Response to the Letter to the Editor We would like to thank Dr. Felipe Barreto Schuch for his response to our article entitled Depression in Athletes: Prevalence and Risk Factors (7). We appreciate his thoughtful comments, and we gave them careful consideration in constructing this brief response. We do agree that a more appropriate title for our article would be ‘‘Depressive Symptoms in Athletes: Prevalence and Risk Factors.’’ This title is more consistent with the intended purpose of the outcome measures (BDI-II and CES-D) that were used in the reviewed studies. Both the BDI-II and CES-D are used to assess the presence and severity of symptoms that comprise the categorical diagnosis of major depressive disorder (MDD) as described in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (1). Given that both measures assess the symptoms upon which a diagnosis of MDD is made, research has explored their correlation with ‘‘gold standard,’’ diagnostic instruments used to diagnose this disorder. For example, Sprinkle et al. (6) found that among a sample of 137 students receiving treatment at a university counseling center, BDI-II scores correlated strongly (r = 0.83) with their number of SCID-I depressed mood symptoms and the BDI-II cutoff score of 16 produced a sensitivity rate of 84% in identifying depressed mood. In another study, the BDI-II, CES-D, MINI, and SCID-I were administered to a sample of patients with epilepsy to examine whether the BDI-II and CES-D could identify major depression among this population. The findings of this study revealed that the BDI-II and CES-D ‘‘exhibited significant ability to identify major depression’’ among this sample (3). Additionally, the CESD continues to be used as a well-validated tool to assess depressive symptoms in a college student population (2). However, caution should be noted when this measure is used to correctly identify the diagnostic presence of major depression among a sample of student-athletes, and selfreport measures of psychological symptoms should not be used in isolation for diagnostic purposes. Lastly, we agree that overtraining syndrome (OTS) may lead to some confusion in making an MDD diagnosis with this population; however, there does not appear to be sufficient evidence to suggest that OTS may account for a consistent and significant explanation of psychological symptoms. Wyatt et al. (8) completed a meta-analysis of OTS and found that ‘‘psychological disturbances were not consistently established across the studies.’’ This is consistent with the joint position statement of the European College of Sport Science and the American College of Sport Medicine’s


2013 Position Statement on OTS (5), which states that the symptoms are varied and that there is no standardized diagnostic tool necessary to research mechanisms and prevalence rates of OTS. In addition, Kreher and Schwartz (4) provided a review of OTS, indicating that OTS appears to be rare but exact prevalence rates are unknown. We agree that OTS should be considered when identifying the cause of depressive symptoms in athletes, but we caution that there does not appear to be research evidence to suggest that significant proportions of depressive symptoms reported by athletes are clearly and directly related to OTS. Eugene Hong, MD Drexel Family Medicine Drexel University Philadelphia, PA [email protected] Andrew Wolanin, PsyD Combined School and Clinical Psychology Kean University Union, NJ Michael Gross, MA Kean University Union, NJ

References 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington (TX): American Psychiatric Association. 2013. 2. Herman S, Archambeau OG, Deliramich AN, et al. Depressive symptoms and mental health treatment in an ethnoracially diverse college student sample. J. Am. Coll. Health. 2011; 59:715Y20. 3. Jones JE, Hermann BP, Woodard JL, et al. Screening for major depression in epilepsy with common self-report depression inventories. Epilepsia. 2005; 46:731Y5. 4. Kreher JB, Schwartz JB. Overtraining syndrome: a practical guide. Sports Health. 2012; 4:128Y38. 5. Meeusen R, Duclos M, Foster C, et al. Prevention, diagnosis and treatment of the overtraining syndrome: joint consensus statement of the European College of Sport Science and the American College of Sports Medicine. Eur. J. Sport Sci. 2013; 13:186Y205. 6. Sprinkle SD, Lurie D, Insko SL, et al. Criterion validity, severity cut scores, and test-retest reliability of the Beck Depression Inventory-II in a university counseling center sample. J. Couns. Psychol. 2002; 49:381Y5. 7. Wolanin A, Gross M, Hong E. Depression in athletes: prevalence and risk factors. Curr. Sports Med. Rep. 2015; 14:56Y60. 8. Wyatt FB, Donaldson A, Brown E. The overtraining syndrome: a metaanalytic review. J. Exerc. Physiol. 2013; 16:12Y23.

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