Supervised by: Amanda Liu, BEng, MSc. Amanda spent her undergraduate years studying Biochemical Engineering at UCL (University College London), where she was awarded First Class Honours. She then completed her Master’s degree in Clinical and Therapeutic Neuroscience at the University of Oxford. She is currently studying Medicine (Graduate Entry) at the University of Cambridge.
The Mental Impact of the COVID-19 Pandemic on Athletes: A literature review
The SARS-CoV-2 virus, the first cases of which were reported in Wuhan, China, in 2019, has been declared a pandemic by the World Health Organisation due to its rapid spread. Not only has it caused the closure of recreational, cultural, and sports facilities, but it has even led to the confinement of whole nations. The number of deaths is continuously growing, even now, with vaccination rates rising in most countries. Also, there is still the threat of new, more fatal, and contagious variants spreading. Although the general situation is improving, for the sectors that have faced closure in the pandemic, and for people that have worked on the frontline at the peak of infection and deaths, challenging times still lay ahead.
A wave of mental health problems has been expected. Much research is planned or underway regarding modulators in the risk of commonly found pandemic-related psychological problems. While many healthcare workers put their lives on the line and worked many overtime hours, there were also the people who had their daily routine limited by government-imposed restrictions. Here, athletes, especially professional ones, posed a fascinating subject for research. Before the pandemic, it was widely accepted that physical activity has a positive effect on both the physical and psychological health of an individual. Also, it is known that practicing a sport to a high level often involves performing under pressure and dealing with stress, anxiety, etc. However, we have to ask ourselves a question: was simply exercising at home sufficient to overcome the challenges posed to professional athletes by the pandemic, including the closure of sports facilities, lack of social contact, potential loss of income, and illness of loved ones? What about the postponement and cancellation of competitions and even the Olympics and Paralympics?
This has been a particular focus area for recent studies, many with specific points of focus including athletic identity, type of sport, gender and age as variables possibly affecting the impact of the pandemic on mental health. Several studies also feature different regions or countries. In this literature review, we will summarise the findings in the field of psychology, the toll COVID has taken on the mental health of high-performance and other athletes during the pandemic, as well as how the postponement of the Olympics and different restrictions across the world have affected their situation. This literature review will cover the major findings in the area as well as possible differences in results and possible suggestions for optimising the data. We will be looking at how the coronavirus has changed the world we live in, then how it altered the lifestyles of elite athletes, what effects this change in lifestyle has had on these athletes, and how this might have impacted the 2021 Tokyo Olympics. Everyone on Earth was somehow affected by COVID-19, and including the athletes we look up to. In the end, when they go to the Olympics, they’re not just standing there for themselves, they represent their country, and carry with them the pride and hope of millions of people.
COVID and Mental Health:
Mental health has been an increasing area of focus over the past few years, and awareness of the issue has increased significantly. In times of COVID-19, the World Health Organization has particularly expressed its concerns about the psycho-social impact of the pandemic. The interruption of usual activity, routines and social contact gave rise to feelings of loneliness and boredom, while also enforcing a lack of distraction from the stress caused by the pandemic and working from home. In times of confinement, high rates of loneliness, anxiety, depression, insomnia, harmful alcohol and drug use, and self-harm or suicidal behavior have been found (1). Studies have found that this pandemic is taking a huge toll on the mental health of the general public. “For instance, one of the first studies carried [out in 2020] reported an increase in depressive and anxiety symptoms and stress levels in a sample of Chinese people from different cities in China during the initial stages of confinement, and Zhang et al. (2020) found individuals reporting several mental and physical health issues; the larger the restrictions to their ordinary life, the worse their mental and physical health conditions, just one-month after the commencement of confinement in that country” (2). We, as humans, are social beings, and we feel the need to be surrounded by others. For years, the worst kind of punishment reserved for prisoners was solitary confinement. Studies have shown a correlation between mental illness, post-traumatic stress, self-harm, and the length of isolation, whether it’s on polar expeditions, trips to space, or time in solitary confinement (3).
Physical and Mental Health:
Previous to the pandemic, the relation between sport or regular exercise and mental health had already been studied. A study performed by the state university of Arizona found that regular exercise reduced both anxiety and depression, and could be associated with positive self-esteem, restful sleep, and the ability to respond to stress. Additionally, being active was recently found to reduce the risk of death by cardiovascular disease by about fifty percent, and it reduces the overall risk of premature death in both men and women by twenty-five to thirty percent (3). With all of these benefits, sports can be considered simply a “healthy outlet”, but for professional athletes, it is so much more than that. It is their source of income, their full-time job, and a commitment that can’t be taken lightly.
Athletes During COVID:
The interlinkages between mental health, physical activity, and the pandemic, have been an area of interest for several studies. In these studies, the results varied: some finding a negative psychological effect on athletes during home confinement (2), others stating the protective effect of physical activity on mental health (4). This can be explained by the number of variables involved, since it is perhaps not simply the positive effect of PA (physical activity), but also other coping strategies necessary for handling pressure in competitions. Another important factor is the interruption of daily routine, with the closure of sports facilities and the attendanr worries this may bring for training and future competitions.
In light of the postponement of the Olympics in 2020, attention was brought to the effect of the pandemic and its measures on the mental health of elite athletes (5). It was feared that quarantine regulations would affect an athlete’s ability to practise. Concerns were also reported by the World Health Organization regarding potential mental challenges brought about for all age groups.
The closure of sports facilities, lack of in-person training, and the isolation of quarantine led to many changes in the athletes’ lives. In a research survey conducted by five US universities, athletes were asked about their training habits as well as their perceived wellbeing. This survey showed that, even though 99% of athletes still received guidance from their primary coach or trainer, 84% of them were completing all their activities alone. In many sports, not having someone there, especially a coach, who can see your performance from an outside perspective, can be very detrimental to an athlete’s performance. Also, these athletes shared that pre-covid, 80% of them were participating in training 5-6 days a week, while during COVID, only 45% of them were. This was a drop of 35%, which can be considered significant. This drop in training habits seems to have been caused, as the study suggests, by a lack of motivation. When asked, 68% of the athletes reported that they felt less motivated to participate in physical activity during COVID, and 66% of athletes reported reduced training satisfaction. When these athletes were asked to give a score from 0-100 that described their emotional state, the average score was found to be around 52. These athletes were barely above the midway mark of emotional wellbeing (6).
On 6 September 2020, a Nigerian study was published in the Frontiers Scientific Journal, one of the first research papers to be published about the mental health of athletes in the pandemic (4). It is also one of the pre-eminent pieces of research performed on the African continent in the field of psychology. The study was motivated by a lack of agreement in the field regarding the importance of the athlete’s mental health in a culture that often emphasises mental toughness. It sought to identify the factors which may predict vulnerability for mental health problems in athletes, researching the effects of athletic identity, category of sport, level of competition, age and years of sport, as well as financial rewards in sport. In order to collect this data, the Kessler Psychological Distress Scale (K10) was employed to assess the likelihood of a common mental health disorder, next to an original athletic identity scale of 10 items. The results found that some of the variables that were researched could to some degree predict psychological distress. Both the postponement of major international events such as the Olympics, the UEFA Euro Cups, and that of the local National Sports Festivals were identified to impact Nigerian athletes’ mental health during the pandemic. Additionally, a survey was conducted during total lockdown measures at the end of March 2020, over a period of four weeks. Coaches were contacted to reach out to athletes for possible participation in the study. The total sample comprised 64 athletes, of whom 20 were professional. The participants taking part were active in 9 different sports including athletics, badminton, gymnastics, cycling, taekwondo and table tennis. The data collected was analysed using a Mann-Whitney test to identify possible interactions between particular groups and psychological distress. After additional multiple regression, between variables and psychological distress as a dependent variable, it was discovered that only athletic identity and sport participation had a significant, negative relationship with mental distress. This first finding revealed that individual athletes overall had more psychological distress than team sport athletes, which is supported by a number of other studies. This can be explained by the fact that team sport athletes have more social contact opportunities, which is proven to be beneficial for mental health. Apart from that, the result is partly owing to the responsibility of individual athletes being higher while in a team this responsibility is shared. The second finding (the negative relationship between athletic identity), however, hasn’t been completely supported by other studies, despite a theory of self identity being proposed. Study limitations, namely a relatively small sample size and some problems in the methodology, might account for this difference. These methodology problems include the presence of social desirability, voluntary response bias, under-coverage of professional athletes and an uneven split between genders. The study could be improved using random sampling across a bigger sample, with which selection bias as well as under-coverage could be resolved, making the results of the study more reliable .
An equally significant study, conducted on athletes in Italy, was performed and published in the journal of Environmental Research and Public Health (7). In the study, the enhancing psychological effect of general fitness and physical activity on athletes’ mental health were weighed up against the training routine interruption, boredom, and lack of social contact posed by the pandemic. In the research, this was measured using the Impact of Event Scale variations, which was applied for different age categories. The scale consists of 3 sections: Avoidance, Intrusion and Hyperarousal, standing for different psychological impact-related symptoms. The methodology included a letter being sent to National Federation Presidents to inform them about the online survey and the opportunity to participate. Although this study was conducted with a volunteering bias, national federations include a wide range of sports and therefore there shouldn’t be a big influence regarding under-coverage. The sample also includes 1508 athletes, adding to its significance. The study sampled both genders, a number of sport types, different age categories, and different competitive levels. The data collected from these participants showed that 35.8% of the participants showed subjective distress symptoms relating to sports withdrawal in the pandemic. Kruskal Wallis analysis suggested that age category is an important factor. Younger participants’ mental health was more likely to be affected, potentially caused by less experience in managing anxiety in daily life. Other variables were also found to affect the scores. As the Nigerian study had previously shown, individual athletes were usually more affected, with higher total scores and specifically higher HYP scores. Gender and competitive level’s effect on mental health were also shown to be statistically significant. Here, gender mainly affected psychological distress in adults, with AV scores higher in female athletes. The study attributes this AV score to a technique called compartmentalisation. Similarly, slightly higher AV scores in male adolescent athletes were attributed to an avoidant coping strategy.
Competitive level affected age categories differently, where overall a higher HYP score would be measured amongst higher level athletes. While in adolescents AV scores were significantly higher, in children INT scores were found to be higher. Intrusive behaviour could have been enhanced by a peritraumatic response to pressure from coaches and parents. Adolescents, on the other hand, are generally more capable of oscillating with coping strategies. The overall rise in HYP score can be explained with the rise of a feeling of emptiness in the pandemic, particularly in elite athletes who would otherwise occupy a lot of their time with sport, impacting mental health. Elite athletes with a high athletic involvement also showed particularly high HYP scores, experiencing greater emotional symptoms and affecting stress response following cancellation of competitions significantly more than in other athletes. This seems to clash with the findings of the Nigerian study. However, an under-coverage of professional athletes in the Nigerian study, and support from other studies make this result more reliable. Furthermore, high HYP scores can be caused by the fact that athletes with a higher athletic identity will be more affected by a career pause, which could interfere with life goals. The few limitations to the study could include volunteering bias and social desirability, but, despite these, it remains a significant piece of research.
A similar, supplementary study was published in The Physician and SportsMedicine. Although titled similarly, this study includes both a scale of physical activity, the IPAQ, as well as a non-athlete control group, which allows comparison of athletes with the general public. The study consists of a cross-sectional survey conducted two months after the start of isolation in Turkey, with 418 athletes and 194 non-athletes participating. The effect of not being able to go outside was measured, using the Depression Anxiety-Stress Scale (DASS-21), the Impact of Event Scale (which was also used in the Italian study), and IPAQ-SF. Interaction effects were observed in some variables,such as between gender and sports groups. Physical activity in sports groups was generally higher in men than in women, with the exception of individual athletes where PA was the same across genders. In both men and women, the physical activity of team and individual athletes was also higher than in the control group. The was statistically no difference in physical activity between team and individual athletes. Despite the physical activity differences in gender in all sports groups, the total DASS-21 scores were similar among the genders in the three groups. Differences, on the other hand, can be observed in the subsections where depression in athletes was significantly lower than in non-athletes. When looking at anxiety, it was lower only in team athletes when compared to the control group. Stress levels were similar in all groups, with only male team athletes doing better than the non-athlete control, which can be attributed to more regular physical activity. The results of the IES-R confirmed the results of the Italian study. The results show that increased physical activity in athletes results in an overall lower DASS-21 in both genders, similar to IES-R, showing the relationship between sports and better mental health during the pandemic. Furthermore, it is notable that the lower depression symptoms for team athletes compared to individual athletes is once again confirmed, despite differences in methodology and location. The similarities in gender mental health status isn’t as much supported by other studies, but that could be due to a lack of self efficacy in males.
Despite lower levels of psychological distress regarding the general situation, in a culture of mental toughness it is important to monitor the situation and prevent escalation of mental health issues, which could affect athletes’ performance and wellbeing. A study was therefore performed in Turkey, in which 18 elite athletes participated in a semi-structured interview that was audiotaped. The study was particularly small, but this can be attributed to the method, which was particularly time-consuming. Furthermore, the method doesn’t allow for measurement of degree and the open-ended questions make it difficult to generalise results within the wider sports community. Despite this, the study is of vital importance in obtaining information on subjects that are difficult to research, as well as identifying potential future areas of research. The athletes were interviewed online and the interviews were recorded. The pattern that could be identified was the following: the study suggests that the most common thoughts passing through athletes’ minds are about the future. This could be related to the fact that the most common emotion was anxiety, possibly caused by the uncertainty of the future. 14 out of 18 of the athletes talked about managing strategies to cope with these anxious thoughts and emotions.
As shown by the previous study, fear of future performances is another important factor in the protection of the mental health of athletes. A study was conducted on the effects the pandemic has had on the performance of strength athletes. The cessation of sports competitions and interruption of training, which occurred in most countries, strongly affected athletes’ fitness. It was found that strength is lost in 4-5 weeks and a reduction of sensorimotor ability was also observed. Additionally, there was a max strength reduction in both upper (6-9%) and lower limbs (14-17%). Competitive weightlifters who exercised after 2 weeks of de-exercise decreased in ability by about 6%.
The combination of the effect of the pandemic on physical health and physiological health can largely affect performances. While this might not impact team athletes as much, due to shared responsibility, it might lead to even more anxiety in individual athletes and athletes with high athletic identity. Policymakers should therefore remain cautious regarding sports restrictions and sports organisations should keep offering support to their athletes. That way the culture of mental toughness might, step by step, be broken.
Everyone on Earth was somehow affected by COVID-19, including the athletes we look up to. The isolation, lack of in-person training, and stress that comes with a worldwide pandemic have led to many detrimental mental health conditions, a loss of training and musculature, as well as much anxiety about the future, careers, and the ability to return to the sport. Even though the athletes faced fewer mental health issues than the general population due to their involvement in physical activity, they still were faced with challenges different from most of the world. Through all of this, athletes managed to push through and even find ways to deal with the anxiety and negative emotions. Their tenacity was demonstrated in this year’s 2021 Tokyo Olympics, where athletes from 206 countries came together in a celebration of sports and competed to the best of their abilities, despite the huge setback the pandemic posed. When these athletes go to the Olympics, they’re not just standing there for themselves, they represent their country, and carry with them the pride and hope of millions of people.
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