Mental health issues in
competitive Athletes

Depression in the competitive athletes is still considered a taboo subject while studies have demonstrated that about 21 % of athletes may suffer from the disease. The athlete seems to have a fear of disappointing a public coupled with the anxiety of the moment while competing. This situation may trigger such a catastrophic “phenomenon” forcing him/her to lose his/her emotional control. It appears to be much common than one wants to think. Such athletes may have a better way in hiding the situation or dismissing it. They find reasons to create an escape or an evasion. I will try to review what many performing athletes may have experienced. I do not have the pretention of becoming an apprentice-psychiatrist or a psychologist but I needed to understand well what pressure brings to an athlete.

Can we ever imagine what went in Michael Phelps head, for him to reveal to the world how often he has experienced bouts of depression through his long winning carrier while being the best swimmer in the world. Who would think that such an athlete may have fermented thoughts of suicide while on the top of his game?  Or a Serena Williams, #1 tennis player in the world fighting bouts of depressive episodes? She may have added to her struggle a post-partum depression following the birth of her daughter.

We could go on talking about these high performing athletes in different professional disciplines. A Kevin Love, NBA professional player or Andres Iniesta, a soccer professional player, or Rafael Nadal, a professional tennis player who have all suffered silently of depression but many of other one may have not been able to cope perhaps with the problem or to even admit it. In fact, depression is also the main cause of suicide among such athletes. If the rate of depression in the general population is 6%, among athletes, it varies between 17 to 21% and even to 25% in professionals. What does trigger this state of depression? may be a million-dollar question to answer. Often, the athlete has to think that he/she is a human being and not a super hero, invincible.

Indeed, athletes are not invincible but it does matter how many medals or championship they win. A physical preparation through a perfect technique is no match for a lack of spirit; everybody has emotional needs. Athletes need to learn how to handle the pressures and the fears of the unknown. Once pressure and anxiety are not controlled, depression will soon surface because it built gradually while the individual suffer with panic attacks.

Athletes learn soon about the fear of failure while they may be exposed to criticism. They become afraid of disappointing and start feeling anxious. They need to rely on somebody around them on which they can count upon to communicate their fears, sadness and emotions. They have to understand that stress and anxiety are part of the competition and they need to boost their self-esteem.

Recent events dealing with the American gymnast Simone Biles’ withdrawal from competing for her country at the Olympics in Tokyo, Japan, have filled up the actuality. The issue of mental health grounds has marked all conversations in the press and among athletes. This is not new in the world of sport but when it happens to a top athlete assured to become the most decorated individual in Gymnastics during the Olympics, it is certainly not surprising that such event will cover the news media. She suffered in the past from ADHD and like to comment about the medications she received in prescription.

The Olympics regorge of examples of competitors who failed to reach their goals and fell down in a state of depression. We will try to review individually the case of some of these athletes and try to find perhaps a reason for such downside after their high mark of successful. In recent memory so many top athletes become victims and needed to withdraw from the competition. I am not too sure if such cases would not be better discussed by a psychiatrist or a psychologist or simply by the athlete himself/herself who experienced all the tension while participating in the games.

A gentleman, the most decorated Olympian, a swimmer who has collected a total of 28 medals after participating to many Olympics since the year 2000 has retired once from the games and returned to competition to retire again in 2016 after winning an impressive 23 gold medals. I believe that no one can doubt that I am talking about the most decorated Olympic swimmer Michael Phelps. It was said that he battled depression and anxiety with suicidal thoughts and sought for professional help more than once. He even stated that after every athletic competition he participated to during the Olympics, he fell down in a major depression.

Michael Phelps described a state of euphory mixed with emotion which did not appear to be natural the first time he felt that way in 2004 or after in 2008. He described it as an internal struggle.

A young lady of mixed heritage, born in the United States where she also grew up until she was able to definitively chose her nationality. Part Haitian and part Japanese, she opted to become Japanese with the option of representing her country at the next Tokyo Olympics 2020 which were postponed to the summer 2021 because of the COVID-19 pandemic. She made her mark as a famous professional tennis player and reached the number one top position in the world after beating another world champion Serena Williams in a Grand Slam at the US Open in 2018. I am talking about Naomi Osaka, tennis champion, the first Asian player to be ranked No 1 in single.

Recently, she created a lot of controversy when she chose to skip a press conference after participating to the French Open with an early exit loss, under the pretext of protecting her mental health from issues debated by some American journalists. She did not feel comfortable being asked about Black Life Matter issues or anything about her race and her personal life. She dropped out after being asked to comment on the police brutality in the United States and the racial tension of the moment.

She withdrew from the tournament and later on, was fined by the organizers. Although being 23-year-old, she stated that she has suffered from long bouts of depression since the 2019 US Open and her shy nature let the public to often discover her habits with the wear of headphones during the tournaments, listening to music helping her cope with the moment. She assured publicly not being comfortable addressing the news media because of her anxiety.

The 2020 (2021) Tokyo Olympics finds her bearing the torch for Japan to initiate the games, and she describes the moment as the ultimate honor she was given to. Many can also read on her face apprehension mixed with fear and happiness during this moment of glory.

Serena Williams and her sister Venus changed the world of tennis and repeated maybe what Wilma Rudolph had performed as the first Afro American woman to step successfully on a tennis court. The Williams sisters became the first pair of African American sisters to impose their tempo on woman tennis. Serena had a more successful carrier and a long reign as the top woman player in the world. She battled depression since her winning Wimbledon in 2010 and she revealed it to the public while being interviewed in 2011. She complicated her condition by sustaining a post-partum depression with the birth of her daughter in 2017.

Other athletes are not spared. A German goalkeeper is drafted to play for some big professional teams in Europe like Benfica and Barcelona and Borussia during the end of his career. Robert Enke played for his hometown with the team Carl Zeiss Jena. He finally went to Barcelona and fail to make the team and was traded to a second division Spanish team. He rapidly suffered than from Depression and may have recovered a little when he returned to Germany in 2004 with Hannover.

He was voted goalkeeper of the year 2005-2006 by a German Sport magazine but battled again a personal tragedy with the loss of his daughter in 2006. He continued his fight, kept playing and was nominated again for the goalkeeper award of the year for the season 2008-2009. Depression caught with him. A few months prior to the 2010 world Cup, he was on the national team rooster list ready to participate to the festivities. Unfortunately, he killed himself in front of a train on November, 10, 2oo9.

A NCAA survey on athletes found out that near 30% of athletes have reported feeling depression over the course of the year. We know already about Michael Phelps who has also admitted using drugs to self-medicate himself and contemplate suicide. He now uses his experience to helps others through the Michael Phelps Foundation and the Boys and Girls Clubs of America.

Imani Boyette, a professional basketball player experienced depression during her childhood after she was raped by a family member. She attempted suicide at the age of 10 but recovered and later on, she became a spoke person and a counselor for Sparks of Hope raising awareness of Mental Health in the African American community to help children survive abuse.

Another Olympic gold-medal winner battled depression and wrote her memoir in 2012: “In the water, they can’t see you cry”, describing her way of coping with anorexia, bulimia and drug abuse.

A former professional baseball pitcher, Justin Duchscherer was diagnosed with depression by the team physician in 2009 because of the pressure from the game and a divorce.

An Olympic swimmer Allison Schmitt battled with depression and contemplated suicide after losing her teenage cousin by suicide. This motivated her to reveal her illness and to raise mental health awareness. She is now a spoke woman who speaks at schools and events to educate people about mental illness.

An ex-NFL star Ricky Williams who become millionaire at the age of 23, was diagnosed with depression and social anxiety disorder. He voiced the way he felt isolated from his friends and family because he was unable to express his feelings.

We all knew the famous Jerry West as an NBA basketball legend but not too many heard about him battling depression since childhood. He tells his story of abuse he suffered from his father. He explained in his memoir “My Charmed, Tormented Life” the way he did not want to live. Once married, he eased the effects of depression and became the luckiest person in the world.

Ronda Rousey a WWE fighter, former UFC champion lost her belt and suffered from Depression and even contemplated suicide. Period lasted two years and she returned to the ring two years later with the help of her husband.

I can go on and keep providing examples of successful athletes who followed the same pathway. Exercises are often credited for combatting depression but it is not always true because if often it represent the solution, other time the solution can become the problem.

The British Journal of Sports Medicine reported that 25% of Division I athletes enrolled at one East Coast University reported symptoms of depression. 465 athletes were interviewed over the course of several years. Women were almost twice as likely to demonstrate signs of depression with more than 1/3 being female athletes performing in track and field discipline.

Athletes training for long-distance run marathon or triathlon and may not realize how much solo time they have on their hands with definitely less opportunity for social interaction.  Overtraining can cause some psychological changes driving the athlete toward depression. Often if you overdo it, your sleep may suffer, draining your autonomic nervous system which carry with it a hormonal imbalance affecting the mind and the body. The athlete needs to set realistic goals.

New allegations on Simone Biles are surfacing and the Olympic committee is investigating seriously the charges. She is facing a challenge because of new finding in her recent blood tests: an alarming high level of “Cannaboids” is present although she assets having never taken marijuana, substance prohibited. She explains the high level on her use of CBD (Cannabidiol) which is not a recreational drug or a performance enhancer but a natural product that help her calm her nerves and control her chronic pain.

Many will ask if that prime nature CBD is permitted in the Olympics? It is a natural remedy that Simone Biles has freely discussed with her teammates. The oil is regularly used by athletes to ease their pain but the Olympic committee may have reasons to ban the drug because it is clinically proven that the majority of athlete using it, are more focused. It is considered as a rejuvenating agent used by veteran athletes to relieve joint pain. The Olympic committee may decide that the substance CBD may provide the athlete with an unfair edge and may consider it as a “cheat”. CBD has been advertised as a miracle drug for chronic pain and anxiety with disappointing effects. Others may have found a medication stabilizing their life and allowing them to enjoy better working or sleeping conditions. Some state that it may also make you lose weight. We need to wait on the decision of the Olympic committee on her use of this substance.

We have already discussed what seems to trigger the depression in the athletes with the fear of disappointing a person or a public, the anxiety about a performance and the lack of emotional support. You definitely can enhance strength with the use of such a drug.

Unfortunately, athletes do not always look for professional help or assistance from coaches, counselors or mental health professionals for their problems. They want to appear invincible to their opponents. Many believe that the male athletes may have more the tendency of avoiding mental health help by fear of losing their manhood or their masculinity while the female athletes are more passive in accepting the depression. Others may  even think that being emotional represents a sign of weakness.

By increasing the awareness of depression in athletes, more parents, coaches and fellow athletes will find the opportunity to play a role in encouraging athletes to seek for help anytime they feel general fatigue, irrational irritability, loss of confidence, use of drugs, excessive drinking of alcohol or when suicidal thoughts are encountered.

On the night of January 17, 2014, a freshman track athlete at the University of Pennsylvania, Madison Holleran, jumped over the ninth-floor railing of a parking car garage and took his own life. A quarterback at Washington State, Tyler Hilinski shot himself in January 2018 because he was found to have a degenerative brain condition perhaps due to multiple head trauma.

It is important to understand that even the most accomplished athletes are not immune of depression. Mental health issues must be taken seriously and diagnosed properly so the best treatment can be offered through a mental health provider.

The dynamics involved in competitive sports, impose a feeling of pressure on the athletes for the love of the sport. Overtraining, fear of failure, lack of self-care, injuries, inability to compete, fear of success, joy and happiness, well-balanced diet, lack of social or emotional support, sleeping habits, relaxation etc. are as many components which can interfere with the well-being of an athlete.

It is important to recognize these factors enumerated above to avoid disturbing the training of an athlete. Such factors may trigger negative feelings among athletes, interfering with their will to perform in the best of their ability. I will invite you as well to review the AMHE Newsletters relating on Opioid and Marijuana as well as the one reviewing ADHD.

Maxime Coles MD

Boca Raton FL

References:

1-    “The influence of ADHD medication on physiologic processes and exercises”. www physiopedia.com (26 June 2021).

2-    Strachan, Maxwell (September 16, 2016) Simone Biles Proudly opens up about having ADHD”. Huffington Post Archived 25 October 25, 2016.

3-    “Most Dominant athlete of 2018 Simone Biles”. The Undefeated: December 11, 2018.

4-    AMHE Newsletters on Marijuana and ADHD published in the spring of 2018.

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