Mental health services at the Tokyo 2020 Olympic and Paralympic Games during the COVID-19 pandemic

Overview of The Tokyo 2020 Summer Olympic and Paralympic Games

The Tokyo 2020 Summer Olympic and Paralympic Games were held for nine weeks from July 23 to September 5, 2021. They are most notable for being held under the exceptional circumstance of the COVID-19 (coronavirus disease 2019) global pandemic. During this time, Tokyo was experiencing an outbreak of COVID-19 infection, which is why, most competitions were held without audiences as a safety measure along with restricted entry of all associates. Nevertheless, approximately 11,000 Olympic athletes and 41,000 of their associates, 4,400 Paralympic athletes, and 12,000 officials from over 200 countries participated in the games [1].

An Olympic village polyclinic was established to provide medical services at the athlete’s village. The polyclinic provided services including internal medicine, orthopedics, dermatology, urology, ophthalmology, dentistry, female athlete clinic, physical therapy, 24-hour emergency services as well as mental health services, for which five qualified psychiatrists were assigned. Studies on previous Olympic Games have reported a small number of mental health consultations with minor psychiatric manifestations in the Olympic polyclinic [2, 3]. However, we presume that due to the COVID-19 pandemic, unusual mental health issues would have been experienced during the 2020 Games.

Demographics of the mental health service

The mental health service at the polyclinic in the Olympic village was open three times a week from 10 am to 7 pm. Five board-certified psychiatrists were assigned to work in rotation, and on-call telephone support was provided during the absence of a physician on duty.

Eight patients (seven male, one female) visited the polyclinic for mental health services during the Olympics. Among them, three were athletes and five, members of the team staff. During the Paralympics, two patients (one male, one female), both of whom were members of the team staff, visited the polyclinic for mental health services. Thus, 11 people were examined at the polyclinic throughout the Olympic and Paralympic games. All patients, except for one, met the diagnostic criteria for Adjustment Disorder. Plausible factors contributing to psychological stress are likely to be associated with the prolonged stay in the Olympic village, work-related exhaustion, and the behavior of others that may be considered harassment. None of the clients required hospitalization in the psychiatric ward in the hospital designated by the Tokyo Metropolitan Government and the organizing committee.

In addition, although two inquiries regarding the handling of psychostimulant medication for Attention-Deficit / Hyperactivity Disorder were made, they did not result in a formal medical visit. Specifically, one Olympian had stimulant drugs confiscated by the customs department for failure to follow the Therapeutic Use Exemption (TUE) procedures. However, the drugs were returned to the participant after following proper procedures. Moreover, another Paralympian was unable to bring Amphetamine/dextroamphetamine (Adderall^®) due to incomplete TUE procedures. Although policlinic staff was asked whether they could prescribe methylphenidate (Concerta^®) as an alternative; it was only an inquiry, and no procedure or alternative medication was prescribed.

Services for people under quarantine

During the 2020 Olympic and Paralympic Games, those who tested positive for COVID-19 had to follow quarantine rules which possibly took a toll on their mental health. The organizing committee of the games announced that a total of 863 athletes and officials had tested positive, of which 41 were athletes [4]. Those who tested positive for COVID-19 were promptly quarantined at a designated isolation facility.

A patient in quarantine must meet all of the following criteria to be discharged:

1. (1)
   Symptomatic patients

   • •
     10 days after the onset of symptoms and 72 hours after the symptoms have abated
   • •
     Negative results confirmed by two PCR tests at an interval of at least 24 hours, after 24 hours of symptom relief
2. (2)
   Asymptomatic pathogen retainers

   • •
     After 10 days from the date of specimen collection
   • •
     After 6 days from the date of specimen collection, confirmed negative results of two PCR tests at an interval of at least 24 hours.

Although previous studies have demonstrated that the lockdown affected the mental health of athletes, such as depressive mood and confusion [5], anxiety [6], and elevated distress [7], to our knowledge, no studies have reported psychiatric disorders caused by individual isolation during quarantine. Nevertheless, it is not contradictory that isolated athletes or associates were restricted freedom of action, including training, as well as tremendously distressed as they were deprived of the opportunity to participate in the main competition. Two quarantined, Olympic male staff members sought consultation complaining of severe anxiety symptoms. The psychiatrists provided online telemedicine consultations and treatment, as they were not allowed to visit isolation facilities due to infection control regulations. Eventually, one patient (an associate) was able to visit the polyclinic once their quarantine period had ended. A quarantine camp of Olympic and Paralympic athletes, known as “sporting bubbles,” which was specifically designed to reduce the risk of transmission, was shown to function effectively for conditioning [8]. The mental distress caused by individual quarantine was expected to be stronger for athletes and officials than for the public [9]. Moreover, being forced to abandon their participation in the main competition due to quarantine would make the despair and helplessness unimaginable. Therefore, although there were only two consultations for mental health services because of quarantine, we speculate that the need for psychological support in this scenario is more than that in ordinary situations. Thus, psychological support for individually quarantined people require further improvement.

Issues for future games

Although holding the Olympic and Paralympic games under pandemic conditions appears unprecedented, future games may need to be held in similar circumstances. Therefore, it is critical to summarize the issues ahead of the 2022 Beijing Olympic and Paralympic Winter Games. While it is uncertain whether the pandemic will be under control by then, we suggest that the psychological support system for athletes and officials should be further developed and expanded. The polyclinic at the 2020 Games consisted of only psychiatrists and lacked clinical psychologists. Therefore, the importance of deploying well-trained psychologists among the policlinic staff should be emphasized [10].

In light of the increasing demand for clinical psychologists, more flexibility in locations and hours will be required for collaboration and to ensure more opportunities for online consultations. Although the mental health teams experienced no cases of admission to psychiatric hospitals or wards, we strongly recommend careful coordination with affiliated hospitals in advance. Especially, as it is difficult for psychiatric hospitals to admit patients under pandemic conditions and provide mental health services to people from other countries.

Finally, although the polyclinic only catered to three athletes, several staff members, including coaches, athletic trainers, and team-doctors, were substantially exhausted by the unprecedented workload, highlighting the importance of also providing support for these professionals [11, 12].