IOC Mental Health in Elite Athletes Toolkit 2021

I O C M E N TA L H E A LT H I N E L I T E
AT H L E T E S T O O L K I T
S P R I N G 2 0 21
Human well-being must be at the heart of elite
athletic performance. Athletes should feel
empowered and nurtured both physically and
mentally… mental health and physical health
are two halves of a whole, and care
for both must be seen as priority.
ABHINAV BINDRA
Olympic champion; IOC Athletes’ Commission member;
IOC Mental Health Working Group member
CONTENTS
FOREWORD �� 4
SECTION 1. INTRODUCTION �� 6
SECTION 2. MENTAL HEALTH SYMPTOMS AND

DISORDERS IN ELITE ATHLETES ��14
SECTION 3. ROLES AND RESPONSIBILITIES�� 23
SECTION 4. RESOURCES �� 80
3
P R O F. D R U Ğ U R E R D E N E R MR SERGEY BUBK A MS KIRST Y COVENTRY
IOC Medical and Scientific Commission Chair IOC Entourage Commission Chair IOC Athletes‘ Commission Chair
FOREWORD
IOC Mental Health in Elite Athletes Toolkit
Foreword by Uğur Erdener, Sergey Bubka and Kirsty Coventry
The well-being of athletes has always been and will always be the top priority of the
International Olympic Committee and the entire Olympic Movement. Athletes often seem
to embody the feelings of joy and hope, and they give the very best of themselves to
achieve their dreams; but like us all, they may also find themselves in need of mental health
support. It is important to remember that elite athletes are people first, and that their
mental health is just as important as their physical health.
It is with this understanding and knowledge that the IOC Mental Health in Elite Athletes
Toolkit has been developed by the IOC Medical and Scientific Commission, the IOC
Athletes’ Entourage Commission and the IOC Athletes’ Commission, which, respectively,
we have the privilege to chair.
As a sporting community, we need to create a sporting environment that better supports

athletes’ mental well-being and mental health. This toolkit is the first step in that journey.
It is a trusted and valuable resource for Olympic Movement stakeholders - IFs, NOCs,
athletes’ entourage members, healthcare professionals, national federations, clubs and
teams - to be used in developing and implementing initiatives and best practices related
to the protection and promotion of mental health and well-being in elite athletes.
We believe that the information available within this toolkit can and will make a difference
to the lives of elite athletes around the world. We also strongly believe that athletes’
mental health and wellness should be a collective concern, and we thank you for making
it a priority within your organisation.
5
1. INTRODUCTION
1.1 Why develop this toolkit?
1.2 To whom the toolkit applies
1.3 Foundation
1.4 How was this toolkit developed?
1.5 How to use the toolkit

IOC MENTAL HEALTH IN ELITE ATHLETES TOOLKIT – SECTION 1: INTRODUCTION
This toolkit is aimed at assisting Olympic Movement stakeholders,

including International Federations (IFs), National Olympic Committees
(NOCs), National Paralympic Committees (NPCs), athletes’ entourage
members, healthcare professionals and other stakeholders such as National
Federations (NFs), clubs and teams, to develop and implement initiatives
related to the protection and promotion of mental health and well-being in
elite athletes.
1.1. WHY DE VE LOP THIS TOOLKIT? Whilst it is estimated that the prevalence of

mental health symptoms and disorders may be
even higher in elite athletes than in the general
It is estimated that approximately 13 per cent of
population, it is important to note that all
the global population experience some form of
athletes can optimise their mental well-being and
mental health disorder.(1) Indeed, mental health
life balance.
disorders have been found to be one of the leading
causes of functional impairment worldwide, This toolkit is intended to equip Olympic Movement
causing the highest disease burden.(2,3,4) stakeholders with the knowledge and guidance to
protect and promote elite athletes’ mental health
Whilst evidence consistently demonstrates
and well-being.
that regular physical activity is associated
with improvements in physical and mental
13 %
wellness, studies nonetheless show that just
over one in three athletes may experience mental
OF THE GLOBAL
health symptoms.(5,6) POPULATION EXPERIENCE
SOME FORM OF MENTAL
Despite their unique sporting talents, athletes DISORDER
are not immune to mental health challenges,
such as burnout, distress, anxiety, depression,
unhealthy eating patterns, insomnia and alcohol 1.2. TO WHOM THE TOOLKIT APPLIES
or drug misuse.(6)
Many different factors can impact athlete mental This toolkit has been developed for IFs, NOCs,
wellness: Injury, performance pressures, dealing athletes’ entourage members, healthcare
with failure and/or success, and career transition professionals and other stakeholders, including
out of sport are all associated with mental health NFs, clubs and teams. The toolkit is intended to
symptoms. This is in addition to the life challenges provide resources to benefit the health and mental
experienced outside sport, such as grief, well-being of athletes.
relationship conflicts and financial difficulties.
7
1.3. FOUNDATION IPC Code of Ethics (2016)(10)
Article 1.5: “Safeguard the athletes’ physical and

The protection and promotion of athletes’ mental mental health and equilibrium.”
health and well-being is encompassed within the
fundamental principles and frameworks of the Article 1.6: “Not tolerate any practice constituting
Olympic and Paralympic Movements, including: any form of physical or mental injury. All forms
of harassment including physical, mental,
The Olympic Charter (in force from July 2020)(7) professional, or sexual, are prohibited.”
Article 1.10: “The IOC’s role is …to encourage and Basic Universal Principles
support measures relating to the medical care and of Good Governance (2008)(11)
health of athletes;”
Article 6.3: “Sports organisations shall adopt rules
IOC Athletes’ Rights and Responsibilities for the protection of the athletes’ health and to limit
Declaration (2018)(8) the risk of endangering the athletes’ health.”
Article 1.7: promotes “the protection of mental and The IOC Olympic Movement Medical Code (2016)(12)
physical health, including a safe competition and
training environment and protection from abuse Article 1: “The Olympic Movement, to accomplish
and harassment.” its mission, encourages all stakeholders to take
measures… necessary to protect the health of
IOC Code of Ethics (2020)(9) participants by minimising the risks of physical
injury, illness and psychological harm.”
Article 1.5: “Respect for the universal
fundamental ethical principles is the foundation Article 2.1.1: “Conditions and environments of
of Olympism. These include: … Ensuring the training and competition must be conducive to the
participants’ conditions of safety, well-being and physical and psychological well-being of athletes…”
medical care favourable to their physical and
mental equilibrium.” Article 2.1.4: “For the benefit of all concerned,
measures to safeguard the health of the athletes
and to minimise the risks of physical injury and
psychological harm must be publicised.”
International Paralympic Committee (IPC)

Medical Code (2011)(13)
Article 1: “The Paralympic Movement, in

accomplishing its mission, should encourage
all stakeholders to take measures… necessary
to protect the health of participants and to
minimize the risks of physical injury and
psychological harm.”
Article 40: “No practice constituting any form of

physical injury or psychological harm to athletes is
acceptable. Members of the Paralympic Movement
must ensure that the athletes’ conditions of safety,
well-being and medical care are favourable to their
physical and mental equilibrium. They must adopt
the necessary measures to achieve this end and to
minimize the risk of injuries and illness.”
Article 42: “For the benefit of all concerned,

measures to safeguard the health of the athletes
and to minimize the risks of physical injury and
psychological harm should be publicized.”
The Olympic Movement, to accomplish

its mission, encourages all stakeholders
to take measures… necessary to protect
the health of participants by minimising
the risks of physical injury, illness and
psychological harm.
THE OLYMPIC MOVEMENT MEDICAL CODE (2016)
9
1.4. HOW WAS THIS TOOLKIT DE VE LOPE D? MARGO MOUNTJOY
Canada
This IOC Mental Health Toolkit has been

developed in collaboration with the IOC Mental
Health Working Group and a Virtual Task Force
composed of representatives from IFs, NOCs,
NPCs and IOC Athletes’ Entourage Commission
members. The goal of this process is to provide
recommendations that are relevant, applicable
and aligned with research and international
expert consensus.
WORLDWIDE PARTNE RS
International Judo Federation:

VLAD MARINESCU
Chief Media and Marketing Officer MARGOT PUTUKIAN
USA
World Rugby:
MARK HARRINGTON
Head of Technical Services
FIFA:
ANDREW MASSEY
Medical Director CHERI BLAUWET
Paralympian, USA
ALEXIS WEBER
Head of Anti-doping
International Bobsleigh and Skeleton Federation:

DARRIN STEELE
Vice President Sports
DAVID MCDUFF
USA
US Olympic and Paralympic Committee: KAREN COGAN

AMBER DONALDSON Senior Sport Psychologist
Vice President, Sports Medicine
Colombian Olympic Committee:

PAULO VILLAR
Chair, Athletes’ Commission
Maltese Olympic Committee:

ALAN CURRIE VINCENT GOUTTEBARGE
JOSEPH CASSAR
UK Chair, France/Netherlands
Secretary General
ROSEMARY PURCELL
Australia
NICCOLO CAMPRIANI OLY ABHINAV BINDRA OLY

Olympian, Italy Olympian, India
Uganda Olympic Committee: Jordan Olympic Committee: NASSER MAJALI Fiji Association of Sports and National
NANA JACQUELINE NAKIDDU NADIN DAWANI Secretary General Olympic Committee:
Chairperson, Medical Commission International Relations Manager MATELITA VUAKOSO
Voices of Athletes (VOA)
Project Officer
The IOC Mental Health Working Group The Virtual Taskforce
11
1.5. HOW TO USE THE TOOLKIT
This toolkit is divided into four main sections:
INTRODUCTION
SECTION 1 outlines the objective and scope of the
toolkit, to whom it applies and how it was developed.
It also details the frameworks that provide the
foundation and directives for Olympic Movement
stakeholders to address this important topic.
MENTAL HEALTH
SYMPTOMS AND
DISORDERS IN
ELITE ATHLETES
SECTION 2 provides an overview of the
multifaceted aspects of mental health symptoms
and disorders in elite athletes, including
terminology, prevalence and an overview of the
IOC Mental Health Consensus Statement (2019).
ROLES AND
RESPONSIBILITIES
SECTION 3 outlines the roles and responsibilities of
three key stakeholder groups related to the creation of a
psychologically supportive athletic environment. These
stakeholder groups are: sports organisations, athletes’
entourage members and health care professionals.
RESOURCES
SECTION 4, the final section of the toolkit,
highlights available resources and where to find
further information.
THIS TOOLKIT IS UNDERPINNED BY RESEARCH AND BEST PRACTICE GUIDELINES.
13
2 . M E N T A L H E A L T H
SYMPTOMS AND
DISORDERS IN
E L I T E AT H L E T E S
2.1. Terminology
2.2. International Olympic Committee

Consensus Statement (2019)
2.3. Overview of mental health symptoms

and disorders in elite athletes
2.4. Prevalence of mental health symptoms

and disorders in elite athletes
IOC MENTAL HEALTH IN ELITE ATHLETES TOOLKIT – SECTION 2: MENTAL HEALTH SYMPTOMS AND DISORDERS
This section provides an overview of the multifaceted aspects of mental

health symptoms and disorders in elite athletes and an introduction to the
IOC Mental Health Consensus Statement 2019.
2.1. TE RMINOLOGY Elite Athlete
Many terms are used when discussing mental The IOC Mental Health Working Group defined
health and occasionally these terms are used the elite athlete as an Olympic, Paralympic,
interchangeably. In this document we use the professional or collegiate athlete, though it is
following terms with the following meanings: acknowledged that this category is abstract and
risks overlooking some individuals who have
Mental Health devoted significant time and effort to the pursuit of
athletic excellence.(18)
A state of well-being in which an individual realises

his or her own abilities, can cope with the normal REMEMBER:
stresses of life, can work productively and is able
to make a contribution to his or her community.(14)
Mental health exists on a continuum.
Mental health is personal and subjective,
An athlete can be mentally healthy, may
and includes:
have a mental health disorder, or may be
1. a sense of internal well-being in between experiencing mental health
symptoms. Some mental health symptoms
2. feeling in line with one’s own values and beliefs and disorders can have a wax-and-wane
3. feeling at peace with oneself pattern, for example, periods of good mental
health alternating with episode of sadness or
4. feeling positive and optimistic about life(15) depression.
Athletes experiencing a mental health

Mental Health Symptoms disorder can recover and have periods of
optimum mental health, while athletes
Self-reported negative patterns of thinking, without mental health symptoms or
emotions and behaviours that can/may cause disorders can experience times of poor
distress and/or interfere with functioning, including mental health (such as feeling stressed or
sports performance.(16) overwhelmed).
Therefore, it is important to improve

Mental Health Disorders understanding and awareness of mental
health symptoms and disorders in elite
Clinically diagnosed conditions which produce athletes, to recognise the signs, and to
significant and persistent changes in a person’s create a culture that supports help seeking.
thinking, emotions and/or behaviours that are We shall discuss each of these points in
associated with significant distress and/or SECTION 3 of the toolkit.
disability in social, occupational or other important
activities, like learning, training or competition.(17)
15
14,689
2.2. M ENTAL HE ALTH IN ELITE ATHLE TES:
INTERNATIONAL OLYMPIC COMMITTEE
CONSENSUS STATEMENT (2019) (18)
In 2018, the IOC convened a consensus meeting

at which a panel of 23 experts from 13 nations
SCREENED ARTICLES
reviewed the scientific literature addressing mental
23 13
health symptoms and disorders in elite athletes.
The expert panel screened 14,689 published

articles, analysing the current best evidence
to provide a consensus statement to inform
clinical practice, guide individual and systemic
interventions and improve mental health
among athletes. EXPERTS NATIONS
The consensus statement, which provides the foundation for this toolkit,
addresses the following key areas:
Background and methods Major stressors and key environmental factors

that influence elite athlete mental health
Defines the mandate of the expert panel, the aim
of the consensus paper, who it applies to, and the Shares the consensus findings on harassment and
consensus process. abuse; how injury, performance and mental health
intersect; barriers to seeking care for mental health
General prevalence of mental health symptoms and disorders; the athlete’s transition
symptoms and disorders in elite athletes out of sport; mental health emergencies and how
it may be possible to create an environment that
promotes mental well-being and mental resilience.
Provides an evidence-based overview of the
prevalence of mental health symptoms and
Special considerations: mental
disorders in elite athletes.
health in Paralympic athletes
General approaches to management

of mental health symptoms and Details specific considerations related to mental
disorders in elite athletes health in Paralympic athletes, including prevalence.
Future directions
Outlines general management approaches
including psychotherapy and pharmacological
treatment. Provides 13 suggestions for possible future
direction for additional research, change
Specific mental health symptoms in clinical practice, and optimisation of
and disorders in elite athletes environmental factors.
Considers specific mental health symptoms

and disorders in elite athletes.
17
2.3. O VE RVIE W OF ME NTAL Studies have shown that the most common
HE ALTH SYMPTOMS AND presentations of mental health symptoms and
DISORDE RS IN E LITE ATHLE TES disorders in elite athletes include:
Regular participation in sport has been Anxiety

demonstrated to have a great number of benefits,
including for physical, psychological and social Excessive fear, anxiety-related behavioural
health.(19) There is also a growing body of disturbances (including phobias and panic attacks)
literature that recognises the positive effects of
exercise on mood states such as anxiety, stress
Depression
and depression.(20) However, despite these well
recognised benefits, elite athletes appear to
experience levels of mental health symptoms and Persistent and pervasive sadness/low mood,
disorders similar to the general population.(21) Some excessive fatigue and loss of interest/pleasure
conditions such as eating disorders have even
been found to be more common in elite athletes.(22) Sleep-related problems
NOTE: Such as insufficient sleep, difficulty falling

or staying asleep, or misalignment of
sleep-wake patterns
Some of the hurdles for athletes seeking
help for mental health symptoms and Alcohol misuse
disorders are stigma, either self-imposed
or perceived through others, and low Includes drinking despite impaired function, harm
mental health literacy, meaning knowledge and alcohol dependence.
and beliefs about mental health disorders
that aid their recognition, management or
Eating disorders
prevention.(23)
Research has demonstrated that improving Disturbance of eating and related behaviours
mental health literacy can assist athletes in including excessive restriction, compulsive
seeking help.(23) This is why it is so important exercise, and/or bingeing and purging.(18,23,24,25)
for everyone involved in sport to have an
understanding of mental health symptoms
and disorders in elite athletes and of the role
that they can play in creating psychologically
safe sporting environments in which athletes
may train and compete.
You can find further information on the

barriers to seeking care for mental health
symptoms and disorders in SECTION 3.2.3.
The IOC Mental Health Consensus Statement

(2019)(18) further identifies the following mental The IOC Mental Health Consensus
health symptoms and disorders in elite athletes: Statement (2019) highlights factors
likely to be associated with mental
• Post-traumatic stress disorder and other health symptoms and disorders in elite
trauma-related disorders athletes. These include suffering severe
musculoskeletal injuries, undergoing
• Attention-deficit/hyperactivity disorder
multiple surgeries, suffering from
• Bipolar and psychotic disorders decreased sports performance or
tending toward maladaptive
• Suicide perfectionism.(26,27,28,29,30,31,32,33) These
• Other substance use and substance factors are discussed further in SECTION 3
use disorders (e.g., drugs) of this toolkit.
• Gambling disorder and other It is also important to consider that an

behavioural addictions. athlete might have mental health symptoms
or suffer from a mental health disorder with
Just as in the general population, the impacts of no apparent association between elite sports
mental health symptoms and disorders in athletes participation and the mental health condition.
can be severe and debilitating. For athletes,
those impacts may include poor performance, It is incumbent upon those working with
increased injury risk, delayed recovery from injury athletes to recognise the importance of
and decreased quality of life.(6) However, with athlete mental health and well-being to
appropriate and timely support and intervention overall athlete health and performance,
such impacts can be reduced. as well as educating athletes and all
stakeholders surrounding athletes to
recognise mental health symptoms and
Further information on mental health seek effective help.
symptoms and disorders in elite
athletes may be found in the IOC Mental
Health Consensus Statement (2019).
To read the full consensus statement,
please follow THIS LINK.
19
2.4. PRE VALE NCE OF ME NTAL HE ALTH SYMPTOMS AND DISORDE RS IN E LITE ATHLE TES
Determining the prevalence of mental health However, prospective studies have reported
symptoms and disorders in elite sport remains that mental health disorders occur in between
challenging, largely because elite athletes are not 5 and 35 per cent of elite athletes.(24,25,34,35,36,37,38)
an easily reachable study population, and that The infographic below details different mental
reliable, valid, sport-specific screening instruments health symptoms and disorders, and research
are scarce. results related to prevalence, as detailed in the IOC
Mental Health Consensus Statement (2019).(18)
ANXIETY AND DEPRESSION
33.6%
A 2019 meta-analysis found that 33.6% of elite
athletes and 26.4% of former athletes reported
symptoms of anxiety/depression.(6)
A 2020 study found a higher prevalence of anxiety

OF ELITE ATHLETES AND 26.4% OF
and/or depression in female athletes (26.0%) FORMER ATHLETES REPORTED
compared to male athletes (10.2%).(39) SYMPTOMS OF ANXIETY/DEPRESSION
SLEEP-RELATED SUBSTANCE USE

PROBLEMS AND SUBSTANCE
MISUSE DISORDERS
49%
OF OLYMPIC ATHLETES
WOULD BE CLASSIFIED The substances most commonly used and
AS “POOR SLEEPERS”
(A TERM THAT misused by elite athletes across countries, sports
INCLUDES MULTIPLE and genders are alcohol, caffeine, nicotine,
SLEEP PROBLEMS).(40)
cannabis/cannabinoids, stimulants and anabolic-
androgenic steroids.(18)
BIPOLAR AND
PSYCHOTIC
DISORDERS It is important to note that most of the
prevalence studies cited on this page are
A 2019 review notes that whilst evidence from Europe and North America. They
demonstrates that the typical age of onset of may therefore not be representative of all
bipolar and psychotic disorders coincides with athletes. Further research to determine
average peak performance in elite athletes, prevalence rates worldwide is required.
information on their prevalence in elite athletes and
their impact on athletic performance is limited.(40,41)
EATING DISORDERS ATTENTION-DEFICIT/

The estimated prevalence of eating disorders and/ HYPERACTIVITY
or disordered eating among athletes in
general ranges from 0 to 19% in men and from DISORDER
6 to 45% in women. These figures are higher than Though there is little data regarding the prevalence
in non-athletes.(43,44,45) of ADHD in athletes, a 2020 study of 333 elite
Swedish athletes found that 5.4% had symptoms
of ADHD.(39)
SUICIDE
5.4%
In the largest study of suicide in elite collegiate
student athletes in the USA, 7.3% of all athlete OF ATHLETES
deaths were attributed to suicide. However, HAD SYMPTOMS
OF ADHD
collegiate athletes still had a lower rate of suicide
than individuals within the same age group in the
general US population. A 2020 study found that
1 in 6 international athletics athletes reported
having experienced suicidal ideation.(46,47,48)
GAMBLING DISORDER
AND OTHER
POST-TRAUMATIC BEHAVIOURAL
STRESS DISORDER ADDICTIONS
AND OTHER A 2016 study investigating gambling among
TRAUMA-RELATED European professional athletes showed that 56.6%

had participated in some form of gambling during
DISORDERS the past year, and 8.2% had a gambling problem
(either current or in the past).(49)
Athletes may encounter traumatic experiences
from inside or outside sport, and such experiences
may range from sports injuries to life events
independent of a sports injury. Research on the ALCOHOL MISUSE
prevalence of trauma-related disorders in elite
A 2020 study reported that hazardous drinking
athletes is limited.(18)
was found in 25.8% of athletes.(39)
A 2018 meta-analysis found that 19% of athletes

and 21.1% of former athletes reported symptoms
of alcohol misuse.(6)
21
NOTES
3 . R O L E S A N D
RESPONSIBILITIES
3.1 Working Together
3.2 Role of the Athletes’ Entourage
3.3 Role of Sports Organisations
3.4 Role of Health Professionals
23
In this section we examine the roles and responsibilities of key stakeholder
groups in creating psychologically safe athletic environments. The key
stakeholder groups addressed here are the athletes’ entourage, sports
organisations and health professionals.
We explore a range of topics, including placing responsibilities or focus areas which influence
athlete mental wellness as a priority, creating the psychological safety of athletic environments,
a psychologically safe culture which supports there are many areas of crossover that will require
help‑seeking, considerations for sporting events, mutual understanding and support, as is seen in
and understanding pathways to care. the diagram below. We therefore encourage all
stakeholders to read this section in its entirety in
3.1. WORKING TOGE THE R order to gain a more comprehensive overview of
their role and how it complements efforts by other
key groups.
It is important to recognise that whilst various
stakeholder groups may have different roles,
SPORTS ATHLETES' HEALTH

CORE COMPONENTS ORGS ENTOURAGE PROFESSIONALS
Prioritising athlete mental health
Mental Health Action Plan
Crisis competency
Education & prevention
Understanding mental health stressors
Post-career transition
Resources & funding
Rules and regulations
Assessment & treatment competency
Establishing pathways to care
Understanding MH symptoms and

disorders in elite athletes
Supporting safe return-to-play
Encouraging help-seeking behaviours
Scheduling & event considerations
Diagram demonstrating crossover of different stakeholder roles and

responsibilities to foster psychologically safe athletic environments.
IOC MENTAL HEALTH IN ELITE ATHLETES TOOLKIT – SECTION 3: ROLES AND RESPONSIBILITIES
ROLE OF THE ATHLETES’ ENTOURAGE:

KEY LEARNING POINTS
• Entourage members should foster • It is important that entourage

psychologically safe athletic members know how to respond to an
environments; described as athlete who is in distress and know
environments where athletes feel safe how to help them determine the best
in taking interpersonal risks within the course of action.
sports ecosystem, feel accepted as an
integral part of the sports ecosystem,
• Entourage members should be
knowledgeable of the referral
and feel respected by the sports
pathways available if they have
ecosystem.(50)
concerns about an athlete’s mental
• The athletes’ entourage plays an health. Positive discussions around
enormous role in reducing the these pathways can reduce barriers
stigma around the discussion of to help seeking.
mental health. Particular attention
should also be paid to deconstructing
• It is advised that all entourage
members are familiar with the
cultural and gender-based taboos and
IOC Sport Mental Health Recognition
misconceptions.
Tool 1 (SMHRT-1),(51) which, although
• Entourage members should work not a diagnostic tool, was developed
with athletes to better understand to assist entourage members in
the stressors they face in all aspects recognising when an athlete may need
of their lives (e.g., competitive stress, further help and/or support.
personal stress and organisational
stress) in order to help develop
• It is important to be mindful of any
strategies, interventions or treatment
healthy coping strategies.
that athletes may be following to
• Mental health should have the same improve their mental health, and to
level of significance as physical facilitate a safe and supported return
health. Mental health screenings to play in the event that an athlete
should be included as a routine part has been absent from training or
of physical health screenings and competition for physical or mental
be actively encouraged by athletes’ health reasons.
entourage members.
25
3.2. ROLE OF THE ATHLE TES’ E NTOUR AGE In this sub-section we focus on all entourage
members, with the exception of health care
professionals and sports organisations, as
What is an athlete’s entourage? these stakeholders are specifically discussed
in SECTIONS 3.3 and 3.4.
The entourage consists of all the people

associated with an athlete including, but not limited
to, managers, agents, coaches, physical trainers,
medical staff, scientists, sports organisations,
sponsors, lawyers and any person supporting the
athlete’s sporting career, including family members
and friends.
Parents Friends
Primary
caregivers
Partners
Siblings Coaches
Managers
Sport
Scientists Strength &
ILY & FRIENDS
FAM Conditioning
Agents Specialists
Lawyers
L
IA
Mental
RC
PE
Skills
RF
ME
Trainers
ORM
LEGAL & COM
Athletic
ANCE
Trainers
Sponsors Sport
Psychologists
ATHLETE
OR
AN
G
IS T
H
AT AL
IO N
AL HE Psychiatrists
NOCs
Physiotherapists
Psychologists
IFs NPCs
Nutritionists
Athletic
Trainers
Counsellors
NFs
Physicians
Other
health
providers
Diagram displaying an example of an athlete's entourage

Responsibility of the athletes’ entourage

E X TR ACT FROM THE IOC GUIDE LINES
FOR THE CONDUCT OF THE
Members of the athletes’ entourage often
ATHLE TES’ E NTOUR AGE
have a substantial influence on athletes.
It is therefore important that they always
act in their best interests.
2. GENERAL PRINCIPLES
In 2011, the IOC set out minimum standard
2.1. The Entourage must respect and
Guidelines for the Conduct of the Athletes’
promote ethical principles, including
Entourage.(52) The protection and promotion
those contained in the Olympic
of athlete mental health is encompassed in
Charter, the IOC Code of Ethics and the
these guidelines, as demonstrated in the
WADA Code.
following extract:
2.2. The Entourage must, in accordance
with such principles, always act in the
best interests of the athlete.
3. RESPONSIBILITY/ACCOUNTABILITY
3.1. The Entourage must always respect

the moral, physical and psychological
integrity of the athlete.
27
Entourage members have an important role to play
in supporting athlete mental wellness. In the elite The International Olympic Committee
sporting context, it is essential that mental health Mental Health Working Group developed the
symptoms are detected early and followed with Sport Mental Health Recognition Tool to
swift intervention.(53) Entourage members, being in assist entourage members in recognising
frequent contact with athletes, may therefore be in mental health symptoms or disorders in elite
the best position to recognise when an athlete may athletes. The SMHRT-1 can be found HERE.
be in need of support.
They also play an important role in fostering

athletic environments which are psychologically
safe and encourage help-seeking. Studies show,
however, that when it comes to mental health,
members of the entourage are often unsure
of what to do and are concerned that they
may unintentionally engage in behaviours that
negatively impact athletes.(54) This is an important
issue to address, and underlines why it is important
to be aware of the tools available (such as the
Sport Mental Health Recognition Tool-1) to assist
entourage members in recognising when an
athlete may be in need of specialist support, and to
improve understanding of mental health symptoms
and disorders in elite athletes. In this section we
therefore examine:
• Stressors and environmental factors that

influence elite athlete mental health
• How to foster psychologically safe cultures

that support help-seeking
• Understanding pathways to care

• Responding to a mental health concern
• Supporting safe return to play
IN FOCUS: COACHES
Coaches are hugely influential stakeholders in an athlete’s entourage. The IOC’s “Quality Of A Great
Sports Coach” guidelines(55) describe a good coach as being positive, enthusiastic, supportive,
trusting, focused, goal-oriented, knowledgeable, observant, respectful, patient and a clear
communicator.
As coaches tend to work closely with athletes on a day-to-day basis, they are afforded the opportunity
to ensure that mental wellness is placed as a priority, and are in a position to recognise differences
in moods, performance, social interactions and other changed or abnormal behaviours that might
indicate further support is needed.(56) In addition, support by a coach when an athlete is seeking or in
need of mental health treatment can greatly decrease stigma and improve help seeking behaviours
for athletes.
The able coach attempts to instil

confidence, inner peace, courage, ethics,
initiative, discipline, concentration, and a
sound respect for nutrition, training, a drug-
free body, and a balanced lifestyle in their
athletes – all of which have a profound
impact on self-image. Finally, the proficient
trainer seeks to promote efforts toward
self‑fulfilment and self-actualisation.
(57)
29
IN FOCUS: PARENTS/GUARDIANS/FAMILY/FRIENDS
Family and friends have a unique role in the life of an athlete and can create a strong and trusted
support system. Athletes may feel more at ease opening up about mental health concerns or
challenges to those closest to them, especially during their downtime when they have less direct
pressure from training or the need to perform. This close circle may include parents, siblings,
partners, friends, grandparents, etc.
Some symptoms and disorders (as well as life stressors) may be more readily identified by this group
due to the closeness of their relationships. This may especially be the case for observing changes in
mood or behaviour over time. This presents the opportunity to support athletes and communicate
with support networks to discuss mental health with confidence while in a safe environment.
IN FOCUS: PHYSIOTHERAPISTS AND ATHLETIC TRAINERS
Injury is a risk factor associated with mental health symptoms and disorders, and is a risk faced by
every elite athlete. When elite athletes are injured or ill and are not able to train or compete, there are
often mental challenges to overcome in addition to physical healing.
Physiotherapists and athletic trainers may play a crucial role in the early detection of mental health
symptoms and disorders. They may be in a position to notice changes in behaviour such as signs of
self-harm or indications of eating disorders or substance abuse. Furthermore, this group may also be
able to identify unhealthy training environments.
In a recent survey of sports medicine

physicians, it was found that 80% of the
time athletes coming to treatment for
an injury also discuss psychological
issues related to the injury. (58)
3.2.1 ATHLE TIC PE RFORMANCE In sport, mental health is often overlooked. It

AND ME NTAL HE ALTH is important to acknowledge that an athlete’s
mental health needs are as important as their
physical health needs, and that both contribute
The #MentallyFit continuum to optimising the athlete’s overall well-being in
conjunction with performance excellence.(56)
It is important to recognise that mental health

is on a continuum (FIGURE 1). Athletes who at one KE Y TAKE AWAYS:
point may be mentally healthy may at other times
experience mental health symptoms and disorders
that are influenced by environmental and other • An athlete’s mental health needs are as
factors.(59) This is the same for athletes as it is for important as their physical health needs.
the general population.
• In sporting culture, psychological illness
“Peak performance flows” or “zone states” are should be accepted as readily as physical
often correlated with full athletic potential and injury, and the same process of recovery
athletic performance, but athletic performance and return to sport process should apply.
and quality of life can be negatively affected by
the presence of a mental health disorder.
FIGURE 1
LIFE BALANCE
Occasional
symptoms
MENTAL HEALTH GOOD MENTAL
SYMPTOMS HEALTH
Some distress Well-being and
and dysfunction optimism
MENTAL HEALTH DISORDER PEAK PERFORMANCE

Likely distress and dysfunction Flow or zone states
INTERFERENCE WITH FULL POTENTIAL AND

LIFE AND PERFORMANCE Adapted from M Lardon, 2012 (59) OPTIMAL PERFORMANCE
31
3.2.2 U NDE RSTANDING STRESSORS A 2014 study by Sarkar & Fletcher(61) identified in
AND E NVIRONME NTAL FACTORS excess of 640 organisational stressors during
a professional sports career that may induce
common mental health disorders. These are
As for all of us, there are many stressors and
further divided into four categories: Leadership
environmental factors that can influence athlete
and personnel, cultural and team, logistical and
mental health. At elite levels, the intensity of
environmental, and performance and personal.
competition may lead to increased stress levels.
Additionally, athletes may also experience adverse Another important category of stressors which
life events outside sport, such as relationship athletes may experience are traumatic stressors.
issues, financial trouble, etc. which can exacerbate These stressors, which can be experienced
their stress level.(60) Both life-event stress and high inside or outside sport, may include bullying,
stress responses can in turn lead to an increased cyberbullying, physical abuse, psychological abuse
risk of injury.(18) As members of an elite athlete’s or sexual harassment or abuse.
entourage are often closest to the athlete on a day-
to-day basis, it is important that they are equipped As noted by Lazarus in 2000,(62) the ways in which
with the knowledge and skill to understand and athletes appraise and cope with these stressors
recognise key stressors and environmental factors can be a powerful determinant of the impact the
which may impact elite athlete mental health. stressors have on both their mental health and
their sporting success. As members of an athlete’s
entourage, it is important to recognise the impacts
What are the key stressors?
that such stressors can have on an athlete’s mental
health, and work with them to develop healthy
Key stressors can be split into three categories: coping strategies.
competitive stress, organisational stress and
personal stress.(61) These three categories are
not exclusive and can have knock-on effects or
impacts on other categories.
Competitive stress
• the environmental demands associated primarily

and directly with competitive performance
Personal stress
• the environmental demands associated

primarily and directly with personal
“non‑sporting” life events
Organisational stress
• the environmental demands associated primarily

and directly with the organisation within which
an individual is operating
Examples of competitive, personal and organisational stressors are

outlined in the below infographic:
FIGURE 2
ONAL STRESSO
RS RS
PE
• Work-life interface
• Family issues
• Death of a family member/friend
• Academic commitments
• Other work commitments
RS
CO
• Preparation • Leadership & personal
STRESSO
issues (e.g., entourage behaviour)
MP
• Injury
• Pressure • Cultural & team issues
(e.g., interaction, cultural norms)
E TITIVE S
• Under-performing
• Logistical & environmental issues
• Expectations
(e.g., facilities & equipment)
• Self-presentation
NAL
• Performance & personal issues

• Rivalry (e.g., finance, career transition,
• Major competition media attention)
IO
TR
• Unexpected success
AT
ES
O
IS
RS
S
A
N
G
OR
33
3.2.3 C RE ATING A PSYCHOLOGICALLY Breslin et al., (2017)(64) argues that athletes have
SAFE CULTURE AND ONE WHICH traditionally been poorly supported in managing
SUPPORTS HE LP SE E KING their mental health, with the perceived “costs” of
seeking help outweighing the benefits in a culture
where strength and power are celebrated and
In this context, when we speak of psychological
weakness is shunned. Consequently, that stigma,
safety, it is the creation of an athletic environment
either self-imposed or through others, inhibits
where athletes feel comfortable being themselves,
the willingness of an athlete to express emotion
can take necessary interpersonal risks, have the
and has a significant detrimental impact on an
knowledge and understanding of mental health
athlete’s willingness to seek treatment for mental
symptoms and disorders, and feel supported and
health issues.(63,65,66,67)
comfortable in seeking help if needed.
In addition to stigma there may be additional
In order to establish psychologically safe
barriers depending on an athlete’s cultural
environments that encourage help-seeking, it is
background. Dr Jacqueline Nakiddu, Medical
important to understand the key barriers that may
Commission Chair for the National Olympic
be faced by athletes. A 2012 athlete survey by
Committee of Uganda, notes that: “In Uganda and
Gulliver et al.(63) identified the following key factors
other African countries, mental wellness is rarely
(listed from 1-10 in the order of most applicable to
discussed and is surrounded by superstition.
least applicable):
Talking openly about feelings or emotions is
uncommon in most traditions, carries negative
BARRIE RS TO HE LP SE E KING perceptions, and is seen as taboo to the male sex”.
Indeed, studies have indicated that gender

may also be a determinant in seeking help,
1. Stigma
especially in cultures where males may be
2. Difficulty or unwillingness to express conditioned to be “stoic”, which can inhibit the
emotion willingness to seek help and lead to maladaptive
coping strategies.(64,68,69)
3. Lack of problem awareness
It is clear that members of an athlete’s entourage
4. Lack of time have a vital role to play in addressing barriers
5. Denial of problem to help-seeking, including reducing stigma and
fostering environments where mental health self-
6. Scared of what might happen awareness and expressing emotions is encouraged
and supported.
7. Impacts on ability to play or train
8. Not sure who to reach out to
9. Accessibility
10. Belief that it would not help

In addition to identifying the key barriers to help- Educational interventions aimed at improving
seeking, Gulliver et al.(63) also went on to determine mental health literacy have been widely
the key facilitators to help-seeking behaviours in recommended as a strategy to both prevent and
athletes. These were identified as: treat mental health symptoms and disorders
in elite athletes. It is important that these
interventions are evidence-based, developed in
KE Y FACILITATORS TO HE LP-SE E KING collaboration with professionals (such as sports
psychiatrists, sports psychologists and clinical
psychologists), and are tailored and adapted to the
1.
Education and awareness raising of
cultural and social context.
mental health issues and services
Such educational interventions should consider
2.
Social support
knowledge and understanding of self-management
3.
Encouragement from others strategies, including:(70)
4.
Accessibility (money/transport)
• challenging stigma
5.
Positive relationship with
entourage members • improving awareness and understanding around
mental disorders
6. Confidentiality
• the use of mental health or psychological
7.
Integration into athlete lifestyles
first‑aid to assist others
and cultures
8.
Openness and ease of • the facilitation of help-seeking behaviours
expressing emotions
9.
Time
10.
Positive past experiences
Over 40% of the barriers listed by

participants related to stigma and the
embarrassment an athlete would feel in
seeking help... a lack of knowledge
about symptoms of mental disorders
was considered a major barrier. (63)
35
Positive relationships with entourage members, In summary, whilst there are many barriers that
social support and encouragement are all key athletes may face in recognising, acknowledging
facilitators to help-seeking. Studies have found and seeking help for mental health concerns,
that coaches – as leaders of the social group – members of the entourage play a crucial role in
have the opportunity to actively impact athlete addressing these barriers and working to overcome
mental health in a positive manner,(54) including them. Cultivating athletic environments where
taking steps to reduce stigma. These steps understanding and communication about mental
may include: health are encouraged and services are made
available if an athlete needs support is key.
• Normalising conversations around

mental health and psychological stress
• Easing access to mental health

professionals and encouraging
support seeking
• Practising communication skills such

as empathic listening, which may
contribute to creating greater ease and
understanding when responding to an
athlete raising concern
• Collaborating with athlete role models

and educating them on how they may
help others by addressing stereotypes
and de‑stigmatising mental health
conversations(64)
The National Collegiate Athletic Association

(NCAA) has designed education
materials specifically for coaches. These
communication tools can be found HERE.
FIGURE 3 3.2.4 U NDE RSTANDING

PATHWAYS TO CARE
In this section we look to better understand the

pathways to care for athletes. As gatekeepers and
trusted confidantes, it is important that members
of an athlete’s entourage understand how to
further support the athlete should they express
concerns regarding their mental health.
PREVENTATIVE OR
‘FOUNDATIONAL’
COMPONENTS
INDICATED (AT RISK) EARLY
• Building mental PREVENTION INTERVENTION
health literacy COMPONENTS SPECIALIST
For emerging MENTAL
• Individual athlete Early detection (e.g., first episode)
development and and identification HEALTH CARE
or existing mental
skill acquisition (by navigators) health problems
• Mental health
screening and
feedback
Purcell et al., 2019
37
It is important to mention that entourage members should not attempt to
diagnose athletes’ mental health without the appropriate background or
training needed to do so. This is why a clear and structured pathway to
determine the most effective route to assessment and treatment for each
individual athlete should be established and followed.
RECOGNITION/
EARLY DETECTION:
The earliest recognition of mental health
symptoms or disorders may often be by those
PREVENTION: closest to the athlete: a family member/close
friend, a coach, physio or other members of the
The first step in pathways to care, as shown in entourage, who might notice changes in behaviour
FIGURE 3,(53) encompasses prevention and or other signs and symptoms, and to whom
foundation; establishing a safe environment for an athlete may disclose concerns. Because of
athletes and entourage members to recognise their access and proximity, athletes’ entourage
and promote the importance of mental health members are therefore key stakeholders in an
and well-being. This includes practices such as athlete’s pathway to care and may find themselves
regular check-ins to discuss how athletes are responsible for taking the first steps. These first
feeling, standardised screening for mental health steps may include reducing stressors, adapting
symptoms or disorders, education in mental an athlete’s immediate environment and/or
health literacy, building supportive and trusting promoting or facilitating access to professional
personal relationships, and removing the stigma care. But how do you know if an athlete needs
surrounding requesting assistance for mental further support? The IOC’s Mental Health Working
health care. Although each athlete is unique, Group has developed The IOC Sport Mental Health
these elements are the foundation of every Recognition Tool (SMHRT-1).(51) The SMHRT,
athlete’s pathway to care. although not a diagnostic tool, was developed
specifically for athletes, coaches, family members
and all other members of an athlete’s entourage
to assist in determining if an elite athlete requires
further professional assistance. You can find more
information on this tool in SECTION 3.2.5.
EARLY
INTERVENTION:
This is described as being “necessary in instances
where the performance and life demands placed
on an athlete exceed their ability to cope (i.e. major
SPECIALIST
career-threatening injury or significant life
stress)”.(53) In this case, when you recognise that
MENTAL HEALTH
an athlete needs formal or professional care, early
intervention by sports or clinical psychologists or CARE:
psychiatrists, or medical staff where appropriate, The final step in pathways to care is seeking
is required. This should ideally be provided by specialist mental health care. This is required when
in-house professionals or professionals who are athletes experience severe or complex mental
known to the athlete and are part of the club/ health problems that cannot be addressed purely
team’s network. As part of early intervention, by preventative measures or early intervention.
mental health clinicians will offer individualised The need for a referral to a mental health specialist
approaches specific to the context and situation will usually be made by the team doctor. In the case
of that athlete in order to target the psychological of a mental health emergency, clinicians should
processes and other factors that are impeding the follow the club/team’s Mental Health Emergency
athlete’s return to mental health or wellness. More Action Plan (MHEAP). The development of such
information for mental health professionals on action plans is discussed in SECTION 3.3.2. As a
early intervention can be found in SECTION 3.4. member of an athletes’ entourage, check that your
team/club has a MHEAP and if so, understand your
role in it.
Although you may wish to solve all of the athlete’s problems, there are limits to what you can
do without specialised mental health training – being understanding and facilitating access to
appropriate care are extremely important.
It is important to keep in mind that treatment cannot be forced. Aside from when an athlete poses an
immediate danger to themselves or others, you can only encourage and support an athlete in seeking
further help. For cases involving minors, primary caregivers (e.g., parents/guardians) should assume
the responsibility of initiating help-seeking if an athlete may be unwilling.
39
3.2.5 T HE IOC SPORT ME NTAL HE ALTH 3.2.6 R ESPONDING TO A
RECOGNITION TOOL 1 (SMHRT-1) ME NTAL HE ALTH CONCE RN
The IOC Sport Mental Health Recognition Tool 1 The framework shown in FIGURE 4 has been
(SMHRT-1)(51) was developed by the IOC Mental designed to assist members of an entourage to
Health Working Group to assist athletes, coaches, respond to an athlete who is in distress and may
family members and other members of an athlete’s need help determining the best course of action.
entourage to recognise mental health symptoms or If you have concerns about an athlete’s mental
disorders in elite athletes. health or wellness and decide to speak with them
about it, here are a few things to keep in mind:
The SMHRT-1 presents a list of athlete experiences
(thoughts, feelings, behaviours, physical changes) • Practise empathic listening
that could be indicative of mental health
problems. If an athlete reports and/or displays • Focus and relate to them as a person and not as
an athlete
these experiences and they are significant and/
or persistent, you, as members of the athlete’s • Let them know what specialist support is
entourage, have a crucial role in encouraging available
the athlete to get the support needed as early
as possible. • Consider their culture, gender, age and
social norms
The tool is simple, easy to use, and can be • Respect their right to make their own decisions
found HERE. (Please note that the SMHRT-1 related to seeking further help (unless
is not a diagnostic tool.) they present an immediate risk of harm to
themselves or others)
• Don’t judge or blame them for their symptoms

or actions
• Don’t promise things you cannot deliver or

provide inaccurate/false information
• Respect their need for privacy and don’t

pressure them to share their story
• Provide a safe space and environment to share

their concerns should they wish to
• Do not isolate or punish athletes for talking

about their mental health concerns
FIGURE 4
Athlete in distress
Do you know the athlete?
Yes No
Talk to the athlete Consider involving another

entourage member who has
Express concern an existing relationship with
the athlete
Are you concerned that there could be serious and immediate

danger to the athlete or to others?
Yes No
This is important,
THIS IS AN EMERGENCY but not an emergency
Contact emergency services Listen to and validate the
athlete’s concerns
Stay with the athlete until help
arrives (if it is safe for you) Offer to contact your club/
team's sports medicine
physician and/or licensed
mental health provider
Follow-up response
Follow the reporting and notification procedures designated by your club/team/organisation’s

Mental Health Emergency Action Plan (see SECTION 3.3.2).
Follow up with the athlete within 24 hours to determine if further action is needed.
Adapted from the NCAA Mental Health Referral Decision Tree(71)
41
3.2.7 SUPPORTING SAFE RETURN TO PLAY More formal check-up measures may include
regularly scheduled appointments with a health
care professional. Appointments should follow
After an athlete has been absent from training
a similar procedure as would be applied to injury
or competition, whether it be for reasons of a
rehabilitation. Normalising these appointments
physical or mental health problem, they need a
by approaching the issue as akin to any physical
safe and supported return to play. In this section,
injury can help athletes and stakeholders reduce
we will discuss supporting a safe return to play for
stigma and encourage open and honest mental
athletes whilst a mental health problem is being
health conversations. During this time, coaches
addressed.
and trainers can take extra measures to ensure
The first step in a supported return to play is that athletes are not segregated from team
simply checking in. Entourage members can environments, traditions or social interactions,
support athletes on an emotional, informational making sure that athletes do not feel left out
and motivational level. Engaging in informal or as if they are being punished for their mental
conversations regarding the athlete’s progress health issue.(73)
and mental status, supporting self-monitoring
Steps for a safe return to play should be created,
techniques, encouraging goal setting, and helping
initiated and supported as soon as long-term
to maintain motivation are strong initial steps of
rehabilitation begins for either a physical injury
support during the rehabilitation process.(72)
or mental health disorder. Considering that many
athletes have mental health symptoms during
rehabilitation for physical injuries, a supported
recovery can help aid in a faster and less
complicated recovery.(74)
It is important for coaches, athletic

trainers and team physicians to provide
support for injured athletes and keep
athletes involved and part of the team.
This might include keeping athletes
engaged and encouraging athletes to
seek help instead of “tough it out”. (75)
3.2.8 E XE RCISE: KE Y TAKE AWAYS FOR

ATHLE TES’ E NTOUR AGE ME MBE RS
We hope this section has helped to emphasise the

crucial role that members of an athlete’s entourage
play in protecting and promoting elite athlete
mental health. We recommend that you take some
time to reflect upon the section and consider
how what you have learnt may inform your own
relationships and interactions.
LIST THRE E TAKE AWAYS (THINGS WHICH STOOD OUT TO YOU) FROM THIS SECTION.
KE Y TAKE AWAYS:
1. ___________________________________________________________
___________________________________________________________
2. ___________________________________________________________
___________________________________________________________
3. ___________________________________________________________
___________________________________________________________
43
We now recommend that you complete this short
traffic light exercise:
Thinking back to what you have read in this section,

list three things that you will start doing, three
things that you will stop doing and three things that
you will continue to do related to cultivating and
promoting psychologically safe environments for
athletes that support help‑seeking.
LIST 3 THINGS THAT YOU WILL START DOING:
1. ___________________________________________________________
___________________________________________________________
2. ___________________________________________________________
___________________________________________________________
3. ___________________________________________________________
___________________________________________________________
LIST 3 THINGS THAT YOU WILL STOP DOING:
1. ___________________________________________________________
___________________________________________________________
2. ___________________________________________________________
___________________________________________________________
3. ___________________________________________________________
___________________________________________________________
LIST 3 THINGS THAT YOU WILL CONTINUE DOING TO

PROMOTE AND CULTIVATE PSYCHOLOGICALLY SAFE
ENVIRONMENTS FOR ATHLETES:
1. ___________________________________________________________
___________________________________________________________
2. ___________________________________________________________
___________________________________________________________
3. ___________________________________________________________
___________________________________________________________
45
ROLE OF SPORTS ORGANISATIONS:
KEY LEARNING POINTS
• Sports organisations have an • Organisations should develop

essential role in facilitating a safe and appropriate mental health policies
supportive environment that allows and communicate those policies to
athletes to feel comfortable in coming all departments and stakeholders,
forward with concerns about their regardless of the nature of their
mental health. relationship with athletes.
• A positive culture surrounding • All sporting organisations should

mental health should be adopted at develop a Mental Health Emergency
all levels of a sports organisation, Action Plan (MHEAP) to support
and supported by the top leadership/ athletes in the event of a mental
management. health emergency.
• Sports organisations also play a role • Those in sports organisations with

in promoting positive mental health specific mental health roles and
values within their local community, responsibilities for mental health
and should ensure that all internal should receive sufficient training to
policy is in line with public policy. support them in exercising their role.
• Sports organisations must recognise • Sports organisations should create

their duty of care and how that and implement career transition
extends to safeguarding athletes’ programmes to support athletes’
mental health. mental health as they make the
transition out of sport.
• Sports organisations should include
the protection and promotion of
mental health in formal written
documentation alongside the
protection of athletes’ physical safety.
3.3. ROLE OF SPORTS ORGANISATIONS Sports organisations also play an important role in

supporting mental health in the wider community
through the social support and resources
Sports organisations play a powerful role in
available to members. This may be especially
facilitating the creation of psychologically safe
effective when:
environments, not just for elite athletes, but
for all stakeholders linked to the organisation. • their organisations’ activities are aligned with
In this section we will discuss the roles and public policy concerning mental health and
responsibilities of sports organisations in physical activity
supporting elite athlete mental health, and outline
key recommendations. • they seek to utilise the power of
sport to help promote physical and mental
well-being.(76,77)
Recognition of the importance of mental
health and well-being by the top leadership “Sports organisations” includes, but is not limited
and at executive levels helps to foster to: National Olympic Committees, National
a supportive organisational culture Paralympic Committees, International Federations,
that can positively impact employees Continental Associations, National Federations,
and all of those who are influenced by clubs and teams.
the organisation.
The Olympic Movement, to accomplish

its mission, encourages all stakeholders
to take measures… necessary to protect
the health of participants by minimising
the risks of physical injury, illness and
psychological harm.
47
3.3.1 P L ACING ATHLE TE ME NTAL
WE LL-BEING AS A PRIORIT Y QUICK CHECK:
As discussed in SECTIONS 2 and 3.2 of this

Does your organisation specifically reference
toolkit, participation in sport has many benefits
the protection and promotion of mental
for both physical and psychological health.
health and well-being in its foundational
However, it is acknowledged that “the very nature
guiding documents?
of [sports] competition can provoke, augment
or expose psychological issues in athletes”.(16)
Knowing this and considering the duty of care
3.3.2 D E VE LOPING AND
that sports organisations have towards athletes,
IMPLE ME NTING ME NTAL HE ALTH
it is incumbent upon them to make certain that
POLICIES AND ACTION PL ANS
athlete mental wellness is placed as a priority and
that measures are in place to protect and promote
mental health and well-being. The next step is to verify that appropriate mental
health policies and action plans are in place.
One way for this to be clearly demonstrated is
by ensuring that the protection and promotion Policies and action plans clearly define the
of athlete mental health and the requirement approach your organisation intends to take to
to minimise the risk of physical injury and uphold the principles to which it has committed.
psychological harm are included in the formal Having policies related to “sports medicine
written documents that outline your organisation’s support” and “athletic and post career support”
authorities, commitments and responsibilities, (both of which should include athlete mental
for example, your organisation’s statutes, code health) has also been shown to be a factor in
of ethics, medical code, code of conduct, etc. influencing both individual and national athletic
(hereafter, foundational guiding documents). success.(78) Below we will seek to identify the key
By clearly stating this, your organisation is: mental health policies, action plans and guidance
that your organisation may look to develop and
1. Demonstrating a commitment to placing implement. These include:
mental well-being as a priority
– An organisational mental health action plan
2. Sending a strong message of support, which
may help to raise awareness and reduce the – A Mental Health Emergency Action Plan
stigma surrounding mental health (MHEAP)
3. Providing a foundation on which your – Mental health referral pathways

organisation’s mental health policies,
– Coaching frameworks and education related
guidelines and action plans can be developed.
to athlete mental health
Examples of how such provisions are included in
Other important organisational policies which also
the foundational guiding documents of the Olympic
help to protect the mental well-being of members
and Paralympic Movements can be found in
include those which address discrimination of all
SECTION 1.3.
kinds – which underpin harassment and abuse in
sport policies and diversity and inclusion policies.
BEST PRACTICE EXAMPLE:

The Mental Health Charter for Sport and Recreation, developed by the
Sport+ Recreation Alliance, encourages sports organisations to help embed
mental health and wellness in the sports and recreation sector by:
Publicly promoting and adopting good Actively tackling discrimination on the

mental health policies and best practice grounds of mental health to make sure
in sport and recreational activities. that everyone is treated with dignity
and respect.
Using the power of sport and recreation
to promote well-being, with a special Supporting the establishment of
focus on encouraging physical activity a network to work closely with the
and social interaction due to their mental health sector to develop
contribution to good mental health. resources and best practice.
Promoting positive public health Regularly monitoring performance,

messages using diverse role models assessing progress and taking positive
and ambassadors to reduce the stigma action on mental health issues.
attached to mental health issues.
49
Developing an organisational mental health action plan
A mental health action plan will help your organisation to translate commitments made into tangible
actions promoting and protecting athlete mental health. It will help you to set out key activities and/
or initiatives that your organisation can implement in order to prioritise mental health, and support best
practice such as:
Ensuring mental health and well-being is set as a priority
Developing organisational campaigns to raise awareness of mental health and the

role of sport in protecting and promoting mental and physical well-being
Developing coach, athlete and other stakeholder educational programmes and tools
Developing and implementing key mental health policies such as an

Emergency Mental Health Action Plan
Identifying champions of mental health, including athletes, entourage members,

leadership and community champions, to tackle stigma and improve recognition
Building formal and informal external support networks, including referral pathways,
links to community organisations, schools and mental health services
Creating and implementing effective athlete safeguarding policies, procedures

and education
Developing initiatives embracing diversity and inclusion
Developing initiatives that build a culture of support, promote open lines of

communication and foster mental wellness
Adapted from Orygen 2019(79)

Your organisational mental health action plan Ensuring the existence and
will provide a framework to help you outline the effective implementation of routine
key initiatives to be developed, the resources and mental health referral pathways
support required, timeframes, and how progress
will be monitored. In essence, it provides a tangible
Routine mental health referral plans are a key
roadmap to help you monitor your organisation’s
component in the recognition and diagnosis of
commitment and progress in protecting and
mental health disorders in elite athletes. These
promoting athlete mental health.
plans define the referral procedures that should
be followed in the event that an athlete presents
with a non-emergent mental health concern. Within
An example of a mental health action plan your organisation it is important to designate those
template for sports organisations can be people responsible for developing this plan and
found HERE.(80) those responsible for facilitating referrals.
An example of a Governmental Mental Designated persons should receive training
Health and Elite Sport Action plan can be in the recognition of signs and symptoms of
found HERE.(81) mental health disorders. It is also important
that the existence of key information related
to the plan is well communicated to all those
Ensuring the existence and effective in your organisation.
implementation of a Mental Health
Emergency Action Plan (MHEAP) Providing mental health education
within the framework of coaching
Mental Health Emergency Action Plans (MHEAPs) expectations and duties
outline the steps that are to be followed when
faced with an emergency or non-emergency Supporting the development of educational
mental health situation and the stakeholders who initiatives to improve mental health awareness
should be involved. MHEAPs are usually developed and understanding for critical stakeholders
by an organisation’s medical team in conjunction such as coaches is another significant form of
with licensed experts in mental health, such as organisational guidance. This education should
clinical psychologists or psychiatrists. be embedded in the framework of a coach’s
This plan should be well communicated throughout expectations and duties established by the
your organisation and to your key stakeholders to sports organisation – providing motivation,
make certain that they are aware of the procedure obligations and pathways for coaches to increase
to be followed if faced with a mental health their awareness and adapt their responsibilities
emergency. surrounding this issue.
As a sports organisation, it is your responsibility to

ensure that your organisation has an MHEAP, and
if not, to make sure that one is developed and that
those who are responsible for its implementation
are trained to do so.
51
3.3.3 RESOURCES AND FUNDING
In order to establish a solid and reliable mental BEST PRACTICE

health framework for athletes, sports organisations
must first recognise the need to allocate resources EXAMPLE: NCAA
and funding to support mental health programmes
In 2017, the NCAA Sports Science
and initiatives.
Institute formed a task force
Organisational resources and funding may refer
to advance mental health best
to human resources, such as project managers,
mental health specialists, etc., or to monetary
practice strategies. This task force
funding earmarked for developing mental health included NCAA school presidents,
initiatives such as educational programmes, administrators, coaches, student-
seminars, communication campaigns, research or athletes and mental health experts,
event-specific considerations.
and delivered a comprehensive
That being said, there are often limitations to database of Mental Health Best
resources and available funding. In this instance, Practice educational resources.(82)
sports organisations may seek to request advice
The interactive tools, videos and
on developing organisational mental health
policies and practices from external experts, such training that were developed can be
as professionals on your organisation’s Medical found HERE.
Commission. You may also consider collaborating
with community mental health services, charities
and non-governmental organisations in order to 3.3.4 CHOOSING THE TE AM
establish a network of services and support for
athletes. An example is the Australian Institute of
It is important to note that it is not just mental
Sport’s Mental Health Referral Network.(83) This
health practitioners or medical personnel who
network was created to support high performance
play a role in creating and promoting safe and
athletes in Australia’s elite sports system who
psychologically supportive athletic environments.
may be struggling with mental health or well-being
In fact, many members of your organisation and
concerns.
wider stakeholder network may play a direct or
In addition, resources that have already been indirect role in influencing athlete mental health
created to assist athletes and sports organisations, and well-being. Therefore, it is crucial to build a
such as the IOC’s #MentallyFit initiatives,(84) could multi-stakeholder, multi-disciplinary team or task
be shared by your organisation to raise awareness force when looking to monitor and/or implement
and educate stakeholders. mental health programmes and procedures in a
sports organisation.
We need to tackle the day-to-day

wellness of athletes rather than wait
to intervene in critical situations.
The Australian Institute of Sport’s
Mental Health Referral Network enables
athletes to check in, to talk to someone
outside the athlete's sporting
environment in order to help them
understand and manage any issue they
may be facing.
MATT BUTTERWORTH
AIS Mental Health Manager
53
The planner, adapted from the NCAA
Mental Health Interdisciplinary Funding/ Policy
Support Development
Team Planner,(82) may assist you
in identifying the personnel to Sports Director
include in your organisation’s mental Medical Director
health task force and the roles they Athletics Medical

Care Administrator
could play.
Athletics Health
Care Providers
Note: When forming a team or network of support Human Resources

personnel, it is critical to ensure that individuals
are trained and/or have the credentials needed to Medical Commission
provide effective and safe treatment to athletes.
Professional Mental
Health Representatives
PERSONNEL
Coaching Representatives
Athletes’ Commission
Representative
Entourage Commission
Representative
Athlete Education
Staff
Public Health
Representative
Parent/Guardian
Representative
Communications
Legal
Other
TASKS
Education Referral Education/
Stafﬁng Screening Intervention Treatment Activism
and Training Protocols Communication
55
Inclusion of a mental health professional 3.3.5 C ONSIDE R ATIONS FOR E VE NTS,
on the Medical Commission CALE NDARS AND SCHE DULING
If your organisation has a Medical Commission For many sports organisations, the hosting and
(or similar body), it is recommended that mental organisation of and/or participation in sports
health professionals be represented in the competitions and events is one of its most
composition of the Commission. fundamental roles and activities.
Establishing a seat for a mental health professional There are many different aspects of sports events
on your Medical Commission (or similar body) that can directly impact elite athlete mental health.
demonstrates your organisation’s commitment Examples include travel, sleep, accommodation,
to placing athlete mental health as a priority. communication, nutrition, calendar and scheduling
Furthermore, this approach ensures that mental considerations, all of which should be factored
health considerations will be discussed at the into planning and operations when hosting a
organisation’s decision-making level and will sports event or when travelling with a delegation.
be integrated into organisational policies and The IOC Consensus Statement on Load in Sport
standards from the outset. and Risk of Illness(85) suggests that frequent
and prolonged air travel across multiple time
zones may be associated with the risk of illness
in athletes, suggesting that sports governing
bodies concerned with athlete health need to
consider the overall competition load when
planning event calendars. It further recommends
that more research is conducted on the impact
of competition calendar congestion on the risk of
illness, including psychological factors.
Athletic administrators should reassess

metrics of success for the sport
psychologist beyond athletes performing
better on the field. On-field performance
improvement is certainly key, but the
overall betterment of athletes' mental
health status and well‑being is of
utmost importance.
(86)
EXAMPLE APPLICATION: SCHEDULING

IN ELITE PROFESSIONAL FOOTBALL
An example of reforms being made to sporting calendars following

concerns for athletes’ physical and mental health comes from elite
professional football.
During a normal competitive season, mentally. Studies have indicated that the
individuals may play more than 60 matches inclusion of a winter break (or some form
per season, considering domestic leagues, of break during the season) can have
domestic competitions and international a positive effect on an athlete’s health
competitions. This can see athletes and well-being. Results pointed to the
travelling over 100,000km in a season.(87) conclusion that athletes suffer fewer
Over the past few years, many leagues injuries throughout the entire season(88)
have taken measures to adapt competition and also benefit from psychological and
schedules to allow for a winter break – physiological stress relief.(89) The entire
providing a period for players and team FIFPRO report on athlete workload can be
staff to rest not only physically, but also found HERE.
When the rigours of training for

professional sports teams or
individual sports are combined with a
comprehensive competition schedule,
the risk associated with injuries and
‘mental fatigue’ is elevated.
(90)
57
Accommodation and sleep Nutrition
As highlighted in SECTION 2, a study by Drew Even for those people closest to an athlete, eating
in 2018(40) surmised that 49 per cent of Olympic disorders or disordered eating by an athlete may
athletes would be classified as “poor sleepers” be difficult to identify. Athletes have been shown to
(a term that includes multiple sleep problems). underreport this issue more frequently than non-
Poor sleep is strongly linked to poor mental health athletes.(93) In addition to the multitude of health
and can negatively impact athletic performance. concerns caused by eating disorders, an athlete
Therefore, it is important for both event organisers with an eating disorder can expect to be more
and those managing travelling delegations to make prone to injury, and to have a shorter sports career
certain that athletes have sufficient rest time and that is troubled by inconsistent performances.(94)
adequate rooms that encourage a good night’s
There are steps that can be taken during travel
rest. This may mean making sure that hotels in
and/or events to monitor athlete nutrition, easing
noisy locations are avoided, bedrooms are not
detection of signs that an athlete may need further
overexposed to bright light, which can delay sleep
support. One example is to ensure boarding
onset, and educating athletes on how they can
locations have communal areas in which group
improve their sleep quality.(91,92)
eating can take place. It should also be guaranteed
49%
that the catering available to athletes is varied
and nutritious and considers dietary restrictions
and/or allergies. If boarding locations have on-
OF OLYMPIC ATHLETES
site gyms, pharmacies or supermarkets in close
WOULD BE CLASSIFIED
AS “POOR SLEEPERS” proximity, the ability to observe athletes’ use of
such facilities may also be a consideration in the
selection of the location.
Communication
When travelling away from home, communication

with family and friends (or lack thereof) can be
a stressor that can impact an athlete’s mental
health, especially for those suffering from anxiety,
depression or post-traumatic stress. Sports
organisations can take measures to support
athletes by ensuring easy and readily available
access to good Wi-Fi connections.
Alcohol and gambling 3.3.6 S UPPORT FOR POST-

CARE E R TR ANSITION
Studies have shown that even at the most elite
level of sport, athletes may be prone to alcohol Elite athletes often live a life of structure and
abuse, heavy drinking and/or binge drinking. sacrifice that revolves around a full-time training
A 2015 study of elite rugby league players over schedule. Their identities (as seen by themselves
a competitive season found that 62.8 per cent and others) are often connected only to their
had hazardous levels of alcohol use during the athleticism. Due to their demanding schedule,
season.(24) This data highlights that even during athletes often forgo academic, personal, romantic
competition and travel, measures should be taken or financial pursuits during their athletic career,
to support healthy decision-making, particularly making the transition out of sport into “regular life”
related to the avoidance of alcohol, gambling and overwhelming. While some athletes do experience
substance misuse. Precautions might include a positive and healthy retirement transition, others
vetting accommodation to ensure onsite casinos, find the process particularly difficult, potentially
bars, mini-bars or small arcade-type facilities that triggering pre-existing or previously unrecognised
can encourage gambling or drinking are avoided. mental symptoms and disorders.(95)
62.8%
OF ATHLETES HAD HAZARDOUS LEVELS
OF ALCOHOL USE DURING THE SEASON
In summary, it is important that mental health and

well-being is routinely considered when planning a
sporting event, managing a competition calendar
or making travel arrangements for a delegation.
Sports organisations should view their

athletes as whole persons from a
life‑span perspective and be especially
vigilant in reducing threats to mental
health during difficult career transitions. (95)
59
Sports organisations need to support this chapter of an athlete’s career in
the same way they supported the chapters that came before. A study by
Crook and Robertson(96) refers to this transition as “a discontinuity in one’s
life”, and highlights five career transition factors:
1. Anticipatory socialisation
The process of learning new norms in anticipation of taking on a new role.

Organisations should consider the need for athletes to be involved and proactive in
planning for their upcoming transition out of sport. In many cases athletes are so
focused on their remaining sporting careers that they do not pay (or do not want to
pay) much attention to life after sport.
2. Identity and self-esteem
When it’s time to transition out of sport, many athletes are left feeling lost and
disconnected from their identity which has been closely connected with their sport;
they find that they have lost confidence to function outside the sporting world.
3. Personal management skills
Many elite athletes are surrounded by entourage, organisational, and coaching

frameworks which dictate much of their life and many of their decisions. A lack of
personal management skills (e.g., decision making, financial management, daily
structure) can become a challenge area for athletes who feel the loss of systematic
direction and support as they step out of organised sport.
4. Social support systems
Leaving sport can be a very emotional and psychologically taxing experience.

This factor highlights the need for effective emotional support and communication
from friends and family to assist the athlete during this time of change.
5. Voluntary versus involuntary retirement
Unplanned or forced retirement (e.g., due to injury or being cut from the team)
can be especially stressful for an elite athlete, made worse by the lack of an
adjustment period.
All sports organisations should develop and

implement a structured career transition CAREER TRANSITION SUPPORT
programme that provides meaningful support to
practical suggestions for sports
athletes transitioning out of sport.
organisations
These programmes may provide educational
resources for both athletes and their entourage
to increase awareness of the expected and • Educate athletes and make them aware of
unexpected stressors that may come with leaving the potential challenges that may occur
sport, and/or workshops for athletes focused during their transition into retirement
on the fundamentals of applying their skillset in
• Encourage the development of strategies
the outside world, financial management, career
that enable athletes to self-manage their
services, coping skills, mentoring programmes,
previous injuries and lifestyle when they
etc. Career transition programmes should also
are outside the high-performance system
consider the experiences of retirement that are
unique to Paralympic athletes (such as retirement • Aim to increase the understanding
due to declassification) in order to provide more of these issues amongst the
targeted support.(97) high‑performance team, and
encourage open discussion, which in
turn will benefit the athletes
The IOC has developed a number of
resources to provide support for athletes • Raise awareness of this issue among
during their career transition. You can governing bodies to help improve the
find the Athlete365 “Life after Sport” post-retirement support they offer
courses HERE. to athletes
• Encourage athletes to use their

downtime effectively during their
careers; optimising the development
of a broader range of social identities
outside sport, thus providing a stronger
social support network before, during
and after retirement
• Encourage athletes to develop life

and lifestyle management skills in
sports organisations throughout their
athletic career
• Find ways to keep previously and/or

soon-to-be retired athletes in the sports
system. Coaching and ad-hoc mentoring
programmes are viable options that
sports organisations could fund
Hattersley et al., 2019 (98)
61
3.3.7 CHECKLIST FOR SPORTS ORGANISATIONS
■ Specifically reference mental health ■ Allocate resources and funding to

and well-being in organisations’ support mental health initiatives
foundational documents (code of
ethics, etc.)
■ Set up a multi-stakeholder and
multi‑disciplinary working group to
■ Promote positive public health develop mental health initiatives.
messages around mental health This group should include athletes,
using diverse role models and mental health professionals and
ambassadors to reduce the stigma public health representatives
attached to mental health issues
■ Consider allocating a seat on
■ Develop an organisational mental your organisation’s Medical
health action plan, with clear key Commission to a mental health
performance indicators (KPIs) and professional (e.g., a psychologist
time frames against which progress or psychiatrist with sports
can be monitored specialisation or experience)
■ Ensure existence and monitor ■ Make certain that both mental and
correct implementation of a Mental physical health is considered when
Health Emergency Action and looking at competition scheduling
Management Plan and planning events
■ Ensure existence of a routine mental ■ Develop and implement initiatives to

health referral plan and designate a prepare for and support post-career
referral lead transition
■ Staff, coaches and athletes to

receive mental health awareness
training and support – which
should also be included as part
of induction processes
ROLE OF HEALTH PROFESSIONALS:

KEY LEARNING POINTS
– There are many professionals – The Sport Mental Health

who may be involved in managing Assessment Tool 1 (SHMAT-1)(51)
the health of elite athletes. It is has been developed to assist health
important to understand the roles professionals in the assessment
and responsibilities of different of mental health symptoms and
professionals, how these interrelate, disorders in elite athletes.
and how to quickly and appropriately
refer if needed. – Health professionals working with
elite athletes should have additional
– All health professionals working training or experience of operating
with athletes should work together in a high-performance sports
towards the common goal of environment.
protecting and promoting athletes’
physical and psychological – Health professionals play a key role
well‑being. in developing and implementing
mental health management
– Those health professionals working strategies, ranging from general to
with athletes should be cognisant targeted interventions.
of their own competencies and
limitations related to the recognition, – The voice of the athlete should
assessment and management always be taken into account when
of mental health symptoms and assessing the referral pathways
disorders in elite athletes. available to them.
– Health professionals working with – Sports organisations should

athletes should have knowledge and have a clearly defined Emergency
understanding of referral pathways. Mental Health Action Plan. All key
stakeholders should be aware
– Mental health screenings should be of this plan, and the role and
a part of an athlete’s regular health responsibilities that they have
and well-being check-up, just like within it.
physical health screenings.
63
Benchmarking:
Specific suggestions in this section have been This format attempts to ensure universality in
broken down using a Bronze/Silver/ Gold format. implementing the suggestions detailed in the
This is to demonstrate what may be considered toolkit, taking into account the many different
as best practice (Gold), good practice (Silver) and contexts of stakeholders and organisations.
minimum requirements (Bronze). The examples are not exhaustive, and further
research is recommended.
BRONZE SILVE R GOLD
Access to services Access to an extended Integrated services

and support network of services and support
and support
Access to primary care/sports Primary care/sports
medicine physicians delivering Primary care/sports medicine medicine physician and
simple pharmacological physician with competency consulting psychiatrist or
interventions and brief in providing mental health clinical psychologist with
psychological interventions. care and directing access to a knowledge and experience in
mental health network mental health care and high-
OR
(e.g., licensed/registered performance sport.
A licensed/registered mental health professionals).
AND
healthcare professional
with the skills to recognise Onsite and embedded
mental health symptoms (direct and timely) access to
and disorders; training and registered licensed mental
experience in mental health health professionals with
support and/or knowledge of experience working in a
referral pathways. high-performance sports
environment.
3.4 ROLE OF HE ALTH PROFESSIONALS

DID YOU KNOW?
Health care professionals play a crucial role in
ensuring that high quality mental health care
Additional opportunities to advance your and support is available for all athletes, from
knowledge of mental health in elite sport developing and implementing prevention
have been made available by the IOC Medical strategies, to establishing referral pathways and
and Scientific Commission through: managing crisis situations.
• The IOC Diploma in Mental Health in
Elite Sport 3.4.1 BUILDING YOUR TE AM
This postgraduate-level diploma
programme is designed primarily to meet As is demonstrated by the diagram on the
the needs of sports medicine physicians, following page, there may be a great many
psychiatrists, other physicians and other professionals involved in managing the health of an
qualified mental health professionals. elite athlete.
• The IOC Certificate in Mental Health in It is important that these professionals, whether
Elite Sport they have a technical scientific role or are primarily
This certification course equips concerned with either health or performance,
members of the athletes' entourage with work in collaboration towards a common goal that
the knowledge and skills to recognise considers athletic performance and physical and
potential mental health problems at an mental well‑being as equally important.
early stage and to appreciate the need
for referral to professionals equipped Oftentimes, athletes will not have or not require
to provide appropriate treatment. direct access to all of these health professionals.
There is usually an inner circle of support
staff and services that an athlete might have
immediate access to, and an outer circle of
professionals to whom the athlete is referred to
as required (such as an orthopaedic surgeon or
other medical specialist).
65
Psychotherapist
Exercise
Psychologist Physiologist
Team
Orthopaedic Physician
Surgeon
Nutritionist
Dietitian
TEC
HN
I
L
CA
ICA
LS
Psychiatrist Physiotherapist
MED
CIEN
TIFIC
Strength &
Conditioning
Athletic ATHLETE Specialists
Biomechanist
Trainer
Primary Care
Physician
PER
FORMANCE
Athletic
Coaches
Trainers
Strength &
Conditioning
Mental Specialists
Sport
Skills
Psychologist
Trainers
Scouts Performance
Director
Video
Analyst
The professionals on the inner and outer circles Clear access pathway to professionals
change depending on the organisation/team/ in the inner and outer circles.
context, and professionals may be in either the
inner or outer circle at different times.
This graphic shows that professionals are not

always purely one category or another, there is a
high degree of crossover, and variations in access
and terminology.
Understanding and recognising the

interrelatedness of the different roles and
responsibilities of health professionals, and
ensuring a clear pathway from the inner circle of
healthcare professionals to those who may not be
around the athlete on a daily basis is paramount.
Health professionals involved in the mental health

management continuum, from recognition and
screening to treatment, recovery and return to
play, include:
LICE NSE D ME NTAL HE ALTH • Clinical or counselling psychologists

PROFESSIONALS
• Psychiatrists
• Licensed clinical social workers
• Psychiatric mental health nurses
• Licensed mental health counsellors
• Licensed family therapists/licensed marriage

and family therapists
• Primary care physicians with core competencies

to treat mental health disorders
ME DICAL GE NE R ALISTS Medical generalists or General Practitioners (GPs)

WITH ME NTAL HE ALTH typically include family or local community doctors. GPs
MANAGE ME NT KNOWLE DGE provide care and treatment across the broad scope of
health and well-being of individuals.
ALLIE D HE ALTH These professionals may include:

PROFESSIONALS
• Physiotherapists
• Athletic trainers
• Chiropodists
• Dietitians
• Osteopaths
• Paramedics
• Podiatrists
67
ALLIE D HE ALTH PROFESSIONALS
Allied health professionals may have frequent contact with athletes. Whilst they do not routinely have the
specialist training to evaluate and treat mental health symptoms and disorders, they are often in a position
to recognise indications that an athlete may need mental health support (see SECTION 3.2.5) and activate
the referral pathway. They can also play an important role in the rehabilitation and return-to-play processes,
and in ensuring that athletes regularly complete mental health screenings. Some of the key competencies
of allied health professionals related to mental health include:
The ability to recognise

Involvement in mental health symptoms or
development and promotion disorders in elite athletes
of prevention interventions, (e.g., using the SMHRT-1, see
(see SECTION 3.4.2) SECTION 3.2.5)
1.PROMOTE 2.RECOGNISE
4.RE TURN
TO PL AY
3.RE FE R AND CARE E R
TR ANSITION
Knowing when and how Supporting the athlete

to refer an athlete to through rehabilitation,
further support return to play and transition
out of sport
ME DICAL GE NE R ALIST WITH ME NTAL HE ALTH MANAGE ME NT KNOWLE DGE
The titles “Primary Care Physician”, “Medical Generalist” or “General Practitioner” typically include family or
local community medical doctors practising general medicine.
Working with a medical generalist with mental health management knowledge can be beneficial as the
athlete may already be familiar with the doctor associated with the team. If that is the case, there may
already be an established relationship of trust, and the doctor will likely have a deeper understanding of the
athlete’s individual environment and previous knowledge of their medical history.
In cases where a medical generalist does not have sufficient mental health management knowledge,
referral to licensed mental health professionals should be the next step in treatment. Some of the key
competencies of medical generalists with mental health management knowledge may include:
Involvement in Competency in mental

development and promotion health assessment (e.g.,
of prevention interventions, using the SMHAT-1, see
(see SECTION 3.4.2) SECTION 3.4.3)
1.PRE VE NT 2. ASSESS
4.
3.MANAGE
FOLLOW UP
AND RE FE R
Competency in managing Knowledge of referral

mental health symptoms and pathways to licensed mental
disorders, and in managing health professionals when
crisis situations indicated and ensuring
appropriate follow-up and
continued monitoring.
69
LICE NSE D ME NTAL HE ALTH PROFESSIONALS
When referring athletes to licensed mental health professionals, it is highly recommended that you make
certain as much as possible that they have the additional training and/or experience required to treat
athletes; work in sport-specific environments, and treat persons within the age group of the referred athlete.
It is important to identify licensed medical professionals with the required competencies in advance, and
establish an ongoing relationship with them, integrating them into the team dynamic or care pathway. This
will improve familiarity of the athletes and team with the professional, thereby reducing barriers to seeking
help and facilitating access to further specialist care as required.
Licensed mental health professionals should work closely with the team physician and/or medical
generalist as well as the allied health professionals in the athlete’s entourage when looking to facilitate
return-to-play following a mental health referral and/or treatment.
Assessment and evaluation Formulation and

of a presenting mental classification/ diagnosis of
health concern presenting issue
1.ASSESSME NT
2.DIAGNOSIS
AND E VALUATION
3.TRE ATME NT
4.
AND
COORDINATION
INTE RVE NTION
Providing and/or overseeing Collaborating with medical

mental health treatments generalists and allied health
and interventions professions to facilitate
return-to-play
3.4.2 D E VE LOPING AND IMPLE ME NTING

PRE VE NTION STR ATEGIES The three main types of preventative
interventions are:
As we mention in the previous sub-section, health • Universal prevention – targeting an entire
professionals play an essential role in developing team, independent of risk
and implementing mental health prevention
strategies, which in turn form a foundational part • Selective prevention – specifically
of mental health promotion. targeting individual athletes displaying
signs or symptoms but not yet meeting
Prevention strategies aim to “reduce incidence, the diagnostic criteria of individuals or
prevalence and recurrence of mental disorders”, sub-groups who are considered at a
and lessen the time spent with symptoms high risk
and lower the impact of the condition on the
individual.(99) • Indicated prevention – targeting
individuals or sub-groups who are
considered at high risk
ION
ENT
ERV
Y INT TREATMENT
RL RE
CO
EA VE
RY
EARLY
T
ILL
EN
TM
TREAT
NE
SS
EA
ON
IN
TR
IDE
TI
DI
MENT
T
EN
CA
CO
EN
RD
NT
EV
TE
NT
EM
DA
D
IFI
PR
G
INU
(H
NA
AN
CA
IG A
ING
H-
TIO
ST
RI - M
SEL SK LF NT
CAR
ECT
N
IVE ) SE AT ME
(AT TRE
E
RIS E
K) APS
REL
UNIVERSAL (GENERAL) REHABILITATION
MENTAL HEALTH PROMOTION
Mrazek and Haggerty Mental Health Promotion Spectrum(99)
71
Universal preventative interventions
There are some general points that
should be considered when considering
The integration of universal preventative
the development and implementation
interventions into sports culture may include:
of a mental health prevention strategy.
• Making education available to both athletes The list below has been adapted from
and entourage members to improve mental the World Health Organisation report on
health literacy, reduce stigma, and support Prevention of Mental Disorders: Effective
early help-seeking Interventions and Policy Options (2004)(100)
to a sporting context:
• Working with athletes and entourage members
to establish career and personal development
Prevention strategies are part of a
goals (and the skills to help them achieve them) multi-pronged approach
• Establishing routine mental health screenings • There are multiple factors that can
that are integrated into an athlete’s formal impact elite athlete mental health
routine physical screenings, and/or into their which should be encompassed into
rehabilitation programme post physical injury prevention strategies. These include:
• Ensuring that your sports organisation has • S

ocial factors such as
specific and effective policies to prevent and environmental stressors, barriers to
respond to harassment and abuse in sport help-seeking
• For allied health professionals, injury • Physical factors such as injury

surveillance and prevention strategies and and illness
programmes may also be an important
I mplementation should be guided by
prevention tool due to the link between physical
available evidence
illness and injury, and psychological well-being
in athletes Programmes and policies should be
made widely available to all athletes
Prevention needs to be sensitive to

culture and to resources available
Protecting human rights is a major

strategy in preventing mental disorders
• This relates to, for example, the

importance of ensuring your
organisation has a policy in place to
safeguard athletes from harassment
and abuse in sport. For further
information please see the IOC
Athlete Safeguarding Toolkit.(101)
3.4.3 T HE IOC SPORT ME NTAL HE ALTH Ideally, use of the SMHAT-1 should be scheduled
ASSESSME NT TOOL 1 (SMHAT – 1) as a routine screening alongside an athlete’s
regular physical screenings or check-ups. It is
recommended that the SMHAT-1 be used during
As discussed in SECTION 3.2.5, the IOC Mental
the pre-competition period (i.e., a few weeks after
Health Working Group developed the IOC Sport
the start of sports training), as well as within the
Mental Health Recognition Tool 1 (SMHRT-1)(51)
mid- and end-season period. The tool may also
to assist athletes, coaches, family members
be used when any significant event for an athlete
and other members of an athlete’s entourage to
occurs, such as injury, illness, surgery, unexplained
recognise mental health symptoms or disorders in
performance concerns, after a major competition,
elite athletes. (As noted earlier, SMHRT-1 is not a
at the end of a competitive cycle, if there is
diagnostic tool.)
suspected harassment/abuse, if there is a sudden
In addition to the SMHRT-1 tool, the IOC Mental adverse life event, or if the athlete is transitioning
Health Working Group developed the IOC Sport out of sport.
Mental Health Assessment Tool 1 (SMHAT-1).(51)
As mentioned above, the clinical assessment (and
The SMHAT-1 is a standardised assessment tool
related management) within the SMHAT-1 should
to be used by sports medicine physicians and
be conducted only by sports medicine physicians
other licensed/registered health professionals to
and/or licensed/registered mental health
help identify at an early stage those elite athletes
professionals. You can find the SMHAT-1 HERE.
who may be at risk or are already experiencing
mental health symptoms and disorders, and to
help facilitate timely referrals for those in need of
support and/or treatment.
73
BEST PRACTICE EXAMPLE:
WORLD RUGBY
On World Rugby’s “Player Welfare” educational web portal, you will

find “Mindset – A Mental Health Resource”.(102) This mental health
awareness and education programme was developed in conjunction
with International Rugby Players to support team medical staff in the
identification of mental health problems.
This resource:
• Supports early recognition of mental • Provides guidelines that support early

health problems and appropriate referrals to experts
• Provides background information • Available in six languages, “Mindset”

relevant to mental health disorders was built as a resource for elite
rugby medics and is a mandatory
• Provides overviews of different
core component of World Rugby’s
mental health disorders, and supports
Tournament Player Welfare
diagnosis by making mental health
Standards. You can find the Mindset
screening tools available
programme HERE.
3.4.4 C OMPE TE NCY IN The Mental Health in Elite Athletes: International

MANAGING ME NTAL HE ALTH Olympic Committee Consensus Statement
SYMPTOMS AND DISORDE RS (2019)(18) provides information on prevalence,
assessment and treatment for elite athletes.
This expert statement also discusses the clinical
Once it has been decided that professional care
interventions recommended for a number of
is the best option for an athlete, the road to
mental disorders, including depressive disorders,
recovery may include psychological treatment,
anxiety and related disorders, post-traumatic
pharmacological treatment or a combination of the
stress, bipolar and psychotic disorders, and
two. This is usually delivered by consultation in an
substance abuse. The information below has been
out-patient/office setting. Occasionally, treatment
taken from this statement.
may take place more intensively in a day-patient
facility and, in rare circumstances, as an in-patient.
It is imperative that health professionals have the The consensus statement in its entirety can
correct clinical competencies to manage mental be found HERE.
health symptoms and disorders in the setting of
high-performance sport or know when and how
to refer to those in your organisation’s network
who do.
When treating elite athletes, it is of utmost

importance that care providers…
“…understand the physical, psychological
and emotional demands placed upon
athletes during training and competition,
and the unique circumstances and
pressures of the sport environmentˮ.
75
Treatment In the event of a mental health emergency (presenting
immediate danger to the athlete themselves or
others), it is best practice to develop and rehearse a
Psychotherapy or counselling is often the first step
mental health emergency action management plan
in professional mental health treatment. When
that involves all relevant sports stakeholders. This
psychotherapy has been prescribed as treatment,
plan should include clarity on what constitutes an
medical professionals are recommended to:
emergency, who should be contacted and when, and
• be flexible about the timing of sessions (without familiarity with local emergency services and mental
allowing constant cancelling of sessions) health legislation. Information on the development of
an MHEAP is coming up in SECTION 3.4.6.
• urge couple’s or family therapy when relational
issues impact functioning or performance
3.4.5 K NOWLE DGE AND UNDE RSTANDING
• recommend psychotherapy plus OF RE FE RR AL PATHWAYS
pharmacological therapy where indicated
for more severe or complex mental health Competency is critical when considering referral
symptoms or disorders pathways. There may be health professionals
on your team with the knowledge and training to
Medical professionals should not:
diagnose mental health concerns and to offer
• agree to the use of a surrogate (such as a coach some interventions. There may also be instances
or athletic trainer) for psychotherapy sessions where even an experienced and licensed expert
may not be able to provide full competency when
• provide experimental treatments, which may addressing a specific mental health issue (e.g.,
give false hope to athletes
eating disorders or drug abuse). It is important
Along with psychotherapy, pharmacology may to keep this in mind when considering the best
be considered for the treatment of symptoms, referral pathway in each specific situation.(103,104)
but significant consideration must be given when
All health professionals should be aware of the
treating elite athletes. When prescribing, clinicians
scope and limits of their competencies, including
need to consider:
knowledge of when it is appropriate to refer to a
• Potential negative impact on athletic mental health expert.
performance
An athlete’s reaction to suggestions of a referral
• Potential therapeutic performance enhancing should also be considered. During this scenario it
effects (i.e., based on improvement in the may be useful to reach out to an athlete’s entourage
condition the medication is designed to treat) members, such as family, friends or coaches, to
assist in providing a personalised approach when
• Potential non-therapeutic performance communicating with the athlete, provided you have
enhancement effects (i.e., ergogenic effects) consent to do so. Role plays may be a useful strategy
to prepare for such sensitive communications.
• Potential safety risks
All four of the above points should be considered,
NB. It is also important to document the
and experience working in sport and with athletes
reasons for referral, and considerations or
is especially important in relation to the first, third
consultations with persons surrounding the
and fourth points.
case and athlete.(104)
3.4.6 C OMPE TE NCY IN MANAGING • Contact details of consultative personnel able to

A CRISIS SITUATION provide direct crisis intervention in emergency
and non-emergency scenarios
Development and implementation of a mental • Clearly defined roles and responsibilities of each
stakeholder within the athlete’s entourage and
health emergency action plan (MHEAP)
organisation in an emergency situation
Here we discuss the development and • Clearly defined follow-up procedures in order to
implementation of a mental health emergency support athletes after the emergency
action plan (MHEAP). In this context, an MHEAP
• Formal policy defining when to contact parents
refers to the procedures to be followed when faced
or guardians in the case of a minor’s mental
with a mental health crisis. It is important that each
health emergency.
sports organisation/club/team has an MHEAP, and
that you as health professionals are aware of it and It should be clearly specified in the MHEAP who
of your role in it where applicable. the first internal point of contact is for the mental
health issue until an appropriate clinical referral
The NCAA Mental Health Best Practice Checklist(85)
can be made. In cases involving a minor, it is
states that written procedures for managing
important that the contact details of parents or
emergency mental health situations should, at a
guardians are readily available, and that they are
minimum, include the elements listed below:
contacted at the earliest opportunity.
• Clear definitions of what constitutes a mental When identifying licensed professionals for a
health emergency (scenarios, symptoms or
referral, the following points should be taken
behaviours to look out for)
into consideration:
• Clearly written procedures for handling Who is responsible for initiating the referral to
mental health scenarios such as: suicidal or
the clinical professional?
homicidal scenarios, sexual assault, threatening
behaviours including psychosis, paranoia, Where should the referral be made in the event
delirium or confused states, and intoxication of an emergency?
or drug overdose
This is particularly important information to have
• Clearly defined scenarios in which emergency when travelling with a delegation away from the
services should be contacted Additionally, usual team services and networks.
scenarios in which an emergency counsellor
should be contacted
An example of an MHEAP, developed by the
National Athletic Trainers' Association, can
be found HERE.(105)
77
3.4.7 C HECKLIST FOR HE ALTH PROFESSIONALS
■ I understand the importance of documenting why referral is

of prevention strategies and necessary, and that different
my role in their development, situations will require different
implementation and promotion. clinical competencies and
professionals.
■ I am knowledgeable of my own
competencies and limitations ■ I know my role in responding
related to the recognition, to a mental health crisis and in
assessment and management ensuring that my organisation has
of mental health symptoms and a dedicated MHEAP available.
disorders in elite athletes.
■ I recognise the important role of
■ I understand the referral pathways health professionals in supporting
available, how, when and where to athletes’ mental health and well-
refer an athlete, the importance being during return-to-play.
NOTES
79
4 . R E S O U R C E S
4.1 Additional IOC tools and resources
4.2 IOC Diploma and

Certificate Programmes
4.3 Courses
4.4 Safe Sport

IOC MENTAL HEALTH IN ELITE ATHLETES TOOLKIT – SECTION 4: RESOURCES
In this final section of the toolkit, we present additional IOC tools and
programmes which provide further information related to elite athlete mental
health and well-being.
This Toolkit's aim is to provide guidance and Available tips and tools focus on:
information to Olympic Movement stakeholders
on the development of initiatives to protect • building psychological resilience,
and promote elite athlete mental health, and to • developing the non-athletic identity,
highlight the influential role that stakeholders
play in fostering psychologically safe athletic • managing competition stress,
environments.
• preparing for life after sport,
As noted throughout, it is fundamental that
athletes themselves are consulted in the
• promoting healthy sleep behaviours,
development of initiatives designed to protect and • and much more.
promote their mental health and well-being. In
addition, they should be afforded the opportunity to These resources are regularly updated in
receive guidance and support to improve their own consultation with the IOC Mental Health Working
awareness and mental health literacy. Group and other international experts.
We therefore recommend encouraging athletes to

visit the #MentallyFit section of Athlete365, where For more information, please visit
they will find information, guidance and support #MENTALLYFIT ON ATHLETE365
to help them navigate their #MentallyFit journey
through high-performance sport.
81
4.1 RESOURCES
Sport Mental Health

Assessment Tool 1 (SMHAT-1)
The International Olympic Committee Sport

Mental Health Assessment Tool 1 (SMHAT-1)
is a standardised assessment tool developed for
sports medicine physicians and other licensed/
registered health professionals. It assists in
identifying, at an early stage, elite athletes
(defined as professional, Olympic, Paralympic
and collegiate level; 16 and older) potentially at
risk for or already experiencing mental health
SMHAT-1 symptoms and disorders in order to facilitate
timely referral for those in need of adequate
support and/or treatment.
More information can be found HERE.
Sport Mental Health

Recognition Tool 1 (SMHRT-1)
The International Olympic Committee Sport

Mental Health Recognition Tool 1 (SMHRT-1) was
developed for athletes, coaches, family members
and all other members of the athletes’ entourage
to help them to recognise mental health symptoms
but not to diagnose them. The SMHRT-1 presents
a list of athlete experiences (thoughts, feelings,
behaviours and physical changes) that could be
indicative of mental health disorders.
SMHRT-1
Athlete365 Career+
Athlete365 Career+ supports athletes while they

prepare for and go through their career transition. It
provides resources and training required to develop
life skills, maximising education and employment
opportunities.
Mental health in elite athletes:

International Olympic Committee
consensus statement (2019)
The IOC Medical and Scientific Commission

published a landmark consensus paper on mental
health which is aimed at addressing the many
different mental health issues that elite athletes
may face.
83
The Athletes’ Declaration (2018)
The Athletes' Declaration outlines a common set of

aspirational rights and responsibilities for athletes
within the Olympic Movement.
Athlete365 Community App
This app helps to strengthen the athlete

community by allowing the community itself to
create and run its own private or public groups;
share expertise, experiences and key documents;
and stay in the know with regular updates from the
Athlete365 community.

4.2 IOC DIPLOMA AND CE RTIFICATE PROGR AMMES
IOC Diploma in Mental Health in Elite Sport
Sportsoracle offers a one-year diploma

programme aimed at licensed practitioners who
are qualified to provide mental health services.
IOC Certificate in Mental Health in Elite Sport
In addition, a three-month certificate programme

aimed at athlete entourage members (in addition
to physicians and licensed practitioners) is also
available.
IOC Certificate: Safeguarding Officer in Sport
The IOC Certificate: Safeguarding Officer in Sport

course, available on sportsoracle, will equip those
certified with the knowledge and tools needed
to fulfil the role of Safeguarding Officer for their
sports organisation.
85
4.3 IOC COURSES
Career Transition
Learn why planning is fundamental to settling

into a life after sport; what strategies to prioritise;
how to better manage time; and the importance of
networking to enhance employment opportunities
and life after sport.
Sports Psychology: Getting in the Zone
Gain an understanding of the fundamentals of

focusing your energy, how to embrace and manage
emotions and how to approach setbacks in a
positive way.
Physical Preparation
In this course you will gain a better understanding

of exercise physiology and how it affects your
training, explore the impact nutrition has on
preparation, and learn how to create both high-
performance training and recovery plans.

The Measure of Success
Here you will learn aspects of taking your training

to the next level, learning the importance of
measuring fatigue, wellness and performance.
Sports Medicine: Understanding Sports Injuries
Previous injury, fatigue or poor movement skills

are just some of the factors that can contribute to
an injury. In this course you will learn preparation,
load management, and why general well-being is
the key preventative element.
LinkedIn Learning
LinkedIn Learning is a platform that helps you not

only discover and develop business, technology-
related and creative skills through expert-led
course videos, but also helps you with your mental
well-being.
87
Safeguarding athletes from
harassment and abuse in sport
4.4 SAFE SPORT
IOC Toolkit for IFs and NOCs
RELATED TO CREATING AND IMPLEMENTING ATHLETE SAFEGUARDING POLICIES AND PROCEDURES
Sport which is fair, equitable and free from all forms of harassment and abuse.
IOC Safeguarding Toolkit (2017)
This toolkit is aimed at assisting National Olympic

Committees (NOCs) and International Federations
(IFs) in the development and implementation of
policies and procedures to safeguard athletes from
harassment and abuse in sport.
DOWNLOAD TOOLKIT
Athlete365 Safe Sport Webpages
Safe Sport - where athletes can train and compete

in an environment which is respectful, equitable,
and free from all forms of harassment and
abuse. Visit Athlete365 for educational courses
and modules, videos, and other resources and
materials created to help support a safe sporting
environment.

NOTES
89
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ACKNOWLEDGEMENTS
The IOC wishes to recognise the contributors who have made it possible to
publish the IOC Mental Health in Elite Athletes Toolkit.
The development of this resource would not have On behalf of the IOC, the IOC Medical and Scientific
been possible without the guidance and expertise Department and the IOC Sports Department, we
of the IOC Mental Health Working Group. The IOC applaud and thank you for your tireless efforts and
further expresses its appreciation for the valuable dedication to the protection and promotion of elite
contributions by the Virtual Task Force. athlete mental health.
CONTRIBUTORS
IOC Mental Health Working Group
CHAIR – VINCENT GOUTTEBARGE DAVID MCDUFF

Chief Medical Officer, FIFPRO; Assistant Professor, Clinical Professor, University of Maryland School of
Amsterdam University Medical Centers Medicine, Baltimore, Maryland USA
ABHINAV BINDRA OLY MARGO MOUNTJOY

IOC Athletes’ Commission; Founder, Abhinav IOC Prevention of Harassment and Abuse in Sport
Bindra Foundation Working Group; Chair, ASOIF Medical and Science
Consultative Group; Assistant Dean, McMaster
CHERI BLAUWET
University Medical School
Paralympian; Assistant Professor, Harvard Medical
School; IOC Medical and Scientific Commission; ROSEMARY PURCELL
International Paralympic Committee (IPC) Medical Director, Knowledge Translation, Orygen; Professor,
Committee; Board of Directors for the United The University of Melbourne; Deputy Editor-in-
States Olympic and Paralympic Committee Chief, “Early Intervention in Psychiatry”
(USOPC)
MARGOT PUTUKIAN
NICCOLO CAMPRIANI OLY Director of Athletic Medicine, Head Team Physician
IOC Senior Sports Intelligence Manager at Princeton University; Chief Medical Officer,
Major League Soccer
ALAN CURRIE
Consultant Psychiatrist, Cumbria, Northumberland
Tyne and Wear NHS Foundation Trust; Mental
Health Expert Panel, English Institute of Sport;
Visiting Professor, Sport and Exercise Sciences,
University of Sunderland; Chair of the Scientific
Committee of the International Society for Sports
Psychiatry (ISSP)
IOC MENTAL HEALTH IN ELITE ATHLETES TOOLKIT – ACKNOWLEDGEMENTS
Virtual Task Force
JOSEPH CASSAR ANDREW MASSEY

Secretary General, Maltese Olympic Committee Medical Director, FIFA
KAREN COGAN NANA JACQUELINE NAKIDDU

Senior Sport Psychologist, US Olympic and Chairperson, Medical Commission, Uganda
Paralympic Committee Olympic Committee
NADIN DAWANI DARRIN STEELE

International Relations Manager, Jordan Olympic Vice President Sports, International Bobsleigh
Committee and Skeleton Federation
AMBER DONALDSON PAULO VILLAR

Vice President, Sports Medicine, US Olympic and Chair, Athletes’ Commission,
Paralympic Committee Colombian Olympic Committee
MARK HARRINGTON MATELITA VUAKOSO

Head of Technical Services, World Rugby Voice of Athletes Project Officer, Fiji Association
of Sports and National Olympic Committee
NASSER MAJALI
Secretary General, Jordan Olympic Committee ALEXIS WEBER
Head of Anti-doping, FIFA
VLAD MARINESCU
Chief Media and Marketing Officer,
International Judo Federation
99
International Olympic Committee,
Château de Vidy, 1007
Lausanne, Switzerland
Tel +41 (0)21 621 6111
© This publication may not be reproduced, even in part, in any form, without the
written permission of the IOC. All reproduction, translation and adaptation rights
are reserved for all countries.
Directors in charge:
Richard Budgett, Director of the IOC Medical and Scientific Department
Kit McConnell, Director of the IOC Sport Department
Senior Manager in charge:

Susan Greinig, Senior Manager, IOC Medical Programmes
Authors:
Kirsty Burrows, Lucy Cunningham and Carrie Raukar-Herman
Designed and produced by tandt.design
® All trademarks acknowledged

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I O C M E N TA L H E A LT H I N E L I T E

SECTION 1. INTRODUCTION ��������������������������������������������������������������������������������� 6

SECTION 2. MENTAL HEALTH SYMPTOMS AND

SECTION 3. ROLES AND RESPONSIBILITIES������������������������������������������������������ 23

SECTION 4. RESOURCES ������������������������������������������������������������������������������������� 80

IOC Mental Health in Elite Athletes Toolkit

Foreword by Uğur Erdener, Sergey Bubka and Kirsty Coventry

As a sporting community, we need to create a sporting environment that better supports

1.2 To whom the toolkit applies

1.4 How was this toolkit developed?

1.5 How to use the toolkit

This toolkit is aimed at assisting Olympic Movement stakeholders,

1.1. WHY DE VE LOP THIS TOOLKIT? Whilst it is estimated that the prevalence of

Article 1.5: “Safeguard the athletes’ physical and

International Paralympic Committee (IPC)

Article 1: “The Paralympic Movement, in

Article 40: “No practice constituting any form of

Article 42: “For the benefit of all concerned,

The Olympic Movement, to accomplish

This IOC Mental Health Toolkit has been

International Judo Federation:

International Bobsleigh and Skeleton Federation:

US Olympic and Paralympic Committee: KAREN COGAN

Colombian Olympic Committee:

Maltese Olympic Committee:

NICCOLO CAMPRIANI OLY ABHINAV BINDRA OLY

The IOC Mental Health Working Group The Virtual Taskforce

This toolkit is divided into four main sections:

THIS TOOLKIT IS UNDERPINNED BY RESEARCH AND BEST PRACTICE GUIDELINES.

2.2. International Olympic Committee

2.3. Overview of mental health symptoms

2.4. Prevalence of mental health symptoms

This section provides an overview of the multifaceted aspects of mental

2.1. TE RMINOLOGY Elite Athlete

A state of well-being in which an individual realises

Athletes experiencing a mental health

Therefore, it is important to improve

In 2018, the IOC convened a consensus meeting

The expert panel screened 14,689 published

Background and methods Major stressors and key environmental factors

General approaches to management

Considers specific mental health symptoms

Regular participation in sport has been Anxiety

NOTE: Such as insufficient sleep, difficulty falling

You can find further information on the

The IOC Mental Health Consensus Statement

• Gambling disorder and other It is also important to consider that an

ANXIETY AND DEPRESSION

A 2020 study found a higher prevalence of anxiety

SLEEP-RELATED SUBSTANCE USE

EATING DISORDERS ATTENTION-DEFICIT/

TRAUMA-RELATED European professional athletes showed that 56.6%

A 2018 meta-analysis found that 19% of athletes

3.2 Role of the Athletes’ Entourage

3.3 Role of Sports Organisations

3.4 Role of Health Professionals

SPORTS ATHLETES' HEALTH

Prioritising athlete mental health

Mental Health Action Plan

Education & prevention

SECTION 1. INTRODUCTION �� 6

SECTION 3. ROLES AND RESPONSIBILITIES�� 23

SECTION 4. RESOURCES �� 80

2.2. International Olympic Committee

2.3. Overview of mental health symptoms

2.4. Prevalence of mental health symptoms

3.1. The Entourage must always respect

3.2.1 ATHLE TIC PE RFORMANCE In sport, mental health is often overlooked. It

8. Not sure who to reach out to

10. Belief that it would not help

FIGURE 3 3.2.4 U NDE RSTANDING

3.2.8 E XE RCISE: KE Y TAKE AWAYS FOR

3. Providing a foundation on which your – Mental health referral pathways