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].”

“Sample sizes for these studies varied on the basis of the population of interest, ranging from N = 2067 for a national-level study [51] to N = 14 for a study of distance runners.”

“With the exception of the three studies that used an interviewer-administered diagnostic interview [35, 40, 43], all studies on eating disorders and body image used”

“As in the general population, major negative life events, including injury [23], may increase the risk of mental ill-health in elite athletes [50], though focused quantitative studies with adequate followup assessment periods are needed to confirm this.”

“While it is well established 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].”

“elite athletes relative to the general community, there is significant scope for coaches, team psychologists and sport administrators to focus on targeted screening and early detection, monitoring and intervention—especially at key risk periods, such as significant injury [91, 92], transition to retirement [44, 93] an…”

“In contrast, one study found no difference between elite athletes and controls when the sample was restricted to females [43].”

“While it is well established 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].”

“Development of comprehensive, targeted, disorder-specific treatment models are a required next step, and the National Athletic Trainers’ Association statement on preventing, detecting and managing disordered eating provides a useful disorder-specific model [99].”

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

“Furthermore, the peak competitive years for elite athletes [10] tend to overlap with the peak age for the risk of onset of mental disorders [11, 12].”

“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].”

“The prevalence of diagnosable psychiatric disorders in this population remains a matter of debate [4]; however, notions that elite athletes are devoid of mental health problems have been increasingly scrutinised by sports medicine practitioners [5].”

“The methodological rigour of the included studies was assessed according to relevant published criteria [27, 28].”

“…stress, elite athletes face a unique array of ‘workplace’ stressors, including the pressures of increased public scrutiny through mainstream and social media, limited support networks due to relocation, group dynamics in team sports and the potential for injuries to end careers prematurely [13–17].”

“ted for prevalence rates of depression (34 %) based on diagnostic interviews undertaken with swimmers [45] and self-reported depression and anxiety (26 %) in European”

“Hausenblas and Symons Downs [37] Quantitative; metaanalysis Literature review; body image in athletes and non-athletes 19 studies with elite athletes, sex not reported Various; various Overall findings highlighted that athletes had a more positive body image than non-athletes.”

“[33] Quantitative; crosssectional, observational Anxiety and performance 211 (sex not reported), 97 elite athletes Swimming; UK Elite performers interpreted anxiety as more facilitative to performance than non-elite performers.”

“[11] Quantitative; experimental, RCT Internet-based intervention to increase mental health help seeking 59 (16:43) Various; Australia None of the interventions were efficacious in improving either attitudes, intentions or behaviour for mental health help seeking.”

“Researchers have emphasised the limited peer-reviewed literature regarding the mental health and wellbeing of elite athletes [9, 19].”

“The ten general-prevalence studies on elite athlete mental health (see Table 4) reported data from either mixed samples [23, 46, 50, 51] or specific codes, including football [44], swimming [45], weight lifting [47], equestrian [48], distance running [49] and tennis [52].”

“…stress, elite athletes face a unique array of ‘workplace’ stressors, including the pressures of increased public scrutiny through mainstream and social media, limited support networks due to relocation, group dynamics in team sports and the potential for injuries to end careers prematurely [13–17].”

“Ivarsson [67] Quantitative; longitudinal, observational Psychological predictors of injury 56 (38:18) Soccer; Sweden Trait anxiety, negative-life-event stress and daily hassles significantly predicted injury among professional soccer players, accounting for 24 % of variance”

“Higher levels of athlete anxiety were also found to be related to negative patterns of perfectionism [34].”

“Pensgaard and Roberts [84] Mixed method; cross-sectional, observational Sources of distress, motivation, role of coach 7 (5:2) Skiing; Norway All athletes rated very highly on task orientation, and in the moderate to high range on ego orientation.”

“The ten general-prevalence studies on elite athlete mental health (see Table 4) reported data from either mixed samples [23, 46, 50, 51] or specific codes, including football [44], swimming [45], weight lifting [47], equestrian [48], distance running [49] and tennis [52].”

“Gastin [65] Quantitative; longitudinal, observational Monitored coping over the season 27 (sex not reported) Australian Rules Football; Australia Players generally coped well with the demands of elite competition; however, relative poor sleep quality was observed.”

“Robazza and Bortoli [29] Quantitative; crosssectional, observational Perceived effects of trait anger 197 (197:0) Rugby; Italy Players experienced a moderate frequency of anger symptoms, interpreting these as facilitative rather than debilitative.”

“[69] Mixed method; longitudinal, observational Stressors and coping strategies 8 (8:0) Rugby; Europe Frequently cited stressors were injury concerns, mental errors and physical errors, with a general decline in frequency as the season progressed.”

“Pensgaard and Roberts [83] Quantitative; crosssectional, observational Sources of distress, motivation, role of coach 69 (49:20) Various (winter sports); Norway Performance climate significantly predicted high total distress.”

“Encouraging progress has been made in the development of mental health guidelines for working with school-aged athletes [95] and collegiate-level athletes [96– 98].”

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

“Psychoeducation should also extend to substance use— in particular, alcohol—given the tendency for hazardous use (bingeing) outside competition periods [100] and the stigma related to athlete help seeking in this domain [61].”

“[76] Quantitative; crosssectional, observational Coping with expected and unexpected stressors 91 (sex not reported) Various; New Zealand Unexpected stressors were perceived as more threatening than expected stressors.”

“[31] Quantitative; crosssectional, observational Achievement motivation for performance anxiety 190 (101:89) Various; Norway Females reported greater performance worry, concentration disruption and somatic anxiety than males.”

“[62].”

“[71] Mixed method; longitudinal, observational Stressors and coping strategies 5 (5:0) Rugby; various Differences in stressors were identified in comparison of match and training days.”

“Hulley and Hill [38] Quantitative; crosssectional, observational EDs and general health and wellbeing 181 (0:181) Distance runners; UK Levels of anorexia nervosa and EDNOS were higher than expected in similarly aged, non-athletic women.”

“Encouraging progress has been made in the development of mental health guidelines for working with school-aged athletes [95] and collegiate-level athletes [96– 98].”

“Coping strategies based on problem solving and behavioural change were found to be the most effective in managing stress [64, 70, 77] and developing resilience [74].”

“Pensgaard and Ursin [82] Mixed method; cross-sectional, observational Stressors and coping strategies 69 (49:20) Various (winter sports); Norway Stress was mainly experienced prior to competition.”

“[60] Quantitative; cross-sectional, observational Hazardous drinking and drinking motives 1214 (630:584) [275 in elite group] Various; New Zealand Elite provincial sportspeople reported the highest level of hazardous drinking, and elite international sportspeople reported the lowest.”

“and impairment appears to be warranted [3, 101].”

“[59] Quantitative; cross-sectional, observational Hazardous drinking and level of sport participation 430 (147:283) [270 in elite group] Various; New Zealand Elite sportspeople reported higher rates of hazardous drinking than non-sportspeople and non-elite sportspeople.”

“[53] Quantitative; longitudinal, observational Effects of interstate travel on sleep patterns 19 (19:0) Australian Rules Football; Australia In comparison with baseline, sleep duration was greater on the nights before home and away games (by 48 and 39 min, respectively, P\ 0.”

“There is comparatively less research on, but growing interest in, the mental health and psychological wellbeing of elite-level athletes [1–3].”

“Some, though not all, research suggests that this population has an increased risk of mental health problems, including eating disorders [21] and suicide [22].”

“One study [79] found that coping behaviour varied between sporting types, with athletes in team-based sports more likely to seek social support than individual competitors, and female athletes more likely to engage in strategies focused on managing affect.”

“Nonetheless, higher rates of alcohol use may occur in elite athletes relative to the general population, though this may be largely due to a binge pattern of consumption during non-competitive or vacation periods [54].”

“Coping strategies based on problem solving and behavioural change were found to be the most effective in managing stress [64, 70, 77] and developing resilience [74].”

“[86] Quantitative; crosssectional, observational Stress and motivation 82 (82:0) Football; Europe A mastery climate was directly and negatively associated with coach–athlete stress, while a performance climate was directly and positively associated with coach–athlete stress”

“There were single studies identified for the domains of help seeking [11], sleep [53] and wellbeing [63] (see Table 7).”

“Devantier [75] Quantitative; crosssectional, observational Psychological factors and injury vulnerability 87 (87:0) Soccer; Denmark Somatic anxiety and coping with adversity were the best predictors of injury severity.”

“and planning ahead) were frequently reported [66, 71, 81]; however, there was a tendency for athletes to engage in less adaptive (i.”

“collaborative efforts would be required between sports medicine practitioners, psychiatrists, psychologists and other mental health professionals [105], mindful of overcoming treatment barriers and stigma for athletes at the elite level and balancing the need for treatment with the need for ongoing performance in, or…”

“Coping strategies based on problem solving and behavioural change were found to be the most effective in managing stress [64, 70, 77] and developing resilience [74].”

“[39] Quantitative; crosssectional, observational Food preferences, body image perceptions, dieting 49 (23:26) Figure skating; USA Disordered eating and preference for a thin body contour were reported among this group of athletes, particularly in females.”

“[41] Quantitative; crosssectional, observational Influences on eating, body shape perception, mood 103 (59:44) Rowing; UK Risk of EDs among elite rowers was moderated by age, sex and weight category; body shape concerns were greater for younger athletes, greater for heavyweights than lightweights and greater for femal…”

“fellow players or staff assuming that information seeking equates to actual drug use), a substantial proportion of elite athletes expressed a desire to receive additional information regarding the effects of some classes of recreational drugs [61].”

“Objective data, based on the results of medical review and tests, would likely assist in the assessment of eating pathologies and help counter the limitations of self-reporting (i.e. underreporting) [88].”

“Coping strategies based on problem solving and behavioural change were found to be the most effective in managing stress [64, 70, 77] and developing resilience [74].”

“[57] Quantitative; cross-sectional, observational Illicit drug use and consensus estimates 974 (736:238) Various; Australia Participants tended to report that there was a higher prevalence of drug use among athletes in general than among athletes in their sport, and these estimates appeared to be influenced by partici…”

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

“Dunn and Thomas [56] Quantitative; cross-sectional, observational Factors associated with illicit drug use 1684 (1212:472) Various; Australia 8 % of the sample reported use of at least one illicit drug in the previous year.”

“[66] Quantitative; longitudinal, observational Psychological impact of training 11 (11:0) Speed skating; USA Stress reactivity and emotional lability likely to be detrimental to performance and characteristic of less experienced athletes.”

“[55] Quantitative; cross-sectional, observational Prevalence of illicit drug use 974 (736:238) Various; Australia One third of the sample had opportunity to use illicit drugs in the previous year; overall prevalence was lower than that reported by the general population.”

“elite athletes relative to the general community, there is significant scope for coaches, team psychologists and sport administrators to focus on targeted screening and early detection, monitoring and intervention—especially at key risk periods, such as significant injury [91, 92], transition to retirement [44, 93] an…”

“There is comparatively less research on, but growing interest in, the mental health and psychological wellbeing of elite-level athletes [1–3].”

“Grove and Hanrahan [85] Quantitative; crosssectional, observational Psychological strengths profile; athlete and coach comparison 39 athletes (15:24), 5 coaches Field hockey; Australia Ranking by players (greatest perceived strength to weakness): control of anxiety, maintaining concentration, planning and analysis, em…”

“[58] Quantitative; longitudinal, experimental (no controls) Illicit drug– testing programme 640 (640:0) Australian Rules Football; Australia Steady decline in the annual number of positive tests over the 7 years of the programme.”

“Recommendations to elite-level coaches included development of athlete skills in appraisal and interpretation of anxiety states [32] and the type of training culture facilitated among athletes (i.e. mastery as opposed to performance) [31].”

“Emerging research suggests that retired elite athletes may be at particularly elevated risk of mental ill-health [24], corresponding to both low rates of formal athlete mental health screening processes [25] and player perceptions of inadequate availability of mental health support [26].”

“Emerging research suggests that retired elite athletes may be at particularly elevated risk of mental ill-health [24], corresponding to both low rates of formal athlete mental health screening processes [25] and player perceptions of inadequate availability of mental health support [26].”

“As comparatively little progress has been made in the area of mental health, there is enormous scope for programmes to boost athlete wellbeing, which would likely flow on to benefits in competitive performance and increase the likelihood of a successful transition to retirement [24, 26, 49, 90].”

“The ten general-prevalence studies on elite athlete mental health (see Table 4) reported data from either mixed samples [23, 46, 50, 51] or specific codes, including football [44], swimming [45], weight lifting [47], equestrian [48], distance running [49] and tennis [52].”

“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).”