Mental illness in athletes: the best way forward to brighter times

In part one of this 2-part article, we explored the incidence of mental health disorders in athletes and learned that they are just as much at risk as the general population at large. In part two, we look at the most 'at-risk' sports and explore the best pathways forward for athletes seeking to regain maximum mental well being. 

So far, we have seen that while elite athletes may be less at risk from severe mental illnesses such as schizophrenia and bipolar depression, the prevalence of other types of mental illness is just as high in athletes as in the population at large. But are there some sports particularly associated with mental illness? And what are the best management and treatment options are for athletes in need of help and the implications for coaches and clinicians with athletes in their care?

Sport-specific risk

Although it's not possible to make sweeping generalisations about the relationship between sport type and the risk of mental illness,  one important trend that IS evident is the sport-specific risk of generalised anxiety disorders. The evidence available shows that the greatest prevalence of this type of disorder is found in athletes practicing aesthetic sports; gymnastics, synchronised swimming, figure skating etc. This might be as a result of the psychological inevitability of being highly invested in a sport where success is heavily dependent upon judgement by others - jury members, coaches, or even teammates - and the pressure to deliver a ‘perfect’ performance is therefore tremendous.

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Figure 1: Lifetime prevalence (%) of anxiety disorder by type of sport practiced

NB: # = significant difference with all other sports.  * = significant difference between men and women - notice the very large difference between aesthetic sports and high risk sports.

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In a study on elite gymnasts, researchers found that many expressed the feeling of ‘lacking control’ - not only over the ultimate outcome of their performances, but also many other aspects of their careers⁽⁸⁾. A sense of powerlessness in important aspects of life is known to be an important triggering factor for the development of anxiety disorders so this is something that those with such athletes in their care should keep very much in mind. By contrast, athletes in high risk sports such as motorsport, skiing, snowboarding etc tend to show the lowest rates of anxiety disorders.

One theory is that such ‘thrill seeking’ athletes may need higher levels of stimulation in order to compensate for a chronic deficit in basal arousal and also have a greater natural capacity to cope with stress or to deal with fearful situations, perhaps through an innate ‘optimistic bias’, making them less vulnerable to anxiety disorders. It’s also likely that the low rates of anxiety in high-risk sport athletes may be due to the fact that individuals with anxious predispositions and unable to manage fear and stress well, would be very unlikely to practice such dangerous sports in the first place.

Self help and treatment

The research above⁽²⁾ and elsewhere⁽⁹⁾ suggests that athletes are likely to experience a prevalence of symptoms of depression similar to that of the general population. To complicate matters however, there’s also evidence that athletes have less positive attitudes toward seeking help than non-athletes⁽¹⁰⁾. Since such attitudes are thought to influence help-seeking in the general population and this age group is already at risk, young elite athletes may be particularly vulnerable to not seeking help. Researchers examined the reasons why young people don’t tend to seek professional help for mental disorders and found that the perceived barriers to help-seeking included stigma and embarrassment, problems recognising symptoms (poor mental health literacy), and a preference for self-reliance⁽¹¹⁾. The good news was that the same study also found that by increasing mental health literacy and reducing stigma, positive past experiences, good social support and encouragement from others may facilitate help seeking.

Despite this however, more recent Australian research on persuading athletes to seek help is less encouraging⁽¹²⁾. In the study, 59 young elite athletes were recruited online and underwent different interventions consisting of:

• A mental health literacy and destigmatisation condition;
• A feedback condition helping athletes to assess their symptom levels;
• A minimal content condition (just a list of help-seeking resources);
• A control condition (no intervention)

When the researchers measured help-seeking attitudes, intentions and behaviour using self-assessed surveys, they found that while mental health literacy and destigmatisation improved knowledge and decreased stigma none of the interventions yielded a significant increase in help-seeking attitudes, intentions, or behaviour relative to the control condition.

Psychiatric treatment

In more severe cases of mental health disorder (minor or major depression), the intervention of a psychologist/psychiatrist is frequently required. However, one of the challenges for psychiatric health professionals with athletes in their care is that providing psychiatric consultation presents unique and complex issues. This is because such athletes usually have a range of medical, psychological, and performance concerns, which all need to be addressed as a part of a treatment protocol. The problem however is that to date, there’s very little published research on how best to treat athletes presenting with a psychiatric disorder. To try and come up with some evidence-based recommendations, US researchers recently conducted a meta-study into this issue⁽¹³⁾.

In their study, the researchers searched for previously published studies in this area by using a variety of search terms such as psychiatry, athletes, elite athletes, professional athletes, sports, sport psychiatry, mental illness, major depressive disorder, depression, bipolar disorder anxiety, eating disorders etc. Once all these studies were assembled, the researchers whittled their selection down to those discussing psychiatric diagnosis or psychiatric treatment of athletes and noted that there seemed to be no controlled data to guide treatment when working with elite athletes. However, the team described the literature that does exist and presented four case examples to illustrate diagnostic and treatment issues with elite athletes. In particular, they outlined the key pitfalls that tend to interfere with treatment, which were as follows:

• Elite athletes expecting ‘special treatment’;
• Issues of flexibility in treatment in order to accommodate travel schedules;
• The need for privacy during training camps etc;
• The need for the inclusion of coaches and significant others in treatment.

They went on to make recommendations for those working with this population including being flexible (within reason) about the timing of therapy sessions, involving family members when relationship issues are involved, and not compromising on delivering the appropriate treatment, including medications and hospitalisations as necessary. Overall, they concluded that ‘the challenges of treating psychiatric illness in the elite athlete are great, but with the right approach, successful treatment is possible’. They also suggested that seeking help from psychiatric health professionals with prior experience of treating elite athletes may also be desirable. 

Summary and practical recommendations

Although there’s evidence that athletes may be less like to suffer from major depression, the incidence of anxiety-related disorders is surprisingly common with potentially serious consequences for performance. In particular, it seems that athletes involved in sports with an aesthetic element or where making weight is important are particularly vulnerable. Here then are some practical recommendations for those with athletes in their care:

• When it comes to the psychological well-being of their athletes, coaches and trainers should be vigilant; the signs that all is not well may manifest in a number of different ways (eg sleep disorders, eating disorders, generalised anxiety etc), many of which might not be immediately apparent;
• Even when problems or issues are suspected, coaches and health professionals should be aware that many athletes may be reluctant to admit that they need help due to stigmatisation and/or embarrassment;
• Developing a caring and empathetic relationship with athletes is vital; this will foster an environment in which an athlete is more likely to feel confident enough to seek help;
• When professional intervention is required, carers of athletes are advised to seek out a psychologist/psychiatrist with a proven track record of treating athletes. 

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