Mental Health Considerations for Athletes
Introduction[edit | edit source]
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[edit | edit source]
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.
Prevalence of Mental Health Symptoms in Elite Athletes[edit | edit source]
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[edit | edit source]
- 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[edit | edit source]
Specific mental health symptoms and disorders in athletes include:
- Sleep disorders
- Sleep concerns
- Major depressive disorder
- Depression symptoms
- 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[edit | edit source]
Prevalence of Depression in Athletes[edit | edit source]
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:
- 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)
- Competitive failure
- Retirement from sport
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[edit | edit source]
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:
|Non-Sport Specific Factors||
|Sport Specific Factors||
Anxiety and Sports Performance[edit | edit source]
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:
- 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.
Impact of Mental Health on Performance[edit | edit source]
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:
- Performance pressure
- Sporting failures, setbacks, successes
- Transition into and out of sport
- General lifestyle challenges
Impact of Injury on Mental Health[edit | edit source]
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||
|Sociocultural risk factors to injury||
An athlete’s response to an injury plays a role in the outcome. Important factors to consider are the cognitive, emotional and behavioural responses.
- 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[edit | edit source]
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[edit | edit source]
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
- 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
- Maladaptive coping strategies
- Increased hostility
- General life stresses
- Relationship difficulties
- Financial concerns
- Major events such as COVID-19 pandemic
Roles and Responsibilities of Healthcare Professionals to Minimise Negative Impacts[edit | edit source]
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[edit | edit source]
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.
- 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
- 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:
- 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
- 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
- Positive social relationship with coaches and support staff
- Integration of mental health into sporting environment
- Openness and ease of expressing emotions
- 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[edit | edit source]
Early detection and interventions for mental health symptoms are essential in the sporting environment. Three areas to focus on include:
- 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.
- 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
- 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[edit | edit source]
- 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[edit | edit source]
References[edit | edit source]
- Pachón-Blanco N, Peña-Ciro MC, Pineda-Ortega J, Restrepo-Martínez A, Palencia-Sánchez F. Mental Health and the Correlation with Professional Athlete’s Performance, a Rapid Literature Review. Available at SSRN. 2022 Feb 17.
- World Health Organization. Mental health. Mental health in the Western Pacific. Available from https://www.who.int/westernpacific/health-topics/mental-health
- World Health Organisation. Mental Health Definition by WHO. Available from https://www.publichealth.com.ng/mental-health-definition-by-who/
- Wall Street Journal. Olympic Athletes Biles, Osaka Shift the Conversation on Mental Health | WSJ. Available from: https://www.youtube.com/watch?v=dakoO8WJ3mY [last accessed 01/08/2022]
- Keyes CL. he mental health continuum: From languishing to flourishing in life. Journal of health and social behavior. 2002 Jun 1:207-22.
- Association of Ambulance Chief Executives. The Mental Health Continuum - Visual Aid. Available from https://aace.org.uk/mental-health-continuum/
- 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.
- Casali N, Cerea S, Moro T, Paoli A, Ghisi M. Just do it: High intensity physical activity preserves mental and physical health in elite and non-elite athletes during COVID-19. Frontiers in psychology. 2021:5242.
- Bescoby C. Mental Health Considerations for Athletes. Plus. Course. 2022
- Schaal K, Tafflet M, Nassif H, Thibault V, Pichard C, Alcotte M, Guillet T, El Helou N, Berthelot G, Simon S, Toussaint JF. Psychological balance in high level athletes: gender-based differences and sport-specific patterns. PloS one. 2011 May 4;6(5):e19007.
- Hammond T, Gialloreto C, Kubas H, Davis IV HH. The prevalence of failure-based depression among elite athletes. Clinical Journal of Sport Medicine. 2013 Jul 1;23(4):273-7.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- Correia M, Rosado A. Anxiety in athletes: Gender and type of sport differences. International Journal of Psychological Research. 2019 Jun;12(1):9-17.
- Reardon CL. Psychiatric comorbidities in sports. Neurologic Clinics. 2017 Aug 1;35(3):537-46.
- Herring SA, Kibler WB, Putukian M, Coppel DB. Psychological issues related to illness and injury in athletes and the team physician: a consensus Statement-2016 update. Med Sci Sports Exerc. 2017;49(5):1043-54.
- Castaldelli-Maia JM, e Gallinaro JG, Falcão RS, Gouttebarge V, Hitchcock ME, Hainline B, Reardon CL, Stull T. Mental health symptoms and disorders in elite athletes: a systematic review on cultural influencers and barriers to athletes seeking treatment. British Journal of Sports Medicine. 2019 Jun 1;53(11):707-21.
- Haslam C, Lam BC, Yang J, Steffens NK, Haslam SA, Cruwys T, Boen F, Mertens N, De Brandt K, Wang X, Mallett CJ. When the final whistle blows: Social identity pathways support mental health and life satisfaction after retirement from competitive sport. Psychology of Sport and Exercise. 2021 Nov 1;57:102049.
- Purcell R, Gwyther K, Rice SM. Mental health in elite athletes: increased awareness requires an early intervention framework to respond to athlete needs. Sports medicine-open. 2019 Dec;5(1):1-8.
- Gulliver A, Griffiths KM, Christensen H. Barriers and facilitators to mental health help-seeking for young elite athletes: a qualitative study. BMC psychiatry. 2012 Dec;12(1):1-4.
- WISH Qatar. Mental Health and Sport Webinar. Available from: https://www.youtube.com/watch?v=1jPhsEGsXJo [last accessed 1/08/2022]
- TEDx Talks. Athletes and Mental Health: The Hidden Opponent | Victoria Garrick | TEDxUSC. Available from: https://www.youtube.com/watch?v=Sdk7pLpbIls [last accessed 1/8/2022]