“The pursuit of higher, faster, and stronger has led some athletes to risk shame, bans, and even death to get an extra competitive edge…” This quote is from the introduction to the recent Raw Talk Podcast episode titled, “Podium Pills: Fame or Folly?" The episode dives into the world of performance enhancing drugs, with perspectives from the World Anti-Doping Agency, Olympic athletes, and a supplement formulator, to find out why and how performance enhancement occurs in sport.
You may have heard of famous athletes such as cyclist Lance Armstrong, baseball player Jose Canseco, tennis star Maria Sharapova, and UFC fighter Jon Jones, who have all been caught using banned performance enhancements in their sport. These discoveries drew criticism and had many debating the legitimacy of the athletes’ accomplishments. The use of performance enhancing drugs (PEDs) is deeply entrenched even in junior levels of sport, but the question is: why do athletes use PEDs?
According to a 2002 British Medical Association report, motivations of athletes to take PEDs included media pressure to win, financial rewards, or to improve their body image.1 Dr. Vivienne Nathanson, the head of ethics and science at the British Medical Association, added, “What is really worrying is that people who use drugs in sport are taking potentially life-threatening drugs and think its worth it. Surely no accolade is worth your health or indeed life?” Our struggle to understand the decision to used PEDs may be due to the fact that, while the physical impacts of sport have been well documented, there is comparatively less research on the mental health and psychological well being of athletes.2
When exploring the mental health of athletes, it is important to note the intense mental and physical stressors that are a unique to a sporting career. Some of these stressors include, “the pressure of increased public scrutiny through mainstream and social media, limited support networks due to relocation, group dynamics in team sports, and the potential for injuries to end careers prematurely”2. How athletes cope and appraise these stressors partly determines their impact on their mental health.3 For example, perceiving anxiety symptoms in a facilitative manner was related to adaptive ways of thinking (and consequently behaving) that are beneficial to one’s well-being.4 On the other hand, perception of anxiety in a debilitating manner was found to be related to negative patterns of perfectionism.5 Maladaptive perfectionism, characterized by “setting consistently unrealistic personal standards”6 may be a precursor to obsessive-compulsive disorder.7 When looking at sex differences, females have reported greater focus on performance (as opposed to cooperation and effort), concentration disruption, and anxiety compared to males.8 Furthermore, athletes may have traumatic experiences during their sport, such as serious injuries, which may pose an even greater risk of progression to a chronic trauma-related mental health disorder.9
Comparing physique with others through social media, the pressures of maintaining a lean body shape (e.g. gymnastics), or cutting weight to participate in a certain weight class (e.g. wrestling), contribute to higher vulnerability of eating disorders and body image issues among athletes.2 In 2016, the estimated prevalence of eating disorders among athletes in general ranged from 0-19% in men and from 6-45% in women.12 According to Hilkens and colleagues (2021), young male gym users have been indicated as ‘at risk’ for the use of PEDs, and gym users in general have a higher prevalence (~18%) compared to the general population’s (~3%) use of PEDs.10,11 In the episode by Raw Talk Podcast, Dr. Dean St. Mart, a product formulator for Supplement Needs, discussed the dangers of misinformation about PEDs in gym and bodybuilding forums, leading to a significant knowledge gap in how these substances can affect the user’s health. Exposure to this misinformation and the plethora of fitness-related content on social media may drive the use of PEDs due to the construction of negative body images, especially in male gym users.12
Athletes face many unique stressors; however, various barriers prevent athletes from seeking support to cope with such stressors. These barriers may include stigma (public and private), the lack of understanding or misinformation about mental health, busy athlete schedules, and perceptions that seeking help is a sign of weakness.13,14 Even athletes with positive attitudes towards seeking mental health support have reported concerns regarding how they will be perceived by their peers, coaches, and sport managers.15 Furthermore, in some contexts, mental health services and education may be scarce, and approaches to understanding and treating mental health symptoms and disorders may not be evidence-based.16 Therefore, mental-health frameworks that can help understand, assess, manage, and intervene to enhance athletes’ mental health are required. Purcell and colleagues (2019) developed a new mental health framework that recognizes the impact of athlete-specific risk factors and engages individuals that can help monitor and promote the athlete’s mental health and well-being. This framework has 3 main aims: 1) help athletes develop skills to manage psychological distress; 2) train individuals in the sport environment, such as coaches, to recognize and respond to concerns regarding athletes’ mental health; and 3) highlight the need for multi-disciplinary teams to manage athletes with mental health disorders.17 Although this is a promising framework, its efficacy is still being evaluated using controlled trials and other high-quality study designs.17
Athletes are always searching for ways to get an edge in competition, and some turn to PEDs. But using PEDs may represent the symptom of untreated mental health disorders related to sport, such as inadequate stress management strategies, challenges with body image, eating disorders, as well as barriers to accessing mental health supports. Such challenges represent opportunities for more research related to the athletes’ mental health, psychological well being, and delivery and treatment for related disorders.
Edited by Jeffrey Lynham & Curtis D'Hollander
2. Rice, Purcell, R., De Silva, S., Mawren, D., McGorry, P. D., & Parker, A. G. (2016). The Mental Health of Elite Athletes: A Narrative Systematic Review. Sports Medicine (Auckland), 46(9), 1333–1353. https://doi.org/10.1007/s40279-016-0492-2
4. Hatzigeorgiadis, & Chroni, S. (2007). Pre-Competition Anxiety and In-Competition Coping in Experienced Male Swimmers. International Journal of Sports Science & Coaching, 2(2), 181–189. https://doi.org/10.1260/174795407781394310
5. Koivula, Hassmén, P., & Fallby, J. (2002). Self-esteem and perfectionism in elite athletes: effects on competitive anxiety and self-confidence. Personality and Individual Differences, 32(5), 865–875. https://doi.org/10.1016/S0191-8869(01)00092-7
6. Stoltz, K. & Ashby, J.S. (2007). Perfectionism and lifestyle: Personality differences among adaptive perfectionists, maladaptive perfectionists, and nonperfectionists. Journal of Individual Psychology. 63. 414-423.
7. Chen, Chen, M.-Y., Kee, Y. H., & Tsai, Y.-M. (2008). Relation of Perfectionism with Athletes’ Burnout: Further Examination. Perceptual and Motor Skills, 106(3), 811–820. https://doi.org/10.2466/pms.106.3.811-820
8. Abrahamsen, Roberts, G. C., & Pensgaard, A. M. (2008). Achievement goals and gender effects on multidimensional anxiety in national elite sport. Psychology of Sport and Exercise, 9(4), 449–464. https://doi.org/10.1016/j.psychsport.2007.06.005
9. Cloitre, Stolbach, B. C., Herman, J. L., Kolk, B. van der, Pynoos, R., Wang, J., & Petkova, E. (2009). A developmental approach to complex PTSD: Childhood and adult cumulative trauma as predictors of symptom complexity. Journal of Traumatic Stress, 22(5), 399–408. https://doi.org/10.1002/jts.20444
10. Hilkens, Cruyff, M., Woertman, L., Benjamins, J., & Evers, C. (2021). Social Media, Body Image and Resistance Training: Creating the Perfect “Me” with Dietary Supplements, Anabolic Steroids and SARM’s. Sports Medicine - Open, 7(1). https://doi.org/10.1186/s40798-021-00371-1
11. Sagoe, Molde, H., Andreassen, C. S., Torsheim, T., & Pallesen, S. (2014). The global epidemiology of anabolic-androgenic steroid use: a meta-analysis and meta-regression analysis. Annals of Epidemiology, 24(5), 383–398. https://doi.org/10.1016/j.annepidem.2014.01.009
12. Joy, Kussman, A., & Nattiv, A. (2016). 2016 update on eating disorders in athletes: A comprehensive narrative review with a focus on clinical assessment and management. British Journal of Sports Medicine, 50(3), 154–162. https://doi.org/10.1136/bjsports-2015-095735
13. Gulliver, Griffiths, K. M., & Christensen, H. (2012). Barriers and facilitators to mental health help-seeking for young elite athletes: a qualitative study. BMC Psychiatry, 12(1), 157–157. https://doi.org/10.1186/1471-244X-12-157
14. Reardon, & Factor, R. M. (2012). Sport Psychiatry: A Systematic Review of Diagnosis and Medical Treatment of Mental Illness in Athletes. Sports Medicine (Auckland), 40(11), 961–980. https://doi.org/10.2165/11536580-000000000-00000
15. Green M, Morgan G, Manley A. Elite rugby League players’ attitudes towards sport psychology consulting. Sport Exerc Psychol Rev 2012;8:32–44
16. van der Watt, Nortje, G., Kola, L., Appiah-Poku, J., Othieno, C., Harris, B., Oladeji, B. D., Esan, O., Makanjuola, V., Price, L. N., Seedat, S., & Gureje, O. (2017). Collaboration Between Biomedical and Complementary and Alternative Care Providers: Barriers and Pathways. Qualitative Health Research, 27(14), 2177–2188. https://doi.org/10.1177/1049732317729342
17. Purcell, Gwyther, K., & Rice, S. M. (2019). Mental Health In Elite Athletes: Increased Awareness Requires An Early Intervention Framework to Respond to Athlete Needs. Sports Medicine - Open, 5(1), 1–8. https://doi.org/10.1186/s40798-019-0220-1