Depression and Anxiety in Athletes

Several features of elite and competitive sport drive risk. Serious injury and long rehabilitation, overtraining and low energy availability, intense performance pressure and perfectionism, deselection and competitive failure, the transition out of a sport and retirement, concussion, harassment or abuse, and constant public and social media scrutiny all feature prominently. General risk factors apply as well, including a personal or family history of mental illness and stressful life events outside sport. Alongside these, the environment can delay help. Stigma, the expectation to appear mentally tough, and the habit of attributing symptoms to overtraining or simple tiredness all mean an athlete may struggle for a long time before anyone asks the right question. Recognising these drivers, and paying particular attention around known flashpoints such as injury and career transition, helps the clinician stay alert.

Depression typically presents with persistent low mood and a loss of interest or pleasure, together with changes in sleep, appetite, energy and concentration and feelings of worthlessness or guilt. Anxiety presents with excessive and hard-to-control worry, restlessness, irritability and physical symptoms such as palpitations, breathlessness and muscle tension, sometimes with panic attacks. In athletes the picture can be less obvious. An unexplained decline in performance, social withdrawal, uncharacteristic irritability, recurrent physical complaints with no clear cause, more frequent injury or illness, and a presentation that looks like overtraining should all prompt a gentle enquiry about mood and worry. Asking directly and without judgement is safe and is often a relief to the athlete.

Assessment is clinical, supported by validated questionnaires. The Patient Health Questionnaire (PHQ-9) is widely used for depression and the Generalised Anxiety Disorder scale (GAD-7) for anxiety, both helping to gauge severity and track change. For elite athletes the International Olympic Committee (IOC) developed the Sport Mental Health Assessment Tool (SMHAT-1), a clinician-led assessment pathway that starts with an athlete-specific screening questionnaire and leads into structured clinical assessment, rather than a standalone diagnostic test. Physical contributors are considered and investigated when clinically indicated, since low energy availability, thyroid dysfunction, anaemia, a sleep disorder, the after-effects of concussion, and alcohol or substance use can all mimic or worsen the picture, and routine blood tests are not needed for every presentation. Collateral history, with the athlete's consent, adds context.

Management follows the stepped, collaborative approach used in UK practice, matched to severity and preference. For less severe depression, antidepressants are not routinely offered first-line, and psychological or psychosocial treatment such as cognitive behavioural therapy (CBT) is preferred; for more severe depression, a choice of psychological therapy, an antidepressant, or the two combined is offered according to need and preference. For generalised anxiety disorder, high-intensity psychological therapy or a medicine may be offered by preference. Where an antidepressant is used, a selective serotonin reuptake inhibitor (SSRI) such as sertraline is a common first choice, with an alternative SSRI or a serotonin and noradrenaline reuptake inhibitor (SNRI) such as venlafaxine or duloxetine, or mirtazapine, as further options, and pregabalin is an option for generalised anxiety where an SSRI or SNRI is unsuitable. Attention to sleep, training load, nutrition and social support matters throughout. For athletes under 18, assessment, referral and any antidepressant prescribing follow separate guidance for children and young people. Care is usually shared across a multidisciplinary team that may include a Health and Care Professions Council registered sport and exercise psychologist or a psychiatrist, the general practitioner and, with consent, the coaching and support staff. Anti-doping needs specific thought: the exact medicine is checked before use, since some are prohibited in specified sports, such as beta-blockers, and some need a therapeutic use exemption. Confidentiality is maintained, with its limits explained where there is a risk to the athlete or to others, and clear crisis pathways are in place for urgent situations, including same-day assessment and emergency care when there is immediate danger.

Participation during treatment is individualised, weighing the athlete's risk, degree of functional impairment, the effects of treatment and the safety demands of the sport. Many athletes keep training and competing while being treated, but acute suicidality, psychosis or physical instability may require temporary restriction until they are safe to return. Return is then graded, with ongoing monitoring, attention to workload, and a relapse-prevention plan that names early warning signs and what to do about them. The guiding principle is that the athlete's health comes first and performance follows. Support is kept in place through the known high-risk moments, particularly injury, deselection and the transition towards retirement, when symptoms can re-emerge, and good communication across the team, within the bounds of consent, keeps everyone aligned.

• •The International Olympic Committee consensus statement on mental health in elite athletes sets out the risk factors and principles of care, and underpins the Sport Mental Health Assessment Tool.
• •Current NICE guidance on depression in adults and on generalised anxiety disorder, and separate guidance for children and young people, informs stepped care, psychological therapy and medication.
• •Faculty of Sport and Exercise Medicine and wider sports medicine guidance frame mental health as core to athlete care.
• •National mental health charities and crisis services provide support and clear routes to urgent help.

• •Depression and anxiety are at least as common in athletes as in the general population and are easily missed.
• •Injury, low energy availability, overtraining and career transition are key risk points to watch.
• •A picture that looks like overtraining, or an unexplained drop in performance, should prompt enquiry about mood and worry.
• •Use the Patient Health Questionnaire and the Generalised Anxiety Disorder scale, with the Sport Mental Health Assessment Tool pathway for elite athletes.
• •Any self-harm or suicidal thoughts need an immediate risk assessment, with urgent same-day referral where the risk is considerable.
• •Antidepressants are not routinely first-line in less severe depression; where used, an SSRI such as sertraline is common, and every medicine is checked against anti-doping rules.