Resilience versus risk: Why mental health issues pose pro cycling’s biggest problem

“If you’ve been racing for over 10 years, the chances of breaking your collarbone are around 25%. Is that the worst ‘injury’? Not when you take into account the lifetime risk of a cyclist suffering from depression. That’s around 27.8%.” Those are the words of Professor Dr Michael Liebrenz, head of the department of forensic psychiatry at the University of Bern in Switzerland.

Liebrenz has helped to establish the Swiss Mental Health Hub, which offers confidential consultations and educational outreach. It’s targeted at the Swiss national team, but he helps riders all around the world, many of whom share common issues.

“In our systematic review, the rates of self-reported substance use or addiction-related behaviour among cyclists was around 20 to 22%,” he adds.

What Liebrenz sees, especially in riders dealing with insomnia, anxiety or depression, is a pattern of reliance on prescription medications like benzodiazepines or Z-substances, particularly around multi-stage races.

Cavendish has spoken publicly about the clinical depression he suffered due to his battle with Epstein-Barr virus (Image credit: Artur Widak/NurPhoto/Getty Images)

“Anecdotally, there seems to be a fairly relaxed prescribing culture during long tours, often with limited explanation or tapering guidance. Riders may sleep better for a week or two, then return home and face abrupt discontinuation, rebound insomnia or even mild withdrawal symptoms,” he explains.

“In rare but serious cases, this has evolved into longer-term dependence or combinations with other substances,” he adds. “One case we reviewed involved both benzodiazepines and cocaine. But in most instances, it’s not about reckless abuse. It’s about small, cumulative coping strategies in a high-pressure environment where seeking psychological help is still seen as a sign of weakness.”

However the mental health disorder manifests itself – eating disorder, overtraining, substance abuse – riders often share an underlying neurobiology, says Liebrenz, especially when performance becomes the athlete’s only strategy for emotional regulation. In that kind of setting, the slope is slippery.

“It’s a super performance-oriented environment, which places a lot of pressure on the rider,” he says.

This could include earning a new contract, achieving the team’s race goals on any given stage, or sponsor exposure so the team doesn’t fold. Injuries are always a high-risk pressure, as are the extra stresses of a Grand Tour. That’s where Adam Hansen comes in. The Australian holds the record for the most Grand Tours in a row – 20 between 2011 and 2018 – and knows more than most about the oppressive environment it can be.

“Race the Giro d’Italia, Tour de France or Vuelta a España and you’re away from home for around four weeks,” Hansen says. “You might arrive on the Tuesday before the race starts. During that time, you’ll have team presentations, media commitments, and time with the sponsors.

“As soon as you wake up, you might have 15 minutes free, and then you have breakfast. You’re then surrounded by people, which isn’t always great for many pro cyclists who are naturally introverts.

“You jump on the bus, again surrounded by people. As you leave the bus, everyone’s screaming at you, wanting attention. The quietest moment is actually when the race starts and is often the most peaceful time for a rider.”

It’s a pressure-cooker situation, exacerbated by heat and increasing fatigue. But one of the growing issues is the modern phenomenon of social media.

“It comes with permanent insecurities and must be managed,” Liebrenz says.

There’s also the growing understanding of neurodevelopmental disorders like ADHD (attention deficit hyperactivity disorder), which can lead to or exacerbate mental health conditions like anxiety and depression.

Concussion could be another cause of mental health disorders, says Liebrenz, as could a rider’s training load. “We’ve recently undertaken research that examined if there is a link between hours trained and mental health,” he says. “There is.”

Along with a team at Harvard University, Liebrenz looked at 531 endurance athletes, across cycling, triathlon, running and skiing. They were assessed using the Patient Health Questionnaire, which screens for depression, and categorised their weekly workload into one of the following five categories: zero to seven hours; eight to 10 hours; 11 to 13 hours; 14 to 20 hours; and 21-plus hours. The results were stark.

“Under seven hours, around 5% displayed symptoms of a mental health disorder. Between eight and 13 hours, it was around 11%. Between 14 and 20, you’re looking at around 20%, which grew to 26% when training over 21 hours per week,” he explained.

This is arguably every professional at the WorldTour level, where the women average around 25,000km and the men 30,000km.

“It’s clear, progressive rise in risk. When physical pain was part of the picture, too, that risk skyrocketed, with nearly one in two athletes above the clinical threshold.

“I don’t want to jump to conclusions about why this happens – there are likely multiple interacting factors, both physiological and psychosocial – but the trend is too strong to ignore,” he adds. “My main goal here is to raise awareness: high training volume, especially when combined with pain, should be treated as a potential warning sign, not just a badge of dedication. We need to monitor athletes better, not just for overtraining syndrome or injury, but for the mental health risk that can build quietly under the surface.”

Is that 21-plus-hour benchmark the cause or effect of that 26% figure? Are highly driven individuals, who heap huge amounts of pressure on themselves in search of the unreachable – peak performance – attracted by the huge volume of training? Or do the many hours of inflicting pain on oneself, with one’s own thoughts, take a mental toll?

Whatever the reason(s), one thing is clear, says Liebrenz: you can’t out-train a mental health disorder.

“Riders are used to suffering; they accept it’s something they need to do and think the torture is all part of the game. But those hard training sessions, those hard intervals, can delay them from seeking help. They believe that is how they should feel.”

What’s being done to address the issue? Like other sports, historically, there’s been a paucity of mental health initiatives across professional cycling.

“This was compounded by stigma and adverse sociocultural attitudes, often leaving riders exposed to psychiatric vulnerabilities during and following their careers,” says Liebrenz. “Thankfully, progress is being made. The UCI now recommends that all teams screen their riders at mandatory medical examinations using the Sport Mental Health Assessment Tool. This directive aims to help facilitate early detection and prevention of mental illness in elite-level cyclists.”

“A 20-year-old female Continental[-level] rider came to us,” says Liebrenz. “She’d experienced a performance decline, fatigue, impaired sleep and inconsistent training. She was quite tearful, especially after transferring to a new team.”

During the assessment by Liebrenz, she reported suicidal ideation and scored 31 on the Beck Depression Inventory (BDI-II), which translates into severe depression.

“She described how she’d be training, head into the woods, dismount and just cry. She’d be descending and think what would happen if she just rode into oncoming traffic.”

The rider was immediately started on antidepressants (fluoxetine), before a period in psychiatric care. Slowly, her symptoms improved. After registering a score of 13 on the BDI-II, she transferred to another team “whose flexible racing contract was based on her mental health status. Today, she is doing well and is a strong advocate for mental health.”

Thankfully, many riders don’t reach such dangerous depths, helped by a team’s psychologist, who might be full-time or used on a freelance basis. Liebrenz and his contemporaries fit alongside psychology and medicine, teams and riders tapping into their services if concerns tip beyond common issues like fitting into the team, as he explains.

“After diagnosis, I might see an athlete weekly during a crisis (usually anywhere between 60 and 90 minutes),” he says. “It might be monthly in stable phases or just twice a year for routine screening. During the race season or training camps, that might mean video calls, messages or a good old phone call.

“We often use cognitive behavioural therapy (CBT), so athletes have mental exercises or ‘homework’, just like they’re used to with training plans. This might include tracking sleep, reframing unhelpful thoughts or stress inoculation strategies. They’re receptive, as structure makes sense to them.”

Liebrenz stresses that psychiatric care doesn’t happen in isolation.

“Our role is to guide treatment and shape the environment around the athlete, which means working closely with team doctors, coaches, agents, families and management,” he says. “I routinely collaborate with cardiologists, for instance, when a patient might need medication that could influence cardiovascular function or heart rate under load. The goal isn’t just to treat illness. It’s to create conditions where mental health is protected, understood and actively supported. At Swiss Cycling, for example, we’ve created a confidential support hub for national-level riders. It’s open to anyone needing help.”

To that end, Liebrenz is an advocate for the REACT framework in professional cycling:

Routine check-ups. Mental health should be screened regularly, just like physiological parameters. Every six months, not just when there’s a crisis.External help. Not every athlete will want to open up inside the team. Make sure confidential, independent options are available outside the structure.Assess early, refer early. If there’s even a suspicion of trouble, act. Mental health is like injury management – earlier is always better.Collaborate with specialists. Especially for complex cases like ADHD or comorbid conditions, teams need sports psychiatrists involved, not just general mental coaches.Treat early, manage long-term. Mental health doesn’t end when a rider stabilises. It requires ongoing care, monitoring and support across seasons.

“The goal shouldn’t be to slow down talent development, but to balance it with appropriate psychological scaffolding,” he says. “Young riders need space to be human, not just high-performance machines. Teams that recognise this, and act on it, will not only protect their athletes but also improve longevity and performance outcomes.”