“It was fun. Yes, it was,” he says. In fact, he loves the sport so much, he hasn’t stopped playing since, except for when he’s been injured. For Terry, the best part of playing was having fun hanging out with friends and learning more about the sport, he says. But Terry, a rising college senior at Kennesaw State University in Georgia, admits that being a football player has had its rough patches. In high school, he was part of a multistate champion football program. “Everything was serious — workouts, practice, and training even outside team workouts,” says Terry. “It was really serious, and I wasn’t progressing on the field as much as I hoped for or would have liked to. Football wasn’t necessarily fun anymore.” Terry felt during that rough stretch that football wasn’t the safe haven it had once been for him. At one point, Terry says, the sport felt more like a job than the sport he fell in love with as a kid. For Terry, being on such a competitive football team exacerbated his depression, a mental health condition he’d been diagnosed with in middle school after his parents divorced. “My struggles with football didn’t help that much mentally,” he says. “If I didn’t do well with sports, then I would be sadder, and it would add to my depression.” His family also moved around a lot, which worsened his depression, too. “I didn’t fit in too much,” says Terry. “I just felt really alone.” Terry says he first began having thoughts of suicide in middle school. And when he started high school and football became increasingly stressful, Terry experienced suicidal thoughts again. He didn’t tell anyone, however, because he thought it would ruin his chances of becoming the professional football player he dreamed of being. He felt he had to keep his mental health struggles secret. “Having a mental health disorder is stigmatizing,” says Terry. “Athletes have to be tough, and things can’t bother you because you have to be so ingrained in your sport. That’s why I didn’t want to tell anyone. I didn’t want to alarm anyone, so people were used to seeing me as a happy-go-lucky person who was always smiling and joking around. “You would never know [I had thoughts of suicide] because I looked so happy,” he adds.
A Wide-Ranging Problem
Research shows that participation in team sports can offer several mental health benefits to kids and teens, including reduced anxiety, depression, and attention problems, according to a study with more than 11,000 participants published in June 2022 in PLoS One. Participation in sports teams is also tied to better mental health in adulthood among kids affected by adverse events during childhood, such as domestic or sexual abuse, separation or divorce of their parents, or having a parent in jail, per a study published in May 2019 in JAMA Pediatrics. The study included nearly 10,000 participants who were in grades 7 to 12 when the study began and were ages 24 to 32 when the study ended. So where did things go wrong for Terry and other young athletes like him? Experts believe that the challenges of elite and high-level competition sports in particular can play a role in causing or worsening depression, anxiety, and suicidal ideation among young adults and even adolescents. “There is a big debate about youth sports specialization and professionalization, where adolescent and younger athletes are asked to practice and play in a manner similar to professionals,” says Ashwin L. Rao, MD, a sports medicine physician in Seattle and the team physician for University of Washington Athletics. “This can lead to injury and burnout, and many young athletes can be turned off to this level of stress, and hence sport, at a young age. These effects and impacts are still being studied,” adds Dr. Rao. In fact, researchers are just beginning to get a handle on how pervasive mental health struggles are among elite teen and young adult athletes, says Rao, who adds that many previous studies have been focused on older adults. An analysis of multiple scientific studies of mental health disorders among elite athletes, including young adults, published in June 2019 in the British Journal of Sports Medicine, found that the prevalence of mental health issues among the athletes ranged from 19 percent for alcohol misuse to 34 percent for anxiety and depression. Currently, experts believe this prevalence is similar to that of the general population, but more research is needed to know for sure. And while suicide is the second leading cause of death for all youth ages 10 to 14 and adults ages 25 to 34, according to the Suicide Prevention Resource Center, suicide among young teen athletes has not been well studied, says Rao. Suicidal thoughts and behaviors among young elite athletes are currently believed to be similar to those of the general population. One study of Swedish elite athletes, published in the British Journal of Sports Medicine in February 2021, showed that 17.4 percent of male and 14.2 percent of female athletes experienced suicidal thoughts — a rate similar to that of the general population. Participants were an average age of 29. Another study, published in September 2015 in Sports Health: A Multidisciplinary Approach, found that suicides accounted for 7.3 percent of all student-athlete deaths that occurred in the National Collegiate Athletic Association (NCAA) between the 2003–2004 season and the 2011–2012 season.
What Is It About Elite Sports That Can Cause or Worsen Mental Health Issues?
While team sports have been shown to be very beneficial for mental health in kids, teens, and young adults, the pressures of high-level and elite competition sports in particular can compound with other issues, such as the preexisting depression Terry had, performance pressure from parents, teachers, and peers to succeed academically and athletically, perfectionism, and unrealistic goals. Unchecked, these stressors can be dangerous and lead athletes to think they are failures if they feel they don’t meet others’ or their own expectations. Worst of all, they often won’t share how these pressures are destroying them. “If you ask an athlete if they’re depressed, we think they’re going to try to give you an answer you want to hear,” warns Eugene Hong, MD , the chief physician executive with Medical University of South Carolina (MUSC) Physicians and MUSC Health, and a professor of orthopedics and family medicine at MUSC in Mount Pleasant, South Carolina. He formerly served as the team physician for athletes in all major sports at Drexel University, Philadelphia University, and Saint Joseph’s University in Philadelphia. One reason? Many young athletes fear that if they speak up about having mental health problems, they won’t get playing time and might not get the same opportunities as if they hadn’t admitted these struggles, says Dr. Hong. This is especially problematic because athletes have unique risk factors for depression, Hong says. They risk injury every time they play, and those injuries can take them out of the game temporarily or be career-ending, causing them to feel isolated. “We all have aspects of self-identity, but the concept of athletic self-identity is very important,” says Hong. In fact, some athletes’ toughest moments may be when they leave the sport, either voluntarily or due to injury. The aforementioned analysis published in the British Journal of Sports Medicine found that 16 percent of former athletes had feelings of distress, and 26 percent of athletes had anxiety and depression. Terry’s darkest moments came when he tore his meniscus and needed knee surgery, as well as when he injured his hip. “One of the hardest things I ever had to do was watch people I know and people in general play football and everyone giving them their props while I sat at home and watched it on TV and social media,” Terry explains. “It hurt me so much. I didn’t even really want to watch college football very much or go to any of my university’s football games because of the mental toll it would take on me. As time went along, I learned to deal with it better, but it still hurt.” Another reason experts say high school and college athletes struggle with mental health issues is the time demands of being a student athlete. “A Division 1 college athlete might spend 40 hours a week on their sport on top of their academics. The time pressure alone can be overwhelming,” says Hong. What’s more, the environment in which athletes live and compete is very complex because of the internal and external pressures they face every day. “Athletes have a complicated, high-performance mindset and have high expectations of themselves because of their abilities,” says the gold medal–winning Paralympic athlete Cheri Blauwet, MD, who is now a sports medicine physician at Brigham and Women’s Hospital in Boston and Spaulding Rehabilitation Hospital in Charlestown, Massachusetts. “That in and of itself makes it difficult for athletes to have self-empathy. So, they may struggle for some time and not seek or receive the help they need,” Dr. Blauwet adds.
High-Profile Elite Athletes Struggle, Too
The aforementioned statistics are borne out by a series of recent events. Katie Meyer, 22, a soccer goalie at Stanford University, died by suicide in March 2022. The combined pressure of school and sports, along with a fear of potential disciplinary action from school over an incident on campus, may have contributed to her suicide, according to Today. About a month later, the James Madison University (JMU) softball star Lauren Bernett, 20, died by suicide. She had just been named Colonial Athletic Association Player of the Week , according to JMU. This cluster of recent high-profile athlete suicides might have resulted from suicide contagion, a phenomenon in which direct or indirect exposure to a suicide can result in an increase in suicides, or copycat deaths, says Rao. Experts believe athletes are less likely to die by suicide than nonathletes, Rao wrote in an invited commentary published in the December 2021 issue of Current Sports Medicine Reports. Nevertheless, experts say these athletes’ untimely deaths highlight the need to screen high school and college athletes, as well as Olympic athletes, for mental health issues using suicide-specific screening tools. “It is my belief that, as a care network for athletes, we need to do better as a whole in screening our athletes for depression, anxiety, and suicidality,” says Rao. “What is clear is that just asking about depression and anxiety is not enough. We must ask about suicidal thoughts, plans, and intent as well.” In fact, some high-profile athletes are leading by example by coming out from the shroud of secrecy surrounding their mental health struggles. In May 2021, the professional tennis player Naomi Osaka withdrew from the French Open because she had been struggling with depression and anxiety. Just a couple of months later, in July 2021, the Olympic gymnast Simone Biles pulled out of several events at the rescheduled Tokyo 2020 Olympics because of ongoing mental health issues.
Osaka and Biles Inspired a Young Athlete to Put Her Mental Health First
Biles’s and Osaka’s striking actions reverberated throughout the athletic world and beyond. Kai McClelland, 18, of Apex, North Carolina, a rising sophomore Division 3 cross-country runner at Trinity University in San Antonio, Texas, has struggled with anxiety and depression for most of her life. Like Biles and Osaka, McClelland ultimately took a leave from her sport to care for her mental health. McClelland’s mental health issues began in high school, where the pressures of balancing her academics and a competitive sport rattled her to the core. “I was in a really competitive high school,” says McClelland. “There was a lot of pressure to succeed and take advanced placement (AP) classes and no regular classes. “Anytime there were factors outside my control or [things] got complicated, I didn’t have coping strategies to figure out what to do,” McClelland adds. “I was freaking out. Asking for help felt like admitting weakness.” By the end of 10th grade, McClelland had begun to have panic attacks and unexplained vomiting, to the point where she couldn’t keep any food down and eventually needed to be hospitalized. Doctors said her condition was related to stress, leading McClelland to decide she needed some time away from her sport. “I always feared people would see my temporary struggles as permanent,” McClelland says. “[Biles and Osaka] showed that mental health is worth taking a break for. You can prioritize yourself over your sports performance in order to have future successes both in your life and in your sport.”
How Do We Stop the Pattern?
“On the one hand, athletes are so resilient and do incredible things. On the other hand, athletes are so fragile and we need to take care of them,” says Emily Clark, PsyD, a licensed clinical psychologist and the associate director of mental health services for the United States Olympic and Paralympic Committee in Colorado Springs, Colorado. The good news? Research shows that evidence-based treatment for mental health works: Medication and psychotherapy can help people manage and improve symptoms of various mental health conditions, including depression and anxiety. But experts say we need to change our approach to keeping athletes and everyone else mentally healthy. Because many athletes still don’t know that they can — and should — seek help, they miss out on early intervention and potentially even prevention, says Dr. Clark. “We need to normalize mental illness or [mental] struggle, to allow athletes to feel comfortable seeking and receiving help,” says Rao. Clark has very specific ways of helping her athletes avoid long-term mental health issues. The United States Olympic and Paralympic Committee now uses two recently developed mental health recognition tools, which are short-answer questions to help them assess whether the 4,500 athletes they regularly work with are at risk for or already experiencing mental health issues. The athletes also attend educational programs to help them understand and become aware of mental health issues so they can learn to recognize the signs and symptoms and know when they need to seek help, ideally before a crisis. For instance, Clark says she helps athletes learn to differentiate the signs and symptoms of clinical anxiety from ordinary, everyday anxiety, because sometimes it can be normal for athletes to feel sadness or fatigue. “The goal isn’t to make sure no one ever struggles,” Clark explains. “If you’re alive on this planet long enough, you’re going to run into obstacles and you’re going to have to deal with grief and loss. So, it’s our goal to make sure people know when they’re struggling. That’s the mental health literacy piece.” Clark also works hard to destigmatize mental health struggles and help-seeking among her athletes by building trust with them. “I want them to know they can access care without telling me, and I don’t want there to be bottlenecks,” Clark adds. “My goal here is to decrease barriers to access and increase points of access. I want them to feel empowered.” The athletes’ coaches, as well as staff, are trained in Mental Health First Aid, a national program that teaches people how to identify, understand, and respond to signs of mental health and substance abuse challenges. College athletic programs across the country are adopting a lot of the same strategies because many athletes share similar mindsets. “In general, there are studies that point to providers’ lack of comfort in addressing mental health, so providers who care for amateur, competitive, and pro athletes must be willing to ask and utilize validated screening tools,” says Rao. At the University of Washington in particular, Rao adds, athletes have access to resources including psychologists, social workers, physicians, coaches, and trainers, some of whom have advanced skills to help athletes struggling with mental health issues and an awareness of the need to care for athletes’ bodies and minds. “I’m proud of them for coming forth if they have a concern because it will enable us to help toward a better mental health outcome for them,” Rao says.
Prevention Needs to Start at a Young Age
Research shows that children who participate in team sports often experience several mental health benefits, including a lower risk of anxiety and depression. But to be competitive, many parents are trying to get their children into sports earlier and earlier and are looking for their child to specialize in one sport, says Bradley Donohue, PhD, a distinguished professor of clinical psychology at the University of Nevada in Las Vegas. That’s not always a good idea, experts say. “If you have one particular goal in one area of life and something happens, like you get an injury or something else happens that is out of your control and it doesn’t work out, then because your focus was so extreme and everything was riding on that, it can lead to a mental health problem,” says Dr. Donohue. To cut that risk, he says, it’s best to engage younger, grade-school children in different sports or club sports, as long as they are not taking a lot of trips focused on the sport itself. Sports team travel can be problematic, Donohue says. “Then they don’t really have much of an opportunity to develop social skills and intimacy in ways that a typical child does,” he says. Children need to “spread out and have multiple identities beyond sports, so if something doesn’t pan out, they don’t have all the anxiety associated with that,” says Donohue. He also says parents shouldn’t just praise a child’s accomplishments in sports. “An optimal program in sports should focus on all things, including mental wellness and strength and stability and physical health and relationships,” says Donohue. Of course, parents are very important in modeling sportsmanship for their children, and they shouldn’t just be bystanders in the bleachers at their kids’ sporting events. Parents should be “thoughtful and proactive” with their child’s involvement in sports, says the child and adolescent psychiatrist Patrice Harris, MD, MA, FAPA, the 2020–2021 president of the American Medical Association and the chief health and medical editor for Everyday Health. Some examples of how to do so:
Match your child’s needs, desires, and skill sets with a sport that can nurture them.Attend practices and look at the way the coach, the team, and your child are interacting with each other. It’s important to find a team, coach, or sport that matches your child’s personality.See for yourself if your child is really enjoying the sport, and continuously monitor that.Talk to your child about the sport. Ask them if things are going well, and give them permission to tell you when things are not going well.Garner a circle of support around your child — it could be you, a friend, or other parents.Allow failure. No one is good at everything or is immediately good when just beginning a sport. It’s important to teach your child that failure and disappointment are a part of life.Monitor your own behavior at games and practices. Model behavior you would expect from your child.
From Secrecy to Speaking Out: How Terry Bounced Back
Terry’s life began turning around once he confided in his college coaches about his depression. “They worked with me on it. They told me if I had to go home and see my therapist that it was okay,” says Terry. “I got the sense that they understood or had an idea of what I was going through mentally. “What also helped me get out of my funk and helped me deal with my mental health struggles was leaning on my faith, seeing a therapist, and connecting with other athletes and regular people dealing with the same mental health struggles and hearing their mental health stories,” says Terry, adding that he journals about his struggles online for Medium. Terry has also found it rewarding to coach fifth and sixth graders, as well as high school kids, in football. “I try to be a role model by showing good character, hard work, and leadership,” he says. “I also want them to know I care about them beyond their sport.” These days, Terry says he’s successfully managing his mental health challenges. He says he wishes he had told people around him about his mental health struggles sooner. “It would have made more of a difference,” Terry says. “It’s okay to not be okay, and it’s okay to reach out for help,” he adds. The National Suicide Prevention Lifeline is available 24 hours a day, seven days a week at the number 988 as of July 16, 2022. You can also text HOME to 741741 for free crisis counseling.
