Key points

Introduction

The saying “Baseball is 90% mental. The other half is physical”. is attributed to Yogi Berra. Indeed, holistic care of the baseball athlete would be incomplete without attention to mental health, but little is known about the impact of baseball participation on psychological health. In a scoping review investigating baseball participation and health, only 15 of 678 articles focused on psychological health. Sport is linked to positive and negative impacts on health. It is associated with disease prevention and positive physiologic effects but also overtraining and injury. Mentally, sport participation may positively impact anxiety, mood, and self-esteem but is also linked to burnout, sleep disturbance, eating concerns, and potential exposure to abuse. Injury and performance pressures can worsen mental health and vice versa. Due to the potential for mental health–related impacts, giving the mental health of baseball athletes similar attention as physical health is critical.

Prevalence

Little is known about the prevalence of mental disorders in baseball athletes due to a paucity of research. Baseball athletes, however, are not immune to mental illness. Professional baseball athletes have gone on the injured list due to mental health reasons and some baseball athletes have died by suicide. ^, Many fall into an age group that coincides with a peak time for onset of mental illness, as 75% of all mental disorders emerge prior to 24 years of age. ^, The risk of disorder may be greater in athletes experiencing injury, adverse life events, performance difficulties, or transitioning out of sport.

Studies on substance use in baseball athletes demonstrate increased rates of tobacco and alcohol use compared to the general population. In a study of high school students, a 50% increase in alcohol use was seen in the baseball athletes compared to their nonathlete peers. In collegiate baseball athletes, alcohol use declined from 88% in 2009 to 75% in 2023 while binge drinking declined from 63% to 38%. In a study of professional baseball athletes, alcohol consumption increased from rookie year to retirement. The prevalence of smokeless tobacco has ranged from 34% to 50% in baseball athletes. Baseball was second to ice hockey in sports with the highest use of spit tobacco in collegiate athletes. While rates of traditional smokeless tobacco products appear to be decreasing due to tobacco-free initiatives, e-cigarettes, vapes, and nicotine pouches are on the rise in baseball athletes. ^, Young athletes may be unaware of the negative effects e-cigarettes, vapes, and oral nicotine products can have on the developing brain, including addiction. In a study of high school athletes, baseball athletes reported significantly higher use of cannabis compared to other athletes. The National Collegiate Athletic Association (NCAA) research demonstrated the opposite, with collegiate baseball athletes reporting lower cannabis use compared to other athletes and nonathlete college students.

Stressors of the baseball athlete

Several factors in the life of a baseball player can negatively impact mental health or exacerbate a preexisting condition ( Box 1 ). Frequent exposure to failure, competition and performance pressures, fear of deselection, and public criticism can lead to stress, self-doubt, and anxiety. Rigorous schedules, frequent travel, and time away from loved ones can contribute to fatigue and family strain. Evening games lend themselves to excessive bright light exposure, late-day caffeine and meals, high adrenaline, and performance-related rumination which can impair sleep. Tobacco, alcohol, and caffeine are ingrained in baseball culture and may lead to problematic use in some athletes.

International athletes have additional stressors with which to contend including separation from family, acculturation stress, and racial discrimination. Transportation and food differences have also been identified by international student athletes as major stressors. Some may have the responsibility of financially supporting immediate and extended family, which can lead to financial strain or family conflict. Time zone differences, visa issues, and the inability to travel easily, particularly in the event of a birth of a child or family emergency, can present hardships. Grieving the death of a loved one from afar without access to one’s support system can put an international athlete at risk for delayed or complicated bereavement.

Screening

Athletes often do not seek professional help due to various factors ( Box 2 ). In a small study of baseball athletes, stigma, macho mentality, and lack of awareness of mental health services were identified as barriers to help-seeking. Men and black athletes are also less likely to use mental health services. Therefore, early identification of mental health challenges is critical to ensure timely support and prevent negative outcomes. National and international athletic organizations recommend that mental health assessment occur annually as part of pre-participation examinations, yet only one-third of Division I schools required them. Mental health assessments need not be limited to once a year, as they can be helpful in other circumstances as well ( Box 3 ). Screening should be performed by a professional with training and experience addressing mental health concerns and can be performed with or without the use of screening instruments. An assessment should screen for the most common mental health symptoms in athletes including anxiety, depression, substance misuse, disordered eating, and sleep difficulties. While less common, suicidal ideation should also be included in screening to identify at-risk athletes. It is worth noting that the 2022 to 2026 collective bargaining agreement states that sports psychology services “shall be voluntary, provided on a confidential basis, and offered in a private space.”

While research on athlete-specific mental health screening tools is limited, reliable and psychometrically validated instruments in the nonathlete population are often utilized. Two broad screening tools used in athletes include the Athlete Psychological Strain Questionnaire and the Sport Mental Health Assessment Tool. ^, Box 4 lists several disorder-specific screeners that may be useful in athletes. ^, Keep in mind that screening instruments do not diagnose mental disorders but rather provide information about symptoms that indicate that an athlete may be at risk is crucial. They should not be used as stand-alone assessments. Taking time with the athlete to explain results, provide referrals, and answer questions helps to destigmatize mental health concerns. Screening is of little benefit without procedures to connect athletes who screen positive to resources including crisis services. Therefore, a screening program should not be implemented until referral pathways have been outlined. The NCAA Mental Health Best Practices includes a helpful resource checklist that outlines main elements for devising a mental health referral plan.

Service delivery considerations

Establishing trust and rapport is critical when working with baseball athletes and often starts outside the office. Ease in seeking out the team mental health professional usually comes after the baseball athlete has grown comfortable with the clinician’s presence on “their turf.” Regular on-site presence has been a key factor in high utilization rates of team assistance programs. Mental health professionals working in baseball need be flexible with time and space, as the initial clinical contact may be brief and spontaneous, initiated by the baseball athlete in a clubhouse, dining area, athletic training room, bus, or on the field. A casual conversation may turn into a disclosure of marital discord. The athletic trainer may need immediate assistance for a player having a panic attack. In such instances, the mental health professional works as confidentially as possible to triage the concern, provide support, and arrange follow-up in a private space if indicated. Due to time constraints, a few meetings may be needed to gather the information necessary to develop a formulation and plan. Shorter sessions, informal settings outside the office, use of humor, and self-disclosure may be considered, as they are more in line with male cultural norms. Mental health professionals working with athletes may find it helpful to refer to Andersen and colleagues (2001), which covers the many nuances associated with mental health service delivery in sport including “hanging out,” time and space modification, confidentiality, out-of-office contacts, overidentification, and dual relationships.

Lastly, telehealth, both video and telephone, is a convenient option and facilitates treatment consistency in the setting of frequent travel. Mental health professionals should become familiar with state licensure requirements, interstate reciprocity, telehealth laws, ethics, and regulations based on their respective discipline. Those traveling with teams should refer to the Sports Medicine Licensure Clarity Act of 2018, which outlines permissions and protections to practice across state lines, to see if it is applicable to one’s licensure, practice, and discipline.

Evaluation

The American Psychological Association and American Psychiatric Association have published guidelines on mental health evaluation and assessment. ^, The diagnostic interview in a baseball athlete will have the same main components as one in a nonathlete. The clinician must first assess language needs. For a non-English speaker, ideally the interview will be conducted by a mental health clinician in the preferred language of the athlete. If that is not possible, an experienced translator can be used. Table 1 offers several clinical considerations when conducting a history in a baseball athlete.

Table 1

Diagnostic evaluation of a baseball athlete: components and clinical considerations ^,

Consent for treatment and confidentiality	• Discussed at the outset • Include confidentiality and limits of confidentiality • Inform how records are stored. • Ask who, if anyone, the athlete would want to collaborate in their care (e.g., coach, parent, partner, medical staff).
History of the presenting problem	• Investigate symptom frequency, onset, duration, persistence, severity, alleviating and aggravating factors, and impact on quality of life, performance, and functioning. • Collect third-party information as necessary with athlete’s permission (e.g., coach, teammate, teacher, agent, and loved ones). • Inquire about coping styles and strategies including what has worked and what has not. • Ask about common mental health symptoms seen in athletes: anxiety, depression, relationship problems, eating concerns, substance misuse, and sleep disturbance. • Investigate quality of “energy sources”: nutrition, hydration, time for recovery, sleep, socialization, and self-care • Less common yet worthwhile to investigate are obsessive-compulsive symptoms, problem gambling, flight anxiety, health anxiety, and body or muscle dysmorphia (i.e., preoccupation with muscularity in which one has a distorted view of being insufficiently muscular despite a normal or even muscular build). • A thorough risk assessment including but not limited to suicidal ideation, threat to harm others, and self-injurious behaviors, which must not be omitted. • Conduct a psychiatric and medical review of systems.
Past psychiatric history	• Assess prior psychiatric concerns, illnesses, treatment providers, treatments including benefits and harms, suicide attempts, and hospitalizations.
Past medical history	• Assess past and current medical symptoms and conditions including those that may be contributing to the presenting problem. • Ask about past and current injuries and concussions. • Ask about past, recent, or upcoming surgeries. Include details such as time away from play, rehabilitation, pain, sleep, performance, and psychological impacts.
Medication history	• Prescription medications • Over-the-counter medications • Pain medications including NSAIDs: Chronic NSAID use is important to be aware of with concomitant SSRI/SNRI use given the potential for gastrointestinal bleeding. • Dietary supplements and CAM: Ask the athlete specifically about “herbals,” “Eastern medicines,” and cannabidiol products. The literature suggests that athletes may be high utilizers of CAM. If taking supplements, investigate if the products are NSF Certified for Sport, which verifies that the product “does not contain unsafe levels of contaminant, prohibited substances, or masking agents.” Athletes should consult the team physician before starting any supplement and be informed that an NSF Certified for Sport product is the safer option for health and play over one that is not. • Products considered performance enhancing: Clinicians must be aware of medications banned by the NCAA, MLB, and WADA due to their performance-enhancing effects. Medications, such as stimulants prescribed for ADHD, require approval through a therapeutic use exemption process designating medical necessity by the treating physician. • Allergies: Allergic reactions to medications including the characteristic of the reaction
Substance use history	• Inquiry should be careful, nonconfrontational, and nonjudgmental. • Past and current use of licit and illicit substances • Be alert to indicators of misuse or a substance use disorder. • Substances that are stimulating, sedating, or perceived by the athlete to help with performance or recovery • Substances used for calming or sedative effects such as alcohol, cannabis, and benzodiazepines • Substances used to alleviate symptoms of low mood, anxiety, insomnia, and others (ie, self-medicating) • For alcohol, assess for heavy drinking, which is defined by the National Institute on Alcohol and Alcoholism as 5 or more drinks on any given day or 15 or more in a week for men or 4 or more drinks on any given day or 8 or more drinks per week for women. • Assess smokeless tobacco use and nicotine: While smokeless tobacco use is declining due to anti-tobacco initiatives, nicotine continues to be used by many baseball athletes, is addictive, and may be delivered in a variety of ways (eg, pouch, e-cigarette, vape). • Assess caffeine habits: Caffeine is embedded in baseball culture and should be quantified including types (eg, pre-workout supplement, coffee, energy drinks, pills) amounts (eg, number of espresso shots per coffee), frequency, times of the day consumed (eg, timing in relation to play, pitching, sleep). Assess for negative effects of caffeine: sympathetic hyperactivity, anxiety, and sleep disturbance. • Any evidence of substance abuse should lead to further nonjudgmental inquiry including under which stage of behavior change the athlete falls to determine the next appropriate course of action.
Trauma history	• Assess trauma sensitively, guided by the athlete’s comfort level of disclosure including the option not to disclose. • It is not uncommon for individuals to not endorse a trauma history initially but later disclose as therapeutic alliance develops. • Examples of trauma include physical, emotional, and sexual traumas; adverse childhood experiences; loss of loved ones; substance use in caregivers; and natural disasters. • Be attuned to injuries or surgeries experienced as trauma-inducing to a baseball athlete, as PTSD symptoms and fear of re-injury are not uncommon. Athletes may also witness injuries in teammates that may be experienced as traumatic. • Athletes may disclose mistreatment or abuse by coaches, parents, or others. An athlete may disclose being a victim or perpetrator of domestic violence. In cases of suspected or confirmed child and elder abuse, health care providers have a duty to protect and must contact appropriate authorities. Health professionals should refer to the policies and regulations of their organization, professional code of ethics, and state and federal laws to determine reporting requirements.
Personal history	• Gathering personal history is not only important clinically but also in building rapport with baseball athletes. Casual conversations occurring on or off the field about partners, families, hobbies, academic pursuits, and sports teams followed may help to facilitate connection. • Ask about the athlete’s history with sport and baseball. At what age did they start? What other sports did they play? When did they begin to specialize? What is their first baseball memory? For professional athletes, explore their baseball journey including minor and major league affiliates, teams, jobs overseas, and challenges. • Inquire about upbringing. This may provide pertinent information as to the degree of adjustment an athlete may experience over the course of a career, especially in professional baseball. An athlete from an impoverished, rural environment with little caregiver support is likely to have a different experience transitioning to the “bigs” than one raised in a metropolis with a multitude of resources. For international baseball athletes, they may have left home at a young age to pursue baseball. • Ask about how the athlete has managed transitions. This may provide insight into how they cope with change in the future. Professional baseball is rife with change: hotels, cities, teams, countries, progression in the minors from single A to AAA, minor to major for the chosen few, athlete to coach, and active to retired. • Ask about education including the highest grade achieved and performance in school. Be alert to any indicators of learning disorders or potential for undiagnosed ADHD. For student athletes, be aware of academic progress and how one is managing academics, baseball, and social life. Failing to meet academic requirements may jeopardize an athlete’s ability to play. • It may take several sessions to get a full picture of an athlete’s social circle or entourage including partner, children, parents, friends, teammates, coaches, agent, school, and work relationships. • Explore relationship stresses, conflicts, and strengths including those individuals that provide the most support to the athlete. • Exploring emotional expression, communication styles, and boundaries in the family of origin and current relationships can be informative. • Be alert to mistrust and boundary issues in romantic partnerships, which may manifest in disruptive and ineffectual behaviors on the part of the partner, athlete, or both such as checking the other’s e-mails, text messages, social media, or browsing histories. • Parent-child conflict may be present for youth and adult athletes. • Assessing sexual orientation is standard practice and should not be omitted.
Cultural history	• Exploring race, ethnicity, and culture can provide information related to identity, connection, strengths, health-related perceptions, beliefs, and preferences. • Explore experiences of bias, racial discrimination, and prejudice in and outside baseball. • For international athletes, explore their journey from home country to the United States including stressors listed in Box 2 .
Spiritual history	• Assessing spirituality and/or religious practice can provide information on supports, strengths, conflicts, health-related perceptions, beliefs, and preferences.

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