All of that raises questions: What is the prevalence of mental health struggles among big leaguers? What are the resources available to big leaguers? And why are they under-utilized?

MLB has not conducted comprehensive studies on the prevalence of mental health struggles across the sport. But it’s reasonable to assume those issues are at least as widespread in the game as they are outside of it, particularly given numerous stressors within the sport.

“It’s inherent to the business,” said Laz Gutierrez, a former Red Sox mental skills coach who is now the pitching coach at the University of Miami. “You’ve got alpha males who are the 2 percenters in their world. They ride this fine line between high standards of achievement that sometimes crosses the line to perfectionism.”

On-field performance is an obvious source of anxiety. Beyond that, players regularly navigate: physical injuries that can impact their mental health; uncertainty of place, particularly early in their careers while wondering if struggles can result in getting sent to the minors, traded, or released; isolation from friends and family members; irregular sleep schedules; and burnout or overtraining syndrome, among other elements.

A widely cited consensus statement by the International Olympic Committee in 2019 found that “nearly 45 percent” of male athletes in team sports experienced anxiety and/or depression — well above the one in four adults whom the CDC identified in 2024 as living with a mental health condition.

“They’re in such a strange situation. I don’t even know how one’s supposed to develop effective mechanism [to cope] when you’re on the road all the time or being traded,” said Cindy Miller Aron, an athletic mental health provider who contributed to the IOC consensus statement. “The social support of their families, all those things that help hold us together emotionally, they don’t have.”

Bob Tewksbury, who after a pitching career of 13 big league seasons spent 17 seasons as a mental skills coach with the Red Sox, Cubs, and Giants, estimated that 35 to 40 percent of baseball players experience mental health struggles.

“There’s pressure on these people to live up to other people’s expectations,” said Tewksbury. “There’s a lot of sadness because of unmet expectations.”

The amount of resources for both proactively and responsively helping players to address their mental health is very different than it was when Tewksbury broke into the big leagues in 1986.

“There was no one to talk to,” Tewksbury recalled. “There was no support.”

When Tewksbury joined the Sox in 2004, team-employed mental skills instructors were a rarity. But over time, they became relatively widespread.

The focus of those instructors was typically on-field performance, but Gutierrez noted that such professionals built relationships that made them “conduits” who could earn the trust of players and direct them to mental health professionals — either through team medical departments or outside the organization.

Awareness grew during the 2010s of the need to provide more foundational needs for members of the baseball community — starting with players but also extending to coaches, front office staff, and other team employees.

While mental performance coaches offered a valuable resource, many lacked the training to address more profound struggles. A growing appreciation of the distinction between mental skills and mental health formed.

“One is to perform, one is to live,” said Red Sox manager Alex Cora.

In recognition of that notion, in 2015, the Red Sox formed a behavioral health program overseen by Mass. General Hospital clinical psychologist Dr. Richard Ginsburg that could offer structured clinical support, prescriptions, and/or referrals.

The Sox’ behavioral health program has grown to include four members — though the team’s mental skills staff has shrunk from five full-time instructors in 2023 to two this year.

Ginsburg and the behavioral health program have provided direct services to players while also creating clinical support networks both in Boston (for players who wanted help outside the team structure) and in every city with a Red Sox affiliate. Support for players like Brian Johnson in 2016 and Chris Martin in 2024, both of whom were placed on the injured list while seeking treatment for anxiety, occurred through the behavioral health program.

The league has likewise steadily expanded resources, partly by mandate. The 2017-21 Collective Bargaining Agreement made all teams provide “confidential mental health resources, including access to a licensed psychologist, in a private space.”

Subsequently, MLB has added a number of initiatives outside the CBA to offer services to players: a Professional Baseball Mental Skills Group has been organized, through which club representatives convene to cultivate best practices; training courses for groups such as mental skills coaches and trainers in mental health first aid, offering guidance for non-clinicians on how to intervene in mental health emergencies; and tools have been made available directly to players and their families.

The Players Association, meanwhile, offers its own list of clinical providers for those players who want to seek support outside of the team. It also launched a Mental Health and Wellness Program in 2024.

“Whenever you hear a story of anyone — inside or outside baseball — dealing with a mental health struggle, a mental health concern on their own, it’s heartbreaking because there are individuals and resources available that can help manage that,” said Jon Coyles, MLB vice president of drug, health, and safety programs. “There is still growth needed. Until we reach the point where anyone who needs responsive counseling or proactive support for mental health and mental well-being is taking advantage of it, we’re going to continue to try to get better.”

Even as resources for helping players deal with mental health have expanded, reluctance to use them has proven difficult to overcome. Players have long been trained to think that it’s necessary to push through physical injuries and downplay them to teams — notions that have transferred to the mental health space.

“I always compare [mental health attitudes] to the phrase, you can’t make the club from the tub,” said Robinson. “There’s an incredibly outdated stigma that [seeking help for mental health] is a sign of weakness … It’s outdated and in some cases it costs lives.”

Some players are reluctant to seek assistance from their team, fearing that any information they provide might be used against them in financial negotiations.

“If you work for a team, the players automatically don’t trust you in [a mental health] capacity,” said Tewksbury. “They don’t want the team to know, because it affects your contract. It affects everything.”

The concern isn’t unfounded. In arbitration hearings, the CBA permits teams to introduce “physical and mental defects” when arguing about a player’s salary. It also permits disclosure within and between organizations about players’ mental health — something that may work against players using team or league channels to seek help.

There’s the potential for a conversation between MLB and the MLBPA about whether players’ mental health could be better supported by amending that language.

“There is no more important aspect of effective mental health services and resources than considering the importance of confidentiality and privacy. That’s kind of a core pillar,” said Coyles. “We are open to having a discussion about ways that we can better promote the use of mental health resources that are made available by our teams.”

While there’s a long history of player reluctance to seek assistance for mental health, the norms are evolving.

Team, league, and union efforts have not only introduced players to the array of available resources, but also offered education on how to use them. Meanwhile, the public vulnerability and openness of players like Robinson and Duran in discussing their mental health crises — and the benefits of seeking and accepting help — can change the landscape.

“Unfortunately, these can become life and death situations,” said Robinson, who survived a gunshot wound to the head. “Hopefully my willingness to address my mental health and commitment to the resources I’ve been using for the last five years can hopefully be a walking example of what could happen in someone else’s life if they’re dealing with similar depths.

“There are resources, whether organizational or out in the world, that can help manage this a little bit better and a little bit less extreme than how I did.”

The Sox believe Duran can and will be able to use his own visibility to help others as well. The outfielder is slated to talk to the media on Tuesday for the first time since his suicide attempt became public.

“I truly believe that him opening up is going to help a lot of people. It takes a person with courage and being transparent and genuine to do that,” said Cora. “He will impact others, and he’s going to save lives with what he did.”

Alex Speier can be reached at [email protected]. Follow him @alexspeier.