study by doctors and researchers, yet a dearth of information about athletes and mental illnesses exists.
• Though more than 450,000 students competed in college sports in 2011-12, no hard data are being collected on how many athletes are coping with psychological concerns.
• Athletic departments handle psychological concerns in very different ways, and at many schools, mental health resources are downright sparse when compared to those dedicated to the physical health of the athletes. Many athletic programs have medical staffs of more than a dozen people, yet fewer than 25 Division I athletic departments have a full-time licensed mental health practitioner on staff.
Statistics indicate that in any given year, tens of thousands of college athletes struggle with psychological issues. While the topic is becoming more frequently addressed in professional sports with athletes such as Brandon Marshall and Royce White openly discussing their mental illnesses -- at the collegiate level, the age when most serious mental illness first presents itself or manifests -- there historically has been little public discussion.
"I liken the awareness and management of mental health issues in student-athletes to where we were with concussion awareness and management about 10 to 15 years ago," Neal said. "The landscape, in my opinion, is a little behind."
Things may be changing. Last January, the NCAA hired neurologist Brian Hainline as its first chief medical officer. In late November, 30 members of the newly formed NCAA Mental Health Task Force met at NCAA headquarters in Indianapolis and is updating the NCAA Mental Health Handbook, scheduled to be released this spring. And last fall, the National Athletic Trainers Association released its first consensus statement on the psychological concerns of student-athletes.
"If I were to put a priority, I think [concussions have] to be addressed meaningfully -- we need to get objective bio markers, we need to get that solidified -- but long term, I think student-athlete mental health concerns are even more important," Hainline said.
Taking the difficult step forward
Mental health remains at its core a personal and stigmatized issue. Professional athletes and teams in recent years have openly discussed consulting with a person referred to as sports psychologist, but those consultations are almost always revolve around game play issues such as building mental strength and overcoming fear.
But feeling comfortable enough to seek help for off-the-field mental health concerns in a competitive environment where many college athletes worry about whether their scholarship will be renewed each year can be a more complicated issue.
John Sullivan, a consulting psychologist for Providence College and the University of Rhode Island athletic departments, said he has seen an increase in the number of athletes receiving medical waivers for mental health reasons. (Some are for co-occurring reasons such as a knee injury and a mental health issue.). He estimates he used to provide documentation for one or two athletes a year, but now that number is up to five or six.
"Outside the Lines" attempted to determine how many waivers are granted for such reasons, but none of the five largest conferences could or would provide the data.
Michigan's Heininger said he was reluctant to share his debilitating depression with anyone on his football team or athletic department, but he eventually became overwhelmed.
"I was breaking down; I couldn't keep functioning the way I was without any help. It happened one day after practice, tears were welling in my eyes, and I didn't want to cry in front of my football family. My athletic trainer … saw me and took me aside."
Heininger was sent to a clinical social worker, Barb Hansen, who works full time for the athletic department. He began therapy and was prescribed an antidepressant, and said he had an epiphany one day while meeting with a team doctor:
"He mentioned to me that over half of the student-athletes were on antidepressant medication for the unique stressors that we go through as student-athletes and that alone made me feel like, 'Whew, like this is not just me. This is normal and that there's no reason to be embarrassed about it,' so it was huge to have those people know and know that they cared."
Hansen is a member of the Big Sky Sport Psychology Group, a collection of licensed mental health providers who work in college sports.
"I'm hoping that this continues to evolve to the point where in-house psychologists for athletics or coordinators of psychological services for athletics becomes as common as athletic trainers and strength coaches," said Chris Carr, one of the organizers of the group, who is also a member of the NCAA Mental Health Task Force.
Carr is encouraged by recent developments but said there is more that can be done.
He shares concerns with others about how the use of the term "sports psychologist" can be misleading to athletic administrators, coaches and athletes. Numerous athletic departments employ people to help with athletic performance or team building. But unless someone is a licensed psychologist in the state in which he or she works, the person legally cannot refer to herself as a psychologist.
At Menu Courey's school, Missouri, the school's longtime track coach Rick McGuire retired in 2010 and transitioned into a role overseeing the athletic department's psychological services.
In a university document obtained by "Outside the Lines" and signed by McGuire, his title was listed as "psychologist" when he started the job. He was called "sports psychologist" on the school's website as recently as last month. (In an e-mail obtained by "Outside the Lines," he said he had no contact with Menu Courey.)
In September, licensed psychologist Debbie Wright was hired to work full time in the athletic department.
"I would love that every athletic administrator or director of sports medicine, or director of academic services -- the first question they would ask is, 'Are you a licensed psychologist?'" said Carr. "If they say yes, then follow up with, 'What is your training and experience in sports psychology?'… if you bring someone on board who isn't a licensed individual, you're really limiting what they can do."
Another issue: Many athletic departments send athletes to counselors who do not have much experience working with athletes.
"I think a university that only has a counseling center … their resources are neither intense enough nor rich enough to deal with athletics, on top of which, they don't understand the culture," said Sullivan, who helped write the NATA Consensus statement.
Said Heininger: "You are dealing with somebody's life ... the athletic departments really are responsible in my opinion for the well-being of their student-athletes. They require a lot of them, they give them a lot of opportunity, and they should want and it should be the first priority to have healthy, stable student-athletes."
The parents of Missouri swimmer Sasha Menu Courey, who was diagnosed with borderline personality disorder before she committed suicide in June 2011, are encouraged by the recent attention and new procedures regarding college athletes and mental health.
Since Menu Courey's death, Lynn Courey and Mike Menu have tried to focus their energy on preventing similar tragedies. They started a foundation called SashBear and often speak about mental illness and borderline personality disorder.
"When I look at Sasha, she was afraid, she felt that she wasn't allowed to feel this way, it wasn't OK for her to feel this way, she could not feel this way -- because she was an athlete, with high standards, with a 4.0 [grade-point] average, and it could not happen to her," Courey said.
"We need to talk about mental health. We need to remove the stigma surrounding mental health. Not one day, I don't think about my kid, not one day, I don't do something -- to raise awareness. To hope to make a difference for someone. Because what she went through is unacceptable, and this has to change."
Reporter Tom Farrey contributed to this report. Nicole Noren is a producer for ESPN's Enterprise/Investigative Unit and can be reached at Nicole.K.Noren@espn.com.