Let's Talk About Mental Health in Male Athletes

Collectively, athletes are a very physically fit group of people. However, pushing the body to its limit on a daily basis can come at a mental cost. While exercise and physical activity are shown to protect against depressive symptoms, athletes of all genders can still struggle with mental health symptoms. [1] And men have continually been under-researched and underserved in the mental health space. This article aims to shed light on the unique relationship between men, mental health, and athletics; risk factors for mental health symptoms in male athletes; and how those symptoms manifest and impact performance. 

*This article is intended to share the latest research on the mental health status of men in sports. It is not intended to diagnose or treat mental health disorders. Reach out to a healthcare provider or trained mental health professional with questions or for personalized care. 

Men's mental health is often ignored in both research and culture

Mental health is defined as “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.” [2] Men’s mental health is unique because, despite its prevalence, resources, support, and research are still inadequate. 

It’s established that suicide rates in men are higher than in women; in 2019, the rate was 3.7 times higher in men. [3] And it’s also well known that most people who commit suicide have a mental or emotional disorder. [4] Yet despite this clear indication that men do indeed suffer from mental health issues, it’s not an issue that’s been prioritized by researchers or the public until recently.

Cole Sager, a 7x CrossFit Games athlete and former Division-1A football player, says the stigma around men directly addressing their mental health is still prevalent. “The macho thing to do was to suck it up and figure it out yourself,” he says. There’s still hesitation for men to admit they may be going through mental health problems, but Cole says he feels like it’s being addressed more frequently, although still not sufficiently. And the data support his observation.   



The trend in research on men's mental health

A search for “men’s mental health” in PubMed—a search engine for scientific studies—showed only 402 results between 2000 and 2005. But that same search returned 8,030 results for 2015-2020. So yes, scientific and clinical interest in men's mental health is increasing, but the current environment is not set up to support men’s mental health. In fact, it has resulted in a lot of undue harm for men not getting the care they need. Here’s how. 

Men are less adept at recognizing symptoms associated with mental health than women, and those who do recognize them are typically more reluctant to acknowledge them with friends or family. [5,6] Men, especially those who adhere to traditional masculine norms, are also less inclined to seek out or utilize mental health services. [5] And even when they do seek care, mental health disorders (like depression) can manifest differently and warning signs may be missed by support systems. For example, men tend to externalize symptoms via behaviors like alcohol consumption, irritability, and aggression. [5] They may also underreport or use different language to express internal feelings. And these manifestations don't necessarily align with traditional diagnostic criteria, potentially leading to missed or inaccurate diagnoses and treatments. [6]

New research is focusing on trying to understand and address the gaps in this lifecycle, and there’s an intensified focus on the mental health of male athletes. 



Risk factors for mental health symptoms in athletes

The inability to properly manage stresses can spur the onset of mental health concerns. Athletes face both common stressors (like relationship strains or financial concerns) and specific stressors related to their sport. Here are some of the most impactful of the latter group.

Injuries and concussions

Athletes are at increased risk for injuries and concussions, and the repercussions of these injuries can last far longer than the immediate pain. One study showed that former athletes who experienced severe injuries were anywhere from two to seven times more likely than their non-injured counterparts to report mental health symptoms. [7] A systematic review of 27 studies also found an association in elite athletes between a sports-related concussion and symptoms of depression. [8]  

Retirement and extreme athletic identity

Athletes train their entire lives. But the lifespan of a competitive athletic career is limited. So what happens when it’s over? The lack of an identity or interest outside of the sport can become more apparent after retirement and play a role in the onset of depressive symptoms. [9]

Need to perform

“One of the other things I’ve noticed in men’s mental health is this need to perform. We have to get results. Whether you’re in an athletics or corporate space, you see men exhausting themselves trying to get results and perform better, ” says Sager. This need to perform can lead to common mental health symptoms like sleep deprivation or may be a response to depressive symptoms. [9,10]

Coach-athlete relationships

Athletes have reported stressors related to their coach relationships. This includes performance criticism or feedback, tension, and conflict.[10]

Spectators and the media

Some athletes are thrust into the public eye—think about how much coverage the Olympics gets compared to the normal spectatorship of some of the most popular events. Whether its criticism, words of affirmation, or expressed disappointment, external chatter can impact an athlete’s mental state.[10] 

Cultural and team issues

These can range from demanding training sessions, to the team atmosphere, interaction with teammates, or competing goals of teammates. Travel schedules and changes or uncertainty regarding training facilities or equipment can also cause stress. [10] 

If these stressors can’t be properly managed or coped with, then can act as catalysts for developing mental health symptoms. And mental health symptoms are prevalent in elite male athletes (defined as anyone who competes or has competed at the varsity, professional, national, or international level in a sport). Mental health symptoms can directly impair athletic performance, and common symptoms among male athletes include depressive moods, disordered eating, sleep problems, and substance use. [11] 

Depressive symptoms and overtraining in male athletes 

It’s estimated that up to 68% of elite athletes experience depressive symptoms, and there may be a higher prevalence in individual sports compared to team sports. [11] Female athletes are more likely to report depressive symptoms than their male counterparts. 

Impact on athletes:

• Loss of focus during training and in competition
• Decreased motivation
• Intrusive thoughts of failure [11]

According to the International Olympic Committee, overtraining should be considered as a relevant factor in athletes experiencing depressive symptoms, as overtraining is associated with a depressive mood. [11] Overtraining syndrome can be summarized as excessive exercise without enough rest or recovery. It not only results in mood changes but impacts hormonal health, immune system functioning, and performance. [12] Low testosterone levels and high creatine kinase levels (an enzyme in the body that indicates muscle damage) are objective signs of overtraining that can be measured through blood work.[13] Athletes may think training more will improve performance, but training too much can impede it (read more about overtraining in this blog). [14]

Diet is also associated with mood and depressive symptoms. Nutrients like omega-3 fatty acids, selenium, folate, zinc, vitamin B6, and vitamin D all have research supporting their role in improving or maintaining good mental health. Read more about those foods here. 

The impacts of disordered eating and underfueling among male athletes

Up to 19% of male athletes have an eating disorder or engage in disordered eating. [11] Disordered eating patterns are more common than a diagnosed case of anorexia nervosa or bulimia nervosa. [11] However, it is well observed that these symptoms are often underreported. Dissatisfaction with body image is reported to be the strongest predictor of disordered eating in athletes. [11,15] 



Disordered eating is a concern for all male athletes, regardless of sport type. [11] One study of Brazilian male athletes found that nearly 25% of the 156 men included reported disordered eating behaviors and there were no differences in prevalence between different types of sports (like weight class sports such as boxing vs. endurance sports vs gymnastics). [16] And other studies—particularly in wrestlers—have found an association with athletics and disordered eating. [15] Athletes in weight class sports are also at greater risk for underfueling (read more about underfueling and its consequences in this blog). [17]

Impact of disordered eating on athletes: 

• Increased risk of muscle loss and stress fractures [11] 
• Lower energy stores and energy availability [17]
• Increased risk of dehydration and electrolyte imbalances [17]
• Decreased muscle strength and endurance performance related to underfueling [17] 

Underfueling also puts the body under stress, so the fight or flight hormone cortisol may be elevated. Testosterone levels are also likely linked to underfueling, but research is still ongoing. [17] Read more about underfueling and its consequences in this blog.

Athletes should talk with a sports dietitian or mental health professional if they think they may be underfueling or if they have an unhealthy relationship with food. 

Poor sleep can perpetuate physical and mental fatigue and stress

Sleep problems can occur on their own, but there is a strong link between depression and sleep disturbances like insomnia. [18] Sleep deprivation can also be a contributing factor to feelings of anxiety, depressive thoughts, and mood swings. [19] And many athletes experience some type of sleep problems in their careers, including sleep restriction or deprivation. Almost anything can impact sleep: travel, training, stress, pressure, and late or early competition times. Around 50% of college athletes get insufficient sleep (or less than seven hours per night) in season, around 50% of Olympic athletes qualify as poor sleepers (reporting more than one sleep concern), and athletes often sleep poorly the night before a competition. [11] A 2019 study in Brazilian Olympic athletes also found that men took significantly longer to fall asleep and spent more time awake in the middle of the night compared to women. [20] 



Impact of poor sleep on male athletes: 

• Sleep regulates hormones like testosterone and growth hormone, and maintaining optimal levels is essential for muscle recovery and growth
• Sleep deprivation affects training and performance of elite athletes [21]
• Sleep deprivation has been shown to decrease running performance, submaximal strength, and spring times while negatively affecting mood [22]
• Prolonged sleep deprivation can result in chronic inflammation, resulting in increased susceptibility to illness and injury

Melatonin is the best studied sleep aid in athletes. Melatonin is a hormone the body produces to help induce sleep, but it can be found as a supplement. Melatonin supplements promote sleep without negatively impacting performance. [11] Read more about the popular sleep supplement in this blog. Room temperature, humidity, light, and noise can all either positively or negatively impact sleep. Check out this blog for tips on getting a more restful sleep (it’s not just, go to bed earlier).  

Treatment for sleep disorders like insomnia or sleep apnea should be overseen by a medical provider. 

The use of alcohol and other substances as a coping mechanism

Men are more likely than women to turn to alcohol as a result of mental health concerns. Alcohol is also one of the most used substances among athletes—around 19% of current and former elite athletes reported symptoms of alcohol misuse. [23] Lacrosse, hockey, football, weight lifting, and skiing are some of the male sports with the highest rates of substance use. [11] Athletes may turn to alcohol to cope with an injury, relieve stress or feelings of anxiety, boost confidence, or bond with a team. [11]  

The team culture plays a major role in influencing the norms or practices around drinking. [11] While alcohol can be a part of a balanced diet, misuse needs to be addressed and coaches, parents, and trainers are needed to create a supportive environment for athletes.   

Impact of alcohol misuse on athletes: 

• Dehydrates the body [24]
• Impairs aerobic performance [24]
• Impairs motor skills (including during hangovers) [25, 26]
• Decreases strength, power, and spring performance [27]

While alcohol is still one of the most used substances in men and in athletes, marijuana has replaced nicotine as the second most widely used drug. [11] One study showed that males in youth sports had significantly higher rates of initiating marijuana use compared to female athletes, with decreased rates in alcohol use. [28] Heavy and even regular use of marijuana may decrease motivation, trigger anxiety, and even promote aggression. [11] And the research is continually evolving. For more on the research behind cannabidiol AKA CBD, a derivative of hemp rather than marijuana, check out this blog.

Supporting men’s mental health in athletics

It’s clear that men’s mental health issues have been hiding in plain sight, shoved under the rug, and not talked about. But that conversation (or lack thereof) is shifting. Michael Phelps was one of the first and is now one of the most influential voices when it comes to advocating for the mental health of men and all athletes. His 2020 HBO documentary The Weight of Gold shed light on some of the same unique stressors discussed here that Olympic athletes face, the lack of resources athletes have available, and how the environment perpetuates the cycle of mental health conditions. Cole Sager was willing to share his story with us, and to his over 278,000 Instagram followers. Conversations like the ones these men are initiating are setting the stage for making it OK for men, boys, and athletes to talk about mental health. 



But more systemic change is also needed to halt this current toxic cycle. The future of men’s mental health in sport should encompass (at the least):

• Providing mental health training to leaders (coaches, trainers, etc.) in the athletic space to create an environment in which these concerns can be shared and addressed 
• Improving, normalizing, and increasing mental health care access for athletes
• Establishing appropriate diagnostic tools that are appropriate for men [5] 
• Investing in research to establish evidence-based solutions to adequately treat mental health symptoms and concerns of men [5]

Having a successful career as an athlete isn’t solely dependent on physical performance. Mental health needs to be addressed for optimal performance and true longevity in an athletic career. 

Mental health resources for athletes, coaches, and men:

• National Alliance on Mental Illness
• National Institute of Mental Health
• NCAA 
• The Moving On! Program 
• Man Therapy
• The Baron Depression Screener for Athletes (used to determine whether athletes should be screened further by a mental health professional 

References: 

1. https://pubmed.ncbi.nlm.nih.gov/27486418/
2. https://www.ncbi.nlm.nih.gov/pubmed/26043341
3. https://www.nimh.nih.gov/health/statistics/suicide
4. https://www.ncbi.nlm.nih.gov/pubmed/30227658
5. https://www.ncbi.nlm.nih.gov/pubmed/29673272
6. https://www.ncbi.nlm.nih.gov/pubmed/31184251
7. https://pubmed.ncbi.nlm.nih.gov/30569248/
8. https://www.ncbi.nlm.nih.gov/pubmed/29159546
9.  https://pubmed.ncbi.nlm.nih.gov/27486418/
10.  https://pubmed.ncbi.nlm.nih.gov/22691400/
11.  https://pubmed.ncbi.nlm.nih.gov/31097450/
12. https://www.ncbi.nlm.nih.gov/pubmed/27660501
13. https://www.ncbi.nlm.nih.gov/pubmed/24688268
14. https://pubmed.ncbi.nlm.nih.gov/20086477/
15. https://pubmed.ncbi.nlm.nih.gov/25916949/
16. https://pubmed.ncbi.nlm.nih.gov/24142083/
17. https://pubmed.ncbi.nlm.nih.gov/29773536/
18. https://www.ncbi.nlm.nih.gov/pubmed/18979946
19. https://www.ncbi.nlm.nih.gov/pubmed/30186717
20. https://www.ncbi.nlm.nih.gov/pubmed/32318244
21. https://pubmed.ncbi.nlm.nih.gov/18076267/
22. https://www.ncbi.nlm.nih.gov/pubmed/31288293
23. https://pubmed.ncbi.nlm.nih.gov/31097451/
24. https://www.ncbi.nlm.nih.gov/pubmed/22254055
25. https://pubmed.ncbi.nlm.nih.gov/17286346/
26. https://pubmed.ncbi.nlm.nih.gov/27166364/
27. https://www.ncaa.org/sites/default/files/Alcohol%20and%20Athletic%20Performance%20Fact%20Sheet.pdf
28. https://pubmed.ncbi.nlm.nih.gov/26594059/