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Review
Mental health symptoms and disorders in Paralympic athletes: a narrative review
  1. Leslie Swartz1,
  2. Xanthe Hunt2,
  3. Jason Bantjes2,
  4. Brian Hainline3,
  5. Claudia L Reardon4
  1. 1 Alan Flisher Centre for Public Mental Health, Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
  2. 2 Department of Psychology, Stellenbosch University, Stellenbosch, South Africa
  3. 3 National Collegiate Athletic Association (NCAA), Indianapolis, Indiana, USA
  4. 4 Department of Psychiatry, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
  1. Correspondence to Professor Leslie Swartz, Alan Flisher Centre for Public Mental Health, Department of Psychology, Stellenbosch University, Stellenbosch 7602, South Africa; lswartz{at}sun.ac.za

Abstract

Objectives This narrative review summarises the literature on the mental health of Paralympic athletes, explores possible reasons for the paucity of research in this area and suggests directions for future research.

Methods A systematic search of PubMed, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, SPORTDiscus, Scopus, and Cochrane databases was conducted using search terms related to disability, sport and mental health.

Results The search yielded 665 publications. Of these, 129 were duplicates, resulting in 536 publications identified for initial screening. A total of 72 publications were to be relevant at initial screening. Only seven publications addressed Paralympic athletes specifically. Of these papers, three included measures of depression and three included measures of anxiety. In the studies that were not concerned with mental health symptoms or disorders, the focus of enquiry included identity and self, stress, and well-being.

Conclusion Most of the studies reviewed are small in scale, and there are almost no comparative data on Paralympic versus Olympic athletes. There is a paucity of data on rates of mental health symptoms and disorders in this population and the factors that might contribute to poor mental health among elite athletes with disabilities. We propose that stereotypes about people with disabilities—and the disability rights movement’s rightful reaction to these stereotypes—have created barriers to mental health research among Paralympic athletes. There is a need for enquiry into the differential stressors experienced by Paralympic athletes, including trauma, transition out of sport, sport and personhood, and the potential for disability sport to promote psychological health.

  • athlete
  • disability
  • mental
  • psychiatry
  • review
  • paralympic

https://doi.org/10.1136/bjsports-2019-100731

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    What is already known

    • Social forces that differentially affect people with disabilities, as well as the demands of high-level sports performance, could put Paralympic athletes at risk for mental health symptoms and disorders.

    What are the new findings

    • It is possible that certain stereotypes about people with disabilities—and the disability rights movement’s rightful reaction to these stereotypes—create barriers to mental health research among Paralympic athletes.

    • There is a need for enquiry into the differential stressors experienced by Paralympic athletes, including trauma, transition out of sport, sport and personhood, and the potential for disability sport to promote psychological health.

    Introduction

    Disability sport is the field of sport for all people with physical impairments, and parasport is the field where sport is played by the rules governed by the International Paralympic Committee. The Paralympic Games is the major event on the parasport calendar, held every 4 years concurrent with the Olympics. Parasport makes use of adapted equipment or rules to make sport accessible to this population. The aim of this narrative review is to summarise the existing literature on the mental health of Paralympic athletes, suggest possible reasons for the lack of research in this area and propose directions for future research. This paper focuses on Paralympic athletes as a subgroup of elite-level Para-athletes. The reason for this focus is twofold. First, because this review was conducted as part of an IOC initiative, a focus on athletes who had participated in Paralympic competition was warranted. Second, there are specific pressures that impact Paralympic athletes, as opposed to other elite athletes with disabilities, which might make enquiry into their mental health especially salient.

    Methods

    A systematic search of PubMed, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, SPORTDiscus, Scopus, and Cochrane databases was conducted up until October 2018. Searches were conducted using the following three groups of terms:

    • Bucket 1 (sport terms): Sport OR athlete OR sportsmen OR sportswomen OR olymp*.

    • Bucket 2 (disability terms): Disab* OR quadrip* OR parapleg* OR wheelchair* OR spinal cord injury OR Paralymp* OR disability sport OR adaptive sport OR adaptive physical activity OR impair* OR People with Disabilities OR Persons with Disabilities OR Physically Disabled OR Mentally Disabled OR Sports for the Disabled OR deaf OR Vision Disability OR Hearing Disabled Persons OR cerebral pals*.

    • Bucket 3 (mental health terms): Psychology* OR psychiatr* OR mental health OR stigma* OR exclusion OR isolation OR discrimination* OR depress* OR anxiety* OR supercrip OR mood OR mental disorder.

    Journal articles (excluding reviews), book chapters, theses and books were included. Reference lists of the included publications were reviewed to identify additional materials. Finally, the non-sporting literature was reviewed for relevant papers to inform the overall topic. Given the probability that there would not be a large number of articles, chapters or books, the search was designed to be overinclusive so as not to miss any potential material, with irrelevant material omitted at hand-screening stage. Publications must have been available in English to be included in this analysis. Based on this, we conducted a narrative review.1 2

    Results

    The search yielded 665 publications. Of these, 129 were duplicates, resulting in 536 publications identified for initial screening. A total of 72 publications met the inclusion criteria. The included publications were grouped into those focused on social measures of well-being (n=24) and those focused on psychological measures (n=49); one was included in both categories. We also divided the included publications into those focused on Paralympic athletes (n=7) and those focused on athletes with disabilities who were not Paralympic athletes (n=64).

    Of the seven publications addressing the mental health of Paralympic athletes specifically, one examined how participation in parasport resulted in psychological, physiological and emotional changes in an elite athlete,3 one explored the role of parasport in athletes’ self-perceptions and identity development,4 and one compared mood and personality differences between elite athletes who were and were not chosen for their country’s Paralympic team.5 A study from Iran assessed the quality of working life and levels of depression in Paralympic athletes and non-athletes working together at a training institution in the country.6 Another examined the sleep quality, sleepiness, chronotype and anxiety levels among Brazilian Paralympic athletes before the 2008 Beijing Paralympic Games.7 Finally, one article presented findings regarding the well-being, needs and strengths of Paralympic athletes,8 and another the sources of stress experienced by members of a Paralympic basketball team9 (see online supplementary table 1 for a summary of these publications).

    Supplemental material

    Among the included publications, there was one case study employing qualitative methods,3 three other qualitative studies with sample sizes between 5 and 23 Paralympic athletes,4 8 9 and three studies that used quantitative analyses.5–7 Study samples were drawn from Paralympic athletes in Italy, England, USA, Iran, Brazil and Australia. Three studies included measures of depression3 5 6 and three included measures of anxiety.3 5 7 In the studies that were not concerned with mental health symptoms or disorders, the focus of enquiry included identity and self,4 stress,9 and well-being.8

    Discussion

    Most of the studies reviewed are small in scale, focus on a narrow range of mental health symptoms (ie, depression and anxiety), and draw on samples from remarkably few (mostly high-income Western) countries. There is a marked lack of comparative data exploring differences in rates of mental health symptoms and disorders between Paralympic and Olympic athletes, and Paralympic athletes and individuals with disabilities who do not participate in elite competitive sport. It is thus difficult to draw firm conclusions about the mental health status and mental health needs of Paralympic athletes from available evidence. The only definitive conclusion that can be made from this literature review is that there is a clear need for more focused research on the mental health of Paralympic athletes.

    Paralympic athletes are likely to experience a range of sport-specific and disability-specific stressors that have the potential to compromise their personal well-being.8 9 It is thus remarkable that there have been so few studies exploring the lived experience of Paralympic athletes, their perception of psychosocial and sport-specific stressors, and their expressed mental health support needs, despite a growing body of literature looking more broadly at the experiences of Paralympians.10–13 The studies included in this review paid scant attention to the sociopolitical nature of disability, and instead tended to focus on issues of individual identity. In the absence of data allowing for full discussion of the mental health of Paralympic athletes, we provide a discussion of contextual issues relevant to this topic and suggest possible reasons for the dearth of literature in this field.

    Contextual issues in the field

    Before the advent of the disability rights movement, a common stereotype held that people with disabilities must, reasonably, have emotional problems, including but not limited to mental health symptoms and disorders.14 15 This stereotype is rooted in the pervasive belief that disability is a medical problem and a mental health burden.16 17 For example, samples of primarily people without disabilities believe that suicide is more acceptable when a vignette character is disabled than when the character is not.18 Contemporary research into stereotypes about people with disabilities indicates that this way of perceiving disability endures.19 This problematic history of assuming that disability is inevitably associated with psychological impairment may be one reason for the paucity of research into the mental health of athletes with disabilities.20–22 Researchers may have been reluctant to be seen as contributing to problematic stereotyping. Thus, it is perhaps not surprising that in the past decade or so, in the general (non-athlete) population, relatively few studies have explored the mental health of people with disabilities. Some literature does suggest that the rates of mental health symptoms or disorders, specifically depression, among the general population of people with disabilities are higher than in non-disabled individuals.23–26 However, most of that literature concerns individuals with intellectual and not physical disabilities.

    Comparatively recently, however, a field of study focusing on ‘psycho-emotional disability’ has emerged. Researchers in this field agree that the assumption of a causal relationship between physical or intellectual impairment and mental health symptoms or disorders is both incorrect and discriminatory. They emphasise that the social exclusion and stereotyping of people with disabilities, coupled with possible anxieties among the general population about disability and disablement, may have profound psychological and mental health consequences for people with disabilities.14 15 27 In this regard, one of the leading texts in the field of psychoemotional disability is entitled Towards a Contextual Psychology of Disablism.28 The focus in this work is on the enactment and consequences of the social process of disablism—a process akin to racism; such a focus does not simply assume that living with an impairment is necessarily distressing in and of itself. Just as research on mental health among minorities no longer assumes that mental health issues are attributable to inherent racial differences, the contemporary trend in disability studies is to explore the social context of individuals with disability rather than to attribute emotional distress and disorder to impairments themselves.

    Given the widespread social denigration and exclusion of people with disabilities, when people with disabilities do well, or achieve, it is often viewed as something extraordinary, unusual or superhuman. Within disability studies, this veneration of people with disabilities who achieve is known as the ‘Supercrip’ phenomenon.29 30 There is nothing wrong with admiring or being inspired by the achievements of others; Supercrip discourse, however, has been described as potentially problematic for a number of reasons.29–32 First, the excessive veneration of people with disabilities who achieve suggests that the overall expectation is that they will not achieve. This is similar to the excessive admiration of high-achieving women, masking the implicit view that women in general are less capable than men. Second, many people with disabilities who achieve great heights do not encounter the same social barriers and exclusion as most people with disabilities. For example, South Africa’s most famous Paralympic athlete, Oscar Pistorius, an undoubtedly highly gifted and talented athlete, is a white man from a privileged background. This does not detract from his achievements, but the context in which he achieved is vastly different from the context in which most South Africans with disabilities live.33

    The Supercrip phenomenon may be better than other types of stereotypes about disability, such as narratives of helplessness and discourses of pity.16 The notion of the Supercrip may paradoxically reinforce tragedy narratives by viewing Paralympic athletes who achieve as being, of necessity, people who overcome tragedies.30 A third problem with the Supercrip narrative is how it may be internalised to a potentially damaging degree by athletes. The Supercrip narrative is not accepted by all athletes with disabilities as reflecting their experience.29 On the other hand, a number of elite athletes may claim personhood on the basis that their extraordinary achievements are what signals to others their equality.34 35 The potential mental health consequences of Paralympic athletes believing that they have to achieve to an extraordinary level simply to be respected as a person have not been explored in the existing literature.

    These broad social issues regarding people with disabilities being depicted either as abject or tragic on one hand, or overvalorised and idealised on the other, may seem distant from research gaps in studying the mental health of Paralympic athletes. Yet the study of mental health issues among Paralympic athletes will be affected by how people with disabilities are viewed socially. For example, studies of depression or anxiety among Paralympic athletes may fit neatly into stereotypes about the inherent emotional weakness of people with disabilities. On the other hand, Paralympic sport is marketed to inspire. The motto of the International Paralympic Committee is ‘to enable Para athletes to achieve sporting excellence and inspire and excite the world’.36 By contrast, the IOC explicitly seeks to ‘contribute to building a peaceful and better world by educating youth through sport practiced without discrimination of any kind, in a spirit of friendship, solidarity and fair play’.37 Both exemplify high ideals, but the burden (and opportunity) to inspire others is implicitly placed on the Paralympic athletes rather than on Olympians. With this background, exploring struggles of Paralympic athletes—especially struggles that have not been overcome, such as ongoing mental health symptoms or disorders—may be difficult.

    A way forward

    These contextual features notwithstanding, Paralympic athletes and other athletes with disabilities should enjoy the same rights to having their mental health studied and addressed as other elite athletes. In this regard, everything that is currently known about mental health in elite athletes is of relevance to elite athletes with disabilities. In what follows, we outline suggestions for how these general issues may need to be taken into account in future research focused on understanding the mental health of Paralympic athletes:

    Explore stressors particular to participation in elite disability sport

    Some stressors affecting elite athletes in general38 may disproportionately and commonly affect elite athletes with disabilities, compared with elite athletes in general. Other stressors may be relatively unique to elite athletes with disability. Stressors from either or both categories include chronic pain; overtraining and injury in often complex medical situations (eg, with the need to distinguish sport fatigue, discomfort from the disability and sport injuries); lack of sufficient adaptive sport facilities; logistical challenges in travel to competition sites; challenging sleep conditions and inferior sleep quality in Paralympic villages; recent rapid escalation of Paralympic sport competitiveness and associated rapid increases in training demands; malfunctioning sports equipment; costs associated with new technology; negative coaching behaviours (eg, demeaning comments); and being ‘misclassified’ or assigned to the wrong disability category for competition. Studying the impact of these stressors on the mental health of Paralympic athletes would be valuable in order to understand the aetiology of mental health symptoms and disorders in this population and plan symptom management accordingly.

    Explore a wider range of symptoms of psychological distress, including the impact of trauma

    Trauma is an important concern for all athletes.38 A substantial proportion of Paralympic athletes have acquired disabilities directly resulting from trauma. While there has been some research into experiences of trauma, more needs to be done to understand how trauma may affect Paralympic athletes and the extent to which symptoms of traumatisation are prevalent in this population. Given that studies have hitherto focused narrowly on depression and anxiety, it may be helpful to expand the focus to include other mental health disorders, including eating disorders, substance use disorders, sleep disorders, bipolar spectrum disorders and obsessive-compulsive disorder. This would allow for a more comprehensive assessment of the mental health needs of Paralympic athletes. While it would be important for future studies to report mental health symptoms, it may also be helpful to employ validated methodologies (such as the procedures used in the WHO World Mental Health Surveys) to determine caseness and hence establish prevalence estimates for actual mental health disorders. Using well-validated and widely used instruments to establish prevalence estimates for common mental disorders in future studies would also allow for meaningful comparisons between Paralympic athletes and other groups.

    Explore the impact of participation in disability sport on personhood and mental health

    As suggested above, athletes live in a world in which people with disabilities may be perceived to be inherently different from (and implicitly inferior to) those without disabilities. Because disability sport positions itself to inspire and challenge stereotypes, athletes with disabilities may be discouraged from discussing openly their experiences of discrimination, even by health professionals. As a result, some athletes may have internal conflicts around their identity and personhood, which could have adverse effects on mental health. Hardin and Hardin29 discuss some of these issues and show the way forward, but what is still needed is a more systematic and thorough account of the mental health implications that are inherent with holding a potentially pressurised and yet tenuous social position.

    Investigate the mental health impact of retirement from elite disability sport

    The transition out of sport is an issue for all elite athletes.38 When that elite athlete is a person with a disability, the social value of their prior position (hero, inspiration, Supercrip) may be more distant from their postretirement position (person with a disability) than for non-disabled athletes. Furthermore, the careers of many Paralympic athletes start shortly after the onset of disability. With relatively short-lived professional sport careers, some of these athletes face the challenge of simultaneously needing to adjust to a relatively new disability and starting to prepare for retirement from sport; healthcare providers should be aware of these dual transitions. For some athletes with disabilities, the sporting identity may have buffered them in transitioning to a life with increased likelihood of discrimination. Many have suggested that in these circumstances, sport participation may promote mental health.39 However, when these athletes transition out of sport, they may move rather quickly from being ‘inspirational’ to living in a world in which discrimination is a reality. It is well established globally, for example, that people with disabilities are more likely than those without disabilities to be unemployed or to be underemployed; access to education and to a host of other social inclusion opportunities is similarly compromised.33 The experience of having been a Paralympic athlete may be somewhat protective by providing skills and networks that the person would otherwise lack. Yet, without further research, we do not know what the psychological impact of this transition is and what interventions may be required.

    Investigate the therapeutic potential of disability sport to promote mental health

    Two journals recently devoted special issues to disability sport.40 41 These publications correctly emphasise the health-promoting role of sport for athletes with disabilities, and make claims for the mental health benefits of sports. Indeed, the Paralympic movement was started as a way of providing rehabilitative sport to survivors of spinal cord injuries. However, unintended negative consequences may be associated with this emphasis on disability sport as a form of treatment. For example, healthcare personnel and others may view athletes with disabilities as people with impairments first and as athletes second. Within the disability movement in general, much has been written about the mental health consequences of being viewed primarily as a person with a condition that requires treatment, rather than a person with a right to participate. It would be helpful for future research to explore the potential mental health benefits of participation in parasport, without obscuring the possibility that participation in elite disability sport may also have adverse consequences for an athlete’s mental health.

    In summary, despite initiatives to investigate the mental health of Paralympic athletes, most data remain anecdotal; there is a lack of accurate epidemiological data on mental health symptoms and disorders of those who participate in elite competitive disability sport. We have suggested some possible reasons for the current gaps in knowledge and have proposed potential focus areas to advance our understanding of this topic. There remains much to be done in order to generate the data needed to understand the mental health of Paralympic athletes.

    Acknowledgments

    The authors thank the other participants in the 2018 IOC Consensus Meeting on Mental Health in Elite Athletes, including Cindy Miller Aron, David Baron, Antonia Baum, Abhinav Bindra, Richard Budgett, Niccolo Campriani, Joao Mauricio Castaldelli-Maia, Alan Currie, Jeffrey L Derevensky, Lars Engebretsen, Ira Glick, Paul Filip Gorczynski, Vincent Gouttebarge, Michael Grandner, Doug Hyun Han, Margo Mountjoy, Aslihan Polat, Rosemary Purcell, Margot Putukian, Simon M Rice, Allen Sills, Torbjorn Soligard, Todd Stull and Li Jing Zhu, for their input on the development and interpretation of this research, and Mary E Hitchcock for her assistance with the literature search.

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      . Issue targeted topic – Paralympic athletes, 2018.

    Footnotes

    • Contributors LS conceptualised the paper and the analytic framework. XH collected the data and contributed substantially to the first draft. JB contributed substantially to the first draft. BH was central in writing the consensus statement of which this article is a subspecialty paper. CLR was the PI for the consensus statement of which this article is a subspecialty paper. All authors contributed to a series of rounds of drafts and approved the final version as submitted.

    • 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.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.