When an athlete gets injured, there is a team of medical personnel employed to ensure a speedy, successful recovery. However, when an athlete struggles with mental health issues, the approach is very different and can leave many feeling isolated. Many believe that mental illness does not affect athletes, but mental illness is as common in athletes as in the general population. Research suggests there are risk factors unique to the athletic population that may increase the risk of depression in comparison to the general population (Wolanin et al., 2014).
Unique Risk Factors
For some athletes, career termination is done with ease, while for others sport career termination has been associated with depression, anxiety, increased hostility and anger, and substance abuse. One particular variable that impacts the transition is whether retirement was voluntary (i.e., person wants to retire) or involuntary (i.e., injury, cut, age out). Voluntary retirement was associated with fewer negative emotional reactions when compared with unplanned retirement (Wippert & Wippert, 2010). Involuntary retirement is associated with significantly greater psychological symptoms and it's suggested that symptoms of psychological distress reduce as one adjusts to life outside of sport (Wippert & Wippert, 2010).
Injury is a common contributor to psychological distress in athletes. One study found that half of athletes who sustained injury during the course of the study endorsed mild-to-severe symptoms of depression, although there are limitations with sole reliance on self-report measures (Leddy et al., 1994). Emerging evidence also suggests that sports concussions can lead to changes in emotional state (Hutchinson et al., 2009).
Declines in athletic performance, and "choking" under pressure, can contribute to the experience of depressive symptoms (Wolanin et al., 2014). Poor athletic performance may result in negative self-perceptions and evaluations, a lack of external reinforcement, behavioral deactivation, and feelings of hopelessness (Wolanin et al., 2014).
Hammond et al. (2013) investigated the relationship between the prevalence of diagnosed failure-based depression and self-reported symptoms of depression within a sample of 50 elite swimmers. Researchers found that after competition, 34% of athletes had clinically elevated depression scores on the Beck Depression Inventory - II, but the top quartile of elite performance had 2 times higher rate of elevated depression scores (Hammond et al., 2013). This illustrates that some high-performing athletes may actually be more susceptible to depression when faced with performances that are below their expectations (Hammond et al., 2013).
Differences Between Team Sports and Individual Sports
There are significant differences between team sports and individual sports in terms of motivation of athletic success and psychological skills. Organized sports and playing on a team encourage fitness and the development of mental and social skills (Pluhar, 2019). In team sports, athletes work together resulting in a sense of support and acceptance. Support and acceptance are both protective factors in reducing depression symptoms. Boone & Leadbeater (2006) found that experiences on teams with coaching, skill development, and peer support decreased body dissatisfaction and contributed to feelings of social acceptance. Additionally, participating in team sports are associated with decreased risk of anxiety, depression, suicidal ideation, suicide attempts, feelings of hopelessness, and drug use (Sabiston et al., 2016).
On the contrary, individual sports provide less social opportunity and encourage self-reliance, responsibility, and a higher level of preparation. Individual-sport athletes reported playing sports for goal-oriented reasons, as opposed to for fun (Pluhar et al., 2019). Self-reported diagnoses of depression and or anxiety were higher among individual sport athletes (Pluhar et al., 2019). In these sports, success often depends completely on one's training and skills. This increases accountability and furthers deep feelings of shame upon failure (Pluhar et al., 2019). This being said, playing an individual sport alone was not a risk factor for anxiety or depression (Pluhar, 2019).
Athletic Identity and Depression
Athletic culture may have an impact on psychological health through its effect on existing personality traits and mental health disorders. Certain personality traits can aid in athletic success, yet these same traits can also be associated with mental health disorders. This interactive relationship between athlete personality traits (perfectionism, pessimism, introversion) and athletic culture may have both positive and negative effects on the individual athlete and sport environment.
An athletic identity is the degree to which an individual views themselves within the athletic role and looks to others for confirmation (Chang et al., 2020). Having a strong athletic identity can have positive outcomes on athletic performance, but at the same time:
Higher rates of depression are seen in individuals with strong tendencies to evaluate themselves exclusively to athletic performance;
Athletes are often perfectionists, which can result in overly critical self-evaluation and the development of disordered eating;
Individuals with low self-esteem are associated with social anxiety which can impede performance and confidence (Chang et al., 2020).
Additionally, there are limitations when studying athletes and mental health. Athletes may have some reservations when filling out depression measures in fear that coaches may discover their scores or concerns over imagined reactions to admitting being depressed (Proctor & Boan-Lenzo, 2010). Thus, athletes will underreport depression symptoms in attempt to portray themselves in a favorable light.
Non-Suicidal Self-Injury (NSSI)
Non-suicidal self-injury (NSSI) is the intentional damage to one’s self without intent to die (i.e., skin cutting, burning, self-hitting, hair pulling, head banging).
In a study examining prevalence rates of disordered eating and NSSI in NCAA Division II female varsity athletes (Lash, 2013). 30% of the 272 participants in the sample had engaged in some form of NSSI at least once in their life, and 18.5% met the criteria for NSSI established for the current study.
Due to feelings of shame and the secretive nature of NSSI, people are very adept at hiding marks or explaining them away as accidental injuries (i.e., a cat scratched me, scratched myself trying to grab my blade, tree branch scraped me on a run, forgot the stove was on).
Some common signs of NSSI in athletes include:
Consistent, inappropriate use of clothing designed to conceal wounds that often appear on arms, thighs, or abdomen;
Only wearing long sleeve unitards and dresses in competition;
Secretive behaviors (i.e., unusual amounts of time in the restroom);
General signs of depression, social isolation, and disconnectedness;
Evidence of self-injury in art projects, journals, work samples, etc.;
Risk taking (i.e., playing with guns, sexual acting out); (Lieberman & Poland, 2006)
Physical and sport educators and coaches have an increased chance of identifying students who are currently engaging in NSSI (Trujillo, 2014). If you suspect an athlete or teammate is engaging in NSSI it's important to refer the individual to a licensed professional.
What do I do if I’m concerned one of my athletes may be struggling with Non-Suicidal Self-Injury (NSSI)?
Approach your athlete sensitively and in private.
Provide evidence for your concern and express your concern for the athlete’s health and well-being. Reassure that you are there to help, that they are safe, and you are not judging them.
Do not tell them to stop, pressure them to talk, or give them ultimatums. Although it seems very counter intuitive, this is extremely important. It can take time and support to stop.
Make a prompt and appropriate medical referral to a general practitioner or licensed healthcare specialist.
Suggest a follow up with the athlete and/or parents in one week to confirm that they have scheduled an appointment with a licensed professional.
Educate yourself on NSSI and seek help for yourself if you need support.
I.e. ”I’m not here to judge and regardless, I will still see you as the same strong athlete, but I need to check in. Sometimes, when people are in emotional pain, they hurt themselves on purpose. Is this how _____ happened?”
Some common NSSI myths:
NSSI is an attention-seeking behavior. Many feel ashamed and want to hide their behaviors. Research suggests that people often don’t tell anyone, and they have difficulty talking to others and asking them for help.
NSSI is rare and only happens in adolescents. According to data, the prevalence is 17.2%during adolescence,13.4% during early adulthood, and 5.5% among adults.
People who engage in NSSI want to die. Often times, it’s a coping skill and a way to cope with problems and pain.
If the NSSIs aren’t bad, it’s not that serious. Severity of the injury has very little to do with how much someone is suffering.
Suicide
In a study investigating National Collegiate Athletic Association student athletes, researchers found suicide represented 7.3% (35/477) of all-cause mortality among NCAA student athletes (Rao, 2015). Additionally, 20% of international athletic athletes reported having experienced suicidal ideation (Timpka, 2019).
Researchers have identified five key factors that may contribute to suicidal behavior in athletes:
Serious injury necessitating injury;
Extended rehabilitation process (6 weeks to 1 year);
Reduced athletic skills despite adherence to rehabilitation;
Perceived lack of competence upon returning to sports when compared with pre-injury levels
Being replaced by a teammate (Rao, 2015).
Barriers to Seeking Support
In our society, mental health has a stigma that is tied into weakness. It’s an ongoing issue in society and is heightened even more in athletes. Athletes are often perceived as physically healthy and “strong” individuals, with the ability to face challenges on their own. This results in a lot of athletes neglecting to seek help and increases stigma surrounding mental health. It’s important to recognize that getting help will most likely improve, not damage, one’s self confidence.
It’s also important to recognize that athletes don’t have to maintain the “super-human” identity. Athlete’s don’t have to “handle things” alone and reaching out for help does not make one less of an athlete. In fact, it makes someone a good athlete. Psychological ailments are equally as important as physical ailments because your mental health impacts your performance too. For everyone, especially athletes, seeking out mental health assistance is a proactive and brave decision.
Building Mental Resilience
Research shows that reducing your exclusive identification with your sporting role and expanding your self-identity to other pursuits decreases the likelihood of depression, anxiety and eating disorders. This does not mean that athletics aren’t important or don’t identify you. It means recognizing that you are more than your sport and what your body can do. It’s so important to cultivate a sense self-worth and identity outside of your sport.
Understanding that athlete bodies come in all shapes and sizes is critical to the mental health of athletes. The belief that there is one ideal body type for athletes cultivates poor body image, eating disorders and poor self-esteem. An athlete’s body changes as they go through various stages of their athletic career: heavy training, competition season, off season, retirement, etc.
Regardless of body size, any athlete is much better off eating for normal growth and repair. If someone isn’t in “good enough physical shape” to be able to execute something, then it would be about strength and endurance training.
References
Boone, E. M., Leadbeater, B. J. (2006). Game on: diminishing risks for depressive symptoms in early adolescence through positive involvement in team sports. Journal of Research on Adolescence: 16(1), 79-90.
Chang, W. H., Wu, C., Kuo, C. Chen, L. H. (2018). The role of athletic identity in the development of athlete burnout: The moderating role of psychological flexibility. Psychology of Sport and Exercise: 39. doi:10.1016/j.psychsport.2018.07.014
Hammond, T., Gialloreto, C., Kubas, H., Davis, H. (2013). The prevalence of failure-based depression among elite athletes. Clinical Journal of Sports Psychology: 23. 273-277.
Hutchinson, M., Mainwaring, L. M., Comper, P. (2009). Differential emotional responses to varsity athletes to concussion and musculoskeletal injuries.
Lash, M. I. (2013). The relationship between non-suicidal self-injury and disordered eating in female collegiate athletes. All NMU Masters Theses, 434.
Leddy, M. H., Lambert, M. J., Ogles, B.M (1994). Psychological consequences of athletic injury among high-level competition. Res. Q. Exerc. Sport: 26. 347-354
Lieberman, R. & Poland, S., (2006). Self-mutilation. In G. G. Bear & K. M. Minkle (eds.), Children’s needs III: Development, prevention, and intervention. Washington, DC: National Association of School Psychologists [http\://www.nasponline.org]
Pluhar, E., McCracken, C., Griffith, K. L., Christino, M. A., Sugimoto, D., Meehan, W. P. (2019). Team sport athletes may be less likely to suffer anxiety or depression than individual sport athletes. Journal of Sports Science and Medicine: 18, 490-496.
Proctor, S. L., Boan, Lenzo, C., (2010). Prevalence of depressive symptoms in male intercollegiate stuend athletes and non-athletes. Journal of Sports Psychology: 4(1). 204-220.
Sabiston, C. M., Jewett, R., Ashdown-Franks, G., Belanger, M., Brunet, J., O’Loughlin, E., and O’Loughlin, J. (2016). Number of years of team sport and individual sport participation during adolescence and depressive symptoms in early childhood. Journal of Sport and Exercise Psychology: 38(1). 105-110.
Timpka, T., Spreco, A., Dahlstrom, O. (2019). Suicidal thoughts (ideation) among elite athletic (track and field) athletes: Associations with sport participation, psychological resourcefulness and having been a victim of sexual or physical abuse.
Trujillo, N. P. (2015). Nonsuicidal self-injury: What physical and sport educators should know. A Journal for Physical and Sport Educators: 28(6). doi:10.1080/08924562.2015.1087902
Wippert P. M., & Wippert, J. (2010). The effects of involuntary athletic career termination on psychological distress. Journal of Clinical Sports Psychology: 4,133-149.
Wolanin, A., Gross, M., Hong, E. (2014). Depression in athletes: Prevalence and risk factors. Current Sports Medicine Reports: 14(1). 56-60.