The Paradox of Ultra-Endurance Sports

A challenging ride is good medicine. At some point for each of us, too much medicine becomes poison.

Source: Jaimie Lusk

The benefits of regular exercise for both mental and physical health are well-documented. Interventional studies have consistently supported moderate aerobic exercise (4-5x per week, 50 min) as a treatment for depression (Onate, 2019). This leads to the question: more is better, right?

Ultra-Endurance Sports: A Double-Edged Sword

Ultra-endurance sports, defined as events lasting at least 6 hours and often extending to multi-day challenges over thousands of miles with minimal or no sleep, have surged in popularity. Personally, I've encountered transformative moments during several multi-day, sleepless bikepacking races. While some athletes report these grueling events as beneficial to their health, others acknowledge a contribution to mental health challenges.

Research indicates significant rates of depression, anxiety, and substance use among ultra-endurance athletes (Onate, 2019). The very traits that drive athletes to complete these events— perfectionism, high self-expectation, and an extraordinary work ethic—can also precipitate mental health issues, creating a paradox where mental health is both a casualty and a critical factor in achieving peak performance.

Unique Risk Factors for Ultra-Endurance Athletes

Ultra-endurance athletes face several unique risk factors that may contribute to mood and anxiety disorders (Onate, 2019; Colangelo et al, 2023), including:

• Pressure to perform and expectations from sponsors/community.
• High-volume training and its psychological impacts.
• Personal sacrifices for training, impacting other commitments.
• Navigating identity and self-worth related to performance changes (injuries, aging, pregnancy, etc.).
• Recreational substance abuse or anabolic steroid use.
• Overtraining can blunt the stress response and lower the production of brain-derived neurotrophic factor (BDNF), posing risks for a wide array of disorders, including depression, anxiety, and eating disorders (Scheer, et al., 2022).
• High-volume training affects neurotransmitter balance, producing abnormally high levels of serotonin. Brains then downregulate receptors to maintain balance. This potentially leads to medical depression if training is reduced (Scheer, et al., 2022).

Exercise Dependence: A Growing Concern

Exercise dependence (ED) is a condition where athletes continue exercising despite deteriorating physical health and quality of life. Although not yet recognized in the DSM-5 or ICD-11, ED shares similarities with substance use disorders, including tolerance, withdrawal, and loss of control over exercise habits (Remilly, et al, 2023).

A Call for Comprehensive Tailored Psychological Intervention

The unique challenges faced by ultra-endurance athletes necessitate specialized therapeutic approaches. While sports psychology has traditionally focused on performance enhancement, there is a critical need for mental health screening, and psychotherapeutic interventions tailored to athletes with mental health concerns. Cognitive Behavioral Therapy (CBT) is recommended for treating athletes with mental health issues, yet empirical evidence on its effectiveness in this context is scarce (Ekelund, et al, 2022).

A Call for Comprehensive Care

The journey of an ultra-endurance athlete is as much a mental endeavor as it is a physical one. By highlighting the psychological challenges they face and advocating for comprehensive mental health care, we can support these individuals not just in their pursuit of excellence, but in leading balanced, fulfilling lives.