Mental Health Issues and Psychological Factors in Athletes: Detection, Management, Effect on Performance and Prevention
Publication Date: February 3, 2020
Last Updated: March 14, 2022
Key findings
Sports medicine physicians should be familiar with the psychological, cultural and environmental factors that influence mental health (MH) in athletes as well as common MH disorders affecting the athletic population.
Personality issues
High athletic identity is associated with both positive and negative health and performance outcomes. (B)
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Personality traits and disorders deemed problematic for athletes may be best addressed via psychotherapy. (C)
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Sexuality and gender issues
The creation of a strong supportive environment that is welcoming to sexual minorities is key to the MH of the athlete and the sports team. (A)
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Reducing the risk of negative health consequences for the sexual minority athlete starts with education of all stakeholders associated with athletic participation. (C)
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Hazing
Hazing leads to both short-term and long-term health ramifications that can affect an individual’s athletic success and ability to participate in sport. (C)
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The prevention and management of hazing requires a global investment from athletes, coaches, administrators and healthcare providers centred on a zero-tolerance policy for any form of maltreatment and a focus on positive team building activities that promote dignity and teamwork as opposed to victimisation. (C)
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Bullying
Bullying in athletics can take on many different forms and be the actions of teammates or coaches. Signs and symptoms of being bullied may vary greatly. (C)
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Preventing bullying is the responsibility of all the stakeholders in athletics. Educational programmes can be found on the NCAA website. (C)
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Sexual misconduct
Authority figures are more often perpetrators of sexual abuse, but peer athletes are far more likely than coaches to be perpetrators of sexual harassment. (C)
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Populations at higher risk for sexual abuse in youth sports reflect trends in the general population. Those participating at higher levels of competition are also at an increased risk. Sport type, amount of touching or degree of clothing cover during participation do not appear to correlate with higher rates of abuse. (C)
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Transitioning from sport
Athletic departments, national governing bodies and professional leagues should assist athletes who are retiring from their sport with development of a comprehensive preretirement plan addressing issues surrounding their transition out of athletic participation. (A)
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Long-term psychological effects of career-ending injuries are common for many athletes. (C)
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Psychological response to injury and illness
Psychological and sociocultural factors have been raised as potential risk factors for injury. Stress consistently demonstrates a relationship with injury risk as well as the ability to rehabilitate from injury and return to sport. (B)
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Cognitive, emotional and behavioural responses to injury are important in determining outcome. (C)
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Self-medication in response to injury/illness
Limited data exist on the use of self-medication by athletes as a coping mechanism. However, certain demographics of athletes are emerging as higher risk groups for medication misuse and for negative MH and other consequences of their use. (C)
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Targeted interventions that incorporate health and athletic performance considerations tend to be more successful for the athletic population and this includes addressing the underlying issues leading to substance use/self-medication. (C)
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Eating disorder/disordered eating
Annual preparticipation screening for eating disorders in athletes should be routine. (C)
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Eating disorder prevention programmes have benefit in reducing risk for eating disorders. (B)
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Cognitive behavioural therapy (CBT) and family therapy are recommended as treatments for eating disorders in athletes. (B)
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Depression and suicide
Athletes have unique risk factors for depression compared with non-athletes. Early recognition and appropriate management of depression in athletes lead to improved clinical and performance outcomes. (C)
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College student-athletes report depression symptoms at a higher prevalence than previously reported; these rates are comparable to non-athlete college students. (B)
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Suicide incidence in college student athletes is lower than in college student non-athletes. Football has the highest suicide rate by sport in college athletes. (B)
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Anxiety/stress
CBT for the treatment of anxiety is the optimal non-pharmacological intervention. CBT is an established and effective treatment method for many clinical populations with different types of anxiety disorders, but there are no randomised controlled trials of CBT interventions specifically within athletes. (B)
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While selective serotonin reuptake inhibitors may be considered, as-needed anxiolytics are not recommended for athletic performance anxiety. (B)
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Overtraining
A management approach to the athlete with overtraining syndrome should be individually developed and should include evaluation for MH stressors and relative or absolute rest depending on the clinical situation at the time. (C)
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Monitoring training loads, getting adequate rest periods and maintaining optimal nutrition and hydration status are all important in preventing the development of overtraining syndrome. (C)
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Sleep
While not specific for athletes, insomnia-specific CBT is first-line treatment for sustained improvements in sleep in those with insomnia alone or insomnia comorbid with other MH disorders. (A)
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Benzodiazepine sedative hypnotics are not recommended for athletes because of their marked ‘hangover’ effect, which includes a negative impact on reaction time. (A)
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While melatonin has not been shown to improve sleep quality in athletes, short-term use is safe with no decrements in performance. (A)
Because melatonin is not regulated by the FDA, caution for the presence of impurity is necessary and it should be purchased as a single-ingredient product from a reputable company.
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Attention deficit hyperactivity disorder (ADHD)
The optimal management approach for ADHD is individualised and may include behaviour therapies, academic accommodations, pharmacotherapy (eg, atomoxetine, amphetamine salts or methylphenidate formulations) and psychological interventions to manage associated features and comorbid diagnoses. (C)
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The risk of heat illness may be increased in athletes taking ADHD medications. Those taking stimulant medications have elevated core temperatures while exercising, although an increased incidence of exertional heat injury or heatstroke in these groups has not been reported. (C)
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Team physicians should be aware of and educate the athlete on regulations and requirements regarding medication treatment of ADHD. (A)
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Recommendation Grading
Overview
Title
Mental Health Issues and Psychological Factors in Athletes: Detection, Management, Effect on Performance and Prevention
Authoring Organization
American Medical Society for Sports Medicine
Publication Month/Year
February 3, 2020
Last Updated Month/Year
February 5, 2024
Supplemental Implementation Tools
Document Type
Consensus
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Male, Female, Adolescent, Adult, Child, Older adult
Health Care Settings
Ambulatory, School
Intended Users
Athletics coaching, nurse, nurse practitioner, physician, physician assistant
Scope
Diagnosis, Management, Prevention
Diseases/Conditions (MeSH)
D003863 - Depression, D001289 - Attention Deficit Disorder with Hyperactivity, D001068 - Feeding and Eating Disorders, D001007 - Anxiety, D000067450 - Psychology, Sports
Keywords
athletes, Mental health, psychology in sports
Source Citation
Chang C, Putukian M, Aerni G, 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. British Journal of Sports Medicine 2020;54:216-220.