Brief history

Mental illness and the stigma attached to those suffering from its affects have been part of human existence throughout history.1 Despite efforts to bring more awareness to the causation and effective treatment of mental health issues, this stigma persists both socially and in the athletic culture. Long established beliefs have proven to be as challenging to change as many of the other discriminatory practices receiving media attention, political dialogue and legal debate (eg, race, gender, religion, sexual orientation, gay marriage, immigration, legalisation of recreational drugs). Although these other issues have their own set of challenges that inhibit healthy social change, a thread of historical stereotyping is common to all of them, including mental health.

Prevalence of mental health issues

The US Department of Health and Services (USDHS) reported in 2012 that 1 in 5 adults (20%) experience a mental health issue each year.2 USDHS also reported that rate increased to 30% in the age group 18–25 years, yet less than one-third of those in this age group received treatment. This age range encompasses many athletes in high school, collegiate and professional athletics.

Sport culture regarding mental health

The stigma attached to athlete mental health issues are driven by many factors including:

• Social history;

• Sport organisations motivated to be profitable;

• People within those organisations who are driven to be successful;

• Individual athletes who are expected to be successful by a parent, relatives, sport organisations and people within those organisations;

• Financial gain or loss for all involved;

• A multitude of media outlets that glorify those who succeed and are critical of those who fail.

These all fuel an additional expectation for athletes who have been championed to be ‘mentally tough’. Mental toughness and mental health are seen as contradictory terms in the world of elite performance. Sports culture has been slow to respond to athletes seeking psychological treatment. Seeking help may expose an athlete to risks of losing playing time, their starting role or even their contract to compete. Therefore, the incentives to ask for help and potentially get better are essentially outweighed by the negative consequences of appearing mentally weak.

The life an elite athlete is not easy. The pressure to perform on demand, injuries and the stress of feeling overloaded are part of sport. However, today's athletes face a different set of stressors than athletes in previous generations. The differences are seen in a growing number of complex and more intense mental health challenges. These include, but are not limited to, mental health issues beginning at earlier ages, a wider range of mental health issues, athletes being channelled into specific sports at younger ages, a change in sport and life demands, young athletes with fewer psychological coping skills, rule changes by the National Collegiate Athletic Association (NCAA) and professional sport that permit recruiting young athletes at an earlier age, and often a decreased emphasis on young athletes independently and effectively resolving their own life issues or expectations to be an active participant in resolving their mental health issues. Unidentified or ignored mental health issues that began in the earlier ages become more evident when athletes are faced with the stressors associated with elite sport.

Changing sport culture

Sport continues to primarily focus on improving the competitive ‘hardware’ (physiology and biomechanics) of young athletes to the exclusion of developing their healthy ‘software’ (mental health and performance psychology).3 The challenge is to close the gap between where we are—focusing on ‘hardware’ and where we need to be—focusing on both ‘hardware’ and ‘software’.

From personal and professional experience, I see growing organisational support for addressing athlete mental health and performance psychology. These efforts include (1) college athletic departments, USA Olympic Committee, US Olympic Governing Bodies and professional sport organisations are hiring more full-time mental health professionals who are embedded within the organisations and working directly with athletes, coaches, other support staff and administrators, (2) the National Association of Athletic Trainers has published a consensus4 that addresses the growing concern for mental health issues in athletes and provides recommendations for development in this area, and (3) the NCAA published Mind, Body and Sport5 identifying the need for college athletic departments to address this growing concern and also providing guidelines for implementing a dedicated response to assist student-athletes.

We need to ensure a new norm—an environment where athletes are free to ask for help, without negative consequences and receive that assistance from expert mental health professionals. When that happens, a new and healthier culture will replace the existing one where athletes and mental health issues are ignored, hidden or discarded.