Depression in athletes: when “mental toughness” becomes a reason to stay silent

“It’s nothing. My form has just dipped.”

That was how a young athlete answered when her sister asked why she no longer got in touch after training. Her form really had dipped. But not because of bad sessions. It had dipped because for weeks she had been sleeping four hours a night, because food had lost its taste, and because after winning a home competition she sat in the car and felt nothing — no joy, no relief, only a tiredness that rest did not take away. She told no one any of this. In the world she grew up in, “my form has dipped” is an acceptable explanation. “I think I’m depressed” is not.

For a long time nobody talked about depression in athletes, because it seemed not to exist. In the public imagination athletes were the picture of health: strong, disciplined, full of endorphins that were supposed to protect them from every dark mood. Today we know that picture is wrong. Exercise does protect the mental health of most people, but elite sport also brings burdens of its own — and a particularly complicated relationship with weakness.

I am writing from a psychotherapeutic point of view. I am a therapist in training under supervision in marriage and family therapy, not a sport psychologist. I will not tell you how to improve your results. I will talk about the person who competes — about what happens when the result is the only thing they still feel about themselves.

How many athletes go through this

In 2019 a group of researchers led by Vincent Gouttebarge pooled data from a large number of studies on the mental health of current and former elite athletes. In that meta-analysis, roughly a third of current elite athletes (34%) and roughly a quarter of former ones reported symptoms of anxiety or depression. It matters what this figure means and what it does not: these are symptoms measured with questionnaires, not formal diagnoses, and the studies differed considerably from one another. But the message is clear — elite athletes are not protected from depression. According to these data, symptoms trouble them at least as often as they trouble everyone else.

In the same year the International Olympic Committee published an expert consensus statement on the mental health of elite athletes (Reardon et al., 2019). Among other things, it stresses that depressive symptoms in athletes are often linked to injuries, to the end of a career, to poor performances and to overload — and that those around them, athletes included, often recognise them late.

Why late? The answer is not a lack of knowledge. The answer lies in the culture.

The stigma of “mental toughness”

In sport, mental toughness is a virtue. Being able to bear pain, not giving up on the last repetition, staying focused when everything screams at you to stop. These are real abilities, and they have helped many athletes succeed. The trouble starts when toughness is taken to mean the absence of distress. When “being strong” means “not feeling”, “not needing anyone” and, above all, “not talking about it”.

An Australian study in which Gulliver, Griffiths and Christensen (2012) asked young elite athletes what stopped them seeking help for mental health problems identified stigma as the most important barrier. The athletes were afraid their coach, team or selectors would see them as weak. They were afraid of losing their place on the team. Many could not recognise that what they were going through even had a name.

This fear is not irrational. In an environment where your place on the team depends on how reliable you are judged to be, admitting distress can genuinely be risky. That is why depression in athletes often does not appear as sadness, but in a form that is more “permitted” in sport: anger at training, extra hours in the gym, cynicism towards the coach, complaints about the body. As with depression in men, the distress hides behind behaviour that others read as character, not pain.

How depression shows in an athlete

Depression in athletes has the same core as in anyone else: a lasting low or empty mood, loss of pleasure, changes in sleep and appetite, fatigue, difficulty concentrating, feelings of guilt or worthlessness, sometimes thoughts of death. If you want a closer look at the difference between depression and ordinary low mood, you will find it in Depression is not sadness: how to tell them apart and why it matters, and a short explanation in the knowledge base under depression.

In athletes, though, some signs are harder to spot because sport “explains” them:

• Fatigue is put down to training load.
• Poor sleep is put down to travel, competitions at odd hours, time zones.
• Loss of appetite and weight is even praised in some sports.
• Withdrawal is read as focus or introversion.
• Loss of pleasure in the sport is mistaken for the “normal” weariness of doing something you have done for as long as you can remember.

What often reveals that this is more than a rough patch is duration and breadth. If the emptiness lasts longer than two weeks and covers not just sport but friends, food, music, your partner — everything that used to have colour — it is time to take it seriously. A common form is the one I describe in High-functioning depression: when everything works outside and it is empty inside: the athlete still trains, competes, perhaps even wins, but everything runs on autopilot.

Where sport itself becomes a burden

Research and expert reviews (e.g. Rice et al., 2016) mention certain circumstances in which the risk of depressive symptoms in athletes is higher. These are not causes in the narrow sense, but moments when many things fall apart at once.

• Injury. The body that was both tool and pride suddenly does not work. You lose your daily rhythm, your team, the meaning of your day. I write about this in more detail in Injury and mental health: when your body stops you.
• Failure at an important competition. Especially when years of preparation went into it — and when others comment on the failure publicly.
• The end of a career. Whether voluntary or not, it means losing identity, routine and community all at once.
• Overload and too little rest. Chronic exhaustion can overlap with depression, which is one reason a medical assessment matters too.
• Loneliness. Moves, travel, life at a club far from home.
• Perfectionism. Standards that allow no “good enough”.

None of these circumstances means that a person will become ill. But they do mean it is worth paying attention at those times — both the athlete and the people around them.

When results are the only measure of worth

In relational family therapy, in which I am training, we always ask what place an experience has in a person’s relationships. With athletes it often turns out that sport became more than an activity very early on. It became the way you earned attention in the family, the way you were seen, the way you were “all right”. Your parents were proud after wins and tense after losses. The coach was warm when results went up and cold when they went down.

From experiences like these an identity can grow in which “what I do” and “who I am” overlap completely. When sport is going well, this can even be useful — the person is committed, focused, motivated. But when injury, a slump or the end comes, they do not lose only a result. They lose themselves. And because in this world talking about distress is weakness, they are left alone with it.

After a failure, what speaks up in such a person is not guilt (“I made a mistake”) but shame (“I am a mistake”). Shame is an emotion that hides — and that is exactly why it is so closely tied to the silence that keeps depression in athletes going.

How the conversation can open

To illustrate, here is a conversation between a player and his older sister, a few weeks after he was dropped from the national team (composite, not a real person):

“I don’t understand why you’re so quiet. You’ll be back, everyone knows that.”
“It’s not about getting back. I don’t know why I even train any more.”
“Because you’re good. Because it’s always gone well for you.”
“That’s just it. If it’s not going well, I don’t know what I am.”
“…Then tell me how it is now. Not about training. About you.”
“I don’t get up in the morning. I lie there and wait for it to pass.”

In this conversation the sister first did what most of us do: she comforted him with results. “You’ll be back.” Only when she turned the question from the sport to her brother did she hear what was really going on. This is one of the most important shifts anyone around an athlete can make: ask about the person, not the form.

Exercise: separating form from mood

Athletes are used to tracking data — heart rate, kilometres, times, weights. You can start tracking yourself in a similar way. The exercise takes a few minutes a day, and you can start today.

1. Every evening write down two scores from 0 to 10: how training or the competition went, and how you felt as a person — separately. Do not average them.
2. Add one line about what made you glad today outside sport. If you cannot find anything, write “nothing”. That is data too.
3. Note how many hours you slept and whether you ate with appetite.
4. After two weeks, look at the pattern. Does your mood lift when training goes well? Does it stay low whatever the result? Is the “what made me glad” line often empty?
5. Show your notes to someone. Your club doctor or GP, a psychologist, a psychotherapist or someone you trust. Written data is often an easier way into a conversation than the words “I feel bad”.

If your mood stays near the bottom for two weeks or more regardless of form, and changes in sleep, appetite and loss of pleasure outside sport join in, this is not a “soft” problem you will train your way out of.

It may seem strange for an athlete to keep a mood diary. But it follows the same logic as training: what you measure, you notice. And what you notice is easier to talk about.

Where to turn — and who is the right person

One of the barriers athletes often mention is confusion: who is actually right for what? In sport you meet sport psychologists, mental coaches, club doctors, physiotherapists. When it comes to depression, it helps to know who helps with what.

If you are having thoughts that it would be better if you were not here, or you are thinking about harming yourself, do not wait. In Slovenia, call the crisis line Klic v duševni stiski on 01 520 99 00 (every day from 7 pm to 7 am) or the Samaritans helpline (Samarijan) on 116 123 (24 hours a day), and in immediate danger 112.

When symptoms are strong, last a long time or get in the way of basic functioning, the first port of call is a doctor or psychiatrist. I write about when that is the case in When you need a psychiatrist first: signs that therapy is not the first step. For athletes, any treatment with medication also needs to take anti-doping rules into account — talk about this with a doctor who knows sport, and never take medication on your own initiative.

A sport psychologist is the right person when the issue is mainly performance: pre-competition nerves, focus, preparation, working with routines. Psychotherapy comes in when the distress goes beyond sport — when there is a loss in the background, a relationship with family or a partner, a sense that without results you are nothing. I write about the difference between these two roles in Psychotherapy for athletes: when the coach and the sport psychologist are not enough.

Where this story does not apply

I want to be honest about the limits of what I have written.

Not every dip in form is depression. Fatigue, low mood and a drop in performance can have entirely physical causes: iron deficiency, thyroid problems, the after-effects of concussion, overtraining syndrome or relative energy deficiency, when the body gets too little food for the load. So with lasting fatigue the first step should also be a medical check-up — psychotherapy cannot rule these causes out.

Not everything is the culture’s fault. Depression also has a biological and genetic component. An athlete can become ill in the most supportive environment, with a coach who understands them and a family who loves them whatever the result. Then there is no culprit to look for.

Mental toughness is not the enemy. The ability to persist through discomfort is valuable. The problem is not toughness, but attributing to it something it cannot do: prevent illness. Research and personal accounts often show that the toughest athletes are those who also knew how to ask for help.

For most people, sport is protective. I do not want anyone to read this and conclude that sport is harmful. For many, training is exactly what keeps them above water. Problems arise at the elite level, under pressures that turn sport from play into the only measure of worth.

What the people around an athlete can do

Coach, parent, partner, teammate — each of them can do something to lower the threshold for a conversation:

• Ask about the person, not the result. “How are you?” sounds different when it does not come straight after “How did it go?”.
• Do not comfort with the next match. “You’ll get them next time” can close a door that was just beginning to open.
• Normalise help. If a coach or captain says they once sought help themselves, it is worth more to the team than any poster.
• Do not diagnose. It is not your job to work out whether it is depression. Your job is to notice and help find someone who can.
• Look after yourself. Being alongside someone with depression is demanding — I write about this in How to support someone with depression without burning yourself out.

The public conversations of recent years, in which some elite athletes have spoken openly about depression, anxiety or withdrawing from major competitions for the sake of their mental health, have done a great deal in this respect. They have shown that admitting distress does not wipe out a career. For young athletes this may be the most important message: you can be excellent and struggling. One does not rule out the other.

What to remember

• Elite athletes are not protected from depression; according to research, a significant share of current and former athletes experience symptoms.
• The biggest barrier to seeking help is stigma — the fear that distress will be read as weakness.
• In athletes, depression often hides behind explanations that sport offers: a dip in form, fatigue, focus.
• Separate form from mood: if someone feels empty whatever the result, it is more than a bad week.
• With lasting or strong symptoms, the first port of call is a doctor or psychiatrist; for performance, a sport psychologist; for distress that goes beyond sport, a psychotherapist.