Mental Health Considerations for Athletes

This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (1/08/2022)

Original Editor - User Name

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

Introduction

Athletes and 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 Organisation 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, and 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 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 feel. A person can move between these states of well-being on the continuum. The different states are thriving, surviving, struggling and in crisis. (Keyes CL. The mental health continuum: From languishing to flourishing in life. Journal of health and social behavior. 2002 Jun 1:207-22.)

See this useful tool:

Mental Health Continuum Visual Aid  - https://aace.org.uk/wp-content/uploads/2022/05/Mental-Health-Continuum-Final-Visual_b.pdf

Prevalence of Mental Health 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: Reardon CL, Hainline B, Aron CM, Baron D, Baum AL, Bindra A, Budgett R, Campriani N, Castaldelli-Maia JM, Currie A, Derevensky JL. Mental health in elite athletes: International Olympic Committee consensus statement (2019). British journal of sports medicine. 2019 Jun 1;53(11):667-99.

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: Reardon CL, Hainline B, Aron CM, Baron D, Baum AL, Bindra A, Budgett R, Campriani N, Castaldelli-Maia JM, Currie A, Derevensky JL. Mental health in elite athletes: International Olympic Committee consensus statement (2019). British journal of sports medicine. 2019 Jun 1;53(11):667-99.

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 used 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% - 35% of elite athletes

Eating disorders are quite prevalent among female elite athletes

Collegiate athletes – 10% to 25% prevalence of mental health disorders such as depression and eating disorders

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 (ioc consensus)

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 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: Carl Bescoby)

Bereavement

Health concerns

Relationship breakdowns

There is a wide variation in the prevalence of depressive symptoms in elite athletes and it ranges from 4% to 68%. In US college athletes 21% of athletes self-reported clinical symptoms of depression Yang J, Peek-Asa C, Corlette JD, Cheng G, Foster DT, Albright J. Prevalence of and risk factors associated with symptoms of depression in competitive collegiate student athletes. Clinical Journal of Sport Medicine. 2007 Nov 1;17(6):481-7.and in Australian athletes 46% of athletes experienced symptoms of at least one common mental health disorder and 27% specifically for depression. Gulliver A, Griffiths KM, Mackinnon A, Batterham PJ, Stanimirovic R. The mental health of Australian elite athletes. Journal of science and medicine in sport. 2015 May 1;18(3):255-61.

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 (ioc)

Athletes in individual sports are more likely to report depressive symptoms than athletes in team sports Pluhar E, McCracken C, Griffith KL, Christino MA, Sugimoto D, Meehan III WP. Team sport athletes may be less likely to suffer anxiety or depression than individual sport athletes. Journal of sports science & medicine. 2019 Sep;18(3):490.

Risk factors associated with depressive symptoms include: ioc

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: ioc

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 Baron DA, Baron SH, Tompkins J, Polat A. Assessing and treating depression in athletes. Clinical sports psychiatry: An international perspective. 2013 Jun 24:65-78.

Anxiety

Anxiety in athletes occurs at a similar rate to the general population. In sport, anxiety is often closely associated with performance. Related anxiety disorders in athletes include: Reardon CL, Gorczynski P, Hainline B, Hitchcock M, Purcell R, Rice S, Walton CC. Anxiety Disorders in Athletes: A Clinical Review. Advances in Psychiatry and Behavioral Health. 2021 Sep 1;1(1):149-60.

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. Du Preez EJ, Graham KS, Gan TY, Moses B, Ball C, Kuah DE. Depression, anxiety, and alcohol use in elite rugby league players over a competitive season. Clinical Journal of Sport Medicine. 2017 Nov 1;27(6):530-5.

Individual sports athletes may be at greater risk for anxiety than team sport athletes Correia M, Rosado A. Anxiety in athletes: Gender and type of sport differences. International Journal of Psychological Research. 2019 Jun;12(1):9-17. Possible reasons for this include

Young athletes often join a team for fun whereas reasons for athletes joining an individual sport can include goal-oriented reasons such as scholarships and weight control Pluhar E, McCracken C, Griffith KL, Christino MA, Sugimoto D, Meehan III WP. Team sport athletes may be less likely to suffer anxiety or depression than individual sports athletes. Journal of sports science & medicine. 2019 Sep;18(3):490.

Individual sports athletes are also more likely to: Reardon CL, Gorczynski P, Hainline B, Hitchcock M, Purcell R, Rice S, Walton CC. Anxiety Disorders in Athletes: A Clinical Review. Advances in Psychiatry and Behavioral Health. 2021 Sep 1;1(1):149-60.

internalise failure

set higher goals

be perfectionists

have less social support

compete year round in single sport

experience an injury

These may all increase anxiety in these athletes

Other factors that may cause anxiety in athletes: Reardon CL, Gorczynski P, Hainline B, Hitchcock M, Purcell R, Rice S, Walton CC. Anxiety Disorders in Athletes: A Clinical Review. Advances in Psychiatry and Behavioral Health. 2021 Sep 1;1(1):149-60.

Sport specific: Performance pressure

Public scrutiny

Sporting career uncertainty, dissatisfaction

Injury

Harassment and abuse in sport

Non – sport specific:

Female

Younger age

Recent experience of adverse life events

Behavioural inhibition

Social withdrawal or avoidance

Rumination

Anxiety and Sports Performance

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 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.

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, behavioral responses, and/or physiologic arousals.” Reardon et al

Learn more on Anxiety Disorders in Athletes here (link to researchgate where article can be requested from authors)

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 mental health condition. Reardon 2017 Psychiatric comorbidities in sport. Furthermore, sport participation may also protect against mental health symptoms taking into consideration the antidepressant effect of exercise. Cooney Exercise for depression

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

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 factors:

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

Culture of sport and team

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

Cognitive responses include:

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

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

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.

Some strategies that can aid in positive return to sport experiences:

Reduce re-injury anxiety – watch videos of previously injured athletes where they 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 athlete involved in sport or team, without 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 strive 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 these high 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 transition out of sport are at risk of developing mental 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 and the influence this will have in 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

Key point to remember: Athletes also experience general life events outside of performance and sport and this will also impact the athlete’s mental health. Carl Bescoby

General life stresses may include:

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, change in coaching style, and changes in training demands) Purcell et al 2019

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 sport 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 sport.

Convey the importance of mental health care to parents of young athlete

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

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 (Gulliver et al)

Education and raising awareness of mental health issues and services

Social support

Encouragement from others

Accessiblity

Positive social relationship with coaches and support staff

Confidentiality

Integration of mental wealth 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 and their coping skills, attitudes as well as support structure around the athlete need to be considered.

Recommendations for the management of mental health symptoms in sporting contexts

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 developed 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 in identifying commonalities and creating 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 to mental health symptoms and physiotherapists, athletic trainers, sports medicine professionals are in the unique position to identify possible at risk athletes and support these athletes through referral networks or specialist mental health care routes.

Conclusion

Mental health is on a continuum and athletes ebb and flow between ill health and high functioning and situations, stress and circumstances have an impact on where an athlete will be on this continuum.

Athletes are susceptible to mental health symptoms and disorders similar to the general population. The sporting environment can further increase their risk.

All involved with athletes have a role to play in supporting the athlete’s mental health

Multidisciplinary teams with mental health professionals as part of these teams are crucial to support athlete biopsychosocially.

Resources

• bulleted list
• x

or

1. numbered list
2. x