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Kelly Holmes, one of the many high profile sports start to have suffered from depression during her career
By Russell Garner derivative work: MachoCarioca (Kelly_Holmes_at_Athens_2004.jpg) [CC BY-SA 2.0], via Wikimedia Commons |
Mental illness in cricket
England cricketer Marcus Trescothick returned home from the 2006-07 Ashes in Australia due to a 'recurrence of a stress-related illness'. Despite several attempts, Trescothick never returned to play for England, and announced his retirement from the international game in 2008, seemingly unable to cope with the stress of touring. In his autobiography,
Coming Back to Me, released later that year, Trescothick revealed that he had suffered from anxiety attacks since he was 10.
Cricketers appear to be at particularly at risk. As is well known, mental health issues are higher in men than in women, and so, in a male dominated sport, it's no coincidence that depression is common. But it would appear that there's more to it than that. Writing in the wake of the Trescothick case, Geoffrey Boycott blames the congested international test calendar, and states that 'the burden of playing non-stop cricket is taking its toll'. This may be a slightly simplistic view. An online article by Antionette Muller (2013), looked at why cricketers, more than other sports people, are at risk. She concluded that the long periods of time spent away from home, the pressure of top-level, high-profile sport, and the game itself were contributing factors.
Cricketers can spend as much as half the year on tour, and a disproportionate amount of that time, particularly during test matches, is spent waiting to bat, or to bowl. Skill is important, but luck also plays a major factor, and after waiting for hours to have their chance in the spotlight, a highly-skilled batter can often be left reflecting on why they are walking off the field without even hitting a ball. Knowing that their public perception and perhaps their place on the team are dependent on their latest performance, it's little wonder that cricketers are at risk of developing a distorted perception of their own self worth. And the long periods of inactivity in hotel rooms and media analysis which follows provides the perfect conditions for such distorted perceptions to fester, distort further and ingrain themselves in the individual's psyche.
A batter's performance can last anything from a single ball, to a prolonged innings stretching over the course of two days, with a completely unpredictable outcome to each ball bowled in their direction. In few other sports is the duration of the performance so unpredictable. In many sports, the better you perform, the shorter the race or match. In cricket, the complete opposite is true.
In cricket, more so than in other sports, there is a lot of time to contemplate failure, but not an awful lot of time to celebrate success.
In his book
Silence of the heart: cricket suicides (2001), David Frith poses a further, important question:
'... does cricket more than any other game, actually attract the susceptible by virtue of its wicked, teasing uncertainties, its long-drawn-out routine, its compulsive, all-consuming commitment? Or conversely, by its sometimes cruel and frustrating pattern, does it gradually transform unwary cricket-loving boys into brooding, insecure and ultimately self-destructive men when the best days are past?'
This is one of the points that former New Zealand cricketer Iain O'Brien touches on in the excellent video which follows. O'Brien also speaks about his own depression and the social anxiety that he experienced as a player. He felt at home on the park, but it was in the dressing room that O'Brien was least comfortable, and he spend much of his career trying to fit in with the other personalities on the team.
Football, too, appears to have an above average incidence of mental illness. Research carried out by the international footballers association, FIFAPro, reported that just over a quarter of 149 current players and 39% of 104 former footballers experienced anxiety and/or depression (Gouttebarge, 2015). While there may have been a response bias (the response rate was 29%), these are pretty stark results. Recent life events and low social support were among the factors significantly associated with mental health problems in this study.
In reports associated with this study (Telegraph Sport and agencies, 2014), former New Zealand captain Chris Jackson, linked his disappointment at not making it into European football with his depression and substance abuse. Jackson says:
High disposable incomes can lead to gambling and substance abuse, and may in turn may lead to depression. Not having interests or work outside of football may increase the likelihood of psychosocial problems such as these, particularly when a player is injured or not getting game time.
Rugby league is among the other sports which recently recognised that it
has a mental health problem. Many of the factors associated with depression in football may also play a part here. Constant pressure to perform and media spotlight, along with issues surrounding injury and lack of form, are likely to play a large part.
Boxing, particularly at a professional level,
also seems to have a major problem. In addition to Hatton, Bruno and Tyson - who all have had mental health issues - there have been a number of suicides in the sport. Jonny Tapia, a five times world champion, and Lewis Pinto, a promising young super middleweight fighter, both ended their own lives in May 2012. Irish 2008 Olympic bronze medallist Darren Sutherland's death in 2009, not long after turning professional, is presumed to have been by suicide. He too had suffered from depression.
Along with all the aforementioned issues, repeated brain injury, making weight, inconsistent income, a long time between fights and the bravado and intense rivalries surrounding fights, could all contribute to the high rate of suicide and depression in boxing. Another important factor is the extreme self believe that goes alongside fighting. This focus on the positives, and complete dismissal of vulnerabilities, weaknesses and fears, and its effect on mental health will be discussed in more detail later, but is probably most evident in a sport where the aim of your opponent is to literally knock you out.
Highlighting these sports and some of the factors within them may help us gain a better understanding of mental illnesses, the unique pressures that sportspeople face, and what can be done to prevent depression. But it should not detract from the fact that no sport is immune to depression and mental illness. Gaelic footballers and hurlers, who do not have the money, lack of distraction and changing team issues evident in football, are also at risk.
Identity and purpose
Depression is highly associated with identity issues, low self-esteem, and a low sense of self-worth. While it is unknown whether low self-esteem and low self-worth cause depression, or are as a result of it, there is considerable evidence to suggest that identity issues in athletes can lead to depression.
Athletic identity, the degree to which an individual feels that his or her identity is built around his or her role as an athlete, is a major factor in determining the degree of depression felt by an injured athlete. Athletic identity is also a major cause of post retirement depression in sportspeople. When the thing that a person feels defines them and gives them purpose is taken away, their self-esteem and purpose diminishes.
Temperament and personality traits
Various personality traits common in successful athletes have been associated with mental illness, though much more research is required to ascertain whether susceptible personalities are attracted to sport, or sport 'creates' susceptible personality characteristics. As was suggested in relation to cricket, individuals with certain traits may be attracted to certain activities, and these traits may predispose them to depression and anxiety. A form of natural selection may exist, meaning that the most successful athletes are those who are most susceptible to depression.
Perfectionism has been associated with various forms of maladjustment, particularly in sports (Hewitt, 1990). Flett and Hewitt (2005) have identified and described what they call the perfectionism paradox - the way in which certain sports require athletes to achieve perfect performance outcomes, though being 'cognitively preoccupied with the attainment of perfection often undermines performance and fosters a sense of dissatisfaction with performance'. In addition to maladjustment, this obsession with perfectionism can actually hinder sporting performance.
Research by the
Black Dog Institute indicates that those with certain temperament and personality styles are at a greater risk of developing depression. Among the susceptible personality and temperament styles are self-focused and perfectionistic personalities, both of which may be high among sports people.
Obsessive compulsive disorder (OCD) is just one of the mental disorders for which former footballer Paul Gascoigne has received treatment. He has also suffered from bipolar disorder, alcoholism and eating disorders. Obsessive-compulsive disorder (OCD) is highly linked with depression, and some aspects of high performance sport may contribute to the development of OCD (Aldhous, 2009). Those susceptible to OCD may, of course, be attracted to certain skilled sports sports to begin with, and there is little, if any evidence to link OCD in such cases with depression.
Retirement
Examples of sportspeople who have struggled with the 'loss' that comes with retirement are plentiful. Indeed, research by the Professional Players Federation, published in 2013, found that 16% of 1200 ex-footballers, rugby union and rugby league players, jockeys and cricketers surveyed experienced depression or feelings of despair in the 12 months post retirement.
In 2014, Rubgy League star and former Great Britain player Sean Long
admitted to attempting suicide, having struggled to cope since being forced to give up the game, due to injury, in 2011.
'I didn't finish playing on my terms really. It was the injuries...I didn't know at the time but I've had depression and suffered from anxiety over two-and-a-half years.'
Those who are forced to retire because of injury or deselection generally have greater difficulty in adjusting to life after sport than those who retire on their own terms. Forced retirement is often followed by a period of grieving, as the individual attempts to come to terms with their loss.
But even those who retire on their own terms can struggle, as athletes lose their perceived purpose in life, the structure and routine which they have lived around for so many years and, for some, their livelihood. Others simply miss the endorphin kick that comes with exercise. Endorphins are, of course, a natural antidepressant.
Athletic identity, the degree to which an individual feels that his or her identity is built around his or her role as an athlete, is also a major factor in determining the degree of depression felt by an athlete post retirement. Planning for retirement is an important determinant for successfully transitioning from the life of an athlete to the life of an ex-athlete, and finding meaning and purpose in the world outside of sport is crucial.
Gail Emms recently spoke about
suffering from depression after retiring, and stated that it was only when she had her first child that she found a new meaning to her life. Hers is just one of thousands of stories
Retirement and the associated problems will be dealt with in more detail in a forthcoming post.
Post Olympic blues
The aftermath of an Olympic Games, FIFA World Cup, or other major sporting can be a major breathing ground for depression and addiction. Post Olympic Depression Syndrome (or Post Olympic Stress Disorder, as it is sometimes known) is a well-known phenomenon, and not just something that is experienced by the fans! Even (or more accurately, especially) athletes that have been successful suffer from the condition. Only a small proportion of the world's population will ever win an Olympic gold medal, and no medal comes with an instruction manual on how to deal to the emotions that go along with it.
After a major sporting event as big as the Olympics, athletes struggle to adjust to normal life and find their place in the world. For many athletes, the completion of a Games coincides with retirement or an unplanned for future, with some having put off retirement decisions until after the Olympics. Identity and retirement issues have been dealt with earlier, so only get a passing mention here.
Other causes of Post Olympic Depression Syndrome relate to coming down from a massive high, dealing with becoming famous, a sudden lack of routine, achievement of extrinsic goals or dealing with failure on the world's greatest stage, and simply readjusting to life in the real world.
An overwhealming majority (77%) of surveyed South African participants at the 2000 Olympic Games reported subjective feelings of post-Olympic depression (Portgieter, 2001). Of these, 27% reported 'extreme' depression after the Games.
The Olympics provide a platform for successful athletes, particularly in minority sports, to gain media attention. Athletes previously unknown to the outside world find themselves in a strange and unfamiliar place; one which some may find particularly stressful. While some gain the recognition that they have craved for so long, many struggle to come to terms with their new found fame and the social and media demands that go along with success.
Bradley Wiggins is just one of the numerous athletes to have suffered depression and addiction after the Olympics. In his 2008 autobiography Wiggins revealed how, having little else to do with his time, he found himself waiting outside his local pub at 11am each day, for a period of 8 or 9 months following the 2004 Olympic Games. 'I wasn't just drinking for England during this period, I wasn't quite at the races mentally either. For a while my life threatened to spiral out of control.' He had won 3 medals, including his first gold in Athens.
For Wiggins, it was not the fame, but the lack of fame, which was most difficult to deal with. He expected things to change after the Olympics. He thought that sponsorship and endorsements would come flooding in and things to be a little easier financially. They didn't. In a 2008 interview (McRae, 2008), Wiggins says:
"You end up trying to give the perception you've got a bit of money. 'Yeah, it's great, lots of offers rolling in ...' The reality was quite different. I woke up every Monday morning and we were still overdrawn and I'd think, 'God, I don't feel like riding my bike again.' There was a bitterness that nothing had changed after all the hard work but it went deeper than that. I'm not saying I was clinically depressed but there were definite bouts of depression - and lots of drinking."
Those who are extrinsically driven and motivated purely by winning are more likely to suffer from post Olympic depression than those who are motivated by the process.
Those who were successful and achieved their goals may suffer from something known as post achievement depression, similar to the feeling many get following the completion of a PhD thesis or other project in which they have been engrossed for a prolonged period of time. Post-Olympic blues and post achievement depression are similar in some ways to post-natal depression, post wedding blues, and other emotional come-downs following a 'high'.
Injury
The link between injury and depression can operate on at least three different levels, namely the emotional stress and boredom as a direct result of the injury and subsequent loss of training, the link between any prolonged or chronic pain and depression, and depression as a result of opioid painkillers.
Injury, a constant worry and major interruption to the attainment of their goals, and indeed their livelihood, plays a major role in lives of many athletes. In most athletes, depression is a short-term response to an injury, and is seen as a normal emotional response to severe injury. In extreme cases, recurrent injury can constitute stress, one of the factors which can lead to major depressive episodes. Boredom, if training is not possible, can also exacerbate the depressed mood.
Athletic identity, the degree to which an individual feels that his or her identity is built around his or her role as an athlete, is a major factor in determining the degree of depression felt by an injured athlete. Like retirement, athletes who see injury as a threat to their core identity are more likely to experience depressed mood during an injury. While this response is depression the emotion, rather than depression the illness, it's likely that prolonged, repeated and severe injury could result in long-term depression.
Though not all injuries involve pain, it is important to note that chronic pain can often go hand in hand with depression. Both physical and emotional pain are registered in the same part of the brain, which essentially treats depression in the same way as physical pain. Physical pain therefore often causes depression, and depression can worsen the physical pain. Some antidepressants can actually help relieve the physical as well as the mental pain
Opioid painkillers, often prescribed for chronic pain, have been linked with depression (Scherrer et al., 2014), anxiety, hallucinations and suicidal tendencies. Their abuse to enhance performance is dealt with the doping section below.
Doping?
While it may be unethical and practically impossible to prove a link between doping in sport and depression, there is at least a theoretical and anecdotal basis for such an association. Some drugs, including steroids, have been associated with mental disorders, and may result in depression in those who abuse them.
The use and discontinuation of anabolic steroids in particular have been associated with depression (Pope & Katz, 1994) and other mood disturbances and mental disorders such as paranoia, mania, hypomania, steroid dependence and schizophrenia. Cortiosteroids, a group of steroids often prescribed for injury and other medical conditions and abused by cyclists and other athletes to enhance performance, have also been linked with mood disturbances and depression in a large proportion of users (Patten, 2000).
EPO, the performance enhancing drug of choice for endurance performancers overstepping the doping rules, appears to actually treat depression. However, anecdotal accounts report that cyclists associate depression with the use and discontinuation of EPO. Amphetamines, beta blockers and cannabinoids, drugs abused to varying degrees in various sports, may also lead to depression.
Opioids, a group of drugs with both pain killing (analgesic) and narcotic properties that includes codeine and Tramadol, among others, appear to be abused in cycling (Benson, 2013), and are taken by riders simply to get them through a race. This group of substances, though not currently on the WADA banned list, are highly addictive, and can cause a number of nasty side effects, including anxiety, depression, suicidal thoughts and hallucinations. Withdrawal can also cause serious side effects, including insomnia, depression and anxiety.
In her excellent article outlining the high incidence of depression in cycling, Suze Clemitson (2014) proposes that there is a possible link between the prevalence of doping and the seemingly high incidence of mental health issues and suicides in the sport. In the article Clemitson quotes cyclist and whistleblower Jesus Manzona, who says:
'The drugs lead you to other addictions. The anti-depressants almost automatically accompany other doping treatments. I took up to eight pills of prozac a day when I was racing...Prozac cuts the appetite, keeps you in another world, a world where you're not afraid of what you're doing. You're no longer afraid to inject yourself with all the crap. It takes you to a world where you don't ask any more questions, especially you don't ask your doctor questions either or your sporting director. Then there are periods where you must stop doping you feel like superman. Then one day all of the sudden it stops and you become dramatically depressed.'
When you put it like that...!
A cycle of shame and guilt, a constant fear of being caught, a redirection of one's moral compass as a result of choosing to dope, and dealing with the sense of loss if caught, are just some of the other factors which may result in depression.
While there are many possible causes behind the high rates of depression, suicide and unexplained deaths in cycling, the sport we most associate with doping, there is at least a theoretical link between doping and mental illness.
Concussion and other medical issues
We often think of depression as a purely psychological issue. But physiological factors may contribute to depression and anxiety. Overtraining, iron-deficiency anaemia and thyroid problems - which can be common in athletes - and a number of other underlying medical conditions may also contribute to a depressed mood or result in similar symptoms.
Among the many symptoms of iron-deficiency anaemia are depression and anxiety, which may result in OCD-type obsessions and compulsions, as well as many of the symptoms of depression itself, including insomnia, irritability and poor appetite. While these depressive symptoms appear to be reversed with treatment, they may lead to full blown depression in those who are already at risk.
Many of the signs and symptoms of overtraining syndrome and depression overlap, making it difficult to establish if overtraining and burnout can cause depression, if depressed mood is simply a reversible symptom of overtraining, or if overtraining syndrome is, in fact, a form of depression experienced by athletes. In addition to sharing many physical and emotional signs and symptoms, biochemical responses, including immune, endocrine, and neourtransmitter patterns, are remarkable similar in the two conditions. The cycle of poor performance and inadequate recovery which result in overtraining could, in theory, independently also lead to depression.
A history of recurrent concussion and head trauma appears to be linked with an increased likelihood of being diagnosed with clinical depression in retired America Football players (Guskiewicz, 2007). Other sportspeople who experience recurrent concussions may also be at risk.
Performance psychology and a focus on winning
Sports psychology is all about winning at all costs, ignoring all weaknesses and negative thoughts, and 'believing' that you can do it. An unrealistic mental environment in which you believe that you are better than anybody else is often created. There is no room for weakness or vulnerability on the playing field.
While this may be the optimum approach from a performance perspective, it is far removed from everything that psychiatry has thought us. Failing to acknowledge and work through our tiny everyday concerns, worries and weaknesses can lead to major psychological issues in the long term, and in an environment where the focus is always placed on the positive, unbreakable and invincible can remove the opportunity for sportspeople to learn everyday coping skills.
This is not to say that some sports psychologists don't take a holistic approach, or that they fail to deal with everyday concerns and worries, but more that performance psychology in its purest sense can fail to take into account such issues.
Stress
Stress, or a series of stressful events, can trigger depression and anxiety. Performance in itself, particularly under constant media scrutiny, can be seen as a form of stress. While good and bad days are an accepted part of the life of a development athlete, there is little room for an off day for those in the media spotlight. This pressure to perform week in, week out for the duration of an ever extending season can place a lot of stress on a sportsperson, and the fear of a bad performance, while not likely to be the sole cause of depression, may contribute to depression in those that are particularly susceptible.
Defeats, disappointments and failures are accepted steps along the path to the top. Individuals often learn more from their mistakes than they do their successes, and shouldn't be afraid to take risks and to make mistakes along the way. Issues may arise when athletes are suddenly shot into the media spotlight and suddenly feel that they can no longer make mistakes, are not used to having their performance analysed in such a public way, or go through a particularly bad dip in performance.
Trying to maintain a place on a team, making up for previous misfortune or underperformance, or simply trying to reward somebody's belief in you can be additional sources of stress.
Other factors associated with professional sport
Professional sport does much to disempower participants. Those who participate in a very structured and protected environment from a young age (e.g. footballers who join a club academy) rarely have to make major decisions for themselves, and don't go through the same life learning as their peers. The life skills that a typical 18 year old is learning is far removed from those of an 18 year old academy player, and while the typical 18 year old can set out on their voyage of discovery in a pretty anonymous fashion, the professional sportsperson is growing up in the media spotlight. Modern sports support structures often try to make life easy for the sportsperson and reduce the 'stress' in their lives. In doing so, they often reduce the opportunities for athletes to grow and learn, and to deal with manageable amounts of stress.
Professional sportspeople often spend large amounts of time away from home. Cricketers, for example, often spend months at a time on tour, away from family, and lack certainty and routine. While life on the road may be an ideal life for some, it is not for everyone, and can be particularly difficult for those with young children. Despite being around their team mates, many can feel isolated and lonely. Spending large amounts of time in the presence of those who may be fighting for your place on the team can also be difficult.
Being a fulltime athlete has many advantages. But it also has downsides. Large amounts of downtime can result in boredom, overanalysis of performance and results, or a reduction in self worth, all of which may contribute to the development of depression. Boredom or having time on their hands, together with access to large amounts of cash, may, in turn, lead to problem drinking and substance abuse.
The sports supporter
We always talk about the sports participant, but is there a risk for sports supporters? Participants are, at least most of the time, in control of their own destiny. Once they get out on the pitch or track, they are doing what they can to win, but the supporter can do nothing to control their destiny. They have no arena in which to dissipate the pressure. If superstition is an issue for the player, then what potential does it have to upset the onlooker?
And then there's the off season! Where does the sports fan get their kicks from during the off season? Or do they, like the player, benefit from taking time away from the sport, recuperating from the season's exertions, bringing some sense of balance to their lives, and preparing for the inevitable highs and lows of the season ahead?
It appears that experiencing the blues after a sports related defeat is a common experience among sports fans. Sometimes, after watching their team losing an important game fans can go through a form of grieving. Indeed, some radio phone-in shows after weekend football fixtures sound more like counselling sessions than they do sports programmes. Prolonged post-mortems in modern sport can add to the grief felt by fans, and extend the depressed feelings beyond their natural life (Woods, 2014).
On the flip side, some research suggests that those who have a close affiliation with a sports team have fewer bouts of depression and alienation than those uninterested in sport (Branscombe & Wann, 1991).
And of course, spectators as well as participants can experience post-Olympic blues.
The final paradox
Exercise is a known cure for depression and other forms of mental illness. It is often a prescribed treatment for such illnesses. Chemicals known as endorphins, a form of natural anti-depressant, are released during exercise. Regular exercise can help relieve stress, and provide an opportunity to unwind after a difficult or stressful day. Sports participation can also give individuals a sense of routine and a purpose in life. It can increase self-esteem and feelings of self-worth. And most of all, it can empower.
This seems to contradict everything that has gone before. I guess, like everything in life, a sense of balance is needed. Sport has the power to enrich the lives of those who participate in it, but it also has the power to destroy them. Knowing the risks, spotting the warning signs and recognising that individual growth is more important than winning at all costs, are good first steps in the fight against mental illness in sport.
Conclusion
There are lots of unknowns, and much more research is needed in the area. The question, however, is not whether or not sportspeople are more susceptible to mental illness that the general population. Many top level professional sports are dominated by males in their twenties and early thirties – the group in which mental illness and suicide are at their highest – and so, a high level of mental illness should not be unexpected. Depression, in many cases, is preventable, and the real questions that we should ask is why sport - something that should empower, increase self-esteem, promote self-worth, and allow talented individuals achieve their goals - can, in certain circumstances, take all that away? Why, when exercise is often prescribed as a treatment for depression, does it lead to depression in some, and what can be done to ensure that sports can have positive outcomes for participants at all levels? And finally, and most importantly, are there still barriers stopping those suffering mental illness from seeking help?
No one factor leads to depression, and the information discussed here include hypothetical aspects of sport that may lead to mental illness. We hope that this article will help raise awareness of some of the issues faced by high performance sportspeople, and lead to more open discussion on the topic. Please share your thoughts by commenting below.
Useful reading
References
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