Skip to main content Accessibility help
×
Home
Hostname: page-component-684899dbb8-5dd2w Total loading time: 0.365 Render date: 2022-05-27T22:49:54.634Z Has data issue: true Feature Flags: { "shouldUseShareProductTool": true, "shouldUseHypothesis": true, "isUnsiloEnabled": true, "useRatesEcommerce": false, "useNewApi": true }

Setting the bar: athletes and vulnerability to mental illness

Published online by Cambridge University Press:  02 January 2018

Lynette Hughes*
Affiliation:
Compass Research and Policy, Northern Ireland Association of Mental Health, Belfast
Gerard Leavey
Affiliation:
Northern Ireland Association of Mental Health, Belfast, UK
*
Lynette Hughes, Compass Research and Policy, Northern Ireland Association of Mental Health, 80 University Street, Belfast BT7 1HE, Northern Ireland. Email: l.hughes@compasswellbeing.org
Rights & Permissions[Opens in a new window]

Summary

Whereas physical sport activity is generally considered a health benefit, extreme exercise may be harmful. Of particular concern in this regard is the considerable variation between doctors in the primary care setting and those working within the sports setting around the diagnosis and treatment of athletes presenting with similar symptoms. Known risk factors for athletes are herein presented to raise awareness of the negative side of sport and to bring attention to the psychological outcomes and needs of athletes. The need for research into the incidence and aetiology of mental illness within elite level sport is also raised.

Type
Editorials
Copyright
Copyright © 2012 The Royal College of Psychiatrists 

The level of financial investment in the 2012 Summer Olympic Games, in London, is testament to its symbolic, cultural and financial importance as a national project. Sport is a major platform for encouraging the general population to become more physically active, a key element of health promotion strategies in high-income countries. Reference Schwenk1 It is not hard to see why. Physical inactivity has been reported as the most prevalent chronic disease risk factor, costing the UK National Health Service an estimated £1.06 billion annually. Reference Allender, Foster, Scarborough and Rayener2 A dose–response relationship between physical activity and health benefit has been reported with physical activity found as more effective than no treatment, and as effective as traditional interventions such as cognitive therapy, antidepressant treatment and cognitive–behavioural therapy. Reference Str÷hle3 However, there is no consensus regarding the optimal amount and type of activity required to achieve such benefits. Reference Hamer, Stamatakis and Steptoe4

Risk factors for athletes

Although moderate or vigorous-intensity aerobic activity is important in the prevention of and recovery from mental and physical health problems, when performed more intensely at ‘professional/elite’ levels, physical activity can compromise health. Reference Schwenk1,Reference Peluso and de Andrade5 Beyond the national prestige, fame and glory of Olympic success lies the darker side of overexposure to elite sport such as overtraining, injury, burnout, increased risk for sudden cardiac death and other non-cardiovascular conditions such as respiratory symptoms, iron deficiency, increased incidence of allergies, immunological suppression and infection, gastrointestinal symptoms, diabetes mellitus and eating disorders. Reference Ljungqvist, Jenoure, Engebretsen, Alonso, Bahr and Clough6

Athletes may also be vulnerable to mental illness for several reasons. First, the social world of many organised elite sports is one that requires investments of time and energy, often resulting in a loss of personal autonomy and disempowerment for athletes. Reference Cresswell and Eklund7 The elite-sport environment can result in ‘identity-foreclosure’ leaving athletes few other avenues through which to shape and reflect personality. Reference Cresswell and Eklund7 High athletic identity has been linked to psychological distress when this function of identity is removed, and to overtraining and athlete burnout. Reference Cresswell and Eklund7 The latter conditions strongly correlate with affective disorders such as major depressive disorder. Reference Peluso and de Andrade5,Reference Cresswell and Eklund7 Moreover, injury, competitive failure, ageing, retirement from sport and other psychosocial stressors, precipitate depression in athletes. Reference Reardon and Factor8 In addition, the literature on elite sport indicates a range of other vulnerabilities such as disordered eating Reference Sundgot-Borgen and Torstveit9 and risk-taking behaviours among athletes such as hazardous drinking, driving while intoxicated and unprotected sex. Reference Lisha and Sussman10

The prevalence of overtraining in elite athletes has been reported at between 20 and 60%, with distance runners most severely affected. Reference Peluso and de Andrade5 Burnout, the most extreme end of the overtraining continuum, has been reported in approximately 10% of elite athletes. Reference Cresswell and Eklund7 Moreover, a recent review of eating disorders among those participating in high-intensity sports, reported a prevalence of 17.2% for males and 32% for females. Reference Sundgot-Borgen and Torstveit9 Other studies have reported eating disorders in women athletes to be as high as 60%, with athletes found to be in more severe stages of the disorder than controls. Reference Reardon and Factor8 Compounding this, the injury experience of an elite athlete has been likened to the grief process observed following bereavement, with an estimated 10–20% of athletes warranting clinical intervention, with suicide a cause of concern. Reference Walker, Thatcher and Lavallee11 A dose–response relationship exists between physical activity and the likelihood of injury; again, with elite athletes at most risk.

The appendix summarises a growing body of evidence pointing to both the positive and negative health outcomes of elite sport. However, despite a number of high-profile breakdowns and tragedies among athletes there remains a tendency among sports governing bodies and officials to downplay or ignore the significance of psychiatric symptoms among this population. Reference Reardon and Factor8 Schwenk's work indicates how the current approach to mental illness in athletes is ‘fraught with stigmatisation, denial, and dichotomous paradigms of “psychological” versus “physical” disease, which are inaccurate, unhelpful and deprive the athlete of effective care’. Reference Schwenk1 This scenario is in no way helped by the unusual clinical environment whereby the traditional relationship between doctor and patient it distorted or absent. Doctors working within the sporting environment are frequently under intense pressure from management, coaches, trainers and agents to improve performance in the short term and are therefore faced with a myriad of ethical dilemmas that compromise the well-being and treatment of the athlete. Reference Devitt and McCarthy12

Appendix Positive and negative effects of elite sport on health outcomes Adapted from Hamer et al, Reference Hamer, Stamatakis and Steptoe4 Lisha & Sussman, Reference Lisha and Sussman10 Walker et al, Reference Walker, Thatcher and Lavallee11 Smith Reference Smith13 and Maffulli et al Reference Maffulli, Giuseppe Longo, Gougoulias, Caine and Denaro14

Positive effects
Neurological Mental Physical
↑ neurological functioning (central
norepinephrine neurotransmission, secretion
of atrial natriuretic peptide, metabolism
and beta-endorphins, availability of brain
neurotransmitters dopamine, serotonin
and noradrenaline, enhanced cognitive
functioning and brain plasticity)
Increases peripheral catecholamine plasma
levels which are associated with learning and
memory improvements
Can reverse the effects of stress, depression
and ageing on neurotrophic expression and
neurogenesis in the brain
↓ incidence of dysthemic (mood
and chronic depressive) disorders
Provides immediate psychological
benefits (↑ mood, ↑ level of brainderived
neurotrophic factor acting
just like a regular antidepressive
drug)
↓ emotional distress and anxiety
Increased self-efficacy, mastery
and self-concept
↓ incidence of somatoform (physical symptoms of mental disorders)
↓ risk of chronic disease and comorbid mental disorders, delaying the onset
of neurodegenerative processes
(↑ circulation of pro-inflammatory cytokines that is normally up-regulated
during a stress response that over time can increase immune system
threshold for stress)
Negative effects
Neurological Mental Physical
Overtraining: body's up-regulation of acute
inflammation resulting in the production of
elevated levels of cytokines and cortisol
levels
Psychological impact of injury
(e.g. depression, low motivation,
isolation, bereavement responses
of denial and anger, loss of
identity, loss of confidence,
performance decrement)
Disordered eating: anorexia
nervosa, bulimia and body
dysmorphia
Burnout: # mood and self-esteem,
loss of confidence, exhaustion,
depression/helplessness,
withdrawal
Injury incidence: resulting in limb deformities, leg length discrepancy,
susceptibility to growth plate injury, limited thermoregulatory capacity
and maturity associated variation in young elite performers; increased risk
of developing osteoarthritis and spine pathologies in former athletes
Overtraining: altered immune function including susceptibility to colds, flus
and infection, gastrointestinal disturbances, headaches and muscle aches13
Athlete burnout – physical exhaustion, reduced performance accomplishment
and sporting devaluation that serves to compromise future physical
activity involvement. Symptoms include disrupted sleep, ↑ muscle soreness,
chronic fatigue, ↓ incidence of injury/illness, and # aerobic power
Risk-taking behaviours of sports people (e.g. hazardous drinking, driving
while intoxicated, having unprotected sex and antisocial behaviour)
Increased risk for sudden cardiac death, respiratory symptoms, iron
deficiency, increased incidence of allergies, immunological suppression
and infection, gastrointestinal symptoms, diabetes mellitus

Conclusions

Given the range of mental disorders and stresses inherent in elite sports there is a need to balance the message around the benefits of physical activity. Limited research exists within mainstream mental health literature and within the sporting community on the mental health and well-being of elite athletes. It would be remiss for sporting governing bodies and the UK government to assume athletic immunity to mental health disorders. Tackling obesity is an important public health activity but it is also the case that we require better understanding of the psychological needs of athletes during their career and once it is over. Currently there is little understanding of the diagnostic and therapeutic issues unique to the sporting population. Reference Reardon and Factor8 More research is needed on the incidence and aetiology of mental illness within elite-level sport, which would serve to inform those working with athletes. Importantly, the inclusion of competitive athletes in mainstream mental health research will help establish a comprehensive continuum of well-being that would shape and inform physical activity guidelines that are reflective of the entire population and its mental health needs.

Footnotes

Declaration of interest

None.

References

1 Schwenk, TL. The stigmatisation and denial of mental illness in athletes. Br J Sports Med 2000; 34: 45.CrossRefGoogle ScholarPubMed
2 Allender, S, Foster, C, Scarborough, P, Rayener, M. The burden of physical activity-related ill health in the UK. J Epidemiol Community Health 2007; 61: 344–8.CrossRefGoogle ScholarPubMed
3 Str÷hle, A. Physical activity, exercise, depression and anxiety disorders. J Neural Transm 2009; 116: 777–84.Google Scholar
4 Hamer, M, Stamatakis, E, Steptoe, A. Dose-response relationship between physical activity and mental health: the Scottish Health Survey. Br J Sports Med 2009; 43: 1111–4.CrossRefGoogle ScholarPubMed
5 Peluso, M, de Andrade, LH. Physical activity and mental health: the association between exercise and mood. Clinics 2005; 60: 6170.CrossRefGoogle Scholar
6 Ljungqvist, A, Jenoure, P, Engebretsen, L, Alonso, JM, Bahr, R, Clough, A, et al. The International Olympic Committee (IOC) consensus statement on periodic health evaluation of elite athletes (March 2009). Br J Sports Med 2009; 43: 631–43.CrossRefGoogle Scholar
7 Cresswell, SL, Eklund, RC. Athlete burnout: a longitudinal qualitative investigation. Sport Psychol 2007; 21: 120.Google Scholar
8 Reardon, CL, Factor, RM. Sport psychiatry: a systematic review of diagnosis and medical treatment of mental illness in athletes. Sports Med 2010; 40: 961–80.CrossRefGoogle ScholarPubMed
9 Sundgot-Borgen, J, Torstveit, MK. Aspects of disordered eating continuum in elite high-intensity sports. Scand J Med Sci Sports 2010; 20: 112–21.CrossRefGoogle ScholarPubMed
10 Lisha, NE, Sussman, S. Relationship of high school and college sports participation with alcohol, tobacco, and illicit drug use: a review. Addict Behav 2010; 35: 399407.CrossRefGoogle ScholarPubMed
11 Walker, N, Thatcher, J, Lavallee, D. Psychological responses to injury in competitive sport: a critical review. J R Soc Promot Health 2007; 127: 174–80.CrossRefGoogle ScholarPubMed
12 Devitt, BM, McCarthy, C. Review: ‘I am in blood Stepp'd in so far …’: ethical dilemmas and the sports team doctor. Br J Sports Med 2010; 44: 175–8.CrossRefGoogle Scholar
13 Smith, LL. Tissue trauma: the underlying cause of overtraining syndrome? J Strength Cond Res 2004; 18: 185–93.Google ScholarPubMed
14 Maffulli, N, Giuseppe Longo, U, Gougoulias, N, Caine, D, Denaro, V. Sports injuries: a review of outcomes. Br Med Bull 2011; 97: 4780.CrossRefGoogle ScholarPubMed
Figure 0

Appendix Positive and negative effects of elite sport on health outcomes Adapted from Hamer et al,4 Lisha & Sussman,10 Walker et al,11 Smith13 and Maffulli et al14

Submit a response

eLetters

No eLetters have been published for this article.
You have Access
68
Cited by

Save article to Kindle

To save this article to your Kindle, first ensure coreplatform@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Setting the bar: athletes and vulnerability to mental illness
Available formats
×

Save article to Dropbox

To save this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Dropbox account. Find out more about saving content to Dropbox.

Setting the bar: athletes and vulnerability to mental illness
Available formats
×

Save article to Google Drive

To save this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your Google Drive account. Find out more about saving content to Google Drive.

Setting the bar: athletes and vulnerability to mental illness
Available formats
×
×

Reply to: Submit a response

Please enter your response.

Your details

Please enter a valid email address.

Conflicting interests

Do you have any conflicting interests? *