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It was January 2015, and Bailey Kowalczyk was racing the mile at the Clemson Orange & Purple Classic when she started to feel out of control. She felt tired, her muscles spasming. In training, she’d been progressing, getting faster. But on race day, the mile felt like a marathon.

In school, Kowalczyk had always been an overachiever and a people pleaser, aiming for top marks to impress her parents, teachers, and peers. She brought that same energy to the track as a middle-distance competitor on a Division I team. She wanted to be the best. So when her Clemson University coaches told her what the path to success looked like, she fell in line. They told her losing weight could turn her into an NCAA Champion.

“The general message was if I lose weight, then I will be more successful. And so that’s kind of the quest that I went on,” she says. It worked, until it didn’t. “It was like the needle had gone too far.”

Kowalczyk didn’t run for two years after that.

Now a professional trail runner for Nike, Kowalczyk says that overcoming disordered eating and all the physical dominos it knocked down along the way has been a long process. Even so, she says, “the mental journey is harder than the physical journey.” For her, and many other athletes in a similar situation, the two are very much intertwined.

Kowalczyk admits she’s always been on the anxious-side, even before college. However, she reports her mental health issues get louder when she’s underfueled. The high-pressure environment of collegiate sports, under the guidance of coaches who were misinformed, was the perfect storm that led Kowalczyk to being diagnosed with the Female Athlete Triad.

RELATED: FASTR Seeks to Close the Research Gap for Female Athletes

Female And Male Athlete Triad

The Female and Male Athlete Triad is characterized by three related conditions: a deficit in energy, menstrual dysfunction in women and reduced testosterone in men, and poor bone health. It is estimated that 60 percent of exercising women experience at least one condition of the Triad. The condition has not been studied as in depth in men, so it is hard to get a grasp on how many men might be affected.

Now researchers want to know more about the connection between mental health and the triad. Is there a relationship between athletes managing the psychological symptoms of depression and anxiety and athletes managing the physical symptoms of the triad?

A study published this month in the Clinical Journal of Sports Medicine argues, yes. The study comes out of a research consortium at Stanford University called FASTR: Female Athlete Science and Translational Research. 

The study surveyed more than 1,000 athletes and was distributed via social media. Most of the respondents (780) were female. In order to understand what kind of correlation mental health might have with the triad, the survey asked questions about the athletes’ training history, history of bone stress injuries, menstrual history (when applicable), eating disorder history, and eating behaviors.

The results revealed a strong correlation between moderate to severe depression and anxiety and the conditions of the triad in female athletes. The correlation may not have been a surprise to the researchers. But documenting it is a significant stepping stone. “Through our medical training, we know about this relationship of anxiety and depression with eating disorders. But we noticed that it hadn’t been studied in the athletic population before,” says Emily Miller Olson, M.D., lead author on the paper.

What might that correlation mean? It could mean a lot of things. It could mean an athlete who is experiencing anxiety about their sport may be restricting their diet to try and look more like peers. Or it could mean that an athlete not consuming enough calories is finding themselves in a depressed state due to their lack of energy. What it really means is that there is a starting point in understanding the relationship.

Researcher and running coach Megan Roche, M.D. and Ph.D. feels driven to learn more about that feedback loop. “That bi-directional arrow is really interesting. We need more and more research to continue to untangle that and to understand what’s the line of causation there.”

Opening The Door for More Studies on Mental Health and Athletes

What the study has confirmed for the research team is that sports clinicians and coaches must include mental health experts on their rosters and in their referrals.

“Being able to fully address disordered eating behavior goes beyond just telling [the athlete] to fuel their body differently or eat more or train less,” says co-author Emily Kraus, M.D. “The clinician needs to pull in other disciplines, including mental health specialists in that conversation.”

The female and male athlete triad is a puzzle that sports clinicians, physical therapists, coaches, dietitians, and psychologists should be working on together. “If they’re being seen for bone stress injuries, if they have been talking to their providers about low energy, et cetera, it may be worth talking to a psychologist or a therapist as they’re working through all of this in order to come back in a healthier state overall,” says Dr. Miller Olson.

For Kowalczyk, she has a team that she can rely on between her coach, a sports psychologist, and a sports dietitian. “I think the big message here is that seeking out some sort of help is really helpful because this process is not simple,” she says.”It’s helpful to have somebody in your corner regardless of what you’re going through, or if you’re prone to mental health issues, somebody that has eyes on the whole situation.”

The researchers have a clear vision of future studies surrounding triad care: like looking at how mental health fluctuates along the triad recovery journey. “The triad comes with a lot of uncertainty in terms of addressing it, diagnosing it, the injuries, and the performance impacts that can come from it,” says Dr. Roche. “I’d be really curious to see how an athlete’s mental health fluctuates in terms of that trajectory.”

A study like that will take more resources and time. “But it will be valuable,” says Dr. Kraus, “because then we can understand how best to treat and intervene and prevent [the female and male athlete triad] earlier.”

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