The importance of mental health among athletes is becoming more recognized and valued. Athletes experience symptoms of depression, anxiety, and related mental health disorders at rates similar to those of the general population, but because athletes face unique cultural and environmental pressures, such disorders are exacerbated in the context of an injury. Furthermore, we review the less well-known evidence that mental health disorders in athletes are associated with an increased risk of injury. We discuss the increasing awareness of the deficiencies in mental health support for athletes, which has been especially highlighted during the COVID-19 pandemic as well as in prominent professional and Olympic athletes, and describe both internal and external barriers to appropriate care.
Evidence Acquisition:
We searched PubMed for pertinent peer-reviewed studies.
Study Design:
Clinical review.
Level of Evidence:
Level 5.
Results:
There is a known psychological response to injury that can prolong recovery from musculoskeletal injury; conversely, mental health disorders in athletes are not only associated with an increased injury risk but also portend poorer outcomes subsequently, including prolonged recovery times, increased rates of injury recurrence, decreased rates of return to sport, and reduced performance upon return. Because of inherent barriers to appropriate care of athletes, including identification, stigma, and resource availability, there are currently various ongoing efforts nationally to create and implement initiatives regarding athlete mental health screening, support systems, and directed interventions to address the inextricably linked physical and mental health of athletes.
Conclusion:
Athletic injury negatively impacts the mental health of athletes. Likewise, mental health can and does influence athletic performance and is also intimately tied to the risk of athletic injury, thus creating a complex cycle with inability to separate physical and mental health.
AloscoMLFedorAFGunstadJ. Attention deficit hyperactivity disorder as a risk factor for concussions in NCAA Division-I athletes. Brain Inj. 2014;28(4):472-474.
2.
ArdernCLÖsterbergATagessonSGauffinHWebsterKEKvistJ. The impact of psychological readiness to return to sport and recreational activities after anterior cruciate ligament reconstruction. Br J Sports Med. 2014;48(22):1613-1619.
3.
AvedesianJMForbesWCovassinTDufekJS. Influence of cognitive performance on musculoskeletal injury risk: a systematic review. Am J Sports Med. 2021;50(2):363546521998081.
4.
BailliePHFDavisHOgilvieBC. Working with elite athletes. In: Van RaalteJLBrewerBW, eds. Exploring Sport and Exercise Psychology. 3rd ed.Washington DC: American Psychological Association; 2014:401-425.
5.
BeableSFulcherMLeeACHamiltonB. SHARPSports Mental health awareness research project: prevalence and risk factors of depressive symptoms and life stress in elite athletes. J Sci Med Sport. 2017;20(12):1047-1052.
6.
BrownDRBlantonCJ. Physical activity, sports participation, and suicidal behavior among college students. Med Sci Sports Exerc. 2002;34(7):1087-1096.
7.
Castaldelli-MaiaJMGallinaroJG de M eFalcãoRS, et al. Mental health symptoms and disorders in elite athletes: a systematic review on cultural influencers and barriers to athletes seeking treatment. Br J Sports Med. 2019;53(11):707-721.
8.
Centers for Disease Control and Prevention/National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Adolescent and School Health (DASH) | CDC/Youth Risk Behavior Survey Data Summary & Trends Report 2009-2019. Centers for Disease Control and Prevention. https://www.cdc.gov/healthyyouth/index.htm. Accessed January 17, 2023
9.
ChangCPutukianMAerniG, et al. Mental health issues and psychological factors in athletes: detection, management, effect on performance and prevention: American Medical Society for Sports Medicine Position Statement - Executive Summary. Br J Sports Med. 2020;54(4):216-220.
10.
CromerLKaierEDavisJStunkKStewartSE. OCD in college athletes. Am J Psychiatry. 2017;174(6):595-597.
11.
DrewMKVlahovichNHughesD, et al. A multifactorial evaluation of illness risk factors in athletes preparing for the Summer Olympic Games. J Sci Med Sport. 2017;20(8):745-750.
12.
DudekDSiwekMJaeschkeR, et al. A web-based study of bipolarity and impulsivity in athletes engaging in extreme and high-risk sports. Acta Neuropsychiatr. 2016;28(3):179-183.
13.
FordIWEklundRCGordonS. An examination of psychosocial variables moderating the relationship between life stress and injury time-loss among athletes of a high standard. J Sports Sci. 2000;18(5):301-312.
14.
GalambosSTerryPMoyleGLockeSLaneA. Psychological predictors of injury among elite athletes. Br J Sports Med. 2005;39(6):351-354.
15.
GarnerAAHansenAABaxleyCRossMJ. The use of stimulant medication to treat attention-deficit/hyperactivity disorder in elite athletes: a performance and health perspective. Sports Med. 2018;48(3):507-512.
16.
GoodeJH. Are pilots at risk of accidents due to fatigue?J Safety Res. 2003;34(3):309-313.
17.
GouttebargeVBindraABlauwetC, et al. International Olympic Committee (IOC) Sport Mental Health Assessment Tool 1 (SMHAT-1) and Sport Mental Health Recognition Tool 1 (SMHRT-1): towards better support of athletes’ mental health. Br J Sports Med. 2021;55(1):30-37.
18.
GulliverAGriffithsKMChristensenH. Barriers and facilitators to mental health help-seeking for young elite athletes: a qualitative study. BMC Psychiatry. 2012;12:157.
19.
GulliverAGriffithsKMMackinnonABatterhamPJStanimirovicR. The mental health of Australian elite athletes. J Sci Med Sport. 2015;18(3):255-261.
20.
HåkanssonAJönssonCKenttäG. Psychological distress and problem gambling in elite athletes during COVID-19 restrictions - a web survey in top leagues of three sports during the pandemic. Int J Environ Res Public Health. 2020;17(18):6693.
21.
HammondTGialloretoCKubasHHap DavisHIV. The prevalence of failure-based depression among elite athletes. Clin J Sport Med. 2013;23(4):273-277.
22.
HarrisW. Fatigue, circadian rhythm, and truck accidents. In: RRMackie, ed. Vigilance: Theory, Operational Performance, and Physiological Correlates. NATO Conference Series. New York: Springer US; 1977:133-146.
23.
IvarssonAJohnsonU. Psychological factors as predictors of injuries among senior soccer players. A prospective study. J Sports Sci Med. 2010;9(2):347-352.
24.
IvarssonAJohnsonUAndersenMBTranaeusUStenlingALindwallM. Psychosocial factors and sport injuries: meta-analyses for prediction and prevention. Sports Med. 2017;47(2):353-365.
25.
IvarssonAJohnsonUPodlogL. Psychological predictors of injury occurrence: a prospective investigation of professional Swedish soccer players. J Sport Rehabil. 2013;22(1):19-26.
26.
Jansson-FröjmarkMHarveyAGLundhL-GNorell-ClarkeALintonSJ. Psychometric properties of an insomnia-specific measure of worry: the anxiety and preoccupation about sleep questionnaire. Cog Behav Ther. 2011;40(1):65-76.
27.
JohnsonUIvarssonA. Psychological predictors of sport injuries among junior soccer players. Scand J Med Sci Sports. 2011;21(1):129-136.
28.
JohnsonUIvarssonA. Psychosocial factors and sport injuries: prediction, prevention and future research directions. Curr Opin Psychol. 2017;16:89-92.
29.
JungeA. The influence of psychological factors on sports injuries. Am J Sports Med. 2000;28(5 Suppl):10-15.
30.
JungeAFeddermann-DemontN. Prevalence of depression and anxiety in top-level male and female football players. BMJ Open Sport Exerc Med. 2016;2(1):e000087.
31.
KaiselerMPooltonJMBackhouseSHStangerN. The relationship between mindfulness and life stress in student-athletes: the mediating role of coping effectiveness and decision rumination. Sport Psychol. 2017;31(3):288-298.
32.
KerrZYMarshallSWDompierTPCorletteJKlossnerDAGilchristJ. College sports-related injuries - United States, 2009-10 through 2013-14 academic years. MMWR Morb Mortal Wkly Rep. 2015;64(48):1330-1336.
33.
KokotailoPKHenryBCKoscikREFlemingMFLandryGL. Substance use and other health risk behaviors in collegiate athletes. Clin J Sport Med. 1996;6(3):183-189.
34.
KroshusE. Variability in institutional screening practices related to collegiate student-athlete mental health. J Athl Train. 2016;51(5):389-397.
35.
KroshusEDavorenAK. Mental health and substance use of sexual minority college athletes. J Am Coll Health. 2016;64(5):371-379.
LavalléeLFlintF. The relationship of stress, competitive anxiety, mood state, and social support to athletic injury. J Athl Train. 1996;31(4):296-299.
38.
LiHMorelandJJPeek-AsaCYangJ. Preseason anxiety and depressive symptoms and prospective injury risk in collegiate athletes. Am J Sports Med. 2017;45(9):2148-2155.
39.
McArdleSMeadeMMBurrowsE. Service providers’ attitudes toward athletes with eating disorders. Clin J Sport Med. 2018;28(1):51-55.
40.
MelinATorstveitMKBurkeLMarksSSundgot-BorgenJ. Disordered eating and eating disorders in aquatic sports. Int J Sport Nutr Exerc Metab. 2014;24(4):450-459.
NealTLDiamondABGoldmanS, et al. Inter-association recommendations for developing a plan to recognize and refer student-athletes with psychological concerns at the collegiate level: an executive summary of a consensus statement. J Athl Train. 2013;48(5):716-720.
43.
NealTLDiamondABGoldmanS, et al. Interassociation recommendations for developing a plan to recognize and refer student-athletes with psychological concerns at the secondary school level: a consensus statement. J Athl Train. 2015;50(3):231-249.
OwensJAWeissMR. Insufficient sleep in adolescents: causes and consequences. Minerva Pediatr. 2017;69(4):326-336.
46.
ParkJHRheeS-MKimHSOhJH. Effects of anxiety and depression measured via the hospital anxiety and depression scale on early pain and range of motion after rotator cuff repair. Am J Sports Med. 2021;49(2):314-320.
47.
PinkertonRSHinzLDBarrowJC. The college student-athlete: psychological considerations and interventions. J Am Coll Health. 1989;37(5):218-226.
48.
PlateauCRArcelusJLeungNMeyerC. Female athlete experiences of seeking and receiving treatment for an eating disorder. Eat Disord. 2017;25(3):273-277.
49.
PrinzBDvořákJJungeA. Symptoms and risk factors of depression during and after the football career of elite female players. BMJ Open Sport Exerc Med. 2016;2(1):e000124.
50.
RamoseCôrteACCamargo-JuniorFChalhubT, et al. COVID-19 and its effect on Olympic sport: the importance of studying social isolation and the harm it causes, in order to minimize it. Rev Bras Med Esporte. 2020;26(5):371-377.
51.
RaoALAsifIMDreznerJAToresdahlBGHarmonKG. Suicide in National Collegiate Athletic Association (NCAA) athletes: a 9-year analysis of the NCAA resolutions database. Sports Health. 2015;7(5):452-457.
52.
ReardonCLFactorRM. Sport psychiatry. Sports Med. 2010;40(11):961-980.
53.
RiceSOliveLGouttebargeV, et al. Mental health screening: severity and cut-off point sensitivity of the Athlete Psychological Strain Questionnaire in male and female elite athletes. BMJ Open Sport Exerc Med. 2020;6(1):e000712.
54.
RiceSMPurcellRDe SilvaSMawrenDMcGorryPDParkerAG. The mental health of elite athletes: a narrative systematic review. Sports Med. 2016;46(9):1333-1353.
55.
SaracNSaracBPedrozaABorchersJ. Epidemiology of mental health conditions in incoming Division I collegiate athletes. Phys Sportsmed. 2018;46(2):242-248.
56.
ShuerMLDietrichMS. Psychological effects of chronic injury in elite athletes. West J Med. 1997;166(2):104-109.
57.
SmithAMMillinerEK. Injured athletes and the risk of suicide. J Athl Train. 1994;29(4):337-341.
58.
SmythEANewmanPWaddingtonGWeissensteinerJRDrewMK. Injury prevention strategies specific to pre-elite athletes competing in Olympic and professional sports - a systematic review. J Sci Med Sport. 2019;22(8):887-901.
59.
SteffenKPensgaardAMBahrR. Self-reported psychological characteristics as risk factors for injuries in female youth football. Scand J Med Sci Sports. 2009;19(3):442-451.
60.
SturmRRingelJSBaoY, et al. Mental health care for youth: who gets it? How Much does it cost? Who pays? Where does the money go?RAND Corporation. https://www.rand.org/pubs/research_briefs/RB4541.html. Accessed January 17, 2023
61.
SudanoLEMilesCM. Mental health services in NCAA Division I athletics: a survey of head ATCs. Sports Health. 2016;9(3):262-267.
62.
Sundgot-BorgenJTorstveitMK. Prevalence of eating disorders in elite athletes is higher than in the general population. Clin J Sport Med. 2004;14(1):25-32.
63.
TimpkaTJacobssonJBargoriaV, et al. Preparticipation predictors for championship injury and illness: cohort study at the Beijing 2015 International Association of Athletics Federations World Championships. Br J Sports Med. 2017;51(4):271-276.
64.
TrinhLNBrownSMMulcaheyMK. The influence of psychological factors on the incidence and severity of sports-related concussions: a systematic review. Am J Sports Med. 2020;48(6):1516-1525.
65.
TrojianT. Depression is under-recognised in the sport setting: time for primary care sports medicine to be proactive and screen widely for depression symptoms. Br J Sports Med. 2016;50(3):137-139.
66.
Wiese-BjornstalDM. Psychology and socioculture affect injury risk, response, and recovery in high-intensity athletes: a consensus statement. Scand J Med Sci Sports. 2010;20(Suppl 2):103-111.
67.
WilliamsJMAndersenMB. Psychosocial antecedents of sport injury: review and critique of the stress and injury model. J Appl Sport Psychol. 1998;10(1):5-25.
68.
WolaninAHongEMarksDPanchooKGrossM. Prevalence of clinically elevated depressive symptoms in college athletes and differences by gender and sport. Br J Sports Med. 2016;50(3):167-171.
69.
XanthopoulosMSBentonTLewisJCaseJAMasterCL. Mental health in the young athlete. Curr Psychiatry Rep. 2020;22(11):63.
70.
YangJChengGZhangYCovassinTHeidenEOPeek-AsaC. Influence of symptoms of depression and anxiety on injury hazard among collegiate American football players. Res Sports Med. 2014;22(2):147-160.
71.
YangJPeek-AsaCCorletteJDChengGFosterDTAlbrightJ. Prevalence of and risk factors associated with symptoms of depression in competitive collegiate student athletes. Clin J Sport Med. 2007;17(6):481-487.
72.
ZakrajsekRAMartinSBWrisbergCA. National Collegiate Athletic Association Division I Certified athletic trainers’ perceptions of the benefits of sport psychology services. J Athl Train. 2016;51(5):398-405.
