Sport and athlete mental health: the AU general practice approach

Mental health conditions in athletes are at least as common as in the general community — and for some disorders, substantially more common. The IOC consensus statement (Reardon BJSM 2019) found pooled anxiety and depression symptom prevalence of ~33.6% in current elite athletes, a figure that includes the Olympic medallists and national-team representatives who present to the outside world as the population least expected to struggle.

The clinical picture extends beyond depression and anxiety to eating disorders and Relative Energy Deficiency in Sport (REDs), alcohol misuse, sleep disturbance, substance use, gambling, and acute adjustment problems around injury, deselection, and retirement from sport. What makes recognition harder is the cultural context: “mental toughness” framing, fear that disclosure will cost selection, and — in many general practice settings — a lack of sport-literate clinicians who know how to hold the sport-specific history alongside the standard mental health assessment.

This article covers the AU general practice framework for identifying and managing mental health conditions in athletes — from the weekend footballer to the nationally-funded elite competitor. The framework applies across levels; the sport-specific intensity of the stressors varies, but the access pathways and the duty of care do not.

A. Core clinical — the AU general practice framework

The SMHAT-1 screen

The SMHAT-1 (Sport Mental Health Assessment Tool 1), developed under IOC endorsement, is the recommended structured screening instrument for athletes presenting in clinical or pre-participation settings. Six modules use validated scales:

• Module A — Athlete Psychological Strain Questionnaire (APSQ-10) as triage gate
• Module B — general distress (K-10)
• Module C — sleep (Athlete Sleep Screening Questionnaire)
• Module D — alcohol use (AUDIT-C)
• Module E — anxiety (GAD-7)
• Module F — depression (PHQ-9)
• Module G — eating concerns (Brief Eating Disorder in Athletes Questionnaire)

The companion SMHRT-1 is a one-page tool for non-clinicians — coaches, physios, strength-and-conditioning staff — to recognise warning signs and trigger a GP or sport psychologist referral.

History: beyond the standard mental health screen

Standard PHQ-9, GAD-7, and K-10 apply. Additional sport-specific history includes:

• Training load and recovery — volume, intensity, rest weeks; any recent escalation
• Injury status — acute or chronic injury is the strongest individual psychiatric risk factor in elite athletes; depressive symptoms occur in approximately 30% following significant injury
• Performance and selection pressures — contract negotiations, deselection events, upcoming major competitions
• Body-composition demands — dietary restriction history, weigh-in requirements, aesthetic expectations
• Transitions — recent retirement from elite or representative sport, deselection from a team, return from long-term injury
• Supplement use — cross-check any supplement against Sport Integrity Australia batch-testing databases (Informed Sport / HASTA); undeclared anabolic and stimulant content is a documented contamination risk
• WADA testing-pool status — is this athlete subject to anti-doping testing? Any current Therapeutic Use Exemptions (TUEs)?
• Online abuse exposure — particularly relevant for elite female athletes and racialised athletes

Physical examination

• BMI and weight trajectory
• Vital signs including postural BP and HR: bradycardia below 40 bpm combined with syncope, electrolyte abnormality, or ECG changes is not simply athletic adaptation
• Signs of dietary restriction: dental erosion, parotid enlargement, Russell’s sign (knuckle calluses from purging), lanugo
• Self-harm scars
• Mental state examination including insight into how symptoms are affecting sport and daily function

Investigations for eating disorder or REDs concerns

• FBC, UEC, fasting glucose/HbA1c, lipids, iron studies, TSH, vitamin D, calcium/magnesium/phosphate, LFTs
• Endocrine panel if amenorrhoea or hypogonadism suspected: FSH/LH/oestradiol (female) or testosterone/LH/FSH (male), prolactin, IGF-1, beta-hCG
• ECG for bradycardia, low BMI, syncope, or electrolyte derangement
• DEXA bone density: Medicare criteria include anorexia nervosa; amenorrhoea ≥6 months and stress fracture history are additional triggers

B. Evidence: IOC data, REDs, and prescribing with a WADA lens

Mental health epidemiology in athletes

Gouttebarge et al. (BJSM 2019) meta-analysis of elite athletes found pooled current-symptom prevalence of ~33.6% for anxiety/depression in current elite athletes and ~26.4% in former elite athletes. Female athletes report anxiety at higher rates than male athletes, broadly mirroring community sex differences.

Eating disorders are elevated across aesthetic sports (gymnastics, figure skating, dance), weight-class sports (boxing, wrestling, lightweight rowing, jockeys), and endurance sports (marathon, triathlon, cycling) — recent meta-analytic data confirms persistent elevation versus general community rates.

Gambling disorder is elevated in male elite-athlete and former-athlete cohorts — driven by income transitions, risk-tolerance traits, sponsor exposure, and post-career income reduction. Sleep disorders are common, driven largely by travel and circadian disruption; the IOC sleep consensus (Walsh BJSM 2020) recommends CBT-I as first-line for chronic insomnia in athletes, identical to the general community recommendation.

Relative Energy Deficiency in Sport (REDs)

The IOC’s 2023 REDs consensus (Mountjoy BJSM 2023) replaced the older Female Athlete Triad concept and extended the framework across sexes. REDs is defined by chronically low energy availability — energy intake minus exercise expenditure relative to fat-free mass — driving a 10-system health impact: menstrual function, bone health, endocrine, metabolic, haematological, psychological, cardiovascular, GI, immunological, and growth/development.

Depressive symptoms, cognitive impairment, and fatigue are prominent features of REDs. The critical distinction from primary depression: REDs mood symptoms respond to energy restoration, not antidepressants. Initiating an SSRI without first identifying low energy availability delays the diagnosis and allows ongoing physiological harm. Management is led by a sports-accredited dietitian alongside the GP.

Overtraining syndrome (OTS) — chronic excessive training load with inadequate recovery — overlaps clinically with REDs and primary mood disorder. A GP cannot reliably distinguish OTS from depression without a training-load review alongside bloods and a structured mental health assessment. Treatment for OTS is load reduction and rest; antidepressants are deferred until adequate recovery has occurred and genuine mood disorder is confirmed.

Prescribing with a WADA lens

Per eTG Psychotropic and AMH, standard pharmacotherapy for depression, anxiety, ADHD, and PTSD applies in athletes with the following sport-specific considerations:

Permitted under WADA (no TUE required):

• All SSRIs (sertraline, escitalopram, fluoxetine, paroxetine, citalopram)
• All SNRIs (venlafaxine, duloxetine, desvenlafaxine)
• Mirtazapine, trazodone, bupropion
• Non-stimulant ADHD agents: atomoxetine, guanfacine
• Benzodiazepines (permitted but high-risk: sedation, dependence, motor impairment)

Prohibited in-competition (TUE required for testing-pool athletes):

• Stimulant ADHD medications: dexamfetamine, lisdexamfetamine, methylphenidate
• Beta-blockers: prohibited in archery, shooting, billiards, darts, golf, and some additional sports per WADA Prohibited List 2024

Conditionally permitted:

• CBD is WADA-permitted but OTC products are frequently contaminated with prohibited THC — Sport Integrity Australia recommends only Informed Sport or HASTA-batch-tested products

C. Management pathways: MHCP, EDP, and TUE

Mental Health Care Plan

Any athlete meeting DSM-5-TR or ICD-11 criteria for a mental health disorder qualifies for a Mental Health Care Plan. The SMHAT-1 modules (K-10 ≥22, PHQ-9 ≥10, GAD-7 ≥8) triage directly into MHCP eligibility thresholds. Better Access allows 10 individual plus 10 group psychology sessions per calendar year.

For sport-specific presentations, the preferred referral is a psychologist trained in sport and exercise psychology — available through the APS College of Sport and Exercise Psychology directory and via Sports Medicine Australia. Sport psychiatry referrals route via the RANZCP Sport and Exercise Psychiatry Network.

For elite and nationally-funded athletes, the AIS Performance Health Mental Health Referral Network provides a direct access pathway bypassing waiting lists.

Eating Disorder Plan

Athletes meeting criteria for anorexia nervosa, bulimia nervosa, BED, or OSFED with EDE-Q ≥3 (or equivalent clinical severity) and functional impairment qualify for an Eating Disorder Plan. This allows up to 40 psychology and 20 dietetic sessions per 12-month plan. Sport-specific presentations in aesthetic, weight-class, and endurance sports frequently qualify. Management includes sports dietitian-led energy rehabilitation alongside psychological treatment; training load reduction is often a necessary component of the medical safety plan.

The InsideOut Institute is the national eating disorder research and clinical translation centre and provides GP resources.

TUE process for stimulant ADHD treatment

For an athlete in a WADA registered testing pool who requires stimulant ADHD medication:

1. Document the ADHD diagnosis with supporting specialist letter
2. Document why non-stimulant alternatives are insufficient
3. Submit a TUE application via Sport Integrity Australia — before treatment starts where possible (retrospective TUE is available in genuine emergencies)
4. Wait for TUE grant before prescribing for competitive use
5. Continue monitoring and TUE renewal as required; the stimulant PBS authority is not affected by the TUE process

D. Australian operations

MBS-funded pathways

• MHCP preparation 2715 (≥20 min) or 2717 (≥40 min); review 2712
• Better Access psychology 80000–80020 — 10 individual + 10 group per calendar year
• Eating Disorder Plan 90250–90263; review 90264 range
• GP Chronic Condition Management Plan 965 / review 967 for athletes with REDs sequelae, post-concussion syndrome, or chronic injury comorbidities

PBS prescribing

Per AMH:

• SSRIs and SNRIs: PBS General Schedule for depression and anxiety
• Mirtazapine: PBS General Schedule
• Atomoxetine, guanfacine: PBS Authority Required for ADHD
• Stimulants: PBS Authority Required for ADHD; WADA-prohibited in-competition — TUE required for testing-pool athletes

Sport-specific governance

Any prescription for an athlete in a registered testing pool should be cross-checked against the WADA Prohibited List using the Global DRO tool at Sport Integrity Australia. For elite athletes, the team doctor or sport physician is a co-management partner.

Players’ associations

Professional athletes’ associations maintain confidential support programmes:

• AFL Players’ Association — Mind Set programme
• Australian Cricketers’ Association, Rugby League Players Association, Rugby Union Players’ Association, Professional Footballers Australia, Australian Netball Players’ Association

E. Special populations

Young athletes. School-age athletes have elevated eating disorder and perfectionism-related anxiety risk. The adolescent HEADSSS framework applies. Parent, school, and coaching team involvement in the management plan (with the young person’s consent) is appropriate; mandatory reporting applies for any disclosure of harm or abuse in the sporting context.

Female athletes. Higher rates of anxiety; elevated eating disorder risk in aesthetic, weight-class, and endurance sports; REDs with menstrual disruption is a red flag requiring prompt assessment and treatment.

Post-concussion. Mood and anxiety symptoms are common within the first four weeks after concussion. Monitor suicidality. Persistent symptoms beyond four weeks warrant referral to a multidisciplinary concussion clinic. Stimulant medications for ADHD remain TUE-required during this period.

Retiring or deselected athletes. Identity-foreclosure (investment in single athletic identity) is the strongest predictor of poor adjustment to retirement from elite sport. A referral to a psychologist with sport experience alongside players’-association transition support addresses both clinical and vocational dimensions.

LGBTIQA+ athletes. Additional stigma layers, online abuse exposure, and potential family non-acceptance compound standard mental health stressors. An affirming clinical approach is fundamental.

When to escalate

Immediate or same-day referral when:

• Active suicidality — state mental health crisis assessment, ED if necessary; Lifeline 13 11 14
• Severe REDs: amenorrhoea plus bradycardia below 40 bpm plus syncope plus BMI below 17.5 — consider hospital admission
• Eating disorder with medical instability: significant electrolyte derangement, cardiac arrhythmia, extreme or rapid weight loss
• First-onset psychosis or mania, particularly in association with stimulant or supplement use
• Post-concussion mental health deterioration with suicidality
• Disclosure of abuse, harassment, or sexual assault in a sporting relationship — route to Sport Integrity Australia 1300 027 232, police where criminal conduct is involved, and mandatory reporting if the athlete is a minor

Urgent but not immediate:

• Gambling disorder with significant financial or relationship harm — Gambling Help Online 1800 858 858
• Alcohol use disorder — eTG-guided management; see your GP for a withdrawal plan

What this article is and is not

This is general health information drawn from current Australian general practice guidelines — RACGP, eTG Psychotropic, AMH — and IOC consensus statements on athlete mental health. It does not constitute personal medical advice and does not create a doctor–patient relationship. Specific treatment decisions — including medication selection and WADA compliance verification — are made with your own GP and treating clinicians.

For support: AIS Mental Health, Headspace (ages 12–25), Beyond Blue 1300 22 4636, Black Dog Institute, Butterfly Foundation 1800 33 4673 (eating disorders), Lifeline 13 11 14 (crisis).

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Sources cited

1. Reardon CL et al. — IOC consensus: mental health in elite athletes (BJSM 2019)
2. Gouttebarge V et al. — Mental health symptoms in current and former elite athletes: systematic review and meta-analysis (BJSM 2019)
3. Gouttebarge V et al. — SMHAT-1 and SMHRT-1 (BJSM 2021)
4. Mountjoy M et al. — IOC consensus on Relative Energy Deficiency in Sport (BJSM 2023)
5. Walsh NP et al. — IOC sleep consensus statement (BJSM 2020)
6. RACGP
7. Therapeutic Guidelines — Psychotropic
8. Australian Medicines Handbook (AMH)
9. Australian Institute of Sport — Mental Health
10. Sports Medicine Australia
11. Australasian College of Sport and Exercise Physicians (ACSEP)
12. Sport Integrity Australia — anti-doping, TUE, supplements
13. WADA Prohibited List 2024
14. RANZCP Sport and Exercise Psychiatry Network
15. InsideOut Institute — eating disorders
16. Headspace
17. Beyond Blue
18. Black Dog Institute
19. Butterfly Foundation
20. Gambling Help Online
21. Lifeline