Depression in Elite Sports: Causes, Symptoms & Treatment

Depression in elite sports has attracted media attention at the latest after the suicide of goalkeeper Robert Enke. Nevertheless, the topic has not yet been adequately addressed. Although the illness has long since arrived in society, there has not yet been a bridge to top-level sport, despite many cries for help from athletes and those responsible. On the contrary, it must be assumed that the subject continues to be tabooed, despite prominent sufferers and widespread dissemination. In addition to this cloak of silence, it must be added that despite the alarming figures of the German Sports Aid (9.3% of the athletes surveyed suffer from a depressive illness), only little initiative has been taken to counteract the problem. The taboo as well as the shame of those affected is also evident in the survey by the Federal Institute for Sports Science. Although 49.8 percent said they were not depressed, another 40.9 percent abstained from the question. This shows that the topic is still taboo in sports.

What is depression?

Schematic representation of triggers and precipitants for depression in competitive sports. In order to adequately present the topic, it is first necessary to explain what depression is in the first place and what symptoms can occur. Definition: “Depressions are psychological disorders in which characteristic symptom patterns with pronounced mood changes, especially dejection, joylessness, emotional emptiness, lack of interest and loss of drive exist over longer periods of time. Associated with this, a wide variety of physical complaints often occur.” (Source: Institute and Polyclinic for Medical Psychology – Universtitätsklinikum Hamburg-Eppendorf).

First, the causes that can cause depression are explained in a chapter. Here, especially stress, too high demands, injuries and the associated lack of the required performance are to be mentioned. Another point is the experience and processing of failures as a cause of depression. Chapter two deals primarily with the preventive measures that have been established in isolated cases after Enke’s death. Chapter three describes some prominent cases. This is not only with regard to the wide spread of the disease, but rather with regard to the prevailing taboo and shame of athletes to turn to the public because of the disease. The last chapter subsumes the results. In addition, an outlook is ventured. Is breaking the taboo realistic and how will society deal with the disease in the future? What development can be expected? These are the central questions to be answered in conclusion.

Causes

Athletes are largely judged by their performance. A player who additionally defines himself by his performance is at the mercy of considerable pressure and is particularly susceptible to depression if performance fails to materialize. Moreover, the triggers of depression include several factors. On the one hand, biological reasons, i.e. stress hormones and neurotransmitters in the brain are decisive. These neurotransmitters transmit information between synapses and influence daily life. On the other hand, some psychological factors play an overriding role. Permanent overload at work or stressful life events are situations that can trigger depression. Applied to the field of elite sports, the following triggers can be mentioned.

Symptoms, complaints and signs

Depression in a top athlete is usually very difficult to diagnose, because the environment very often lacks the necessary attention. Nevertheless, it is a very common clinical picture that can be triggered by pressure to perform and succeed in combination with self-doubt and sometimes setbacks. Most sufferers try to hide their illness and the associated emotional fluctuations as best they can and often develop great skill in doing so. The symptoms, however, are just as severe as with any other depression: the joy in one’s own life dwindles, lethargy sets in and leads to a lack of motivation and a lack of drive. This has a negative effect on training behavior and training effects.In addition to the pressure to perform, the affected person is now also under pressure to hide his lack of performance and the illness, which he himself often does not recognize. As a result of the repression, further symptoms appear, these can range from loss of appetite and insomnia to psychosomatic illnesses. Very often there is also a disturbed eating behavior, digestive problems and symptoms that are mistakenly classified in the area of allergies. In the case of advancing, unrecognized and untreated depression, the clinical picture develops to such an extent that sooner or later the patient is no longer able to practice his sport at a performance level.

Trigger or triggers

Stress: many athletes mention the enormous stress that rests on athletes. A distinction is made between competition-related and everyday stressors. Here, fear of failure and conflicts with coaches, partners or the family are particularly worth mentioning. The sports psychologist Nixdorf, as well as her colleagues Beckmann and Hautzinger, have described this condition in their publication: “Prevalence of depressive symptoms and correlating variables among German elite athletes: First insight. J Clin Sport Psychol” they applied it to elite sports and worked out a correlation between chronic stress and depression. Other sport psychologists, however, argue that psychological stress is not sufficient as a sole trigger. Excessive demands: The physical stress to which an athlete is exposed is another reason for the development of depression. These high levels of stress are necessary to enhance performance. The demands on the athlete become greater and greater, and he or she can no longer meet the expectations without permanent increases in performance. The problem, in such cases the recovery phase is often ignored. As soon as the relationship between load and recovery becomes imbalanced over a longer period of time, the risk of getting into a state of overtraining increases. This is characterized by fatigue, weight loss, loss of appetite, emotional lability as well as sleep disturbances. A comparison to conventional depression shows the similarity of symptoms and further illustrates how quickly the athlete can fall into this trap. Injuries: A serious injury is another trigger that can lead to depression. Injuries such as a torn cruciate ligament or a fractured tibia or fibula can put athletes out of action for several months. Not everyone has the patience and motivation to fight their way back into the ranks of top athletes. If, in addition, recovery does not proceed according to the athlete’s wishes, but is protracted and the athlete can no longer reach his or her former level of performance, the risks of a depressive illness increase. In such cases, the athlete falls short of his or her own expectations as well as those of fans and supporters. This article informs about the possibilities to prevent these injuries. According to this article, the three most important aspects of prevention are often disregarded. Proper warming up, stretching and cooling down should be taken to heart by every athlete at higher levels of exertion. The survey by the German Sports Aid also revealed that female athletes in particular suffer from depression after an injury. This was also confirmed by the psychologists Appaneal, Levine, Perna and Roh in 2009 in their publication: “Measuring postinjury depression among male and female competitive athletes”. The Sporthilfe study also found that around 10 to 20 percent of injured top athletes suffer from depression. However, the number of unreported cases is very high, so the true number is rather speculative. Failures: The lack of processing of frequently occurring failures is another trigger for depression. In addition, professional sports have become a significant economic factor. Especially the advertising money that flows annually is immense. Athletes who act as advertisers are usually also the top performers and are particularly in the public eye. It becomes critical when these players in particular have to deal with frequent failures. On the one hand, because they enjoy a high level of media attention and are therefore regularly featured, and on the other, because supporters and fans of the teams are more likely to hold the “leading wolves” accountable than those who are less in the spotlight.

Appearance

According to studies, an athlete reaches the aforementioned state of overtraining at least once in his or her career.This is accompanied by depressive symptoms, which in the worst case can end in depression. But how does this become noticeable? Some of the symptoms have already been mentioned. Basically, depression is not only noticeable by sadness. This rumor circulates in society, which proves how little this disease is reflected in the population. This is because the symptoms of depression are multifaceted. In addition to increased pessimism, a loss of sexual interest is also apparent. This can culminate in suicidal thoughts. Furthermore, depression makes itself felt through concentration disorders and an inability to make decisions. Physically, symptoms such as a tightness in the chest area, diarrhea as well as constipation can also be mentioned.

Complications

In the worst case, depression in elite sports can lead to suicidal thoughts and eventually suicide. In most cases, suicide is preceded by long periods of sadness and depression. The psychological symptoms have a strong negative effect on social contacts and also on athletic performance. The patient often feels sad and weak and loses the meaning of life. Often there are also feelings of shame and inferiority complexes, which can further aggravate the psychological complaints and depression. Often, depression in elite sports also causes physical complaints and complications, such as dizziness, headaches and vomiting with diarrhea. Concentration and perception disorders also occur. It is not uncommon for patients to suffer from anxiety and no longer have complete control over their lives. In most cases, treatment is provided by a psychologist. In severe cases or in the case of a self-injurious condition, admission to a closed hospital may be necessary. In most cases, a long period of time passes before treatment for depression in elite sports is effective and the patient becomes aware of his or her condition. The treatment often leads to success and no further complications occur. However, there is a risk that the patient will relapse.

When should you see a doctor?

Top athletes very often suffer from the emotional pressure they feel during their career. As soon as they perceive a listlessness that lasts for several days, they should consider working with a therapist in a supportive manner. Since depression develops slowly, timely contact is recommended. If several gains occur as a secondary placement, in most cases the feeling of failure increases and a doubt about one’s own abilities sets in. Therefore, it is advisable that the inner perceptions after a competition are always discussed with a doctor. This person can assess more neutrally whether further help is needed. If the affected person has the feeling that his performance does not correspond to his possibilities, a doctor or therapist will help to find a solution. If the athlete feels that he is not being understood by his coach or team members, he needs someone he can trust. He can often find this outside of the club members with a therapist. If the joy and fun of the sport is lost, the causes must be investigated. If, despite a sense of achievement and winning competitions, feelings of happiness repeatedly fail to appear, a therapist should be consulted. If there are thoughts of suicide or a persistent lack of drive, the top athlete needs help and emotional support from a psychologist or psychotherapist.

Treatment Pathways

Athletes who experience these symptoms several times in themselves should see a doctor. It is advisable to first visit the family doctor for an initial objective assessment, recommends Dr. Frank Schneider, a specialist in psychiatry, psychotherapy and psychological psychotherapist. If the family doctor considers depression to be a possibility, the affected athlete is referred to a specialist in psychiatry and psychotherapy. There are several psychiatric-psychotherapeutic treatment services that not only preventively try to sensitize athletes and caregivers, but can also intervene early in an emergency.

Psychotherapy

To alleviate depressive thinking patterns and symptoms, psychotherapy is divided into three steps. The first is to establish a normal daily structure.This means that, on the one hand, the patient should consciously perform pleasant activities, but on the other hand, he also has to cope with duties in everyday life. The second step deals with the reduction of negative thought patterns. The patient should realize that the one-sided, negative thought patterns can certainly be viewed from a different perspective, possibly leading to a more positive conclusion. The third aspect is the training of social skills. This is particularly important because depressed people must learn, on the one hand, to make contact with other people and, on the other hand, to represent their own views with self-confidence.

Drug treatment

It is not uncommon to resort to antidepressants for depression. For athletes, this means that the medication must be checked against the World Anti-Doping Agency list. This is because various substances are declared as doping agents and banned in professional sports. This further information helps to find out which substances are banned in professional sports. For this reason, it is important to check the prescribed drugs against the list. In principle, however, antidepressants are not on the list, but the guidelines should still be taken into account.

Outlook and prognosis

The prognosis of depression in elite sports is individual and depends on various factors. The course is unfavorable as soon as further mental illnesses occur. These often require several years of intensive therapy. The prognosis improves with an open approach to the illness and an understanding social environment. Many athletes experience this as a relief. Also helpful for a good prognosis is the combination of psychotherapy with the administration of medication. Since the drugs are subject to strict sporting guidelines of the Anti Doping Agency, special consideration must be given. Alternatively, the use of natural remedies can be resorted to. Top athletes are under special attention and public interest. This presents a challenge in the treatment of depression that must be addressed. As often the private activities of the top athlete are under observation by the press and are passed on to the public, the athlete’s privacy is violated. This has a negative impact on the prognosis of many affected individuals and can increase the risk of a renewed depressive phase. In the absence of sporting success, there is also the risk of a negative impact on the health of the top athlete. If the sufferer manages to build up a sense of achievement outside of sport, well-being normally improves.

Preventive measures

The Chair of Sports Psychology at the Technical University of Munich has issued a series of suggestions for preventive measures to help both athletes and those responsible in clubs to combat depressive symptoms. In particular, coaches and trainers should be mentioned here, as they are in a good position to objectively assess players’ behavior and thus detect the illness at an early stage. Preventive measures include adjusting the training load, because the condition of overtraining is a permanent danger in competitive sports. Furthermore, regeneration should be promoted. Varied recovery phases help athletes to counteract stress. The stress factor should be given more attention in competitive sports anyway, because if an athlete can manage it, he or she reduces the risk of depressive symptoms. Furthermore, dealing with these situations helps to cope with failures. Some athletes who cannot process the failures run the risk of breaking down from permanent failures. In addition, it is important that athletes are provided with an environment in which they have access to help at all times if they experience any symptoms and, if necessary, are given appropriate consideration during training and competition.

Aftercare

Depression in elite sports is a common but mostly taboo phenomenon. From this sentence, the problem of aftercare already arises. If the sports world would deal openly with this topic, every depressed competitive athlete could go to a therapist during the day and in public. He or she could receive adequate acute treatment and aftercare to ensure that he or she remains psychologically stable afterwards.The problem is that many top athletes with burnout, eating disorders, anxiety disorders, sleep disorders or depression have to hide their suffering. Some top athletes secretly go to a psychiatrist or a specialized clinic under a false name. Others remain without any treatment out of fear for their reputation. Under such conditions, aftercare is difficult to implement. In addition, hospital stays are often passed off as injury-related hospital stays. This is to avoid any suspicion of mental illness. Psychiatric aftercare would be particularly useful among competitive athletes. Most depressed elite athletes remain active in elite sports. So they continue to be exposed to stress, pressure to succeed, and pressure to perform. In addition, some of them take antidepressants. Some of them replace or supplement them with tranquilizers and the like. For this reason, top athletes with depression would have to be monitored medically – and not just in terms of their physical condition. Preventive measures would be just as necessary by sports clubs as follow-up care of depressed top athletes by trained specialists.

Consultation with a sports psychologist.

Athletes and clubs should employ a sports psychologist on their advisory staff. The psychological department of the German Football Association looks after both players and coaches of national teams. Hans-Dieter Hermann has been the psychologist for the men’s national team for ten years and confirms the findings that have been published in research to date. The fact that national players have to perform both on the field and their behavior off the field is always judged can affect the mental performance of athletes. Furthermore, it should not be forgotten that professional athletes also have a private life in which things can go wrong from time to time. Accordingly, the sports psychologist does not necessarily act only as a sports therapist, but also as a contact person when private life gets out of control. However, it must always be remembered that the sports psychologist is employed by the “employer”. Especially when it comes to the taboo subject of depression, it must be remembered that the athlete “outed” himself to his club. Independent therapists or psychologists are therefore another alternative if the topic is not given the necessary attention within the club.

Reactions of the federations and clubs

Robert Enke (2008)

Robert Enke’s suicide five years ago not only woke up the public, but equally the clubs and associations. The German Football League (DFL) has now obliged the clubs to hire a psychologist. However, according to a report in the news magazine Focus, the scene has still not been sufficiently sensitized. Maximilian Türk of the DFL confirmed that the clubs were obliged to do so. The focus, he said, was on preparing young players in particular for the tough business of professional soccer. In the fan camps, however, the clubs’ initiatives count for relatively little. Here, only success counts and if this fails to materialize, individual players have to face the vituperations and whistles.

The Robert Enke Foundation

Following the goalkeeper’s suicide, both the German Football Association, the League Association and the Bundesliga club Hannover 96 have set up a charitable foundation to help raise awareness of depression as an illness. The Robert Enke Foundation informs the sport as well as the general public about the disease through studies and discussions. In the process, the initiative is experiencing great popularity. For example, a five-day special exhibition was recently held in Hanover, Germany, both to commemorate the goalkeeper and to give people an idea of what depression can “feel like.” This was presented in a separate room through different acoustic, social and visual stimuli. In addition, the foundation offers a counseling service for people who also suffer from this disease.

Known examples

Sebastian Deisler

The former professional soccer player made his illness public in 2003. In doing so, he broke a taboo in professional sports. At the time, the national team playmaker was just 23 years old. Four years later, he officially ended his career after undergoing several therapies. In total, Deisler had to undergo seven knee and groin operations during his career.While he earned understanding for his move, he was also called a “care case” by some in the scene.

Gianluigi Buffon

One athlete who managed to beat the disease and continued to compete as a professional goalkeeper later in life is Gianluigi Buffon. “The problems occurred precisely at an intersection in my life. In the transition period between youth and growing up. In my head, many things have changed. Now I’m fine again,” said Buffon, who was able to overcome depression within six months.

Robert Enke

Enke’s death in 2009 was a shock moment for German soccer. Before his suicide, the goalkeeper went through a gauntlet of professional soccer. Initially celebrated as an absolute talent in the youth selections and a Bundesliga goalkeeper at Borussia Mönchengladbach and later at Hannover 96, Enke went through various ups and downs in the meantime, which shaped him but also plunged him into depression. For German professional sports, the suicide represented a caesura, after all, it was only from this point that the first initiatives were launched to combat the disease in sports.

Conclusion

What has happened in the public sphere regarding the disease of depression in professional sports? This question is not easy to answer. The initiatives that have been launched by the DFL on the one hand, and the foundations that deal with the topic on the other, certainly deserve positive mention. In addition, it must be acknowledged that a large number of studies examine the topic from a wide variety of angles. Representative here is the study of the German Sports Aid, which has shown the urgency through an anonymous survey in professional sports.

Breaking Taboos

The thesis put forward at the outset that depression continues to be taboo in professional sport cannot be entirely refuted. Although some prominent examples have shown that the disease represents a high suicidal risk on the one hand, but can certainly be overcome by professional therapeutic measures on the other, there continues to be little public understanding of athletes who struggle with depression.

Outlook

It is therefore very difficult to venture an outlook on this sensitive topic. The fact is, however, as long as the social opinion towards the disease does not change, professional sports will continue to make the topic taboo. Especially the fan camps continue to be characterized by ignorant tendencies that will not change unless the overall impression about the disease within society changes.

Here’s what you can do yourself

The disease of depression can have a negative impact on the lives and success of elite athletes. Anyone suffering from depression should immediately consult a specialist in the form of a psychiatrist or psychotherapist. In addition to medical treatment, numerous self-help tips can also have a positive effect on the clinical picture of depression. Since top athletes are usually under a great deal of pressure to perform, it is important to relax sufficiently. In addition to periods of tension, there should also be sufficient relaxation periods in the athlete’s daily routine. Athletes should follow their inner voice and more often pursue activities that do them good – whether it’s a hot bath, a good book, relaxing music or a quiet walk. Everyone is different and has individual preferences and hobbies. Relaxation techniques such as autogenic training or progressive muscle relaxation can also reduce physical and mental tension and thus increase the satisfaction and well-being of athletes. In addition, athletes should always pay attention to a balanced diet that is adapted to the increased physical activity. A good diet provides the body with all the nutrients needed for smooth functioning. Since high performance pressure is usually part of the life of a top athlete, athletes should always work on their self-esteem and mental strength.