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Mental health symptoms and disorders are ubiquitous in society and are too often underdiagnosed and undermanaged—or worse, ignored. We speak of mental health symptoms and disorders as if they are somehow separate from other ‘physical’ symptoms, injuries and illnesses. Mental health symptoms and disorders and other physical symptoms, injuries and illnesses are intertwined yet artificially separated by diagnostic criteria that perpetuate a mind–body dualism. This dualism ignores brain circuits and the human being. Although clinicians are constrained to work within the current established criteria for mental health symptoms and disorders, they must also be mindful of a broader interconnectedness: mental health symptoms and disorders increase the risk of injury, delay recovery following injury and impair athletic performance, while injury and poor athletic performance often trigger mental health symptoms and disorders, especially depression and anxiety.1–10 Physiology and perception are one.
Elite athletes are not unbreakable
Even though elite athletes live in a culture of being ‘tough’ and ‘looking fit’, they suffer from many mental health symptoms and disorders at rates similar to those of the general population.11 12 The incidence of eating disorders and some substance use disorders in elite athletes exceed those in the general population.13–23 Sport-specific stressors and environmental factors, including psychological, physical or sexual abuse,24 injury,25 barriers to mental health help-seeking because of significant mental health stigma in this population,26–33 and transition out of sport,34–47 may compound mental health symptoms and disorders in elite athletes.10 36 37 39 48–54 We must always be mindful that elite athletes are human beings who happen to be gifted in athletics.
Elite athletes are products of their subculture
Who is the elite athlete? The IOC working group defined the elite athlete as an Olympic, professional or collegiate athlete. This category—elite athlete—is abstract and risks overseeing the individual who has dedicated his life to the pursuit of athletic excellence. She is determined to win yet will often lose. He is relentless, feels invincible and will push himself to the extreme, sometimes at the cost of proper recovery or health. They are highly visible, sometimes suffer from public shame and may carry deep scars from those who live vicariously through them.
The discerning clinician must understand the subculture of sport so as to avoid diagnostic confusion. For example, lifestyle factors of elite athletes commonly lead to sleep deprivation and sleep disorders, which increase the risk of mental health symptoms and disorders.55–68 Depressive symptoms may be compounded by the athlete’s choice of sport,69–72 and overtraining may manifest with depressive symptoms.12 73 74 Anxiety disorders may present on a continuum with competition performance anxiety.75 76 Serious injuries77 78 and exposure to sexual and interpersonal violence in sport24 confer risk for post-traumatic stress disorder. Eating disorders and ‘exercise addiction’ may be difficult to discern from functional dietary and exercise habits in this highly disciplined population.79 80 Attention-deficit/hyperactivity disorder (ADHD) may be hard to discern from adaptive relative hyperactivity,81 and overlap in symptoms of ADHD and sport-related concussion may further complicate diagnosis.82 83 Indeed, sport-related concussion should be rightly viewed as a neuropsychiatric condition,84–86 with mental health symptoms being a core manifestation of concussion.87–90 Substance use by elite athletes may manifest in various mental health manifestations, including anxiety, mood or psychotic symptoms; thus, primary mental health disorders must be distinguished from side effects of substance use.91–95 Finally, addictive disorders in elite athletes include gambling disorder,96–101 which threatens both the athlete and the integrity of sport.
Mental health symptoms and disorders need active management
Management of mental health symptoms and disorders in elite athletes includes psychotherapy, pharmacologic treatment or both.102 Untreated mental health symptoms and disorders in elite athletes impair health and quality of life, and diminish sport performance.77 103–133 Cultural barriers and stigma may dissuade elite athletes from seeking mental health treatment, especially psychotherapy.134 135 However, elite athletes typically possess discipline and the ability to comply with advice, making them well suited for psychotherapeutic interventions.136 Medications may be needed in those elite athletes with more severe mental health symptoms and disorders, but should not be viewed as an easy-fix or first-line treatment.137 Prior to prescribing medication to this population, the clinician should pay careful attention to potential negative impact on performance, potential therapeutic versus non-therapeutic (ie, ergogenic) performance enhancement, and potential World Anti-Doping Agency violation and safety risks.138
What can coaches and local/national/international sporting bodies do?
At a systems level, organisations, coaches and sport governing bodies can create an environment that supports mental well-being.139–146 The diagnosis and management of mental health symptoms and disorders in elite athletes is on a separate but related continuum with personal well-being.147 148 On one extreme, sport systems must be ready with well-developed and rehearsed protocols for managing mental health emergencies.149 Simultaneously, they can foster positive psychosocial development and well-being by helping athletes respond to stressors in healthy ways,139 150 151 which includes skill-building in resilience,152 psychological flexibility,153 self-compassion154 and consistency in core values.153 Elite athletes, like all human beings, thrive on compassion and consistent ethical values.
We are pleased to present a consensus statement on mental health in elite athletes from a 27-member work group of the IOC (figure 1).155 This consensus statement is based on 20 systematic reviews and provides recommendations for diagnosis and management of mental health symptoms and disorders in athletes while also providing guidance for developing a sports environment that promotes mental well-being. We highlight population-specific mental health considerations regarding epidemiology, relevant stressors and environmental factors, diagnostic challenges, symptom manifestations and management at the individual athlete and systems levels. This consensus statement is the first of its kind in depth and scope, and we hope it will be a catalyst to improve the health and well-being of elite athletes. Sport should be a public good. The healthy athlete provides a symbol of an ideal society—a society where personal well-being is promoted and those who seek treatment for mental health concerns are not stigmatised.
Contributors This editorial accompanies the IOC consensus statement on mental health in elite athletes, and also serves as an Executive Summary.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
Patient consent for publication Not required.
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