The world’s best gymnast pulled out of many events this Summer Olympics, citing her mental health as the reason. Simone Biles has been heralded as both a hero and a villain for her decision.

The four-time Olympic gold medalist is just the latest athlete to put their mental health above their desire to compete.

Tennis player Naomi Osaka made headlines earlier this year when she withdrew from the French Open. After her early exit from Tokyo Games, she said lighting the Olympic cauldron was a bit too much to handle.

Former Olympian Michael Phelps, winner of a record 23 gold medals and now retired, has long been open about his own mental health struggles. Phelps said he contemplated suicide after the 2012 Olympics while wracked with depression. Now an analyst for NBC’s swimming coverage, he said watching Biles struggle “broke my heart.”

A new study by University of Toronto researchers suggests that elite athletes experience mental health challenges such as depression, anxiety and eating disorders far more frequently than most people realize.

“Athletes face a huge amount of stress and pressure, and have to manage lots of different expectations — especially at the Olympics,” said Zoe Poucher, a graduate student in the faculty of Kinesiology & Physical Education. “This can have a very negative impact on their well-being.”

Poucher recently published a paper in the journal Psychology of Sport and Exercise that explores the prevalence of symptoms of common mental disorders among elite Canadian athletes.

She found that as many as 41.4% of Canadian national team athletes — those training for Tokyo 2020 — met the cut-off criteria as proposed by the Diagnostic and Statistical Manual of Mental Disorders for depression, anxiety and/or an eating disorder. That’s compared to an estimated 10% of Canadians in general who report a mental disorder in a given 12 month period, according to the study.

Specifically, 31.7% of athletes reported symptoms of depression, 18.8% reported symptoms of moderate (12.9%) to severe (5.9%) general anxiety and 8.6% reported scores indicating a high risk of an eating disorder.

“We found a significant positive correlation between stress and the three different mental disorders we measured, so I think that is one important piece of the puzzle,” Poucher said in a press release.

Another unexpected finding, according to Poucher, was that athletes who made the Olympic team had more symptoms of depression prior to the Games.

“We hear a lot about post-Olympic depression, but I have not seen any research on mental health prior to the Olympics,” she said. “I think the assumption is that people are happy they made the team.”

Stress, social support, coping skills and self-esteem were all found to have an effect on the athletes’ mental health.

“Mental health is obviously impacting a large portion of elite athletes, but it is still not getting the attention it deserves and athletes are made to feel bad about it,” Poucher said. “If we can demonstrate that this is a large problem, I am hopeful that it will help to shift the conversation around mental health, increase awareness of the issue and help inform policy-level change.

“Having world renowned athletes like Simone Biles and Naomi Osaka speak openly about their mental health is helping change the stigma many athletes still face.”

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