Mental Health in Adaptive and Para Athletes

Adaptive and para athletes’ mental health and well-being are an essential aspect of their care. These athletes deal with unique factors including lack of accessible facilities and accommodations, cost and difficulty with adaptive sports equipment, social stigma, and medical factors including chronic pain, spasticity, bladder and bowel dysfunction, and medication usage. While screening tools for mental health symptoms are readily available and can be used among adaptive and para athletes, it is not routinely performed. Additional research and education among health care providers are needed to improve early identification and proper interventions and treatment.

Key points

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Adaptive and para athletes commonly experience mental health symptoms and disorders accompanied by unique challenges that are often overlooked or normalized due to disability stigma.
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Mental health screening is critical and there are numerous screening tools available to identify risk factors, although not specific to this athlete population. Many health care providers lack confidence or routine protocols for mental health screening in this population.
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Research regarding risk and protective factors such as social supports, coaching relationship, media, sleep, competitive pressure of sport, injury is varied and adaptive and para athletes have additional stressors that can negatively affect their mental health.
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More research is needed to help expand screening tools, interventional strategies, reduce negative perceptions around mental health and increase education among health care providers.

Abbreviations

APSQ	athlete psychological strain questionnaire
PHE	periodic health evaluation
PHQ	patient health questionnaire
REBT	rational emotive behavior therapy
SMHAT	sport mental health assessment tool

Introduction

Mental health is widely recognized as a critical component in athletes’ overall well-being, especially within the elite sports world. While the majority of mental health research has been on athletes living without disabilities, emerging research highlights the unique psychosocial and mental health stressors faced by para and adaptive athletes. Meidl and colleagues reported positive screening for anxiety and/or depression in up to 40% of para athletes, and Fagher and colleagues found that nearly half of para athletes reported weekly pain or inadequate sleep, which are both linked to mental distress. ^, Some athletes in this population also have to cope with variables related to their disability including chronic pain, barriers to travel, adaptive equipment requirements, social stigma, and other medical issues. ^, These elements, less common among athletes living without disabilities, can become onerous on the mental health of adaptive and para athletes.

Many articles have documented the benefits of generalized exercise and sport participation for people with disabilities. Paralympic sports began as part of rehabilitation for patients with spinal cord injuries and ultimately evolved to become the paralympic games. A 2023 meta-analysis of adaptive sports and mental quality of life described significant improvements in physical and mental quality of life for those participating in adaptive sports. A 2024 review of effects of exercise for those with spinal cord injury found exercise improved mental health, stress levels, depression, and general life satisfaction. There also may be benefits not just to general participation in sport, but to participating in structured sporting events. Various studies have explored implementing intervention for those with disabilities including competitive swimming, wheelchair basketball, wheelchair tai chi ball, and adaptive surfing. These studies have noted improved emotional and psychological wellbeing among those who participated in sport. ^,^,^, These organized sporting interventions can also help promote developments in other elements such as improving muscle strength, flexibility, and mobility. ^, Sahlin and colleagues found that young adults and children with cerebral palsy and myelomeningocele had improved self-worth, competence, and perceived physical appearance. They additionally reported that those with spinal cord injuries showed increased life satisfaction, community integration, and employment when participating in sports.

Although there has been a larger body of research on the effects of sports participation for those with disability on mental health, the effects for elite adaptive and Para athletes have been less robustly investigated. Some current research suggests there may be discrepancies related to whether the additional factors that affect adaptive and para athletes have a significant impact on adaptive and para athlete mental health. Many studies have not found significant differences in overall rates between adaptive athletes and nonadaptive athletes. ^,^, Some studies on para and adaptive athletes noted weekly rates of reported anxiety and depression symptoms of 15% and 21% respectively, with these rates increasing during periods of stressors such as illness, injury, or competition. The rates of mental health symptoms among these athletes are often similar to the general population. Despite the growing awareness of mental health issues in this population, it is still often overlooked. Büyüklüoğlu and colleagues (2025) suggested that some adaptive athletes normalize psychological distress as they may feel it is inherent to having a disability; this type of thinking may lead to unaddressed mental health issues.

Compounding the problems, health care professionals have varying levels of comfort with screening and treating mental health in adaptive & para athletes. In a 2024 study based on the Tokyo 2020 and Beijing 2022 paralympic games, it was found that 95% of health care providers thought it is important to address mental health and symptoms among para athletes. A little less than 60% of providers felt confident in their abilities to detect mental health symptoms among the athletes. Half of the providers felt that athletes with disabilities had increased bias related to disclosing their mental health symptoms as opposed to athletes without disability. However, many reported they did not screen for mental health symptoms and that it was not made mandatory by their teams. Most of the health care providers (87%) wanted to improve their skill set regarding mental health care and felt that additional training was needed.

We aim to provide a more comprehensive review of mental health in the adaptive athlete population, with the support of current research. We explore screening methods and certain risk and protective factors influencing mental health in this population, as well as proven interventional strategies including the role of coaches, health care providers, and sport organizations.

Screening

Mental health screening in adaptive athletes is a critical component of their comprehensive medical care yet is not always implemented across sport systems. Compared to their nondisabled peers, para athletes are exposed to an additional layer of psychosocial stressors, including but not limited to chronic pain, potential disability-related medical barriers and problems, limited access to resources, and complex travel and lodging logistics. ^, These unique demands with the added pressure of their respective sport demonstrate the need for mental health surveillance ( Table 1 ).

Table 1

Mental health screening tools for adaptive and para athletes

Screening Tools	Description	Strengths	Limitations
PHQ-4 ^,^,^,^,	4-item screener combining PHQ-2 and GAD-2 to assess depression and anxiety symptoms.	Reliable & valid for elite para athletes high weekly compliance, correlates with stress & mood, enabling early detection.	Potential for false negatives, limited to depression/anxiety.
PHQ-2	2-item screener for depression; quick and often used as an initial step in assessments.	Very brief; good sensitivity, ideal as an initial screener.	Lower specificity than PHQ-9; not diagnostic on its own.
GAD-2	2-item screener for generalized anxiety; part of PHQ-4.	Very brief, good sensitivity & specificity; ideal as an initial screener.	Limited to GAD; may miss broader or comorbid mental health concerns.
PHQ-9	9-item self-report tool assessing severity of depressive symptoms.	Comprehensive; high reliability; effective for depression screening in athletes.	Longer to complete; may cause survey fatigue; not diagnostic alone.
APSQ	Triage tool in SMHAT-1 is used to detect psychological strain in athletes.	Efficient triage tool; flags athletes for further evaluation; low burden.	High false-negative rate when used alone; requires full SMHAT-1 for accuracy.
SMHAT-1 ^,	Multistep mental health assessment for athletes, including APSQ, disorder-specific tools, and clinical evaluation.	Comprehensive; detects mood, substance use, sleep issues; includes clinician input.	Time-consuming; not practical for frequent monitoring.

One of the most widely studied and validated tools for screening mental health symptoms in elite para athletes is the Patient Health Questionnaire-4 (PHQ-4). This short self-reported measure includes 2 items each for depression (PHQ-2) and anxiety (generalized anxiety disorder scale-2). A score of 5 or greater is used as a threshold to flag potential mental health issues. In a 43-week validation study of 78 elite German para athletes, they filled a weekly questionnaire over the course of the study. The PHQ-4 demonstrated excellent internal consistency and strong validity, with significant correlations between PHQ-4 scores and self-reported stress and mood ( P <.001). The same study reported a high response rate from athletes (82.7%) indicating acceptance and feasibility for athletes needed for sustained monitoring.

Screening can be done separately at different times of the year during an athlete’s care or as part of their general health assessment. The PHQ-4 has been integrated as part of the comprehensive Periodic Health Evaluation (PHE) in the preparticipation medical assessment used by the Norwegian Olympic and Paralympic training center (Olympiatoppen). This multidisciplinary PHE includes modules on musculoskeletal, cardiovascular, cognitive, and nutritional health, with mental health evaluated through a structured health history questionnaire administered digitally before the clinical visit. A 2024 international position statement further reinforced the importance of integrating mental health into the PHE. This was based on the recommendations and consensus from 15 experts in para sport medicine; they called for PHE to be adapted to the specific needs of athletes, stating that mental health, including depression and anxiety screening, should be a core domain of the evaluation, with PHQ-4 being the valid tool for monitoring.

To address the limitations of single-time-point assessments, several national sport organizations have implemented longitudinal mental health surveillance using weekly or biweekly assessments. In a study with elite para athletes in Germany, weekly PHQ-4 data were collected using an online platform (AthleteMonitoring), and athletes with persistent elevated scores (≥5 over 2 consecutive weeks) were contacted by a sports psychiatrist for follow-up. Of those who were contacted, 76.6% reported at least 1 mental health concern, and nearly two-thirds were either already receiving or referred for psychological/psychiatric care.

One study with Swedish elite Para athletes demonstrated the application of PHQ-4 screening before, during, and after the 2022 Beijing Paralympic Games. It further highlighted an important aspect of screening, which included the integration of the coaching staff. This method was done by updating the coaches on their athletes’ mental health status and allowing them to participate in the postgames focus group. They reported improved awareness and communication with their athletes thus providing the coaches with overall knowledge to recognize early signs of mental health symptoms.

Other screening methods are available such as the International Olympic Committee the Sport Mental Health Assessment Tool 1(SMHAT-1), which offers a more comprehensive assessment for mental health including triage, 6 disorder-specific screening tools and a section for sports medicine physician or mental health professional clinical evaluation. Although it might offer a clearer diagnostic picture and detect early signs of mental health distress not picked up by the PHQ4, the complexity and lengthiness of this tool may limit use in routine weekly monitoring. A 2023 study analyzed the SMHAT-1 among all team US athletes who competed at the Tokyo 2020 and Beijing 2022 Olympic and Paralympic Games and other athletes competing in associated national and international competitions. Results showed a high false negative rate when relying solely on a brief screening questionnaire; in this study, the Athlete Psychological Strain Questionnaire (APSQ) was used as the initial triage step. They recommended the use of all sections of the SMHAT-1 to improve detection of mental health concerns. However, if time is limited for the use of this lengthy assessment tool (SMHAT-1), the authors recommended combining PHQ-9 to APSQ for a more thorough screening.

Discussion

Risk Factors Affecting Mental Health

Numerous factors contribute to the mental health of all athletes. These range from categorical elements such as age, gender, and sport to personal factors such as coping skills and social supports, to the environmental factors surrounding them such as their relationship with their coach, national and international sports roles, and the media. Studies have explored whether there is an association between mental health symptoms and certain risk factors.

Some paralympians noted negative effects related to preparation for competition, which include dwelling on negative aspects of personal or team performance, as well as the perception of evaluation by others. A cohort study of Swedish elite para athletes found a relationship between higher levels of anxiety during weeks when athletes had fewer hours of sleep or in concurrence with episodes of illness. The authors theorized this may be due to the athlete’s additional concerns regarding effects of illness on sport such as worsening spasticity. They additionally noted higher levels of depression during weeks when athletes were injured. Lisa and colleagues in a 2022 study found weak evidence for worse mental health outcomes among para athletes with lower levels of social support, prior concussion, 2 or more adverse events in the year, lower psychological safety, and higher rates of self-judgement. These associations could potentially be due to loss of connection from the athlete’s sport community or reflect ongoing mental health struggles, which may be exacerbated by sports performance. A German prospective cohort study noted athletes reported risk factors for worsening mental health including education, negative dynamics with team, coach, or federation, physical health difficulties, and overall expectations to succeed in their sport. A 2019 study stated that para athletes report more adverse events than nonpara athletes throughout their life. They additionally reported more experiences of injury, discrimination, and feeling undervalued. Additional stressors could include lack of accessible facilities, difficulty with travel logistics, worse conditions in paralympic villages that negatively impact sleep, increased sport competitiveness, difficulties with sport equipment, cost of assistive technologies, and misclassification for competition.

Swartz and colleagues raised concerns that in addition to these risk factors, there may be concerns among athletes about being perceived negatively when they raise concerns with health professionals. Given the history of paralympic sports beginning as rehabilitation for spinal cord injuries, there is also concern that these athletes may continue to have their sport viewed as a treatment modality by health care providers. This may foster a lack of trust in the medical community and thus prevent athletes from feeling comfortable sharing mental health concerns with their providers.

Special considerations

Elite versus para elite mental health

There is paucity in the literature regarding differences in mental health between elite and para elite athletes, which shows few differences between the overall rates of mental health symptoms between paralympic and nonpara athletes. A 2021 cross-sectional study of Australian athletes found no significant differences other than lower alcohol consumption and lower self-esteem in para athletes. A different but related study from Australia in 2022 also found no significant differences in mental health outcomes. Similar significant rates of coping strategies between olympic and paralympic athletes have been reported in literature. A Swedish prospective cohort study of elite para athletes over 52 weeks reported no significant difference among rates of anxiety/depression, hours of sleep, or pain in weeks before injury. A South African cross-sectional study at the 2019 National Championships did not find any association with anxiety rates, of which 25% of the athletes reported, with level of competition, sport, type of impairment, geographic location, or wheelchair use. A cross-sectional survey of the National Athletic Federation in Turkey found no significant difference between para athletes and nondisabled athletes in exposure to bullying.

On the other hand, some studies do report variability in mental health between paralympic and olympic athletes. This is mostly related to external factors, such as sleep, which can influence mental health. A study of Norwegian paralympic and olympic athletes over 4 consecutive Games reported that paralympic athletes experienced more sleep disturbances, while olympic athletes had more stress related to social media/gaming. Paralympic athletes have numerous elements, which could potentially lead to sleep disturbances including medication side effects, spasticity, chronic pain, bladder and bowel dysfunction, or body temperature dysregulation. Additionally, paralympic athletes were more likely to already have contact with sports psychologists.

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