Purcell et al. Sports Medicine - Open(2019) 5:46
https://doi.org/10.1186/s40798-019-0220-1

CURRENT OPINION

Open Access

Mental Health In Elite Athletes: Increased
Awareness Requires An Early Intervention
Framework to Respond to Athlete Needs
Rosemary Purcell1,2, Kate Gwyther1,2 and Simon M. Rice1,2*Abstract
The current ‘state of play’ in supporting elite athlete mental health and wellbeing has centred mostly on building mental
health literacy or awareness of the signs of mental ill-health amongst athletes. Such awareness is necessary, but not
sufficient to address the varied mental health needs of elite athletes. We call for a new model of intervention and outline
the backbone of a comprehensive mental health framework to promote athlete mental health and wellbeing, and respondto the needs of athletes who are at-risk of developing, or already experiencing mental health symptoms or disorders. Early
detection of, and intervention for, mental health symptoms is essential in the elite sporting context. Such approaches help
build cultures that acknowledge that an athlete’s mental health needs are as important as their physical health needs, andthat both are likely to contribute to optimising the athlete’s overall wellbeing in conjunction with performance excellence.
The proposed framework aims at (i) helping athletes develop a range of self-management skills that they can utilise to
manage psychological distress, (ii) equipping key stakeholders in the elite sporting environment (such as coaches, sports
medicine and high-performance support staff) to better recognise and respond to concerns regarding an athlete’s mental
health and (iii) highlighting the need for specialist multi-disciplinary teams or skilled mental health professionals to manage
athletes with severe or complex mental disorders. Combined, these components ensure that elite athletes receive theintervention and support that they need at the right time, in the right place, with the right person.

Key Points
 Currently, there is no comprehensive framework ormodel of care to support and respond to the mental
health needs of elite athletes.
 We propose a framework that recognises the impactof general and athlete-specific risk factors, and engages key individuals that may identify and promoteathlete mental health.
 The framework is adaptable and responsive to varied
career stages and mental health states.
There has been a rapid increase in research examining
the mental health of elite athletes culminating with the* Correspondence: simon.rice@unimelb.edu.au1
Orygen, The National Centre of Excellence in Youth Mental Health, 35
Poplar Road, Parkville, Melbourne, Victoria 3052, Australia
2
Centre for Youth Mental Health, University of Melbourne, Melbourne,
Victoria, Australia

International Olympic Committee’s (IOC’s) recent Expert
Consensus Statement on mental health in elite athletes [1].
This statement provides a comprehensive analysis of, andrecommendations for, the treatment of both high prevalence (e.g. anxiety and mood symptoms) and more complex
mental health disorders (e.g. eating and bipolar disorders)in the elite sporting context. This is a timely resource which
will help guide and ultimately improve the clinical management of athletes by sports medicine, mental health, andallied health professionals. The primary focus of the consensus statement, along with much of the extant literature,is on managing the individual athlete affected by mental illhealth. There has been little scholarly and service-level attention to more comprehensive frameworks that (a) recognise the role of the broader elite sports ecology as both acontributor to athlete mental health difficulties and a facilitator of their remediation, and (b) approaches that emphasise the prevention of mental health symptoms, along withearly detection and intervention to restore athlete wellbeing(and ideally optimise performance).

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made.

Purcell et al. Sports Medicine - Open(2019) 5:46

Risk Factors for Mental Ill-health in Elite AthletesMeta-analytic reviews indicate that elite athletes experience broadly comparable rates of mental ill-health relative
to the general population in relation to anxiety, depression, post-traumatic stress and sleep disorders [2, 3]. Thisshould not be unexpected given the considerable overlap
in the years of active elite competition and the primaryages of onset for most mental disorders [4–6].
Increasing evidence points to a range of both athletespecific and general risk factors associated with mental
ill-health in elite athletes. Athlete-specific risk indicators
include sports-related injury and concussion [3, 7–9],
performance failure [10], overtraining (and overtraining
syndrome) [11] and sport type (e.g. individual sports
conferring a higher risk that team sports) [12]. Generalrisk indicators include major negative life events [13,14], low social support [15, 16] and impaired sleep [17,18]. These risk factors may impact the severity and onsetof particular mental health symptoms, but can also guide
appropriate response strategies.
The salience of particular risk factors may vary acrosscareer phases. For example, in junior development years,
supportive relationships with parents and coaches areimperative to athlete wellbeing [19, 20]. During the highperformance and elite phase, in addition to the coaching
relationship, environmental and training demands become more relevant to mental health and wellbeing [21],including extended travel away from home and exposure
to unfamiliar (training) environments [22]. Environmental
conditions and travel may be especially salient for the mental health of para-athletes, who often encounter disruptive
logistical issues associated with travel, such as a lack ofadaptive sport facilities and sleeping conditions [23]. Prominent risk factors during the transition out of sport include
involuntary or unplanned retirement and lack of a nonathletic identity, both of which are associated with a rangeof psychological challenges [24]. For para-athletes, involuntary retirement due to declassification (i.e. no longer meeting the required criteria to be classified as a para-athlete) isa unique burden [25].
Optimising the Mental Health and Wellbeing of
Elite Athletes: Barriers and Facilitators
A comprehensive framework for mental health in elite
athletes needs to consider the range of relevant risk factors across key career phases, as well as factors that inhibit or facilitate the ability to effectively respond toathletes’ needs. Key barriers include more negative attitudes towards help-seeking amongst athletes than thegeneral population [26], as well as greater stigma andpoorer mental health literacy. Fear of the consequencesof seeking help (e.g. loss of selection) and lack of time
are also influential [26–28]. Facilitative factors include
support and acknowledgment from coaches [27] who

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can help to create a non-stigmatised environment where
help-seeking can be normalised [28]. Approaches that
seek to optimise athletic performance while simultaneously providing intervention for mental health symptoms may also facilitate engagement [29, 30]. Brief antistigma interventions and mental health literacy programs that seek to increase knowledge of mental healthsymptoms have been shown to improve help-seeking intentions in elite athletes [31–33], although the impact ofsuch programs on help-seeking behaviours is not known.

Are there Existing Frameworks or Models of Carefor Mental Health in Elite Sport?
To date there are no published frameworks regarding
how best to support the mental health needs of elite athletes. In addition to the IOC Consensus Statement, recent position statements have emphasised the need tobuild awareness of mental health problems and increase
help-seeking behaviours [34–36]. These initiatives areunquestionably warranted; however, improving awareness and help-seeking behaviours are at best pointless,and at worst unsafe, if systems of care to respond to athlete’s need are not available. A whole of system approachneeds to be developed simultaneously.
Beyond the peer-reviewed literature, useful guidelines
exist within selected sporting associations regarding supporting athlete wellbeing [37–39]. These resources highlight a number of critical factors in managing athlete
mental health in the sporting context including (i) the
sports’ responsibility for managing the athlete’s care andsupport (e.g. duty of care issues); (ii) the need for regular
screening or monitoring of athletes to detect changes inmental state or behaviour; (iii) privacy and confidentiality
regarding mental health as key ethical issues and challenges; (iv) athlete preferences for help-seeking (how andfrom whom); (v) the need to refer out to or engage external mental health professionals where expertise does notexist within the sporting environment; and (vi) the valueof trained peer workers (former athletes/players) to provide support and guidance to athletes and to coordinate
activities related to professional development needs (suchas public speaking or financial planning) and individual
goal-setting (e.g. around educational or post-sport vocational interests). However, no single framework incorporates all of these factors nor is there a framework that
focuses on the spectrum of athlete/player mental healthneeds, from symptom prevention to specialist mental
health care. There has been some progress in developing
mental health guidelines in collegiate-level athletes [40–42], which highlight the need to provide specific andtargeted support, while noting that few comprehensive or
targeted models of care for mental health have been developed for this population.

Purcell et al. Sports Medicine - Open(2019) 5:46

Developing a Comprehensive Mental Health
Framework to Support Elite Athletes
Many of the general and athlete-specific risk factors formental ill-health are potentially modifiable (e.g. coping
strategies, coaching style, training demands) and requireintervention at the individual athlete, the sporting or environmental and/or organisational levels. A comprehensive
framework for athlete mental health that is conceptualised
within the broader ‘ecology’ of elite sporting environments
will be best able to respond to the range of risk indicatorsin this context (see Fig. 1). Ecological systems help to explain the relationship between the aspects or experiencesof an individual (termed ‘ontogenetic’ factors, such as coping or substance use) and the broader social and culturalcontexts in which they exist [43]. In the case of elite athletes, this includes the ‘microsystem’ of coach(es), teammates (where appropriate) and family/loved ones. The
wider sporting environment (e.g. the athlete’s sport, its
rules and governing body) forms the exosystem, while therole of national and international sporting bodies and the
media and broader society form the macrosystem.
Any mental health framework that ignores wider ecological factors runs the risk of focusing exclusively on,
and potentially pathologising the individual athlete,
when other factors may be more influential in contributing to, or perpetuating poor mental health. Such factors
may include maladaptive relationships with coaches orparents, social media abuse and/or financial pressures.
In addition to ecological factors, a comprehensive framework for mental health should encompass both prevention
and early intervention, consistent with established models
that are influential in public health and social policy (e.g.
Haggerty and Mrazek’s mental health promotion spectrum[44]; see Fig. 2). An early intervention framework can optimise athlete mental wellbeing and respond rapidly to

Fig 1. An ecological systems model for elite athlete mental healthPage 3 of 8

mental health symptoms and disorders as they emerge tobest maintain the athlete’s overall function.
Within this framework, the prevention stages aim to reduce the risk of mental health symptoms developing or tominimise their potential impact and severity; the treatment and early intervention stages seek to identify andhalt the progression of emerging mental health difficulties;
and the continuing care stages help an individual to recover and prevent relapse, typically through ongoing clinical care with a mental health professional [44].
Based on the extant literature regarding risk factors formental ill-health in elite athletes, along with existing sporting guidelines or statements regarding athlete wellbeing,
and our experience developing and implementing earlyintervention services and system reform for young people’s mental health [45–47], we propose the following
framework to respond to the mental health of elite athletes (see Fig. 3).
Preventative or ‘Foundational’ Components

Core foundational components should include (i) mental
health literacy to improve understanding, reduce stigma andpromote early help-seeking; (ii) a focus on athlete development (both career and personal development goals) and skill
acquisition to help attain these goals; and (iii) mental healthscreening of, and feedback to, athletes. The purpose of thesefoundational components is to enhance awareness of the importance of athlete wellbeing across the elite sport ‘ecology’.
This in turn addresses workplace duty of care and occupational health and safety responsibilities towards athletes’
overall wellbeing in the context of sport-related stressors.
Mental Health Literacy

Mental health literacy programs should be provided toathletes, coaches and high-performance support staff toPurcell et al. Sports Medicine - Open(2019) 5:46

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Fig 2. The mental health promotion spectrum

help to create a culture that values enhancing the mental
health and wellbeing of all stakeholders. Programs
should also be offered to the athlete’s family or friends
to build their capacity to identify symptoms and encourage help-seeking, particularly as these are the individuals
from whom athletes will initially seek help and support [48,49]. Engaging an array of individuals, including organisational staff, in these programs broadens the reach of mental
health literacy within an athlete’s (or sport’s) ecology (seeFig. 1). Gulliver and colleagues effectively trialled theFig 3. Elite athlete mental health and wellbeing framework

delivery of a mental health literacy program to elite athletes
via team-based workshops facilitated by mental health professionals [26]. This delivery method is preferred given theopportunity for qualified facilitators to discuss and explore
athlete questions or concerns (especially regarding confidentiality and the implications of help-seeking for selection)and to potentially problem-solve together. The content ofsuch training should be customised to address the specificaspects of the sport (e.g. team-based versus individual
sport) and developmental stages (e.g. junior versus retiring

Purcell et al. Sports Medicine - Open(2019) 5:46

athletes). Basic program content should cover (i) athletespecific and general risk factors that can increase susceptibility to mental ill-health; (ii) key signs or symptoms of impaired wellbeing; (iii) how and from whom to seek help,
both within and outside the sport; and (iv) basic techniques
for athletes to self-manage transient mood states or psychological distress, such as relaxation techniques, adaptive coping strategies, self-compassion and mindfulness.
Individually Focused Development Programs

Individually focused development programs can assist
athletes to identify personal/vocational goals and acquire
the skills necessary to achieve them. This is necessary tohelp develop a parallel non-athletic identity, the skills tomanage life-sport balance and to prepare for the eventual end of competitive sport. The latter may be challenging in younger athletes who often lack the longer-term
perspective or life experience to perceive the need forsuch planning. However, a focus on developing a nonathletic identity must occur at all phases of the sporting
career and not be confined to the transition out of sport
phase, since building such skills takes time (and athletes
are prone to unplanned retirement due to injury). These
activities are ideally facilitated by a skilled, well-trained‘peer workforce’. These are individuals who have a lived
experience of mental ill-health and sufficient training toshare their knowledge to help support others in similar
situations [50]. In the sporting context, a peer workforce
could include former athletes or coaches who work withcurrent athletes to discuss and normalise experiences ofmental health symptoms or their risk factors. Former
athletes can assist with athlete development programs
and mobilise athletes to the importance of actively participating with such programs, based on their own experiences [39].
Mental Health Screening

Mental health screening should be included alongsideroutine physical health checks by medical staff as part ofa comprehensive framework. Screening items should besensitive to the elite context [50, 51] and should be designed to provide feedback to athletes to help promote
improved self-awareness, such as their mental state andtriggers for symptoms. Critical times to screen are following severe injury (including concussion) and during
the transition into, and out of sport [1], and the lead-up
to and post major competitions may also be periods ofhigher risk. It is important to note that there is currently
a lack of widely validated athlete-specific screening tools,
though one elite athlete sensitised screening measure—
the Athlete Psychological Strain Questionnaire—hasbeen validated in a large sample of male elite athletes
reporting strong psychometric properties [52], and isunder further validation with female and junior athletes.

Page 5 of 8

Research potential exists to not only develop further
athlete-specific measures, but to determine who is best
suited to conduct screening, and what credentials or
training may be required to ensure safety and integrityin this process (e.g. that appropriate help or referral isprovided to athletes who screen positive).
Indicated (‘at-risk’) Prevention Programs

The second phase is indicated prevention programs for
those considered or assessed as being ‘at-risk’ of impaired mental health and wellbeing. This phase aims to
mitigate the likelihood of deterioration in mental healthby detecting symptoms as early as possible and facilitating referral to appropriate health professionals. Key staff
within the sports system can be assisted to develop skills
in early symptom identification and to promote professional help-seeking. This includes coaches, athletic
trainers and teammates (where appropriate) who are ina position to notice ‘micro’ changes in an athlete overdays or weeks, and sports medicine staff, such as physiotherapists who may detect other non-observable signs,
such as changes in energy or body tension. We term
these individuals ‘navigators’ in the mental health framework, as they have a crucial role in observing the athlete’s behaviour or mental state and being able to linkthem to professional care. These navigators can be provided with additional training (adjunctive to mental
health literacy) to better recognise and interpret the athlete’s behaviour in relation to their overall wellbeing,
understand athlete privacy concerns that inhibit thedisclosure of mental health symptoms and build selfefficacy to be able to raise their concerns safely with theaffected athlete or medical/mental health staff.
Sport administrators should also consider developing
guides on ‘what to do if concerned about an athlete’s mental wellbeing’ and make these available to all relevant staff.
These should include information regarding appropriate
referral sources, responses (e.g. prevention program vs.
early intervention) and facilitators to engage athletes, suchas support and encouragement [27, 28] and/or linking
mental wellbeing with athletic performance [29, 30]. Protocols or guides for responding to mental health concerns
become less stigmatised when wellbeing needs are alreadyroutinely promoted via foundational programs.
Early Intervention

Early intervention is necessary in instances where the performance and life demands placed on an athlete exceed
their ability to cope (i.e. major career-threatening injury or
significant life stress). Structured clinical interventions for
mild to moderate mental ill-health are typically indicatedat this phase and should ideally be provided ‘in-house’ bymental health clinicians, such as sports or clinical psychologists or psychiatrists, or medical staff where appropriate

Purcell et al. Sports Medicine - Open(2019) 5:46

(e.g. pharmacotherapy). The use of in-house professionals
helps to counter the low levels of service use associatedwith referring athletes out to external service providers
and the stigma that is associated with the athlete needing
expert ‘outside help’ [53]. Where requisite in-house expertise does not exist, this can be managed by the use ofqualified consultants, but ideally these professionals
should be ‘embedded’ to some extent within the sporting
environment to ensure that athletes and other staff
understand ‘who they are and what their role is’, even
if their presence is infrequent [54]. When referral out
is necessary, or preferred by the athlete, ideally thisshould be to a mental health professional with appropriate sport sensitised training, knowledge and experience assisting elite athletes.
Early interventions need not always be face-to-face, but
can be augmented by telephone or web-enabled consultations, the latter particularly relevant given the frequency
with which elite athletes travel unaccompanied by the
sporting entourage. All interventions, regardless of themode of delivery, should use an individualised care approach that is based on assessment and conceptualisationof the individual athlete’s presenting problem(s). The intervention should target the psychological processes of theathlete that are impeding mental health [55] and take account of the specific familial, sporting and organisational issues that may be impacting on the athlete’s wellbeing.
An example of an early intervention model of care is
the Australian Institute of Sport (AIS) mental health referral network [56]. Athletes are assessed by an AIS
mental health advisor, who can make a referral, if necessary, to a qualified mental health practitioner who has
been credentialed to work within the network. This
practitioner then works individually with the athlete toaddress their needs and ideally restore their mental
health and functioning [57].
Specialist Mental Health Care

Despite best efforts to prevent or intervene early, someathletes will nonetheless experience severe or complex
psychopathology requiring specialist mental health care,particularly where there is a risk of harm to self or others.
In some cases, this may include hospitalisation or specialist inpatient or day programs. The IOC Expert Consensus
Statement provides a summary of recommended clinicalinterventions for a range of mental disorders, including bipolar, psychotic, eating and depressive disorders, and suicidality [1]. Developing and implementing a mental healthemergency plan may also be required, particularly in cases
where an athlete presents with an acute disturbance intheir mental state, for instance agitation/paranoia, or suicidal ideation [58]. The IOC Expert Consensus Statement
recommends that structured plans should acknowledge
and define what constitutes a mental health emergency,

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identify which personnel (or local emergency services) arecontacted and when, and consider relevant mental healthlegislation [1].
There is also arguably a need for ‘return to sport or training’ guidance for athletes who have been unable to compete
or train for their sport due to mental illness, akin to guidelines for managing concussion [59]. Such guidance could
potentially provide a graduated, step-by-step protocol that
prepares not only the athlete for a successful return tosport, but also the microsystem that supports them.

Conclusions
We have proposed a comprehensive framework for elite
athlete mental health. More research is needed to bolster
the efficacy of the approaches discussed here in the elitesports context, as well as other factors that are underresearched in the literature, such as gender-specific considerations in mental health [60] and considerations forpara-athletes [23]. We are mindful that coaches andother high-performance staff are vulnerable to mental
health problems [61] and the needs of these individuals
need to be incorporated into a more inclusive model ofcare. Further, we recognise the scope of this framework
does not cover the needs of non-elite athletes. Elementsof this framework may be tailored in the future to be applicable and contextualised for non-elite environments
where there may be limited resources, less professional
staffing and greater limitations in athlete schedules.
Despite the exponential increase in research interest
related to athlete mental wellbeing, major service delivery and treatment gaps remain. Evaluating the efficacy ofmental health prevention and intervention programs via
controlled trials or other high-quality designs is urgently
needed. Program evaluation should ideally adopt an ecological systems approach to account for competitionrelated, individual-vulnerability and organisational factors on mental health outcomes, for example by seeking
to measure system-level variables (e.g. the degree of perceived psychological safety within the sporting organisation [62, 63]) and individual athlete-level variables (e.g.
coping skills, relationship with coach, injury history). As
initiatives are evaluated and enhanced or adapted, developers should consult with elite sport organisations andindividuals to ensure the relevance and sport sensitivityof their programs. Increased resources and researchfunding to support the evaluation and implementationof athlete mental health programs is needed, such as
currently exists for managing athletes’ physical health(e.g. musculoskeletal injuries, concussion).
Finally, we are acutely aware that a framework such asthat articulated here requires substantial investment andthat such funding is scant even in high income settings.
The foundational and at-risk components lend themselves, we believe, to be adaptable to low resource settings,

Purcell et al. Sports Medicine - Open(2019) 5:46

given the emphasis on athlete self-management and a
trained peer workforce. Adaptations to providing earlyintervention in low resource settings will be needed, andinnovations in general mental health can act as a blueprint[64]. Regardless of settings or resources, investment in acomprehensive response to athlete mental health needs attention if it is to ever gain parity with physical health.
Abbreviations
IOC: International Olympic Committee; AIS: Australian Institute of Sport
Acknowledgements
Not applicable.
Authors’ Contributions
RP and SMR made substantial contributions to the conception of themanuscript. RP, KG and SMR drafted, revised and approved the final version.
Funding
Simon M Rice was supported by a Career Development Fellowship(APP115888) from the National Health and Medical Research Council.
Availability of Data and Materials
Not applicable.
Ethics Approval and Consent to Participate
Not applicable.
Consent for Publication
Not applicable.
Competing Interests
The authors, Rosemary Purcell, Kate Gwyther, and Simon M. Rice, declare thatthey have no competing interests relevant to the content of this article.
Received: 7 July 2019 Accepted: 9 October 2019

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