The Sports and Exercise Medicine community and other sport stakeholders are becoming increasingly aware of the mental health symptoms (eg, depression, anxiety, substance misuse) reported by athletes. In 2019, this led to the publication of the first International Olympic Committee (IOC) consensus statement on mental health in this cohort and the establishment of the IOC Mental Health Working Group.1 Over the past 2 years, the COVID-19 pandemic and related public health measures have presented additional challenges to the well-being of all populations, including athletes. This editorial reflects on how the COVID-19 pandemic has highlighted a growing need to protect and promote athlete mental health.
Athlete mental health during the COVID-19 pandemic
Mental health symptoms are common among professional, Olympic/Paralympic and collegiate athletes, with prevalence rates (15%–35%) equivalent to or exceeding those of non-athletes.1 Mental health symptoms are also common among youth and adolescent athletes, with a prevalence of up to one-third in some samples.2 Recent epidemiological evidence collected during the COVID-19 pandemic suggests increased rates of mental health symptoms among athletes during lockdown.3 In professional football (soccer), the prevalence of anxiety and depression doubled during the COVID-19 emergency period compared with immediately prior in both females (N=600; 18% vs 8% for anxiety) and males (N=1309; 13% vs. 6% for depression).4 A significant difference was also found in US professional endurance athletes (N=114; 27% vs 5% for feeling anxious; 22% vs 4% for feeling depressed),5 as well as in the top leagues of Swedish football, ice hockey and handball (N=327), all correlated with COVID-19 pandemic distress.3 In Norway, symptoms of insomnia (38.3%) and depression (22.3%) were common among female and male elite athletes during COVID-19 (n=378).3 Among US high school athletes, the prevalence of moderate to severe depression more than tripled during the COVID-19 emergency period compared with years prior in both female (N=1877; 37% vs 11%) and male athletes (N=1366; 27 % vs. 6%).6 Increased mental health symptoms among athletes in the aforementioned studies might be linked to a range of pandemic-associated factors.7 Of concern, while athletes who have been able to return to sports participation after the end of the emergency period have shown some improvement in mental health, in many cases their mental health has not fully recovered to prepandemic status.7
COVID-19 specific contributing factors
Beyond generic (eg, adverse life event) and sport-specific (eg, injury) factors, it is likely that COVID-19 has specifically challenged athlete mental health (figure 1).1 COVID-19-specific experiences and related home-confinement directives were associated with increased mental health symptoms among athletes, although these effects were somewhat attenuated by home conditioning programs and quarantine training camps.3 In particular, social isolation (eg, with team and tournament ‘bubbles’), concerns about well-being and financial problems, a fear of body changes with altered training and dietary regimens, as well as uncertainty about their identity, career and future, have been mentioned as COVID-19-specific mental health contributing factors.3–5 8 Loss of athlete motivation, meaning and identity may also have perpetuated depressive symptoms in athletes, especially for those exposed to competition postponement.9
Clinicians’ approach to athlete mental health during the COVID-19 pandemic
With alarming rates of mental health symptoms among athletes during the COVID-19 pandemic, it has never been clearer that mental health of athletes is a significant concern.10 This highlights that while sport confers important mental health benefits, athletes are nonetheless vulnerable to life stressors and major events. The disruptions in sport that the pandemic has wrought can be likened to the mental health impacts that occur at the time of injury and (forced) retirement. Injury, retirement and the COVID-19 pandemic alike bring important changes to athletes’ lives through impacts on daily structure, support systems, livelihood, career trajectories and identity. Clinicians have learned the importance of checking in with their athletes at any time of transition—whether pandemic related or not.10 Mental health must be discussed explicitly and screening undertaken.11 All sport stakeholders and members of the athletes’ entourages (including coaches) should receive training and resources to be able to identify mental health ‘red flags’ so that appropriate referrals can be made.11 Clinicians should routinely ‘check in’ with all athletes and take prompt steps to intervene when warranted.10 The IOC Sport Mental Health Assessment Tool 1 (SMHAT-1) provides one framework to screen athletes for mental health symptoms.11
A constant need to protect and promote athlete mental health
Athletes’ mental health was a growing concern before the pandemic, and pandemic-related influences will likely continue to have an impact well into the future. Beyond the individual clinician’s work, stakeholders such as governing bodies, sports leagues and event management teams must take steps to improve the mental health of their athletes and to change the culture of sport for the better. This is even more important as the pandemic continues, enabling the mental resilience of athletes to be optimized when they confront an increase in stressors. Team clinicians and management should prioritize steps to safeguard and monitor athlete mental health. High-profile sporting events should highlight the importance of mental health as the United States Tennis Association did during the 2021 US Open.12 Ultimately, mental health assessments, resources and treatment should be destigmatized and more widely available. Athletes should be made to feel that addressing mental health is a priority, and not a sign of weakness. Now more than ever, minds matter! As athletes and as humans, they deserve to be well in every respect.
Patient consents for publication
This article is part of a series commissioned by the BJSM for the World Innovation Summit for Health (WISH) 2022. The BJSM peer reviewed, edited and made the decision to publish. The lead author(s) received a small honoraria for this work. The series, including open access fees and honoraria, is funded by WISH, which is an initiative of the Qatar Foundation.