Alícia Sassi Ogliari, Pan American School of Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
It has been demonstrated that while exercise boosts mental health, the high-performance sports environment can present risks of compromising athletes' health and emotional well-being. This risk is particularly due to cultural, societal, and media portrayal, aggravated by the competitive, demanding nature of sports. An alleged "culture of stoicism" has led to stigma surrounding high-performance sports and demonstrating vulnerability. Various athletes have confronted this mindset, advocating for a change in sports-related societal expectations and increased awareness around physical and mental health. These discussions help normalize mental health conversations and bring greater attention to the issue. Some international organizations have suggested implementing early intervention and diagnosis measures to improve treatment outcomes with decreased impacts on athletic performance.
Mental health disorders (MHD) are defined by the American Psychiatric Association as "health conditions involving changes in emotion, thinking or behavior associated with distress and problems functioning in social, work or family activities" (Parekh, 2018). In 2019, according to the World Health Organization and the Institute of Health Metrics and Evaluation, "1 in every 8 people, or 970 million people around the world, were living with a mental disorder", with the most common being depressive and anxiety-related disorders (Institute of Health Metrics and Evaluation, 2022). A significant prevalence of MHD has been observed in a specific group of individuals, elite athletes, defined by sports scientists as national or international high-level competitors usually involving several hours of daily training (Rankinen et al., 2000). Furthermore, cultural perceptions associated with sports have contributed to stigma surrounding mental health among high-performance athletes. The following article will pertain to how these customs have helped shape the role of mental health in elite sports and how recent events have challenged these cultural perceptions.
A 2019 meta-analysis by Gouttebarge et al. comprising 4474 to 7241 former and current elite athletes found that 34% of current and 26% of former athletes showed signs of anxiety and depression. Furthermore, 19% of current athletes demonstrated alcohol misuse, and 16% of former athletes exhibited signs of distress (Gouttebarge et al., 2019). A Swedish Health Sciences Department of Performance and Training study illustrated that 51.7% of Swedish national team athletes reported a lifetime prevalence of depressive, eating, or burnout-related disorders (Akesdotter, 2019). Analyses from the Melbourne Centre for Youth Mental Health and Centro Universitário Santo Agostinho in Brazil confirmed these findings (Purcell, 2020; Farias & Lima da Silva, 2021). However, in the 2020 study by Purcell, athletes reported higher self-esteem and lower rates of risky alcohol consumption and problem gambling (Purcell, 2020). Thus, this evidence demonstrates that while exercise can increase well-being, the exceptionally high physical and mental demands of elite sports can negatively impact mental health. Moreover, it is essential to consider that pain and pressure are integral parts of high-performance athletes' professional lives. An analytical study by Dr. Tesarz at the University of Heidelberg found that high-performance athletes demonstrated higher pain tolerance than ordinarily active people (Tesarz et al., 2012).
Furthermore, not only are the physical demands substantial, but for an elite athlete, every performance is the culmination of years of sacrifice, training, coping with challenges, and intense psychological pressure, all of which require significant mental preparation (Park, 2021). Dr. Wilkinson of Loughborough University describes that "stress is the result of an exchange between two factors: demands and resources [to cope with these demands]" (Wilkinson & Barker, 2021). He explains that athletes might enter a so-called "threat state” if the demands are greater than what they can handle, resulting in anxiety, increased heart rates, perspiration, muscle tremors, breath shortness, nausea, stomach pain, weakness, and reduced concentration and self-control (Wilkinson & Barker, 2021).
Figure 1 demonstrates the correlation between pressure and performance established by the Yerkes-Dodson Law. These studies on human arousal and performance emphasize that an optimal region can be achieved with moderate to high amounts of pressure, with low and very high amounts leading to decreases in performance capacity. The "Zone of delusion" is the false belief that working harder will increase performance and is often characterized by stagnation and stress-related disorders (Dodson & Yerkes, 1908). The curve emphasizes mental health as one of the most critical assets of performance in sports, which inherently involves pain, pressure, facing expectations, and the desire to succeed.
Figure 1: The Pressure-Performance Stress Curve, according to the Yerkes-Dodson Law studies on human arousal and performance (Martin, 2020).
Furthermore, a phenomenon described as a "culture of stoicism" has contributed to stigma surrounding mental health and high-performance athletes. The American Heritage Dictionary defines stoic conduct as being "seemingly indifferent to or unaffected by pleasure or pain" (Stephans & Feezell, 2004). Its qualities, such as ignoring pain and sacrificing well-being over results, are valued in athletes. They can be labeled frail for demonstrating vulnerability or injury. According to Dr. Magavi, a sports psychiatrist fellow at the Johns Hopkins Hospital, societal expectations from fans and the media can make athletes feel as though "every single step that they take will be significantly scrutinized, and this kind of pressure is so severe that they can have trouble even focusing on their day-to-day activities" (Silva, 2021). She also states that Olympic athletes "symbolizing and representing a country" can face tremendous pressure, never to falter or demonstrate signs of weakness. This strain can lead them to "lose that passion for the game that was the reason they joined in the first place" (Silva, 2021). It is, therefore, vital to consider how cultural perceptions associated with winning at all costs may result in excessive pressure and athletes prioritizing results above listening and taking care of their bodies, which can potentially impair performance and daily life.
More recently, athletes' increased discussions and mental health advocacy have helped raise awareness and contribute to cultural changes. According to clinical sports psychologist Hillary Cauthen, "A shift in cultural acceptance began in 2015-16 when the National Collegiate Athletic Association created a mental health initiative" (Longman, 2021). Following this, swimmer Michael Phelps, the most decorated Olympic medalist, began discussing handling depression. Since then, basketball players DeMar DeRozan and Kevin Love, figure skater Gracie Gold, Japanese tennis player Naomi Osaka, and artistic gymnast Simone Biles have publicly discussed facing these conditions (Longman, 2021). For instance, after Simone Biles withdrew from the individual and team finals to focus on her mental health, this concern became one of the focal points in the 2021 Olympic Games. Alice Park, a health and medicine national correspondent for Time Magazine, stated that her actions "created a rare opportunity for moving the discussion from raising awareness to positive action" and led to a peak in mental health searches online (Park, 2021).
Since 2019, the International Olympic Committee consensus affirmation has stated that "mental health cannot be separated from physical health, as evidenced by [increased] risk of physical injury and delaying subsequent recovery" (Reardon, 2019). It proposed measures such as promoting discussions, establishing consensus-based guidelines for timely diagnosis, screening for psychological distress, and implementing early intervention measures (Reardon, 2019). The widespread application of such interventions throughout the high-performance sports sphere has the potential to positively impact high-performance athletes' psychological and physical health, subsequently increasing their ability to achieve optimal performance.