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The mental health burden athletes face
Why it matters, how it's been perpetuated, and ways to move forward...
Mental health and wellness 🧠 are as important to athlete performance as physical conditioning. Today’s athletic-industrial complex (from amateur teams to the professional leagues) is poorly set up to support these needs and is complicated by misaligned incentives between athletes and organizations in the time horizon of goals. It will take sustained and intentional effort to bridge these gaps and support the bodies and the brains of athletes of all ages 🙌🏽 .
Sports truly are the great American (and global) pastime. As two Midwesterners, sports are tantamount to religion ⛪️, and run through our veins. The sports industry is expected to reach nearly a half-trillion dollars globally this year (2023) - that’s some serious dough 💰👀. There’s nothing quite like making your way to a field to watch your kids play under the Friday night lights 🏈 , immersing yourself in the fantastic world of F1 racing with Netflix’s recent hit series Drive to Survive 🏎, or making your way to an NBA court to watch the best basketball player to ever walk the earth 👑 🏀. Athletes are idolized for their dedication to the craft and the game, and the intense physical training and preparation it takes to compete at the highest levels (for personal, team, or country pride).
However, what is often missed in all of the above is the mental aspect of sports and performance. Every now and then, we think about the role the brain plays in an athlete’s performance (for example, when star athletes take devastating hits on the field 😢 and we see the consequences of brain trauma play out in front of us, or when Olympic stars tell their stories about struggling with psychiatric disease and their journeys to finding care). But too often, these conversations and discourses are short-lived, and while they make an impact in the lives of some, they inevitably fade into the background. But not for everyone.
There are a group of folks around the world who have dedicated their professional careers not only to taking care of diseases of the brain, but also to specifically doing so for athletes. They are doing the work daily to help athletes optimize their mental wellness and well-being, not as an adjunct to physical performance but as a requirement in unlocking it 🔑. In this piece, we want to shed light on just why this connection is so critical and uncover some of the barriers athletes face in addressing mental health concerns and how these barriers impact athletes’ abilities to make prudent and informed decisions about their futures.
We’re excited to have Dr. Kim Quigley and Dr. Neevon Esmaili join us on this piece. Dr. Quigley is a fellow psychiatrist, former co-worker, and friend. She is an entrepreneur and sports psychiatry expert and currently scaling a company that builds custom mental health support solutions for athletic organizations and teams, from high schools to the professional leagues. Dr. Esmaili is also a fellow psychiatrist (fellowship trained in Child and Adolescent Psychiatry), a current co-worker, and friend. He has a well-established Sports Psychiatry practice in Los Angeles and works with athletes across the age spectrum (from children to adults).
Athletes’ mental wellness is as important as (or even more important than) their physical conditioning
Mental wellness and well-being are just as important as (if not more important than) physical conditioning 🏋🏽 when it comes to athletic performance. Performing at a high level involves awareness of one's emotional state and the ability to adapt to negative emotional states; several research articles (see here and here) describe the mental aspect of sports.
Athletes must possess an awareness 💭 of how they emotionally react to competitive environments of different stages and intensities. This awareness can include identifying thought patterns, physical reactions (such as rapid breathing 🫁 or increased heart rate 🫀), or a subjective sense of anxiety. Once this awareness is present, the process of honing mental skills can begin. Knowledge of stressful situations that lead to typical reactions can aid the athlete in creating a coping plan to optimize performance in the moment. One useful framework developed by sports psychologist Ken Ravizza et al. utilizes the 7 Rs; frameworks like this ought to be table stakes for all young athletes:
Responsibility (knowing that the athlete has control over their emotions and behaviors)
Recognizing variables that impact performance
Releasing factors that impact negatively (i.e., ‘let it go’)
Regrouping (centering once more)
Refocusing (find a new focus that will aid performance; focus on the process, not the outcome)
Ready (take a deep breath and hone in on the plan)
Responding (muscle memory and less thinking)
Beyond mental wellness, un(der)treated psychiatric disease can also impair performance. For example, untreated OCD can cause rituals to take up training time. PTSD left unchecked can cause an athlete to not participate in rehabilitation after a sport-related injury. Performance-related social anxiety can cause distress levels to spike and impair athletes during competition. Eating disorders and the resulting medical consequences (e.g., low BMI, low electrolyte levels, or cardiac injury) can have serious consequences → reduced energy and focus during play. These are just a few examples underscoring why the treatment of psychiatric symptoms is critical to preserve athletic functioning.
Children who participate in sports tend to enjoy mental health benefits such as higher self-esteem and an improved sense of well-being stemming from socialization and physical activity. However, they also invariably face competitive situations they may not be emotionally equipped to handle. The sports culture of hypermasculinity, mental strength, and avoidance of signs of weakness creates a significant stigma against reporting mental health concerns and seeking treatment among athletes.
What happens when athletes need more mental health support?
Many aspects of the mental health journey, from the detection of symptoms to referral to treatment, are suboptimal within the structures of athletic departments or sports teams. ‘Be mentally strong.’ ‘Play like a Champion Today.’ Athletes are inundated with the idea that a mentally strong 💪🏽 athlete is preferred and that a lack of mental strength is a personal failure. Words like grit, resilience, and toughness are painted on walls in every locker room in the country, and these concepts have been ingrained across the age spectrum, from youth leagues to the professional ranks.
The dark side of espousing mental toughness as an ideal to young athletes, and now financially rewarding it, is that these athletes are programmed to not even recognize when they are slipping emotionally. Athletes regularly delay their physical and emotional needs - hunger, pain, exhaustion, etc. - for their sport's sake. Often, they will not self-detect problems until symptoms reach a severe level. And even if / when they realize that they need help, stigma and hesitation on the part of athletes prevent accessing care (even if provided in-house by the team, school, or league).
From the 2021 NCAA Student-Athlete Wellbeing Study, ‘Two-thirds of student-athletes indicated knowing where to go on campus for mental health concerns, and a majority (56%) reported knowing how to help a teammate experiencing a mental health issue. However, fewer than half (47%) felt they would be comfortable personally seeking support from a mental health provider on campus.’ Let that last bit sink in… This leaves staff (such as athletic trainers and assistant coaches) in the challenging position of looking for behavioral clues 🔎 to burgeoning mental illness. Many times, these non-clinical team members lack the knowledge or experience of how to deal with mental health issues (not only in identifying them but also in helping athletes navigate accessing treatment).
And even when a staff member detects an issue, there is often no place to turn. Counseling and Psychiatric Services on college campuses have long wait times ⏱ and few ex-athletes as clinicians, reducing the odds of meaningful engagement with athletes seeking care. These campus centers operate during daytime hours, which is often not pragmatic for college athletes (former college athletes will attest to the rigorous training and academic schedules they endure). Clinicians alike have hesitation to even care for these athletes, who are often relatively sicker when they start treatment. Further, clinicians often worry they will feel pressure to violate HIPAA 🤫 (by team officials, athletic department staff, coaches, or boosters) when they do start treatment.
Professional teams often have ‘Sports Performance’ professionals on staff, who aim to bolster the mental game in the name of winning. Sports Performance is not psychiatry. Very few, if any, professional teams or leagues provide their athletes with timely, unbiased access to psychiatric care. The delivery system of mental health to athletes is further complicated by liability and financial incentives that organizationally do not align with the goals an athlete may have personally (long-term athletic success and commensurate financial reward).
How misaligned incentives impact athlete decision-making…
This brings us to ‘informed consent.’ Many of you probably associate that word with surgery and assessing patients’ capacity to make decisions. Many clinician readers have probably even over-consulted 😬 your friendly inpatient psychiatrist to do a capacity assessment for your patient’s ability to provide informed consent (it’s ok, we forgive you, and will continue to make you tag along while we assess your patient for capacity 😉). However, we propose that the concept of informed consent is very valuable outside of the clinical context whenever an important decision is being made. For example, we talk about informed consent when teaching residents and fellows in the context of choosing what to do after training (before deciding to pursue a particular clinical job or path, consider all the alternatives and their associated pros and cons).
Applying this same concept to athletes, the concept of informed consent should be baked into the decision-making process when athletes (and their families in the case of student-athletes) are assessing return to play from injury. This came to the forefront of public discourse over the summer with the case of Miami Dolphins Quarterback Tua Tagovailoa (though we in the sports psychiatry world have been thinking of such concepts for years). In such a case (an NFL player suffering one, then two, then three concussions), it’s critical for the athlete to make a fully informed decision to return to play.
It’s clear that there are misaligned incentives between the many interested parties (including professional teams, professional leagues, coaching staffs, and league/team-sponsored clinicians) and the athlete themself. This likely manifests itself most glaringly from the perspective of time horizon: leagues / teams / coaching staffs / team clinicians / team owners all have primarily short-term measures of success (and associated financial rewards). They want to win a championship 🏆 this year, achieve great ratings 📈 this year, sell lots of tickets 🎟 this year, etc. On the other hand, the time horizon of an individual athlete’s incentives is much longer. Now don’t get us wrong, while there are no doubt short-term incentives, longevity is much more important to the athlete than to other stakeholders (both from a financial perspective and a legacy/achievement perspective - it allows for ‘more shots on goal’ and opportunities to achieve greatness).
Taking this into account, we propose that athletes should have better access to information about the risks, benefits, and alternatives (informed consent - sound familiar?) when considering the impact of injury and the timeline to return. And we are specifically talking about neuropsychiatric conditions here. It’s not too difficult to consider the risks, benefits, and alternatives to treating and returning from a fractured bone 🦴 - this information is freely available (thanks to a lack of stigma and a better understanding of orthopedic injuries by athletes and stakeholders). However, considering the impact of a concussion / brain injury, or un(der)treated depressive or anxiety disorders is a much more opaque process, and one in which we are convinced athletes must engage their own resources and advocate on their own behalf.
What does this look like? For professional athletes who have access to financial resources, perhaps it means independent medical consultants (particularly neurologists / psychiatrists) to help them consider the risks, benefits, and alternatives to returning to a game in the moment (? is there a business to be started providing real-time, expert, remote consultation to athletes on the field during game day). These consultants would be fully aligned with the interests of the athlete because they would be paid 💵 by the athlete. Remember - incentives matter, and even though nobody would suggest that physician behavior is impacted by who is paying them…(actually, we would say that clinician behavior is impacted by who is paying them, even if on a subconscious level - don’t kid yourself and think otherwise).
Side note: A great example of athletes supporting one another in making informed decisions about returning to play from injury occurred this past week when RGIII tweeted 🐦 in response to the controversy around Lamar Jackson sitting out a playoff game. Yes, Lamar’s decision may have ultimately impacted his team’s ability to progress in the playoffs this year, but he’s the only one looking out for his long-term prospects and should be empowered to make the risk / benefit decision himself. Bravo 👏🏽.
Where do we go from here?
We hope that it’s now clear (if it wasn’t already) that mental wellness and performance are not just nice-to-haves but must-haves when thinking about what it takes to be a high-performing athlete. And not only are they requirements, but they are also components that our current society and organizational structures (amateur teams, higher education athletic departments, and professional leagues) are poorly set up to deliver. That’s not to say that teams, leagues, and schools aren’t making real efforts and strides in supporting the mental health of their athletes. There is no doubt that awareness of the above has increased exponentially over the last 2-3 years, and there are some specific examples of models to be replicated (for example, the MLS Chicago Fire’s PASS program to arm its athletes with tools to build resilience and also resources to access care when necessary).
It is likely a combination of stigma, misaligned incentives, and poor information sharing that has resulted in the creation of an environment in which mental wellness is not taken as seriously (or resourced as heavily) as physical health. It will take continued and intentional efforts (some of which re already underway) to shift the conversation and bias. We owe it to athletes at every level of play to continue having these discussions 🗣, impress upon these institutions why these are important, and empower athletes and their loved ones with knowledge so they can continue to be advocates on their own journeys to greatness. So next time you’re out at a ballgame ⚾️, furiously refreshing your fantasy football matchup, or yelling at the TV to will your team to a win, take a moment to reflect on the unfair compromises athletes are often expected to make with regard to their health for the sake of other stakeholders, and the role we all play in perpetuating (and potentially mitigating) these patterns.
We want your suggestions on how to better equip athletes with information, access to high-quality care, and better alignment of incentives with the organizations they play for. What do you think can move the needle on athlete mental health?
If you’re an athlete: what have some of your experiences been when it comes to accessing mental health support (the good, bad, and ugly)? Feel free to contact us directly if you don’t want to share publicly; we can aggregate and anonymize.
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