Mental Health of Elite Athletes
This article is currently under review and may not be up to date. Please come back soon to see the finished work! (2/05/2020)
- 1 Introduction
- 2 What is Mental Health in the Elite Athlete Context?
- 3 Prevalence of Mental Health Disorders in Elite Athletes
- 4 Athlete-Specific Stressors to Mental Health
- 5 The Help-Seeking Challenge for Elite Athletes
- 6 Recommendations to Optimise Mental Health Support for Elite Athletes
- 7 Conclusion
- 8 References
Society perceive elite athletes as "superhuman beings" with unfathomable willpower, speed, strength, skills and abilities that mere mortals can only aspire to. Even the word Olympian with its roots in the Greek mythology, implies that these athletes are superhuman beings. This, of course, makes it difficult to fathom that these individuals can struggle with the same health problems and illnesses of the general population. Elite athletes can be defined as those athletes who compete at professional, Olympic or collegiate levels. Collegiate athletes are included as they often train and compete at similar levels to professional athletes (Reardon et al).
Research has focused on the nature and impact of physical injuries in elite athletes and groundbreaking advances have been made in these areas. In comparison to these high-quality studies, limited research is available on the mental health and psychological well-being of elite athletes. However, in recent years mental health disorders (MHD) and mental health symptoms in elite athletes have been receiving increased attention and new research directions are being suggested and reported.The International Olympic Committee also published a consensus statement on Mental health in elite athletes in 2019(Reardon et al). Elite athletes are seen as highly mentally functioning individuals with various positive mental attributes such as "focused', "resilient," "confident" and "composed."The assumption is also that only the mentally and emotionally strong athletes will succeed and be able to compete at the highest level. This has lead to the limited attention on MHD and mental health symptoms in the world of elite sports. The perception that elite athletes are without mental health problems is being challenged and research is indicating that elite athletes are also vulnerable to and struggle with mental health problems such as anxiety, depression, eating disorders, obsessive compulsive disorders, addictions and substance misuse. The media has reported a rising number of elite athletes suffering from MHD, as for example Michael Phelps (Olympic swimmer), Marcus Trescothick (international cricketer), Victoria Pendleton (Olympic cyclist), Johnny Wilkinson (international rugby player), to mention just a few. These public cases highlight the fact that elite athletes can also be affected by MHD.
What is Mental Health in the Elite Athlete Context?
The World Health Organisation (WHO) states that "mental health is an integral and essential component of health." According to the WHO constitution, health is defined as " a complete state of physical, emotional and social well-being and not merely the absence of disease or infirmity." This definition implies that mental health is therefore, more than just the absence of mental disorders or disabilities. It is a state of well-being wherein an individual is aware of his or her own abilities, wherein individuals can cope with life's normal stresses and work productively and also be able to make a contribution to their community,
In sport, there are physical challenges such as intense training and injury that can lead to psychological challenges, albeit cognitive, emotional or behavioural. Furthermore, athletes also have to deal with personal challenges, such as relationships or traumatic life events, just like the general population. All these different stressors can impact athletic performance and influence training, career transitions, interpersonal relationships and physical rehabilitation, if not properly addressed.
Wylleman et al (2015) defines mental health in relation to athletes as " a state of successful performance or mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and cope with adversity."
Prevalence of Mental Health Disorders in Elite Athletes
The prevalence of mental disorders is greatest in younger people with 25% of young people between the ages of 16-34 meeting the clinical criteria for one or more disorders. These mental health disorders include depression, generalised anxiety disorders, social anxiety disorders, panic disorders and eating disorders. It is valuable to note that the peak age for the risk of athletes' onset of MHD do overlap with the peak competitive years for athletes due to the intense mental and physical demands of their sport. Although elite athletes mostly fall within the younger age categories, there is limited evidence available on the prevalence of mental health disorders in this population. The available data suggests that elite athletes experience a broadly comparative risk of high-prevalence mental disorders (i.e. anxiety, depression) relative to the general population. It is however difficult to compare prevalence in elite athletes to prevalence in the general population, for a number of reasons(Reardon etl al):
- Most studies in elite athletes have lacked reference groups from the general population
- Different instruments have been used to assess mental health symptoms and disorders in athletes compared with the general population
- Studies do not necessarily consider cross cultural differences in meanings and manifestations of mental health symptoms and disorders
- Studies vary in whether they describe self-reported specific mental health symptoms or physician diagnosed disorders.
In male athletes from team sports such as cricket, football, handball, ice hockey and rugby, the prevalence of mental health symptoms and disorders varies form 5% for burnout and adverse alcohol use to almost 45% for anxiety and depression (Reardon et al ref). Mental health disorders occur in 5% - 35% of elite athletes over a follow-up period of 12 months as reported in prospective studies. (Reardon et al ref). In female athletes, mental health disorders - especially eating disorders- are prevalent (Reardon et al). The prevalence of mental health disorders in collegiate athletes ranges from 10%-25% for depression and eating disorders (Reardon et al)
Among French elite athletes, a 6 month prevalence rate of 6% was reported for generalised anxiety disorder. Studies done on the mental health of elite athletes in the United Kingdom reported a prevalence of 47,8% for anxiety/depression and 26,8 % for signs of distress.Research on the the mental health of Australian athletes documented a prevalence of 46,4% of athletes experiencing symptoms of at least one of the mental health disorders assessed. The findings of this study was similar to other epidemiological studies on the mental health of elite athletes with 27% of athletes experiencing symptoms of depression, 22, 8% showing symptoms of eating disorders, 16,5 % experiencing general psychological distress, 14,7 % showing signs of social anxiety and 7,1 % of athletes showing signs of generalised anxiety disorders. Furthermore, injured athletes showed higher levels of both depression and generalised anxiety disorders. Hammond et al (2013) reported that depression in elite athletes has been underestimated, with 68% of Canadian international level swimmers having major depression episodes prior to competition, while 34% met the same diagnostic criteria post-competition.
The majority of studies researching mental health disorders in athletes have been done with college athletes. Within the university sport context, it has been reported that male athletes are more likely to engage in atypically aggressive behaviour, compared to their non-athlete counterparts. Other issues are drinking and drug use, In female collegiate athletes, 33% reported consuming more that four alcoholic drinks in one sitting, 44% of males reported consuming more than 5, with 16% of male collegiate athletes reporting consuming over 10 drinks in one sitting. Furthermore, 21% of male and 28% of female collegiate athletes reported symptoms of depression and 31% of males and 48% of female collegiate athletes reported symptoms of anxiety.
A combination of generic and sport specific factors may increase the risk of mental health symptoms and disorders in an elite athlete's career (Reardon et al ref). Elite athletes may face a greater overall risk of mental health symptoms and disorders compared with their athletic counterparts if they experience severe musculoskeletal injuries, multiple surgeries, decreased sports performance or be inclined toward maladaptive perfectionism(Reardon et al ref). Sport participation can protect against mental health symptoms and disorders, since exercise has an antidepressant effect. (Reardon et al ref). It might also be possible that an athlete can have mental health symptoms or a mental health disorder with no association between their elite sport participation and the specific mental health condition (Reardon et al ref).
From these studies it is evident that athletes are confronted with various stressors and do show signs and symptoms, as well as suffer from mental health disorders.
Athlete-Specific Stressors to Mental Health
Elite athletes face an unique array of stressors throughout their sporting career. Anyone of these stressors can lead to mental ill-health in an individual as elite athletes operate in very different environmental and social contexts.
- Athletes in the retirement phase of their career
- Athletes experiencing performance failure 
- Performance expectations
- Major negative life events
- Sports requiring a particularly lean body shape
- Female athletes
- Low social support
- Organisational factors, such as travelling and spending long periods away from home
- Personal stressors (i.e. family issues)
- Social media scrutiny
The Help-Seeking Challenge for Elite Athletes
Elite athletes tend to not seek for support or help for mental health problems for various reasons such as:
- Stigma 
- Lack of understanding about mental health and it's potential influence on performance
- The perception of help seeking as a sign of weakness
- Sport's culture of masculine ideas, valuing strength and mental toughness
- Athletes being encouraged to minimise and suppress signs of weakness and vulnerability
- Fears of being excluded from the team
- Fears of being not allowed to compete
- Athletes feeling that they cannot raise their mental health concern in their specific sport organisation
Although measures are being taken by various sporting bodies around the world to distribute sport-related health findings, in order to advance the prevention, identification and early intervention of MHD in elite athletes,there is still a long way to go. It is positive to note, however, the various sporting bodies that are implementing mental health support systems for their elite athletes.
Action Plan - Mental Health and Elite Sport in the United Kingdom
Recommendations to Optimise Mental Health Support for Elite Athletes
- Education of athletes, coaches, support staff and friends and families about symptoms of different mental health conditions
- Education of medical professionals in relation to the different high performance sport contexts
- Seminars for medical and sport psychology professionals involved with elite athletes
- Normalising and validating the issue of MHD and athletes' vulnerability in elite sports will help to destigmatise the topic in this specific population
- Provide information about the success of professional assessment and treatment of MHD to athletes and support staff
- Reinforce all behaviours that will facilitate help-seeking when athletes suffer with MHD, such as social support, positive relationships with service staff, confidentiality, time for therapy sessions, encouragement from others,
- Healthy and more sustainable environment is possible when athletes feel comfortable and are able to ask for help, without the fear of negative consequences for their career
Sports-Specific Approach in Detecting and Treating MHD
- Further research is needed to determine possible sport-specific mental health disorders and then define specific diagnostic criteria for such disorders
- Development of sport-specific screening tools for MHD in elite sport
- Develop and enhance treatment protocols for athletes suffering from sport-specific related issues, such as overtraining, psychological reactions to injuries, and retirement form sport
- Concentrate on sport-specific situations athletes may find themselves and which may increase the likelihood of developing MHD
- Ensure that all professionals involved in the referral network are aware of the nature of high performance sport and understand the issues related to performance
Clear Pathway Provided by Institutions and Stakeholders
- Athletes should have knowledge about the support available to them
- Athletes should have access to support for MHD
- Aim to align mental health support across all different sport organisations
Elite athletes are vulnerable to mental health disorders as a result of the various specific stressors they experience in their sporting environment. Key factors are the impact of injury, overtraining, social media scrutiny and ongoing competitive pressure to perform. Athletes and their support staff need to be educated about MHD and be able to seek help without fear.
- Rice SM, Purcell R, De Silva S, Mawren D, McGorry PD, Parker AG.The Mental Health of Elite Athletes: A Narrative Systematic Review. Sports Med. 2016 Sep;46(9):1333-53.
- Moesch K, Kentta G, Kleinert J, Quignon-Fleuret C, Cecil S, Bertollo M. FEPSAC position statement: Mental health disorders in elite athletes and models of service provision. Psychol Sport Exerc. 2018; Sep 38: 61 -71
- Hill A , MacNamara A, Collins D and Rodgers S. Examining the Role of Mental Health and Clinical Issues within Talent Development. Front Psychol. 2016 Jan 11;6:2042.
- Schinke R, Stambulova N,SI G, Moore Z. International society of sport psychology position stand: Athletes' mental health, performance, and development. Int J Sport Exerc Psychol. 2017 Apr
- World Health Organisation. (2018)http://www.who.int/en/news-room/fact-sheets/detail/mental-health-strengthening-our-response. (last accessed 30 September 2018)
- Wylleman P, Rosier N, De Knop P. Transitional challenges and elite athletes' mental health. In Baker J, Safari P, Fraset Thomas J (Eds) Health and Elite Sport: Is high performance sport a health pursuit. London: Routledge. 2015 (p 99 - 116)
- Gulliver A, Griffiths KM, Mackinnon A, Batterham PJ, Stanimirovic R. The mental health of Australian elite athletes. J Sci Med Sport. 2015 May;18(3):255-61
- Schaal K, Tafflet M, Nassif H, Thibault V, Pichard C, Alcotte M, Guillet T, El Helou N, Berthelot G, Simon S, Toussaint J. Psychological Balance in High Level letes: Gender-Based Differences and Sport-Specific Patterns. PLoS One. 2011; 6(5): e19007.
- Foskett RL, Longstaff F.The mental health of elite athletes in the United Kingdom. J Sci Med Sport. 2018 Aug;21(8):765-770.
- Hammond T, Gialloreto C, Kubas H, Hap Davis H. The prevalence of failure-based depression among elite athletes. Clin J Sport Med. 2013 Jul;23(4):273-7.
- Reardon CL, Factor RM..Sport psychiatry: a systematic review of diagnosis and medical treatment of mental illness in athletes. Sports Med. 2010 Nov 1;40(11):961-80.
- Bauman NJ. The stigma of mental health in athletes: are mental toughness and mental health seen as contradictory in elite sport? Br J Sports Med. 2016 Feb;50(3):135-6.
- US Today Sports. 30 August 2017. Athletes opening up about mental health in sports