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The impact of mental health symptoms and disorders in elite athletes is increasingly recognised. This led the International Olympic Committee (IOC) to produce a consensus statement1 and establish a Mental Health Working Group. Members of this group have extensive experience in research and practice in the field of athlete mental health and have collectively ascertained gaps in current knowledge and practices. This editorial reflects the authors’ opinions and aims to provide researchers and practitioners with future directions relating to mental health symptoms and disorders in elite sport, focusing on prevalence/incidence, prevention, screening, assessment and treatment.
Prevalence and incidence
The prevalence studies that are currently available have significant limitations,2 including the lack of data distinguishing mental health symptoms from disorders. The latter require a clinical assessment accounting for the intense and unique demands athletes face, which influence how symptoms and disorders may manifest. An example is the presence of mental health symptoms in overtrained athletes, how these are understood from perspectives such as low energy availability or impaired immune function and where existing classification systems may be inadequate.
Studies are limited by the influence of stigma related to mental health symptoms and disorders both in and out of sporting contexts, which likely impact athletes’ responses and do not take account of additional barriers to reporting, specifically cultural barriers including sex, religion, race and socioeconomic factors. Studies also under-represent significant groups including female athletes; lesbian, gay, bisexual and transgender+ athletes; individual rather than team sports; ethnic minority groups; para athletes; officials; coaches; and entourage members. Longitudinal studies exploring the onset (ie, incidence) and course of mental health symptoms and disorders are also lacking.
Prevention
As with all interventions in elite sport, preventive interventions require evaluation. Improving the mental health literacy of athletes and organisations is critical. The sporting ecosystem should be psychologically safe, with no repercussions for seeking help. On the contrary, services should be readily available, and athletes positively encouraged to use them. The recently released IOC Mental Health in Elite Athletes Toolkit provides sports organisations with descriptions of key roles and responsibilities alongside policies and practice guidelines (figure 1). It includes practical measures that could be implemented without significant financial resources.
IOC mental health toolkit (https://stillmed.olympics.com/media/DocumentLibrary/IOC/Athletes/Safe-Sport-Initiatives/IOC-Mental-Health-In-Elite-Athletes-Toolkit-2021.pdf).
Prevention initiatives should continue to focus on known high-risk periods such as after an injury and the transition into retirement. Determining other stressors likely to incite mental health symptoms and disorders, and how to mitigate their impact, is also needed. Future directions should include evaluating the needs of young athletes transitioning into an elite sporting environment, and the relationship between athletic and disability identity and how this exacerbates retirement stressors for para athletes.3
Screening and assessment
The first step to improve the outcome for mental health symptoms and disorders is to identify those in need. A validated tool developed by the IOC (Sport Mental Health Assessment Tool 1) is an important advance, providing comprehensive screening and identification of ‘next steps’ such as when to seek further assessment and clinical support.4 It is recommended that mental health screening is conducted as systematically as other health checks, and further work is needed to ensure that screening tools remain valid when used in different languages and cultures as well as in different sporting contexts such as individual or team sports and at developmental and elite levels.
Treatment
A broad array of psychological and pharmacological treatments demonstrate efficacy in treating mental health disorders, but little is known about their efficacy in sport or how to adapt them to the unique needs of athletes.5 6 The suggestion that cognitive–behavioural therapy is suited to goal-orientated individuals such as elite athletes merits evaluation. Pharmacological treatment for athletes is currently based on expert opinion and extrapolation from studies in the general population, taking into account safety, tolerability, unique athlete physiology and whether the treatment is a prohibited substance in that sport. Studies need to evaluate the effects of medication prescribed to athletes over months rather than days to reflect clinical practice and should include relevant measures of athletic performance. As the sample size of elite athletes eligible for a study of a mental health intervention may be too small to yield scientific validity, we advocate for the development of multicentre collaborations with pooled study samples from global sources.
Future work should also evaluate the delivery of effective treatments across a range of different sporting contexts. For athletes who are travelling or have significant time pressures, virtual consultations may offer advantages over face-to-face consultations,7 and medication prescribing may be enhanced by treatment algorithms that improve clinical outcomes.8
Conclusion
The mental health of athletes should be a concern for all clinicians and researchers. Athletes deserve mental health support that is informed by evidence and equal to the support they receive for their physical health. The following recommendations outline priorities to meet the current and future mental health needs of elite athletes:
Develop and sustain a high level of mental health literacy among athletes, the entourage and sports organisations.
Conduct epidemiological studies that identify both mental health symptoms and disorders and include a more representative range of participants.
Implement athlete mental health support services at events and in daily training environments, and evaluate these for effectiveness.
Determine athlete-centred treatments that account for their unique demands and the unusual ecosystems in which they must flourish.
Incorporate mental health clinicians as key members of the sports medicine community collaborating in holistic athlete healthcare.
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Acknowledgments
The authors would like to thank the IOC Medical and Scientific Department and in particular Fiona Trabelsi for coordinating the series of meetings which resulted in this paper.
Footnotes
Twitter @DrAlanCPsych346, @CheriBlauwetMD, @Abhinav_Bindra, @campriani, @BrianHainline, @dmcduff52, @margo.mountjoy, @Mputukian, @vgouttebarge
Contributors AC, CB, DM, MM, RP, MP, CLR, VG: substantial contribution to conception and design; acquisition, analysis and interpretation of data; drafting the work and revising it critically; agreement to be accountable for all aspects of the work. AB, RB, NC, BH: substantial contribution to conception and design; interpretation of data; drafting the work and revising it critically; agreement to be accountable for all aspects of the work.
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 MP wishes to declare the following: consulting fees from Major League Soccer (USA); participation on advisory board as senior advisor, NFL (USA), Head, Neck and Spine Committee; participation on advisory board as committee member, US Soccer Medical Advisory Committee; participation on advisory board as committee member, USOPC Mental Health Task Force. All authors are members of the IOC Mental Health Working Group.
Provenance and peer review Not commissioned; externally peer reviewed.