A Review of Mental Health Issues in High-Performance and Elite-Level Cycling

Abstract

Despite the public health benefits of cycling in the general population, mental health issues may be evident in high-performance and elite-level competitive domains. With prominent riders disclosing their experiences with psychiatric symptoms, distinctive socioenvironmental factors could exacerbate psychopathological vulnerabilities. This suggests a need for greater mental health awareness amongst stakeholders, supplemented by actions from international and national federations and regulators. To synthesise relevant observations about psychiatric concerns in high-performance and elite-level cycling, we conducted a keyword search of articles in APA PsycINFO, PubMed, and Scopus based on specified exclusion criteria. Thirteen papers were identified that examined mental health issues in high-performance and/or elite-level cycling per classifications from the World Health Organization’s International Classification of Diseases 11th Revision. A large proportion of articles illustrated eating disorder symptomatology, but others discussed attention deficit/hyperactivity disorder, anxiety disorder, depression, sleep wake disorders, and substance use disorder. Existing literature underlines important considerations for all stakeholders within the cycling community around mental health initiatives and care provisions, which are currently lacking across the sport. Such programmes could incorporate consensus statements, psychiatric screening, psychoeducation, stigma-reducing policies, and athlete advocacy. These can help mitigate socioenvironmental risk factors and prioritise athlete wellbeing over performance-centred motivations.

Key words

mental health - sports psychiatry - eating disorders - risk factors - psychoeducation

Publikationsverlauf

Eingereicht: 23. März 2023

Angenommen: 23. Juli 2023

Accepted Manuscript online:
31. Juli 2023

Artikel online veröffentlicht:
06. Oktober 2023

• References

• 1 Oja P, Titze S, Bauman A. et al. Health benefits of cycling: a systematic review. Scand J Med Sci Sports 2011; 17: 496-509 DOI: 10.1111/j.1600-0838.2011.01299.x.
• 2 Johan de Hartog J, Boogaard H, Niland H. et al. Do the health benefits of cycling outweigh the risks?. Environ Health Perspect 2010; 118: 1109-1116 DOI: 10.1289/ehp.0901747.
• 3 Celis-Morales CA, Lyall DM, Welsh P. et al. Association between active commuting and incident cardiovascular disease, cancer, and mortality: prospective cohort study. BMJ 2017; 357: j1456 DOI: 10.1136/bmj.j1456.
• 4 Kaplan S, Wrzesinska DK, Prato CG. Psychosocial benefits and positive mood related to habitual bicycle use. Trans Res F: Traffic Psychol Behav 2019; 64: 342-352 DOI: 10.1016/j.trf.2019.05.018.
• 5 Hicks R. Graeme Obree: why we need to talk about depression in sport. 2015 Available online https://www.cyclingweekly.com/fitness/depression-in-sport-45337. Accessed 23rd March 2023
• 6 Arthurs-Brennan M. Does elite cycling have a problem with mental health. 2019 Available online https://www.cyclingweekly.com/fitness/training/elite-cycling-problem-mental-health-410224.
• 7 Flickinger L. 6 Pro cyclists open up about their struggles with depression. 2019 Available online https://www.bicycling.com/culture/a26897000/pro-cyclists-open-up-about-depression.
• 8 Cochrane A. 5 Pro riders share how they manage their mental health. 2022 Available online https://www.bicycling.com/culture/a37669486/pro-riders-share-their-mental-health-journeys.
• 9 Bramham P. ‘Dishing out the pain’ in professional cycling. In: Wagg S, Pollock AM, eds. The Palgrave Handbook of Sport, Politics and Harm. London: Springer Nature; 2022: 293-307
• 10 Apfel P. Jan Ullrich suffers from ADHD [Ullrich leidet an ADHS]. Available online https://www.focus.de/gesundheit/ratgeber/psychologie/keine-struktur-im-alltag-jan-ullrich-leidet-an-adhs-darum-ist-die-krankheit-fuer-erwachsene-so-tueckisch_id_9385137.html.
• 11 Ballinger A. Sports dietician says eating disorders in cycling are becoming a serious problem. 2020 Available online https://www.cyclingweekly.com/news/latest-news/sports-dietician-says-eating-disorders-cycling-becoming-serious-problem-445709.
• 12 Ströhle A. Sports psychiatry: mental health and mental disorders in athletes and exercise treatment of mental disorders. Eur Arch Psychiatry Clin Neurosci 2019; 269: 485-498 DOI: 10.1007/s00406-018-0891-5.
• 13 Arnold R, Fletcher D. A research synthesis and taxonomic classification of the organizational stressors encountered by sport performers. J Sport Exerc Psychol 2012; 34: 397-429 DOI: 10.1123/jsep.34.3.397.
• 14 Gouttebarge V, Castaldelli-Maia JM, Gorczynski P. et al. Occurrence of mental health symptoms and disorders in current and former elite athletes: a systematic review and meta-analysis. Br J Sports Med 2019; 53: 700-706 DOI: 10.1136/bjsports-2019-100671.
• 15 Currie A. Sport and eating disorders – understanding and managing the risks. Asian J Sports Med 2010; 1: 63-68 doi: DOI: 10.5812/asjsm.34864.
• 16 Pluhar E, McCracken C, Griffith KL. et al. Team sport athletes may be less likely to suffer anxiety or depression than individual sport athletes. J Sports Sci Med 2019; 18: 490-496
• 17 Braeckman A. Tom Dumoulin: “Everyone saw me unhappy, but no one could help me” Tom Dumoulin: Tout le monde m’avait vu malheureux, mais personne ne pouvait m’aider. Available online https://www.lequipe.fr/Velo-mag/Route/Article/Tom-dumoulin-avant-le-giro-tout-le-monde-m-avait-vu-malheureux-mais-personne-ne-pouvait-m-aider/1331228.
• 18 Currie A, Blauwet C, Bindra A. et al. Athlete mental health: future directions. Br J Sports Med 2021; 55: 1243-1244 DOI: 10.1136/bjsports-2021-104443.
• 19 Reuters. World Rugby launches brain health education campaign for elite players. 2021. Available online: https://www.reuters.com/lifestyle/sports/world-rugby-launches-brain-health-education-campaign-elite-players-2021-11-17. Accessed 19th March 2023 .
• 20 Reardon CL, Hainline B, Aron CM. et al. Mental health in elite athletes: International Olympic Committee consensus statement (2019). Br J Sports Med 2019; 53: 667-699 DOI: 10.1136/bjsports-2019-100715.
• 21 Union Cycliste Internationale. The UCI. Available online: https://www.uci.org/the-uci/2QDMyzhoBXyWbVrsxge0EH.
• 22 Union Cycliste Internationale. Mental Health. 2023. Available online: https://www.uci.org/mental-health/3U57vF98R1zjolF0WNDWIT. Accessed 6th June 2023
• 23 Stadnyk AMJ, Impellizzeri FM, Stanley J. et al. Testing, training, and optimising performance of track cyclists: A systematic mapping review. Sports Med 2022; 52: 391-401 DOI: 10.1007/s40279-021-01565-z.
• 24 McCabe T, Johnston A. BMJ Blogs. The importance of being a sports psychiatrist. Available online https://blogs.bmj.com/bjsm/2018/08/13/sports-psychology-a-review/.
• 25 Claussen MC, Imboden C, Raas MI. et al. Sportpsychiatrie und -psychotherapie im Leistungssport [Sports Psychiatry in Competitive Sports - Interdisciplinary and Interprofessional Care and Collaboration]. Praxis 2022; 110: 213-219 DOI: 10.1024/1661-8157/a003832.
• 26 Leibovitz AP, Martin SB. Cycling coaches’ trauma–specific education, familiarity with post-traumatic stress, and coaching efficacy. Int J Sports Sci Coach 2022; 17: 701-712 DOI: 10.1177/17479541221088578.
• 27 World Health Organization. International Classification of Diseases 11th Revision. Available online: https://icd.who.int/en.
• 28 Swann C, Moran A, Piggott D. Defining elite athletes: Issues in the study of expert performance in sport psychology. Psychol Sport Exerc 2015; 16: 3-14
• 29 World Health Organization. Mental Disorders. Available online https://www.who.int/news-room/fact-sheets/detail/mental-disorders.
• 30 Yates A, Edman JD, Crago M. et al. Eating disorder symptoms in runners, cyclists, and paddlers. Addict Behav 2003; 28: 1473-1480 DOI: 10.1016/s0306-4603(02)00263-0.
• 31 Riebl SK, Subudhi AW, Broker JP. et al. The prevalence of subclinical eating disorders among male cyclists. J Am Diet Assoc 2007; 107: 1214-1217 DOI: 10.1016/j.jada.2007.04.017.
• 32 Filaire E, Rouveix M, Pannafieux C. et al. Eating attitudes, perfectionism and body-esteem of elite male judoists and cyclists. J Sports Sci Med 2007; 6: 50-57
• 33 Haakonssen EC, Martin DT, Jenkins DG. et al. Race weight: perceptions of elite female road cyclists. Int J Sports Physiol Perform 2015; 10: 311-317 DOI: 10.1123/ijspp.2014-0070.
• 34 Lichtenstein MB, Johansen KK, Runge E. et al. Behind the athletic body: a clinical interview study of identification of eating disorder symptoms and diagnoses in elite athletes. BMJ Open Sport Exerc Med 2022; 8: e001265 DOI: 10.1136/bmjsem-2021-001265.
• 35 Koppenburg C, Saxer F, Vach W. et al. Eating disorder risks and awareness among female elite cyclists: an anonymous survey. BMC Sports Sci Med Rehabil 2022; 14: 172 DOI: 10.1186/s13102-022-00563-6.
• 36 Verriet J. Representing embodied expertise: anorexia and the celebrity athlete’s lifestyle advice. Celebr Stud 2022; 13: 448-466 DOI: 10.1080/19392397.2020.1760908.
• 37 Cook O, Dobbin N. The association between sport nutrition knowledge, nutritional intake, energy availability, and training characteristics with the risk of an eating disorder amongst highly trained competitive road cyclists. Sport Sci Health 2022; 18: 1243-1251 DOI: 10.1007/s11332-022-01003-1.
• 38 Zandonai T, Lugoboni F, Zamboni L. A risk for athletes: when the desire to sleep becomes a nightmare. A brief case report on benzodiazepine addiction. Psychopharmacology (Berl.) 2018; 235: 3359-3360 DOI: 10.1007/s00213-018-5047-9.
• 39 Newman HJ, Howells KL, Fletcher D. The dark side of top level sport: An autobiographic study of depressive experiences in elite sport performers. Front Psychol 2018; 7: 868 DOI: 10.3389/fpsyg.2016.00868.
• 40 Kuettel A, Pedersen AK, Larsen CH. To flourish or languish, that is the question: exploring the mental health profiles of Danish elite athletes. Psychol Sport Exerc 2021; 52: 101837 DOI: 10.1016/j.psychsport.2020.101837.
• 41 Lastella M, Roach GD, Halson SL. et al. The impact of a simulated grand tour on sleep, mood, and well-being of competitive cyclists. J Sports Med Phys Fitness 2015; 55: 1555-1564
• 42 Liebrenz M, Smith A, Buadze A. Pharmacotherapeutic undertreatment of ADHD in elite-level cycling and anti-doping regulations: Preliminary analysis from 2020–2021. Sports Psychiatry 2022; 1: 137-143 DOI: 10.1024/2674-0052/a000028.
• 43 Skorski S, Hecksteden A. Coping with the “small sample-small relevant effects” dilemma in elite sport research. Int J Sports Physiol Perform 2021; 16: 1559-1560 DOI: 10.1123/ijspp.2021-0467.
• 44 Ekelund R, Holmström S, Stenling A. Mental health in athletes: where are the treatment studies?. Front Psychol 2022; 13: 781177 DOI: 10.3389/fpsyg.2022.781177.
• 45 Currie A, Lunn B. Cycling. In: Glick I, Kamis D, Stull T, eds. The ISSP Manual of Sports Psychiatry. London: Routledge; 2018: 27-41
• 46 Roberts CJ, Hurst HT, Hardwicke J. Eating disorders and disordered eating in competitive cycling: A scoping review. Behav Sci 2022; 12: 490 DOI: 10.3390/bs12120490.
• 47 Coyle EF. Improved muscular efficiency displayed as Tour de France champion matures. J Appl Physiol 2005; 98: 2191-2196 DOI: 10.1152/japplphysiol.00216.2005.
• 48 Bailey M. Eating disorders and professional cycling: the thin end of the wedge. 2022 Available online https://www.bikeradar.com/features/long-reads/eating-disorders-pro-cycling. Accessed 23rd March 2023
• 49 Donlevy M. How thin is too thin for a cyclist?. Available online https://www.cyclist.co.uk/in-depth/how-thin-is-too-thin-for-a-cyclist. Accessed 22nd March 2023
• 50 Stout J. Eating habits of (pro) cyclists: The weight debate. 2015 Available online https://www.ridemedia.com.au/features/eating-habits-of-pro-cyclists-the-weight-debate.
• 51 Giovinazzo S, Sukkar SG, Rosa GM. et al. Anorexia nervosa and heart disease: a systematic review. Eat Weight Disord 2019; 24: 199-207 DOI: 10.1007/s40519-018-0567-1.
• 52 Dunn EC, Neighbors C, Fossos N. et al. A cross-lagged evaluation of eating disorder symptomatology and substance-use problems. J Stud Alcohol Drugs 2009; 70 1: 106-116 DOI: 10.15288/jsad.2009.70.106.
• 53 El Ghoch M, Soave F, Calugi S. et al. Eating disorders, physical fitness and sport performance: a systematic review. Nutrients 2013; 5: 5140-5160 DOI: 10.3390/nu5125140.
• 54 Cook B, Luke R. Primary and secondary exercise dependence in a sample of cyclists. Int J Ment Health Addiction 2017; 15: 444-451 DOI: 10.1007/s11469-017-9745-z.
• 55 Smith A, Buadze A, Colangelo J. et al. A narrative review of sleep deprivation in ultra-endurance cycling. Sports Psychiatry 2022; 2: 32-26 DOI: 10.1024/2674-0052/a000032.
• 56 Perry J. Win at all costs: who pays the price?. 2017. Available online https://www.cyclingweekly.com/news/latest-news/win-at-all-costs-mentality-who-pays-the-price-335608.
• 57 Sowislo JF, Orth U. Does low self-esteem predict depression and anxiety? A meta-analysis of longitudinal studies. Psychol Bull 2013; 139: 213
• 58 Smith C. Tour du dopage: Confessions of doping professional cyclists in a modern work environment. Int Rev Sociol Sport 2017; 52: 97-111
• 59 International Testing Agency. Webinar on doping and mental health. 2022. Available online: https://ita.sport/news/ita-webinar-doping-and-mental-health.
• 60 Kutcher S, Wei Y, Coniglio C. Mental health literacy: Past, present, and future. Can J Psychiatry 2016; 61: 154-158 DOI: 10.1177/0706743715616609.
• 61 Gorczynski P. et al. Developing mental health literacy and cultural competence in elite sport. J Appl Sport Psychol 2021; 33: 387-401 DOI: 10.1080/10413200.2020.1720045.
• 62 British Cycling. British Cycling launches new Mental Health Strategy to support the Great Britain Cycling Team. Available from: https://www.britishcycling.org.uk/gbcyclingteam/article/20190515-gb-cyclingteam-news-British-Cycling-launches-new-Mental-Health-strategy-to-support-the-Great-Britain-Cycling-Team-0. Accessed 7th June 2023
• 63 Rice S. et al. Mental health screening: severity and cut-off point sensitivity of the Athlete Psychological Strain Questionnaire in male and female elite athletes. BMJ Open Sport Exerc Med 2020; 6: e000712 DOI: 10.1136/bmjsem-2019-000712.
• 64 Gallagher KA, Sonneville KR, Hazzard VM. et al. Evaluating gender bias in an eating disorder risk assessment questionnaire for athletes. Eat Disord 2021; 29: 29-41 DOI: 10.1080/10640266.2019.1613846.
• 65 Baum A. Eating disorders in the male athlete. Sports Med 2006; 36: 1-6 DOI: 10.2165/00007256-200636010-00001.
• 66 Bauman NJ. The stigma of mental health in athletes: are mental toughness and mental health seen as contradictory in elite sport. Br J Sports Med 2016; 50: 135-136 DOI: 10.1136/bjsports-2015-095570.
• 67 Smith AJ, Buadze A, Claussen MC. et al. On the same team: A call for increased medicolegal knowledge exchanges between forensic psychiatry and sports psychiatry. Front Psychiatry 2022; 13: 1041891 DOI: 10.3389/fpsyt.2022.1041891.
• 68 Allen H, Backhouse SH, Hull JH. et al. Anti-doping policy, therapeutic use exemption and medication use in athletes with asthma: A narrative review and critical appraisal of current regulations. Sports Med 2019; 49: 659-668 DOI: 10.1007/s40279-019-01075-z.
• 69 Lentillon-Kaestner V. The development of doping use in high-level cycling: from team-organized doping to advances in the fight against doping. Scand J Med Sci Sports 2013; 23: 189-197 DOI: 10.1111/j.1600-0838.2011.01370.x.
• 70 Sandgren SS, Haycraft E, Arcelus J. et al. Evaluating a motivational and psycho-educational self-help intervention for athletes with mild eating disorder symptoms: A mixed methods feasibility study. Eur Eat Disord Rev 2022; 30: 250-266 DOI: 10.1002/erv.2891.
• 71 Smith A, Haycock D, Jones J. et al. Exploring mental health and illness in the UK sports coaching workforce. Int J Environ Res Public Health 2020; 17: 9332 DOI: 10.3390/ijerph17249332.
• 72 Turocy PS, DePalma BF, Horswill CA. et al. National Athletic Trainers' Association position statement: safe weight loss and maintenance practices in sport and exercise. J Athl Train 2011; 46: 322-336 DOI: 10.4085/1062-6050-46.3.322.
• 73 Rumbold J, Fletcher D, Daniels K. A systematic review of stress management interventions with sport performers. Sport Exerc Perform Psychol 2012; 1: 173-193 DOI: 10.1037/a0026628.
• 74 McHenry LK, Beasley L, Zakrajsek RA. et al. Mental performance and mental health services in sport: a call for interprofessional competence and collaboration. J Interprof Care 2022; 36: 520-528 DOI: 10.1080/13561820.2021.1963218.
• 75 Erickson K. USA Cycling announces Team USA Well-Being Program. 2020 Available online https://usacycling.org/article/usa-cycling-announces-team-usa-well-being-program.
• 76 Meister A, Lavanchy M. Athletes are shifting the narrative around mental health at work. 2021 Available online https://hbr.org/2021/09/athletes-are-shifting-the-narrative-around-mental-health-at-work.
• 77 Bertollo M, Forzini F, Biondi S. et al. How does a sport psychological intervention help professional cyclists to cope with their mental health during the COVID-19 lockdown?. Front Psychol 2021; 12: 607152 DOI: 10.3389/fpsyg.2021.607152.
• 78 McCabe T, Peirce N, Gorczynski P. et al. Narrative review of mental illness in cricket with recommendations for mental health support. BMJ Open Sport Exerc Med 2021; 7: e000910 DOI: 10.1136/bmjsem-2020-000910.
• 79 Woods G, McCabe T, Mistry A. Mental health difficulties among professional footballers. Sports Psychiatry 2022; 1: 57-69 DOI: 10.1024/2674-0052/a000010.
• 80 Colangelo J, Smith A, Buadze A. et al. Mental health disorders in ultra endurance athletes per ICD-11 classifications: A review of an overlooked community in sports psychiatry. Sports 2023; 11: 52 DOI: 10.3390/sports11030052.
• 81 Beaudouin F, Tröss T, Hadji A. et al. Do sports-related concussions induce subsequent injuries in elite male football players?. Int J Sports Med 2023; 44: 454-459 DOI: 10.1055/a-1974-3965.