Mental Health Considerations for Athletes

Original Editor - Wanda van Niekerk based on the course by Carl Bescoby

Top Contributors - Wanda van Niekerk, Kim Jackson, Jess Bell and Nupur Smit Shah  

Introduction

Athletes and their mental health have been at the forefront recently, with Olympic and professional athletes publicly opening up about their struggles. The mental health of athletes is as important as their physical health. Athletes rely on their mental health and strength to “provide a necessary basis for efficient practice and competition performance."

The World Health Organization defines mental health as follows:

“Mental health is the foundation for the well-being and effective functioning of individuals. It is more than the absence of a mental disorder; it is the ability to think, learn, and understand one's emotions and the reactions of others. Mental health is a state of balance, both within and with the environment. Physical, psychological, social, cultural, spiritual and other interrelated factors participate in producing this balance. There are inseparable links between mental and physical health.”

Our mental health influences the way we think, feel and act. It determines how we cope with stress, how we relate to others, and it influences our decision-making processes.

The Mental Health Continuum

Mental health is not an all-or-nothing concept, and it can change. Thus, one should consider it as being on a continuum, spanning from excelling through to struggling or being in crisis. Where a person finds themselves on this continuum will influence the way a person thinks, acts and feels. A person can move between these states of well-being on the continuum. The different states are thriving, surviving, struggling and in crisis.

See this useful tool: Mental Health Continuum Visual Aid  

Prevalence of Mental Health Symptoms in Elite Athletes

It remains difficult to accurately compare the prevalence of mental health symptoms in athletes to the general population. Reasons for this are:

• Studies investigating elite athletes lack reference groups from the general population
• Different instruments are utilised to assess mental health symptoms and disorders in athletes compared with the general population
• Cross-cultural differences in the meaning and manifestation of mental health symptoms and disorders are not considered in some research studies
• Variance in methods of reporting mental health symptoms – self-reported or physician-diagnosed disorders

Reported Prevalence

• In male elite athletes involved in team sports (such as cricket, football, handball, ice hockey and rugby), prevalence varies from 5% for burnout and adverse alcohol use to 45% for anxiety and depression
• Prospective studies with follow-up studies of up to a 12-month period indicate that mental health disorders are prevalent in 5% to 35% of elite athletes
• Eating disorders are considered quite prevalent among female elite athletes
• In collegiate athletes, there is a prevalence of mental health disorders such as depression and eating disorders of 10% to 25%

A combination of generic and sport-specific factors may increase the risk of mental health symptoms and disorders in elite athletes. Athletes may experience an increased risk when confronted with:

• Severe musculoskeletal injuries
• Multiple surgeries
• A decline in sporting performance
• A tendency for maladaptive perfectionism

On the other hand, sports participation may protect athletes against mental health symptoms and disorders seeing that exercise has antidepressant effects. Sometimes athletes may even have mental health symptoms with no clear association between sports participation and the mental health condition.

Specific Mental Health Symptoms and Disorders in Athletes

Specific mental health symptoms and disorders in athletes include:

• Sleep disorders
• Sleep concerns
• Major depressive disorder
• Depression symptoms
• Suicide
• Anxiety and related disorders
• Post-traumatic stress disorder
• Trauma-related disorders
• Eating disorders
• Attention-deficit/hyperactivity disorder
• Bipolar and psychotic disorders
• Sport-related [[assessment and management of concussion]
• Substance use and substance use disorders
• Gambling disorder

Depression in Athletes

Prevalence of Depression in Athletes

Some research shows that athletes may be predisposed to depression compared to the general population. Reasons for this may include the physical and psychological demands in the sporting environment. However, athletes are also exposed to similar stresses as the general population such as:

• Bereavement
• Health concerns
• Relationship breakdowns

There is a wide variation in the prevalence of depressive symptoms in elite athletes, ranging from 4% to 68%. In United States (US) college athletes, 21% of athletes self-reported clinical symptoms of depression. In Australian athletes, 46% of athletes experienced symptoms of at least one common mental health disorder - 27% experienced depression.

Different sports are linked to different risks for depressive symptoms and/or major depressive disorder:

• French athletes competing in fine motor skills sports were more at risk of depressive symptoms than athletes competing in team ball sports
• Athletes in individual sports are more likely to report depressive symptoms than athletes in team sports

Risk factors associated with depressive symptoms include:

• Genetic factors (family history)
• Environmental factors (relationship issues, lack of support)
• Injury
• Competitive failure
• Retirement from sport
• Pain
• Concussion

Depressive symptoms or depression can lead to:

• Decreased performance
• Effects on personal life and relationships
• Retirement/exit from sport

See this athlete-specific screening tool for depression: Baron Depression Screener for Athletes in Box 3 of this article: Mental health in elite athletes: International Olympic Committee consensus statement (2019).

Anxiety

There are similar rates of anxiety in athletes and the general population. In sport, anxiety is often closely associated with performance. Related anxiety disorders in athletes include:

• Generalised anxiety disorder (GAD)
• Panic disorder
• Social anxiety disorder
• Obsessive-compulsive disorder
• Competitive performance anxiety

In elite rugby league players, the prevalence of general anxiety disorder was 14.6% preseason and 10.1% in-season. Individual sports athletes may be at greater risk for anxiety than team sports athletes. Possible reasons for this may be that young athletes often join a team for fun, whereas athletes may join an individual sport for goal-oriented reasons such as scholarships and weight control. Individual sports athletes are also more likely to:

• Internalise failure
• Set higher goals
• Be perfectionists
• Have less social support
• Compete year round in a single sport
• Experience an injury

These factors may all increase anxiety in these athletes.

Other factors that may cause anxiety in athletes:

Table 1. Factors that may cause anxiety in athletes.

Non-Sport Specific Factors	Female Younger age Recent experience of adverse life events Behavioural inhibition Social withdrawal or avoidance Rumination
Sport Specific Factors	Performance pressure Public scrutiny Sporting career uncertainty, dissatisfaction Injury Harassment and abuse in sport

Anxiety and Sports Performance

Competitive performance anxiety is defined as: “fear an athlete has occurring around the time of sport participation, especially competition, that they will not be able to perform in the desired manner, that the situation will be too challenging, and/or that it will be dangerous or harmful, thus resulting in anxious cognitive appraisals, behavioural responses, and/or physiologic arousals.” In elite athlete studies, a higher rate of self-reported anxiety is linked to negative performance outcomes. Anxiety affects:

• Attention
• Executive function
• Stimulus processing
• Information selection
• Muscle tension

These are all key factors in sports competition.

Some symptoms such as feelings of stress and worry may be normal before a competition, but how the athlete interprets and copes with these emotions will affect the impact it has on performance. For example, if the athlete experiences these feelings as facilitative in gaining focus and getting psyched up before competing, this may be seen as helpful. However, if the athlete experiences these feelings as unfavourable, the athlete’s behavioural response will be less adaptive and this may negatively influence performance.

Learn more on Anxiety Disorders in Athletes here: Anxiety Disorders in Athletes. A Clinical Review

Impact of Mental Health on Performance

It is important to recognise that athletes may have mental health symptoms and disorders with no apparent association between sport participation and the mental health condition. Furthermore, sports participation may also protect against mental health symptoms.

Factors that may impact an athlete’s mental health:

• Injury
• Performance pressure
• Sporting failures, setbacks, successes
• Transition into and out of sport
• General lifestyle challenges

Impact of Injury on Mental Health

Potential risk factors for injury in sports include psychological and sociocultural factors. Some of these factors are shown in the table below.

Table 2. Psychological and sociocultural risk factors to injury in athletes.

Psychological risk factors to injury	Anxiety/worry Hypervigilance Poor body image Low self-esteem Perfectionism Limited coping skills Life event stresses Risk-taking behaviour Low mood state
Sociocultural risk factors to injury	Limited social resources Lifetime history of abuse Social pressures Organisational stress Stress related to negative self-appraisal of athletic and academic abilities and performance Coaching quality Team and sport culture

An athlete’s response to an injury plays a role in the outcome. Important factors to consider are the cognitive, emotional and behavioural responses.

Table 3. Athlete responses to injury.

Cognitive Responses	Concerns about re-injury Doubts about competency Low self-efficacy Loss of identity Concerns about competency of medical staff
Emotional Responses	Symptoms of sadness Depression Suicidal ideation Anxiety Isolation Lack of motivation Anger Irritation Frustration Changes in appetite Changes in sleep pattern Low vigour Disengagement Burnout

Injured athletes report more symptoms of anxiety and depression. Emotional responses to injury will occur. However, these responses are problematic when:

• They do not resolve
• The worsen over time
• Symptoms seem excessive

Research has also shown that injury may lead to inappropriate behavioural responses and mental health disorders, such as gambling, eating disorders and substance use disorders. Furthermore, athletes with more positive responses may have improved outcomes following injury.

Strategies that can aid in positive return to sport experiences:

• Reduce re-injury anxiety – watch videos of previously injured athletes discuss how they overcame their anxiety
• Cultivate athlete autonomy (explain to athletes why rehabilitation is important and why specific exercises are necessary)
• Build confidence – use functional tests and goal setting
• Social support
• Keep the athlete involved in the sport or team, without a premature return to sport

Relationship between Stress and Performance Pressure

Athletes encounter high levels of physical and psychological stress, such as the demands of their training and competition schedule and the constant desire to perform. Other factors such as their sporting life (training away from home, strict training and dietary regimes, pressure from coaches and close monitoring of achievements, contract negotiations) also add to higher than normal stress levels.

“Athletes are not immune from stress and are vulnerable to specific stresses within sports settings as well as general life settings."

Transition out of Sport

Athletes transitioning out of sport are at risk of developing mental health symptoms, especially if this transition is unplanned or involuntary through injury, health reasons or deselection from the team.

Risk factors for post-sport or career mental health symptoms include:

• Involuntary retirement as a result of injury
• High levels of athletic identity
• Lack of retirement planning
• Lower educational attainment
• Post-sport unemployment in elite athletes
• Chronic pain

The transition out of sport can result in:

• Changes to an athlete’s interpersonal relationships
• Changes to an athlete’s role
• Changes to an athlete’s daily routine
• Conflict may arise within the athlete in decision-making on further pursuing a sport career or retiring - this may have an influence on symptoms such as depression
• Athletes may develop feelings of worthlessness

There is an association between a career transition from sport and:

• Maladaptive coping strategies
• Depression
• Anxiety
• Increased hostility
• Anger

Athletes also experience general life events outside of performance and sport. These will also impact the athlete’s mental health. General life events may include:

• General life stresses
• Relationship difficulties
• Financial concerns
• Major events such as COVID-19 pandemic

Roles and Responsibilities of Healthcare Professionals to Minimise Negative Impacts

Various general and athlete-specific risk factors for mental health symptoms are potentially modifiable and adaptable. For example, providing athletes with coping strategies, changes in coaching style, and changes in training demands.

To minimise the negative impact of the sporting environment on athletes’ mental health, interventions are necessary at the following levels:

• Athlete level
• The coach and support staff level
• The sporting environment
• Organisational level

A Supportive Environment for Mental Well-Being

In the sporting environment, coaches and sports governing bodies have a key role to play in changing the culture and stigmatisation in sports around mental health.

Coaches can:

• Support the diagnosis and management of mental health symptoms by insisting that mental health help-seeking is an essential function of training and self-care
• Focus on and adapt athlete stressors that may negatively impact athlete mental health such as training load, recovery, injury, burnout and transition out of the sport
• Convey the importance of mental health care to parents of young athletes
• Encourage positive psychosocial development in athletes through:
  • Resilience-promoting skills
  • Psychological flexibility
  • Self-compassion

• Create a process-oriented mindset instead of only focusing on performance and achievements

Coaches, athlete support staff, sporting bodies and organisations must be aware of the barriers athletes face when considering seeking help for their mental health and also the key facilitators that may help athletes to seek help.

Barriers to seeking help for mental health symptoms include:

• Stigma
• Difficulty or unwillingness to express emotion
• Lack of problem awareness
• Lack of time
• Denial of the problem
• Scared of the outcome
• Impacts on training and competition ability
• Unsure who to ask for help
• Accessibility
• Cultural background of athlete
• Belief that it would not help or make a difference

Help-seeking facilitators include:

• Education and raising awareness of mental health issues and services
• Social support
• Encouragement from others
• Accessibility
• Positive social relationship with coaches and support staff
• Confidentiality
• Integration of mental health into sporting environment
• Openness and ease of expressing emotions
• Time
• Positive past experiences

It is imperative that all stakeholders across sporting organisations improve their understanding of mental illness. Increased awareness of mental health and wellbeing is crucial across performance settings. The individual athlete, their coping skills, and attitudes, as well as the support structure around the athlete need to be considered.

Recommendations for the Management of Mental Health Symptoms in Sport

Early detection and interventions for mental health symptoms are essential in the sporting environment. Three areas to focus on include:

1. Athlete education on self-management skills to manage psychological distress. Such as:
   • Individually focused development programmes helping athletes to develop skills to help manage life and sport in a competitive environment
   • Mental health screening should be a priority alongside routine physical screenings
   • This can help identify commonalities and create awareness through psychologically informed practice
   • Physiotherapists and other rehabilitation professionals can play a vital role in the early detection of mental health symptoms. They are in a position to notice changes in athlete behaviour and identify unhealthy training environments.
2. Equipping key stakeholders in elite sporting environments (such as coaches, physiotherapists and sports medicine professionals) to better recognise and respond to concerns regarding an athlete’s mental health
3. Highlight the need for specialist multidisciplinary teams or skilled mental health professionals to manage athletes with severe or complex mental disorders

Injury is a risk factor for mental health symptoms and physiotherapists, athletic trainers, and other sports medicine professionals are in the unique position to identify potentially at-risk athletes and support these athletes through referral networks or specialist mental health care routes.

Key Take Home Messages

• Mental health is on a continuum and athletes ebb and flow between ill health and high functioning. Situations, stress and circumstance have an impact on where an athlete will be on this continuum.
• Like the general population, athletes are susceptible to mental health symptoms and disorders. The sporting environment can further increase their risk.
• Everyone who works with athletes has a role to play in supporting the athlete’s mental health. Role players can help in the following ways:
  • Upskilling themselves
  • Upskilling training
  • Growing awareness of mental health challenges and disorders
  • Physiotherapists, athletic trainers, biokineticists, and clinical exercise physiologists could "investigate psychologically informed practice and support athletes with coping skills and management skills and overarching wellbeing."
• Multidisciplinary teams with mental health professionals as part of these teams are crucial to support athletes biopsychosocially.

Resources

• IOC Mental Health in Elite Athletes Toolkit
• IOC Sport Mental Health Assessment Tool 1 (SMHAT-1)