If there’s one thing that we know about modern Football above just about anything else, it’s that modern football matters. It’s a message that is relentlessly pushed at us, and the reasons for it are many and varied. The amount of money involved is most commonly cited as the root cause for this. Back in the days when many – if not most – financial transactions within the game came in the order of thousands, tens of thousands, or hundreds of thousands of pounds, there was less at stake. The supporters of the 1960s and 1970s simply didn’t discuss the game in the same way that we do today.

It might also be argued that the media is central to the perception of football’s increased importance. It is most certainly in the best interests of all media outlets to persuade us that the football matters, and that we need to be subscribing to their service to either see it live, or to get the best inside track on what’s actually happening at the heart of a game that seems riven through with obfuscation and half-truth. This is, of course, a well-worn path for satire – the comedian David Mitchell was mocking it on the BBC many years ago – but do we ever pause to consider the effects of this increased importance upon those that come into contact with it?

It’s an important question. Scientists have already proven the links between depression, stress, and both heart attacks and heart disease. We’re still in the early years of this world of high-pressure football. We can’t say with much certainty what the long term effects of a lifetime of living at the heart of this crucible of pressure and overblown expectations. What we do know for certain is that stressful situations have a direct correlation with ill health. And if there is any one group of individuals who must feel this more than any other, it’s the Football Managers themselves.

Let’s be clear about something before we talk about anything else. Managers enter the game voluntarily, and are as lavishly rewarded for their troubles as anybody else. When they sign a fixed-term contract for three years and are released after six months, the likelihood is that they will be paid up for the remainder of their time. There are very few managers – certainly in the top two divisions of the game in England, for example – who might have to worry about putting food on their families’ tables in the event of them losing their jobs. But, whilst money can be a cause of stress, anxiety and depression, it isn’t a panacea, either, though. No amount of money can truly compensate for body that is being affected by the effects of stress, many of which can be virtually invisible, initially, at least.

It comes as a cause of considerable surprise to establish that relatively few football managers actually die in the job. The most-remembered example of this happening in the UK is, of course, that of the former Celtic and Scotland manager Jock Stein. In September 1985, Stein took his Scotland team to Cardiff City’s Ninian Park for a World Cup qualifying match. With a draw required for Scotland to proceed to a play-off match against Australia for the following summer’s finals in Mexico, Wales took an early lead before a late penalty kick brought Scotland level and put them through. Anything that could ever have happened on the pitch, however, were overshadowed by events at the final whistle, when Stein suffered a heart attack. He died shortly afterwards in the stadium’s medical room at the age of sixty-two. A further example, if anything an even sadder one, came with the suicide of the Wales manager Gary Speed in 2011, whose death has also been linked with the pressures that he was under as a manager.

There are others, of course, too many to mention on these pages, and perhaps this shouldn’t be that surprising to us. After all, football managers are, on the whole, men between the ages of roughly thirty-five and seventy, and there is no God given reason why their life expectancies should a great deal different to the rest of society, where men between those ages die all the time. On the other hand, though, perhaps the number of football managers who die on the job are a little on the low side, if anything. After all, roughly one in five men in the general population do not live to sixty-five years of age. Football managers are, on the whole, former athletes who keep themselves in shape. It’s likely that they have good diets, don’t smoke, and don’t drink alcohol to excess to the same extent as the rest of the population. But stress doesn’t need any of those other factors to work its black magic. Recent research has shown that if 25% of cases of heart disease are caused by smoking and 15% by high blood pressure, 21% may be caused by stress, depression and anxiety. And, if nothing else, being the manager of a football club is getting increasingly stressful with each passing season, as the stakes get ever higher and higher.

The reaction of three managers over the last couple of years to stressful situations has given some indication of the extent to which stress may be endemic amongst football managers. Much as we may all have laughed at it this time last year, the withdrawn behaviour of Jose Mourinho during his final few months at Chelsea seemed to fit the pattern of a manager suffering from stress. Elsewhere, David Moyes cut a curiously fatalist figure at Sunderland last  season, as his team has struggled to drag itself anywhere near safety at the bottom of the table. When discussing last January’s transfer window, for example, Moyes stated that, “I’d be kidding if I said the players we’re going to bring will massively make a big difference. We probably couldn’t get that level of player and probably wouldn’t have the finances.” This season’s start may be demonstrating that the biggest issue at Sunderland is not the manager.

The final example of this is, perhaps, the news story of the moment in the Premier League. Pep Guardiola was the man that Manchester City had wanted to manage their club for several years, and, if nothing else, his appointment came with a rebuild of its internal structure that was based around his vision of how the game should be played. This, however, did not lead to the automatic success that most expected, and the idea that this season may have needed all long to have been a transitional one having escaped the attentions of most onlookers.

Many of you reading this will be aware of that single shot of Guardiola, screen-grabbed from the television during his team’s four-nil humbling at Everton. In that picture, it felt as though we could see right through Guardiola. There was a despondency at the very heart of his facial expression that feels unsettling to us. Some of us recognise it. Others may have been blessed enough to have not come across it before, finding themselves unable to put their finger upon what precisely was wrong with it whilst knowing absolutely that there was something wrong with it in the first place. It’s impossible to say for certain, but to this seasoned observer of the calamitous effects of depression, stress and anxiety, Pep Guardiola’s entire body language during that particular match did not look healthy in the slightest.

This feeling that there was a cloud over the Manchester City manager last season didn’t end with his body language, either. As his team prepared to take on a Tottenham Hotspur team that was riding the crest of a wave, Guardiola told the press that, “Maybe I am not good enough for them. They are Manchester City players, they have a lot of quality. They showed that many times in the past and this season. I have respect for the guys, so why would I say the guys are not good? I don’t understand the lack of respect for the professionals when they are amazing players and [the question suggests] they are not good enough for me.” Now, the question here might have a mischievous one, and “not being good enough” for the Manchester City players is not the same as “not being good enough” for Manchester City Football Club (this is, after all, the club that once employed Peter Reid, Brian Horton and Alan Ball in succession), as the story has been widely attributed, but is still deeply troubling to hear the manager of any football club openly describing themselves as not being “good enough”, in any sense of the phrase.

The prognosis for what might happen in relation to both the physical and mental health of managers is not good, for the simple reason that there doesn’t seem to be a great deal of interest within the world of football between tackling this problem. The money – which brings with it a heightened sense of importance (just consider, for example, how the Football League Championship play-off final is marketed every single season) – is highly unlikely to stop flowing into the game at ever-increasing levels. The likelihood of much of the press changing its tone with respect to its coverage of the game and the personalities involved is just as unlikely to change in the future, although the reaction to, say, England’s elimination from the 2016 European Championships largely greeted with opprobrium towards the players rather than the coach, which sounds like it could be an even greater recipe for problems, as players are considerably younger than managers and surely less likely to be able to cope with such pressures as managers who have already lived in a goldfish bowl for decades.

And finally, even those amongst us who are just the supporters of clubs play our role in further heating this pressure cooker. We now live in a culture in which more or less any defeat has come to feel like a personal affront, in which the vitriol of a few has become more savage and vituperative than ever before. We have, collectively, to look into ourselves and understand our role in these stress levels and try harder to minimise them. None of this is to say that criticism of any sort should be banned, of course. It’s more about creating a culture that doesn’t create facial expressions like that which seemed to be haunting Pep Guardiola at Goodison Park.

Clubs have a responsibility in this regard, and some owners can be extraordinarily heartless in discussing their managers in the public sphere. We don’t know about the extent to which clubs themselves encourage positive mental health amongst their staff, whether, for example, they would ever consider providing counselling to people in stressful situations, or whether even the use of anti-depressants is encouraged for those who are struggling under this sort of burden. What we can say with a degree of certainty is that if they aren’t, then they should be.

The standard defence mechanism response of those involved is to point to the low levels of mortality amongst managers and to say that the current system works. After all, there is no shortage of managers seeking to join the game at at levels. This, however, feels unsatisfactory. Professional football as a business doesn’t seem to be particularly good at being pro-active. Reactivity is considerably more familiar ground. But the question remains, what happens next? The scope is there for the game to continue to grow. Television rights figures and wages sound astronomically high to us, but in the United States of America, the NFL retains a television deal comparable to that of the Premier League for its domestic audience only. And the Premier League is already effectively a global league. Its scope to grow these revenues remains huge.

That issue of reactivity, however, remains a concern. How long might it be before a manager collapses and dies on the touchline during a match from a condition that might never have come to pass, had their stress levels been lower? There would, without doubt, be an earnest conversation on the subject at such a time, as there was upon the death of Gary Speed. Surely, however, nobody wants things to go that far first. The mental health and the physical health of everybody associated with elite level sports should be a top priority for all right now.