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A COMMENTARY ON MENTAL HEALTH RESEARCH IN ELITE SPORT 1
Running head: A COMMENTARY ON MENTAL HEALTH RESEARCH IN ELITE SPORT
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A Commentary on Mental Health Research in Elite Sport
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Zoё A. Poucher1, Katherine A. Tamminen1, Gretchen Kerr1, & John Cairney1
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1 University of Toronto, Faculty of Kinesiology and Physical Education
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Corresponding author: Zoё Poucher, zoe.poucher@mail.utoronto.ca
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This is the pre-production draft of this article. Please reference this article as:
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Poucher, Z. A., Tamminen, K. A., Kerr, G., & Cairney, J. (2019). A commentary on mental
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health research in elite sport. Journal of Applied Sport Psychology, online, 1-23.
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doi:10.1080/10413200.2019.1668496
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A COMMENTARY ON MENTAL HEALTH RESEARCH IN SPORT 2
Abstract
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Elite athletes may be as likely as members of the general population to experience mental
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disorders (Gorczynski, Coyle, & Gibson, 2017; Moesch et al., 2018), and there has recently been
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a surge of research examining mental health among athletes (Rice et al., 2016). This paper
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provides an overview and commentary of the literature on the mental health of elite athletes and
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explores how trends within and beyond the field of sport psychology have impacted this
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literature. Reviewing the contextual influences on this field, namely disorder prevalence, barriers
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to support seeking, mental toughness, and psychiatric epidemiology, are important to understand
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the broader picture of mental health research and to further strengthen work undertaken in sport
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psychology. In addition, appreciating the influence of various contextual factors on athlete
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mental health research can help to highlight where sport psychology practitioners may focus
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their attention in order to advance research and applied practice with elite athletes experiencing
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poor mental health. It is important that researchers consider how they measure mental health,
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how studies on the mental health of elite athletes are designed, implemented, and evaluated, and
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how both researchers and practitioners may help to combat athletes’ perceptions of stigma
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surrounding mental health. Considering topics such as these may lead to a deeper understanding
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of athlete mental health, which may in turn help to inform sport specific policies, applied
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practice guidelines, and interventions designed to enhance athlete mental health.
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Keywords: mental wellbeing, athlete wellbeing, mental illness, high-performance athlete
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A COMMENTARY ON MENTAL HEALTH RESEARCH IN SPORT 3
Lay Summary
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Recently, there has been an expansion of research on the mental health of elite athletes.
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We discuss some factors that have influenced the study of elite athlete mental health and how
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these factors continue to shape the field. We propose ways that researchers and practitioners may
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advance the field.
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A COMMENTARY ON MENTAL HEALTH RESEARCH IN SPORT 4
A Commentary on Mental Health Research in Elite Sport
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There has been an expansion of research focused on the mental health of elite athletes in
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recent years, and researchers and practitioners have come to appreciate that these athletes are as
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susceptible to mental health problems as the general public (Moesch et al., 2018; Rice et al.,
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2016). Athletes have been found to experience a wide range of disorders including depression,
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anxiety, substance abuse, and eating disorders (Appaneal, Levine, Perna, & Roh, 2009; Gulliver,
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Griffiths, Mackinnon, Batterham, & Stanimirovic, 2015; Rice et al., 2016). The purpose of this
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paper is to provide an overview and commentary of the literature on the mental health of elite
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athletes and explore how trends within and beyond the field of sport psychology have impacted
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this literature. Rather than conduct a review of the literature on the mental health of elite athletes,
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which has already been done (e.g., Rice et al., 2016), this paper will examine the existing
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research on athlete mental health, while drawing on other areas of research, such as community
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psychology, psychiatry, and positive psychology to contextualize the topic of elite athlete mental
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health within broader academic discussions and literatures. Understanding the contextual
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influences on this field, namely disorder prevalence, barriers to support seeking, mental
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toughness, and psychiatric epidemiology, are important for understanding the broader picture of
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mental health research and to further strengthen work undertaken in this area. This knowledge
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will further our understanding of athlete mental health and identify ways that research and
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practice may be advanced, which in turn may lead to improved sport practices and policies
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designed to foster the wellbeing of elite athletes.
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While ‘mental health’ has been conceptualized in different ways, in this paper we use the
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definition presented by the World Health Organization, which defines mental health as “a state
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of well-being in which every individual realizes his or her own potential, can cope with the
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normal stresses of life, can work productively and fruitfully, and is able to make a contribution to
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her or his community” (World Health Organization, 2014, para. 1). A key component of this
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definition is that mental health consists of more than just the absence of disease or disorder, and
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includes an emphasis on wellbeing and the realization of individuals’ potential (World Health
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Organization, 2014). Mental disorder on the other hand, refers to “a syndrome characterized by
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clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior
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that reflects a dysfunction in the psychological, biological, or developmental processes
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underlying mental functioning” (American Psychiatric Association, 2013, p.20); some examples
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include depression, anxiety, and eating disorders. Elite athletes will be the focus of this paper
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given the well-documented uniqueness of this population, particularly with respect to training
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and competition demands (Bruner, Munroe-Chandler, & Spink, 2008; Noblet, Rodwell, &
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McWilliams, 2003). Given the historical inconsistency in the use of the term ‘elite athlete’
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(Swann, Moran, & Piggott, 2015), we included a wide scope of articles in the present review.
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Studies that defined their samples as Olympic athletes, national team athletes, elite athletes, high-
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performance athletes, university level (e.g., NCAA) athletes, and semi-professional or
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professional athletes were included.
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Stressors in Elite Sport
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Elite athletes face unique stressors associated with their sport participation including
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overtraining, pressure to perform, poor athletic performances, tense coach-athlete or teammate-
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athlete relationships, injury, and stressors related to retirement from sport (Bruner et al., 2008;
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Noblet et al., 2003). These stressors have the potential to negatively impact elite athletes’ mental
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health (Nixdorf, Frank, & Beckmann, 2016); in fact, some researchers have suggested that at
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times of increased stress, such as during injury or periods of poor performance, elite athletes are
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A COMMENTARY ON MENTAL HEALTH RESEARCH IN SPORT 6
more likely than members of the general population to experience a mental disorder (Gulliver et
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al., 2015; Rice et al., 2016). It has also been suggested that stressors associated with sport
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participation place athletes at an increased risk of suicide (Baum, 2005). While the
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aforementioned stressors may contribute to decreased mental health among elite athletes
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(Gulliver et al., 2015; Rice et al., 2016), research examining the mental health of elite athletes is
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limited compared to mental health research in fields such as psychiatry and psychology. In the
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next section we review research on the prevalence of mental disorders, paying particular
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attention to sex and age differences in the general population as well as among populations of
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elite athletes, and on the help seeking behaviours of elite athletes.
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Prevalence of Mental Disorders and Help-Seeking Behaviours
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Prevalence of Mental Disorders. Approximately 20% of the general population in
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various countries, including Canada, the Netherlands, and Iran, meet diagnostic criteria for a
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mental disorder over a 12-month period (Bijl, Ravelli, & van Zessen, 1998; Noorbala, Yazdi,
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Yasamy, & Mohammad, 2004; Smetanin et al., 2011). The most common psychiatric disorders
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within the general population are mood and anxiety disorders (specifically major depressive
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disorder and general anxiety disorder), and substance use disorders (McRae, O’Donnell,
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Loukine, Rancourt, & Pelletier, 2016; Smetanin et al., 2011). Elite athletes have been found to
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experience mental disorders at similar rates as members of the general population (Gorczynski et
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al., 2017; Rice et al., 2016), and some athletes, such as those experiencing retirement, injury, or
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performance slumps have been found to be at an increased risk of experiencing a mental disorder
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(Appaneal et al., 2009; Rice et al., 2016).
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A large body of the literature on the mental health of elite athletes has explored the
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prevalence of disorders such as anxiety, depression, general psychological distress, anger,
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substance abuse, and eating disorders (Rice et al., 2016). For example, Gulliver et al. (2015)
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found that close to 50% of the elite athletes they surveyed met diagnostic criteria for at least one
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mental disorder, demonstrating that elite athletes are not exempt from experiencing disorder. In
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addition to understanding the prevalence of mental disorders it is also important to understand
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possible sex and age differences in the prevalence of these disorders, and the help-seeking
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behaviours of those experiencing a mental health problem.
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Sex and Age Differences. Various individual differences, including sex and age
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(Smetanin et al., 2011), have been found to impact the diagnosis of a mental disorder in the
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general population. These differences are important to consider when interpreting the prevalence
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of mental disorders, because they can vary widely among different subgroups of the population
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(e.g., male versus female athletes). For example, research within the general population in has
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demonstrated that rates of both depression and anxiety are higher in females than males from
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Canada, Belgium, France, Germany, Italy, the Netherlands, and Spain (Alonso et al., 2004;
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Patten et al., 2015; Pearson, Janz, & Ali, 2013), with females nearly two times as likely to
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experience depression during their lifetime (Knoll & MacLennan, 2017). Conversely, rates of
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substance use disorders are higher among males than females (Pearson et al., 2013; Smetanin et
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al., 2011). Researchers have been unable to identify the cause of these potential sex differences,
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but have suggested that various behavioural, biological or sociocultural factors, or some
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combination of the three may be responsible for the difference in the prevalence of particular
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mental disorders among males and females (McRae et al., 2016; Rosenfield, Kato, & Smith,
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2017; Weissman & Klerman, 1977).
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In sport, researchers have identified that elite female athletes are more likely to report
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symptoms of depression than their male counterparts (Junge & Feddermann-Demont, 2016;
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A COMMENTARY ON MENTAL HEALTH RESEARCH IN SPORT 8
Wolanin, Hong, Marks, Panchoo, & Gross, 2016); however, few researchers have explored sex
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differences in the rates of other mental disorders among elite athletes (Gulliver et al., 2015). In
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one of the few studies that has explored sex differences in the mental health of elite athletes,
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researchers found that female athletes were more likely to experience at least one mental
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disorder; specifically, females were more likely to be diagnosed with anxiety, eating disorders,
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and depression, and were more likely to report sleep problems and behaviours of self harm
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compared to males (Schaal, Tafflet, Nassif, Thibault, & Pichard, 2011).
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While there may be differences in the sex specific prevalence of some mental disorders
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(Weissman & Klerman, 1977), exploring possible biases in their diagnosis and reporting is also
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important. It has been found that in the general population females are more likely than males to
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seek help for and report symptoms of mood disorders, and are more likely to be diagnosed with
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depression than males even when reporting the same symptoms (McRae et al., 2016; World
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Health Organization, 2018). For example, in a study of the prevalence rates of depression and
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anxiety in elite male and female soccer players, Junge and Feddermann-Demont (2016) had more
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female teams willing to participate than male teams from the same league, and after agreeing to
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participate, more elite female athletes completed measures of depression than elite male athletes.
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These findings appear to support the idea that females are more willing to talk about mental
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disorder (McRae et al., 2016). Findings such as these are important to consider when interpreting
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data on the sex specific prevalence of certain mental disorders, especially among elite athletes
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where notions of mental toughness and stigma are suggested to lead to decreased rates of help
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seeking (Moreland, Coxe, & Yang, 2018).
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The fact that males are less likely to seek help (McRae et al., 2016) compounded by
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greater perceptions of stigma among males athletes who conform to traditional masculine norms
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(Steinfeldt & Steinfeldt, 2012), may mean that when sport psychology researchers do explore sex
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differences in disorder prevalence, the rates of certain disorders among elite male athletes will be
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even further underreported. Therefore, the finding that elite female athletes are more likely to
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experience depression than their male counterparts (Gulliver et al., 2015; Wolanin et al., 2016)
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could reflect actual differences in the rates of depression among elite male and female athletes,
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but it may also reflect the impact of beliefs about mental toughness and stigma among males,
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leading them to underreport their symptoms.
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In the future, it is important for researchers and practitioners to explore if elite female and
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male athletes experience different disorders at different rates. This information would allow for
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the development of education programs that could inform coaches and practitioners about the
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mental disorders their athletes are most likely to experience and how to manage such mental
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health problems. Such coach education programs would ideally lead to sport environments where
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both male and female athletes feel well supported in their mental health and may lead to more
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positive mental health outcomes in the long term. While sex differences in the mental health of
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elite athletes are important to consider, it appears that we should also be aware of potential biases
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in the reporting and diagnoses of mental disorder. These biases have an impact on our
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understanding of the prevalence rates of psychiatric disorders in the general population as well as
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among elite athletes (Biederman et al., 2005). Furthermore, understanding if these biases in
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reporting among elite athletes are due in part to cultural norms of ‘toughness’ may inform how
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researchers try to recruit and engage participants. For example, asking athletes to participate in a
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study about ‘psychological wellbeing’ rather than ‘mental health’ may result in increases in the
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number of males who feel comfortable participating.
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Age is another important consideration when attempting to understand the epidemiology
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of many disorders (Mirowsky & Ross, 2017). Studies indicate that young adults under 25 have
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the highest rates of mood disorders compared to other age groups, specifically depression
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(Smetanin et al., 2011), and substance use disorders (Pearson et al., 2013). The impact of age on
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mental health among elite athletes is an area that few sport psychology researchers and
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practitioners have explored. One exception was a study by Schaal and colleagues (2011), who
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found a higher prevalence of psychopathology among the youngest elite athletes compared to
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any other age group, with 15% of athletes 17 and under showing at least one disorder, compared
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to 13% of athletes between 18 and 21, and 10% of athletes 22 and older. They also found that
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while young athletes under 17 were more likely to experience a disorder in general, they were
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less likely to experience depression compared to athletes over the age of 17 (Schaal et al., 2011).
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Since general mental health research typically breaks the population up into large age groups,
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and those under the age of 25 are typically considered ‘young’, it may be challenging to compare
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these findings to the broader population. Additionally, the finding that younger athletes (under
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the age of 21) were less likely to experience depression (Schaal et al., 2011) may support the
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hypothesis that youth sport participation can lead to lower rates of depression (Jewett et al.,
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2014); however, much of the research suggesting a link between sport and fewer symptoms of
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depression is typically conducted with recreational level athletes, not elite athletes (e.g., Dishman
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et al., 2006; Jewett et al., 2014).
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Barriers to seeking help. Researchers studying the mental health of elite athletes have
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also focused heavily on understanding the perceived barriers to seeking help for a mental
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disorder (Moreland et al., 2018). Some identified barriers include lack of time, lack of
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knowledge around mental health, and negative help-seeking experiences in the past (Gulliver,
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Griffiths, & Christensen, 2012; Lopez & Levy, 2013). However, elite athletes identify stigma as
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the primary barrier preventing them from seeking help (Bird, Chow, Meir, & Freeman, 2018).
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We suggest that these perceptions of stigma may stem from pervasive notions of mental
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toughness in sport (see the next section for a detailed discussion of mental toughness). For
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example, it could be that elite male athletes are less likely to report symptoms of depression (e.g.,
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Gulliver et al., 2015), because they may internalize notions of masculinity and mental toughness
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in sport and subsequently feel more pressure to present themselves as tough compared to elite
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females athletes. This is not to say that female athletes do not also endorse or internalize these
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ideals in sport, but rather males may feel an even greater need to demonstrate their ability to
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remain strong, based on pervasive notions of masculinity and hypermasculinity (Addis &
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Mahalik, 2003), especially because sport settings are spaces that foster and promote
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hypermasculinity (Hickey, 2008). Beliefs about mental toughness may reflect internalized
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cultural values, attitudes, and ideals related to hypermasculinity, denial of vulnerability, self-
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sacrifice, and unrelenting standards and effort (Caddick & Ryall, 2012; Coulter, Mallett, &
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Singer, 2016). Stigma and social pressure may encourage athletes to compete while injured
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(Anderson, 2011; Kerr & Stirling, 2017); similarly, overt comments and encouragement from
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various figures in an athlete’s life to play through disorder or injury, or more subtle suggestions
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that imply those who experience injury are weak may also contribute to an athlete’s desire to
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dismiss and play through mental disorder (Anderson, 2011). As researchers have found that elite
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athletes are less likely to seek help than members of the general population (Gulliver et al.,
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2012), it is important to consider ways of decreasing these perceived barriers to help-seeking.
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While many researchers have developed interventions to improve athlete help-seeking
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behaviours, most of these have focused on increasing athletes’ awareness of various aspects of
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mental health (Breslin, Shannon, Haughey, Donnelly, & Leavey, 2017). While these
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interventions are valuable, as long as athletes perceive stigma surrounding mental disorders, the
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rates of help-seeking will likely remain low, regardless of their awareness and knowledge of
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mental disorder.
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Mental Toughness
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In situating the research on the prevalence of mental disorders among elite athletes and
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barriers to help-seeking, it is also important to consider elite athletes’ perceptions of mental
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toughness and stigma in sport. While there has been debate about the definition of mental
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toughness, it is currently conceptualized as a unidimensional construct which refers to “a
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personal capacity to produce consistently high levels of subjective (e.g., goal progress) or
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objective performance (e.g., sales, race time, GPA) despite everyday challenges and stressors as
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well as significant adversities” (Gucciardi, Hanton, Gordon, Mallett, & Temby, 2015, p. 40).
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While the term ‘mental toughness’ originated in mainstream culture, in the academic literature
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mental toughness arose as a construct rooted in positive psychology (Crust, 2008; Crust & Azadi,
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2010). Positive psychology is “concerned with understanding and fostering well-being by
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studying optimal experiences and functioning across individuals, communities, organizations and
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societies” (Mackenzie & Brymer, 2018, p. 4). Additional areas of inquiry based in positive
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psychology have included positive emotions, positive character traits, and individual flourishing
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(Seligman & Csikszentmihalyi, 2000; Wagstaff, Fletcher, & Hanton, 2012). Understanding
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mental toughness and its ties to positive psychology provides a helpful framework for
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understanding stigma in elite sport (Gucciardi, Hanton, & Fleming, 2017).
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Mental toughness has been a prized trait among athletes, and athletes are commended for
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‘toughing it out’ (Malcom, 2006). Since mental disorder has historically (and wrongly) been
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viewed as a weakness (Charles & Bentley, 2016), and athletes are generally considered mentally
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tough (Zeiger & Zeiger, 2018), athletes who experience a mental disorder may face an additional
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layer of stigma compared to those with a mental disorder in the general population. The
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suggestions that athletes may face an additional layer of stigma is supported by research which
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indicates that high-level athletes report greater levels of stigma toward mental disorder than non-
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athletes (Kaier, Cromer, Johnson, Strunk, & Davis, 2015). While some have suggested that
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mental toughness and mental health are contradictory terms in elite sport (Bauman, 2016), others
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argue mental toughness can act as a positive indicator of mental health (Gucciardi, Hanton, &
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Fleming, 2017). Gucciardi and colleagues (2017) argue that mental toughness includes personal
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resources which allow athletes to “manage everyday challenges or overcome major adversities”
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(i.e., to persevere; p. 308) and that such resources are important indicators of mental health.
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Researchers have found mental toughness to be positively associated with perseverance
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(Gucciardi, Peeling, Ducker, & Dawson, 2016), which may be a positive factor contributing to
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elite sport performances. However, this relationship between mental toughness and perseverance
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may contribute to the stigma that elite athletes experience surrounding mental disorder. As noted
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by Gucciardi et al. (2017):
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“there is reason to believe that the social and cultural conditions of sport may foster
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conditions in which personal resources such as those encompassed by mental toughness
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(e.g., overcoming obstacles, perseverance) are valued so highly that athletes may be less
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likely or unwilling to seek help for mental health issues because of the anticipation of
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personally being perceived or treated unfairly.” (p.309)
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Thus, the endorsement of mental toughness and perseverance through injury or pain may lead to
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athletes developing beliefs that asking for help due to mental disorder reflects an inability to
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persevere (and is therefore mentally weak). To date, however, there is no empirical evidence to
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support these assertions and further research is required to understand athletes’ beliefs about
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mental toughness, and to explore how mental toughness may act as a buffer or as a potential risk
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factor for the development of mental disorder.
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The Influence of Psychiatric Epidemiology and Mental Toughness on Mental Health
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Research in Elite Sport
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It is worth situating the literature on mental health and mental disorder among elite
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athletes within issues and trends in the broader field of psychiatry, especially psychiatric
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epidemiology which for decades has been focused on understanding the prevalence and
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determinants of mental disorders in the general population. In the next section we discuss the
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historical measurement of mental disorder and the creation of the Diagnostic and Statistical
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Manual of Mental Disorders, as well as the conceptualization and measurement of mental
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disorder in sport psychology
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Mental health measurement and diagnosis. Prior to 1980, researchers and clinicians
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lacked consistent definitions of various mental disorders, and as a result, they used different
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measurement and diagnostic tools to classify patients which led to differential diagnoses based
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on the diagnostician (Dohrenwend, 1990). The use of different measurement and diagnostic tools
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was problematic because the reliance on multiple standards led to invalid and unreliable research
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findings and patient diagnoses, which in turn led to a wave of criticism being directed at the field
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of psychiatry (Nesse & Stein, 2012). Critics questioned the use and value of psychiatry as a field,
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and the status of mental disorders as illnesses (Nesse & Stein, 2012; Wakefield & Schmitz,
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2017).
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In order to address inconsistencies in the nosology (i.e., the classification of disease),
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measurement, and diagnosis of mental disorders, and in an effort to assert themselves as a
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legitimate medical profession, psychiatrists developed the Diagnostic and Statistical Manual of
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Mental Disorders III (DSM-III; American Psychiatric Association, 1980; Wakefield & Schmitz,
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2017). The development of the DSM-III was an important landmark in the field of mental health,
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because it led to the creation of standardized diagnostic criteria that could be implemented by
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both health care practitioners and researchers, which increased the reliability of mental health
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measurement (Nesse & Jackson, 2011). The DSM is continually being revised and updated, with
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the most current edition being the DSM-5 (American Psychiatric Association, 2013). The DSM-
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5 is a “diagnostic classification system for psychiatrists, other physicians, and other mental
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health professionals that describe[s] the essential features of the full range of mental
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disorders…providing guidelines for diagnoses that can inform treatment and management”
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(American Psychiatric Association, 2013, p. 6). According to the DSM-5, “reliable diagnoses are
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essential for guiding treatment recommendations, identifying prevalence rates for mental health
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service planning, identifying patient groups for clinical and basic research, and documenting
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important public health information such as morbidity and mortality rates.” (American
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Psychiatric Association, 2013, p. 5). The disorders described in the DSM include symptom and
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functioning checklists that together comprise diagnostic criteria; practitioners use these to
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determine whether or not a disorder is present.
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In sport, the use of these standardized diagnostic criteria to inform clinical interviews and
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survey measures has allowed for more reliable measurement of elite athlete mental health as
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opposed to each researcher or clinician using their own definitions and diagnostic criteria to
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measure the same disorders (Nesse & Jackson, 2011). The standardization of diagnostic criteria
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has allowed researchers to analyze the findings of research on mental health collectively; for
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example, every study included in a recent meta-analysis comparing the depressive symptoms of
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elite athletes and non-athletes used measures based on DSM diagnostic criteria (Gorczynski et
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al., 2017). The use of meta-analyses means that researchers can draw conclusions based on very
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large amounts of data, allowing for more precise estimates of the prevalence of specific disorders
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among elite athletes or the effect of specific interventions in the sport environment, thereby
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providing a more comprehensive and shared understanding of various aspects of mental health
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among elite athletes (Haidich, 2010). If researchers were using different and unrelated definitions
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to measure the same concepts, it would be difficult to assess and understand the findings across
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this body of literature and to compare the results of such work. The ability to reliably measure
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mental disorders in multiple contexts has had a vast impact on current trends in mental health
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research both generally and in sport. However, it is important to note that currently researchers
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often use different measures to identify the prevalence of the same disorders. While these
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measures are based on the same DSM criteria, the use of different measures can make it difficult
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to draw accurate comparisons across different research studies.
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Conceptualization and measurement of mental health in sport. While the DSM has
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led to many important developments in the field of mental health by establishing standardized
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diagnostic criteria and reliable measurement of mental disorders (Nesse & Jackson, 2011), there
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are many critics of the text (Stein et al., 2010; Wakefield, 1997). A main critique of the DSM is
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that it lacks validity, which is thought to stem from the poor conceptualization of mental
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disorders (Borsboom, 2016; Kendler, 2016). Because of this, there is concern that what clinicians
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are able to reliably measure may not in fact be a category of disorder (Insel et al., 2010).
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The desire to represent psychiatric disorders as distinct identifiable entities stems from
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the historical unreliability of psychiatric measurement and the criticism psychiatrists received for
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such unreliable measurement (Dohrenwend, 1990; Nesse & Stein, 2012). However, some now
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suggest that the notion of psychiatric disorders as discrete entities is an inaccurate view, and that
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psychiatric disorders and their associated symptoms should instead be thought of on a continuous
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scale of dysfunction (Borsboom et al., 2016). Insel et al. (2010) asserted that current diagnostic
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criteria based on symptomatology “may not capture fundamental underlying mechanisms of
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dysfunction” (p. 748), while others have argued that the disorders included in the DSM are
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socially and politically determined rather than representative of true psychiatric dysfunction
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(Whooley, 2017). An example of a socially and politically determined diagnoses is that of
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homosexuality, which was classified as a mental disorder in the DSM-II (American Psychiatric
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Association, 1968), but was removed from the DSM in 1973 and is no longer considered a
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mental disorder. This is indicative of the fact that changing social and political environments can
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have a large impact on the diagnosis of psychiatric disorders. While there have been many
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debates among researchers and clinicians about how psychiatric disorders should be
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conceptualized (Borsboom, 2016; Kendler, 2016), it appears as though these groups have been
364
unable to reach a consensus on these issues of conceptualization and measurement. The DSM
365
has allowed different researchers and clinicians to see a patient and agree on the diagnosis of a
366
disorder, although the lack of consensus on the definition of disorders cast doubts on the validity
367
of the measurements. The question that remains is: while researchers and practitioners are
368
reliably diagnosing patients according to a consistent set of criteria, are they diagnosing actual
369
disorders? Until there is a clear etiology for specific psychiatric disorders there will be little
370
agreement on the answer to this question.
371
A COMMENTARY ON MENTAL HEALTH RESEARCH IN SPORT 18
Despite these ongoing debates in the broader field of mental health research about how
372
mental disorders should be re-conceptualized, these problems do not seem to be the focus of
373
much discussion or research in the field of sport psychology. Given the historical lag of research
374
in sport psychology compared to general psychology (Morgan, 1980), it seems likely that this
375
problem will take time to become a topic of interest to researchers studying sport psychology.
376
While the re-conceptualization of mental disorders has not yet been addressed by sport
377
psychology researchers and practitioners, it is an important issue to consider when moving
378
forward. Those involved in studying and treating the mental health of elite athletes should
379
critically consider how mental health is being conceptualized and measured, and consider
380
alternate modes of measurement that may enhance diagnostic validity. Since there is ongoing
381
debate about what constitutes a mental disorder, developing a completely valid measure may be
382
challenging. In the meantime, continuing to use DSM criteria in measurement will allow results
383
to be compared across the field; however, rather than dichotomizing continuous data as is
384
common practice when using many measures of mental disorder, participant responses should be
385
left as continuous rather than broken up into categories of disordered and non-disordered based
386
on predetermined cut-off points.
387
Dichotomizing continuous data is problematic for a few different reasons: it results in the
388
loss of valuable information about differences between respondents, it leads to much smaller
389
magnitudes of effects, and leads to an increased probability of Type II errors (i.e., failing to
390
detect effects that are present; Streiner, 2002). Additionally, larger sample sizes are needed when
391
dichotomizing continuous data in order to reach the same statistical power (Streiner, 2002;
392
Suissa, 1991). In small populations, such as elite athletes, this means that a larger subset of a
393
difficult to recruit population is needed, which can pose challenges for researchers trying to
394
A COMMENTARY ON MENTAL HEALTH RESEARCH IN SPORT 19
reach a desired level of statistical power. Lastly, if cut-off points that are used to dichotomize a
395
measure change (e.g., if threshold scores change upon new or re-validation), such as when a new
396
edition of the DSM is released, data based on the previous threshold can become less relevant.
397
However, if the measure remains continuous it could still be used and compared to research
398
conducted after cut-off points change (Streiner, 2002); researchers can simply apply the old and
399
new cut-off scores on the data. This approach could prove valuable for researchers outside of
400
sport as well. For a more in-depth discussion of the limitations of dichotomizing continuous data
401
please refer to Streiner (2002).
402
Two additional issues related to the measurement and study of mental health among elite
403
athletes that have influenced the development of research in this area are the reliance on cross-
404
sectional data and self-report data. Research on the mental health of elite athletes is characterized
405
by a heavy reliance on cross-sectional data: sport psychology researchers have used various
406
methods including, surveys, qualitative interviews, and diagnostic clinical interviews (e.g.,
407
Appaneal et al., 2009; Gulliver et al., 2015) to collect data, however most of these data are
408
collected at only one point in time. While it is valuable to gain a general understanding or ‘snap
409
shot’ of the prevalence of mental disorders at a single point in time, the lack of longitudinal data
410
on athlete mental health limits the conclusions that researchers have been able to draw on this
411
important topic because they are unable to track the progression or change in the mental health
412
status of athletes. Longitudinal research designs may allow researchers to more fully explore the
413
impact of sport related stressors, such as team (de)selection or retirement, and personal
414
resources, such as social support, on the mental health of elite athletes.
415
The body of literature mental health among elite athletes is also characterized by reliance
416
upon self-report data. While self-report data are important and should not be discounted as
417
A COMMENTARY ON MENTAL HEALTH RESEARCH IN SPORT 20
invalid, stigma and notions of mental toughness may strongly influence an elite athlete’s
418
willingness to provide information about their own mental health (Bird et al., 2018). If elite
419
athletes are afraid that others will view them as weak or that they will be removed from team
420
rosters if they seek help for a mental disorder, then they are likely to underreport their
421
experiences of mental disorder (Lopez & Levy, 2013), which may mean that current estimates of
422
disorder prevalence among athletes are inaccurate. For example, the use of self-report data could
423
be contributing to the differences in the reporting of depression symptoms between males and
424
females (Gulliver et al., 2015). Accurate estimates of disorder prevalence may further
425
demonstrate the degree to which athletes are experiencing mental disorders, which may in turn
426
further incentivize the creation of additional athlete specific support services designed to foster
427
mental health. Additionally, accurate rates of disorder prevalence among elite athletes are
428
important because they can inform interventions and policies based on clear information about
429
what athletes are experiencing. Decreasing stigma and critiquing the notion of mental toughness
430
in sport may lead elite athletes to feel more comfortable with self-report techniques, which in
431
turn may lead to more accurate estimates of disorder prevalence. We acknowledge that
432
decreasing the experience of stigma and the widespread belief in mental toughness is a difficult
433
task; however, combatting the concept of athletes as mentally tough individuals who should not
434
admit to any form of distress may lead to an environment where athletes feel more comfortable
435
seeking and receiving treatment for mental disorders. While this may not solve other limitations
436
of self-report, such as participants who provide what they think are socially desirable answers,
437
exaggerate their symptoms in order to receive treatment, or do not want to admit to ‘bad
438
behaviour’ (Heppner, Wampold, Owen, Wang, & Thompson, 2015), it is an important start.
439
A COMMENTARY ON MENTAL HEALTH RESEARCH IN SPORT 21
Another conceptual issue that is relevant for mental health researchers and practitioners
440
in sport psychology is the theoretical similarity and overlap between burnout and depression.
441
Both depression and burnout are characterized by emotional and physical fatigue or exhaustion,
442
loss of interest, and a loss of pleasure (American Psychiatric Association, 2013; Raedeke, 1997).
443
While these two concepts may represent conceptually distinct entities, the similarity in their
444
symptomology likely means that research in the broader field of mental health on depression
445
could inform future research within sport psychology on burnout. By considering similarities and
446
overlap between constructs commonly studied in sport psychology with those in the broader
447
fields of psychology and psychiatry, sport researchers can consider how research findings and
448
concepts on the topic of mental health can be used to inform their work exploring the
449
experiences of elite athletes.
450
Looking Ahead
451
Understanding the trends in elite athlete mental health research is important as it allows
452
us as researchers and practitioners to look forward and consider ways to advance research and
453
practice in this area. We believe that research on the mental health of elite athletes will continue
454
to flourish, especially as more people recognize that elite athletes are equally as likely, and in
455
some cases more likely to experience mental disorders than non-athletes (Gorczynski et al.,
456
2017; Rice et al., 2016). It is important that sport psychology researchers and practitioners
457
continue to identify the prevalence of various disorders in elite athletic populations, understand
458
why elite athletes do or do not seek help, and design programs that help coaches, administrators,
459
and athletes to deal with mental disorder. In order to build on these already existing trends, key
460
initiatives and various areas of study that will further advance research and practice are
461
proposed.
462
A COMMENTARY ON MENTAL HEALTH RESEARCH IN SPORT 22
Implementation of longitudinal research designs. As noted earlier, a majority of the
463
work on elite athlete mental health is cross-sectional, meaning that researchers are unable to
464
track athlete mental health across time. Therefore, a key to progress in the field will be the use of
465
longitudinal research designs to identify within- and between-athlete changes in mental health
466
(Stenling, Ivarsson, & Lindwall, 2017). Sport psychology researchers should follow the lead of
467
general mental health researchers (Kessler, Chiu, Demler, & Walters, 2005; Patten et al., 2015)
468
and conduct large longitudinal studies of elite athlete mental health across multiple competitive
469
seasons in various sports. Such studies would provide valuable information regarding changes in
470
an elite athlete’s mental health as they face varying athletic stressors (e.g., international travel,
471
team selection, injuries, retirement), which would allow researchers to pinpoint specific times
472
throughout an athlete’s season when they are at risk of experiencing decreases in mental health.
473
For example, longitudinal research may provide empirical evidence supporting the notion that
474
elite athletes experience decreases in their mental health after attending an Olympic Games. This
475
in turn could inform periodized interventions aimed at improving elite athlete mental health by
476
targeting different sport stressors or mental health outcomes at different times. Such
477
interventions could lead to increases in mental health as well as athletic performance. It is
478
therefore important that researchers implement longitudinal research designs so that they may
479
draw stronger conclusions and further understand the trajectories of mental health in athletes.
480
Use of continuous measurement scales. A second initiative that may help advance our
481
understanding of elite athlete mental health would be for researchers and practitioners to
482
continue using the DSM diagnostic criteria to measure mental health, but rather than
483
dichotomizing the continuous data that is collected, researchers should leave the data as
484
continuous. Despite criticisms regarding the DSM’s lack of validity (Dohrenwend, 1990), it does
485
A COMMENTARY ON MENTAL HEALTH RESEARCH IN SPORT 23
provide reliable measures of mental health and is a system widely adopted in the field of
486
psychiatry (Nesse & Jackson, 2011; Wakefield & Schmitz, 2017). Since there are few other ways
487
to measure mental health, one could argue that it makes the most sense to select criteria that have
488
been tested and shown to be reliable across population studies (Narrow et al., 2013). Moreover,
489
using the DSM diagnostic criteria is important because a majority of research on mental health is
490
conducted using measures based on the DSM (Kessler, Petukhova, Sampson, Zaslavsky, &
491
Wittchen, 2012; Kessler et al., 1994; Patten et al., 2015). For example, while continuing to use
492
the Centre for Epidemiological Studies Depression Scale (CESD; Radloff, 1977), researchers
493
could analyze respondent data on a continuous scale instead of using a cut-off point to categorize
494
respondents as at risk of clinical depression. Using the 16-point cut-off suggested by the CESD
495
implies that there is a large different between people who score 15 and people who score 16, but
496
not between those who score 13 and those who score 14. Instead of applying such cut-off points,
497
researchers could explain that higher scores indicate higher symptomology of depression; this
498
will help to reduce Type II errors, and will allow researchers to draw more accurate conclusions
499
(Streiner, 2002). Of course, as previously noted, using a continuous measure like the CESD gives
500
the researcher the option of dichotomizing the outcome, if the research question calls for an
501
identification of diagnosis. The results of studies that employ the DSM criteria may then be more
502
easily interpreted, integrated, replicated, and compared to existing research in the field
503
(Wakefield & Schmitz, 2017).
504
Impact of organizational features of sport environments on elite athlete mental
505
health. In the future, it will also be important for researchers to consider the organizational
506
features of sport environments that contribute to the positive or negative mental health and
507
wellbeing of elite athletes. While it has been found that athletes experience psychological
508
A COMMENTARY ON MENTAL HEALTH RESEARCH IN SPORT 24
distress related to their involvement with sport organizations (Arnold & Fletcher, 2012; Arnold,
509
Fletcher, & Daniels, 2016; Fletcher & Wagstaff, 2009), very little is known about how the belief
510
systems and power structures embedded in these sport organizations may impact athlete mental
511
health or psychological distress. It may be that embedded systems within sport organizations
512
promote ideals of mental toughness and do not foster environments where elite athletes feel
513
comfortable discussing mental health. Alternatively, there may be sport organizations that are
514
working hard to design environments where elite athletes are encouraged to openly discuss their
515
mental wellbeing. However, more research is needed to identify the features of environments
516
that do and do not promote mental wellbeing of elite athletes. Identifying such features may
517
allow for the implementation of policies across sport organizations that are designed to create
518
spaces where athletes are well supported if they experience psychological distress.
519
Athlete abuse and mental health. Looking forward we predict that it will also become
520
increasingly important to explore the impact of abuse on the mental health of elite athletes.
521
Reports such as the one published by the Canadian Broadcasting Corporation (Ward & Strashin,
522
2019) and the testimonies of various elite athletes (Kwiatkowski, Alesia, & Evans, 2018),
523
indicate that abuse in sport may be a much larger issue than has previously been noted. In a study
524
of 507 elite athletes researchers found that 14% reported experiencing sexual abuse, and 18%
525
reported experiencing physical abuse (Timpka et al., 2014). While there is limited literature on
526
the impact that abuse can have on an athlete’s mental health, researchers have found that adults
527
who experienced mental and physical abuse during their youth sport participation were more
528
likely to experience psychological distress and poorer quality of life than those who had not
529
(Vertommen, Schipper-van Veldhoven, Kampen, Uzieblo, & Van den Eede, 2018). While this
530
study was not specific to the experiences of elite athletes, it is not difficult to imagine that abuse
531
A COMMENTARY ON MENTAL HEALTH RESEARCH IN SPORT 25
has the same mental toll on elite athletes, especially because elite athletes spend so much time
532
and develop such close relationships with their coaches (Jowett, 2017; Poucher, Tamminen, &
533
Kerr, 2018), and because of the power that coaches have over their athletes (Pinheiro, Pimenta,
534
Resende, & Malcolm, 2014; Stirling & Kerr, 2009). In addition to coaches, other adults in sport
535
environments hold positions of trust and authority over athletes and it is important that the
536
influence of these individuals is not overlooked. For example, the recent case of athlete abuse
537
involving the USA Gymnastics national team doctor Larry Nassar (Merrill, 2018) demonstrates
538
that elite athletes are not only suffering abuse at the hands of their coaches, but also from those
539
in other positions of power within sport. Researchers and practitioners may seek to better
540
understand the mental health effects of abuse on athletes, as this understanding could inform the
541
development of protocols to assist athletes dealing with the repercussions of abuse. However, it
542
is also important that researchers and practitioners focus on the prevention of abuse and the
543
safeguarding of athletes (Kerr & Stirling, 2019). The International Olympic Committee
544
developed a toolkit “to assist National Olympic Committees (NOCs) and International
545
Federations (IFs) in the development of policies and procedures to safeguard athletes from
546
harassment and abuse in sport” (International Olympic Committee, 2016, para. 1) which is freely
547
available online. This is a valuable resource that sport researchers and practitioners can use to
548
inform their work in this area.
549
Diversity of experiences in mental health research. It is also important to explore the
550
participants who are typically included in studies of mental health in elite sport. Currently, many
551
researchers in the field ask elite athletes to report on their experiences of mental health or mental
552
disorder while they are still competing (e.g., Gulliver et al., 2015). While it is important to
553
continue work with these athletes, it is also important for researchers and practitioners to
554
A COMMENTARY ON MENTAL HEALTH RESEARCH IN SPORT 26
consider the experiences of retired elite athletes, or athletes who have dropped out of sport.
555
During and after retirement, athletes are known to experience outcomes such as the loss of social
556
support networks (Park, Lavallee, & Tod, 2013), and the loss of their athletic identity (Martin,
557
Fogarty, & Albion, 2014; Menke & Germany, 2018; Stronach, Adair, & Taylor, 2014).
558
Therefore, it is important that their experiences are included in studies of mental health and
559
wellbeing. In one of the few studies exploring the mental health of a retired elite athlete,
560
researchers found that upon retirement, which led to a loss of both social support networks and a
561
strong athletic identity, this individual experienced an adjustment disorder with a mix of
562
depression and anxiety (Jewett, Kerr, & Tamminen, 2018). However, there are a limited number
563
of studies that include retired elite athletes or athletes who have dropped out of sport. While
564
these populations may be difficult to recruit, future researchers should strongly consider
565
including retired elite athletes, as well as those who have dropped out of sport in their research
566
projects as these individuals may help provide us with a clearer understanding of elite athlete
567
mental health. In addition, efforts should be made to include both male and female athletes,
568
whether retired or still competing, of varying ages to provide further understanding of the mental
569
health of elite athletic populations. It is also important that researchers engage with marginalized
570
athletes, including racialized, Indigenous, and LGBTQQIA+ (lesbian, gay, bisexual, transgender,
571
queer, questioning, intersex, and asexual people) athletes, and athletes with varying abilities in
572
studies of mental health and mental disorder in sport, as there is research demonstrating that in
573
the general population, individuals identifying with these groups can experience higher rates of
574
mental disorder (McClain et al., 2016; Plöderl & Tremblay, 2015).
575
Age grouping of elite athletes in mental health research. It is important that
576
researchers continue to use smaller age groupings (e.g., Schaal et al., 2011) to learn more about
577
A COMMENTARY ON MENTAL HEALTH RESEARCH IN SPORT 27
the distribution of mental disorders among elite athletes of varying ages, rather than grouping all
578
athletes under the age of 25 in one category. Considering that individuals under the age of 25 are
579
most likely to experience mental disorder (Pearson et al., 2013), many elite athletes are
580
competing and performing under the age of 25, and that young athletes have been found to
581
experience higher rates of disorder than their non-athlete peers (Gulliver et al., 2015), this is an
582
area where further investigation is warranted. Moreover, since the limited sport research that
583
does exist in this area is difficult to compare to broader mental health literature based on
584
differing age categories, additional exploration of variations in mental disorders according to age
585
among elite athletes would be valuable. Knowing if young elite athletes are more likely to
586
experience mental disorders and if some disorders are more common at different ages would
587
allow for the development of interventions and policies that specifically target and protect young
588
athletes in order to enhance or maintain their mental health.
589
Social media, technology, and athlete wellbeing. Another area that is poised to become
590
pertinent for mental health researchers in sport is the impact of social media and technology use
591
on the wellbeing of elite athletes. Researchers have found that in the general population,
592
adolescents aged 11-18 feel that social media can cause anxiety and other mood disorders and
593
that the use of social media is like an addiction (O’Reilly et al., 2018). Moreover, social media
594
was seen as a platform for bullying (O’Reilly et al., 2018), and being a victim of bullying has
595
been found to be related to increased rates of mental distress (Coggan, Bennett, Hooper, &
596
Dickinson, 2003). Additionally, engagement with social media has been associated with the
597
experience of symptoms of depression, anxiety, inattention, and hyperactivity among adolescents
598
(Barry, Sidoti, Briggs, Reiter, & Lindsey, 2017; McCrae, Gettings, & Purssell, 2017). However,
599
much of the research in this area focuses exclusively on adolescents and there has been little
600
A COMMENTARY ON MENTAL HEALTH RESEARCH IN SPORT 28
examination of this topic in a sport context. Given the pervasiveness of social media, it will
601
likely become important for researchers to understand how these online applications impacts the
602
wellbeing of elite athletes, many of whom maintain public profiles and engage frequently with
603
fans on social media. If elite athletes, many of whom are under the age of 25, are impacted in
604
similar ways as adolescents in the general population, practitioners need to consider how elite
605
athletes engage with social media when helping them deal with mental disorder or distress.
606
While elite athletes may experience negative outcomes based on their engagement with
607
social media, there may also be some positives associated with the proliferation of social media
608
and technology for research and applied practice. Social media may allow researchers to recruit a
609
wide range of athletes for research studies and for practitioners to provide psychological support
610
to athletes. It may be that if athletes can contact sport psychologists or mental skills consultants
611
online, their anonymity can be better preserved, reducing barriers due to perceived stigma. For
612
example, e-counselling is becoming an increasingly popular way for individuals to access mental
613
health services (Campos, 2009). Additionally, social media may be used to help combat common
614
notions of mental toughness and as a mode of program or intervention delivery to help athletes
615
deal with mental disorder. Social media has been identified as a valuable tool to help mental
616
health practitioners reach a wide audience with accurate and helpful information regarding
617
various aspects of mental wellbeing (Krausz, 2017; Peek et al., 2015).
618
Combatting stigma in sport. The belief that athletes are inherently mentally tough may
619
contribute to negative perceptions of mental disorder in sport, resulting in additional stigma
620
above and beyond the stigma experienced by those in the general population with mental
621
disorder (Kaier et al., 2015). Attitudes towards individuals with a mental disorder have become
622
more positive in the general population (Horwitz, 2017), however elite athletes still perceive
623
A COMMENTARY ON MENTAL HEALTH RESEARCH IN SPORT 29
large amounts of stigma related to mental disorder and are consequently less likely to seek help
624
when they need it (Gulliver et al., 2012), and they may underreport their experiences of mental
625
disorder (Lopez & Levy, 2013). Addressing stigma may help elite athletes feel more comfortable
626
seeking help for mental disorders, and it could also lead to progress in research if athletes are
627
more willing to talk about mental health issues and participate in studies of mental disorder and
628
mental health. Additionally, reducing stigma may lead to more accurate self-reports of mental
629
disorder from elite athletes, which may lead to better estimates of disorder prevalence and the
630
development of more targeted and effective interventions designed to improve the mental health
631
of elite athletes.
632
While stigma is an important issue, the best way to approach and address its existence is
633
unclear. One way forward could be to further educate sport practitioners, sporting bodies, and
634
athletes about stigma and the negative role it can play in athletes’ mental health. At the same
635
time, researchers and practitioners should be educated about the potential pitfalls of mental
636
toughness and the negative implications of the concept for athletes, so that they are not
637
unknowingly enforcing the notion that athletes who experience mental disorders are weak. While
638
stigma is a large cultural barrier, finding ways to decrease its impact on athletes could improve
639
research quality (via a more specific research focus, and athlete self-report) and the practical
640
implications of that research.
641
More strengths-based approaches. Lastly, rather than conducting research from a
642
deficit perspective, which focuses on the weaknesses of athletes and the skills that they are
643
lacking (Mackenzie & Brymer, 2018), integrating positive psychological perspectives with
644
research on the mental health of elite athletes may help to further develop and advance our
645
understanding of mental health and disorder among this population. Drawing on the work of
646
A COMMENTARY ON MENTAL HEALTH RESEARCH IN SPORT 30
Keyes (2002), who suggested that mental health and mental disorder should be viewed and
647
understood as separate constructs, may allow researchers to develop more strengths-based
648
approaches to studying the mental state of elite athletes. Integrating positive psychology
649
perspectives, such as positive coping and self-compassion, on mental health interventions may
650
allow researchers to design interventions that benefit a wide group of athletes. For example,
651
many elite athletes could benefit from interventions designed to enhance their coping skills or
652
develop compassion toward themselves in sport (Mosewich, Crocker, Kowalski, & DeLongis,
653
2013), rather than interventions targeted specifically towards those suffering from anxiety. While
654
interventions targeting specific mental disorders are still important, strengths-based interventions
655
have the potential to benefit larger groups of athletes and present information on a range of
656
topics that focus on the strengths of the athletes.
657
Applied Implications
658
Given that elite athletes are not exempt from experiencing mental health issues (Moesch
659
et al., 2018; Rice et al., 2016), and may not feel comfortable seeking help for a mental health
660
problem or mental disorders (Bird et al., 2018), it will be important to continue working with
661
coaches and other support staff to emphasize the importance of encouraging help-seeking
662
behaviours among elite athletes. Additionally, elite athletes should be discouraged from playing
663
through distress, whether physical or mental. Moreover, adults in sport in positions of authority
664
(i.e., those who set the climate and expectations for athletes) should be encouraged to critically
665
question the notion of mental toughness and the associated implication of mental weakness.
666
When working with elite athletes, reconceptualizing ‘mental toughness’ as ‘mental fitness’ may
667
help to decrease perceptions of stigma around working with sport psychologists and talking
668
about mental health, as the term implies that it is a skill to be worked on and developed, rather
669
A COMMENTARY ON MENTAL HEALTH RESEARCH IN SPORT 31
than an innate characteristic (Olusoga, 2015). Additionally, sport organizations should consider
670
creating confidential avenues for elite athletes to discuss their mental health if they do not yet
671
exist. It should be made clear to athletes that if they speak to a sport psychologist employed by
672
their team or sport organization that their interactions are completely confidential, what they say
673
to the sport psychologist will not be shared with other support staff, and their position on the
674
team will not be compromised based on their confidential conversations (see also the AASP
675
Ethics Code: Ethical Principles and Standards, section 18: Maintaining Confidentiality:
676
https://appliedsportpsych.org/about/ethics/ethics-code/ and the BASES Code of Conduct, section
677
6.2: Confidentiality: https://www.bases.org.uk/imgs/bases_code_of_conduct872.pdf). Moreover,
678
education and training programs designed to teach adults in positions of authority (e.g., coaches,
679
sport administrators) about how to use their power over athletes constructively, and how to
680
promote healthy personal and athletic development for athletes, may not only improve athlete
681
outcomes, it may also prevent some athletes from experiencing interactions (e.g., various forms
682
of athlete maltreatment) that are related to the experience a mental disorder among elite athletes
683
(Kerr, Willson, & Stirling, 2019).
684
An additional strategy that may help to foster and encourage open discussions of mental
685
health is to address the impact of stigma on elite athletes. There should also be work done to
686
educate the public about the seriousness of athlete mental health, and it should be made clear that
687
by supporting and encouraging notions of mental toughness, people may be contributing to the
688
stigma that athletes experience, which may in turn influence the mental health of those athletes
689
(Kerr & Stirling, 2017). A campaign such as the Bell Let’s Talk initiative, a mental health
690
awareness campaign in Canada, that was made popular by a Canadian Summer and Winter
691
Olympic athlete Clara Hughes, has the specific aim to raise awareness of mental health in the
692
A COMMENTARY ON MENTAL HEALTH RESEARCH IN SPORT 32
general Canadian population (Bell Let's Talk, 2018). Other programs such as ‘NRL State of
693
Mind’ in Australia, work with well-known athletes to raise awareness about mental health and
694
encourage people to offer support to those dealing with a mental disorder (State of Mind, 2019).
695
Involving well-known, successful athletes in such campaigns could prove very effective in
696
educating people about mental health in athletes and could help to reduce the stigma that athletes
697
currently experience, although there is a need for robust evaluation of the these types of mental
698
health awareness campaigns Liddle, Vella & Deane (2017). It may also be that if elite athletes
699
continue to be involved in such campaigns and disclose their personal experiences with mental
700
health and mental disorders, others, both athletes and non-athletes, may feel more comfortable
701
discussing their mental health experiences openly, because many people look up to elite athletes
702
(Swann et al, 2018). Continuing to involve recognizable athletes in mental health campaigns
703
could help to promote a sport environment where athletes feel comfortable seeking the help they
704
need. Lastly, sport practitioners could take advantage of social media and online platforms to
705
disseminate knowledge about protecting the mental health of elite athletes. These suggestions are
706
only a starting point for addressing stigma; much more work will be needed before athletes feel
707
comfortable openly discussing their experiences of mental health.
708
Conclusion
709
Elite athletes experience myriad stressors related to their sport participation, which can
710
lead to decreases in mental health and increases in the risk of mental disorders (Gulliver et al.,
711
2015; Nixdorf et al., 2016; Rice et al., 2016). The recognition of the impact that sport stressors
712
can have on athlete mental health has led to a surge of research exploring the prevalence of
713
mental health outcomes and help-seeking behaviours among elite athletes. Research on mental
714
health in elite sport has also been influenced by other trends and issues within and beyond the
715
A COMMENTARY ON MENTAL HEALTH RESEARCH IN SPORT 33
field of sport psychology, including the concept of mental toughness and the development of the
716
DSM. Important areas of future research include the impact of sport environments on athletes’
717
mental health, abuse and mental health, and the impact of technology on athletes’ mental health
718
and the delivery of sport psychology services to athletes. Researchers studying the mental health
719
of elite athletes should continue to consider the conceptual similarities and differences in their
720
work in relation to the general mental health literature, and consider framing their research from
721
a strengths-based perspective. We highlight the need for longitudinal research designs, and
722
suggest that researchers consider using continuous measurement scales in the assessment of
723
mental disorders. Finally, continued efforts are needed to combat the stigma that athletes
724
perceive surrounding mental disorders and notions of mental toughness in sport.
725
A COMMENTARY ON MENTAL HEALTH RESEARCH IN SPORT 34
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