Assessing mental health risks for those in the public eye

Oa difficult maneuver had cost her a medal—and threatened serious injury—gymnastic phenomenon Simone Biles announced that she was withdrawing from key competitions for mental health reasons. Despite returning several days later to take medals in some subsequent events, Biles was derided as a quitter by some. But upon the whole, the response was respect for her courage in protecting herself, and in going public with her mental health concerns.

Her example was not isolated. Two months earlier, second-seed Naomi Osaka withdrew from the French Open tennis tournament, citing the debilitating effects of stress and her struggles with depression. In recent years, public disclosures have made it clear that mental health problems are by no means uncommon among celebrity entertainers as well, a star cast that includes actors Jon Hamm, Kim Basinger, and Alec Baldwin, and singers such as Bruce Springsteen and Lady Gaga.

Are those who perform before the public—hundreds, thousands, even millions of spectators at a time—at heightened risk of mental illness? It’s complicated.

The mental health of athletes has received the most attention: There are international societies for sports psychiatry and sports psychology, and data for mental health conditions are far more abundant than for other fields. It is possible that problems are underreported due to concerns about image or remaining on the team. But among present and elite athletes, it appears that the prevalence of depression, anxiety, and other mental maladies is the same or just slightly higher than in the general population.

“The mental health [of athletes] is comparable to the public at large,” psychiatrist Carla Edwards University summarizes. “But athlete-specific factors could place them at higher risk in some circumstances.

“[Mental health difficulty] can eke its way into sports in lot of different ways,” says Edwards, president of the International Society for Sports Psychiatry. “Athletes can enter sports with pre-existing problems; or [problems] can develop as result of sport-related issues—such as pressure or maltreatment; arise independently; or be exacerbated by sports. A lot of athletes, conversely, need to keep sports incorporated into their lives for their mental health.”

Many of the same stresses are common to other endeavors in the glare of the spotlight. “Performance is performance is performance,” says Julliard psychologist Noa Kageyama. “The details may vary, but the basic principles are the same. All [performers] experience the same sorts of challenges.”

There may be differences between groups, however. Less robust data suggest that professional musicians suffer more than their share of depression and anxiety symptoms. A recent Norwegian study, for example, found that 18 percent of musicians within Norway reported significant psychological distress, compared to 8 percent of workers in other fields.

Stage Fright and Other Sorrows

Performers of all sorts are unquestionably subject to special challenges. Anxiety surrounding the performance itself—“stage fright”—is the most obvious. This has been most studied in musicians. Various studies have suggested that between 15 and 70 percent of professional musicians report performance anxiety. “These statistics are probably on the low end—every musician gets a little nervous before every performance,” says Kageyama. “It’s a matter of degree, whether they feel their nerves are derailing their performance, or a useful adjunct.”

Attempting to control anxiety can itself be a problem. A 2015 survey of 447 players conducted by the International Society of Symphony Orchestra Musicians found that 70 percent had used beta blockers, cardiac drugs that blunt the physiological response to anxiety. In extreme cases, performance anxiety can end a career. “A lot of musicians are talented enough but can’t make it performance-wise,” says psychiatrist David Shapiro, of Weill Cornell Medical College. “Anxiety leads to avoidance, and they miss gigs or are repeatedly unable to get to jobs on time.”

Severe stage fright crippled singer-songwriter Carly Simon’s career, kept singer Adele from touring, and drove Vladimir Horowitz, one of the great classical pianists of the audience. But while a violinist may feel peak stress when picking up his or her bow before a packed concert hall, many musicians “are not that nervous in front of an audience of strangers, as opposed to teachers, fellow musicians, or friends and family members” whose negative evaluation would carry a special sting, says Kageyama.

Some anxiety in the heat of athletic competition is inevitable (“I don’t think you’re human if you don’t get nervous,” according to hockey great Sidney Crosby), but stage fright per se tends to be less problematic in sports, says Edwards. “Athletes on a high-performance pathway from an early age are exposed to larger and larger crowds... When they’re in their element and know that they’re good at it, the anxiety is not there.

“Even for some athletes with social anxiety—they hate to go to parties—performing in front of 10,000 people is not an issue. They don’t worry about it at all.”

In any case, the performance itself is only part of the story, and not necessarily the biggest part. A more substantial threat to mental health may come outside the arena and off the stage.

“The way the general public views elite athletes is that they have ‘the life.’ They just get to play sports,” says Edwards. “They don’t understand that’s the tip of the iceberg, and in the submerged part is all of the other things that contribute to challenges and pressures.”

It starts early. Elite athletes and musicians frequently excel from their first years, and training and performance may dominate and destabilize their childhood, disrupting family relationships and schooling. Young performers can be subject to pressure from parents and others who identify too closely with and exploit their success—the “achievement by proxy distortion.” Stage mothers (and fathers) have their equivalent in the worlds of sport and music.

The lives that many star entertainers, elite athletes, and virtuoso musicians lead entail years of sustained stresses and pressures, which can include frequent travel and irregular hours, disturbed sleep, and rigorous training or practice schedules. Invasion of privacy comes with the territory, and personal relationships may be strained. “Celebrity can be a mental health risk factor if the person is not psychologically healthy enough before becoming a celebrity,” says Beverly Hills psychiatrist Carole Lieberman, who has worked with actors and other performers and as a consultant in the entertainment industry.

Those in the public eye have always had to deal with audience catcalls and bad press. But the internet puts such assaults on steroids: You’re performing—and living—before an often vociferous public of millions, not thousands. “Social media amplifies the effect of criticism,” says psychologist Michael Hollander of McLean Hospital and Harvard. Failure in competition, or personal disclosures (like Biles’s and Osaka’s concerns about their mental health) can unleash a barrage of vicious commentary that reverberates for weeks or months. “You’re a victim of these comments, and you can’t fight back,” says Hollander. “I think the impact of that shouldn’t be undersold.”

In the pandemic, performers faced the same mental health challenges as everyone, with an extra burden all their own.

“[Covid] cut off access to training,” says Edwards, speaking of the 2021 Olympics. “Athletes always measure themselves against their former selves—they expect to perform as well or better. If they aren’t able to train as much as before, it plants seeds of doubt.” Connection to their programs, teammates, and coaches normally girds athletes’ mental health, she says. Those who were forced to train in isolation lost those supports.

For musicians and entertainers, as well as athletes, the inability to do their thing in front of live audiences, for months on end, has been emotionally taxing, Kageyama says. Now that concert and other venues are reopening, “it’s been difficult for many to get back into performing. Musicians fear being out of rhythm, out of practice. ‘Getting back on the horse’ has been a source of additional stress and anxiety.”

While star performers may turn to alcohol and drugs to cope with the pressures of their lives, relieve physical