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].”

“Numerous studies conducted in different countries yielded consistent results that elite athletes experience a higher risk of mental disorders such as anxiety and depression [5].”

“Given the increased research attention on athletes’ well-being (Henriksen et al., 2019; Rice et al., 2016), we believe this study to be timely.”

“Additional to physical performance, elite athletes need mental resilience to cope with training loads, performance demands and constant pressure from their environment, such as media, teammates, fans and family (Rice et al., 2016).”

“While elite athletes experience psychological distress at rates comparable to the general population, they also face unique stressors associated with high-performance sport (28).”

“Injury is regarded as a noteworthy stressor that can exacerbate mental health issues in athletes (Ardern et al., 2013; Gulliver et al., 2015; Nixdorf et al., 2013; Rice et al., 2016; Sarkar & Fletcher, 2014; Walker et al., 2007).”

“1 Unauthenticated | Downloaded 04/05/22 06:22 AM UTC Athletes’ mental health has received increased attention in the sports community (Chang et al., 2020; Rice et al., 2016).”

“Overall, there is a paucity in the literature concerning the epidemiology of mental distress in elite Para athletes (33), and an improved understanding would allow us to better develop and implement preventive measures targeting Para athletes.”

“…and career transitions are the main risk factors for developing mental health problems in elite athletes (Schinke, Stambulova, Si, & Moore, 2017; Rice et al., 2016; Junge & Prinz, 2018; Junge & Feddermann-Demont, 2016; Gouttebarge, Aoki, et al., 2015, Gouttebarge, Frings-Dresen, et al., 2015).”

“Although published studies including male athletes are less common, men and boys may be at greater risk of disordered eating than women and girls when the type of sport, social environment of teams, assessment used, and specific disordered eating behaviors are examined (Baum, 2006; Papathomas and Lavallee, 2012; Papat…”

“In contrast, dysfunctional impulsiveness processes have been described when there is low emotional quality (De Silva et al., 2016; MacKillop et al., 2016), lack of impulse control (Smillie and Jackson, 2006; Donovan et al., 2014; Harden et al., 2017) and disruptive behavior (Renee-Renda et al.,…”

“poor health—namely, overtraining; excessive external pressure to perform; underperformance; non-selection; training while injured; injury; coach-athlete relationship difficulties; and bullying (Rice et al., 2016).”

“This may include organisational stressors (e.g., disrupted sleep patterns) and personal stressors (e.g., maintenance of relationships; Rice et al., 2016), but it is competitive stressors that may particularly increase their experience of stress.”

“Therefore, it should be noted that these emotional states can become habitual and ingrained in the athlete [42].”

“Although a study of adult elite athletes suggests they have similar incidence of depression to non-athletes (32), a similar study of young athletes is just beginning (10).”

“While the exact prevalence of depression among elite athletes is still unclear (2, 3) and often underestimated (8), the extent to which depressive symptoms occur among them is currently considered comparable (9, 10) or higher (11) to that among the general population.”

“16 to 22%) [20] and somewhat higher than former research among elite athletes, yet error estimates require caution with conclusion of differences between instructors and athletes [21, 22].”

“Injury has known detrimental effects on player welfare (Gouttebarge et al., 2016; Manley et al., 2017; McCrory et al., 2017; Rice et al., 2016) and team and individual athletic performance (Drew et al.”

“While some studies have reported prevalence rates of mental disorders and substance use disorder to be higher or comparable to the general population (Schaal et al., 2011; Rice et al., 2016; Gouttebarge et al., 2019; Akesdotter et al., 2020; Purcell et al., 2020), other studies have found lower suicide rates when comp…”

“In line with previous research (Goodger et al., 2007; Gustafsson et al., 2017; Rice et al., 2016; Röthlin et al., 2023; Woods et al., 2022), our fi ndings add to the literature on the protective nature of social support, suggesting that the perceived emotional, motivational and practical support…”

“Regardless of the magnitude of prevalence, the consensus has been that athlete status is likely not a protective factor against depressive symptoms (Bar & Markser, 2013; Rice et al., 2016).”

“the mental health of elite athletes [8]; mental health interventions in non-elite sport [9]; psychotherapy for mental health symptoms and disorders in elite athletes [10]; mental health literacy interventions in sport [11]; and associations between depression and anxiety symptoms and participation in youth sports [12].”

“Additionally, elite athletes may be exposed to specific sporting and non-sporting stressors that could increase their vulnerability to mental health problems (Palanichamy et al., 2020; Rice et al., 2016).”

“Furthermore, athletes competing in aesthetic sports seem to be more likely to report mental health symptoms or disorders compared to other athletes [8].”

“Indeed, there are several sport-specific issues such as injuries, overtraining, burnout, and retirement that might lead athletes more susceptible to mental health disorders (Rice et al., 2016).”

“However, in line with the increased attention on mental health in elite athletes (Reardon & Factor, 2010; Reardon et al., 2019; Rice et al., 2016; Schinke et al., 2018), it remains to be fully understood how prevalent problem gambling is among athletes at the elite level.”

“Athletes have increased mental health risk factors compared with nonathlete populations, which can be attributed to high training loads, tough competition, and stressful lifestyles (Gorczynski et al., 2017; Rice et al., 2016).”

“Thus, in recent years, there has been a growing interest in athletes’ MH. Studies show that elite athletes suffer from various MH problems such as depression, anxiety, and stress at similar or slightly more rates to the general population (Rice et al., 2016).”

“…awareness of mental health has increased, so too has the interest in the mental health of athletes (Henriksen et al., 2019; Moesch et al., 2018; Rice et al., 2016; National Collegiate Athletic Association (NCAA), 2017) and student athletes (Davoren & Hwang, 2014; L opez & Levy, 2013; Miller &…”

“Furthermore, athletes are likely to experience a high number of exercise‐ and career‐related as well as everyday stressors (Heidari, Hasenbring, Kleinert, & Kellmann, 2017; Heidari et al., 2018; Rao & Hong, 2016; Rice et al., 2016).”

“Injury has a detrimental effect on player welfare, health, and lifestyle, including an increased risk of distress, anxiety, sleep disturbance, depression (35), cognitive impairment (30), and financial cost due to loss of employment (20).”

“Rice et al. (2016) reviewed primarily prevalence and risk factor studies on mental health in athletes, with the major fi nding, again, being elite athletes experience a comparable risk of mental illness to general populations.”

“Reviews of previous studies of athlete groups have identified key transition points, chiefly injury and retirement, as vulnerable periods for the development of psychological morbidity [ 61 , 62 ].”

“Despite methodological and conceptual di ffi culties (Lundqvist and Andersson 2021), there is consensus that athletes su ff er from common mental disorders at rates that are broadly comparable to their non-sporting peers (Gouttebarge et al. 2019; Rice et al. 2016; Tahtinen, Shelley, and Morris 2021).”

“Effectively, factors related to both sporting factors and non-sporting factors can compromise mental health and well-being [8].”

“…Rosen, & Leitenberg, 1988), it is not until recently that 25 literature reviews on the topic have emerged (Armstrong, Burcin, Bjerke, & Early, 2015; 26 Frank, Nixdorf, & Beckmann, 2015; Gorczynski, Coyle, & Gibson, 2017; Gouttebarge et al., 27 2019; Rice et al., 2016; Wolanin, Gross, & Hong, 2015).”

“susceptibility of elite athletes to CMDs [9], with athletes placed under intense physiological and psychological pressure, competing at an age when the incidence of CMDs is most likely to occur [10].”

“Furthermore, inadequate psychological support during rehabilitation often leads to poor coping strategies, including substance use or training avoidance (8).”

“…(e.g., playing through injury, intense physical training), personal matters (e.g., constrained friendship or family life), and organisational issues (e.g., travel, finance) manifest in both elite (Rice et al., 2016), and non-14 elite athletes (Breslin, Shannon, Haughey, Donnelly & Leavey, 2017).”

“During times of increased stress, athletes have been shown to have higher rates of mental health disorders than the general population [7].”

“Football is known for its fast-paced and intensive activities from a professional standpoint [1,2], which certainly contributes to a higher injury risk during the season [3].”

“In competitive sport, there are multiple external and internal stressors that can obstruct peak performance and well-being, including competitive and selection pressures, injuries, burnout, and maladaptive perfectionism (Reardon et al., 2019; Rice et al., 2016; Walton et al., 2021).”

“Elite athletes also demonstrate increased susceptibility to depression and anxiety during times of heightened stress (Rice et al., 2016).”

“2015, Rice et al .”

“, increasing the secretion of antioxidant species and the activation of enzymes involved in the antioxidant response [21]) and thereby neutralizes reactive oxygen species.”

“Under such profit-oriented leadership, athletes are often exhausted by intense physical and mental demands and are stressed by having to deal with public scrutiny, abrasive group dynamics, and the constant exposure to career-terminating or life-altering injury risks [6].”

“Athletes who remain in these negative psychological and physical states are at a much higher risk of engaging in extreme behaviors, such as suicide or self-harm, which can lead to the premature end of their careers (Baum, 2005; Rice et al., 2016).”

“…which may be attributed to several key factors: (1) while positive emotions are often directly triggered by success experiences, negative emotions can stem from multiple sources, including fear of failure, social comparison pressure, and unrealistic expectations (Hanin, 2007; Rice et al., 2016).”

“…having been undertaken to attempt to quantify and classify the nature and prevalence of mental illness within sport (Gorczynski et al., 2017; Rice et al., 2016), Henriksen et al. (2020a) recently argued for the importance of focusing on mental health in addition to mental illness and…”

“athletic career potential can be devastating (Rice et al., 2016).”

“Given the high prevalence of mental health problems in elite athletes and growing awareness of the role that psychological wellbeing plays in long-term sporting success, this may be a pertinent area for future research [91].”

“A different systematic review found major depressive disorder to be no more likely in athletes than non-athletes [22], while another systematic review found comparable levels of anxiety between elite athletes and the general population [48].”

“On the other hand, as emphasized by research in both traditional sports (e.g., Rice et al., 2016) and esports (Freeman & Wohn, 2019; Himmelstein et al., 2017; Kou & Gui, 2020) a positive organizational climate, fostered by coaches and teams, can help athletes manage competitive pressures.”

“Elite athletes execute well-practiced skills with minimal attention or conscious effort (Bennett et al. 2015); however, they experience significant demands which can impact their personal and professional well-being (Rice et al. 2016).”

“Given that the age range for athletic peak performance coincides with the peak age for the greatest risk of the onset of mental health issues, it is appropriate to provide athletes with wellbeing support (Rice et al. 2016).”

“Last but not least, social stigma around depression, especially in athletic culture, could lead to under-reporting and not prioritizing this issue [87].”