The pressure of the Olympic season, the risk of falls, and a hypercompetitive environment can put athletes’ psychological well-being at risk, amplifying a vulnerability that is already widespread among athletes — especially in sports that carry strong social significance. US figure skater Amber Glenn recently recounted that she suffered from depression and fought to return to the ice. The same has happened to many Canadian short-track speed skaters — a sport of major national importance in Canada and a consistent source of Olympic medals.

A recent study published in the Journal de Traumatologie du Sport by Gabrielle Ostiguy, MD, sports physician at the Institut national du sport du Québec, and Alexis Gagnon-Dolbec, PhD, clinical psychologist at Speed Skating Canada, found that 20%-35% of elite athletes report symptoms consistent with common mental health disorders, often showing a fluctuating and nonlinear course. Several cases within the Canadian national team highlighted shortcomings in care when it comes to managing a temporary suspension and the subsequent graduated return after disabling symptoms, without turning the process into a tug-of-war between sporting demands and clinical confidentiality.

A Structured Protocol

The article describes the experience that led to the development of a structured protocol that has become the basis for a Canadian national guideline on returning to sport after a mental health issue. The model draws on posttrauma protocols but adapts them for mental health, inspired by the principles of exposure therapy: Instead of fixed timelines, progression is based on clinical and functional criteria for moving from one phase to the next, with the possibility — considered physiologic — of stepping back.

“This Canadian experience is very interesting and highlights the importance of monitoring athletes’ psychological well-being, offering guidance that can be applied across all sports,” Maria Rosaria Squeo, medical director for the Olympic area at the Italian National Olympic Committee, told Univadis Italy, part of the Medscape Professional network. “For years, the athlete evaluation protocol used at our institute has also included a thorough psychological assessment.”

The process recommended by the Canadian experts is structured into six stages, from the initial assessment to the return to official competition. The progression is guided by three pillars: safety, stability, and functioning. In short, it involves an initial medical and psychologic assessment that can lead to a decision on whether to continue or discontinue athletic activity; suspension from athletic activity until the resumption of daily activities, with close follow-up; a progressive return to training in a “psychologically safe” environment; transition to supervised training in a high‑performance setting, possibly with restrictions; full, unrestricted training but without participation in official competitions, with monitoring; and finally a return to competition, subject to formal medical clearance and clinical compatibility with the demands of the competition.

Normalize Relapses, Protect Confidentiality

An important operational element emphasized by the Canadian clinicians is the integration of formal assessment using standardized tools.

In their experience, the protocol normalizes possible relapses as part of the recovery process, protects confidentiality to reduce stigma and shame, and reduces the risk for conflicting messages from technical staff, medical staff, and the outside world such — as teammates, media, and family, which can confuse and delay recovery.

“Italy is among the few countries that have legally protected athletes’ health since 1982, entrusting sports physicians with the decision to grant eligibility to compete, based on national guidelines,” Squeo added. For example, the COCIS cardiology guidelines (issued by the Italian Society of Sports Cardiology Committee) effectively prevent some athletes — who elsewhere would be free to decide whether or not to participate — in Italy. This happened with Danish footballer Christian Eriksen, who was fitted with an implantable cardioverter defibrillator. He was forced to leave Inter Milan to pursue his career in England’s Premier League and now plays in Germany’s Bundesliga.

“However, there are no guidelines for psychological health, and the onset of a psychological disorder does not, in general, risk compromising athletic fitness, but rather, it triggers a series of interventions to support the athlete,” Squeo noted.

Even in the absence of specific guidelines, however, the decision is up to the physician. “In a case like Lindsey Vonn’s, I’m not sure what an Italian sports physician would have done,” Squeo said, referring to the US ski champion who chose to compete in downhill despite a torn anterior cruciate ligament and later suffered a severe femur fracture in a crash.

This story was translated from Univadis Italy.