Introduction
Research involving elite athletes (EA), high-performance coaches (HPC) and mental health has increased in the last 10 years, especially regarding EA. However, most research on mental ill health in elite sport has been conducted by screening presumingly healthy populations of EA,1 presenting symptoms of psychiatric disorders with the use of questionnaires, and not on clinical cohorts of EA or HPC with psychiatric disorders assessed by a licensed caregiver according to the International Statistical Classification of Diseases and Related Health Problems version 10 (ICD-10).2 3
In Sweden, 17.2% of the general population experienced clinical levels of depression and 10.8% of the general population experienced clinical levels of anxiety in 2013, and of those, nearly 50% had symptoms of a comorbid psychiatric disorder.4 Furthermore, 5.2% of the Swedish population had at least one contact with specialised psychiatric care and a psychiatric medical record in 2020,5 and in Stockholm, 16.5% of the population used some form of psychiatric service in 2017.6
From a lifetime perspective, a longitudinal cohort study following individuals in New Zeeland from birth to age 45 years over time using three versions of the Diagnostic and Statistical Manual of Mental Disorders for diagnosis (versions 3–5) found that 86% were diagnosed with at least one psychiatric disorder7 and only 17% had enduring mental health,8 indicating that episodes of psychiatric disorders may be more the norm than the exception.
EA are as vulnerable to psychiatric disorders in sport as the general population.2 9 The female over-representation for many psychiatric disorders is also present among EA and includes, for example, affective, anxiety and eating disorders.10 11 The prevalence of HPC is unknown.3 For EA, specific risk factors include injury and overtraining, sport-related stressors and stigma towards help-seeking. Generic risk factors also apply to EA and HPC, such as genetics, low social support, poor general health, ineffective coping, history of violence and/or abuse and maladaptive personality traits.2 11–13 Compared with EA, HPC are usually older, and females are under-represented. For HPC, sport-related risk factors include performance-related pressure, job insecurity, excessive workload, feelings of isolation and challenges connected to work-life balance.3 14 15
In Sweden, 8.1% of EA (at the national team level) reported a lifetime prevalence of psychiatric disorders (females 10.7%, males 4.4%). Most common were depressive disorders, eating disorders and stress-related disorders.16 In France, all EA undergo annual psychiatric evaluations, and 16.9% had at least one ongoing or recent psychiatric disorder (females 20.2%, males 15.1%).17 A prospective study (12 months) with Dutch EA found symptoms of psychiatric disorders, that is, reaching the established clinical cut-off using validated questionnaires but without a psychiatric evaluation by a licensed caregiver, ranging from 6% for adverse alcohol use to 57% for symptoms of anxiety/depression.9
Regarding specific diagnoses, eating disorders are over-represented among EA18 19 and substance use disorders may be more prevalent than in the normal population.20 Most research that targets mental health among HPC has addressed coaching stress and/or burnout,3 but anecdotal reports of harmful alcohol use have also been reported.21
To our knowledge, no study has evaluated psychiatric disorders and comorbidity among EA or HPC in psychiatric outpatient treatment. Therefore, this study describes comorbidities between psychiatric disorders and clinical characteristics among EA and HPC in a consecutive clinical cohort.