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.

Mental toughness does not protect anyone from mental illness. Around a third of current elite athletes report symptoms of psychological distress, and only about a fifth of athletes who need professional help go and get it. Hold those two numbers next to each other and the coaching job comes into focus. It is not diagnosis, which coaches are not trained for and should not attempt. It is noticing what has changed in someone you see four times a week, and running a group where saying something out loud does not feel like handing over your selection card.

Toughness is not a shield

Elite sport gives athletes structure, purpose, a social group and, at the top end, medical and psychological support most people never get near. It also gives them selection uncertainty, injury, public scrutiny, weight-sensitive events, constant travel, thin money and a career that tends to end around thirty. The IOC's 2019 consensus statement put the position plainly: mental health cannot be separated from physical health, and sport organisations carry a duty to recognise, respond and refer.

The evidence behind that statement has since doubled. Gouttebarge and colleagues re-ran their meta-analysis in July 2026 ahead of the next IOC consensus, pooling 72 studies instead of the original 34, and adding coaches and support staff to the question for the first time.

Figure 01 / Interactive

How common this is, by who you ask

Group / tap to change

Current athletes Former athletes Coaches & staff

Distress 32.6%

Disordered eating 27.6%

Alcohol misuse 26.5%

Sleep disturbance 21.7%

Depression 18.3%

Anxiety 18.0%

Pooled across up to 10,927 current elite athletes. Every one of these is a self-reported symptom score above a questionnaire cut-off, not a clinical diagnosis.

Alcohol misuse 27.7%

Sleep disturbance 23.0%

Distress 20.0%

Depression 12.4%

Distress and depression fall after retirement. Sleep and alcohol do not. Both sit at or slightly above the in-career rate, which the authors did not expect.

5–53%depending on the symptom

Six studies, no pooled estimate, because there is not yet enough research to run one. The range across high-performance staff including coaches ran from 5% for depression and anxiety to 53% for alcohol misuse.

Among healthcare professionals working the Tokyo and Beijing Paralympics: 12% depression, 8% anxiety, and burnout between 36 and 58%.

Pooled prevalence of self-reported mental health symptoms, from Gouttebarge et al. (2026), 72 studies, 70 of them at low risk of bias. Read these as evidence of scale, not as a rate for your squad. Heterogeneity was extreme, above 95% for most estimates, so each figure summarises very different populations measured different ways. Most of the underlying research is on men in team sports, and most studies carried no general-population comparison group.

Two details in that data deserve more attention than they get.

The first is that retirement does not clear it. Distress and depression are lower in former athletes than current ones, which fits, given how much of the load is sport-specific. But sleep disturbance and alcohol misuse sit at the same level after a career as during one, and alcohol misuse is marginally higher. The authors say they expected the opposite, and offer two readings: drinking is culturally normal inside some sports, including in the off-season, and the transition out brings its own reasons to drink.

The second is sex. Among current athletes, distress ran 34.7% in women against 28.0% in men, anxiety 18.6% against 14.9%, and sleep disturbance 28.8% against 11.8%. Disordered eating ran 34.6% in women and 19.4% in men. Depression and alcohol misuse showed no significant difference. In athletics, where weight-sensitive events sit on both sides of the program, those gaps are worth holding before assuming the men's distance group is the one that needs less attention.

Why the athlete doesn't tell you

Prevalence is only half the problem. The other half is that the person carrying the symptoms has usually already decided not to say anything.

Cosh and colleagues pooled 11 studies covering 3,415 athletes and found that 22.4% had sought help from a mental health professional, with a confidence interval running from 16.2% to 30.2%. Rates were lower again in studies of team-sport athletes only. Their meta-synthesis of barriers turned up the same handful of blockers across sports, sexes and countries, and almost all of them are things a coach either reinforces or dismantles.

Figure 02 / Interactive

Roughly one in five asks. Tap a reason the other four don't.

22.4%sought professional help

Barrier / tap to change

It'll cost me selection Everyone will know Asking means I'm weak This is just how it is here

Fear of deselection. The athlete weighs disclosure against the team sheet. When the person they would tell is also the person who picks, the maths rarely favours telling.

What a coach controls: naming, out loud and in advance, that a wellbeing conversation is not a selection conversation, and identifying at least one person in the support network who has no say in selection at all.

Confidentiality. Squads are small. Physios are shared. Group chats exist. Athletes assume, often correctly, that private information travels.

What a coach controls: stating at the start of the season exactly who sees what, and exactly what you are obliged to escalate. Then holding to it, including when the information would be useful to you.

Stigma and athlete identity. Cosh's group found fear of looking weak and athlete identity behaving as almost the same barrier, because being an athlete is partly defined as being someone who copes.

What a coach controls: how you talk about other athletes who have sought help. One dismissive line about someone else's psychologist costs you disclosure from the whole group.

Team culture. Environments that treat distress as the price of the level. Help-seeking rates in the meta-regression were lower in team-sport athletes than in individual-sport athletes.

What a coach controls: whether "everyone's flat in week six" gets offered as reassurance or as a reason not to check. Role models and normalised conversation were the clearest facilitators in the review.

Pooled help-seeking rate and barrier themes from Cosh, McNeil, Jeffreys, Clark & Tully (2024), 22 studies, help-seeking rates from 11 of them. Heterogeneity was high, so read 22.4% as an order of magnitude rather than a precise figure. The same set of barriers appears in the IOC's review of cultural influencers and treatment barriers, which adds gendered expectations and cultures that treat distress as part of the job.

Fear of looking weak and athlete identity turned out to be one barrier wearing two names. Finding of Cosh et al., Psychology of Sport and Exercise, 2024

Most of that list is culture, and culture is downstream of what the head coach says on an ordinary Tuesday. That is uncomfortable, and it is also the good news, because it means the lever is sitting right there.

What noticing actually looks like

You are not looking for a diagnosis and you are not qualified to make one. You are looking for change against that athlete's own baseline, which you know better than any clinician will after a single appointment. Coaches see people three or four times a week, over years. That is the whole of the coach's advantage here, and it is a real one.

The changes worth attending to sit in a few places. Mood and manner: flatter, more irritable, more reactive, or pulling away from people they normally seek out. Training behaviour: motivation that drops off a cliff, sessions quietly avoided, or the opposite, an athlete who will not stop and will not recover. Performance: inconsistency nobody can account for, concentration that slips, confidence that does not come back after one bad meet. Sleep and energy: persistent tiredness, and repeated offhand comments about not coping. Food and body: new rigidity around eating, anxiety about fuelling, distress about body composition, or weight moving fast in either direction. Injury: a response out of proportion to the injury itself, hopelessness about coming back, or an athlete who has visibly lost the part of themselves the sport was holding.

None of these is diagnostic alone. Athletes are allowed to be flat on a Wednesday. The signal is the pattern that persists and the distance from who this person usually is. And the athlete who worries you least may deserve a look, because performing well and struggling badly are entirely compatible states, and the group most practised at operating under load is also the group most practised at hiding it.

One check-in finds almost nobody

Screening at the start of a campaign has become normal, and on its own it barely works. A German group put a number on how badly, and the number is worth sitting with.

Meidl and colleagues monitored 122 elite Para athletes with the PHQ-4 every week for 124 weeks, collecting 7,543 scores at a mean weekly response rate of 84%. Athletes whose scores stayed elevated across two consecutive weeks were contacted by a sports psychiatrist.

Figure 03 / Interactive

Same squad, same tool. One screen, or every week for two years.

Screening approach / tap to change

One screen Weekly, 124 weeks
Flagged by a single screen Only found by repeating it
6.7%of all scores were positive

Any given week, fewer than seven athletes in a hundred screened positive for symptoms of depression or anxiety. A single screen is a photograph of one Tuesday.

48.4%of athletes, at some point

Fifty-nine of the 122 athletes screened positive at least once across the two years. Nearly half the squad. The condition is episodic, so the timing of the question decides the answer.

124-week prospective cohort of 122 German elite Para athletes, 7,543 PHQ-4 scores, mean weekly response rate 84%, from Meidl et al. (2024). Dots are a schematic of the two figures, not individual athletes. One national Para squad using one four-item screening tool, so the exact percentages will not transfer. The structural point does: symptoms come and go, and a question asked once catches whoever happens to be unwell that week.

What happened next matters as much as the detection rate. Of the follow-up contacts made, 76.6% turned up at least one mental health problem, most often distress, then depressive symptoms, including one athlete in acute crisis. The stressors athletes named most were education and problems with the team, coaches or federation. A quarter of those followed up were already in psychiatric or psychological care. Another third were advised to start.

Note what that system is and is not. The PHQ-4 is a four-item filter, not a diagnosis, and a screen without a clinician attached to the other end of it is an administrative exercise. What made this work was the pairing: a low-cost repeated question, and a named professional who made contact when it flagged. Neither half does anything alone.

When it stops being a check-in

Some things are not a conversation to have at the track on Thursday. If an athlete talks about suicide or self-harm, describes feeling hopeless or trapped, says they are a burden or that people would be better off without them, or behaves in a way that suggests immediate risk, that is an escalation now, not a note for next week.

What a coach does at that point is short and specific. Stay with them if you can, and do not leave them to sort it out alone. Bring in the person your organisation has nominated for exactly this. Follow your safeguarding and emergency procedures. If the risk looks immediate, call 000. Do not attempt to manage acute risk yourself, and do not promise a confidentiality you cannot hold. Tell athletes the limits of confidentiality at the start of the season, before anyone needs them, because an athlete who discovers that boundary during a crisis experiences it as a betrayal.

Fuelling, bodies and the words you use

The 2023 IOC consensus on Relative Energy Deficiency in Sport and the narrative review sitting alongside it make the connection between low energy availability, disordered eating and mental health explicit rather than implied. The 2026 prevalence data puts disordered eating symptoms at 27.6% across current elite athletes, and 34.6% in women. In athletics, where leanness gets discussed as a performance variable across endurance, jumps and sprints, that is not a minor category.

The practical consequence is narrow and firm. Conversations about weight, body shape and body composition belong with qualified people, which means a sports dietitian and, where indicated, a clinician. Not because coaches do not care, but because the same sentence carries different weight coming from the person who picks the team. A comment intended as technical feedback can install a rule that outlasts the season, and often outlasts the career. Where a coach does have something useful to say, it is about fuelling for adaptation, recovery and availability to train, which is the frame that keeps the conversation about performance rather than appearance.

The step up is the sharp end

The transition into elite sport concentrates most of these risks at once. Pilkington and colleagues argue the target should be the system rather than the individual: prepare the environment the young athlete is walking into rather than only preparing the athlete.

That period is when athletes learn what high performance is supposed to look and feel like. If the environment they meet at seventeen treats silence as professionalism, overtraining as commitment, and body dissatisfaction as normal, those settings get installed early and hold. Growth and maturation are uneven at that age, so comparison inside a training group is unusually damaging. Selection uncertainty does more harm when the criteria are vague than when they are demanding. School, sleep, social life and training load all draw from the same account. And athletes need a workable identity outside the sport, which sounds like a soft point until an injury or a non-selection arrives and there is nothing else holding the person up.

What the treatment evidence can and can't carry

Ask what actually helps and the honest answer is that the intervention evidence is thinner than the prevalence evidence. Myall and colleagues pooled 12 trials of mindfulness-based programmes covering 613 athletes and found large effects for reducing anxiety and stress, with lower dropout from the programme arms than from controls. Encouraging, until you look at the construction: an average of 26 athletes per condition, heterogeneity around 90% for the anxiety estimate, and 75% of participants men.

Wang and colleagues reached a similarly hedged position on wellbeing interventions in 2025. Psychological skills training, third-wave approaches and positive psychology all look potentially effective, and the review calls openly for stronger experimental designs before anyone treats that as settled.

So the strongest evidence here is not about which programme to buy. It is about the structures around it: early identification, a referral pathway that exists before it is needed, reduced stigma, and access to qualified professionals. Those are organisational decisions, and they are cheaper than most of what a high-performance program already spends money on.

Ten questions to answer before the season

Every one of these is answerable with a yes or a no. A yes means maintain it, communicate it and review it. A no is not a failure, it is a gap with an owner and a date attached.

  1. Do athletes know, by name, who they can speak to if they are struggling?
  2. Do coaches know the referral pathway for a mental health concern, without having to look it up?
  3. Is there a written process for urgent risk, and does everyone who might need it know where it lives?
  4. Have athletes been told what stays confidential and what has to be escalated, before anything happened?
  5. Are body composition, fuelling and weight conversations handled by qualified professionals rather than by coaches?
  6. Is mental health language kept out of criticism, so that "soft" and "fragile" are not part of the feedback vocabulary?
  7. Are training loads actually modified when an athlete is not coping, or is that only theoretical?
  8. Do injury and return-to-play plans include psychological readiness alongside physical progression?
  9. Are young athletes supported through selection, transition and identity, rather than left to work it out?
  10. Have coaches been given education on recognising distress, and is anyone checking they got it?

One last thing, which the research raises and almost nobody in the system acts on. The 2026 review found alcohol misuse reaching 53% among high-performance staff, including coaches, and among healthcare professionals working the Tokyo and Beijing Paralympics, burnout between 36 and 58%, with 8% reporting thoughts of self-harm or suicide a few days a month. Nobody has run a meta-analysis on coaches yet, because there are not enough studies to pool. The referral pathway you build for your athletes is one you may end up needing yourself.

If you need support now

In an emergency, or if someone is at immediate risk, call 000.

Tools and sport-specific support

These help coaches and athletes recognise a concern earlier and connect with the right person. None of them is for a coach to diagnose with. If you are concerned, refer.

  • IOC Sport Mental Health Recognition Tool (SMHRT-1) for coaches, athletes, families and support staff. Download the tool
  • IOC Sport Mental Health Assessment Tool (SMHAT-1) for qualified health professionals. Read the paper
  • AIS Mental Health Referral Network sport-specific support for eligible athletes, coaches and high-performance staff. ausport.gov.au/ais/MHRN
  • Australian Athletics Wellbeing Hub resources for athletes, coaches and support people. athletics.com.au
  • R U OK? Sport conversation guides built for sporting environments. ruok.org.au/sport
  • Mental Health First Aid Australia training for coaches, staff and volunteers. mhfa.com.au

References

Cat Hoh
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