Transitioning to life as a college athlete, author Kate Fagan writes, is “like walking through an obstacle course wearing a blindfold.” In her 2017 book, What Made Maddy Run, the ESPN reporter draws on her personal experience adjusting to Division I basketball as she spells out the unique challenges that student-athletes face. “No context exists for how hard the workouts will be, how long they will last, what each class will be like, what events are fun, what should be avoided. There is no yin-yang, either; no understanding that one week might feel grueling, unmanageable, but just hang on, because the following week will be light and easy. For someone who struggles with the unknown, freshman year of college can feel like walking a path lined with landmines—heart racing, disaster around every corner.”

What Made Maddy Run, released in August, tells the story of Madison Holleran, a standout high school soccer player and track runner from New Jersey who died by suicide in January 2014 during her second semester at the University of Pennsylvania. It’s an expansion of Fagan’s 2015 feature, which prompted a national dialogue about mental illness and thoughts of suicide among college students. In her chronicle of Holleran’s efforts to seek help for her depression and anxiety while adjusting to the pressure of college life and the expectations of the track team, Fagan notes that many struggling student-athletes don’t have mental health professionals to visit within the confines of their athletic departments. Counselors outside that bubble, both on campus and off, often aren’t familiar with the specific challenges that college athletes face, which can leave them feeling unheard. Fagan reports that a few months before Holleran died, she left her initial appointment with a therapist at Penn’s general counseling center feeling misunderstood.

Fewer than 25 Division I schools had a full-time licensed mental health practicioner on staff in the athletic department as of January 2014, according to ESPN, let alone more resource-strapped Division II and III schools. While that number of professionals has been growing in recent years—per one 2016 survey, mental health clinicians are now in as many as 39 percent of Division I athletic departments—there’s still a critical gap in mental health care for student-athletes who often have access to the support they need physically and academically. That will persist unless this issue remains at the forefront of the college sports conversation.

When players are expected to leave the athletic department’s facilities to seek care, they get the message that they’re outsiders, that what they’re dealing with isn’t a problem common among their peers. They can get the impression that they need to separate who they are as student-athletes from the ways in which their brains work.

“Within the athletic department, a full-time mental health professional that you would point athletes to, that’s something that even top-level FBS schools are just trying to get on—in my opinion—the right side of,” Fagan tells The Ringer.

Having the ability to access mental health support in the same place that they often meet with trainers, watch game tape, and work with academic tutors is key for student-athletes, who face pressure to push down any perceived on- or off-field weaknesses, even when they experience mental illness. College athletes experience anxiety and depression at slightly lower rates than their nonathlete peers, according to an American College Health Association survey based on students’ experiences in 2011, but they’re less likely to seek help for those issues. And while anxiety and depression are two common, relatively low-stigma mental illnesses, they’re far from the only ones student-athletes face: Experts say they also routinely see athletes with eating disorders, personality disorders, and substance-use disorders.

“The stereotype is that student-athletes are tough somehow or more put together than others,” says Brian Hainline, the NCAA’s chief medical officer. “No, people are people.”

Virginia Tech was ahead of the curve in caring for student-athletes’ mental health, hiring Gary Bennett as its in-house clinical and sport psychologist in 2000. Bennett says he now sees about 50 student-athletes each week for individual counseling, and a colleague, who splits his time between the campus’s general counseling center and the athletic department, has a caseload of between eight and 10 athletes. “They don’t have to go anywhere else,” Bennett says. “The campus counseling center is literally 200 yards away on the other side of the parking lot. But it might as well be 200 miles.”

Austin Cannon, a redshirt freshman on the Hokies football team, has been seeing Bennett for his depression for about a year. The left guard arrived at Virginia Tech in January 2016 after spending a semester at a military academy. As he went through his first spring practices, his great grandmother died. A couple of months later, his dog died. Then his dad got diagnosed with kidney cancer. Right before Cannon reported to training camp last fall, his long-term girlfriend broke up with him. During an August scrimmage, he sustained a concussion when a teammate accidentally kicked him in the back of the head as he tried to get off the ground.

All of that stress and sadness, on top of his struggles to make friends and adjust to his college course load, added up. “I couldn’t hold the world over my head anymore,” Cannon says. “It was just crashing down.”

In his dorm room after the scrimmage, Cannon tried to kill himself. Yet he grabbed his phone and saw missed calls from his team’s training staff, who were trying to check in on him post-concussion. He called one of them and asked for help. Head coach Justin Fuente, other football staffers, police officers, and EMTs came to his room. He had never cried in front of a coach before that day. “It’s just a man thing, I guess,” Cannon says. “You have pride. You’re not going to cry. That’s something that you don’t show in front of people.”

Opening up to Fuente and other staff that day saved Cannon’s life. After being discharged from the hospital, he spent a week at a mental health facility, where, to his surprise, he was visited frequently by the team chaplain, Fuente, and other coaches. That season, Cannon started meeting with Bennett for counseling. “It’s a really good thing that Dr. Bennett is here in the facility with us,” Cannon says. “I feel more comfortable going to see him rather than seeing a counselor somewhere else. He’s been talking to athletes. That’s what he does for a living. I think it’d be easier to talk to [someone like that] and he’s more understanding than a regular counselor.”

Fuente regularly asks Cannon how he’s doing mentally and emotionally. And in rallying around Cannon, Virginia Tech’s football team sent the message that it’s OK for athletes to express vulnerability and ask for help. Cannon says his health has turned around in the past year. “I do have my moments where I get down,” Cannon says. “But I don’t think about taking my life again.”

In recent years more athletic departments have created positions similar to Bennett’s as a result of a few factors: the NCAA’s influence, student-athletes’ vocalness about their needs, and national news stories like Fagan’s. When Hainline, a neurologist, joined the NCAA in January 2013, he was focused primarily on concussions, but student-athlete advisory groups quickly asked him to also prioritize mental health. The issue was already on the NCAA’s radar before Hainline came along; he just devoted additional resources to it, putting together a task force in his first year on the job. That led to the association’s 2014 publication of Mind, Body and Sport, a comprehensive guide to mental health challenges student-athletes face and what resources are available, and a 2016 best practices guide for the athletic departments working to support them.

“Through the effort of Dr. Hainline it has become a priority of the NCAA and there is no doubt that this is a giant step in the right direction,” Alabama football head coach Nick Saban, who consistently advocates for mental health awareness, says via email.

One challenge that the NCAA faces with this initiative is coming up with recommendations and policies that apply to its more than 1,100 member schools, which span from small D-III schools to sports powerhouses like Alabama, whose athletic department has a director of behavioral medicine on staff and outsources to professionals including psychologists, psychiatrists, and addiction specialists. And while Hainline doesn’t think it’s necessary for every athletic department to have a dedicated mental health care provider on staff—as is, not every member school even has team physicians on site, preferring to contract out—he could foresee the NCAA implementing a policy requiring D-I, D-II, and D-III schools to have an interdisciplinary health care team that includes a licensed mental health professional.

Student-athletes are also a driving force in the push for better mental health care. As mental illness—particularly common diagnoses like anxiety and depression—becomes less stigmatized, players feel more comfortable speaking out. In addition to its association-wide initiatives, the NCAA in 2014 funded Athletes Connected, a University of Michigan campaign to destigmatize mental illness among college athletes and encourage them to seek help.

Kally Fayhee, a swimmer who graduated from Michigan in 2013, embraced being part of Athletes Connected after contemplating backing out about five or six times. At that point, she says, only a handful of people knew about her bulimia. She’d been swimming competitively since she was 10, but her experience in college felt different. “When I got to Michigan, it was a whole other level of competitiveness, of trying to live up to the expectation, the swimmer that your scholarship means that you are,” she says.

During her freshman year, Fayhee started feeling what she calls “race anxiety,” which hampered her performance. “The harder I tried to control it and white-knuckle it, the worse it got, and the worse the anxiousness got,” she says. Needing to feel some element of control over her races, she started restricting her diet as a sophomore, thinking that if she were lighter, she could go faster. By junior year she was purging. With the help of a close friend and teammate, she began weekly visits to Barb Hansen, a clinical social worker and athletics counselor at Michigan.

Joining Athletes Connected in 2014 meant that, for the first time, the former team cocaptain would speak publicly about her bulimia and how everything in her life wasn’t as perfect as it may have seemed. “You know what, the only way that we’re going to break down the stigma around mental health is if we have a conversation about it,” she remembers telling the first crowd of Michigan student-athletes she spoke to alongside Will Heininger, a former Wolverines defensive lineman who has experienced depression. After one of the sessions, a current student-athlete approached Fayhee to say that she needed help. It made Fayhee’s late nights and early morning commutes between Chicago, where she worked, and Ann Arbor worth it. “Honestly, at that point I would’ve woken up at 3 in the morning and done that until the end of time if we could help kids where I was,” Fayhee says.

As Cannon recovered, he also wanted to help his peers, so he started a SpeakUp campaign to remind his classmates, especially fellow athletes, that they’re not alone in experiencing mental illness. “Football’s not going to last forever, and doing this is so much bigger than strapping up on Saturdays,” he says. He recalls speaking to a service fraternity about depression, nervous to be addressing a large group for the first time, and seeing that his teammates were there to support him. Open discussion of mental illness from student-athletes like Cannon has the potential to be particularly impactful because male football players are at the highest risk of suicide of all student-athletes.

“If there aren’t student-athletes saying they need help, then why would athletic departments—unless they’re proactive in a way that’s out of this world—[take steps to get them help]?” Fagan says. “You’ve seen now more student-athletes talk about this issue, and you’re seeing athletic departments wrap their heads around this issue.”

Ian Connole, the director of sport psychology at Kansas State, thinks student-athletes feel more comfortable speaking about their mental health needs than they have been in the past because they see their professional-athlete idols doing the same. “We see LeBron James meditating on the bench. You see him close his eyes,” Connole says. “He centers himself in the NBA Finals. He clears his mind to prepare for that next trip down the court. [Student-athletes] see what they’re doing, and they want that.”

Those positive examples don’t stop at simple mindfulness exercises. Giants wide receiver Brandon Marshall has spoken out about his borderline personality disorder. Blue Jays closer Roberto Osuna said he missed a game this season due to his anxiety. Every voice makes a difference, and there’s still much progress to be made.

While student-athletes can be motivated to speak out and seek help by both hearing from their peers and watching professionals, school administrators may be most driven to enact change by tragedy. Holleran and five other Penn students took their lives during a 13-month span, and in February 2014 the university put together a task force that recommended sweeping changes, including an expansion of counseling-center hours. “Unfortunately, I think [schools] don’t recognize the importance of it until something really bad has happened,” Virginia Tech’s Bennett says. “And [by then] it’s too late.”

Laura Sudano, the director of behavioral science at Wake Forest Baptist Medical Center, says that the national research she and her colleague Christopher Miles did on the subject suggests that the key to better addressing mental illness in student-athletes is more closely integrating that care with their routine physical treatment in the training room. In practice, this approach could mean that teams would include a mental health portion in their standard preparticipation exam for student-athletes, which covers physical basics like injury history. It could also mean that, when a team’s trainer is following up with a student after surgery, that person can introduce the player to someone like Sudano, facilitating a seamless transition that makes mental health care part of the typical rehabilitation process.

“When you’re in the athletic training room, which is oftentimes a place for camaraderie as people are coming in for treatment, it sort of normalizes that experience,” says Sudano, a licensed marriage and family therapist who routinely treats Wake Forest athletes. “Hopefully it reduces that barrier or stigma that so many athletes feel about addressing those mental health issues.”

For schools looking to support student-athletes’ mental health, professional therapists licensed to provide counseling are an obvious option, but not the only one. According to Connole, Kansas State is one of seven schools that has a full-time sport psychologist on staff who works with students to strengthen their proactive mental habits, such as communicating, rebounding from mistakes, and supporting teammates. Connole can’t counsel athletes experiencing mental illness, but he regularly meets with teams and individual players to work on those proactive skills. When students come in presenting signs of mental illness, he refers them to trained clinicians, on campus and off.

“Whether you’re at your absolute best and your confidence is where you’d love it to be, and you have no stress, or whether you’re going through the hardest time in your life, across the board we’re still working to be a family that supports each other to be better every single day,” Connole says. He attends practices and travels with the teams, which means that players and coaches always know where to find him. More importantly, they know that mental health is a top priority for Kansas State. It’s in the university’s strategic plan, Connole says, to hire a licensed mental health provider to work in tandem with him on the sport psychology program.

Connole, Bennett, and Sudano all played college sports: basketball, baseball, and volleyball, respectively. They might not have been on the elite stage that their Division I athletes are, but they’re all acutely aware of what makes student-athletes tick. All three also have a vested interest first and foremost in students’ mental health, not their statistics and accolades. It’s that culture of familiarity with mental health resources and professionals that other schools should be striving to replicate.

More research is needed, Sudano says, to shed light on how best to help student-athletes. “You just want people to be whole,” Sudano says. “They are going to experience adversity, but how can we give them the skills and tools to be successful not just during their time in participation, but beyond?” There’s a ways to go until the culture of speaking up and asking for help feels commonplace across college sports. Still, there’s reason to be optimistic that several NCAA institutions are on the right track.

Prominent stories like What Made Maddy Run, student-athletes’ advocacy efforts, and NCAA initiatives are pushing many schools in the right direction. “For athletic departments that may not have a student-athlete, thankfully, who has taken their own life, Madison’s story can be like, ‘Let’s be one of those proactive athletic departments,’” Fagan says. “‘We might not have a student-athlete raising their hand, but there might be someone struggling silently.’”

Julie Kliegman