Mental health is an essential component of an athlete’s overall well-being and performance, yet it often remains under-addressed in elite sports. The International Olympic Committee (IOC) has recognized the prevalence of mental health symptoms and disorders among athletes and the need for evidence-based approaches to diagnosis and management. They released an important Consensus Statement on elite athlete mental health in 2019, the first of its kind, and it is summarized below.

Depression and Anxiety Disorders
Depression is one of the most common mental health issues among athletes, with prevalence rates thought to range from 4% to 68% depending on the study. Symptoms include persistent sadness, loss of interest in activities, fatigue, and difficulty concentrating. Female athletes and those in individual sports are particularly vulnerable, with risk factors including injury, competitive failure, and retirement. Depression can significantly impact performance and personal life, and untreated cases may lead to suicidal ideation.

Anxiety disorders, including generalized anxiety disorder (GAD), social anxiety disorder, and panic disorder, are also prevalent among athletes. GAD symptoms include excessive worry, restlessness, and difficulty concentrating, while social anxiety involves fear of negative evaluation in social or competitive settings. Injured athletes often report higher levels of anxiety, which can impair performance and recovery. Cognitive behavioral therapy (CBT) is a widely recommended treatment for anxiety disorders, alongside selective serotonin reuptake inhibitors (SSRIs) like fluoxetine, which have shown minimal impact on athletic performance.

Eating Disorders
Eating disorders, such as anorexia nervosa, bulimia nervosa, and binge eating disorder, are significantly more common in athletes than in the general population. Female athletes and those in sports emphasizing leanness or aesthetics, such as gymnastics and distance running, are at higher risk. Disordered eating behaviors, including restrictive diets and excessive exercise, can lead to severe health consequences like low energy availability, menstrual dysfunction, and stress fractures.

Diagnosing eating disorders in athletes can be challenging due to the overlap between disciplined training diets and pathological behaviors. Tools like the Athletic Milieu Direct Questionnaire and the Brief Eating Disorders in Athletes Questionnaire can aid in diagnosis. Treatment typically involves an interdisciplinary team, including psychiatrists, dietitians, and coaches, with a focus on restoring nutritional health and addressing psychological factors. Prevention programs that educate athletes, coaches, and sport organizations about healthy eating behaviors are also critical.

Substance Use Disorders
Substance use, including alcohol, nicotine, cannabis, and performance-enhancing drugs, is a significant concern in elite sports. Athletes may use substances to cope with stress, enhance performance, or manage pain, but misuse can lead to addiction, injury, and impaired recovery. Alcohol is the most commonly used substance, often associated with binge drinking and post-competition socialization. Cannabis use is increasing, particularly in regions where it is legal, but it can impair reaction time and coordination.

Anabolic-androgenic steroids are another concern, with users often experiencing mood swings, aggression, and psychosis. Stimulants like amphetamines and caffeine are sometimes misused for their perceived performance-enhancing effects, but high doses can lead to anxiety, insomnia, and cardiovascular issues. Screening and brief interventions during pre-season physicals can help identify substance use early, while education programs can deter misuse.

Post-Traumatic Stress Disorder (PTSD)
Trauma-related disorders, including PTSD, acute stress disorder, and adjustment disorder, are common in athletes, often stemming from sport-related injuries or external life events. Symptoms include hyperarousal, avoidance, re-experiencing traumatic events, and dissociation. Diagnosing PTSD in athletes can be challenging, as symptoms may be masked by compartmentalization or perfectionism.

Sport-related musculoskeletal injuries and concussions are significant risk factors for PTSD. Athletes may experience fear of re-injury, which can lead to avoidance behaviors and delayed recovery. Early intervention, including psychological debriefing and trauma-informed care, can mitigate symptoms. Recommended treatments include CBT, prolonged exposure therapy, and SSRIs like sertraline and fluoxetine.

Sleep Disorders
Sleep is vital for recovery and performance, yet many athletes struggle with sleep issues like insomnia, circadian rhythm disruptions, and sleep apnea. Insomnia disorder, characterized by difficulty initiating or maintaining sleep, is a major risk factor for mood disorders and impaired physical function. Circadian dysregulation, often caused by frequent travel across time zones, can negatively impact metabolism, performance, and psychological health.

Non-pharmacological treatments, such as CBT for insomnia (CBTI), are preferred for managing sleep disorders in athletes. Melatonin is a commonly used sleep aid, but athletes must ensure it is sourced from reputable companies to avoid prohibited substances. Addressing sleep hygiene and promoting healthy sleep behaviors at the team level can improve overall well-being.

Sport-Related Concussion (SRC)
Sport-related concussion (SRC) is a traumatic brain injury that can lead to neuropsychiatric symptoms, including depression, anxiety, and impulsivity. While most athletes recover within 7–10 days, up to 21% experience prolonged symptoms. Multiple concussions increase the risk of developing depression and other mental health disorders. Diagnosis of SRC is challenging due to the lack of objective biomarkers, but neuropsychological evaluation can help differentiate cognitive and mental health symptoms.

Management of SRC involves addressing biopsychosocial factors, promoting gradual exercise, and encouraging social activity. Psychotherapy and targeted pharmacological treatments, such as SSRIs, may be helpful for persistent symptoms.

Summary

Elite athletes face unique mental health challenges that require specialized approaches to diagnosis and management. Depression, anxiety, eating disorders, substance use disorders, PTSD, sleep disorders, and sport-related concussion are prevalent in this population, often exacerbated by the pressures of competition and injury. Early detection, evidence-based treatments, and supportive environments are essential to promoting mental health and optimizing performance. By prioritizing mental well-being, the sports community can ensure athletes thrive both on and off the field.