Sport and Mental Health

Sport and Mental Health         
Prepared by  Prepared by: Dr Ralph Richards, Senior Research Consultant, Clearinghouse for Sport, Australian Sports Commission
evaluated by  Evaluation by: Gayelene Clews, Performance Psychologist, Wired to Play Consulting (March 2016)
Reviewed by  Reviewed by network: Australian Sport Information Network (AUSPIN)
Last updated  Last updated: 7 March 2017
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Introduction

Mental health is characterised by emotional wellbeing and resilience to stress. Mentally healthy individuals are able to cope with daily stresses and fully participate in family, work, sport and leisure, and community activities. A mental disorder is a diagnosable illness that affects a person’s thinking, emotional state and behaviour, and disrupts his/her ability to carry out normal daily activities or engage in satisfying personal relationships.

The 2007 National Survey of Mental Health and Wellbeing collected information on three major types of mental disorders: anxiety disorders; affective or mood disorders; and substance use disorders. The measurement of mental health is complex and not simply the absence of mental illness, which generally refers to longer-term conditions. Depending upon the disorder and its severity, specialist management or treatment may be required. The 2007 survey found that 45% of Australian adults experienced some form of mental disorder in their lifetime, and in any given year 20% had some mental health issue. The most common mental health issues were anxiety disorders (14%), depressive disorders (6%) and substance abuse disorders (5%).

Physical activity is generally recognised as an effective adjunct treatment modality for many different physical, mental and emotional conditions.

  • Exercise and Mental Health: An Exercise and Sports Science Australia commissioned review (PDF PDF document - 96 KB), Morgan A, Parker A, Alvarez-Jimenez M and Jorm A, Journal of Exercise Physiology, Volume 16, Number 4 published online (August 2013). Mental disorders are a significant contributor to disability in the community. There is growing interest in the effectiveness of exercise interventions for improving mental, as well as physical health, in individuals with mental disorders. This paper reviews the evidence on the benefits of exercise for mental health problems. Exercise appears most effective for treating persons with depressive disorders and may also improve mental wellbeing in individuals with serious mental disorders, but there is limited research on the optimal type and dose of exercise suitable for individuals with mental disorders. It’s recommended that exercise dose should meet minimum physical activity guidelines for maintaining health and higher doses may have stronger effects, but may be more difficult to implement in practice. Exercise programs should be adapted to accommodate individual circumstances and preferences and to minimise barriers.

Elite athletes (because of their unique relationship with sport participation) should be considered separately when interpreting data available on the general population. The evidence base regarding the facilitating or debilitating influence of sport participation on the mental health and wellbeing of elite athletes is more limited than population data.  

  • A grounded theory of psychological resilience in Olympic champions, Fletcher D and Sarkar M, Psychology of Sport and Exercise, Volume 13, Issue 5 (2012). It is well-established that the ability to manage stress is a prerequisite of sporting excellence. This study explores and explains the relationship between psychological resilience and optimal sport performance. Numerous psychological factors relating to a positive personality, motivation, confidence, focus, and perceived social support, serve to protect the world’s best athletes from the potential negative effect of stress. Challenge appraisal and meta-cognitions are important resilience-related mechanisms that elite athletes learn to use; facilitating these strategies precedes optimal sport performance. 
  • Psychological factors in sport performance: The mental health model revisited (PDF PDF document - 192 KB), Raglin J, Sports Medicine, Volume 31, Number 12 (2001). The 'Mental Health Model' of sport performance suggests that an inverse relationship exists between psychopathology and sport performance (i.e. high anxiety or depression results in low performance). The model postulates that as an athlete’s mental health either worsens or improves performance should fall or rise accordingly. There is considerable support for this view based upon studies indicating that between 70 - 85% of successful and unsuccessful athletes can be identified using general psychological measures of personality structure and mood state, a level superior to chance but insufficient for the purpose of athlete selection. This overview summarises the evidence.

Understanding the causes of mental/emotional stress, learning coping skills, and developing emotional and social support networks can help any individual build resilience and deal with stressful situations. Athletes are regularly challenged by stressful events related to their sport participation, and these may occur on top of daily life stresses. One’s ability to ‘bounce back’ to a normal state of functioning, following exposure to stress, is a predictor of good mental health. 


Key Messages 

1

Physical activity stimulates a biochemical response in the brain that influences one’s mental state. Regular physical activity, in appropriate amounts, contributes to personal wellbeing.

2

Sport, recreation and physical activity can promote and encourage social interaction, which supports good mental health.

3

Athletes are subjected to stressors having specific sporting origins, as well as stress from everyday life. Good mental health is characterised by emotional wellbeing and resilience to all sources of stress.

4

The state of mind of an athlete has a significant impact on their athletic performance and vice versa.

5

Diagnosis and care of an athlete’s mental health concerns must be considered within the context of sport and life.


The World Health Organization (WHO) defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. An important consequence of this definition is that mental health is described as being more than the absence of mental disorders or disabilities. Mental health is a state of wellbeing in which an individual can realise his/her own potential; cope with the normal stresses of life; work productively; enjoy relationships with others; and participate in a variety of activities that contribute to personal satisfaction and community wellbeing. There are multiple social, psychological, and biological factors that determine the level of one’s mental health at any point of time.  

A mental illness is a health problem that significantly affects how a person feels, thinks, behaves, and interacts with other people. It is diagnosed according to standardised criteria. The term 'mental disorder' is also used to refer to serious health concerns. While everyone experiences strong feelings and emotions at times, a mental illness is present when these feelings become so disturbing and overwhelming that an individual has great difficulty coping with day-to-day activities; such as work, leisure activities, and maintaining personal relationships. A ‘mental health problem’ also interferes with how a person thinks, feels, and behaves, but to a lesser extent than a mental illness. Mental health problems are common and include temporary feelings or experiences as a reaction to the stresses of life. However, when a person fails to cope or effectively deal with a mental health problem, it can (over time) develop into mental illness or disorder.

Psychologists and other health care professionals may work with persons in the context of sport, exercise, and physical activity, usually within a competition or training framework, to both improve sporting performance and/or physical activity participation and an individual's wellbeing (i.e. mental health). This interaction is applied across three broad domains:

  1. Performance Enhancement - An individual’s mental state can be either an asset or an obstacle to performance success or participation compliance.
  2. Performance Restoration - Sport is a challenging environment that can at times derail even elite athletes.
  3. Mental Health Promotion and Support - A healthy life balance that includes sport/physical activity participation can help an individual become resilient.
    [Source: The Australian Institute of Sport (AIS) Performance Psychology website]

More information about the application of sport psychology to sporting performance (particularly in a high performance environment) can be found in the Clearinghouse for Sport portfolio, Sports Performance Psychology.

Addressing the third domain, mental health promotion and support, involves many relationships between a sport participant/athlete and other individuals, environments, and conditions, such as: significant others; coaches; administrators; service providers; family and peer networks; the prevailing culture within the sport, club or team, and; team dynamics. Mental health for a sport participant/athlete is also interrelated to mental health as an individual, independent of sports participation.

The challenges faced by athletes, particularly elite athletes, to maintain a balanced state of mental health are similar to those physical challenges they must confront. Physically, an elite athlete must train at a demanding level to enhance their capability; stay healthy and injury free; successfully recover from daily stress and rehabilitate from injuries when they occur; and produce optimum performance in competition. Mentally, an athlete must stay focused on their competitive goals during repetitive training routines; cope with setbacks (including injury and illness when they occur); deal with all manner of performance (both good and bad), and stay mentally tough in competition.

Persons who are resilient to stress and have a positive and realistic perception of themselves (as an athlete and a person) tend to cope with their environment, other individuals, and life activities more successfully.

A number of reasons are put forward to support the synergy between mental health and sport/physical activity participation. Three prominent themes dominate the available literature: (1) a person's state of mind has a significant impact on their performance; (2) participation in sport and physical activities can affect a person’s mood, thinking, personality and health, and; (3) diagnosis and care of an individual’s mental health concerns must consider all life contexts.

Potential positive effects 

Emotional wellbeing is one aspect of good mental health and there is evidence to support the notion that emotional wellbeing supports sport participation and athletic performance, and vice versa. Sport participation appears to have an influence on one’s psycho-social development, even from a very young age and particularly during fundamental (i.e. not elite) stages of sport development.

  • Associations between sports participation and psychological difficulties during childhood: A two-year follow up, Vella S, Cliff d, Magee C and Okely A, Journal of Science and Medicine in Sport, Volume 18, Issue 3 (2015). This paper assessed the associations between sports participation and the development of psychological strengths and difficulties during childhood. A sample (N=4042) of Australian children were followed from age 8 to 10 years. Parents reported children's participation in organised sports, and completed the Strengths and Difficulties Questionnaire. The results indicated that children who maintained participation in sport had lower rates of parent-reported psychological difficulties at 10 years compared with children who dropped out of sport. Less internalising problems were also reported for children who participated in organised sports compared to children who dropped out of sports and children who did not participate in sports. These relationships did not differ by socioeconomic status or parental education.
  • Global self-esteem, perceived athletic competence, and physical activity in children: A longitudinal cohort study, Noordstar J, van der Net J, Kak S, Helders P and Jongmans M, Psychology of Sport and Exercise, Volume 22 (January 2016), published online ahead of print. Two groups of Dutch children were followed; one group from kindergarten to grade 2 and the other group from grades 2 to 4. This study found that an increase in global self-esteem was significantly associated with perceived athletic competence.
  • Sport motor competencies and the experience of social recognition among peers in physical education – a video-based study, Grimminger E, Physical Education and Sport Pedagogy, Volume 18, Issue 5 (2013). Being recognised as a competent and accepted member in the peer group is one of the most important basic human needs for children and adolescents. Often it’s the peer group that decides which competencies are valued and which are not. This study aimed to determine if, and how, sport motor competencies are used as a criterion for recognition or non-recognition among peers. The results of this study show that sport motor competencies and the social position in a peer group are significantly related.

During the years of physical, cognitive and social maturation, there is evidence that children/adolescents’ participation in sport, physical activity and physical education can have a positive effect on their personal wellbeing and mental health.

  • Adolescents and school sport: The relationship between beliefs, social support and physical self-perception (PDF PDF document - 150 KB), Lubans D, Morgan P and McCormack A, Physical Education and Sport Pedagogy, Volume 16, Number 3 (2011). Physical activity declines among adolescents in many countries and strategies to combat this occurrence are included in both educational and public health priorities. This study explored the relationship between students’ beliefs about school sport, social support received during school sport, and self-esteem. This study found that both boys and girls considered school sport an important opportunity to interact with their friends and receive social support.
  • The association between leisure time physical activity in adolescence and poor mental health in early adulthood: a prospective cohort study, Poulsen P, Biering K and Andersen J, BMC Public Health, Volume 16, Issue 3 (2016). This study collected data on 887 boys and 702 girls, age 14 and 15 years, living in the western region of Denmark, to determine their level of leisure time physical activity (LTPA) and mental health (MH). LTPA was scaled into six levels – none, ½ hour/week, 1 hour/week 2-3 hours/week, 4-6 hours/week and, 7 or more hours/week; MH was assessed using a Depression Scale. The subjects were surveyed again at age 20/21 years. This study found that girls having a low LTPA (less than 2 hours/week) during adolescence had an increased risk for poor MH as young adults, compared to adolescent girls having high LTPA. The same relationship was not found among the boys. It also appears that a reduction (i.e. a shift of two or more levels) in LTPA over time, or persistently low level LTPA, increased the risk of depression in young adulthood, for both women and men. This study used self-reporting questionnaires and did not identify the type of physical activity or the intensity. The analysis of data did control for body mass index, initial MH status, smoking status, household income and parental education.
  • Evaluating the relationship between physical education, sport and social inclusion (PDF PDF document - 162 KB), Bailey R, Educational Review, Volume 57, Number 1 (2005). Questions about the outcomes, place and justification of physical education (PE) and school sport continue to generate considerable debate among teachers and educational theorists. This review suggests that there are some areas in which a considerable amount of evidence in favour of the positive relationship between PE and school sport and physical and mental health exists. More recently, policy-makers have begun to stress the social dimensions of sports participation.
  • Social motivation in youth sport (PDF PDF document - 55 KB), Allen J, Journal of Sport & Exercise Psychology, Volume 25 (2003). This study examined the contribution that social goal orientations and perceptions have on youth sport motivation to participate in sports. Evidence suggests that youth sport participants have concerns other than physical competence. That is, individuals’ motivation in sport may not always be related to, or explained by, a desire to demonstrate or develop physical ability. Rather, social concerns such as developing and demonstrating social connections may be equally important. The social opportunities inherent in most sports provide opportunities for individuals to develop social relationships and to feel that they are part of a group. This may enhance their self-esteem and self-perception.
  • Weekly sport practice and adolescent well-being, Merglen A, Flatz A, Bélanger R, Michaud P and Suris J, Archives of Disease in Childhood, published online 20 November 2013. A survey of 1245 adolescents, ages 16 to 20 years, from the general Swiss population compared weekly sports participation time and psychological well-being. The results showed an inverted U-shaped relationship between the duration of weekly sport participation and well-being among adolescents. Peak wellbeing scores were recorded by ‘high activity’ adolescents. The authors infer that engaging in higher or lower durations of physical activity was associated with either greater or lesser perception of wellbeing.
  • What Can Sport Do? The True Sport Report (PDF PDF document - 2.9 MB), Mulholland E, Canadian Centre for Ethics in Sport (2008). This report provides a wide and compelling array of evidence that good sport is good for people and good for communities. In short, ethical sport can make a great difference to personal wellbeing and community cohesion.

At any stage of life, mental health concerns may emerge. Sport, physical activity (e.g. social sport and leisure physical activity) and exercise (i.e. primarily for fitness/health benefits) can be used as an adjunct treatment modality for a range of mental or behavioural conditions. Depression is one common mental health concern that may affect persons at any age. There is a growing body of evidence that supports the use of physical activity, particularly sport participation because of the social interaction benefits, as part of a treatment strategy.

Although not classified as a mental disorder, attention-deficit/hyperactivity disorder (ADHD) is a behavioural condition among children having its origin in brain development. Physical activity and sport participation offers promising results as part of intervention programs for ADHD children. Physical activity is also useful in the treatment/management of other behavioural conditions that may affect mental wellbeing, particularly during childhood and adolescence.

  • Depression and exercise (PDF PDF document - 1.5 MB), Exercise is Medicine Australia, factsheet (2014). People who undertake regular physical activity or exercise, even at low levels, are less likely to experience symptoms of depression and are less likely to experience future depressive episodes. Exercise has a moderate clinical effect on many depressive symptoms, and may be as effective as psychological or pharmaceutical therapies for some individuals. Because physical activity can improve a range of physical functions, it often supports the treatment of mental illness, including depression. A systematic review of research literature indicated that supervised aerobic exercise which is similar to that recommended for the general population, is likely to have beneficial effects on people with depression.
  • Depressive symptomatology, weight status and obesogenic risk among Australian adolescents: a prospective cohort study, Hoare E, Millar L, Fuller-Tyszkiewicz M, Skouteris H, Nichols M, Malakellis M, Swinburn B and Allender S, BMJ Open, Volume 6, Issue 3 (2016). This study examined cross-sectional and longitudinal associations between obesity risk factors and depressive symptomatology in a cohort of Australian adolescents. Data were collected on depressive symptomatology, weight status, physical activity, screen time and diet related measures in a sample of 634 secondary school students (338 males and 296 males), with mean age 13 years at baseline in 2012; follow up data were collected at 15 years of age. The results indicated that males who were classified as overweight or obese at baseline, and remained so over the two years of the study, were at increased risk of depressive symptomatology; and inactivity was predictive of depression. For females, those who increased their consumption of ‘junk foods’ during the study period were at greater risk of developing depressive symptoms. The authors conclude that there are multiple and complex relationships between diet, physical activity and outcomes of obesity and mental health. Healthier diets and increased physical activity should be foundations for mental health among adolescents.
  • Exercise and the treatment of depression: A review of the exercise program variables, Stanton R and Reaburn P, Journal of Science and Medicine in Sport, Volume 17, Issue 2 (2013). A number of randomised controlled trials have demonstrated a reduction in depressive symptoms with both aerobic and non-aerobic exercise interventions. This finding has been supported in a number of systematic reviews and meta-analyses. This review looks at several program variables: frequency, intensity of the physical activity, duration, and type of exercise. This review found that most programs were performed three times weekly and included activities of moderate intensity. All intervention programs predominantly used aerobic exercise; usually treadmill running or outdoor walking, or stationary cycle or elliptical cross trainer exercise. Intervention duration ranged from four to twelve weeks. Both group and individual programs were shown to be effective in lowering the symptoms of depression. Some level of program supervision is recommended. The evidence suggests that supervised aerobic exercise, undertaken three times per week at moderate intensity over a minimum of 9 weeks can contribute to the effective treatment of depression.
  • Exercise as an intervention for first-episode psychosis: a feasibility study, Firth J, Carney R, Elliott R, French P, Parker S, McIntyre R, McPhee J and Yung A, Early Intervention in Psychiatry, published online ahead of print (14 March 2016). Exercise can improve psychiatric symptoms, neurocognitive functioning and physical health in schizophrenia. This study looks at the feasibility of an exercise intervention for early psychosis and to determine if it was associated with changes in physical and mental health. Thirty-one patients with first-episode psychosis were recruited from early intervention services to participate in a 10-week exercise intervention aiming to achieve ≥90 min of moderate-to-vigorous physical activity each week. This study found that negative symptoms were significantly reduced by 33% in the intervention group, compared to controls who did not exercise.
  • Exercise impact on sustained attention of ADHD children, methylphenidate effects (abstract), Medina J, Netto T, Muszkat M, Medina A, Botter D, Orbetelli R, Scaramuzza L Linnes E, Vilela M, and Miranda M, ADHD Attention Deficit and Hyperactivity Disorders, Volume 2, Issue 1 (2010). This study measured the impact of high intensity physical activity (PA) on the sustained attention of 25 children diagnosed with ADHD. The results suggest improvements in cognition after physical effort and that children’s attention deficits can be minimised through PA, irrespective of other treatments. Additional studies are necessary to confirm that exercise mitigates the harmful symptoms of ADHD.
  • The influences of environmental enrichment, cognitive enhancement, and physical exercise on brain development: can we alter the developmental trajectory of ADHD? Halperin J and Healey D, Neuroscience and Behavioral Reviews, Volume 35, Number 3 (2011). Attention-deficit/hyperactivity disorder (ADHD) is characterised by a pervasive pattern of developmentally inappropriate inattentive, impulsive and hyperactive behaviours that typically begin during the preschool years and often persist into adulthood. ADHD is now generally thought of as a chronic disorder that needs treatment throughout the lifetime. This review examines the literature on the neural determinants of ADHD, along with research demonstrating powerful influences of environmental factors on brain development and functioning. Based upon the evidence, the authors propose a treatment approach that employs directed play and physical exercise to promote brain growth which, in turn, could lead to the development of potentially more enduring treatments for the disorder. 

More information can be found in the Clearinghouse for Sport portfolio, Preventive Health, Sport and Physical Activity.

Potential negative effects 

While many studies support the benefits of physical activity and mental health, prolonged intense activity (because of elevated physical stress) may actually have an adverse effect on mood, and there is greater likelihood of overtraining syndrome (which is a mental as well as a physical condition) occurring.

  • Physical activity and mental health: The association between exercise and mood, Peluso M and de Andrade L, Clinics, Volume 60, Number 1 (2005). Physical activity is an important public health tool used in the treatment and prevention of various physical diseases, as well as in the treatment of some psychiatric diseases such as depressive and anxiety disorders. However, studies have shown that in addition to its beneficial effects, physical activity can also be associated with impaired mental health, being related to disturbances like ‘overtraining syndrome’. Although the number of reports of the effects of physical activity on mental health is steadily increasing, the exact mechanisms involved in the benefits and dangers to mental health associated with exercise must be identified. This article reviews the information available regarding the relationship between physical activity and mental health, specifically addressing the association between exercise and mood. 

The psycho-social benefits of sport participation can be undone by unethical or criminal behaviour by persons supervising sport, or by the actions of peers toward one another. Actions that subject sports participants (particularly children and adolescents) to forms of discrimination, harassment and abuse may have an immediate and long-term impact on an individual’s mental health and emotional wellbeing, producing anxiety and depression.

  • Preventing sexual abuse in sport, Foundation for Global Sports Development (2014). Within the context of sport there are several dynamics and situations which make young athletes vulnerable. It is typical for athletes and their parents to trust coaches and other authority figures. This level of trust becomes stronger as athletes progress from novice to elite. Risk factors are generally linked to the culture of a sport or community; some of the risk factors identified for potential sexual abuse of athletes include: (1) an autocratic system; (2) close personal contact between athletes and authority figures; (3) a power imbalance between athlete and coach; (4) separation (time and space) of an athlete from peers; (5) a culture of secrecy; (6) rewards linked to compliance with authority; (7) rules that exclude outside consultation; and (8) lack of formal procedures for screening, hiring and monitoring staff. This article outlines the challenges faced by federations and sports clubs in implementing comprehensive policies to counter situations that may lead to athlete abuse.
  • Summary of the 2010 ethical and integrity issues in Australian sport survey (PDF PDF document - 75 KB), Australian Sports Commission (2010). Research commissioned by the Australian Sports Commission (ASC) and conducted by Colmar Brunton Social Research sought to identify ethical and integrity issues within Australian sport and provide a better understanding of the incidence, prevalence and impact of these issues in the Australian sports system. The survey covered a range of issues that included abuse and violence; inequity and harassment; anti-social behaviours and attitudes, and; athlete wellbeing.

Australian and international sporting organisations have put many policies and procedures in place that address the risk of exposing participants/athletes to situations that may have detrimental mental health outcomes.

More information can be found in the Clearinghouse for Sport portfolios, Child Protection in Sport and Junior Sport Framework.

Ideally, the sporting environment is meant to be one that is socially inclusive and emotionally supportive for all participants. Sport and physical activity can and should have a positive effect on mental and emotional health.

However, some sporting cultures can have the reverse effect on participants’ mental health because of prevailing attitudes, behaviours and values — often based upon gender or sexual identity. There is considerable literature that focuses on the negative impact of masculine and hyper-masculine behaviours and attitudes, which result in gender-based discrimination, aggressive behaviour and homophobia.

In addition, surveys of lesbian, gay, bisexual and transgender (LGBT) experiences in sport have found that deviation from gender and sexuality 'norms' that exist in a sporting culture resulted in hostility or exclusion. Many times LGBT participants in sport feel they have to keep their sexuality hidden from their peers and teammates and this can result in anxiety and depression. LGBT persons frequently report diminished feelings of satisfaction from their sport participation experiences.

  • Actively Engaging Women and Girls, addressing the psycho-social factors (PDF PDF document - 1.9 MB), Johnstone L and Millar S, Canadian Association for the Advancement of Women and Sport and Physical Activity, supplement to Canadian Sport for Life (2012). This report is intended to increase awareness about the experiences of women and girls, and how psycho-social factors influence female athlete development, leadership and life-long participation in sport and physical activity. There are four areas where psycho-social factors present potential barriers to participation among girls and women: (1) intrapersonal, (2) interpersonal, (3) environmental, and policy related.  Intrapersonal variables such as stereo-typed beliefs and values about the appropriateness of female participation in sport; perceived enjoyment and satisfaction related to sport; self-perceptions of competence, body image and physical appearance; are acutely experienced by girls. During childhood and adolescence girls are exposed to many intrapersonal barriers that are, to a large degree, the product of social expectations and cultural influences.
  • Integrity in Sport Literature Review (PDF PDF document - 1.43 MB), Treagus M, Cover R and Beasley C, The Fay Gale Centre for Research on Gender, University of Adelaide, prepared for the Australian Sports Commission (2011). This review of literature was conducted to provide an evidence base for the Australian Sports Commission’s (ASC) ‘National Integrity in Sport Strategy’. The review looked at published material in four areas: (1) negative attitudes, behaviours and values that influence the integrity of sport; (2) the circumstances in which negative attitudes prevail; (3) key drivers or influences on integrity issues, and; (4) the progress, programs and key factors that influence positive behaviours that enhance the integrity of sport.

More information about gender and sexual identity issues in sport can be found in the Clearinghouse for Sport portfolios, Women’s Sport and Sexuality and Gender Perspectives on Sports Ethics.

Evidence suggests that elite and developing athletes, because of their relationship with sport participation, may experience high levels of mental/emotional stress. High performance athletes are exposed to greater stress because they must devote considerable time, physical energy, and emotional investment in their sporting commitment. Developing or pre-elite athletes may be exposed to added family/peer or social pressure to perform. Sport specific stress; on its own, or in conjunction with other life stresses, can present significant challenges. If an athlete lacks resilience, or is unable to manage accumulated stress, their mental health and wellbeing may be compromised. 

Sport also offers the potential for participants to build resilience and strengthen self-concept – to develop ‘mind health’. The known effects of physical activity are underpinned by the physiological response of the body to physical movement, neurochemicals are released in the brain that influence/regulate mood state. These biochemical regulatory responses and their impact on athletes (particularly elite athletes) are explored in a recent book, Wired to Play: The Metacognitive Athlete.

  • Wired to Play: The Metacognitive Athlete, Clews G, self-published (2015). Topics discussed in this book reveal how metacognitive (i.e. the ability to think about our thinking) education through sport can improve an individual’s awareness, reflection and decision making. Examples drawn from developing and elite athletes illustrate how metacognitive outcomes contribute to mental wellbeing or mind health. Athletes who can resolve mental health problems before they descend into a state of mental illness will ultimately be more successful. Chapters in this book deal with contemporary topics that affect elite athletes, such as: anxiety; depression or burn-out; alcohol use; differently gifted (including ADHD) athletes; bipolar disorder; eating disorders; anger; feelings of grief or loss; chasing continuous stimulus; and letting go (retirement from sport).  

Elite athletes may be vulnerable to mental stress for several reasons. The world of elite sports is one that requires large investments of time and energy by an athlete, often resulting in a loss of personal autonomy and disempowerment. The elite-sport environment can result in ‘identity-foreclosure’ leaving the athlete with few other avenues through which to shape and reflect their personality. Linking one’s identity to sport exposes the athlete to psychological stress from the media, the sport’s culture, and public expectations. Loss of identity can be particularly traumatic when the athlete performs poorly, experiences injury, or faces retirement.

The mental stress of elite-level sport can also underpin ‘burnout’, which is defined as emotional exhaustion, a sense of reduced accomplishment, and a devaluation of the athlete’s motivation to participate. Athlete burnout is often associated with overtraining syndrome (i.e. stress having physical as well as mental origins) and may lead to anxiety (mild to clinical) or depression disorder.

Evidence suggests that the inverse relationship – depression contributing to more frequent physical illness – may also be a concern among highly trained athletes.  

The literature on elite athletes provides many examples of psychological vulnerabilities and the mental health issues that may result; such as depressive symptoms, disordered eating, risk-taking behaviours (e.g. hazardous drinking, recreational drug use), and obsessive behaviour. In general, most large sample studies of athletes show that mental health concerns are comparable to the wider population. However, it is worth noting that many case studies of elite athletes show that mental health may be compromised under certain circumstances (e.g. intense pressure to win, injury or illness, poor performance, etc.) because of the accumulated stress. 

  • The stigma of mental health in athletes: are mental toughness and mental health seen as contradictory in elite sport? [editoria], Bauman NJ., British Journal or Sports Medicine, Volume 50 (3), (2016), pp.135-136. Provides a brief history and overview of the prevalence and issues relating to sport culture and athlete mental health. 
  • The dark side of top level sport: An autobiographic study of depressive experiences in elite sport performers, Newman H, Howells K and Fletcher D, Frontiers in Psychology, published online (7 June 2016). This study explored the depressive experiences of top level athletes and the relationship of such experiences with sport performance. Twelve autobiographies of elite athletes representing eight sports were analysed. The analysis revealed that initially, sport represented a form of escape from the depressive symptoms of both external stressors and internal stressors. However, over time, the athletes typically reached a stage when the demands of their sport shifted from being facilitative to being debilitative in nature. For many of the athletes in this study, when their depressive symptoms were at their most intense, sport no longer provided the escape that it once had and a deleterious impact on performance became apparent. The findings support the general psychology literature relating to the negative impact of depression on performance.
  • The mental health of elite athletes: A narrative systematic review, Rice S, Purcell R, De Silva S, Mawren D, McGorry P and Parker A, Sports Medicine, published online (20 February 2016). This review appraises the evidence base regarding the mental health and wellbeing of elite-level athletes, including the incidence and/or nature of mental ill-health and substance use. On the basis of current evidence, elite athletes appear to experience a broadly comparable risk of high prevalence mental disorders relative to the general population. A greater risk of disorder may be experienced by elite athletes who are injured, approaching/in retirement or experiencing performance difficulty.
  • One in five athletes exhibit signs of poor mental health and are at greater risks of illness, Appaneal R, Peterson K, Welvaert M, Vlahovich N, Hughes D, Waddington G and Drew M, Journal of Science and Medicine in Sport, Volume 20, Supplement 1 (2017). Athletes are not immune to poor mental health and the association between stress levels and illness risk are well established in the general population. This study looked at mental health factors (e.g. depression, anxiety and stress) in Olympic level athletes and their relationship to the incidence of physical illness (e.g. upper respiratory tract symptoms, body aches, gastrointestinal, headaches, fatigue and chest symptoms). High scores on the depression questionnaire were associated with increased reports of illness. The authors caution that these results are based upon a symptoms checklist for depression and not a clinical diagnosis by a trained practitioner.
  • Setting the bar: athletes and vulnerability to mental illness, Hughes L and Leavey G, The British Journal of Psychiatry, Volume 200, Issue 2 (2012). This article summarises the growing body of evidence supporting both positive and negative mental health outcomes from elite sport participation.

Survey research on elite Australian athletes indicated that 46% experienced symptoms of at least one mental health issue. This figure is consistent with the Australian Bureau of Statistics survey of the general population, 2007 National Survey of Mental Health and Wellbeing.

The elite athlete survey reported the incidence of depression (27%), eating disorder (23%), general psychological distress (17%), social anxiety (15%), generalised anxiety disorder (7%), and panic disorder (5%). Clearly, being an elite athlete can have a real and significant impact upon mental health. In addition, injured athletes reported higher levels of both symptoms of depression and generalised anxiety disorder.

The symptoms of mental health disorders reported by elite athletes in Australia appear similar to observations in the community. However, caution must be exercised in interpreting findings, as possible demographic differences between athletes and comparison population datasets may exist. Furthermore, self-selection of respondents in the elite athlete study may have reduced the representativeness of the sample. The reported symptoms may be either over-or-under stated. It does appear that athletes who are injured or returning from injury are at particular risk. This study (based on survey results) recommends that elite athletes should be supported and encouraged to seek professional help for mental health concerns as part of the rehabilitation process.

  • The mental health of Australian elite athletes, Gulliver A, Griffiths K, Mackinnon A, Batterham P and Stanimirovic R, Journal of Science and Medicine in Sport, Volume 18, Issue 3 (2015). This study investigated Australian elite athletes’ symptoms of general psychological distress and common mental disorders. A survey design was employed to assess self-reported symptom prevalence in 224 elite athletes (118 female and 106 male) from national sporting organisations.

Evidence suggests that maintaining or improving emotional wellbeing among elite athletes supports good mental health. Three domains are explored when developing interventions and strategies to assist elite athletes; cognitive (i.e. understanding how stress affects the athlete), behavioural (i.e. lifestyle) and social (i.e. support networks). Most interventions employ an integrated approach across all three domains.

  • Athlete social support, negative social interactions, and psychological health across a competitive sport season (abstract), DeFreese J and Smith A, Journal of Sport & Exercise Psychology, Volume 36 (2014). This study examined perceived social support and social interactions as potential moderators of stress and wellbeing in 465 American collegiate athletes. Both social support and negative social interactions represent distinct social experiences that together have the potential to impact on an athlete’s perceived mental health and wellbeing. This study found that the enhancement of social support could be indirectly beneficial to athletes’ psychosocial health and act as a deterrent to negative social interactions. Informed by the present work, strategies to promote positive and deter negative sport-related social experiences merit careful consideration.
  • Barriers and facilitators to mental health help-seeking for young elite athletes: a qualitative study, Gulliver A, Griffiths and Christensen H, BMC Psychiatry, Volume 12 (2012). This study examined what young elite athletes perceive as barriers and facilitators to help-seeking for common mental health problems. Fifteen elite junior athletes, aged 16 to 23, participated in focus group discussions. Participants perceived mental health literacy (i.e. knowledge) and past negative experience when seeking help as the major barriers. Facilitators to help-seeking interventions were encouragement from others (e.g. coach, family, peers) and having an established relationship with an expert source (e.g. sport psychologist or health care professional).
  • Piloting a family-supported approach to concurrently optimize mental health and sport performance in athletes (abstract), Donohue B, Chow G, Pitts M, Loughran T, Schubert K, Gavrilova Y and Allen D, Clinical Case Studies, Volume 14, Number 3 (2015). Participation in sports offers exceptional pro-social opportunities, but it also presents unique stressors that may interfere with athletes’ mental health. This study describes the initial process of empirically developing The Optimum Performance Program in Sports (TOPPS). The authors review the need to adapt evidence-based behavioural interventions to optimise mental health in athletes. Then they highlight the innovative features of TOPPS and report the results of pilot studies. Among the many recommendations made was the need to assist young athletes with their career development and job-getting skills training. Uncertainty of future employment was seen as a significant stress among athletes.
  • Psychological balance in high level athletes: Gender-based differences and sport-specific patterns, Schaal K, Tafflet M, Nassif H, Thibault V, Pichard C, Alcotte M, Guillet T, Helou N, Berthelot G Simon S and Toussaint J, Plos One, published online (4 May 2011). This study aimed to identify the principal psychological problems encountered by French high level athletes, and the variations in their prevalence based on sex and the sport practiced. While the prevalence of psychological problems among elite athletes may be no higher than in the general population, the variations in psychopathology in different sports and by gender suggest that specific constraints could influence the development of some disorders. Overall, generalised anxiety disorder (GAD) was the most prevalent (6%) mental health issue among the elite athletes studied, followed by non-specific eating disorders (4.2%). Among female athletes there was greater anxiety and eating disorders, depression, sleep problems, and self-harming behaviours than among male athletes. The highest rates of GAD appeared in aesthetic sports compared to all other sports; 16.7% vs. 6.8% for men and 38.9% vs. 10.3% for women.

There are several common themes related to athlete mental health reported in the literature. Although athletes may suffer from any/all manner of psychological disorders, commonly reported mental health concerns among athletes include: (1) burnout – diminished satisfaction from sport participation; (2) eating disorders, particularly (although not exclusively) among female athletes; (3) various causes of anxiety and depression – injury or injury rehabilitation, burnout, and retirement from sport are often cited; (4) excessive or risky behaviour – consumption of alcohol and recreational drugs or exercise addiction, and; (5) changes in mood state or cognitive ability – particularly related to recurring head trauma in sport.

  • Sport specificity of mental disorders: the issue of sport psychiatry, Bar K and Markser V, European Archives of Psychiatry & Clinical Neuroscience, Volume 263, Supplement 2 (2013). The authors discuss the issue of the sport specificity of selected mental conditions among athletes. Eating disorders, exercise addiction, and mood disorders are a few of the more common psychiatric problems. The inter-relationships between life and work characteristics that are unique to elite athletes are discussed. The authors suggest that the physical and mental strains experienced by elite athletes might influence the onset and severity of their psychiatric disorders.

Burnout

The symptoms of athlete ‘burnout’ can become a psychological condition and mental health issue (i.e. related to depression) more than simply the physical problems of aging or diminished skills. Stress on an athlete comes from many different sources – training demands, competition, and pressure from coaches, teams, clubs, family, media, etc. The condition known as burnout occurs when the athlete fails to manage stress, or persons and sporting systems fail to moderate stressful situations (i.e. unrealistic expectations for success) that the athlete has little control over.

  • Burnout in elite rugby: Relationships with basic psychological needs fulfilment, Hodge K, Lonsdale Cl and Ng J, Journal of Sports Sciences, Volume 26, Number 8 (2008). This study examined the utility of self-determination theory as a framework for understanding the antecedents of athlete burnout in elite New Zealand rugby union players (N=133). Perceptions of competence, autonomy, and relatedness (i.e. basic psychological needs) were hypothesized to be related to burnout scores. High self-perception of competence, greater autonomy and relatedness would predict a low rate of burnout and ‘high-burnout’ players would report lower needs fulfilment. The results confirmed the hypothesis that players' competence and autonomy accounted for a substantial portion of the variance in the two athlete burnout symptoms.
  • Burnout in sport: A systematic review (PDF PDF document - 147 KB), Goodger K Gorely T, Lavalle D and Harwood C, The Sport Psychologist, Volume 21 (2007). A total of 58 published studies met the selection criteria, 27 focused on athlete burnout and 23 on coach burnout. Correlates were grouped into psychological, demographic, and situational factors. Several themes emerged to explain burnout: (1) lack of motivation and the absence of enjoyment; (2) anxiety due to perceived stress and lack of coping; (3) responses to training and injury recovery; (4) role of significant others, and; (5) loss of identity. Stress and lack of social support were the most common psychological correlates of burnout.
  • A prospective study of the influence of perceived coaching style on burnout propensity in high level young athletes: Using a self-determination theory
    perspective
    (PDF PDF document - 879 KB), Lsoard-Gautheur S, Guillet-Descas E and Lemyre P, The Sport Psychologist, Volume 26 (2012). This study investigated the motivational antecedents of athlete burnout (i.e. coaching style, fundamental psychological needs, and self-determination) using a prospective six-month-follow-up. Subjects (N=514) were French handball players from 15 elite training centres. The current results show that the coaching style is significantly related to psychological needs. A controlling coaching style is negatively linked to autonomy; and a supportive coaching style is positively linked to autonomy and competence. These findings are consistent with theoretical prediction and past research.

Depression

There are many studies that have looked at depression in athlete populations. The majority of studies have come from the United States college system and show mixed results. Some studies report the incidence of depression among athlete groups is above the population mean and some below. In many studies it’s difficult to determine if subjects are elite or sub-elite athletes, or simply sports participants. In general, the development of depressive disorders has many origins and clinical conditions (from mild to serious), so multifactorial models are usually used in the analysis.

Depressive symptomatology in athletes may be linked to both competition-based and everyday life stressors. Often no clear distinction can be made about the origin of the stress or the relative influence of the sporting environment. There are also individual variations in the way athletes, as well as non-athletes, successfully cope with stress. Empirical data supports the existence of depressive symptoms among elite athletes, yet few studies are able to draw clear representative conclusions about elite athlete populations, especially if the clinical validity of assessment criteria is considered.

  • Depression among elite athletes: Prevalence and psychological factors (PDF PDF document - 142 KB), Frank R, Nixdorf I and Beckmann J, Current Sports Medicine Reports, Volume 14, Issue 1 (2015). This paper reviews the current state of research, summarising what is known about the underlying mechanisms leading to depression and trying to answer the question whether or not depression is widespread among elite athletes or similar to the incidence among the general population. In general, the development of depressive disorders has multifactorial causality; there are biological (e.g. genetic), psychological (e.g. cognitive), and social (e.g. relationships and conflict) influences. Looking closer at structures in sport systems and the demands on athletes, factors associated with the incidence of depressive symptoms in elite athletes may include many stressors. Stress may have an exercise-based or competition-based origin; or due to ineffective coping strategies; having social or environmental origins, and; the result of personality traits (i.e. perfectionistic personalities).
  • Prevalence of depression and anxiety in top-level male and female football players, Junge A and Feddermann-Demont N, BMJ Open Sport & Exercise Medicine, Volume 2, Issue 1, published online (19 January 2016). This study evaluated the prevalence of depression and anxiety in top-level Swiss football players in comparison to the general population, and analysed potential risk factors. Data was collected from players of all first league teams (211 males and 182 females) and of four U-21 teams (N=78 males) in Switzerland. Players were asked to complete the Centre of Epidemiologic Studies Depression Scale and the Generalized Anxiety Disorder scale. The results indicated that first league players have about the same prevalence of depression as in the general Swiss population; while depression in male U-21 players was slightly higher. On average, at least one player in each team (both first league and U-21) showed signs of severe depression. Significant differences were observed with regard to player characteristics, such as age, gender, player positions, level of play and current injury.

Nevertheless, the recognition that depression (regardless of its’ origin) is a serious issue among elite athletes must be addressed; first by identifying the symptoms and then applying interventions or changing those conditions that may lead to depression. The end result of dealing with the symptoms of depression is that the athlete, once they understand and confront the origin, is more likely to develop coping strategies or seek assistance from an outside source.

Examples are provided to show the diverse nature of triggers for depressive symptoms.

  • The prevalence of failure-based depression among elite athletes (abstract), Hammond T, Gialloreto C, Kubas H and Hap-Davis H, Clinical Journal of Sport Medicine, Volume 23, Number 4 (2013). This study sought to assess the prevalence of diagnosed failure-based depression and self-reported symptoms of depression within a sample (N=50, 28 men and 22 women) of elite swimmers competing for positions on Canadian Olympic and World Championship teams. About two-thirds of all athletes meet the criteria for some depressive episode during their athletic career, according to their score on the Beck Depression Inventory. However, most symptoms are short-lived and the athlete is not affected. In this study the prevalence of depression was double among the top 25% of athletes, based on their pre competition performance ranking. Within the top group of athletes, performance failure was significantly associated with depression. These findings suggest that the prevalence of depression among elite athletes may be higher than has been previously reported in the literature. Given these findings, it is important to consider the mental health of athletes and have appropriate support services in place, particularly for those athletes at the top end of elite sport.
  • The psychosocial aspects of a return to sport following serious injury: A review of the literature from a self-determination perspective, Podlog L and Eklund R, Psychology of Sport and Exercise, Volume 8, Issue 4 (2007). This review of literature focuses on the psychosocial aspects of a return to sport following injury, using a self-determination theoretical framework. Two important developments have promoted interest in the study of how athletes cope with a return to competition after injury. First, it has increasingly been recognised that physical and psychological readiness to return to sport after injury do not always coincide. Second, advances in medical treatment means that athletes suffering serious injury are now more likely to return to play. Therefore, the number of returning athletes who are physically but not necessarily psychologically prepared to re-enter training and competition may also be on the rise. This review analyses 80 published studies.
  • Psychology and socioculture affect injury risk, response, and recovery in high-intensity athletes: a consensus statement, Wiese-Bjornstal D, Scandinavian Journal of Medicine & Science in Sports, Volume 20, Supplement 2, p103-111 (2010). This consensus statement summarises key contemporary research themes relevant to understanding the psychology and socio-culture of sport injury.

Most elite athletes are likely to experience injury during their career, with an estimated 10–20% of elite athletes warranting clinical intervention for their depression or anxiety as a consequence of their injury or rehabilitation. [source: Setting the bar: athletes and vulnerability to mental illness]

Eating disorders

Anorexia nervosa and bulimia are psychological disorders. Athletes in aesthetic sports, where subjective scores are influenced by appearance and movement qualities; athletes competing in sports having body weight classifications; and/or athletes in sports with high power-to-weight demands are most at risk of developing eating disorders. In addition to physical appearance, some athletes make inappropriate eating decisions on the assumption that energy restrictions may improve their performance. Athletes adopting dietary habits that are not substantiated by nutritional science may also be at risk of disordered eating practices. Disordered eating may have serious psychological impacts on athletes as well as affecting their physical health and athletic performance.

  • 2016 update on eating disorders in athletes: A comprehensive narrative review with a focus on clinical assessment and management, Joy E, Kussman A and Nattiv A, British Journal of Sports Medicine, Volume 50, p154-162 (2016). Eating disorders are devastating psychiatric conditions. Athletes appear to be at risk for eating disorders, given the pressure to achieve a body composition that optimises performance. While females are affected more commonly than males (at nearly a 9:1 ratio), both sexes are at greatest risk for eating disorder in sports where leanness confers a competitive advantage. Screening for disordered eating behaviours, eating disorders and for related health consequences should be a standard component of pre-participation examinations. Athletes with eating disorders should undergo thorough evaluation and treatment by an experienced multidisciplinary team. Efforts to prevent eating disorders should be aimed at athletes, coaches, parents and athletic administrators, and focused on expanding knowledge of healthy nutrition in support of sport performance and health.
  • Aspects of disordered eating continuum in elite high-intensity sports, Sundgot-Borgen J and Torstveit M, Scandinavian Journal of Medicine & Science in Sports, Volume 20, Issue Supplement 2 (2010). Disordered eating behaviour progresses along a continuum – from dieting and restrictive eating, to abnormal eating behaviour, and finally clinical eating disorders. The prevalence of eating disorders among elite athletes may be due to: (1) a perception of one’s appearance in the specific sport; (2) perceived performance improvements from a loss of body fat or weight, and; (c) sociocultural pressures for thinness or an ‘ideal’ body. Athletes most at risk for disordered eating are those involved in sports emphasising a thin body size/shape, a high power-to-weight ratio, and/or sports utilizing weight categories. Data among athletes may vary by sport, performance level, and the methodology of the research. This paper presents an overview of the following aspects of disordered eating: (1) the disordered eating continuum; (2) the prevalence of disordered eating and trends over time; (3) risk factors; (4) health and performance consequences; (5) how to approach athletes with symptoms of disordered eating, and; (6) preventive strategies.
  • Eating disorder pathology in elite adolescent athletes (abstract), Giel K, Hermann-Werner A, Mayer J, Diehl K, Schneider S, Thiel A and Zipfel S, International Journal of Eating Disorders, published online ahead of print (15 February 2016). This study investigated the eating disorder pathology in 1138 elite adolescent German athletes, representing a number of sports. Evidence from senior elite athletes suggests that eating disorder pathology is more common among female athletes and in sports emphasising leanness. This study specifically looked at elite adolescent athletes (male and female) to determine if their developmental stage increased vulnerability to general as well as sport specific risk factors associated with eating disorders. This study found that among elite German adolescent athletes, high risk groups were from: (1) weight dependent sports; (2) athletes who felt negatively affected by body image; (3) female athletes, and (4) male athletes competing in endurance or power sports. The increased psychosocial burden in athletes demonstrating eating disorder pathology was associated with higher levels of depression and anxiety than athletes without eating disorder pathology.
  • Female athletes and eating problems: A meta-analysis, Smolak L, Murnen S, and Ruble A, International Journal of Eating Disorders, Volume 27, p371–380 (2000). Data from 34 studies were used to examine the overall relationship between athletic participation and eating problems. Athletes appeared to be somewhat more at risk for eating problems than non-athletes. Elite athletes, especially those in sports emphasizing thinness, were at greater risk.
  • The first epidemiologic survey among Hungarian elite athletes: eating disorders, depression and risk factors (English abstract), Resch M and Haasz P, PubMed (2009). Before the 2008 Olympics Hungarian elite athletes attending training camps were surveyed to acquire demographic and training data, self-reported information on the incidence of anorexia nervosa and bulimia. Subjects represented six Olympic sports, with the average age of athletes being 22 years. The self-reported prevalence of anorexia nervosa was 16% and bulimia nervosa 7%. However, the prevalence of depressive episodes attributed to eating behaviours or body image was 74% of the athletes surveyed (both male and female).
  • A longitudinal investigation of sports-related risk factors for disordered eating in aesthetic sports, Krentz E and Warschburger P, Scandinavian Journal of Medicine & Science in Sports, Volume 23 (2013). Participants in this study were 65 adolescent athletes, mean age 14 years, from aesthetic sports. Analysis of data showed that the desire to be leaner to improve sports performance was predictive of disordered eating. Athletes are more at risk for disordered eating if they believe it is possible to enhance their sports performance through weight regulation.
  • Parental influences on elite aesthetic athletes’ body image dissatisfaction and disordered eating (abstract), Francisco R, Narciso I and Alarcao M, Journal of Child & Family Studies, Volume 22 (2013). Gymnasts are at greater risk of developing eating disorders. This study looked at 227 adolescents (85 gymnasts and 142 controls), mean age 14.6 years, and their parents. The purpose of the present study was to explore the role of specific family variables in elite aesthetic athletes’ body image dissatisfaction and disordered eating. Among the athletes, direct parental influences are the only significant predictive family variable, which may reinforce the pressure to be thin found within elite-gymnasts. This study’s findings highlight the need to target appropriate parental behaviour and attitudes in prevention strategies.
  • Prevalence of eating disorders in elite athletes is higher than in the general population, Sundgot-Borgen J and Torstveit M, Clinical Journal of Sport Medicine, Volume 14, Issue 1 (2004). This study examined the prevalence of anorexia nervosa, bulimia nervosa, anorexia athletica, and eating disorders not otherwise specified in both male and female Norwegian elite athletes (N=1620) and a representative sample from the general Norwegian population (N=1696). Self-reporting questionnaires and clinical interview were used to collect data. The results indicated prevalence of eating disorders (all types, combined) is higher in athletes than in controls; higher in female athletes than in male athletes; and more common among those competing in leanness-dependent and weight-dependent sports than in other sports. The authors recommend that a collaborative effort among coaches, athletic trainers, parents, physicians, psychologists, and athletes is optimal for recognising, preventing, and treating eating disorders in athletes.
More information can be found in the Clearinghouse for Sport portfolio, Female Athlete Triad.

Excessive behaviours (alcohol and drug use)

The excessive use of alcohol or recreational and prescription drugs represents excessive or risky behaviour that may reflect a number of psychological symptoms – anxiety, depression, poor self-image, loss of emotional control, etc.

  • Alcohol-related aggression and antisocial behaviour in sportspeople/athletes, O’Brien K, Kolt G, Martens M, Ruffmane T, Millerf P and Lynott D, Journal of Science and Medicine in Sport, Volume 15, Issue 4 (2012). This study collected data from male Australian university sportspeople. Participants and a suitable non-athlete control group completed questionnaires on alcohol consumption and aggressive, antisocial behaviours when intoxicated. Consistent with studies from the US, alcohol-related aggressive and antisocial behaviours were greater in male Australian university sportspeople/athletes when compared to non-sporting counterparts. The researchers suggested a need for further research to determine the interaction between alcohol, contextual and cultural aspects of sport, and sport participants.
  • The association between sports participation, alcohol use and aggression and violence: a systematic review (PDF PDF document - 668 KB), Sønderlund A, et. al., Journal of Science and Medicine in Sport, Volume 17, Issue 1 (2014). This article reviewed the research literature on alcohol consumption patterns among sports participants and non-participants. The majority of studies were from the US and focused on collegiate athletes, adolescents, and professional athletes. The available evidence indicates there are higher rates of alcohol use in some athlete populations. However, the relationship between sport participation and alcohol use appears to be contingent, to a degree, on many other contextual factors. This is likely due to the specific drinking culture, norms and expectations that exist within a certain sport, club or team. Research on high-frequency alcohol consumption and high-volume alcohol consumption among athletes indicates that some contextual factors can predict the risk of alcohol-related violence.
  • Drug abuse in athletes, Reardon C and Creado S, Substance Abuse and Rehabilitation, Volume 5 (2014). Athletic life may lead to drug abuse for a number of reasons, including both performance enhancement and to cope with stressors; such as pressure to perform, injuries, physical pain, and depressive symptoms upon retirement from sport. This review examines the history of doping in athletes, the effects of different drugs, the role of anti-doping organisations, and the treatment of affected athletes.
  • A risk profile of elite Australian athletes who use illicit drugs (abstract), Dunn M and Thomas J, Addictive Behaviors, Volume 37, Issue 1 (2012). A Deakin University survey of 1684 elite Australian athletes, representing 18 different sports, found that only 8% of elite athletes self-reported using illicit drugs, such as ecstasy, cocaine, and cannabis. The survey also found that respondents identifying themselves as ‘full-time’ athletes were more likely to engage in illicit drug use. The results of the study also suggest that engaging in worthwhile off-field pursuits (outside of sport) had an important role in protecting athletes from drug use.

There is evidence that alcohol availability at many Australian sporting venues and alcohol consumption within the context of celebration, team bonding, and mateship is part of the culture in some sports; this may influence the alcohol consumption of athletes. There are numerous social and personal factors that determine whether an athlete consumes alcohol, in what setting, and to what extent (moderate to excessive consumption). Research and anecdotal evidence suggests that athletes with emerging mental health issues, particularly those athletes under stress or prone to depressive symptoms, may engage in risky alcohol consumption. Because of the biochemical influence of alcohol on brain function, other mental health concerns (e.g. bipolar disorder among other conditions) may also be compounded by alcohol consumption.

  • Alcohol and depression, Royal College of Psychiatrists, United Kingdom. Alcohol consumption may appear to some people as an effective way of feeling better in the short term. Persons with depression can easy slip into drinking regularly, using alcohol as if it was a medication. However, alcohol affects the chemistry of the brain, increasing the risk of depression.
  • Alcohol consumption in sport: the influence of sporting idols, friends, and normative drinking practices (abstract), O’Brien K, Kolt G, Webber K. Kypri K, and Hunter J, Drug and Alcohol Review, Volume 29, Number 6 (2010). This study examines whether sportspeople and non-sportspeople at two Australian Universities (N=1058) have similar or different perceptions of high-profile sportspeople's (sports stars) and friends drinking behaviours, and whether these perceptions are related to their own drinking behaviours. Contrary to expectations, high-profile sportspeople were not perceived as role models and their perceived drinking was not predictive of university students’ drinking. However, the drinking patterns of friends and the perception of normative drinking practices were predictors of drinking behaviours among the university students.
  • The culture and context of alcohol use in community sporting clubs in Australia: Research into ‘attitudes’ and ‘behaviour’ (PDF PDF document - 121 KB), Duff C, Scealy M and Rowland B, Centre for Youth Drug Studies, Australian Drug Foundation (2005). This study looked at the relationship between alcohol and sport in Australian society. Many professional and amateur sporting clubs are sponsored by alcohol companies, as well as high profile national and international sporting events. Also, the associations between elite level sport and the consumption of alcohol may affect the way the consumption of alcohol is perceived. A number of studies now suggest that alcohol misuse is too common within community level sporting clubs around Australia. This may lead to greater frequency of risky if not dangerous consumption. Given the prevalence of alcohol consumption within sports environments, significant risks and harms may exist.
  • Risky alcohol use in young persons with emerging bipolar disorder is associated with increased oxidative stress (abstract), Chitty K, Lagopoulos J, Hickie I and Hermens D, Journal of Affective Disorders, Volume 150, issue 3 (2013). Young persons with emerging bipolar disorder who drink at risky levels experience increased oxidative stress and its resulting neurotoxic effects that may be especially detrimental.

Mood disorders and cognitive decline

Studies on athletes exposed to head trauma indicate a range of symptoms and mental health outcomes; including cognitive disturbances and changes in personality/behaviour, even clinical depression and suicide. The personal long-term effects of sport related brain injury are emerging in the research literature. Athletes, particularly those participating in ‘collision’ sports may experience mood, personality and cognitive changes during or after their competitive careers. Athlete mental health disturbance may be a consequence of brain injury.

  • Head injury as risk factor for psychiatric disorders: A nationwide register-based follow-up study of 113,906 persons with head injury, Orlovska S, Pedersen M, Benros M, Mortensen P, Agerbo E and Nordentoft M, The American Journal of Psychiatry, Volume 171, Issue 4 (2014). A head injury, especially a severe head injury or one occurring between the ages of 11 and 15, increased the risk for subsequent schizophrenia by 65%, the risk of depression by 59%, the risk of bipolar disorder by 28%, and the risk of organic mental disorders by more than 400% in this largest-to-date analysis of data. The authors used data from Danish nationwide population-based registers to investigate the incidence of mental disorders in persons who had suffered head injuries.
  • Recurrent concussion and risk of depression in retired professional football players (PDF PDF document - 793 KB), Guskiewicz K, Marshall S, Bailes J, McCrae M, Harding H, Matthews A, et.al., Medicine and Science in Sports and Exercise, Volume 39, Number 6 (2007). This study investigated the association between prior head trauma and the likelihood of being diagnosed with clinical depression among retired professional football players (US ‘gridiron’ football). Data was sourced from a questionnaire completed by 2552 retired professional football players, mean age 54 years. About 11% reported having prior or current diagnosis of clinical depression. There was an association between past history of concussion and lifetime history of depression. Compared with retired players with no history of concussion, retired players reporting three or more past episodes of concussion were three times more likely to be diagnosed with depression. These findings emphasise the importance of understanding the potential neurological consequences of recurrent concussion.
  • What is the evidence for chronic concussion-related changes in retired athletes: behavioural, pathological and clinical outcomes? McCrory P, Meeuwisse W, Kutcher J, Jordan Band Gardner A, British Journal of Sports Medicine, Volume 47, p327-330 (2013). This paper reviews the current state of evidence for chronic traumatic encephalopathy (CTE) in retired athletes and diagnostic considerations when retired athletes present with cognitive and psychiatric problems.

More information can be found in the Clearinghouse for Sport portfolio, Sports Concussion and Head Trauma.

Through socialisation, athletes learn and adopt certain attitudes, beliefs and behaviours from their coaches. Therefore, coaches play an important role in positively shaping athletes’ views about how they prioritise their wellbeing.

Coaches can promote mental health and wellbeing by:

  • Encouraging and supporting athletes to have a healthy life balance;
  • Reducing the stigma around seeking help when there is a problem;
  • Understanding stressors faced by athletes, and the impact they can have on mental health and sporting performance;
  • Seeking the help of a professional in supporting those athletes with known mental health problems.

Coaches who identify and discuss mental health concerns with their athletes can increase the likelihood that the athlete will seek help, which in turn can promote a quicker recovery. Coaches with a basic understanding of mental health issues are also better placed to monitor athletes’ behaviour. Symptomatic behaviours associated with mental health disorders that coaches might observe include (this is by no means an exhaustive list):

  • Unexplained weight loss;
  • Drug and/or alcohol use;
  • Withdrawing from social contact;
  • Decreased interest in activities that they used to enjoy;
  • Talking about death, dying, or “going away”;
  • Loss of emotion, or sudden changes of emotion within a short period of time;
  • Problems with concentration, focusing or remembering;
  • Frequent complaints of fatigue, illness, or being injured that prevent sporting participation;
  • Unexplained wounds or suspected self-harm;
  • Becoming more irritable or irrational.

If a coach notices any of these behaviours, or has cause for concern about an athlete’ emotional wellbeing, they should refer them to the team psychologist or doctor or mental health professional.

If there are no team medical staff, the coach should discuss with the athlete his/her possible options for seeking help. If the athlete is a minor, the coach should discuss the observed behaviour with the athlete and/or parents or guardians (jointly or separately as deemed appropriate).

It is important to note that unless a coach is also a mental health professional, they should refrain from “counselling” an athlete who may be experiencing a mental health issue. If an athlete reports suicidal feelings or potential harm to themselves or others, the coach should link them with professional help immediately.

[source: Australian Institute of Sport, Performance Psychology. Information for Coaches provided by Kate Wensley, Residential Athlete Counsellor, AIS.]
 

Canada

Team Canada and partners announce Game Plan to help athletes, Hossain A, Canadian Olympic Committee, published online (24 September 2015). After extensive consultation with stakeholders, the Canadian Olympic Committee has announced ‘Game Plan’. The importance of mental health, financial insight, and post-athletic career preparation are three areas of concern for Canada’s elite Olympic and Paralympic athletes. To address athlete needs, five areas have been identified as ways to help athletes now and in the future: (1) mental health; (2) career management; (3) education; (4) (non-sporting) skills development, and; (5) mentor network.

The program has four key strategies for mental health among the high performance sport community: (1) increasing awareness of mental health problems and the importance of early identification; (2) awareness of the impact of mental health during ‘down time’ and implementing return-to-sport/work plans; (3) prevention measures that increase knowledge of the resources available for support, and; (4) intervention.

The program takes a holistic approach to athlete development and total wellness throughout an athlete’s high performance sport career, and beyond. This enables the development of mentally stronger athletes who can apply what they have learned. The program also addresses athletes’ most pressing needs – career development, personal development, and healthy minds and bodies.

New Zealand

HEADFIRST. New Zealand Rugby. This site was created to help players, coaches, support staff and families in the rugby community to support their own wellbeing and that of others. It provides information, strategies and tips, and videos from players talking about their experiences, relating to mental health and fitness, as well as links to additional information and service providers. 

  • What the All Blacks can teach athletes about accepting mental vulnerability. Mikel Mellick, Senior Lecturer in Athlete Mental Health, Cardiff Metropolitan University, The Conversation, (7 July 2017).  This article provides an overview of some the issues that athletes may experience in trying to discuss or seek help for mental illness as well as highlighting the attitude of the All Blacks rugby team which emphasises that mental health vulnerability is seen as manageable, not a character flaw or a lack of 'toughness'. 

United Kingdom

Mental Health Charter for Sport and Recreation (PDF PDF document - 394 KB), Sport and Recreation Alliance, United Kingdom. The Sport and Recreation Alliance in conjunction with the Professional Players Federation and with support from the mental health charity Mind, have created this Charter. Surveys tell us that one-in-four persons will face a mental health challenge, yet we are reluctant to talk about underlying mental health issues. The Charter asks National Governing Bodies of Sport to commit to these principles: (1) use the power of sport to promote wellbeing, with special focus on encouraging physical activity and social interaction; (2) publically promote good mental health policies and best practice within the sport and recreation sectors; (3) promote positive mental health messages using role models to reduce the stigma attached to mental health problems; (4) actively tackle discrimination that’s based on mental health to ensure that everyone is treated with dignity and respect; (5) work closely with the mental health sector to develop best practice, and; (6) take positive action and monitor and assess progress.

Sporting Chance. Professional Footballers Association (PFA), (20 August 2-14). The PFA provides support and funding for the Sporting Chance Clinic, that provides dedicated counselling, education, and residential treatment for current and former professional sportspeople. The Clinic was started by former Arsenal and England captain Tony Adams MBE inspired by his own experience in recovering from alcoholism. 

United States

2014-2015 NCAA Sports Medicine Handbook, 25th edition (PDF PDF document - 5.6 MB), National Collegiate Athletic Association, Indianapolis, Indiana (2014). This handbook contains a chapter on ‘Mental Health: Interventions’ as one of many medical issues that NCAA student-athletes may experience. The full range of mental health issues found in the general student population can also be found in the life of a student-athlete. The mental health of a college student is challenged by any number of factors of student life, and participation in athletics does not provide the student-athlete with immunity from mental health issues. Rather, participation in intercollegiate athletics imposes additional stressors on the student-athlete that can increase the risk for mental health issues.

Athletes Connected. This program, developed with initial funding from an NCAA Innovations in Research and Practice Grant, is a unique collaboration between the University of Michigan School of Public Health, Depression Center, and Athletic Department that aims to change the culture regarding the mental health and well-being of student athletes at the University of Michigan, and beyond. The site features videos from two former Michigan who have successfully addressed their mental health struggles.

  • Athletes Connected: Inside the University of Michigan’s new approach to mental health for athletes, Zarley B, Vice Sports, published online (19 May 2016). Athletes Connected, is the University of Michigan's athlete-focused mental health program. It is a joint effort of the University's Depression Center, the School of Public Health, and the University’s athletic department. The program aims to combat the stigma around mental illness and encourage athletes suffering from mental health problems to seek help; it aims to do this by helping them understand more about mental health issues, and by making help more readily available. The biggest impact that Athletes Connected may have beyond the University of Michigan campus lies in the program's research component that serves as a model of best practice among US universities.

Websites

Telephone services

Online mental health resources

  • E-couch - E-couch is a free and fun online program providing evidence-based information about emotional problems (including depression and anxiety disorders) and teaches strategies that may help you to prevent problems and understand yourself better. E-couch is not appropriate for crisis assistance.
  • The moodGYM - moodGYM is a free, fun, and interactive program providing information to help you identify and overcome problem emotions related to depression and teaches you how to develop good coping skills for the future. moodGYM is not appropriate for crisis assistance.

Research

  • The associations between sedentary behaviour and mental health among adolescents: a systematic review, Hoare E, Milton K, foster C and Allender S, International Journal of Behavioral Nutrition and Physical Activity, Volume 13, published online (8 October 2016). Sedentary lifestyle is associated with increased risk of non-communicable diseases and obesity. Evidence also suggests that sedentary activity impacts with mental health. This systematic review of literature examines the associations between sedentary behaviour and mental health problems among adolescents. Mental health measures reported in the literature were: anxiety symptoms; self-esteem; suicide ideation; loneliness; stress; and psychological distress. Strong consistent evidence was found for the relationship between both depressive symptomatology and psychological distress, and time spent using screens for leisure (i.e. screen time). Moderate evidence supported the relationship between low self-esteem and increased screen time. Poorer mental health status was found among adolescents engaged in leisure screen time more than three hours per day, some gender differences existed by age-group.
  • Coping strategies among long-term injured competitive athletes: A study of 81 men and women in team and individual sports (PDF PDF document - 606 KB), Johnson U, Scandinavian Journal of Medicine and Science in Sports, Volume 7, p367–372 (1997). Differences in personality, mood and coping ability between elite athletes with long-term injuries (N=81, mean age 24 years) and a matched non-injured group (N=64) were investigated. Although no differences in basic personality traits were found, being injured was found to result in more frequent depressed mood state. Women were found to become more anxious and tense and to have a stronger inclination to use emotion-focused coping strategies. Team-sport athletes were found to cope more in terms of ‘passive acceptance’ of help from others, whereas individual athletes were found to activate ‘problem-solving’ strategies. The results suggest that social aspects of rehabilitative work are important and support the concept that rehabilitative work with long- term injured athletes should be individualised for maximum effect.
  • Depressive symptoms and subclinical vascular disease: the role of regular physical activity (abstract), Mheid I, Held E, Uphoff I, Martin G, Dunbar S, Bidulescu A, Gibbons G, Jones D, Vaccarino V and Quyyumi A, Journal of the American College of Cardiology, Volume 67, Number 2 (2016). Psychological stress triggers a cascade of physiologic responses and increases the risk of vascular disease leading to atherosclerosis. Persons with depressive symptoms have a three-fold increased risk, compared with the general population. This study involved over 900 subjects (mean age 49 years), free of heart disease at the start of the trial. The study highlighted the association between mental health and increased risk of vascular disease, and the possible mediating effect of exercise. This study found that exercise had positive effects of exercise for all patients, including those with depressive symptoms. Depressed subjects who were not physically active (meeting the government recommendations for physical activity) were at greater cardio-vascular risk. This study suggests that exercise may reduce the chances of developing heart disease for persons with depression.
  • Eating attitudes, body shape perceptions and mood of elite rowers, Terry P, Lane A and Warren L, Journal of Science and Medicine in Sport, Volume 2, Issue 1 (1999). This study assessed the influence of age, gender and weight category upon eating attitudes, body shape perceptions, and mood state in 103 elite rowers participating in the 1996 World Championships. Depression, confusion, and tension scores collectively predicted 37% of the variance on the Body Shape Questionnaire scores. The results provide further evidence that the risk of eating disorders among elite rowers is moderated by age, gender and weight category. The authors suggest that measures of mood state may help identify athletes at risk from eating disorders.
  • Examining possible relationships between self-determination and burnout among junior athletes in sport (abstract), Moen F, Federici R and Abrahamsen F, International Journal of Coaching Science, Volume 9, Number 2 (2015). This study assessed 483 Norwegian junior athletes to determine whether need satisfaction was a predictor of burnout. An optimal balance in training and completion loads, school or work commitments, emotional stress, and emotional regeneration/recovery increased the athletes’ level of autonomy, competence, and relatedness. These psychological components are fundamental to self-determination theory. This study found that environments that support optimal functioning (across sport, school and social contexts) will negate the stressors associated with burnout. One possible explanation of the results was that the coping strategies of elite junior athletes are strengthened when they can display competence in areas outside of sport (i.e. school and social environments).
  • A grounded theory of psychological resilience in Olympic champions, Fletcher D and Sarkar M, Psychology of Sport and Exercise, Volume 13 (2012). It has been established that an athlete’s ability to manage stress is a prerequisite of sporting excellence. Twelve Olympic champions (8 men and 4 women) were interviewed regarding their experiences of withstanding pressure in competition. Analysis of responses indicate that numerous psychological factors (e.g. positive personality, focus, motivation, confidence, and perceived social support) protect these athletes from the potentially negative effect of stress. The grounded theory of psychological resilience provides athletes, coaches and sporting organisations with a rationale for building resilience as a means of obtaining optimal sport performance.
  • Holistic life-span health outcomes among elite intercollegiate student-athletes (PDF PDF document - 254 KB), Sorenson S, Romano R, Scholefiend R, Martin B, Gordon J, Azen S, Schroeder E and Salem G, Journal of Athletic Training, Volume 49, Issue 5 (2014). Competitive sport can have both benefits and risks to physical and mental health. This study sought to assess the life-span health (physical and mental) outcomes of elite intercollegiate student-athletes. A sample of 496 current and former intercollegiate athletes were age-matched with non-athlete controls (age range of subjects was 17 to 84 years). On measures of self-reported mental health, the current intercollegiate athletes had better psychosocial health than the non-athlete cohort. There was no difference in the psychosocial health of former athletes and non-athletes.
  • Influence of physical activity on depression and anxiety of former elite athletes (abstract), Backmand H, Kaprio J, Kujala U and Sarna S, International Journal of Sports Medicine, Volume 24, Number 8 (2003). This study investigated the influence of physical activity and other factors on the mood state of former elite male athletes and controls. Variables associated with depressive and anxiety symptoms were assessed for 664 former athletes and 500 age-matched controls. The results indicated that physical activity had a protective effect against depressiveness among former athletes, when compared to controls. An increase of one MET-unit (hour/day) statistically significantly decreased the risk of depressiveness by 8 %. No significant association about anxiety was found between former athlete and control groups.
  • Internet-based interventions to promote mental health help-seeking in elite athletes: An exploratory randomized controlled trial, Gulliver A, Griffiths K, Christensen H, Mackinnon A, Calear A, Parsons A, Bennett K Batterham P and Stanimirovic R, Journal of Medical Internet Research, Volume 14, Number 3 (2012). Despite the incidence of mental disorders among young people, they are less likely to seek professional help for their problems. This study tested the feasibility and efficacy of three internet-based interventions designed to increase mental health help-seeking attitudes, intentions, and behaviour in young elite athletes (N=59) compared with a control condition. At post-intervention, there was a trend toward a greater increase in help-seeking behaviour from formal sources among athletes compared with control. However, the study findings should be treated with caution, due to recruitment challenges (i.e. 120 athletes agreed to participate but only 59 completed the pre/post survey); the achieved sample size fell significantly short of the target size and the study was underpowered. Accordingly, the results should be considered as providing preliminary pilot data only. The results suggest that mental health literacy and de-stigmatization improves knowledge and may decrease stigma but does not automatically increase help-seeking.
  • Junior athletes’ goal orientation, motivation, and emotional and physical exhaustion (abstract), Moen F, Defderici R and Skaalvik E, International Journal of Coaching Science, Volume 8, Number 2 (2014). This study explored the relationships between goal orientation, motivation, and emotional and physical exhaustion (i.e. burnout) among elite Norwegian junior athletes. The results indicated that mastery orientation (i.e. performance improvement) is strongly related to intrinsic motivation, which predicts resilience to burnout. Performance orientation (i.e. winning or losing) is strongly related to extrinsic motivation, which is positively related to emotional exhaustion.
  • Living, resisting, and playing the part of athlete: Narrative tensions in elite sport, Carless D and Douglas, Psychology of Sport and Exercise, Volume 14, Issue 5 (2013). This study used narrative interviews of 21 elite and professional athletes to gain a psychological and sociological understanding of their elite sport experiences. Analysis of the language used helped the authors to determine important psycho-social variables. Although elite and professional athletes’ stories revolved around performance (i.e. sporting accomplishments), this was not the prerequisite for their self-assessment of sporting excellence. Athletes sustaining a multidimensional life experience (e.g. sport, education, work, family relationships) reported a more positive self-image.
  • Managing psychiatric issues in elite athletes (abstract), Glick I, Stillman M Reardon C and Ritvo E, The Journal of Clinical Psychiatry, Volume 73, Number 5 (2012). The authors conducted a literature search to determine the scope and frequency of psychiatric treatment of athletes for various conditions. The search found no systematic data to guide treatment of elite athletes. The authors present four case studies and make these recommendations to medical professionals to improve clinical treatment of elite athletes: (1) be flexible in scheduling treatment; (2) involve family members whenever possible; (3) do not compromise on treatment (athletes often expect ‘special treatment’), and; (4) include medications and hospitalisations as necessary.
  • Mental Health in Athletes. British Journal of Sports Medicine, Volume 50 (3), (2016). This American Medical Society for Sports Medicine (AMSSM) theme issue assembles a group of experts in the field of sports mental health to identify current challenges, barriers, and progress through a series of informative reviews and editorials.
  • Mindfulness and its relationship with perceived stress, affect, and burnout in elite junior athletes (PDF PDF document - 342 KB), Gustafsson H, Skoog T, Davis P, Kentta G and Haberl P, Journal of Clinical Sport Psychology, Volume 9 (2015). This study examined the relationship between dispositional mindfulness and burnout and whether this relationship is mediated by perceived stress in elite junior athletes. Training load and competition place considerable stress on elite junior athletes. Additional factors; such as personal relationships, school or work demands, and other everyday stressors; can overload an athlete’s ability to cope. Some research indicates that mindfulness is associated with lower levels of burnout in athletes. Based on the traditions of meditation, mindfulness is a means of lowering anxiety and reducing stress. Participants in this study were 233 Swedish elite adolescent athletes (123 males and 107 females) ranging in age from 15 to 19 years. Mindfulness was measured using a Mindful Attention Awareness Scale. In this study, mindfulness appears to mediate the negative effect of stress and its role in precipitating burnout. In this preliminary research, the results suggest that being mindful is beneficial as a means of reducing stress, although the potential mechanisms in this relationship are not entirely known.
  • Performance Matters: Mental health in elite sport (PDF  PDF document - 1.5 MB), Mind (2014). Following the increasing number of high profile sportspeople who have spoken out about struggles with their own mental health, and some tragic suicides, Mind commissioned research to explore how sports’ governing bodies and players’ organisations in Britain currently respond to, manage, and prevent mental ill-health amongst athletes. This report also identifies successful programs that can be shared with other sports.
  • Preseason Anxiety and Depressive Symptoms and Prospective Injury Risk in Collegiate Athletes. Hongmei Li, Jennifer J. Moreland, Corinne Peek-Asa, Jingzhen Yang, American Journal of Sports Medicine, Volume 45(9), (July 2017), pp. 2148-2155. This article suggests that athletes with anxiety symptoms at preseason were at an increased risk of injuries during the prospective season. Targeted programs could focus on psychological health and injury prevention for athletes, especially for those exhibiting symptoms at preseason.
  • Prevalence of eating disorders and the predictive power of risk models in female elite athletes: a controlled study (PDF PDF document - 162 KB), Torstveit M, Rosenvinge J and Sundgot-Borgen J, Scandinavian Journal of Medicine & Science in Sports, Volume 18, Issue 1 (2007). This study examined the percentage of female elite athletes and controls with disordered eating behavior and clinical eating disorders (EDs). It also evaluated whether a proposed method of screening for EDs in elite athletes was effective. More athletes in leanness sports (46.7%) had clinical EDs than athletes in non-leanness sports (19.8%) and controls (21.4%). Variables predicting clinical EDs, and thus candidates for valid screening procedures, were menstrual dysfunction in leanness athletes, self-reported EDs in non-leanness athletes, and self-reported use of pathogenic weight control methods in controls. Hence, statistically based risk factors are not universally valid, but specifically related to athletes and non-athletes.
  • Prevalence of eating disorders in elite athletes is higher than in the general population (abstract), Sundgot-Borgen J and Torstveit M, Clinical Journal of Sport Medicine, Volume 14, p25-32 (2004). This study examined the prevalence of anorexia nervosa (AN), bulimia nervosa (BN), anorexia athletica (AA), and eating disorders not otherwise specified (ED-NOS) in both male and female Norwegian elite athletes (N=1620) and a representative sample from the general Norwegian population (N=1696). The results indicated the prevalence of EDs is higher in athletes than in controls, higher in female athletes than in male athletes, and more common among those competing in leanness-dependent and weight-dependent sports than in other sports.
  • Psychological balance in high level athletes: Gender-based differences and sport-specific patterns, Schaal K, Tafflet M, Nassif H, Thibault V, Pichard C, Alcotte M, et al., PLoS ONE, Volume 6, Number 5 (2011). This study aimed to identify the principal psychological problems encountered within French high level athletes, and the variations in their prevalence based on sex and sport speciality. 2067 athletes' evaluations were included in the analysis. This represented 13% of all high performance senior and junior athletes registered on national lists. The results showed that 17% of all athletes surveyed (20% of women and 15% of men) have at least one ongoing or recent disorder, generalised anxiety disorder (6%) as the most prevalent, followed by non-specific eating disorders (4%). The highest rates of generalised anxiety disorder appeared in aesthetic sports and the lowest prevalence was found in high risk sports athletes. Eating disorders are most common among women in racing sports (e.g. athletics and swimming), and for men in combat sports.
  • Psychological consequences of athletic injury among high-level competitors (abstract), Leddy M, Lambert M and Ogles B, Research Quarterly for Exercise and Sport, Volume 65, Issue 4 (1994). This study examined the psychological reactions to injury among 343 male US collegiate athletes from 10 sports. The results revealed that injured athletes exhibited greater depression and anxiety and lower self-esteem than controls immediately following physical injury and at follow-up two months later. These findings supported the general observation that physically injured athletes experience a period of emotional distress that in some cases may be severe enough to warrant clinical intervention.
  • Psychological distress leads to reduced physical activity and fitness in children: the Australian longitudinal LOOK study (abstract), Olive L. Telford RM, Byrne D, Abhayaratna W and Telford RD, Journal of Behavioral Medicine, published online (19 February 2016). Stress and depression can affect an individual’s level of physical activity and fitness. This study investigates the longitudinal effects (over 8 years) of stress and depression on physical activity and cardiorespiratory fitness among youth (N=676), initially aged 8 years, from the LOOK Study. Children who identified with more symptoms of depression and stress were more likely to be less fit and less physically active, which in girls extended to less moderate-to-vigorous physical activity. The findings suggest that both physical activity and fitness are impacted by depression and stress.
  • Recurrent concussion and risk of depression in retired professional football players (PDF PDF document - 793 KB), Guskiewicz K, Marshall S, Bailes J, McCrae M, Harding H, Matthews A, Mihalik J and Cantu R, Medicine and Science in Sports and Exercise, Volume 39, Number 6 (2007). This study was to investigate the association between prior head injury and the likelihood of being diagnosed with clinical depression among retired professional football players with prior head injury exposure.
  • Symptoms and risk factors of depression during and after the football career of elite female players, Prinz B, Dvorak J and Junge A, BMJ Open Sport & Exercise Medicine, published online (31 May 2016). This study looked at the career–time prevalence of depression, analysing risk factors of mental health problems during or after the career of 100 female football players in the German First League. During their playing careers about 40% of players wanted or needed psychological support, but only 10% received help. After their career, the percentage of players wanting or needing psychological support decreased to 24%, of whom 90% received help. The authors concluded that the high prevalence of depression symptoms in combination with low use of psychotherapy during their playing careers demonstrates a need for de-stigmatisation of mental health issues in elite football. Furthermore, it seems very important to educate coaches, physicians, physiotherapists and club managers to recognise and prevent mental health problems of their players.

Reading

  • The effects of depression on the body, Pietrangelo A, Healthline (2014). Everyone feels sad or anxious at times, it’s a normal part of life. However, clinical depression affects how you feel and can also cause physical changes throughout your body, affecting various physiological systems – digestion, cardiovascular, and immune systems being the most common.
  • A game plan for mental health, Taylor S, Coaches Plan, Volume 22, Issue 2, p6 (2015). The author discusses some of the resources that Canadian coaches can use to become more proactive in helping athletes with mental health issues.
  • A lesson learned in time: Advice shared by experienced sport psychologists (PDF PDF document - 191 KB), McCormick A and  Meijen C, Sport & Exercise Psychology Review, Volume 11, Issue 1 (2015).
  • Mental Health: a state of wellbeing, World Health Organisation (2014).
  • Mental health now an issue in Australian sport, Butler J, The Huffington Post (10 October 2015). Sportspeople are not immune to mental health issues, yet mental health is often overlooked in preference to physical health. This news item looks at recent stories from the Australian sporting landscape. High-profile cases have sparked deeper conversations about unique mental health challenges faced by elite Australian athletes.
  • Psychological factors in sport performance, Raglin J, Sports Medicine, Volume 31, Issue 12 (2001). The Mental Health Model (MHM) of sport performance purports that an inverse relationship exists between psychopathology and sport performance. Despite its simple premise and empirical support, the MHM has often been mischaracterised in the sport psychology literature. This overview summarises MHM research, including the more recent work involving the model’s dynamic features in an effort to resolve disputes surrounding the model.
  • Suicide in Professional and Amateur Athletes: incidence, risk factors, and prevention (book), Lester D and Gunn J (Editors), Charles C Thomas Publisher, Springfield, IL (2013). 
  • Understanding athlete wellbeing: The views of national sporting and player associations, Dunn M, Journal of Science and Medicine in Sport, Volume 18, Supplement 1 (2014). Athletes face multiple pressures at various stages in their careers and lives, which can affect their on-field performance and their off-field lives. This study used a case study design to collect qualitative data using semi-structured interviews with seven key individuals associated with NSOs or player associations who worked in the broad space of ‘athlete wellbeing’. Wellbeing was seen as separate to the high performance/sports science side of sport, but participants saw that it was integral to be engaged with and have ‘buy-in’ from that side, particularly from coaches. For some sports, wellbeing programs are entrenched, while for others this is an emerging space.

Videos (access restrictions explained in the Client Service Model)

  • Living with a Mental Illness: Perspectives from an Athlete and a Carer, Kirsten Peterson, Head of Performance Psychology, Josh Sebbens PhD Candidate, Rebekah Alcock PhD Scholar, Josh Di Nucci MAG CoE Scholarship Holder, AIS Smart Talk Seminar Series, Australian Institute of Sport, Canberra (11/10/2016) (available to all Clearinghouse members) October 9th–15th is mental health week. The theme in the ACT is: Learn and grow together. Traditionally there has been a reluctance to talk about mental health and mental illness, particularly in the sporting world. This is changing through awareness campaigns such as Mental Health in Sport and elite athletes speaking publicly about their experiences. Illnesses such as depression and anxiety are more commonly discussed, both in the sporting world and by the general population. In this Smart Talk we’d like to take the road less travelled and discuss living with mental illnesses that are not as well known. We will explore these in and out of the sporting environment. We will present on the prevalence and impact of mental illness on the sufferer, carer, family, and community.  To bring these themes to life there will be two Q&A sessions. Josh, a gymnast and Centre of Excellence scholarship holder, will share his challenges with Obsessive Compulsive Disorder in the daily training environment. Rebekah, PhD Scholar in Nutrition, will share her experience as a carer of family members struggling with mental illnesses. (available to all Clearinghouse members)
  • Libby Trickett, See the signs and ask for help, WorkSafe Queensland, YouTube (10 October 2016). Olympic Gold Medal swimmer Libby Trickett talks about mental health.
  • World leading perspectives on changing attitudes towards mental health in youth and athlete populations, Rosie Purcell, Acting Director of Research, Orygen, Now Best Next Conference (3/06/2016) (available to member groups B and C)
  • Beyond the Black Line, YouTube (2015). Past and present members of the Australia Swimming Team talk about balance in the personal and sporting lives.
  • The excellence delusion, Corrine Reid, Associate Professor and Clinical Program Chair, School of Psychology and Exercise Science, Murdoch University, World Class to World Best 2014, Australian Institute of Sport, Canberra, (November 2014) (available to member groups B and C)
  • Mental health for athletes and coaches, Kate Wensley, AIS Psychologist, World Class to World Best (14/11/2013) (available to member groups B and C)
  • Managing depression in sport, Stephen Luby, Western Creek Cricketer, ACT Sporting Hero Award 2013; Dr Rob Reid, Sports Physician and Kate Wensley, AIS Residential Athlete Counsellor, Psychologist. Sports Medicine Australia, Seminar (October 2013) (available to member groups B and C)
  • Depression: a common complex disorder, Professor Ma-Li Wong, John Curtin School of Medical Research, Australian National University, Smart Talk Seminar Series, Australian Institute of Sport, Canberra, (July 2010) (available to member groups B and C)

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