Beyond Mental Toughness: Understanding Mental Health in Elite Athletes

Psychological Health and Wellbeing
Written By Cat Hoh

The athlete who looks the most “locked in” may also be the one hiding the most.

Elite athletes are often viewed through the lens of discipline, resilience and performance. They train consistently, tolerate discomfort and learn to operate under pressure. Because of this, it can be easy to assume that mental toughness protects athletes from mental health challenges.

It does not.

Mental health symptoms and disorders are common in elite athletes, and they can affect wellbeing, training consistency, performance, recovery, relationships and long-term participation in sport. The International Olympic Committee’s 2019 consensus statement made this clear: mental health cannot be separated from physical health, and sport environments have a responsibility to recognise, respond and refer appropriately [1].

For coaches, this does not mean becoming a psychologist, counsellor or clinician. It means understanding the role they do play: noticing changes, reducing stigma, creating psychologically safer environments and helping athletes access appropriate support early [1,5,8].

Elite athletes are not immune

Elite sport can be protective in some ways. It can provide structure, purpose, social connection, identity and access to support services. However, it can also expose athletes to unique pressures, including selection uncertainty, injury, public scrutiny, performance expectations, body composition demands, travel, financial stress, transitions, retirement and fear of failure [1,3,7].

A systematic review and meta-analysis by Gouttebarge and colleagues found that mental health symptoms and disorders occur in both current and former elite athletes. Across current elite athletes, prevalence estimates ranged from 19% for alcohol misuse to 34% for anxiety/depression. In former elite athletes, estimates ranged from 16% for distress to 26% for anxiety/depression [2].

This matters because many athletes are good at continuing to perform while struggling. In some cases, the athlete who appears “fine” may be the athlete who has learned to mask distress the most effectively.

Why athletes may not ask for help

One of the biggest challenges in sport is not only whether athletes experience mental health symptoms, but whether they feel safe enough to speak up.

A systematic review on cultural influences and barriers to treatment identified several sport-specific issues that can prevent athletes from seeking help, including stigma, concerns around confidentiality, fear of deselection, gendered expectations and sporting cultures that normalise distress as part of being “tough” [5].

More recently, Cosh and colleagues found that the formal mental health help-seeking rate among athletes was 22.4%. Key barriers included team culture, selection concerns and confidentiality worries, while role models and normalised conversations around help-seeking could support better engagement [11].

This is where coaches can have a meaningful influence. The way a coach speaks about stress, failure, injury, body composition, pressure and support can either make help-seeking feel normal, or make it feel risky.

What coaches might notice

Coaches are often in a good position to notice change because they see athletes regularly and understand their usual training behaviours, communication style and mood.

The goal is not to diagnose.
The goal is to notice patterns and respond appropriately.

Possible changes include:

  • Mood and behaviour
    More withdrawn, irritable, flat, emotional, anxious or unusually reactive.

  • Training behaviour
    Sudden drop in motivation, avoidance, overtraining, poor recovery or repeated missed sessions.

  • Performance
    Unexplained inconsistency, difficulty concentrating, loss of confidence or increased fear of failure.

  • Body and fuelling behaviours
    Increased food anxiety, rigid eating rules, distress around body composition or sudden weight change.

  • Sleep and fatigue
    Persistent tiredness, low energy, poor concentration or repeated comments about not coping.

  • Social signs
    Pulling away from teammates, reduced communication, conflict or isolation.

  • Injury response
    Distress that seems disproportionate, hopelessness, identity loss or fear of returning.

Red flags that require urgent action

Some situations require immediate escalation rather than a casual check-in.

Urgent red flags may include an athlete talking about suicide, self-harm, feeling hopeless, being a burden, not wanting to be here, or showing behaviour that suggests immediate risk to themselves or others.

A coach should not try to manage acute risk alone. They should stay with the athlete where possible, involve the appropriate support person and follow the organisation’s safeguarding and emergency procedures.

Mental health, injury and performance are connected

Mental health can influence how an athlete trains, recovers, manages pain, responds to injury and handles pressure. Injury can also increase psychological stress, especially when an athlete’s identity is strongly tied to performance [1,7].

For coaches, mental health should not sit separately from performance planning. It should be considered within athlete support, load management, injury rehabilitation and return-to-play communication.

An athlete returning from injury may need more than physical progression. They may also need support rebuilding confidence, trust in their body, athletic identity and tolerance of uncertainty.

Body composition, fueling and REDs

Mental health also intersects with fueling, body image, low energy availability and Relative Energy Deficiency in Sport [12,13].

This is particularly relevant in athletics, where body composition can become a focus across endurance, jumping, sprinting and other weight-sensitive environments.

Coaches should be careful with language around weight, body shape and “leanness”. Even well-intended comments can reinforce harmful beliefs. A safer approach is to focus on fueling for adaptation, recovery, strength, health and availability to train.

Young athletes and the transition into elite sport

Mental health support is especially important for developing athletes. The transition into elite sport can increase pressure around selection, performance expectations, training load, public visibility, diet, sleep and lifestyle changes [14].

This is often when athletes learn what high performance “should” look like. If the environment normalises silence, overtraining, body dissatisfaction and fear, those patterns can become embedded.

Coaches should be mindful of:

  • Growth and maturation
    Physical development is uneven; comparison can be damaging.

  • Identity
    Athletes need roles and self-worth outside sport.

  • Selection pressure
    Clear communication can reduce uncertainty.

  • Load and recovery
    Sleep, school, social stress and training all interact.

  • Body comments
    Avoid casual comments about weight, shape or appearance.

  • Parent involvement
    Clear boundaries and referral processes are essential.

What actually helps?

Mental health support in sport should not rely on motivational quotes or telling athletes to be more resilient. Current evidence points toward structured systems, early identification, reduced stigma, access to qualified professionals and evidence-informed interventions [1,6,7,8,10,16].

For coaches, the practical takeaway is simple: you are not there to deliver therapy. You are there to help create a performance environment where support is accessible, normalised and integrated.

Practical checklist for coaches

Before the season starts, coaches and organisations should be able to answer the following:

YES = Maintain, communicate and review.
NO = Identify the gap, assign responsibility and create a safer process.

  1. Do athletes know who they can speak to if they are struggling?

  2. Do coaches know the referral pathway for mental health concerns?

  3. Is there a clear process for urgent risk or crisis situations?

  4. Are athletes told what information is confidential and what must be escalated?

  5. Are body composition, fueling and weight-related conversations handled by qualified professionals?

  6. Do coaches avoid using mental health language as criticism?

  7. Are training loads modified when athletes are not coping?

  8. Are injury and return-to-play plans considering psychological readiness?

  9. Are young athletes supported through selection, transition and identity challenges?

  10. Are coaches given education on recognising signs of distress?

Key takeaways

Mental health in elite sport is not separate from performance. It influences how athletes train, recover, adapt, communicate and stay in the sport [1,7].

Coaches do not need to diagnose.
They do need to notice.

They do not need to provide therapy.
They do need to know when and how to refer.

They do not need to remove pressure from sport entirely.
They do need to create environments where athletes can experience pressure without feeling unsafe, unsupported or disposable.

The strongest coaching cultures are not the ones that ignore mental health in the name of toughness. They are the ones that understand that sustainable performance depends on the whole athlete.

Resources, questionnaires and support contacts

These resources can help coaches and athletes recognise concerns earlier and connect with appropriate support.

They are not for coaches to diagnose. If there is concern, refer to a qualified health professional.

Sport-specific tools

IOC Sport Mental Health Recognition Tool 1 — SMHRT-1
For coaches, athletes, families and support staff to help recognise when an athlete may need mental health support.
https://www.olympics.com/athlete365/app/uploads/2021/06/BJSM-SMHRT-1-Athlete365-2020-102411.pdf

IOC Sport Mental Health Assessment Tool 1 — SMHAT-1
A more formal assessment tool for qualified health professionals.
https://bjsm.bmj.com/content/55/1/30

General screening tools

K10
Measures psychological distress.
https://aci.health.nsw.gov.au/__data/assets/pdf_file/0015/212901/Kessler_10_and_scoring.pdf

DASS-21
Screens symptoms of depression, anxiety and stress.
https://maic.qld.gov.au/wp-content/uploads/2016/07/DASS-21.pdf

PHQ-9 and GAD-7
Common screening tools for depression and anxiety, best used by health professionals.

Eating disorder, fuelling and REDs tools

EDE-Q
Screens eating disorder-related behaviours and concerns.
https://insideoutinstitute.org.au/resource-library/eating-disorder-examination-questionnaire-ede-q

LEAF-Q
Screens risk of low energy availability in female athletes.
https://pubmed.ncbi.nlm.nih.gov/24563388/

IOC REDs CAT2
Clinical tool for assessing REDs risk, intended for medical professionals.
https://bjsm.bmj.com/content/57/17/1109

Sport-specific support

AIS Mental Health Referral Network
Sport-specific mental health support for eligible athletes, coaches and high-performance staff.
https://www.ausport.gov.au/ais/MHRN

Australian Athletics Wellbeing Hub
Mental and emotional health resources for athletes, coaches and support people.
https://www.athletics.com.au/participant-hub/high-performance/wellbeing-hub/

R U OK? Sport resources
Conversation guides and resources for sporting environments.
https://www.ruok.org.au/sport

Mental Health First Aid Australia
Training for coaches, staff and community members.
https://www.mhfa.com.au/

Australian support contacts

Emergency: Triple Zero - 000

Lifeline:13 11 14
https://www.lifeline.org.au/

Beyond Blue:1300 22 4636
https://www.beyondblue.org.au/

Kids Helpline:1800 55 1800
https://kidshelpline.com.au/

Headspace:
https://headspace.org.au/

Butterfly Foundation:1800 33 4673
https://butterfly.org.au/

13YARN:13 92 76
https://www.13yarn.org.au/

References

  1. Reardon CL, Hainline B, Aron CM, Baron D, Baum AL, Bindra A, et al. Mental health in elite athletes: International Olympic Committee consensus statement. Br J Sports Med. 2019;53(11):667-699. doi:10.1136/bjsports-2019-100715. Available from: https://pubmed.ncbi.nlm.nih.gov/31097450/

  2. Gouttebarge V, Castaldelli-Maia JM, Gorczynski P, Hainline B, Hitchcock ME, Kerkhoffs GM, et al. Occurrence of mental health symptoms and disorders in current and former elite athletes: a systematic review and meta-analysis. Br J Sports Med. 2019;53(11):700-706. doi:10.1136/bjsports-2019-100671. Available from: https://pubmed.ncbi.nlm.nih.gov/31097451/

  3. Rice SM, Purcell R, De Silva S, Mawren D, McGorry PD, Parker AG. The mental health of elite athletes: a narrative systematic review. Sports Med. 2016;46(9):1333-1353. doi:10.1007/s40279-016-0492-2. Available from: https://pubmed.ncbi.nlm.nih.gov/26896951/

  4. Rice SM, Gwyther K, Santesteban-Echarri O, Baron D, Gorczynski P, Gouttebarge V, et al. Determinants of anxiety in elite athletes: a systematic review and meta-analysis. Br J Sports Med. 2019;53(11):722-730. doi:10.1136/bjsports-2019-100620. Available from: https://pubmed.ncbi.nlm.nih.gov/31097452/

  5. Castaldelli-Maia JM, Gallinaro JGME, Falcão RS, Gouttebarge V, Hitchcock ME, Hainline B, et al. Mental health symptoms and disorders in elite athletes: a systematic review on cultural influencers and barriers to athletes seeking treatment. Br J Sports Med. 2019;53(11):707-721. doi:10.1136/bjsports-2019-100710. Available from: https://pubmed.ncbi.nlm.nih.gov/31092400/

  6. Purcell R, Gwyther K, Rice SM. Mental health in elite athletes: increased awareness requires an early intervention framework to respond to athlete needs. Sports Med Open. 2019;5(1):46. doi:10.1186/s40798-019-0220-1. Available from: https://sportsmedicine-open.springeropen.com/articles/10.1186/s40798-019-0220-1

  7. Chang C, Putukian M, Aerni G, Diamond A, Hong G, Ingram Y, et al. Mental health issues and psychological factors in athletes: detection, management, effect on performance and prevention: American Medical Society for Sports Medicine Position Statement—Executive Summary. Br J Sports Med. 2020;54(4):216-220. doi:10.1136/bjsports-2019-101583. Available from: https://pubmed.ncbi.nlm.nih.gov/31810972/

  8. Gouttebarge V, Bindra A, Blauwet C, Campriani N, Currie A, Engebretsen L, et al. International Olympic Committee Sport Mental Health Assessment Tool 1 and Sport Mental Health Recognition Tool 1: towards better support of athletes’ mental health. Br J Sports Med. 2021;55(1):30-37. doi:10.1136/bjsports-2020-102411. Available from: https://bjsm.bmj.com/content/55/1/30

  9. Mountjoy M, Junge A, Bindra A, Blauwet C, Budgett R, Currie A, et al. Surveillance of athlete mental health symptoms and disorders: a supplement to the International Olympic Committee’s consensus statement on injury and illness surveillance. Br J Sports Med. 2023;57(21):1351-1360. doi:10.1136/bjsports-2022-106687. Available from: https://pubmed.ncbi.nlm.nih.gov/37468210/

  10. Myall K, Montero-Marin J, Gorczynski P, Kajee N, Syed Sheriff R, Bernard R, et al. Effect of mindfulness-based programmes on elite athlete mental health: a systematic review and meta-analysis. Br J Sports Med. 2023;57(2):99-108. doi:10.1136/bjsports-2022-105596. Available from: https://pubmed.ncbi.nlm.nih.gov/36223914/

  11. Cosh SM, McNeil DG, Jeffreys A, Clark L, Tully PJ. Athlete mental health help-seeking: a systematic review and meta-analysis of rates, barriers and facilitators. Psychol Sport Exerc. 2024;71:102586. doi:10.1016/j.psychsport.2023.102586. Available from: https://www.sciencedirect.com/science/article/pii/S1469029223002108

  12. Mountjoy M, Ackerman KE, Bailey DM, Burke LM, Constantini N, Hackney AC, et al. 2023 International Olympic Committee’s consensus statement on Relative Energy Deficiency in Sport. Br J Sports Med. 2023;57(17):1073-1097. doi:10.1136/bjsports-2023-106994. Available from: https://bjsm.bmj.com/content/57/17/1073

  13. Pensgaard AM, Sundgot-Borgen J, Edwards C, Jacobsen AU, Hill L, Wood A, et al. Intersection of mental health issues and Relative Energy Deficiency in Sport: a narrative review by a subgroup of the IOC consensus on REDs. Br J Sports Med. 2023;57(17):1127-1135. doi:10.1136/bjsports-2023-106985. Available from: https://pubmed.ncbi.nlm.nih.gov/37752005/

  14. Pilkington V, Rice S, Walton CC, Olive L, Butterworth M, Clements M, et al. Athlete mental health and wellbeing during the transition into elite sport: strategies to prepare the system. Sports Med Open. 2024;10:39. doi:10.1186/s40798-024-00690-z. Available from: https://pubmed.ncbi.nlm.nih.gov/38460048/

  15. Meidl V, Dallmann P, Steffen K, Bretthauer B, Busch A, Kubosch EJ, et al. Mental health surveillance in elite Para athletes: early identification and follow-up of athletes at risk of mental health problems. Br J Sports Med. 2024;58(16):902-909. doi:10.1136/bjsports-2023-107995. Available from: https://pubmed.ncbi.nlm.nih.gov/38950918/

  16. Wang W, Chow GM, Chen J, Chen Z, Si G. Psychological interventions to improve elite athlete mental wellbeing: a systematic review and meta-analysis. Sports Med. 2025;55:877-897. doi:10.1007/s40279-024-02173-3. Available from: https://pubmed.ncbi.nlm.nih.gov/39815135/

  17. Lifeline Australia. Crisis support. Lifeline Australia. Available from: https://www.lifeline.org.au/131114/

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Cat Hoh
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