Barriers and facilitators to mental health help-seeking for young elite athletes: a qualitative study

Elite Athletes Coping With Depression: A Qualitative Study

Little is known about the coping strategies used by elite athletes suffering from mental health issues. Therefore, this study examined coping strategies implemented by elite athletes facing clinical depression. Semi-structured interviews were conducted with four elite athletes and analysed using Interpretative Phenomenological Analysis (IPA). Results present a broad picture of how elite athletes tried to cope with depression using a range of coping strategies. Among the different strategies highlighted, talking, seeking professional help and social support were particularly emphasized by the participants. Surprisingly, however, only one participant reported transferring the skills and strategies learned on her way to the top to many other aspects of her everyday life such as coping with her depression. Findings, therefore, suggest that athletes should be encouraged to transfer and make the most of the skills learned throughout their sport career to deal with their daily life. Future research perspectives and implications are discussed.

Coach Support of High School Student-Athletes Struggling With Anxiety or Depression

This study sought to identify factors that influence whether coaches support athletes struggling with depression and anxiety. Participants were U.S. public high school coaches who completed a written survey assessing their experiences, attitudes, and behaviors related to student-athlete mental health (n = 190 coaches, 92% response rate). Around two-thirds of coaches were concerned about mental health issues among the students they coached. They were more likely to extend help to a struggling athlete if they were aware of their school’s mental health plan and had greater confidence related to helping, including feeling confident in their ability to identify symptoms of mental health disorders. Mental health professionals, including sport psychologists who work with or consult with coaches, are well positioned to help provide coaches with the education necessary to be able to support and encourage care seeking by athletes who are struggling with anxiety or depression.

Sports psychiatry: mental health and mental disorders in athletes and exercise treatment of mental disorders

Sports psychiatry has developed for the past 3 decades as an emerging field within psychiatry and sports medicine. An International society has been established in 1994 and also national interest groups were implemented, mostly within the national organizations for psychiatry, some also containing the topic of exercise treatment of mental disorders. Where are we now 30 years later? We systematically but also selectively review the medical literature on exercise, sport, psychiatry, mental health and mental disorders and related topics. The number of publications in the field has increased exponentially. Most topics keep remaining on the agenda, e.g., head trauma and concussion, drug abuse and doping, performance enhancement, overtraining, ADHD or eating disorders. Supported by the growing literature, evidence-based recommendations have become available now in many clinical areas. A relatively new phenomenon is muscle dysmorphia, observed in weightlifters, bodybuilders but also in college students and gym users. Further, sports therapy of mental disorders has been studied by more and more high-quality randomized controlled clinical trials. Mostly as a complementary treatment, however, for some disorders already with a 1a evidence level, e.g., depression, dementia or MCI but also post-traumatic stress disorder. Being grown up and accepted nowadays, sports psychiatry still represents a fast-developing field. The reverse side of the coin, sport therapy of mental disorders has received a scientific basis now. Who else than sports psychiatry could advance sport therapy of mental disorders? We need this enthusiasm for sports and psychiatry for our patients with mental disorders and it is time now for a broadening of the scope. Optimized psychiatric prevention and treatment of athletes and ideal sport-related support for individuals with mental disorders should be our main purpose and goal.

Mental health in elite athletes: International Olympic Committee consensus statement (2019)

Mental health symptoms and disorders are common among elite athletes, may have sport related manifestations within this population and impair performance. Mental health cannot be separated from physical health, as evidenced by mental health symptoms and disorders increasing the risk of physical injury and delaying subsequent recovery. There are no evidence or consensus based guidelines for diagnosis and management of mental health symptoms and disorders in elite athletes. Diagnosis must differentiate character traits particular to elite athletes from psychosocial maladaptations.

Management strategies should address all contributors to mental health symptoms and consider biopsychosocial factors relevant to athletes to maximise benefit and minimise harm. Management must involve both treatment of affected individual athletes and optimising environments in which all elite athletes train and compete. To advance a more standardised, evidence based approach to mental health symptoms and disorders in elite athletes, an International Olympic Committee Consensus Work Group critically evaluated the current state of science and provided recommendations.

Mental health symptoms and disorders in elite athletes: a systematic review on cultural influencers and barriers to athletes seeking treatment

OBJECTIVE

To summarise the literature on the barriers to athletes seeking mental health treatment and cultural influencers of mental health in elite athletes.

DESIGN

Systematic review DATA SOURCES: PubMed, Cochrane, Scopus, SportDiscus (Ebsco), and PsycINFO (ProQuest) up to November 2018.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Qualitative and quantitative original studies of elite athletes (those who competed at the professional, Olympic, or collegiate/university levels), published in any language.

RESULTS

Stigma, low mental health literacy, negative past experiences with mental health treatment-seeking, busy schedules, and hypermasculinity are barriers to elite athletes seeking mental health treatment. Cultural influencers of mental health in elite athletes include: (1) the lack of acceptance of women as athletes; (2) lower acceptability of mental health symptoms and disorders among non-white athletes; (3) non-disclosure of religious beliefs; and (4) higher dependence on economic benefits. Coaches have an important role in supporting elite athletes in obtaining treatment for mental illness. Brief anti-stigma interventions in elite athletes decrease stigma and improve literary about mental health.

CONCLUSION

There is a need for various actors to provide more effective strategies to overcome the stigma that surrounds mental illness, increase mental health literacy in the athlete/coach community, and address athlete-specific barriers to seeking treatment for mental illness. In this systematic review, we identified strategies that, if implemented, can overcome the cultural factors that may otherwise limit athletes seeking treatment. Coaches are critical for promoting a culture within elite athletes' environments that encourages athletes to seek treatment.

Young Pacific Male Rugby Players' Perceptions and Experiences of Mental Wellbeing

Recent studies and increased media reporting across Australasia have linked young Pacific maleelite athletes to depression, suicide, and other adverse mental health-related events. Despite these accounts,little is known about the way this group experience emotions and mental wellbeing. The aim of this studywas to explore young Pacific male athletes' perceptions and experiences of emotions and mental wellbeing.This qualitative study involved 20 face-to-face interviews with young Pacific males (16⁻24 years) engaged inelite rugby union and rugby league programmes in Auckland, New Zealand. The results identified thatathletes defined mental wellbeing in a holistic and relational manner and perceived and mental wellbeing asthe culmination of several interconnected factors, including: Family support, reciprocating family support,living a 'well-balanced' life, athletic performance, and personal development away from sports. Themaintenance of a well-balanced athletic identity and positive social relations were deemed central tosustaining mental wellbeing for these young men.

Psychotherapy for mental health symptoms and disorders in elite athletes: a narrative review

Background

Athletes, like non-athletes, suffer from mental health symptoms and disorders that affect their lives and their performance. Psychotherapy, either as the sole treatment or combined with other non-pharmacological and pharmacological strategies, is a pivotal component of management of mental health symptoms and disorders in elite athletes. Psychotherapy takes the form of individual, couples/family or group therapy and should address athlete-specific issues while being embraced as normative by athletes and their core stakeholders.

Main findings

This narrative review summarises controlled and non-controlled research on psychotherapy for elite athletes with mental health symptoms and disorders. In summary, treatment is similar to that of non-athletes—although with attention to issues that are athlete-specific. Challenges associated with psychotherapy with elite athletes are discussed, including diagnostic issues, deterrents to help-seeking and expectations about services. We describe certain personality characteristics sometimes associated with elite athletes, including narcissism and aggression, which could make psychotherapy with this population more challenging. The literature regarding psychotherapeutic interventions in elite athletes is sparse and largely anecdotal.

School mental healthcare services using internet-based cognitive behaviour therapy for young male athletes in Japan

AIM

Preventive intervention and treatment using internet-based cognitive behaviour therapy (iCBT) can be easily administered to school students, as they are quite familiar with internet tools. This study aims to investigate the effectiveness and contribution of iCBT to mental healthcare in a school setting.

METHODS

Eighty Japanese high school boys who were participating in a sports specialist course were enrolled in this study. The participants were randomly assigned to either the iCBT intervention group or the control group. Both programmes were administered for 4 weeks. To evaluate the effects, physical and mental health problems and self-efficacy were assessed.

RESULTS

The mean number of times that the iCBT website was accessed during the intervention period was 16.9, and the mean access frequency (percentage of the number of times the website was accessed during the intervention period) was 40.1% in the iCBT group. A statistically significant interaction between group and time in favour of the iCBT group was observed based on the Kessler-6 (K6) scale for depression and anxiety.

CONCLUSIONS

The results suggest that a school mental healthcare programme using iCBT is suitable for students and useful for coping with stress and reducing depressed mood and anxiety in young people, especially athletes, who are regarded as needing special mental health support.

Men, Mental Health and Elite Sport: a Narrative Review

Mental health in elite sport is receiving more publicity due to an increase in male athletes sharing their personal experiences. Sports injury is recognised as the major risk factor for psychological distress amongst male athletes, although anecdotally this may be that athletes are more likely to discuss their emotional wellbeing when related to the injury they are experiencing. Stress can be amplified within elite sport and the pressure they experience in relation to competition and performance can be exacerbated by adverse life events. This ongoing stress does not end when their sporting career does, it can follow them into retirement. The physical and psychological demands placed upon them by the sporting environment may predispose athletes to developing depression. As an athlete’s symptoms of mental illness intensify, their performance can be negatively affected leaving them vulnerable and exposed to further symptoms of common mental disorders. The pressure of performance can also expose male athletes to overtraining syndrome which can be difficult to distinguish from depression. Male athletes are more vulnerable to eating disorders compared with males in the general population and they do have anxieties, particularly around their bodies, but find it difficult to disclose their concerns. In addition to this, male athletes are more likely to use substances, including opioids to improve both sport and non-sport performance.

Despite the prevalence of common mental disorders in male athletes, stigma still exists, and although some athletes discuss their issues publicly after their career has ended, the majority of athletes prefer to remain silent. There remains a view that athletes who seek help for psychological problems may be seen as weak. Although there is an improvement in help-seeking attitudes within elite sport, further research and education is needed to encourage men to talk about their mental health, share their experiences and to enjoy a greater sense of emotional wellbeing.

Adapting a Technology-Based Eating Disorder Model for Athletes

Eating disorders (EDs) are common amongst athletes, yet few receive treatment. Given that athletes have a unique set of risk factors for eating disorders and are faced with additional barriers to treatment, new models outside of face-to-face treatment are necessary to reach the population and provide more affordable, tailored, evidence-based care. One solution is to use digital mental health programs to provide primary or supplemental therapy. Digital programs can provide accessibility and privacy, and recent advancements allow for more personalized online experiences. However, there have been no studies to date that integrate technology-based tools to address the especially high prevalence rates of EDs in athletes. This paper describes how an integrated model that includes online screening linked to guided self-help programs, all adapted specifically for athletes, can be used to provide prevention and intervention of EDs in athletes.

Learning From Elite Athletes' Experience of Depression

Sport has become increasingly aware of the challenges associated with Mental Disorders and, to a greater extent, mental health issues (MHIs). This study sought to explore in depth the subjective experiences of elite athletes who suffered from a specific clinical MHI, namely depression. In addition, we explored their perceptions of the prevalence and stigma surrounding MHIs in elite sport environments. Data were collected from four elite athletes (1 female and 3 males; 2 team and 2 individual sports) using semi-structured interviews and analysed using Interpretative Phenomenological Analysis. Participants described both sport and non-sport related triggers in regard to their depression (e.g., institutional mistreatment and bullying, injuries, previous MHI, and miscarriage), as well as a range of behaviour, performance (e.g., decline), and personality changes compared to their normal functioning. Although the participants stressed the widespread prevalence of MHIs in elite sport, they also acknowledged the stigma associated with MHIs in high-level sport environments and its detrimental role for athletes. This study has important practical and diagnostic implications, and highlights the need for further research to assess the extent and scope of clinical MHIs in sport as well as to inform the care for this unique population.

Student-Athlete and Student Non-Athletes’ Stigma and Attitudes Toward Seeking Online and Face-to-Face Counseling

This study investigated differences in stigmatization by others, self-stigma, and attitudes (value and discomfort) toward online counseling (OC) and face-to-face counseling (F2F), and the relationships between these variables, in college student-athletes (n = 101) and non-athletes (n = 101). Results revealed no differences in levels of stigmatization by others and self-stigma between student-athletes and non-athletes. Furthermore, both groups reported higher value, and less discomfort, in F2F compared to OC, while non-athletes reported higher levels of value in F2F compared to student-athletes. A multiple group path analysis revealed no difference in the relationship of the stigma and attitudes variables between the two groups. Stigmatization by others was a significant positive predictor of self-stigma and value in OC. In addition, self-stigma was a significant negative predictor of value in F2F, and a significant positive predictor of discomfort in F2F. The current findings have implications for university counseling centers and athletic departments.

Who is coaching the coach? Knowledge of depression and attitudes toward continuing education in coaches

Background

The rate of depression among collegiate athletes ranges from 16% to 23%, with particularly high findings of prevalence in track and field athletes (34%). Collegiate athletes have also been found to underuse mental health resources. Given this high prevalence of depression and demonstrated reluctance to seek help, it is important to explore the awareness and understanding of depression among the individuals who work most closely with this population.

Objective

To assess coaches’ knowledge and awareness of depression among their athletes and describe their level of interest in receiving continuing education.

Method

All National Collegiate Athletic Association Division I cross-country and track and field coaches were invited to participate in an online survey. The sample consisted of 253 participants, of whom 56 (25%) identified themselves as female and 170 (75%) as male with 14 (±10.4) years of coaching experience. Respondents completed the Adolescent Depression Awareness Program (ADAP) questionnaire and related questions. Differences in depression knowledge and interest in continuing education were calculated by gender, event specialty, length of coaching experience and certification history using analysis of variance and χ² analysis.

Results

The mean score on the ADAP depression questionnaire was 83%. Significant differences were not observed by gender, length of coaching experience, coaching title or certification history. Distance coaches scored significantly higher on the test than sprints coaches. Coaches estimated that 11% of their former and current student-athletes have struggled with depression. 77% of coaches indicated a ‘strong interest’ in receiving continuing education.

Conclusions

The findings of this study indicate the participating coaches have a good knowledge of depression for individuals without formal education on the topic but may lack depression awareness. This hypothesis is supported by the finding that coaches in the sample found out an athlete was suffering from depression most often by the athlete self-reporting.

Prevalence and Correlates of Psychological Distress among Retired Elite Athletes: A Systematic Review

This article presents results of a systematic review of the literature (2000-2017) examining the prevalence and correlates of psychological distress among retired elite athletes. Forty articles were selected and included. Our review suggests the prevalence of psychological distress among retired athletes is similar to that found in the general population. However, subgroups reporting medical comorbidities, significant pain, a greater number of concussions, less social support, and adverse psychosocial factors were at greater risk for psychological distress. Additionally, athletes experiencing psychological distress in retirement often do not seek treatment for their distress. Based on the existing literature, there is a need for greater standardization and use of reliable measures, as well as use of diagnostic interviews in order to assess the most accurate prevalence of psychological distress among these athletes. Longitudinal designs, matched control groups, more heterogeneous samples, and use of multivariate analyses would also help to more accurately determine the prevalence and risk factors of psychological distress in this population. This review suggests a number of different clinical implications and highlights directions for future research to enhance our understanding of the long-term psychological health of former elite athletes.

Controlled Evaluation of an Optimization Approach to Mental Health and Sport Performance

Athletes experience unique stressors that have been indicated to compromise their mental wellness and sport performance, yet they underutilize mental health services. Indeed, very few mental health interventions for athletes have been developed to fit sport culture, and well-controlled mental health outcome research in athlete populations is warranted. In this randomized controlled trial, a sport specific optimization approach to concurrent mental health and sport performance (The Optimum Performance Program in Sports; TOPPS) was examined. Seventy-four collegiate athletes (NCAA = 42; club = 11; intramural = 21) formally assessed for mental health diagnostic severity were randomly assigned to TOPPS or campus counseling/psychological services as usual (SAU) after baseline. Dependent measures assessed general mental health, mood, mental health factors affecting sport performance in training, competition and life outside of sports, days using substances, sexual risk behaviors, happiness in relationships, relationships affecting sport performance, and contributions of relationship to sport performance. Intent to treat repeated measures analyses indicated that participants in TOPPS consistently demonstrated better outcomes than SAU up to 8-months post-randomization and for mental health/substance use measures, particularly when diagnostic criteria were most severe. Recommendations are provided in light of the results to assist sport-specific mental health intervention development and implementation within athlete populations.

Symptoms of Anxiety and Depression in Young Athletes Using the Hospital Anxiety and Depression Scale

Elite young athletes have to cope with multiple psychological demands such as training volume, mental and physical fatigue, spatial separation of family and friends or time management problems may lead to reduced mental and physical recovery. While normative data regarding symptoms of anxiety and depression for the general population is available (Hinz and Brähler, 2011), hardly any information exists for adolescents in general and young athletes in particular. Therefore, the aim of this study was to assess overall symptoms of anxiety and depression in young athletes as well as possible sex differences. The survey was carried out within the scope of the study "Resistance Training in Young Athletes" (KINGS-Study). Between August 2015 and September 2016, 326 young athletes aged (mean ± SD) 14.3 ± 1.6 years completed the Hospital Anxiety and Depression Scale (HAD Scale). Regarding the analysis of age on the anxiety and depression subscales, age groups were classified as follows: late childhood (12-14 years) and late adolescence (15-18 years). The participating young athletes were recruited from Olympic weight lifting, handball, judo, track and field athletics, boxing, soccer, gymnastics, ice speed skating, volleyball, and rowing. Anxiety and depression scores were (mean ± SD) 4.3 ± 3.0 and 2.8 ± 2.9, respectively. In the subscale anxiety, 22 cases (6.7%) showed subclinical scores and 11 cases (3.4%) showed clinical relevant score values. When analyzing the depression subscale, 31 cases (9.5%) showed subclinical score values and 12 cases (3.7%) showed clinically important values. No significant differences were found between male and female athletes (p ≥ 0.05). No statistically significant differences in the HADS scores were found between male athletes of late childhood and late adolescents (p ≥ 0.05). To the best of our knowledge, this is the first report describing questionnaire based indicators of symptoms of anxiety and depression in young athletes. Our data implies the need for sports medical as well as sports psychiatric support for young athletes. In addition, our results demonstrated that the chronological classification concerning age did not influence HAD Scale outcomes. Future research should focus on sports medical and sports psychiatric interventional approaches with the goal to prevent anxiety and depression as well as teaching coping strategies to young athletes.

Treatment gap for anxiety disorders is global: Results of the World Mental Health Surveys in 21 countries

BACKGROUND

Anxiety disorders are a major cause of burden of disease. Treatment gaps have been described, but a worldwide evaluation is lacking. We estimated, among individuals with a 12-month DSM-IV (where DSM is Diagnostic Statistical Manual) anxiety disorder in 21 countries, the proportion who (i) perceived a need for treatment; (ii) received any treatment; and (iii) received possibly adequate treatment.

METHODS

Data from 23 community surveys in 21 countries of the World Mental Health (WMH) surveys. DSM-IV mental disorders were assessed (WHO Composite International Diagnostic Interview, CIDI 3.0). DSM-IV included posttraumatic stress disorder among anxiety disorders, while it is not considered so in the DSM-5. We asked if, in the previous 12 months, respondents felt they needed professional treatment and if they obtained professional treatment (specialized/general medical, complementary alternative medical, or nonmedical professional) for "problems with emotions, nerves, mental health, or use of alcohol or drugs." Possibly adequate treatment was defined as receiving pharmacotherapy (1+ months of medication and 4+ visits to a medical doctor) or psychotherapy, complementary alternative medicine or nonmedical care (8+ visits).

RESULTS

Of 51,547 respondents (response = 71.3%), 9.8% had a 12-month DSM-IV anxiety disorder, 27.6% of whom received any treatment, and only 9.8% received possibly adequate treatment. Of those with 12-month anxiety only 41.3% perceived a need for care. Lower treatment levels were found for lower income countries.

CONCLUSIONS

Low levels of service use and a high proportion of those receiving services not meeting adequacy standards for anxiety disorders exist worldwide. Results suggest the need for improving recognition of anxiety disorders and the quality of treatment.

Depression and anxiety symptoms in 17 teams of female football players including 10 German first league teams

BACKGROUND

Information on the prevalence of mental health problems of elite athletes is inconclusive, most probably due to methodological limitations, such as low response rates, heterogeneous samples.

AIMS

To evaluate the prevalence and risk factors of depression and anxiety symptoms in high-level female football players.

METHODS

Female football players of 10 German first league (Bundesliga) and 7 lower league teams were asked to answer a questionnaire on players' characteristics, the Center of Epidemiologic Studies Depression Scale (CES-D) and the Generalised Anxiety Disorder (GAD-7) scale.

RESULTS

A total of 290 players (184 first and 106 lower league players) took part in the study. The CES-D score indicated mild to moderate symptoms of depression in 48 (16.6%) and severe symptoms in 41 (14.1%) players. The GAD-7 score indicated an at least moderate generalised anxiety disorder in 24 (8.3%) players. The prevalence of depression symptoms and generalised anxiety disorders was similar to the female general population of similar age. However, significantly more second league players reported symptoms of depression than first league players, and thus the prevalence of depression symptoms in second league players was higher than in the general population. Only a third of the 45 (15.7%) players who stated that they currently wanted or needed psychotherapeutic support received it.

CONCLUSION

The prevalence of depression and generalised anxiety symptoms in elite football players is influenced by personal and sport-specific variables. It is important to raise awareness of athletes' mental health problems in coaches and team physicians, to reduce stigma and to provide low-threshold treatment.

Service Providers' Attitudes Toward Athletes With Eating Disorders

OBJECTIVE

This study explored the nature and extent of Athlete Support Personnel's (ASP's) attitudes and beliefs toward athletes with symptoms of anorexia nervosa (AN) compared with those with symptoms of depression.

DESIGN

A cross-sectional study with a survey instrument.

SETTING

Sport and Exercise Science Professional Bodies and Associations in the Republic of Ireland, Northern Ireland, and mainland United Kingdom.

PARTICIPANTS

One hundred fifty-two ASP.

MAIN OUTCOME MEASURES

Participants read 2 vignettes describing a fictional female athlete with symptoms of AN or depression after which they completed an on-line survey examining attitudes toward such athletes.

RESULTS

Significant differences in patterns of responses were found between the 2 mental health conditions. The athlete with AN was viewed as significantly more difficult to communicate with F(1,148) = 18.17, P = 0.000, η = 0.11, more likely to be using her disorder to gain attention F(1,148) = 21.69, P = 0.000, η = 0.13, personally responsible for her condition F(1,148) = 10.10, P = 0.00, η = 0.06, and less likely to recover F(1,148) = 23.03, P = 0.000, η = 0.14 than the athlete with depression. Male service providers were more likely to believe that the athletes depicted were attention seeking F(1,148) = 10.69, P = 0.001, η = 0.07 and only had themselves to blame for their mental health condition F(1,148) = 12.97, P = 0.000, η = 0.08.

CONCLUSIONS

Athlete support personnel report stigmatizing attitudes toward athletes with eating disorders such as AN. Male service providers hold greater negative attitudes toward athletes with mental health conditions.

The mental wellbeing of current and retired professional cricketers: an observational prospective cohort study

OBJECTIVE

Scientific knowledge about symptoms of common mental disorders in professional cricket is non-existent. Consequently, the aims of the study were to determine the prevalence and the 6 months incidence of symptoms of common mental disorders (CMD: distress, anxiety/depression, sleep disturbance, adverse alcohol use) among current and former professional cricketers and to explore the association of potential stressors (significant injury, surgery, adverse life events, career dissatisfaction) and CMD.

METHODS

An observational prospective cohort study with a follow-up period of 6 months was conducted among current and former professional cricketers from South Africa. Using validated questionnaires to assess symptoms of common mental disorders as well as several stressors, an electronic questionnaire was set up and distributed by the South African Cricketers Association (SACA).

RESULTS

A total of 116 participants enrolled at baseline (overall response rate of 33%) and 76 of those participants completed the 6 month follow-up (follow up rate of 66%). The prevalence of symptoms of CMD in current professional cricketers was 38% for distress, 38% for sleep disturbance, 37% for anxiety/depression and 26% for adverse alcohol use. Among former professional cricketers, baseline prevalence as was 26% for distress, 24% for anxiety/depression, 21% for sleep disturbance and 22% for adverse alcohol use. Career dissatisfaction led to an increased risk of distress, anxiety/depression and sleep disturbance in current professional cricketers. Surgeries and adverse life events led to an increase in reported symptoms of distress and anxiety/depression in current professional cricketers.

CONCLUSIONS

It was concluded that symptoms of CMD are prevalent in both current and former professional cricketers and the association with surgery, adverse life events and cricket career dissatisfaction may provide some insight into possible mechanisms.

A systematic review of interventions to increase awareness of mental health and well-being in athletes, coaches and officials

BACKGROUND

The aim of the current study was to conduct a systematic review determining the effect of sport-specific mental health awareness programs to improve mental health knowledge and help-seeking among sports coaches, athletes and officials. The second aim was to review the study quality and to report on the validity of measures that were used to determine the effectiveness of programs.

METHODS

Sport-specific mental health awareness programs adopting an experimental or quasi-experimental design were included for synthesis. Six electronic databases were searched: PsycINFO, MEDLINE (OVID interface), Scopus, Cochrane, CINAHL and SPORTDiscus. Each database was searched from its year of inception to October 2016. Risk of bias was assessed using the Cochrane and QATSQ tools.

RESULTS

Ten studies were included from the 1216 studies retrieved: four comprising coaches or service providers, one with officials, four with athletes, and one involved a combination of coaches and athletes. A range of outcomes was used to assess indices of mental health awareness and well-being. Mental health referral efficacy was improved in six studies, while three reported an increase in knowledge about mental health disorders. However, seven studies did not report effect sizes for their outcomes, limiting clinically meaningful interpretations. Furthermore, there was substantial heterogeneity and limited validity in the outcome measures of mental health knowledge and referral efficacy. Seven studies demonstrated a high risk of bias.

CONCLUSIONS

Further, well-designed controlled intervention studies are required. Researchers, practitioners and policy makers should adhere to available methodological guidance and apply the psychological theory of behaviour change when developing and evaluating complex interventions.

TRIAL REGISTRATION

PROSPERO CRD42016040178.

Promoting mental health awareness in sport clubs

Purpose

The World Health Organization estimates that millions of people across the world experience mental health problems, yet traditionally athletes have been poorly supported to manage their mental health. The purpose of this paper is to apply the Theory of Planned Behaviour to determine the effect of a mental health awareness programme on sports coaches’ knowledge and intentions to offer support to athletes who experience mental health problems.

Design/methodology/approach

Adult coaches (n=244) were recruited to attend the Mood Matters in Sport Programme mental health awareness intervention or act as a control. A 2 (group) × 2 (time) quasi-experimental design was adopted. All participants completed the Mental Health Knowledge Schedule and Reported and Intended Behaviour Scale at the beginning and end of the programme. Two months postprogramme delivery focus groups were conducted.

Findings

A mixed analysis of variance showed a significant interaction effect wherein there were improvements in mental health knowledge and intentions to offer support compared to the control group. Focus group findings provided further detail on how to support mental health awareness in sport clubs.

Practical implications

Knowledge and intentions to offer support can be enhanced through a short mental health awareness programme. The already established social networks available in sport clubs can provide a natural environment for delivering mental health awareness programmes. The programme facilitated discussion on mental health issues and highlighted that future programmes should contain more sport-related examples (i.e. case studies, videos, etc.).

Originality/value

This is the first study to apply the Theory of Planned Behaviour to mental health awareness programmes in a sport setting.

The Mental Health of Elite Athletes: A Narrative Systematic Review

Background

The physical impacts of elite sport participation have been well documented; however, there is comparatively less research on the mental health and psychological wellbeing of elite athletes.

Objective

This review appraises the evidence base regarding the mental health and wellbeing of elite-level athletes, including the incidence and/or nature of mental ill-health and substance use.

Methods

A systematic search of the PubMed, EMBASE, SPORTDiscus, PsycINFO, Cochrane and Google Scholar databases, up to and including May 2015, was conducted.

Results

The search yielded a total of 2279 records. Following double screening, 60 studies were included. The findings suggested that elite athletes experience a broadly comparable risk of high-prevalence mental disorders (i.e. anxiety, depression) relative to the general population. Evidence regarding other mental health domains (i.e. eating disorders, substance use, stress and coping) is less consistent. These results are prefaced, however, by the outcome of the quality assessment of the included studies, which demonstrated that relatively few studies (25 %) were well reported or methodologically rigorous. Furthermore, there is a lack of intervention-based research on this topic.

Conclusion

The evidence base regarding the mental health and wellbeing of elite athletes is limited by a paucity of high-quality, systematic studies. Nonetheless, the research demonstrates that this population is vulnerable to a range of mental health problems (including substance misuse), which may be related to both sporting factors (e.g. injury, overtraining and burnout) and non-sporting factors. More high-quality epidemiological and intervention studies are needed to inform optimal strategies to identify and respond to player mental health needs.

Electronic supplementary material

The online version of this article (doi:10.1007/s40279-016-0492-2) contains supplementary material, which is available to authorized users.

Addressing mental health through sport: a review of sporting organizations' websites

AIM

Mental health is a major concern among adolescents. Most mental illnesses have their onset during this period, and around 14% of all young people aged 12 to 17 years experience a mental illness in a 12-month period. However, only 65% of these adolescents access health services to address their mental health problems. Approximately 70% of all Australian adolescents participate in sport, and this presents an opportunity for mental health promotion.

METHODS

This paper reviewed current approaches by sporting organizations to mental health promotion, prevention and early intervention by searching peak body websites, as well as the wider Internet.

RESULTS

Findings revealed many of the sport organizations reviewed acknowledged the importance of mental components of their sport to increase competitiveness, but few explicitly noted mental health problems or the potential of their sport to promote good mental health. Although some had participated in mental health promotion campaigns, there was no evaluation or reference to the evidence base for these campaigns.

CONCLUSIONS

We describe a framework for integrating mental health promotion into sports organizations based on the MindMatters programme for schools.

Depressive symptoms in high-performance athletes and non-athletes: a comparative meta-analysis

OBJECTIVE

To assess whether a difference exists in the prevalence of mild or more severe depressive symptoms between high-performance athletes and non-athletes.

DESIGN

Comparative OR meta-analysis.

DATA SOURCES

We searched PsycINFO, PubMed, MEDLINE, CINAHL, SPORTDiscus and Google Scholar, as well as the reference lists of reviews of mental health issues in high-performance athletes.

ELIGIBILITY

We included studies that compared high-performance athletes and non-athletes, included a validated measure of depressive symptoms and included the prevalence of individuals who indicated at least mild depressive symptoms.

RESULTS

Five articles reporting data from 1545 high-performance athletes and 1811 non-athletes were examined. A comparative OR meta-analysis found high-performance athletes were no more likely than non-athletes to report mild or more severe depressive symptoms (OR=1.15, 95% CI=0.954 to 1.383, p=0.145). Male high-performance athletes (n=940) were no more likely than male non-athletes (n=605) to report mild or more severe depressive symptoms (OR=1.17, 95% CI=0.839 to 1.616, p=0.362). For females, high-performance athletes (n=948) were no more likely than non-athletes (n=605) to report mild or more severe depressive symptoms (OR=1.11, 95% CI=0.846 to 1.442, p=0.464). Overall, male high-performance athletes (n=874) were 52% less likely to report mild or more severe depressive symptoms than female high-performance athletes (n=705) (OR=0.48, 95% CI=0.369 to 0.621, p<0.001).

SUMMARY/CONCLUSIONS

High-performance athletes were just as likely as non-athletes to report depressive symptoms. Researchers need to move beyond self-report measures of depressive symptoms and examine the prevalence of clinically diagnosed depressive disorders in athletes.

Symptoms of common mental disorders among professional football referees: a one-season prospective study across Europe

OBJECTIVE

The primary aim of this study was to determine the prevalence and one-season incidence of symptoms of common mental disorders (CMD; distress, anxiety/depression, sleep disturbance, eating disorders, adverse alcohol use) among European professional football referees. A secondary aim was to explore the view of European professional football referees on consequences, support and needs related to these symptoms.

METHODS

An observational prospective cohort study with three measurements over a follow-up period of one season (2015-2016) was conducted among central or assistant professional football referees from Belgium, Finland, France, Germany, Norway, Russia, Scotland and Sweden. Using validated questionnaires to assess symptoms of CMD (self-reported and not clinically diagnosed), an electronic questionnaire in English and French was set up and distributed by the eight football federations involved.

RESULTS

A total of 391 referees (mean age of 33 years old; mean career duration of 7 years) were enrolled, of which 292 completed the follow-up period. Baseline 4-week prevalence rates were 6% for distress, 12% for anxiety/depression, 9% for sleep disturbance, 19% for eating disorders and 17% for adverse alcohol use. The one-season incidence of symptoms of CMD was 10% for distress, 16% for anxiety/depression, 14% for sleep disturbance, 29% for eating disorders and 8% for adverse alcohol use.

CONCLUSION

While symptoms of CMD occur among professional football referees and can influence negatively refereeing performances, the development of specific support measures for referees are needed in order to manage properly these symptoms of CMD.

Sport psychiatry and psychotherapeutic intervention, circa 2016

The focus of this paper is to provide an update on the use of psychotherapy as a treatment in sport psychiatry, and the use of this approach to address common psychiatric issues encountered with this population. Specifically, family therapy, individual therapy, and group psychotherapy prescribed alone, or in combination with medication, will be examined as methods to manage issues/disorders often associated with athletes. These include obsessive-compulsive rituals and perfectionism, and aggressive and risky behaviours, such as gambling, infidelity, substance use, and suicidal ideation, narcissism, and aggression in the context of individual and team competitive sports.

Working with sports organizations and teams

Athletes and coaches at all competitive levels will utilize sports performance and psychiatric services at very high rates if the services are offered on-site and free of charge and are broad in scope and culturally sensitive. Services should be available throughout the team year and cover areas such as team building, mental preparation, stress control, substance prevention, sleep and energy regulation, injury recovery, crisis intervention, and mental disorder treatment. The staff offering these services should be diverse by gender, profession, and culture, and the fees should be paid by the organization. When these services are endorsed by the team's leaders and integrated with the athletic training/medical/player development staff, their utilization will grow quickly and lead to positive outcomes individually and collectively.

The prevalence and risk indicators of symptoms of common mental disorders among current and former Dutch elite athletes

The aim of the study was to determine the prevalence and comorbidity of symptoms of common mental disorders (distress, anxiety/depression, sleep disturbance, eating disorders, adverse alcohol use) among current and former Dutch elite athletes, and to explore the inference between potential risk indicators (severe injury, surgery, life events, sport career dissatisfaction, social support) and the outcomes measures under investigation. Cross-sectional analyses were conducted on baseline questionnaires from an ongoing prospective cohort study among 203 current and 282 former elite Dutch athletes (response rate: 28% among current athletes and 95% among former athletes). Based on validated scales, an electronic questionnaire was set up and distributed. Prevalence (4-week) ranged from 6% for adverse alcohol use to 45% for anxiety/depression among current elite athletes, and from 18% for distress to 29% for anxiety/depression among former elite athletes. A higher number of past severe injuries, higher number of past surgeries, higher number of recent life events, higher level of career dissatisfaction and lower level of social support were related to the occurrence of symptoms of common mental disorders among both current and former elite athletes. On average, the 4-week prevalence of common mental disorders as shown in our study among current and former Dutch elite athletes were similar to the ones found among athletes from other sports disciplines and does compare with the lifetime prevalence estimates in the general population of the Netherlands.

Epidemiology of symptoms of common mental disorders among elite Gaelic athletes: a prospective cohort study

OBJECTIVE

Scientific knowledge about symptoms of common mental disorders among elite Gaelic athletes is lacking. Consequently, this study aimed to (i) determine the prevalence, comorbidity and 6-month incidence of symptoms of common mental disorders (distress, anxiety/depression, sleep disturbance, adverse alcohol use) among elite Gaelic athletes and (ii) evaluate their association with potential stressors (severe musculoskeletal injuries, surgeries, recent life events, career dissatisfaction).

METHODS

An observational prospective cohort study by means of questionnaires was conducted over six months among elite Gaelic athletes (N=204). Using validated questionnaires to assess symptoms of common mental disorders as well as several stressors, an electronic questionnaire was set up and distributed by the Gaelic Players' Association.

RESULTS

Prevalence ranged from 23% for adverse alcohol use to 48% for anxiety/depression. Around 24% of the participants reported at baseline two symptoms. Six-month incidence ranged from 11% for sleep disturbance to 21% for anxiety/depression. Severe musculoskeletal injury, surgery, recent life events and career dissatisfaction led to an increased risk for common mental disorders.

CONCLUSION

Our findings indicate that raising the self-awareness of all stakeholders in Gaelic sports about common mental disorders should be prioritized, as well as the evidence-based development and application of adequate preventive and supportive measures.

The elite young athlete: strategies to ensure physical and emotional health

This article presents a current review of the risk of physical and psychological injury associated with participation in elite youth sport, and suggests strategies to ensure the physical and emotional health of these young athletes. Although there is lack of epidemiological data, especially with regard to psychological injury, preliminary data suggest that the risk of injury is high in this population. While there is lack of incident and follow-up data, there is also concern regarding burnout, disordered eating, and the long-term consequences of injury. Modifiable injury risk factors identified include postural control, competition anxiety, life events, previous injury, and volume of training. There are presently no studies designed to determine the effectiveness of injury prevention measures in elite youth sports. However, there is adequate evidence arising from injury prevention studies of youth sports participants - including neuromuscular training, protective equipment, mental training to enhance self-esteem, and sport rules modification - to prevent injuries in elite youth sports settings. Although not tested, psychosocial prevention strategies such as adoption of task-oriented coping mechanisms, autonomous support from parents, and a proactive organizational approach also show promise in injury prevention.

Are mental toughness and mental health contradictory concepts in elite sport? A narrative review of theory and evidence

OBJECTIVE

Athlete development and management encompass a complex interaction of biological, psychological, and social factors. Within elite sport, multidisciplinary sport science and medicine teams play an important role in achieving an optimal balance between preventing athlete ill-health and optimizing health and performance. The psychological aspects of athlete health and performance have gained increased attention over the past two decades, with much of this research concerned with the mental health of athletes and the concept of mental toughness. Recently, it was proposed that mental health and mental toughness are contradictory concepts in the world of elite sport. Although an interesting proposition, this claim was not substantiated. Thus, the purpose of this narrative review was to evaluate theory and evidence regarding the thesis that mental health and mental toughness are contradictory concepts in the world of elite sport, with the view to advance scholarly knowledge and inform professional practice.

DESIGN

Narrative review.

RESULTS

A critical evaluation of this literature suggests that mental toughness may represent a positive indicator of mental health, or facilitate its attainment, rather than be at odds with it.

CONCLUSION

When implemented alongside multilayered approaches to organizational change (e.g., group structures, policies), mental toughness could be used as a 'hook' to attract athletes into settings that can open dialogue on the importance of mental health and improve knowledge of key issues (e.g., stigma, symptoms).

Blurred lines: Performance Enhancement, Common Mental Disorders and Referral in the U.K. Athletic Population

Through the awareness-raising efforts of several high-profile current and former athletes, the issue of common mental disorders (CMD) in this population is gaining increasing attention from researchers and practitioners alike. Yet the prevalence is unclear and most likely, under-reported. Whilst the characteristics of the sporting environment may generate CMD within the athletic population, it also may exacerbate pre-existing conditions, and hence it is not surprising that sport psychology and sport science practitioners are anecdotally reporting increased incidences of athletes seeking support for CMD. In a population where there are many barriers to reporting and seeking help for CMD, due in part to the culture of the high performance sporting environment, anecdotal reports suggest that those athletes asking for help are approaching personnel who they are most comfortable talking to. In some cases, this may be a sport scientist, the sport psychologist or sport psychology consultant. Among personnel in the sporting domain, there is a perception that the sport psychologist or sport psychology consultant is best placed to assist athletes seeking assistance for CMD. However, sport psychology as a profession is split by two competing philosophical perspectives; one of which suggests that sport psychologists should work exclusively with athletes on performance enhancement, and the other views the athlete more holistically and accepts that their welfare may directly impact on their performance. To add further complication, the development of the profession of sport psychology varies widely between countries, meaning that practice in this field is not always clearly defined. This article examines case studies that illustrate the blurred lines in applied sport psychology practice, highlighting challenges with the process of referral in the U.K. athletic population. The article concludes with suggestions for ensuring the field of applied sport psychology is continually evolving and reconfiguring to ensure that it continues to meet the demands of its clients.

Mental Health in Sport (MHS): Improving the Early Intervention Knowledge and Confidence of Elite Sport Staff

Mental illnesses are as prevalent among elite athletes as in the general population. Despite this, there is little research examining how to enhance mental health literacy or helping behaviors in elite sport environments. A Mental Health in Sport (MHS) workshop was therefore developed and its effects on mental health literacy and confidence studied in 166 coaches and support staff working with elite athletes and teams in Australia. Results indicated that participants increased their knowledge of the signs and symptoms of common mental illnesses and were more confident in helping someone who may be experiencing a mental health problem. We conclude that even a very brief intervention can be effective in improving the mental health literacy and confidence of key persons in elite sport environments, and may promote early intervention and timely referral of elite athletes with mental health concerns to appropriate professionals.

From Mental Health to Mental Wealth in Athletes: Looking Back and Moving Forward

Considerations of athletes’ mental health are typically framed in the language of mental illness (Hughes and Leavey, 2012), a situation that contributes to stigmatization, denial, and the prevention of effective care. In this article, we provide a critical, narrative review of the extant literature on athlete mental health. Specifically, we begin by providing a brief synopsis of the extant literature on athletes’ mental health, illustrating both what we know about (i) the prevalence of mental health issues in sport and (ii) variables contributing to help-seeking behaviors in athletes. Against, this backdrop, we outline Keyes’ (2002) two-continuum model of mental health as a theoretical framework that has considerable promise in understanding, talking-about, and intervening to enhance, athletes’ mental health. This model posits two related, but distinct dimensions: one continuum indicates the presence or absence of mental health, the other the presence or absence of mental illness. From this perspective, a number of possibilities emerge. For instance, athletes could simultaneously have both positive mental health and experience of mental illness. Alternatively, athletes could be free from mental illness, but in Keyes’ terms be “languishing” (i.e., experiencing low levels of mental health). Implications for interventions based on the two-continuum model are discussed, particularly drawing on assets-based approaches to enhance flourishing (Theokas et al., 2005). We conclude the review by considering limitations in our understanding of how to promote flourishing and suggest avenues for further research.

The MD Blues: Under-Recognized Depression and Anxiety in Medical Trainees

Background

Mental health disease is under recognized in medical professionals.

Objective

To screen medical students (MS), residents and fellows for major depressive disorder (MDD) and generalized anxiety disorder (GAD) under the new era of work hour reform with age-matched controls from a large representative cross-sectional survey.

Methods

We conducted an anonymous online survey at a medical university in 2013–2014. We incorporated the Patient Health Questionnaire 2 (PHQ-2) to screen for MDD and the generalized anxiety disorder scale (GAD-7) to screen for GAD, along with additional questions on life stressors and academic performance. We compared these results to age-matched controls from the National Health and Nutrition Examination Survey (NHANES) database.

Results

126 residents/fellows and 336 medical students participated voluntarily. 15.1% and 15.9% of postgraduates as well as 16.4% and 20.3% of MS screened positive for MDD and GAD, respectively. When compared to national estimates, the prevalence of a positive screen for MDD was over five-fold higher in medical trainees compared to age-matched controls (16% vs. 2.8%, p<0.0001). Similarly, the prevalence of a positive screen for GAD was over eight-fold higher in medical trainees (19% vs. 2.3%, p<0.0001).The prevalence was consistently higher within age strata. 33.3% of postgraduates and 32% of MS believe there is a significant impact of depression or anxiety on their academic performance. For stress relief, one fifth of residents/fellows as well as MS reported alcohol use.

Conclusions

The stresses of medical education and practice may predispose trainees to psychopathological consequences that can affect their academic performance and patient care. The current study showed a significantly higher rate of MDD and GAD positive screens in medical trainees than the prevalence in an age-matched U.S. population, despite significant work hour reform for medical trainees. Increased awareness and support services are required at all levels of medical training. We propose that the ACGME and the Institute of Medicine may consider these findings when implementing future changes to work hour regulations.