Article Review: Determinants of anxiety in elite athletes: a systematic review and meta-analysis


Athlete-specific factors may precipitate or exacerbate anxiety disorders, including pressures to perform and public scrutiny, career uncertainty or dissatisfaction, and injury. General psychosocial factors are also strongly implicated in the onset and maintenance of anxiety disorders within the general population. These include behavioural inhibition, social withdrawal or avoidance, and cognitive patterns of rumination.

How and Who:

1163 articles; 61 studies were included in the systematic review and 27 of them were suitable for meta-analysis.

Studies were selected if they included (1) data on elite athletes, including para-athletes, defined by standard of performance level, competing at the professional (and professional youth, ie, members of elite sports schools), Olympic and collegiate/university levels; (2) a symptomatic or diagnostic anxiety outcome measure (as per the Diagnostic and Statistical Manual of Mental Disorders [DSM-5]criteria) in relation to GAD, specific phobia, social anxiety, panic disorders or obsessive-compulsive disorder (OCD); and (3) currently competing or retired athletes (authors adopted a maximum mean retirement length of 10 years to allow investigation of effects between anxiety and longer-term sport-specific outcomes [eg, concussion], and account for, yet limit the effect of retirement).


The meta-analysis outcomes indicated several general factors as being salient to symptomatic anxiety in elite athletes, including female gender, younger age and recent experience of adverse life events. These factors are consistent with findings from a recent meta-analysis for competitive anxiety in athletes, and trends in the general population. Meta-analysis also indicated the role of two athlete-specific factors, namely current musculoskeletal injury and sporting career dissatisfaction, as being associated with anxiety symptoms. This is the first meta-analysis to highlight these domains as potential risk factors for symptomatic anxiety among elite athletes.

Considering the athlete-specific factors, musculoskeletal injury and career dissatisfaction can be understood as prominently biopsychosocial influences of mental health.

Additionally, retirement status as an athlete-specific subgroup analysis indicated that experiencing recent adverse life events was associated with higher global anxiety/depression in former but not current athletes.

Athletes report anxiety symptoms at comparable severity with the general population. Similarly, a recent meta-analysis identified that high-performance athletes were no more likely than non-athletes to report mild to severe symptoms of depression.

Unsurprisingly, it was found that anxiety symptoms in elite athletes were associated with symptoms of depression, or a depression diagnosis, in addition to other concurrent anxiety disorder diagnoses. Anxiety symptoms were lower among more experienced athletes, and may have a negative relationship with both motivation and discrete aspects of sporting performance.

The overall mean age for participants in the included studies was 24.5 years, which is inclusive of several studies that incorporated recently retired athletes. For most Olympic and professional sports, the years of competitive elite competition directly overlap with the peak ages of onset for mental disorders, with 75% of all mental disorders shown to emerge prior to age 25.


Factors associated with anxiety symptoms among elite athletes provide useful information for preventative intervention or acute phase management. While there are research gaps related to particular sub-types of anxiety in elite populations (eg, OCD, panic disorder), this review highlights both general factors and athlete-specific factors associated with symptom burden. Though data are lacking, it seems feasible that focused and acceptable interventions for anxiety symptoms among athlete populations may enhance career longevity and improve role satisfaction. Youth-specific models of mental healthcare that have been established internationally are likely to be useful for those aiming to develop innovative athlete-specific services. While it remains to be seen whether such approaches will improve sporting or athletic performance, the next decade is certain to see major investment into the mental health of athletes and expansion of sports mental health as a discipline.


Rice SM, Gwyther K, Santesteban-Echarri O, et al

Determinants of anxiety in elite athletes: a systematic review and meta-analysis

British Journal of Sports Medicine 2019;53:722-730.


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