Despite apparent advances throughout the last decade with many high-profile athletes speaking openly about their personal struggles with mental health, the topic remains a veritable “hot potato” that major sports organizations seemingly wish to avoid. Contrary to popular belief, the best athletes in the world are not infallible gods who are immune to the struggles of common folk. Money, fast cars, and lavish homes do not exempt them from tragedy, injuries, or illness.
Professional athletes abstain from major competitions or their associated events for a range of reasons. Scanning sports headlines during the seasons of major sports, such as football, hockey, or baseball, it is common to find injury reports and a list of players who are considered questionable to play because of injuries. During other sporting events such as golf, car racing, or tennis, athletes are often reported as unable to play/drive or withdraw due to injury. When the basis for their absence is attributed to “personal/family reasons,” that could mean a dozen different things. When professional athletes described depression and anxiety during the COVID-19 “bubble” scenarios, it was understood as being related to conditions in the bubble.
However, until just recently, it was unheard of for a high-profile athlete to set boundaries around non-sport activities at a major event due to mental health reasons, let alone completely withdraw from an event. Naomi Osaka did just that at the 2021 French Open.
The Controversy That Is Mental Illness
Roger Federer withdrew from the 2021 French Open citing, “It’s important that I listen to my body,” as he was recovering from two knee surgeries. Stan Wawrinka has already announced that he will not play in Wimbledon and hasn’t played since March when he suffered a foot injury. Bianca Andreescu withdrew from the Strasbourg Open quarterfinal in May following an abdominal injury.
None of these headlines got a second glance, other than fans being disappointed that Federer will not have an opportunity to add to his Grand Slam collection right now. Yet, eyebrows were raised and questions swirled when Osaka expressed her intention to not participate in post-match interviews at the French Open to protect her mental health, and because she felt those encounters perpetuated disregard for the athletes’ mental health. Osaka openly described her struggles with mental illness (anxiety and depression) and received a mixed storm of supportive and critical comments from the media and fans.
After being fined $15,000 and receiving a threat of expulsion from the tournament for missing the first post-match interview — despite her making it clear that those encounters could worsen her mental health — Osaka announced her complete withdrawal from the tournament. Her decision triggered immediate reactions around the world, ranging from support, empathy, and gratitude from the pro-mental health camps, to skepticism, negativity, and judgment from those who believed she was merely using excuses and staging awareness for a cause (as she did throughout the 2020 U.S. Open when she used her platform to raise awareness of the Black Lives Matter movement).
Where Is Mental Illness Hiding in Sports?
Osaka is not the only athlete who struggles with significant anxiety and depression. Many athletes have shared their personal experiences, including Michael Phelps, Kevin Love, Tyler Motte, and Clara Hughes. Many more suffer in silence and will never appear on those injury reports because those injury reports do not capture mental illness. How exactly would one report “day-to-day depression and suicidal ideation” when no platform in sports exists for mental health as a health concern?
Mental health challenges in athletes may be more common than people realize. The prevalence of depressive symptoms in elite athletes is similar to that of the general population; however athletes may not recognize or acknowledge their challenges or seek support. Depression is one of the leading causes for disability in the world and is the third leading cause for disease burden globally. If depression is indeed this prevalent, many more athletes suffer from depression than are disclosed.
Anxiety disorders are the most common mental disorders in adults above the age of 18 in the U.S., affecting 40 million adults (or 18.1% of the population annually). Anxiety symptoms can lead to impaired cognitive performance and overall functioning in general populations, which can have profound effects if experienced in high performance athletes. It’s there, but it’s not discussed.
Physical Health Versus Mental Health
This isn’t really a fair fight: there is no health without mental health. There would be no sport without mental health. While mental health should emerge as the most important ingredient to physical health and sporting accomplishment, it remains a hidden, misunderstood entity that remains heavily laden in stigma and judgement. Instead, it should be addressed, understood, managed, and incorporated into every athlete’s comprehensive medical plan. Appropriate staff (including sports psychiatrists) should be part of core and event staff to navigate challenges that arise, assist in the development of policies and protocols, provide education and insight, and ensure appropriate messaging.
Unfortunately, that is not how it plays out. Physical injuries are easier to understand and easier to talk about, and recovery pathways can often be accurately predicted. Mental illness represents a scary unknown collection of illnesses that can often only be recognized by external behaviors and many people feel powerless to understand or assist the affected person.
Shining a Light in the Shadows
In the wake of Osaka’s statement on mental health, perhaps we can use this opportunity to learn more about common mental illnesses like anxiety and depression, and develop compassion for those who suffer. Be mindful of errant, whimsical statements alluding to mental illness elements, like “wanting to jump off a bridge” or “being schizophrenic” because you have felt disorganized. People all around us have stories, and many are fighting internal battles that we can’t see. When someone expresses that they are struggling, let’s not judge — no matter how great they are in their sport or how much money they made last year. It’s unlikely the major sports leagues will start listing “mental illness” on their injury reports anytime soon, but perhaps if athletes feel safe from penalty and persecution if mental illness is the reason they cannot compete, it will become a more normal sight and we can help build the supports within the sports world.
Carla Edwards, MD, MSc, is a Canadian Sport Psychiatrist and the High Performance Mental Health Advisor for several Olympic programs. She is actively involved in direct care of high performance athletes and development of polices and programs to address and protect athlete mental health. She is the current President of the International Society for Sports Psychiatry.