Psychiatry and elite sports: mental health as the invisible engine

When a footballer tears a knee ligament on the pitch, we know what comes next: X-rays, an orthopaedic surgeon, surgery if needed, rehabilitation, return to play. No one tells him “it’s just a matter of motivation”. No one expects him to heal through discipline alone.

But when that same athlete goes through an anxiety crisis or a depressive episode, the response changes. He is told to “step up”, to “stop being distracted”, to “tough it out”. As if mental health were a character flaw and not a clinical problem as real as a torn ligament.

I call this gap between the physical injury we recognise and the mental injury we minimise the athlete’s paradox. And resolving it is, to a large extent, what sports psychiatry does.

How common is a mental health crisis in elite sport?

More common than most people imagine.

The 2019 International Olympic Committee Consensus Statement —the obligatory reference on the topic— estimates that 35% of athletes will experience at least one mental health crisis during their career. We are not talking about a bad day or pre-competition nerves: we are talking about clinical conditions that affect both wellbeing and performance.

Some additional figures:

• Male team sports such as cricket, basketball and rugby: around 5% experience burnout and up to 45% present anxiety or depressive symptoms at some point.
• Female athletes: eating disorders predominate —anorexia, bulimia, binge eating—, especially in aesthetic disciplines or weight-control sports.
• Collegiate athletes: between 10% and 25% live with depression or eating disorders.

These data are not anecdotal. They are the baseline frequency a sports physician should work with.

Cases that changed the conversation

Three classic stories illustrate how mental health operates —and sometimes collapses— in elite sport.

Jonny Wilkinson, the British rugby player, reached his peak at the 2003 World Cup. He expected success to dissolve his paralysing perfectionism and his fear of making mistakes. The opposite happened: anxiety escalated and triggered a depressive episode. Today, retired, he devotes much of his work to speaking about mental health in sport. His case is one of the most cited examples of a real and counterintuitive phenomenon: psychiatric risk can rise after peaks of success, not only after defeat.

Olatz Rodríguez, Spanish rhythmic gymnast and 2018 European junior champion, publicly shared that at age 17 she was admitted to hospital as an emergency for anorexia: she weighed 36 kilos. In her own words, that admission “kept her from losing her mind”. Today she studies medicine and writes about her experience.

Monica Seles was stabbed by a fan of her rival during a match in 1993. What followed was post-traumatic stress disorder: hypervigilance, brutal sleep problems, slowed reflexes. She came back to the court but body and mind no longer responded the same way. The institution failed her at that moment by refusing to protect her ranking. That is no longer discussed today in the same way, in part because of cases like hers.

Three contemporary cases that rewrote the rules

The culture shifted. In recent years three athletes forced international federations to place mental health on the same level as physical health.

Naomi Osaka won the 2018 US Open amid the boos of the crowd during the Serena Williams–umpire incident. She accepted the trophy in tears, apologising. Three years later, at Roland Garros 2021, she refused mandatory press conferences citing her social anxiety. She was threatened with fifteen-thousand-dollar fines and disqualification. She withdrew from the tournament anyway. Her decision forced the tour to revise its press protocols and to publicly acknowledge that mental health is not optional.

Michael Phelps, the most decorated swimmer in Olympic history, has lived with ADHD since childhood. After every Olympic cycle —2004, 2008, 2012— he went through depressive episodes. A second DUI arrest, together with persistent suicidal ideation, led him to check himself into a clinic for 45 days. In later interviews he explained something key: he could not separate Phelps the athlete from Phelps the person. That fusion of identity was, time after time, the trigger of his crises.

Simone Biles withdrew from several finals at Tokyo 2020 (held in 2021) because of the so-called twisties: a mid-execution mind-body dissociation that makes jumps dangerous. What was seen on screen was the tip of the iceberg. Behind it was unresolved PTSD from a history of sexual abuse, the pressure of being the face of a team in institutional crisis, and the pandemic isolation that had separated her from her support pillars. Her phrase became the banner of an era: mental health before the medal.

What does sport do to the brain?

Before talking about the clinical role, it is worth remembering why sport —in the right dose— is in itself one of the most powerful interventions we have in mental health.

Exercise increases key neurotransmitters —endorphins, oxytocin, dopamine, serotonin— that regulate mood, anxiety and self-esteem. It improves cerebral blood flow and, with it, cognitive functions such as memory, attention and learning. It slows the cognitive decline associated with ageing. It lowers cortisol, the stress hormone. It promotes neurogenesis. It improves sleep quality and recovery.

In clinical practice, exercise is an integral part of the treatment of almost every mental health disorder. That does not mean that the extreme exercise of elite sport protects on its own. It does not. And that is precisely the point of sports psychiatry.

Sports psychology and sports psychiatry: two sides of the same coin

There is a frequent confusion: that sports psychology is for “mild cases” and psychiatry for “severe cases”. That is not how it works.

I like an analogy: imagine a racing car. The psychologist is the engineer. She calibrates the engine, tunes the aerodynamics, designs the race strategy, teaches the mental tools to reach optimal speed. The psychiatrist is the mechanic. He opens the hood, checks the chemical and electrical system, identifies what is damaged and makes sure the engine responds.

We do not compete. We are complementary.And both of us work in synergy with the rest of the medical team, the coaching staff and the athlete’s support network.

The two-way relationship between mind and body

One of the things sports psychiatry does particularly well is recognise that mind and body affect each other in both directions, and the data confirm it.

From mind to body:

• Anxiety without coping tools doubles the risk of injury.
• An untreated mental health disorder can increase the risk of physical injury by up to 50%.
• 30% of athletes with mental health problems suffer chronic insomnia, which slows reflexes. In tennis, in boxing, in any sport where milliseconds matter, that is the difference between winning the point and getting injured.
• Anxiety makes athletes rigid, imposes a “tunnel vision”, and makes them lose tactical perspective.

From body to mind:

• Severe injuries, repeated concussions, early forced retirements: all of these impact mental health.
• A sustained drop in an athlete’s performance can itself be a signal that something is wrong. It is time to look beyond technique and physical condition.

Three roles of the sports psychiatrist

A Scandinavian journal of sports medicine summarises the scope of the work quite well. Sports psychiatry has three main roles:

1. Restore performance.The athlete is already affected by a condition —anxiety, depression, eating disorder, PTSD— and the goal is to recover functioning. Here a wrong diagnosis can be costly: treating someone for depression when they have untreated ADHD, or labelling burnout as anxiety, are errors with consequences. The intervention is individualised, integrating the athlete’s context —their environment, network, vulnerabilities, the demands of their discipline— in a biopsychosocial approach.

2. Maintain performance. For me, this is the most important role. It is pure prevention. It means educating the athlete about mental health, but also their coaching staff, their family, their support network. Doing periodic screenings. Identifying risk factors and modifying them. Recognising stressors early. Designing management plans to avoid relapse. Most of the cases that end in hospitalisation or forced retirement gave signals months earlier that no one knew how to read.

3. Enhance performance. This role is oriented above all to the young athlete, whose personality is still being formed. It goes beyond managing a disorder: it is about helping a kid with competitive drive grow with a balanced personality in a sports context that is naturally demanding and at times hostile. It requires significant ethical judgement, because we are not just talking about performance, we are talking about the development of a human being.

What you take away from this talk

If I had to leave you with three firm ideas:

1. Sporting success and mental health are not contradictory terms. You do not have to choose between performing and being well. On the contrary: mental health is the invisible engine of performance.
2. The psychiatric risks of competitive sport are not an acceptable side effect. They can and should be prevented.
3. Sports psychiatry and sports psychology work in synergy with the rest of the multidisciplinary team. No professional player tries to win alone. Neither is an athlete’s mental health looked after alone.

About this text

This post is a written adaptation of the lecture “The role of psychiatry in elite sport” delivered by Dr. Daniela Málaga on June 4, 2026 at the Salón Social of Club Terrazas in Miraflores, Lima, as part of the event “¡Tú puedes! ¡No te rindas!” organised by the Centro de Alto Rendimiento Terrazas (CART).

References

1. Reardon CL, Hainline B, Aron CM, Baron D, Baum AL, Bindra A, et al. Mental health in elite athletes: International Olympic Committee consensus statement (2019). British Journal of Sports Medicine. 2019;53(11):667-699.
2. Gouttebarge V, Castaldelli-Maia JM, Gorczynski P, Hainline B, Hitchcock ME, Kerkhoffs GMMJ, et al. Occurrence of mental health symptoms and disorders in current and former elite athletes: a systematic review and meta-analysis. British Journal of Sports Medicine. 2019;53(11):700-706.
3. Purcell R, Gwyther K, Rice SM. Mental Health in Elite Athletes: Increased Awareness Requires an Early Intervention Framework to Respond to Athlete Needs. Sports Medicine - Open. 2019;5(46).
4. Claussen MC, Burger JW, Menon R, Nishida M, Yau EKB, Nahman C, et al. The Underestimated Role of the Sports Psychiatrist in Athletic Performance Restoration, Maintenance, and Enhancement in Sports. Scandinavian Journal of Medicine & Science in Sports. 2024;34(8):e14697.