CHARLOTTE, N.C. -- In early August, Steve Smith revealed he had had bouts of depression while an active player with the Carolina Panthers and Baltimore Ravens. He talked about feeling "trapped, inferior and alone."
Carolina's all-time leading receiver spoke out after the suicides of Anthony Bourdain and Kate Spade. Smith also referred to Brian Dawkins' battle with depression and thoughts of suicide the Pro Bowl safety discussed in late July as he was about to be inducted into the Pro Football Hall of Fame.
The prevalence of depression, anxiety and other mental illnesses in people in all walks of life -- including the NFL -- led the Panthers to hire therapist Tish Guerin. She is one of the first -- and currently believed to be the only -- active in-house psychological clinicians in the league.
While most teams have a licensed mental health practitioner available for players and staff members on a contract basis, Guerin, 35, has an office at Bank of America Stadium. She is readily available to any player or staff member seeking help.
Being onsite also helps her observe any potential changes in the mood or behavior of a player that could be an early warning sign. It's a step, Carolina coach Ron Rivera said, toward stressing that the mental and emotional welfare of an athlete is just as important as the physical welfare.
Safety Eric Reid is among several Carolina players who said the hire is long overdue.
"It's something that hasn't been taken seriously long enough," Reid said. "We're dealing with professionals ... we bang a lot. We have to lower our guard and know saying something's wrong isn't a bad thing. You might not have to say it [to] somebody on the team, but you need to talk to somebody...
"It's the right thing to do, to [hire] somebody with the education and background to know what to do when somebody is going through something."
Dr. Allen Sills, the NFL's chief medical officer, applauds the Panthers "for being forward-thinking in this area." He said the NFL and NFLPA are working jointly on a proposal for clubs that would make behavioral and mental health issues a priority.
"One of the things you face in mental and behavioral health that you don't face in other medicines is the concept of stigma," Sills said. "We would like to see mental and behavioral health just as normalized so everyone recognizes the important of these issues to your overall well-being.
"Having someone that is visible and the main fabric of the organization, it really sends a message from the organization about how much they value these issues and this care."
Nyaka NiiLampti, the director of wellness for the NFLPA, reminded that NFL teams aren't much different from the general population in which 20 to 25 percent deal with some sort of mental health issue. She said Carolina's hiring of Guerin is a "game-changer."
Guerin, whose official title is director of player wellness, hopes the Panthers start a trend.
"In terms of thinking about mental wellness and making sure our warriors we see on Sunday are talking to someone, have access to be able to get things off their chest and relieve that stress in a positive way and not a negative way, that's imperative," she said.
"This is something I would hope to see for all teams."
Why has it taken so long?
Steve Beuerlein was the quarterback of the Panthers in 1999 when Rae Carruth became the first NFL player charged with and ultimately convicted of conspiracy to commit murder. Beuerlein was reminded with the recent release of Carruth from prison of how much having a mental health doctor in-house could have helped back then.
"Obviously it's a very unique profession to be a professional athlete," Beuerlein said. "To be that young and have those kind of pressures and resources and everything else, it's very unique.
"Definitely, we all would have benefited from having someone like that with every organization I was a part of. You might think you're invincible and you don't need it. But now that you're older you see there is some value to it."
That it has taken this long speaks to the stigma associated with mental health issues.
"My goal in coming here was to drop that stigma that if you talk to somebody that is a clinician or psycho-therapist or psychologist or psychiatrist that means you're 'crazy,'" Guerin said. "Sometimes you just need to speak to someone.
"It doesn't mean something is deeply wrong with you. It doesn't mean you're crazy. It just [can be], 'I have an issue. Hey, what do you think?'"
Rivera compared the NFL's hesitancy to become fully involved in mental health issues to the lack of understanding people had about soldiers returning from World War I and II with post-traumatic stress disorder.
"Now what's happening is people are starting to understand more and more about mental health," Rivera said. "People like [Smith] speaking out and creating an awareness has been very important for the professional athlete."
New Panthers owner David Tepper played a significant role in the hiring of Guerin. He offered no resistance when Rivera, general manager Marty Hurney and Mark Carrier, who was working in player development, approached him about hiring an in-house clinician.
"It's going to bring awareness, not just to football but to all other sports," said Rivera, who was part of the interview process. "There are a lot of people out there and a lot of us need help."
Dr. Chris Carr, a performance psychologist contracted by the Green Bay Packers and Indiana Pacers, said he was one of five full-time members of a Division I college athletics department in his role when he finished his Ph.D. at Washington State University in the early 1990s.
"Now over 50 to 60 schools have sports psychology and mental health provided in-house for athletes, but it's really been the last five years where the NCAA has made it a priority," he said. "In some ways this is a transitional shift in the culture of sports where we realize these are real issues and you need to have really good, competent providers to take care of those athletes."
Confidentiality
The first thing Rivera did when introducing Guerin was reassure his team. He made it clear Guerin wouldn't come to him whenever she suspected a problem.
"She's a professional and I know she'll handle it the right way," Rivera said.
Although Guerin is an employee of the team, her job falls under the Health Insurance Portability and Accountability Act (HIPAA), which protects the privacy of individual health information.
So unless Guerin sees something that would make her believe the player is threatening bodily harm, everything she is told remains confidential.
"There's a firewall, if you will," Guerin said. "So if a player comes to me and tells me something that is going on in their home or if they're having depression or anxiety or any other clinical diagnosis ... I wouldn't go tell that to a coach."
For the player, that is key.
"If she did tell, I don't think she would be employed here that long," running back Fozzy Whittaker said. "It's safe to say she's looking at the player's best interest at heart. She's here truly to help us."
Rookie wide receiver DJ Moore said that's important for the players to understand.
"She's a good getaway from getting trapped in your own mind," he said. "It lets you get out of your own head at the end of the day."
CTE factor
In 2012, Kansas City linebacker Jovan Belcher murdered his 22-year-old girlfriend, then drove to the Chiefs' training facility and shot himself in the head with a handgun.
In a report obtained by ESPN's "Outside the Lines," there were signs that Belcher's brain showed signs of Chronic Traumatic Encephalopathy (CTE), which has become a major point of conversation and research in the NFL the past few years as it relates to head trauma.
Carolina defensive tackle Kyle Love cited Belcher when arguing that NFL teams should have had an in-house clinician "years ago."
"It's something that hasn't been taken seriously long enough. ... We have to lower our guard and know saying something's wrong isn't a bad thing." Eric Reid, Panthers safety
"Every team should have one, because you never really know what's going on in the mind of guys," Love said. "They're bringing up CTE being a big deal with football players, or athletes with high-contact sports, so you have to have somebody to check on those things because you never know what's going on."
While Guerin can't diagnose concussions or CTE, she might see signs that would allow her to point the player in the direction of professionals who could help. Team physicians can also consult with Guerin.
"If a physician comes to me and says, 'Hey, Tish, I think something is going on. He's having some aggressive moves or I've seen some mood dysregulation,' I can go have that conversation with a player to really see if there is anything there," Guerin said.
"In terms of concussion protocol or injuries, I really will be looking to the medical team. I'm mental health. Mental wellness. If they [doctors and trainers] see something that is off, I definitely encourage them to reach out to me so I can connect to the player."
NiiLampti said the Panthers sent a message to the rest of the league that the NFLPA has been pushing for a while.
"The tagline we use is 'mental health is health,'" she said. "If you make that investment it's going to come out on the back end in terms of performance as well as what their lives will look like when they're out of the game.
"It speaks to what they're willing to invest in their players."