The Mental Health of Elite Athletes: A Narrative Systematic Review

“However, there was a tendency for higher vulnerability to these conditions in athletes involved in sports requiring a particularly lean body shape [21, 35, 38– 40] and in female athletes [41–43]—the latter being consistent with the findings of general population studies [87].”

“Such models should capitalise on an early-intervention framework [102–104], ensuring early detection and prompt access to high-quality, evidence-based interventions.”

“Importantly, the mental health of hard-to-engage populations, such as young men [107] and older men [108, 109], could be targeted.”

“The ways by which athletes appraise and cope with these stressors can be a powerful determinant of the impact the stressors have on both their mental health and their sporting success [18].”

“Three reported a higher incidence of eating disorder or body dissatisfaction in elite athletes relative to controls [36], especially in sports emphasising leanness or lower body weight [21, 35].”

“While the included studies focused specifically on elite-level competition at the national or international level, differences between the included sports in terms of training, remuneration, media pressure and other salient variables must be considered [89].”

“…that physical activity has a positive effect on mental health [6, 7], a review has found that intense physical activity performed at the elite athlete level might instead compromise mental wellbeing, increasing symptoms of anxiety and depression through overtraining, injury and burnout [8].”

“Mahoney and Avener [80] Quantitative; crosssectional, observational Psychological factors and cognitive strategies 12 (12:0) Gymnastics; USA Self-verbalisations and certain forms of mental imagery differentiated Olympic-level and nonOlympic-level gymnasts.”

“Given that stigma, poor mental health literacy and negative past experiences of mental health help seeking are key barriers for elite athletes [12], more welldesigned studies, drawing on larger samples, are needed.”

“Such an understanding is required to provide guidance for sport practitioners—including coaches, medical staff and sport psychologists—in developing the coping abilities of elite athletes and, in turn, improving their emotional wellbeing [20].”

“at major events, and the athlete’s interpretation of pre-competitive anxiety may mediate the functional impact of symptoms.(241)”

“Negative effects include the risk of failure leading to poor mental health [8,9], risk of injury [10,11], eating disorders [12], burnout [13], and exercise-induced gastrointestinal tract discomfort [14].”

“Single studies show that the prevalence of mental health symptoms and disorders among both current and former elite athletes seems substantial and similar to the prevalence in the general population.(5) A professional or elite sport career is characterised by more than 640 distinct stressors that could induce mental h…”

“The peak age for the risk of athletes’ onset of mental disorders overlaps with the peak competitive years for elite athletes due to the intense mental and physical demands they experience (Hughes & Leavey, 2012; Rice et al., 2016).”

“However, the evidence regarding sports participation at the elite level is limited, with available research indicating that elite athletes may be more susceptible to mental health problems, potentially due to the intense mental and physical demands placed on elite athletes [12].”

“First, current scales tend to measure mental illness (e.g. Gorczynski, Coyle, & Gibson, 2017; (Rice, Purcell, De Silva, Mawren, McGorry & Parker, 2016) rather than mental health.”

“These include competitive (e.g., performance expectation), organizational (e.g., travel), and personal (e.g., family issues) stressors, that potentially increase the risk of mental illness in athletes (Rice et al., 2016).”

“It has been proposed that elite sport context-specific factors such as injury, excessive overtraining in combination with inadequate recovery, and career termination may increase vulnerability to certain mental disorders (see e.g., Gulliver et al., 2015; Meeusen et al., 2013; Raglin, 2001; Rice et al., 2016).”

“There is relatively scant research on the mental health of athletes [5], and the prevalence of diagnosable psychiatric disorders in athletes is unclear [5–8].”

“5 Conclusions Regardless of the direction of the relationship, our findings and previous research [69] indicate that amongst elite athletes, both currently competing or retired, concussion and impaired mental health, particularly depression 462 S.”

“A study stated that stress might lead to injury and issues with their mental health (Rice et al., 2016).”

“Therefore, it is no surprise that psychological disorders are highly prevalent among elite athletes.(3) For instance, in a study of Australian athletes, almost half of the participants (46%) reported at least one mental health issue, including depression, eating disorder, general AC CE PT ED M AN US CR IP T”

“According to studies of the past 30 years [17] and a recent meta-analysis [18], overall, depressive symptoms are not increased but also not decreased in high-performance athletes, however, sport-related differences have been reported and it has been repeatedly shown that athletes competing in individual sports were mo…”

“Once athletes have chosen to seek help for mental health concerns, encouraging treatment adherence should theoretically help limit morbidity.”

“Furthermore, much of the research undertaken to date on elite athlete mental health, including psychometric validation studies, has been with non-representative samples (Rice et al., 2016).”

“symptoms and disorders in elite athletes (Gorczynski et al., 2017; Rice et al., 2016).”

“affected by underperformance, pressure and expectations, burnout, and the development of maladaptive psychological symptoms and disorders [5].”

“Depression and anxiety were targeted in the content due to high prevalence rates in elite sport (Gulliver et al., 2015; Rice et al., 2016), as is observed in the general population.”

“Alongside a series of scientific reviews and commentaries (Breslin et al., 2017; Gorczynski, Coyle, & Gibson, 2017; Kuettel & Larsen, 2019, Poucher, Tamminen, Kerr & Cairney, 2019; Rice et al., 2016), the current collaboration bears witness to an increased focus on the topic of athlete mental health.”

“These challenges make it di ffi cult to draw accurate conclusions about the prevalence of MH disorders among student-athletes (Poucher et al., 2021).”

“Although the prevalence rates of mental health disorders have not demonstrated to be higher, an elite level athlete who shows signs of poor mental health is still associated with stigma and at risk of misperceptions of mental health symptoms by health care practitioners since athletes typically are in seemingly good p…”

“This period may represent a sedentary moment for athletes, leading to consumption of high calorie foods due to impulse or anxiety (37).”

“fatigue, and organizational stressors (Rice et al., 2016).”

“Athletes often compete within sport cultures that stigmatize mental health, discouraging help-seeking and contributing to sport dropout.(2) Furthermore, many choose to suffer in silence because they are concerned that practitioners will not understand their unique needs and challenges.”

“For example, the athlete environment produces unique stressors as a result of highpressure circumstances, constant mental effort, and experiences such as injury which may negatively impact mental health (Rice et al., 2016).”

“However, sport-specific mental health interventions for athletes, although warranted, have been slow to develop (Donohue et al., 2013; Rice et al., 2016).”

“Although there may growing awareness about depression in elite athletes, it is not apparent this is translating into clinical practice and practitioners are unlikely to be recognising the true level and frequency of psychological distress.(10,24,25)”

“For combining and reporting the results, we inspected each study’s outcomes and categorised them in accordance with the following key mental health constructs [35]: stigma, mental health knowledge, referral efficacy/confidence, help-seeking intentions and behaviour, well-being and additional outcomes.”

“As recent reviews and commentaries on the state of high performance athlete mental health research have suggested, considerably more research with this population and context is needed to develop our understanding of athletes’ mental healthcare needs (Rice et al. 2016; Lebrun and Collins 2017).”

“Elite athletes experience nearly the same rate of diagnosis of mental health disorders as the general population 54 ; this has been observed in collegiate as well as in internationally ranked athletes, 19,30,61 and some report they may be at greater risk than nonathletes.”

“A direct relationship between exposure to elite sports stressors and mental health concerns is, however, challenged in available research, which indicates comparable levels of symptoms reported among elite athletes and non-athlete populations (e.g., Gulliver et al., 2015; Rice et al., 2016; Gorczynski et al., 2017; Go…”

“Further research in sport has identified that symptoms of burnout have been shown to be significant contributors to diminished psychological wellbeing [27].”

“This concurs with the authors’ assumption and the scientific literature that symptoms of CMD are likely to interfere with several aspects essential to the performance of professional athletes such as, concentration and focus, coordination and emotion (Rice et al., 2016).”

“Rice et al. (2016) argue that athletes need to protect both their mental and physical health and that further intervention studies are required.”

“It is now clear that athletes in elite sports experience mental ill-health at similar rates to the general population [3, 4], with coaches and support staff also increasingly recognised as at risk [5, 6].”

“However, likely reasons for these high rates are the elevated risk of injuries, performance plateaus or decrements or an approaching retirement form elite sports (Rice et al., 2016).”

“It may well be that there are aspects of athletes’ experiences such as injuries, performance slumps, and career transitions that make them more susceptible to such difficulties (Rice et al., 2016).”

“Relationships between mental illness and physical activity has gained significant attention from researchers, however, relatively speaking, little attention has been devoted to elite athletes (Hughes & Leavey, 2012; Rice et al., 2016).”

“Recent studies (Gulliver et al., 2015; Hammond, Gialloreto, Kubas, & Davis, 2013; Rice et al., 2016) have, however, highlighted that elite athletes might be just as likely as non-athletes to experience depression, and that psychosocial benefits attributed to sport do not inherently occur through mere sport participati…”

“Increasing numbers of male role models (i.e. elite sportspeople, musicians and actors) are speaking openly about their mental health challenges and advocating the benefits of help seeking (Rice et al., 2016).”

“Introduction Elite athletes have a comparable high prevalence of mental disorders like depression, anxiety, eating disorders, substance use, and compromised coping strategies.(1) In Australia, when researchers addressed the mental health of elite athletes from national sporting organizations, they found a similar prev…”

“Specifically, there are general risk indicators such as negative life events in which both athletes and the general population experience comparable psychological distress (Rice et al., 2016; Purcell et al., 2019).”

“Elite athletes are constantly exposed to stressors that may impair mental health [31] and negatively influence sleep quality [21].”

“Research has demonstrated consistently that athletes, at all ages and levels of competition, are under pressure to perform well and deal with many stressors, which may result in poor mental health (Coyle et al., 2017; Gorczynski et al., 2017a; Gulliver, 2017; Gulliver et al., 2015; Rice et al., 2016).”

“The potential adverse psychological effects of combining high levels of PA with inadequate nutrition are wide-ranging and include: anxiety; depression; substance misuse; disordered eating (DE) and eating disorders (ED; Mikkelsen et al., 2017; Rice et al., 2016).”

“However, our findings reinforce the need to move beyond individual agency and take action on the cultural climate of high-performance sport (Mountjoy et al., 2016; Rice et al., 2016).”

“In order to fully understand the extent to which elite-level coaches experience symptoms of mental ill-health, future research should seek to identify periods where coaches may experience heightened symptomatology, and also utilise more representative coaching samples ( n > 100) [17].”

“Although physical activity has a positive effect on athletes’ mental health [43], the adopted home confinement measures and the fear of a second wave of COVID-19, which may delay the return to training and normality and may involve financial problems and depressing daily news, might compromise the athletes’ mental wel…”

“From this we deemed that success both within sport and transition out of sport requires an holistic approach to athlete development that includes a complimentary mix of wellbeing, lifestyle practices, performance strategies, psychological attributes, education, and supportive interpersonal relationships [5].”

“Sports injuries are common(47) 48 and are associated with depressive symptoms and disorders.(40) 44 48–50 The relationship between sports injury and mood is not simply cause and effect.”

“…such as increased anxiety over body image and weight, excessive exercising, poor kcal intake, fasting or restrictive eating practices, binge eating and use of dietary supplements, pills and laxatives (Dosil, 2008; Melin, Torstveit, Burke, Marks, & Sundgot-Borgen, 2014; Rice et al., 2016).”

“, injury, de-selection, premature retirement) include feelings of depression and anxiety (Wylleman et al., 2004; Appaneal et al., 2009; Rice et al., 2016).”

“Elite athlete mental health problems recently attracted great discussion as a worldwide relevant phenomenon [1], including reference to sporting factors, such as injury, overtraining, burnout, and career termination as well as nonsporting factors [2,3].”

“A review by Wolanin and colleagues (2015) estimated the prevalence of depression in athletes at 15.6%–21%, while Rice et al. (2016) estimated the rate of depression to be similar to the general population.”

“However, more research is needed concerning elite athletes specifically, who have been found to differ in their motivations when compared to non-elite athletes (Kavussanu et al., 2011) and may be at risk for a number of negative outcomes (e.g., Brand et al., 2012; Rice et al., 2016).”

“In general, it has been suggested that the prevalence of mental health problems in elite sports seems to mirror society as a whole (Rice et al., 2016), however, although a sparsely studied area, participation in team sports has been described as a particular risk factor of addictive behaviour (Grunseit et al.”

“It is also important to consider the idea that physical activity in the form of competitive sports may increase depression and anxiety, as prior studies have shown that athletes are vulnerable to a range of mental health problems [55].”

“Recent evidence has shown athletes are at risk, if not more at risk, at certain times in their careers to: (a) developing mental health and (b) substance misuse problems, compared to the general population (Rice et al., 2016).”