Mental Health and Well-Being in Athletes

In recent years, athlete mental health has received a growing amount of attention in academic research as well as in the media. Whether due to the tragic losses of athletes who have died by suicide, or an increasing appreciation of the ways that psychological factors influence overall health and performance for athletes, public awareness around athlete mental health has grown dramatically. As we have emerged from the COVID-19 pandemic, we recognize the significant impact that the past few years have had on the mental health and quality of life in young athletes. For example, in May 2020, shortly after the universal cancelation of school and sports, a survey of over 13,000 adolescent athletes around the country found that nearly 40% were reporting moderate to severe levels of anxiety and/or depression. ⁸ A year later, a follow-up study found that athletes who had returned to sports reported significantly improved mental health but continued to report higher levels of depression than had been identified before the onset of the pandemic. ¹¹

Previous research has identified the important benefits of physical activity for mental health across a broad range of patient populations, but the benefits of organized sports may extend beyond this for children. Sport participation has been associated with reduced substance misuse and risk-taking behavior, higher levels of academic success, and even greater lifelong financial success. Nonetheless, athletes may experience certain risk factors that their nonathlete counterparts do not, and psychosocial factors may significantly impact the risk of a variety of performance and health outcomes. In this special issue, we present original research and extensive reviews regarding athlete mental health and the ways that mental health and well-being interact with injuries and athlete development. These topics include:

• Youth athlete mental health

• Psychosocial predictors of injury and injury outcomes

• Specialization and burnout in young athletes

• Psychosocial predictors of athletic success

• Implications of Name, Image and Likeness rights in student-athletes

• Mental health consequences of concussions

• Substance use in young athletes

• Mindfulness in athletes

Walton et al ¹⁰ set the stage with a scoping review of mental health in elite youth athletes. They not only present a developmental framework for understanding mental health in this population, but also highlight some of the unique factors that can affect the mental health of elite young athletes, including the influences of parents, peers, and coaches, as well as organizational and societal factors. Building upon this, Biese and colleagues present data showing the impact of sports on mental health during the pandemic. ¹ Specifically, they demonstrate that mental health was dramatically better among adolescent athletes who had returned to sports in May 2021 than those who had not. They also suggest that certain populations of athletes may be disproportionately impacted by the loss of sports, as adolescents athletes from areas of lower household income and athletes who identified as belonging to a racial or ethnic minority group reported significantly worse anxiety and depression when unable to return to sports than those from areas of higher household income or who did not identify as part of a racial or ethnic minority group. Finally, they found that the increased physical activity among those who had returned to sports only explained around 20% to 25% of the mental health and quality of life benefits.

We also present multiple manuscripts regarding the interaction between psychosocial factors and injury outcomes in young athletes. Joachim et al ⁶ present a prospective study of the association between injury and sleep, fatigue, and stress in adolescent cross country runners. Interestingly, while they did not identify an association between week-to-week fluctuations in these factors and injury, they did identify a significant interaction between stress and sex with respect to injury, suggesting that the relationship between stress and injury risk among high school runners may be different for boys and girls. The role of psychosocial factors on anterior cruciate ligament recovery has also received increased attention recently, and Momaya et al ⁹ present a thorough review of the ways in which factors like fear of reinjury, self-efficacy, and social support can influence both return to play and reinjury risk following anterior cruciate ligament reconstruction.

Concussions remain a pervasive problem in youth sports. Utilizing a prospective registry of >3000 children with concussion, Master et al ⁷ report that patients with a history of mental health diagnoses reported significantly more emotional and visiovestibular symptoms postconcussion, as well as a prolonged recovery time.

Substance use is also an enormous problem in American society, and we provide 2 reviews of substance use in young athletes. Benoy et al ³ provide a narrative review of cannabis use among youth and young adult athletes, providing relevant information regarding the prevalence of use, risk factors for use, and the available evidence regarding the influence on performance. We follow this with a narrative review of opioid use among athletes. Benjamin et al ² similarly report the prevalence of opioid use among young athletes, as well as the relevant indications for use, risks related to misuse, and areas of necessary future research.

Last, we present evidence around the potential role of mindfulness in athletics. Haraldsdottir et al ⁵ evaluated the associations between mindfulness practice and well-being and injury in National Collegiate Athletic Association Division I female volleyball players. They found both increased well-being and a reduced incidence of injury on days following a reported mindfulness session, suggesting that mindfulness could be a useful way to address well-being in athletes directly, and perhaps reduce injury risk through improvements in stress, mood, fatigue, or sleep. Finally, Brenner ⁴ provides a truly unique clinical commentary on the development and implementation of mindfulness within a pediatric sports medicine practice that provides valuable insight into the delivery of this intervention to young athletes.

This special issue attempts to highlight both the current state of mental health issues among youth athletes, as well as the cutting-edge research being done to better understand at-risk groups, the interaction between psychological factor and a broad range of health outcomes, and the emerging efforts to intervene to help youth athlete well-being and mental health. Mental health touches every way that we interact with young athletes, and has significant impacts on a broad range of health and performance outcomes. We hope that this issue will help to inform sports medicine clinicians across a broad range of topics and aid in their care of the young athlete.

—Andrew M. Watson, MD, MS
Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health