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Original Research

The Impacts of COVID-19 on Mental Health and Training in US Professional Endurance Athletes

Roche, Megan MD*; Sainani, Kristin PhD*; Noordsy, Douglas MD; Fredericson, Michael MD

Author Information
Clinical Journal of Sport Medicine: May 2022 - Volume 32 - Issue 3 - p 290-296
doi: 10.1097/JSM.0000000000000983

Abstract

INTRODUCTION

The coronavirus (COVID-19) pandemic is affecting global populations in unprecedented ways, including affecting mental health.1,2 COVID-19 presents unique challenges for athletes—cancellation and postponement of sporting events can create a sense of uncertainty, time off from structured training can increase injury rates on the return to competition,3 and social distancing guidelines can limit time spent training with teammates and coaches. In sum, COVID-19 is an external disruption with profound implications for athletes, and it is essential to understand how external disruptions affect clinical and subclinical mental health issues.

In 2020, the International Olympic Committee postponed the Summer Olympic Games, and many community sporting events were canceled for athlete and global health protection.4 Prioritizing the physical health of our athletes and communities is paramount. However, few studies have examined how COVID-19 has affected the mental health of professional athletes. The National Collegiate Athletic Association (NCAA) Student-Athlete Well-Being Survey of 37 000 athletes found that 40% of participants reported lack of motivation, and more than 20% identified feelings of stress or anxiety.5 A study in subelite and elite athletes (n = 565) across a variety of sports found that decreased frequency and duration of athletic training during COVID-19 was associated with higher reports of feeling depressed or anxious.6 To the best of our knowledge, no study has looked at the mental health and training patterns of professional endurance athletes. The professional athlete population may serve as a microcosm of the broader athlete population, allowing us to explore the complex intersection of mental health and physical performance in a world of uncertainty.

We examined how professional athletes are affected by COVID-19 through a survey and activity data analysis in Strava's professional endurance athletes in the United States (US) in August 2020. Strava is an online activity-tracking platform where millions of worldwide users upload Global Positioning System (GPS) files or self-entered workouts from running, cycling, swimming, and a wide range of other activities.7 Our primary aim was to assess changes in mental health and motivation, and our secondary aim was to assess changes in exercise volume and intensity that occurred after COVID-19 restrictions were implemented. We hypothesized that athletes would experience increased feelings of sadness, anxiety, and stress during COVID-19 restrictions, with decreased motivation for training. We also hypothesized that athletes would alter their training regimens with decreased time spent training with teammates and partners and decreased intensity and duration of exercise.

METHODS

Study Procedures and Recruitment

The study population was recruited from Strava US professional endurance athletes primarily consisting of runners, cyclists, and triathletes. Three hundred eighty-six professional endurance athletes were identified by the “Pro Badge” designation on the Strava platform. Strava sent a recruiting email to the “Pro Badge” athletes on August 14, 2020, on behalf of our research team. Each enrolled participant completed an online informed consent on Qualtrics and received a unique, 5-digit study identification (ID) for survey completion.

All enrolled participants were invited to share their activity data for analysis as part of the informed consent process. Participants who consented to share their activity data provided their Strava-designated athlete ID to enable the Strava data analytics team to access their activity data. Strava-designated athlete IDs are provided to all athletes on the Strava platform. After completion of the consent, participants were redirected to take a 10-minute Qualtrics survey. Study participants were not involved in this study design. This study was approved by the Stanford University Institutional Review Board.

Survey Measures

We designed all survey measures (see Appendix 1, Supplemental Digital Content, https://links.lww.com/JSM/A289). The survey included questions on athlete characteristics, COVID-19 symptoms, COVID-19 testing, training structure, financial stability, and mental health. We also had a question that inquired about the percentage of activities participants uploaded to Strava over the past 3 months. Given our small population size and the visibility of the professional athletes, we avoided questions that may identify single athletes or small groups of athletes, including questions on race and geographic region.

Mental health questions were designed based on the Patient Health Questionnaire (PHQ).8 The traditional PHQ is an assessment for diagnosing depression and analyzing depression severity. Patients are asked to assess their symptoms “over the past 2 weeks.” Scores are given for each answer, ranging from 0 to 3 for the scale of “not at all” to “nearly every day,” respectively. A total score is calculated and used to classify the severity of depression.9 We consolidated questions into 5 mental health categories to better consider the experiences of athletes. We structured the modified PHQ into 2 separate time periods: “before COVID-19” and “during COVID-19,” with March 2020 as the cutoff date (Figure 1). Patient Health Questionnaire scores ranging from 0 to 3 were calculated in each category and were also added together for a cumulative score in both time periods. The minimum possible cumulative modified PHQ score was 0, and the maximum possible score was 15. Higher scores reflect increased mental health difficulty.

F1
Figure 1.:
Modified PHQ Questionnaire. We modified the PHQ to include questions specific to the experiences of athletes and to capture responses from both before COVID-19 and during COVID-19 restrictions. We shortened the PHQ to 5 questions to allow athletes to better recall their experiences over this extended time period. PHQ scores ranging from 0 to 3 were calculated in each category and were also added together for a cumulative score in both time periods.

Survey training questions were also structured into 2 separate time periods with March 2020 as the cutoff date. Participants were asked to assess their training habits based on the following weekly frequency categories: “0 days,” “1 to 2 days,” “3 to 4 days,” “5 to 6 days,” and “every day.” Answers were coded with a “0,” “1.5,” “3.5,” “5.5,” and “7,” respectively, to determine the frequency of training habits by average days per week.

Strava Activity Data

The Strava data analytics team provided all GPS and self-entered activity upload data from January 1, 2020, to August 25, 2020, for the participants who opted into activity analysis. Activity data were provided and listed by Strava-designated athlete ID in a .csv file using Stanford University's Med Secure Send process. Strava included 40 training variables for each upload, and we used the activity type and date, distance, moving time, average heart rate, and average relative effort in our analysis. Relative effort is a proprietary Strava metric that estimates the amount of cardiovascular work performed for any activity. To calculate relative effort, Strava has an algorithm that combines the duration of activity with either heart rate data or self-reported relative perceived exertion.

We divided the activity upload data into 2 time periods: “before COVID-19” (January 1-March 14) and “during COVID-19” (March 15-August 25). We linked 5-digit unique IDs to Strava-designated athlete IDs to identify any participants who reported uploading less than 50% of completed training activities to Strava's platform. One athlete reported uploading less than 50% of completed training activities and was discarded from analysis to avoid incomplete and unrepresentative sampling.

Statistical Analysis

We assessed descriptive statistics for survey data. For PHQ survey responses and survey training questions, we used the Wilcoxon signed-rank test to compare scores between the before COVID-19 and during COVID-19 time periods. We used a McNemar χ2 test when treating PHQ survey responses as binary. For the activity analysis exercise minutes per day, heart rate, and relative effort data, we used paired t tests to compare responses between time periods. The data analysis for this article was generated using SAS Software University Edition, Version 9.4 (Cary, North Carolina).

RESULTS

Study Population

Our study population (n = 131) consisted of 80 male and 51 female professional endurance athletes. The age, athlete type, Strava upload percentage, and sponsorship status were similar across genders (Table 1). More than 90% of our population identified as either a runner, cyclist, or triathlete. A total of 114 participants (69 males and 45 females) consented to have their activity data analyzed.

TABLE 1. - Descriptive Characteristics of the Study Population, Mean ± SD or N (%)
Characteristic Male Athletes Female Athletes
N 81 50
Age (yrs) 32.4 ± 6.7 32.9 ± 5.5
Athlete type
 Runner 37 (46.3%) 21 (41.2%)
 Cyclist 28 (35.0%) 23 (45.1%)
 Triathlete 8 (10.0%) 6 (11.8%)
 Others 7 (8.8%) 1 (2.0%)
Strava uploads
 100%-75% activities 74 (92.5%) 43 (84.3%)
 75%-50% activities 3 (3.8%) 8 (15.7%)
 50%-25% activities 1 (1.3%) 0 (0.0%)
 25%-0% activities 2 (2.5%) 0 (0.0%)
Sponsored
 Yes 70 (87.5%) 43 (84.3%)
 No 10 (12.5%) 8 (15.7%)
Activity consent
 Yes 69 (85.2%) 45 (90.0%)
 No 12 (14.8%) 5 (10.0%)

Mental Health Changes

During COVID-19 restrictions, 22.2% of participants reported feeling down or depressed and 27.4% of participants reported feeling nervous or anxious at least half the days in a week compared with 3.8% and 4.6% before COVID-19 restrictions, respectively (P < 0.0001). Similarly, 16.8% of participants reported feeling little interest in doing things and 34.9% of participants reported feeling preoccupied about athletic future at least half the days in a week compared with 2.3% and 10.7% before COVID-19 restrictions, respectively (P < 0.0001). Participants did not have a significant increase in feeling preoccupied about nutrition (Table 2). There was also a significant increase in cumulative, modified PHQ scores with a mean of 4.93 during COVID-19 compared with a mean of 3.00 (P < 0.0001) before COVID-19 restrictions (Figure 2).

TABLE 2. - Modified PHQ Responses by Category, N (%)
Modified PHQ Category Before COVID-19 Restrictions
(n = 131)
During COVID-19 Restrictions
(n = 131)
Feeling down/depressed frequency
 All of the time 0 (0.0%) 4 (3.1%)
 More than half the days 5 (3.8%) 25 (19.1%)
 A few days 60 (45.8%) 75 (57.3%)
 Not at all 64 (48.9%) 25 (19.1%)
 Missing 2 (1.5%) 2 (1.5%)
Feeling nervous/anxious frequency
 All of the time 0 (0.0%) 7 (5.3%)
 More than half the days 6 (4.6%) 29 (22.1%)
 A few days 72 (55.0%) 65 (49.6%)
 Not at all 51 (38.9%) 28 (21.4%)
 Missing 2 (1.5%) 2 (1.5%)
Little interest in doing things frequency
 All of the time 1 (0.8%) 3 (2.3%)
 More than half the days 2 (1.5%) 19 (14.5%)
 A few days 32 (24.4%) 62 (47.3%)
 Not at all 94 (71.8%) 45 (34.4%)
 Missing 2 (1.5%) 2 (1.5%)
Preoccupied by nutrition frequency
 All of the time 7 (5.3%) 5 (3.8%)
 More than half the days 12 (9.2%) 18 (13.7%)
 A few days 37 (28.2%) 33 (25.2%)
 Not at all 72 (55.0%) 73 (55.7%)
 Missing 3 (2.3%) 2 (1.5%)
Preoccupied by athletic future frequency
 All of the time 6 (4.6%) 13 (10.1%)
 More than half the days 8 (6.1%) 32 (24.8%)
 A few days 75 (57.3%) 59 (45.7%)
 Not at all 40 (30.5%) 25 (19.4%)
 Missing 2 (1.5%) 2 (1.5%)

F2
Figure 2.:
Cumulative modified PHQ scores before and during COVID-19 restrictions. There was a significant (P < 0.0001) increase in cumulative, modified PHQ scores during COVID-19 (mean = 4.93, SD = 2.90) compared with before COVID-19 restrictions (mean = 3.00, SD = 2.17).

Exercise Motivation and Financial Difficulty

More than 60% of participants reported that their mental health affected exercise motivation at least some of the time; and nearly 30% of participants reported worrying about financial stability at least half the days in a week. Of the 113 participants who were receiving financial compensation from sponsors, 46.6% reported a reduction in compensation from sponsors. There was a small but nonsignificant difference in reduction in compensation by gender, with 53.5% of female athletes and 44.3% of male athletes reporting a reduction in compensation (P = 0.34).

COVID-19–Suspected Symptoms, Testing, and Infections

Overall, 12.2% of participants reported experiencing at least one possible COVID-19 symptom, and 5.3% of participants reported 2 or more symptoms. The most common symptom was unusual fatigue, which was reported in 9.2% participants. Other reported symptoms included sustained cough (1.5%), fever (3.8%), shortness of breath (5.3%), loss of taste (2.3%), and loss of smell (0.08%). Among the 16 participants who experienced possible COVID-19 symptoms, 8 were tested for COVID-19 and 1 participant tested positive. Among the 115 participants who did not experience symptoms, 40 (34.8%) got tested for COVID-19 and 0 participants tested positive at the time of the survey.

Self-Reported Training Modifications

More participants reported increasing their duration of training (31.0%) compared with the intensity of training (17.1%) during COVID-19 restrictions. Of the participants who reported an increased duration of training, nearly half also reported an increased intensity of training. In addition, there was a significant decline in days spent training with partners and teams during COVID-19 restrictions. During COVID-19 restrictions, athletes spent an average of 1.59 days training with partners and 0.27 days training with team members compared with 2.83 days and 0.98 days before COVID-19 restrictions, respectively (P < 0.0001) (Figure 3).

F3
Figure 3.:
Average days per week spent training with partners and team before and during COVID-19 restrictions. There was a significant decrease (P < 0.0001) in (A) average days spent training with partners during COVID-19 (mean = 1.59, SD = 1.54) compared with before COVID-19 restrictions (mean = 2.83, SD = 1.68) and (B) average days spent training with teams during COVID-19 (mean = 0.27, SD = 0.91) compared with before COVID-19 restrictions (mean = 0.98, SD = 1.54).

Activity Analysis

Based on Strava's GPS and self-entered activity upload data from 113 of our eligible study participants, there was a significant increase in exercise minutes per day during COVID-19—with an average of 103 minutes per day during COVID-19 compared with 92 minutes per day before COVID-19 restrictions (P < 0.0001) (Figure 4). However, there were no significant changes in intensity. The average heart rate (mean = 133.2, SD = 11.9) and the average relative effort (mean = 66.0, SD = 36.3) in training sessions during COVID-19 did not significantly vary compared with the average heart rate (mean = 133.8, SD = 14.1) (P = 0.90) and average relative effort (mean = 67.3, SD = 42.6) (P = 0.88) before COVID-19 restrictions. Self-reported changes in exercise duration and intensity from our survey show similar results to the Strava activity data—on the survey, 31% of athletes reported increasing their duration of training during COVID-19.

F4
Figure 4.:
Activity duration and intensity before and during COVID-19 restrictions. In a subset of our study participants (n = 113) who qualified for activity analysis, there was (A) a significant (P < 0.0001) increase in average exercise minutes per day during COVID-19 (mean = 103.0, SD = 42.1) compared with before COVID-19 restrictions (mean = 92.4, SD = 41.3) with (B) no significant change in average heart rate during COVID-19 (mean = 133.2, SD = 11.9) compared with before COVID-19 restrictions (mean = 133.8, SD = 14.1).

DISCUSSION

We found that professional endurance athletes in the US are at high risk of experiencing increased mental health distress during COVID-19. Athletes experienced significant increases in feeling down or depressed and nervous or anxious despite increasing the duration of daily exercise during COVID-19 restrictions. Although increased mental health issues have been reported in NCAA athletes during COVID-19, to the best of our knowledge, this study is the first to report increased mental health distress during COVID-19 in professional endurance athletes. Our findings highlight the need to assess the impacts of social distancing on mental health and develop programs to support athletes with mental health resources, particularly during times of uncertainty and external disruptions.

Mental Health Implications

Our study found significant mental health distress in athletes during COVID-19 restrictions. Twenty-two percent of professional endurance athletes in our study reported feeling down or depressed and 28% reported feeling nervous or anxious more than half the days during COVID-19 restrictions. The high prevalence of depression and anxiety in our study may reflect changes in training structure, community, and financial compensation as a result of COVID-19. Although we were not statistically powered to detect the relationship between changes in training structure and mental health issues, more than 30% of athletes in our population reported training alone every day. Furthermore, almost half of the sponsored athletes in our study population reported a reduction in financial compensation from a sponsor during COVID-19 restrictions. For many professional athletes, sports participation is a form of identity and source of community, which are jeopardized by COVID-19 restrictions. Given that pandemic restrictions are essential for public health, we need to identify ways to better support professional athletes with social outlets, career options, and mental health support systems.

The importance of mental health among athletes of all types is becoming a greater focus in scientific literature and popular culture as practitioners and coaches become aware of the major stakes that take place off the competitive field. Mental health is health. However, despite efforts to highlight the prevalence of mental health issues, there is still stigma associated with mental health treatment in the athletic community.10 For many athletes, there are also barriers to accessing mental health resources.11 In the NCAA Student-Athlete Well-Being Survey, 80% of participants surveyed knew how to access a medical provider for physical health concerns, but only 60% of male participants and 55% of female participants knew how to access a mental health provider in their location.5 Our study highlights the need to continue to reduce the stigma associated with mental health treatment and to provide information on accessing mental health resources to professional athletes. Given the prevalence of mental health symptoms seen in our study, all experts who are involved in athletic training and treatment including physicians, athletic trainers, and coaches should know where to direct athletes for mental health resources.

Athletic Training Implications

Using GPS and self-uploaded activity data, we found that professional endurance athletes in the US increased their duration of exercise to an average of 103 minutes per day during COVID-19 restrictions compared with 91 minutes per day before COVID-19 restrictions. We did not find a significant difference in the intensity of exercise during COVID-19 restrictions as assessed by the heart rate and relative effort metrics. The increase in duration and maintenance of the intensity of exercise in the activity data parallel the survey responses. On the survey responses, 31% of athletes reported increasing their duration of training, but only 17% of athletes reported increasing their intensity of training during COVID-19.

Physical activity is known to improve mental health by reducing anxiety, depression, and negative mood.12 However, there are inconsistencies reported in the dose-response relationship between the intensity and duration of physical activity and mental health.13,14 Our study population of professional endurance athletes completed a high quantity of physical activity at baseline and may have already achieved maximal mental health benefit. The causal relationship and interaction between the increased duration of activity seen in our population during COVID-19 and mental health status is unclear. More research should be conducted to examine the relationship between physical activity and mental health in professional athletes already completing high levels of exercise.

Limitations and Strengths

There are some important limitations of this study. COVID-19 restrictions varied by the time period. Many of our survey questions instructed athletes to assess their mental health and training structure since the start of COVID-19 restrictions, which captured a 5-month time period and was compared with a two-and-a-half-month period before COVID-19. Athletes surveyed may have had difficulty reflecting across this 5-month time period or could have experienced major life events unrelated to COVID-19. Furthermore, our modified PHQ survey was designed to understand mental health changes of athletes as a result of COVID-19. We shortened the PHQ to 5 questions to reflect the increased duration of recall and changed the focus to athlete-specific content. Given the modifications to the PHQ, our survey cannot diagnose depression or anxiety disorders or assess their severity. Finally, because of the extensive topics surveyed, we did not assess the full scope of some topics. For example, future research should be considered to assess available mental health resources, to determine if there is an interaction between race and mental health issues, and to analyze the affects of positive COVID-19 diagnoses on mental health in professional endurance athletes.

Our study population was recruited from Strava's US professional endurance athletes. Given that COVID-19 restrictions varied by the geographic region, professional endurance athletes in other countries may have experienced different training limitations. Professional athletes in team-based sports such as football, basketball, or soccer may experience additional training challenges compared with professional endurance athletes.

The strengths of the study include the large number and the response rate of professional endurance athletes recruited by Strava in the US. Our methods of inquiring about mental health in a time-structured, modified PHQ survey enabled us to assess changes in mental health issues before COVID-19 compared with during COVID-19 restrictions. We were also able to assess changes in athletic training structure in a survey and compare with activity data on Strava's platform. The identified mental health issues necessitate further investigation in other populations of professional athletes by geographic region, sport type, and age.

SUMMARY AND CONCLUSIONS

We identified a high prevalence of professional endurance athletes who reported feeling down or depressed or who reported feeling nervous or anxious during COVID-19 restrictions despite an average increase in the duration of daily exercise during COVID-19 restrictions. Sports medicine professionals should consider screening for mental health changes during COVID-19 restrictions to identify athletes at risk for depression or anxiety. Future research should determine how to best support athletes with mental health resources and should assess the relationship between changes in physical activity level, social interaction, and mental health in professional athletes who are already completing high levels of exercise.

ACKNOWLEDGMENTS

The authors thank Strava's marketing team for helping recruit our study population and Strava's data analytics team for helping compile GPS and self-reported upload data. The authors also thank the Strava “Pro Badge” athletes who participated in this study.

References

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Keywords:

COVID-19; mental health; depression; professional athletes

Supplemental Digital Content

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