During the Summer Olympics in Tokyo last year, star gymnast Simone Biles shined a light on the mental health struggles many Olympians face when she decided to withdraw from competition.
Now, the United States' best figure skaters, skiers and snowboarders will be vying for gold medals as they also deal with the strain of a global pandemic for the second year in a row.
"The Olympics present particularly unique challenges for elite athletes," Dr. Joshua Norman, a sports psychiatrist at The Ohio State University Wexner Medical Center, told ABC News. "Many of them train their entire life for this one moment and a lot of them are removed from their support systems."
He continued: "With the isolated experience of being at Olympic Village, with having such intense focus on competition … and particularly in today's climate with COVID-19 with the athletes being tested multiple times a day and then they're further isolated out of fear of getting COVID-19, it's a very unique experience that can place significant physical and mental strain on the elite athletes."
For the Winter Olympics in Beijing, Team USA has made it a priority to address and protect the mental health of its more than 200 athletes.
What Team USA plans to do
Athletes will have access to therapists and psychiatrists throughout the Olympic Village and venues, ability to attend individual or group therapy sessions and a crisis hotline they can call, Dr. Jessica Bartley, the U.S. Olympic & Paralympic Committee's director of mental health services, said during a media summit in October 2021.
She said that most of the athletes underwent several mental health screenings.
"The majority of our winter athletes, we actually did some mental health screens around anxiety, depression, eating disorders, sleep, alcohol and drug use over the summer," Bartley said. "And then we're going to repeat that. And just trying to keep tabs on them a little bit too."
Team USA has also compiled a list of counselors whom athletes can contact and will allow free access to wellness apps.
In addition to the pressure of competing, Olympians will have several strict rules in place during the Games including staying within the closed loop system that doesn't allow outsiders, daily screening and testing, mask-wearing with few exceptions and avoiding hugs or handshakes, according to the Olympics playbook.
Norman said the athletes do what they can to be physically and mentally prepared, but that some of the stringent measures may be hard to handle.
"Certainly, once arriving there and that being such a strange experience -- particularly for those who it's their first time participating in the Olympics -- it can be somewhat of an overwhelming experience at times," he said.
Athletes putting their mental health first
Dr. Leela Magavi, a psychiatrist and Regional Medical Director with Mindpath Health with several patients who are student and professional athletes, offered some tips for athletes. For example, instead of practicing all day, athletes can take mindfulness walks, write in a journal or spend time talking to family members.
She also recommended that Team USA advocate for athletes expressing their thoughts openly.
"Rather than asking a close-ended question, 'Are you depressed or anxious?' ask 'How are you coping with the anxiety?'" Magavi told ABC News. "When they're anxious and internalizing those feelings, they don't sleep as well, they don't eat as well, they don't play as well."
Norman said that it's important not only for athletes to keep on top of any current treatments, but to have constant communication with their support staff for any new or evolving conditions that may be affecting them.
Biles is not the first athlete to speak out about mental health. Michael Phelps, the most decorated Olympian of all time, has been candid about his struggles with ADHD, depression and even suicidal thoughts.
However, Biles is perhaps the most high-profile athlete to pull out of events to focus on her mental health after she revealed she had "the twisties," which is when a gymnast loses their sense of where they are in the air.
"Whenever I think about Biles' decision, she really helped people speak up," Magavi said. "I've had people say, 'I never thought you could even do that. If you were experiencing something like twisties, that could even say that.' I do think that her decision did bridge the gap between mental and physical health."
And it seems like some professional athletes have followed suit.
Prior to the NHL announcing that no hockey players would be traveling to the Olympics due to Beijing's strict COVID measures, Las Vegas Golden Knights goalie Robin Lehner said he would not be playing for the Swedish national team, citing mental health struggles.
Lehner, who has been open about his bipolar disorder diagnosis, said that after consulting with his doctors, he had made the difficult decision to stay in the U.S. instead.
"Reality is that what [has] been said about how it's going to be is not ideal for my mental health," he tweeted Dec. 6. "Took long time to make [a] decision with my psychiatrist and family. My well-being [has to] come first and being locked down and not knowing what happens if you test positive is [too] much of a risk for me."
The experts commended Lehner for his decision and called it "courageous."
"It takes an enormous amount of confidence to speak up," she said. "Athletes are accustomed to internalizing their feelings. When athletes are unable to sleep, eat or function, it's often tied to a poor sports performance."
How athletes speaking up removes the stigma
Magavi said that she hopes more athletes speaking out about mental health removes some of the pressure they face.
"Athletes are human beings like you and I," she said. "Athletes have all kinds of insecurities. They want to win the gold as much as we want them to win it for us. But they also have the right to determine whether they want to play."
"They are more attuned to their bodies, their emotions and, if they're feeling the time is not right, it's their decision," she added.
Norman said that athletes speaking up could also remove the stigma around mental health for everyday Americans and help them realize how common mental health conditions are.
"You're not alone. Folks who are extremely high achieving like Simone Biles, Michael Phelps, a lot of elite athletes, also struggle with mental health conditions," he said. "I think having folks like that with those types of platforms speaking out, it really helps not only other athletes but folks within the general population that may look up to these athletes. It may help them seek treatment."
The psychiatrists added that giving Olympians a chance to address their mental health concerns will lead to better performances and, in turn, lead to more medals for the U.S.
"If we come back with healthy, safe players, we may also bring back the gold," Magavi said. "It's a win-win situation."