Measures to protect and promote elite athletes’ mental health in Swiss sports
Current status and areas for improvement
Abstract
Abstract:Introduction: This paper addresses the growing concern surrounding mental health in elite sports. Acknowledging that national sports systems vary in structure and that any evaluation of these issues must necessarily be country-specific, the study explores current mental health provisions in Switzerland. Method: Based on the feedback of 31 experts, including athletes and representatives from sporting organizations, the study evaluates four aspects of existing measures: formulation of a mental health plan, mental health care provision, athlete support systems, and provisions for high-risk events. Results: The findings highlight two key issues. First, experts clearly have different views about mental health initiatives in Swiss sports for reasons that may include variations in access to information, program visibility, regional and sport-specific differences, and emerging strategies that have not yet been widely embraced. Second, despite these disparities, the experts unanimously agreed that some basic mental health measures remain unimplemented. Conclusion: These findings highlight a pressing need for basic interventions such as mental health screening and improved mental health literacy. Another recommended priority is to design and implement a holistic national mental health plan informed by the collaborative contributions of all stakeholders. Furthermore, this discourse on mental health must be in coordination with ongoing dialogues on ethics in sports.
Introduction
In recent years, the issue of mental health in competitive sports has gained increasing attention. Notably, this shift has been influenced by the courageous disclosures of prominent athletes like Simone Biles, Michael Phelps, and Naomi Osaka, who have shared their personal struggles with mental health issues [1, 2, 3]. In Switzerland, several elite athletes have also spoken publicly about their mental health challenges [4, 5, 6, 7, 8, 9], dispelling the myth of the psychologically invulnerable super-athlete.
Mental health is influenced by many factors [10]; for athletes, that includes the sporting ecosystem they must navigate. As the structure and organization of sports systems differ from country to country, any adequate evaluation necessarily requires country-specific analysis of the relevant conditions and prerequisites. The present study aims to develop a comprehensive understanding of Switzerland’s sports systems and associated mental health supports, including possible measures to improve the mental health of elite athletes and the current state of implementation and use.
Mental health is multifaceted; according to the World Health Organization [11], it encompasses positive mental functionality as well as the absence of psychiatric illnesses. It follows that any evaluation must take account of both mental illness and well-being as integral components of mental health [12]. Discussions of well-being typically distinguish between the hedonic and the eudaimonic [13]. Hedonic well-being – also known as emotional or subjective well-being – refers to the presence of positive feelings and life satisfaction [14]. Eudaimonic well-being refers to the social-psychological level, encompassing community involvement (e.g., social integration and contribution) and individual functioning (e.g., self-acceptance, personal growth [15]). Interestingly, because mental illness and well-being are not mutually exclusive [16], it is possible to experience a high level of well-being while also dealing with mental health issues and vice versa.
Existing data indicate that many Swiss elite athletes report mental health symptoms associated with depression (17%), anxiety (10%), eating disorders (22%), and sleep disorders (18%) [17]. These data align with those for elite athletes from other nations [18, 19, 20, 21, 22] and for the general Swiss population (of the same age and collected at the same time [23]). Levels of well-being among Swiss elite athletes are also comparable to other sporting and non-sporting populations [24, 25, 26]. This suggests that even top athletes, who excel in terms of physical performance and are used to handling pressure, are just like everyone else when it comes to mental health. Notably, however, athletes who feel supported by their sporting federation tend to exhibit better mental health [17], which suggests that sports systems may play a key role in this regard.
When addressing the mental health of Swiss elite athletes, it is crucial to first understand Switzerland’s broader healthcare landscape. Existing legislation requires all Swiss residents to have health insurance [27]. As of July 2022, this insurance covers the services of a qualified psychotherapist if recommended by a general physician [27]. The prescribing physician can authorize up to two 15-session courses, and any additional sessions are subject to insurance approval. Psychiatric services are covered by compulsory health insurance. However, challenges persist, and the demand for therapy often exceeds the available supply, for children, adolescents and adults [28], with some clinics unable to accept new patients (e.g., [29]). The July 2022 legal amendment sought to alleviate this problem. For children and adolescents, political initiatives (e.g., [30]) also aim to improve the situation. In addition to therapeutic services, national campaigns look to prevent mental illnesses (e.g., «Wie geht’s dir?» [31]). While athletes also have access to these resources, they are not exempt from the prevailing care shortage.
Beyond these general measures to improve mental health, it is also crucial to understand provisions within a specific context – in the present case, competitive sporting settings. By integrating mental health promotion into individuals’ daily routines and systems, we can more efficiently foster positive mental health outcomes. This approach acknowledges the impact of environmental factors such as living conditions and social support networks on mental health, taking account of systemic issues like stigma and access to services, as well as individual coping skills.
As athletes face unique demands and expectations [32], integrated mental health promotion is especially important in sporting contexts, prompting both Swiss government officials [33] and international professional sporting organizations [34, 35, 36] to demand that mental health protection should take priority over performance goals. This would mean integrating mental health promotion into the day-to-day training and other routines of all individuals and organizations involved in competitive sports. The call to protect and promote athletes’ mental health reflects society’s expectations regarding high-performance sports and acknowledges our responsibility to safeguard their well-being and personal development [37].
A number of recent studies have made recommendations for improving the mental health of competitive athletes, and 13 position statements from national and international sports organizations and professional associations have advanced concrete proposals in this regard (for an overview, see [38]). A meta-synthesis of those position statements showed that these recommendations can be grouped into overarching themes [38], four of which are of immediate relevance here: formulation of a mental health plan, mental health care provision, athlete support systems, and provisions for high-risk events.
Formulation of a mental health plan
A first recommendation for enhancing athletes’ mental health is to formulate a mental health plan [38]. The plan should distinguish between well-being and mental illness, include context-relevant information and be grounded in established mental health theories. The thorough formulation of such a plan should include consultation with all stakeholders, adherence to applicable laws, and formal organizational endorsement. The plan’s content should address the prevalence of mental health disorders, associated risks, management strategies, and legal issues. The plan need not be exhaustive but must be adaptable; its primary aim should be to safeguard athletes, especially those dealing with mental health issues.
Mental health care provision
To support athletes’ mental health, sports organizations must craft and implement robust mental health care strategies that encompass prevention, treatment, and ongoing individualized care [38]. Key elements should include routine screenings for early risk detection and intervention, along with preventive measures such as promoting mindfulness, resilience, positive team dynamics, stress coping strategies, and good lifestyle habits (e.g., good sleep and diet). Particular attention should be devoted to sensitive career phases involving injuries or transitions. Treatment should be of high quality, based on practitioner expertise, programs tailored to athlete-specific needs, stakeholder collaboration, clear referral protocols, and assured confidentiality.
Athlete support systems
Appropriate support systems are a crucial means of enhancing athletes’ mental health [38] by ensuring psychological safety, autonomy, and stigma-free settings, as well as a long-term development perspective that nurtures positive social ties. Organizations should also employ awareness initiatives, research, and policy reviews to advocate for mental health. For example, mental health literacy interventions would inform athletes about prevalent disorders and available resources and promote help-seeking behaviors by reducing stigma. As part of this process, key figures – especially coaches – should actively seek to protect athletes’ mental health as well as their own.
Provisions for high-risk events
To prepare for and seek to prevent high-risk events such as mental health emergencies, crises, abuse, and maltreatment [38], sporting organizations should develop an explicit crisis plan, including measures to address and manage suicide-related concerns. To safeguard athletes from any form of abuse or maltreatment, organizations should enforce a zero-tolerance policy for all forms of harm, including sexual abuse, bullying, and hazing.
While the above recommendations are not comprehensive and may vary in importance, they offer a coherent point of reference for an analysis of mental health provisions. To assess the extent to which these ideas have been implemented in Swiss sporting contexts, we performed a target-performance analysis of the existing system.
Methods
Procedure and participants
Guided by the four overarching themes above, we developed a number of survey questions to evaluate the implementation of these recommendations in Swiss sports. We incorporated these questions in an online survey of relevant experts – specifically, professionals affiliated with Swiss Olympic, the Federal Office of Sport, and Swiss Sport Integrity, as well as representatives from professional associations with a strong focus on mental health, including Sport & Exercise Medicine Switzerland, the Swiss Association of Sport Psychology, and the Swiss Society for Sports Psychiatry and Psychotherapy.
The criteria for inclusion in the expert survey were extensive work experience in the Swiss sport system, a leadership role or specialized knowledge of key mental health issues in sporting contexts. To capture athletes’ perspectives, we also invited members of the Swiss Olympic Athlete Commission and athlete representatives from sports federations in the three highest funding categories [39] to participate in the survey. The invited candidates received a link to the survey, which included information about the research goals, an assurance of anonymity, and a request for their consent to participate.
As the participants were unlikely to be equally knowledgeable about every question, all survey items offered the option I cannot judge. Participants could also add their own comments on each question. In total, 31 experts completed the survey (a response rate of 51%). The sample included 26 representatives from professional organizations or associations (23% female, Mage = 48.00, SDage = 6.99) and five athletes (40% female, Mage = 32.80, SDage = 4.71). Respondents from professional organizations reported an average of 16.10 years of relevant work experience (SD = 8.78) at organizations that included the Federal Office of Sport (42%), Swiss Olympic (31%), a professional association (19%), and Swiss Sport Integrity (8%). The participating athletes had an average of 13.40 years of experience (SD = 5.23) of elite competition. When asked if they knew the Swiss sport system very well, participants either agreed (61%) or somewhat agreed (39%).
Survey questions
Respondents were provided with the following brief definition of a mental health plan: “A national mental health plan within competitive sport refers to a strategic and systematic approach to address the mental health needs of its competitive athletes. The plan typically includes guidelines and strategies for sports organizations on how to protect and promote the mental health of athletes.” Respondents were asked whether (a) no such mental health plan exists; (b) such a mental health plan is in progress; or (c) such a plan exists (in Switzerland).
The further questions assessed the four overarching themes mental health plan, mental health care, athlete support system and high-risk events and are presented in Table 1. Respondents were asked to rate the questions on a four-point scale (from 1 = do not agree to 4 = agree).
Data analysis
Using t-tests and F-tests, we looked for any differences between athletes and other experts and between professionals from the various organizations. For each question, we quantified participants’ responses as percentages; comments were not analyzed systematically but were introduced as illustrative examples.
Results
The analysis revealed no significant differences between athletes and other participants on any of the questions (all ts < 1.69; all ps > .11). Place of work did not influence participants’ responses (all Fs < 0.97, all ps > .44), and there were no gender differences (all ts < 1.10, all ps > .29). On that basis, all participants were analyzed together.
Respondents expressed mixed views about the existence of a mental health plan; while 30% indicated that a plan was being progressed, 44% felt there was no such plan. None of the participants confirmed the existence of a plan, and 26% could not judge the matter. However, there was clear consensus on the preferred characteristics of a national mental health plan (see Figure 1). Specifically, 85% either agreed or somewhat agreed that any such plan should differentiate between well-being and mental illness. Similarly, 85% agreed or somewhat agreed that any definition of mental health should be based on established models and theories. All participants unanimously agreed or somewhat agreed that any plan should be reviewed, shared, and made available to all stakeholders, and 96% agreed or somewhat agreed that a plan should be enriched by the incorporation of extensive contextual information.
Turning to mental health care provision (see Figure 1), a sizable majority (87%) did not agree or somewhat disagreed that Swiss competitive athletes are routinely screened for mental health issues. Regarding the existence of measures to prevent mental illness in Swiss sports, 39% did not agree or somewhat disagreed, while 58% agreed or somewhat agreed. As to whether sufficient attention was paid to athletes’ mental health during critical career phases, 61% disagreed or somewhat disagreed, and no one agreed fully. Regarding the quality of treatment available in Switzerland to athletes with mental health issues, 19% could not judge, and the remaining responses were fairly evenly distributed from disagree to agree, ranging between 16% and 23%.
Figure 1 also captures responses to the issue of athlete support systems. Notably, almost no one fully agreed that this requirement has been adequately addressed. As to whether the climate was conducive to fostering and promoting mental health, 36% somewhat disagreed and 64% somewhat agreed. Regarding the question of whether individual organizations promote and protect mental health, opinion was evenly split, as 48% disagreed or somewhat disagreed while 48% agreed or somewhat agreed. A substantial 78% disagreed or somewhat disagreed that athletes received training in mental health literacy. Regarding the commitment of key figures (particularly coaches) to actively supporting athletes’ mental health, 52% disagreed or somewhat disagreed while 33% agreed or somewhat agreed.
Finally, in relation to provisions for high-risk events, Figure 1 reveals the conspicuous absence of full agreement. When asked about the existence of a crisis plan in sporting organizations, 59% disagreed or somewhat disagreed while only 19% somewhat agreed. When asked whether organizations actively safeguard their athletes against abuse or maltreatment, 48% disagreed or somewhat disagreed while 44% somewhat agreed.
In total, participants submitted 44 comments; an anonymized list is available on request from the first author.
Discussion
The mental health of athletes is shaped by the specific attributes of their sport system. In our study, we delved into the Swiss sports system, exploring its provisions for mental health protection and promotion. Drawing on insights from 31 experts, including representatives from sport organizations and athletes, we evaluated the existence of mental health measures in Switzerland. These measures spanned four primary domains: mental health plan, provision of mental health care, athlete support systems, and high-risk events. Our findings reveal a lack of consensus across many sectors and even straightforward measures remain unimplemented, indicating substantial opportunities for enhancement.
Mental health plan
Opinion was divided about the existence of a national mental health plan for Swiss elite athletes; while some respondents believed that a national mental health plan was being progressed, others insisted that no such plan exists. This divergence may reflect the inconsistent dissemination of information or varying levels of awareness. However, no respondent suggested that a centralized mental health plan had been finalized. Internationally, countries like Canada [40] have advanced clear guidelines for athletes’ mental health that set a benchmark for Switzerland to consider. This raises a pertinent question: whether the Swiss sports system has fallen behind in this regard, or whether there is some as yet unknown alternative in place. The remarks offered by some participants hint at the latter – mentioning, for instance, “various initiatives spearheaded by professional associations, governmental bodies, and universities” and “distinct projects resembling a national plan, evolving under the ‘Ethics in Swiss Sport’ initiative’.” However, the extent to which these efforts directly target mental health or include all the relevant groups remains unclear.
While there was some ambiguity about the existence of a national mental health plan, there was strong consensus about its desired characteristics, such as the inclusion of all stakeholders or enrichment with comprehensive contextual information. This level of agreement indicates a readiness to develop and implement such a plan. However, in light of the apparent accompanying deficit in awareness or clarity, it seems there is a pressing need to develop a comprehensive national mental health plan for Swiss elite athletes or to more effectively communicate existing efforts.
Provision of mental health care
A significant proportion of the respondents noted the lack of routine mental health screening for competitive athletes in Switzerland. This suggests that opportunities have been missed for early detection and timely intervention, both of which are critical for the effective management of mental health challenges [41]. This concern was further underscored by the respondents’ shared view that athletes’ mental health during critical phases (such as post-injury or career transition) is not adequately prioritized. These issues warrant urgent attention and rectifying them offers one straightforward and actionable pathway for enhancing the Swiss sports system.
Opinion was divided in respect of preventive measures; while some respondents asserted the existence of such measures, others did not. This divergence underscores the apparent lack of uniformity of preventive efforts, as some comments indicated: “There are preventive measures, but these are not comprehensive and systematic”; “It depends a lot on the region, the people, the sport, the experience, and the resources used in the different sports. Absolutely no generalization is possible”; “There is a lot of variation across sports. It’s a recognized problem, but the federations address it differently.” To promote mental health for all athletes, preventive measures must be universally adopted and implemented. In general, these findings bolster the case for a national mental health plan.
Finally, the efficacy and quality of treatment for mental illnesses among athletes in Switzerland remains an area of ambiguity. While many respondents expressed uncertainty in this regard, the remaining responses were fairly evenly distributed, indicating a lack of consensus regarding the quality of care provided, and more in-depth evaluation is clearly needed.
Athlete support systems
A significant proportion of participants felt that athletes received insufficient mental health literacy training. This highlights a significant gap in the framework of supports, as many athletes might be ill-equipped to comprehend, identify, or address their own mental health concerns, and it seems clear that enhanced educational initiatives offer a feasible way forward.
However, beyond this point of agreement, there was visible ambivalence about the existing support systems for Swiss athletes. The data reveal divided perceptions of the overall climate and the commitment of key figures (such as coaches) to mental health promotion. While some respondents agreed that the existing climate is conducive and that key players are supportive, others expressed the opposite view. This divergence was especially apparent in respect of organizational efforts to promote mental health. There are two possible explanations for this lack of consensus. First, organizations vary; as one respondent noted, “the differences between the organizations […] are significant.” Second, some comments highlighted the slow and fragmented evolution of recent measures – for example, “Many measures have been implemented in the last few years. They are still relatively fresh, and not all athletes have benefited to the same extent.” Similarly, “The system is aware of its responsibilities in this area and is adapting. However, this realignment takes time, as it involves a culture change.”
Provisions for high-risk events
One significant category of mental health measures relates to system preparedness for high-risk events. These include both immediate crises, such as severe trauma or injury, and longer-term issues such as the potential for maltreatment in sporting settings. Many of the participants expressed skepticism about the adequacy of organizational crisis planning, and concerns were also raised about a lack of active measures to safeguard athletes from abuse. While some respondents believed that efforts were being made in these areas, there was no overarching consensus. Among the efforts likely referenced by participants are the Are You Ok? Campaign [42], the Ethics in Swiss Sport initiative [43], and the introduction of a new ethics statute [44]. Though these initiatives are undoubtedly necessary, they remain not sufficient in themselves. They form just a part of the broader spectrum of strategies required for comprehensive mental health promotion.
By their very urgency and severity, high-risk events require systems that are robust and agile. Yet, this remains a vulnerable area within the Swiss system. As one respondent remarked, “Awareness of this issue is increasing, but many sporting contexts remain unchanged.” Another respondent highlighted athletes’ psychological torment, which is often overlooked: “The issue of protection against psychological abuse – especially in the form of threats, insults, or humiliation – is seldom addressed, and this abuse is even normalized at times in pursuit of high performance.” Among the exceptions, “Swiss Olympic has onboarded an emergency psychologist for the Olympic Games and has crisis plans that include specified procedures.”
General insights and implications
The present findings offer two general insights into the current state of mental health promotion in the Swiss sports system. First, there are noticeable disparities in terms of awareness and understanding of relevant initiatives, including the existence of a national mental health plan, the implementation of preventive measures, and whether sporting organizations actively promote mental health. These differences may reflect the unevenness of information dissemination, a lack of salient programs, variations across sports and regions, or evolving strategies that have not yet been universally adopted. Second, the respondents generally agreed that straightforward and impactful measures for mental health promotion and protection (e.g., screenings, supports for athletes during difficult phases, mental health literacy training) remain unimplemented.
In conclusion, these findings suggest that while the Swiss sports system has significant potential to protect and promote mental health, it currently falls short. To fulfill that potential, there is a need for greater consensus around mental health initiatives and seamless integration of key measures. At present, however, the evident disparities and failures to implement fundamental measures indicate not just scope but a need for improvement.
The present findings have some implications for decision-makers in the Swiss sports system. First, straightforward measures like mental health screening, support during vulnerable phases, and mental health literacy training should be implemented quickly. Second, the urgency of the need to formulate and/or publicize a national mental health plan for Swiss sports cannot be overstated, and all stakeholders must participate in this process. In particular, major stakeholders like the Federal Office of Sport (FOSPO) and Swiss Olympic should collaborate to provide leadership in coordinating mental health strategies. Third, discussions of mental health must be in coordination with existing initiatives like Ethics in Swiss Sport. Fourth, all localized mental health promotion endeavors should be championed on a consolidated platform to ensure widespread benefits. To link safeguarding and mental health, it might be useful to launch a “safe & healthy” program, modeled perhaps on the “cool & clean” approach [45].
Limitations
The present study has several limitations. First, the limited sample size may not fully capture the range of perspectives among Swiss sports professionals and athletes. While we are confident that our participants provided valuable insights, it is conceivable that a broader sample might disclose other views. Our findings may be unduly optimistic or overly pessimistic. However, our respondents’ extensive experience makes these extremes unlikely and if the results were overly optimistic, this would make the urgent need for improvement even clearer. Secondly, our focus on selected position statements may have led us to overlook some existing Swiss initiatives; indeed, some of these statements have been called into question as unsystematic and insufficiently rigorous [38], suggesting potential gaps in our coverage. Finally, as our methodology favored structured rather than open-ended questions, participants may have felt unable to share unique insights or innovative solutions. Future research should broaden the scope of sampling and make greater use of qualitative methods in pursuit of a more thorough understanding of the Swiss sports system. Additionally, subsequent studies should examine the efficacy of mental health interventions.
Conclusion
This study reveals significant potential to enhance the Swiss sports system’s approach to mental health. The introduction of widespread screening for the early detection of mental health problems would be a first step. In addition, and despite local efforts, a cohesive national plan and a unified strategy are needed as a matter of urgency to protect and promote the mental health of Switzerland’s elite athletes.
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