To medicate or not? The thorny mental health issue in the NBA

Joey Guidone

SHANE LARKIN OPENS his eyes, sits up and embarks on his own tortured version of "Groundhog Day." He grabs the remote, clicks on SportsCenter and hops out of bed to wait for his "number.'' He is 8 years old, and every morning presents a new set of unpredictable parameters that are purely arbitrary. As he starts to get dressed for school -- a ritual that can last a few minutes or sometimes hours, depending on the number for the day -- he notices an image of Ray Allen flickering on his television screen. Allen, it seems, hit eight 3-pointers in a game the night before. Suddenly, a sensory message makes a beeline for Shane's brain and informs him of the number for the day: eight.

"And then I know,'' Larkin tells ESPN, "that I have to wash my hands eight times.''

After scrubbing fastidiously, Larkin carefully picks out his clothes. But if his shorts touch the carpet by mistake, he not only has to toss them in the hamper and replace them with new ones, he must retreat to the bathroom again to wash his hands.

Eight times.

From there, Larkin attempts to navigate breakfast in a kitchen that is a cauldron of potential germs. He engages in a deft obstacle course as he sidesteps errant spills, a soggy sponge, a dirty dish. As he approaches the front door, with seconds to spare before he misses the bus (again), the family dog patters up to him, tail wagging, and licks his hand. Larkin has no choice: He heads back to the bathroom for eight more cleansings. By the end of the day, his hands are so raw from the obsessive washing, he falls into bed with bloody open sores.

Larkin's condition, later diagnosed as obsessive-compulsive disorder, or OCD, afflicts just 2.3 percent of the population and just 1 out of 100 children. For a little boy who didn't understand why he was held captive by his own random regimen, it was exhausting, frustrating -- and incredibly frightening.

"You don't know what's going on," Larkin says. "You see your friends wash their hands once, or not wash them at all, and you say, 'What's wrong with me?'''

Ironically, the man who once determined Larkin's "number" so many years ago -- Ray Allen -- diagnosed himself as "borderline OCD" because of his need to have complete order and structure in his day, including a specific repetitive pregame ritual that embarked him on a Hall of Fame career.

On the occasions when Allen's treys were not dictating Larkin's day, it would be something as innocuous as a trio of bluebirds perched on a branch outside Larkin's window. Larkin would breathe a sigh of relief because his obsessive behavior would be more manageable for the next 24 hours with the number at only three.

Inexplicably, his OCD vanished once he sprinted onto the basketball court. There he was free, unencumbered by any concerns about germs or bacteria.

"That was the craziest part,'' Larkin says. "I couldn't touch the elevator button or the faucet to turn on the water because, 'Oh, that's so dirty,' but I could walk on a basketball court where guys were grabbing their armpits, digging in their nose, then touching the ball, and I'd be fine.

"I'd play for hours with that ball, then walk off the court and eat a hamburger without even washing my hands. It made no sense at all.''

Larkin shielded his condition from friends and teammates. Only his family was fully tuned in to his agonizing attempts to get through the day. "I didn't want people to think I was some kind of weirdo,'' Larkin says.

His symptoms persisted as he grew older. If the dog had an accident on the carpet, Larkin would be trapped in his room, unable to bring himself to walk down the hallway. The path to the tub often required a parade of towels to avoid dirt and mold. His mother, Lisa Larkin, washed as many as 20 bath sheets a day. Lisa understood her son's plight; she, too, struggled with mental health issues. Yet Shane's father, retired Baseball Hall of Fame shortstop Barry Larkin, was flummoxed by his son's behavior and implemented the "tough love" approach.

"I didn't want people to think I was some kind of weirdo." Former Celtics guard Shane Larkin

"My dad would test me,'' Larkin explains. "He'd go to the bathroom and purposely not wash his hands, then touch my arm. He'd say to me, 'You're good. You can do this.' That was his solution. It was so difficult -- and it caused problems between us."

Barry Larkin admits when he first encountered his son's symptoms, he thought Shane's obsessive washing was "more a convenience thing, an excuse."

"I challenged him to get through it," Barry says. "In the past, whenever I challenged him, he would accept that challenge and meet it."

But this was different. Something had to change. By middle school, Larkin's symptoms were worsening, so his mother found him a mental health professional, who recommended an antidepressant medication to help him cope. That, too, was confusing. "I'm not depressed,'' Larkin said to his mother. "Am I?"

He tried the pills. They helped alleviate some of his OCD symptoms, but he says they also robbed him of his drive and his energy, qualities that separated him as a budding basketball star. "The medication flat-lined me,'' Larkin says. "It made me way too relaxed -- too chill. I felt like I needed to be on edge to be the competitor I wanted to be. When I was on the medication, it was like, 'Eh.' I told my mom, 'There's no way I can continue with this.'''

To medicate, or not to medicate? It is a decision that permeates NBA locker rooms every day, as professional athletes silently struggle to deal with their mental health issues. The stigma of mental health is one thing; that stigma increases tenfold when their peers discover they're on "meds.'' It's a gamble that some players don't believe is worth taking, because it could affect their ability to be employed by a skeptical coach or general manager.

"I've been on and off medication my whole life,'' explains one NBA star, who debated identifying himself for this story but ultimately chose to remain anonymous. "I'd like to think it doesn't matter, but I'm not sure that's true when free agency comes around. I'm choosing to keep my life private because I don't need the s--- on social media. It's hard enough already.''

MORE: Part 4 -- Behind the anxiety and anger of an NBA ref

DR. WILLIAM PARHAM, the Los Angeles-based psychologist who was hired by the players' union to oversee the growing mental health crisis in the NBA, acknowledges some mental health issues may require medication. "But too often, medication is treating the symptoms, not the real issues,'' Parham says. While the population of NBA players with OCD is minuscule, the debate over medication also pertains to anxiety, depression and attention deficit hyperactivity disorder, or ADHD, which, according to John Lucas, the Houston Rockets assistant coach who runs a wellness and aftercare substance-abuse recovery program for athletes, is rampant in the NBA.

"I have so many guys from the NBA who were put on ADHD medication, and they didn't want to be on it,'' Lucas says. "They needed it, but they didn't want to be that calm on the court. We need them to be at this frantic pace. So when he's on the medication, the coaches are saying, 'Why can't we get more out of him?' But when he doesn't take the medicine, we say, 'He's the player I want.' The problem is that player doesn't know how to turn off that rage, that intensity, once the games are over.''

Clippers coach Doc Rivers says he underwent a personality test when he was coaching the Celtics that concluded both he and Celtics head of basketball operations Danny Ainge had ADHD, a result that was not surprising to the former NBA point guard. "I think most elite players have something," Rivers says. "I don't know for sure. They're so hyper, so overly competitive, but that's also what gives them energy and makes them go. I actually don't mind taking on ADHD guys.''

A rival Western Conference GM disagrees. He admits if two players are equal in ability and one has ADHD, he's taking the other one because, he reasons, "it lessens the likelihood of off-the-court issues as well as disruptions in practice.

"These guys you read about who tear up their hotel rooms?'' the GM says. "That's often guys who are off their meds. So now, in addition to everything else we've got to worry about, we have to make sure our power forward is filling his prescription every week.''

Lakers owner Jeanie Buss has extensive experience contending with mental health, dating back to the former Ron Artest (now Metta World Peace), whose infamous meltdown while playing for the Indiana Pacers led to one of the NBA's darkest chapters -- a 2004 brawl involving fans dubbed Malice at the Palace. In subsequent years, Artest was prescribed antidepressant medication (he flushed it down the toilet), appeared on "Jimmy Kimmel Live" wearing just his boxer shorts, then discovered a psychologist named Dr. Santhi Periasamy, who helped him turn his life around. When the Lakers won the 2010 championship behind Artest's stellar play, he publicly thanked "Dr. Santhi" for saving his career.

"We [the Lakers] don't shy away from players with mental health issues because our team has already drafted players with those issues, and they have been very successful for us,'' Buss says. "What you have to look at is, are they coping with it? How are they coping with it? Does it lead them to make impulsive decisions that are detrimental to their health and well-being? Sometimes medication is the answer, sometimes it isn't.''

"My personal stance was to smoke marijuana. I had no interest in their drugs." Former NBA player Larry Sanders

Players who are battling bipolar disorder, a serious condition that causes extreme mood swings, are often prescribed medication that is critical to their well-being. The suicide rate among bipolar patients is higher than that of the general population, and a greater percentage of people who have been diagnosed with bipolar disorder will attempt suicide at least once in their lifetime. Lucas believes nearly 10 percent of NBA players are bipolar. "And some of them can't make it without medication,'' Lucas says. "They are a danger to themselves when they are off it.''

Rivers says it's easy to tell which players are dealing with mental health issues even if they don't reveal it to the coaching staff, leaving him to walk that fine line between respecting their confidentiality and wanting to reach out and help.

"You notice it as a coach,'' Rivers says. "I had one guy, when he walked in, you could tell, 'OK, he didn't take his medication today.'''

Jalen Rose was ecstatic when he was traded to the Pacers in 1996. He immediately bonded with president Donnie Walsh but clashed with coach Larry Brown, who, he says, put the wheels in motion for Rose to get diagnosed with ADHD.

"Larry was not fond of me as a person or a player,'' Rose says. "I think he decided, 'There must be more to this.' He was the lead domino in a series of events that led to my so-called diagnosis.''

Rose says he was summoned to the training room, where a team doctor asked him a series of questions. He was told he had ADHD and needed medication.

"Now, I probably had [ADHD] then, and I probably have it now,'' says Rose, "but in my mind, it was [Brown's] professional way to justify not playing me.''

Rose doesn't recall what the Pacers prescribed him, but he says he never took any of the pills. As soon as they dispensed the pills to him, he threw them in the trash. Weeks later, Rose recalls Brown coming up and congratulating him for his improved play. "It was a feather in my cap personally when they told me I had 'changed' and the medicine was making me better,'' Rose says.

When Brown left the team in 1997 and was replaced by Larry Bird as coach, Rose revealed to the team he had been medication-free all season. He played another 4 1/2 seasons in Indiana without incident and, he says, "buried the hatchet" with Brown years later.

"I'm sure some guys have ADHD in the league right now who are on medication and don't want to be,'' says Rose. "All I'm saying is, that's not the answer for everyone.''

Celtics coach Brad Stevens' interest in mental health was sparked by his brief employment at the pharmaceutical company Eli Lilly, the first company to patent Prozac, which is used to treat numerous forms of mental illness.

"It was required by everyone who worked at Eli Lilly to understand how Prozac worked,'' Stevens explains. "I learned how effective certain drugs could be, and how many people dealing with issues could be treated -- but, oftentimes, didn't want to be treated. And I also learned there were some side effects to those drugs that presented real problems.''

Stevens has made mental health a priority in his locker room, implementing wellness programs and inviting Dr. Stephanie Pinder-Amaker, the founding director of McLean Hospital's College Mental Health Program, to speak to his players. Both Larkin and Celtics forward Marcus Morris say they have benefited from private sessions with Pinder-Amaker that remained confidential from the team. Morris says before he met Pinder-Amaker, he tried marijuana as a salve for his depression.

"I know guys who drink every day to calm themselves,'' Morris says. "That's how they deal. That's how they cope. And you know that's not going to work long term.''

Union president Michele Roberts recognizes players have turned to marijuana and alcohol for relief, particularly if their prescribed medications leave them feeling "flat-lined.''

"We don't deny that for one second,'' Roberts told ESPN in March.

The decision to self-medicate, says former Milwaukee Bucks forward Larry Sanders, cost him his career. He was once a rising young star, but crippling anxiety and depression led him to seek relief by smoking marijuana. He was cited for four violations of the NBA's substance abuse program, was suspended twice and then made the stunning decision to walk away from basketball in 2015.

"There's still a lot of chastising by the NBA for the byproduct [marijuana] instead of digging in and looking for a cause,'' Sanders says. "Everyone says the game is 90 percent mental, but we're not catering to in that sense.

"What the NBA is afraid of is a player saying, 'Oh, I'm depressed,' and they just want to smoke weed. That's the league's biggest nightmare. There were a lot of medications they wanted me to take that I refused to be on. My personal stance was to smoke marijuana. I had no interest in their drugs.''

Since Sanders' suspension, the NBA has shored up its mental health policy and sent an internal memo to all of its teams on May 31 with suggested guidelines that include: securing the player's privacy regarding his mental health; retaining a professional with experience in clinical mental health issues; identifying a psychiatrist who will be readily available to players; and providing mental health awareness materials to the team.

Lucas, whose program stresses to athletes that "basketball is what you do, not who you are,'' says all the trappings are there for the pros -- too much free time, too much money, too many bad influences -- that if they have no life outside the game, eventually they will succumb to temptations.

"How much does addiction go hand in hand with mental health? It's all one and the same,'' Lucas insists. "Mental health is a spiritual condition. That's what people miss. It's an addiction. An addiction is something where I can't change my behavior to meet my goals, but I change my goals to meet my behavior. And then I have a serious problem.

"So what guys are doing now is not taking their medicine and smoking marijuana instead. THC [tetrahydrocannabinol] is the derivative in marijuana that calms you. When the NBA first put its drug policy together, you couldn't suspend players for it. THC helps epileptics and people in pain.

"The problem with it is it doesn't kill you. But it does kill your spirit, your ability to achieve. It takes away your drive.''

THC is one of 113 chemical compounds in the marijuana leaf that has proved to be the most potently psychoactive. The unnamed NBA star says he, too, tried marijuana to "take the edge" off his depression. "And it worked,'' he says. "But only for a while.''

"What's heartbreaking to me,'' says Pinder-Amaker, "is depression is one of the most treatable diseases we see. It doesn't always have to be medication. There are lots of cognitive behavioral interventions, evidence-based strategies, so many skills people can learn to change their thinking.''

For example, Pinder-Amaker says, if someone has what she deems automatic negative thoughts -- "I'm never going to make that shot, I'll never be a leader of this team, I know they're going to release me" -- she will convince the athlete to jot those thoughts down and identify why he or she feels that way.

"The anxiety, the apprehension, the fear, are triggered by those thoughts,'' Pinder-Amaker explains. "When they write down these thoughts, we learn so much from that.

"These thoughts are not limited to basketball. They're more pervasive than that. So we try to increase awareness, get to the source, then help them restructure what's believable. So if they say, 'It's a fluke I got drafted,' we go back and ask them, 'Is it really? You worked hard. You excelled in college.' How true is that negative thought?

"But the only way it's successful is if the person owns and buys into the positive restructuring of the thoughts.''

"How much does addiction go hand in hand with mental health? It's all one and the same." Rockets assistant coach John Lucas II

DeMar DeRozan, whose public declaration that he suffers from depression has brought the topic into the spotlight, says that while marijuana use garners the headlines, he believes many of his peers are self-medicating with alcohol, too. DeRozan says he's never had a drink, a byproduct of hard lessons learned in childhood. "I watched people suppress their pain with alcohol, which turned them into completely different people -- aggressive, emotional, self-destructive,'' DeRozan says. "I chose not to take that route, but certainly some players have.

"[My depression] forced me to a place where I was confined, quiet, isolated. And over time, that wasn't really healthy either. Those feelings build up.''

Detroit Pistons coach Dwane Casey confirms alcohol abuse is alive and well in the NBA. "Too many guys are turning to that,'' Casey says. "And there's no doubt part of it comes back to the stigma attached to being on medication. I hear players say, 'Oh, I might lose my edge or my toughness,' when, in fact, that's often far from the truth.''

Many of the players interviewed for this mental health series said the NBA should require each team to provide a comprehensive mental health plan, with confidentiality as a requirement. At present, each franchise can offer as many -- or as few -- services as it desires. Team officials speak of the difficulty of getting all their personnel on the same page. If a player is struggling, the sports psychologist may think he needs to back off from training, or see a mental health counselor, while the strength and conditioning coach might feel the player is being "soft" and needs to work harder.

"Mixed messages aren't going to help our players,'' Buss says. "We need to create a nonjudgmental space where there is no place for the opinion that your way of thinking is better than everyone else's. If a player is self-medicating [with alcohol or drugs] because that's what makes them feel better, or at least that's what they think, we have to find a way to provide them alternatives that are collaborative and confidential.''

Lucas says it's imperative for NBA personnel to do a better job of identifying players with mental health issues sooner and to be more proactive in convincing them to seek counseling.

"The guy who's on a road trip and isolates himself is the one suffering from depression,'' Lucas says. "He's easy to identify. He's always alone, always in his room, has a miserable time, never goes anywhere.

"The guy who has ADHD is the one who can't sit still. He's on the bus, he's off the bus. The guy with OCD obsesses over a scrap of paper on the ground. I always tell the coaches, 'If these players were your kids, if they had your last name, you'd be treating this differently. You'd care a hell of a lot more than you do right now.'''

BY THE TIME Shane Larkin reached high school, Lisa Larkin was so worried about her son, it was affecting her health. Shane's obsessiveness was exhausting -- and expensive. If someone sneezed near his phone, he felt compelled to wash it, which caused it to short-circuit. Same with his laptop.

In spite of his OCD symptoms, Larkin continued to excel on the court. He signed with DePaul. By then, his sister had moved out of the house, and his father was traveling and working for ESPN. That left Lisa alone to fret over her son moving halfway across the country.

"With all the change happening in my mom's life, and all the change happening in my life, she got so worried,'' Larkin says. "She'd call me all the time. She was stressing me out. When you stress out, that's when the OCD really kicks in. I was at DePaul taking five showers in a row, and it wasn't helping me feel better."

Lisa started having panic attacks, which sent Shane spiraling into his own cycle of worry. "I was so freaked out about her, my OCD went haywire,'' Larkin says. "It was the worst it had ever been.''

It was summer, and classes at DePaul hadn't even started yet, but Larkin hopped on a plane home to Orlando to regroup. His father, a man of his word, was horrified that his son was reneging on his scholarship commitment. "Barry was telling me, 'You have to support me as a husband,''' Lisa says. "But then I had Shane saying, 'I've got to get out of here.' It was not a good time for any of us.''

Barry Larkin says he hated to watch his son struggle, but, he notes, he didn't fully understand the magnitude of his son's affliction until Lisa told him, "This is real. We need to go to therapy to deal with this."

Shane petitioned for a medical waiver from the NCAA so he could transfer without having to sit out a year. He chose Miami, a school closer to home, to help him manage his anxiety. Larkin found a new therapist, who introduced him to meditation and relaxation techniques. They talked about his childhood, his upbringing, his obsession with basketball.

"The funniest part was when I realized my dad has [OCD],'' Larkin says. "When he walks into the house and sees a piece of paper out of place, or a pin on the floor, he has to fix it or his night is ruined. But he says, 'I don't have it. I'm just a neat person.'"

When Larkin attended the NBA combine prior to the 2013 draft, he was bombarded with questions: How can you function in a locker room environment with these issues? Are you on medication? Are you cured? "I didn't blame them for asking,'' he says.

He played his rookie season for the Mavericks, then a year each for the Knicks and Nets, and last season with the Celtics. He recently signed a one-year deal to play in Turkey for Anadolu Efes.

He still turns on the faucet with his elbow, still needs his hands to stay clean, but his days of obsessively washing are behind him. A year ago, Larkin learned of a family friend who had a 10-year-old daughter with OCD symptoms that were so acute, she couldn't leave the house.

"It hit me hard when I heard that,'' Larkin says. "I know exactly what she's going through.'' Larkin reached out and has been trying to help her find her way. "The worst part was when she told me, 'I'm afraid I'll never have any friends because I'm so different.'''

Larkin says managing his OCD became possible with support from both his mother and his father, who, once he came to understand Shane's situation more clearly, was a source of strength and resolve. Having a family that is part of the solution instead of part of the problem, says Pinder-Amaker, is a huge advantage for the patient.

Shane has managed to thrive without medication, while his mother has chosen to rely on medication to assist her with her mental health issues. For both, the journey to mental wellness is ongoing, and Shane's decision to publicly come forward has given him a sense of freedom.

"When you talk about it,'' Larkin says, "you don't feel quite so alone.''

Part 4: Behind the anxiety and anger of an NBA ref

Part 5: The future of mental health in the NBA