Sport specificity of mental disorders: the issue of sport psychiatry

Initial examination of the mental health disorders: screening instrument for athletes

Introduction

There is a need to psychometrically develop assessment instruments capable of screening mental health disorders in athlete populations. The current study was conducted to determine reliability, validity and clinical utility of the Mental Health Disorders Screening Instrument for Athletes (MHDSIA).

Methods and results

259 collegiate athletes completed the MHDSIA. Factor analysis determined a single factor with good internal consistency, and this factor was positively correlated with an established measure of psychiatric symptomology (Symptom Checklist 90-R), demonstrating its concurrent validity. An optimum clinical cutoff score (i.e., 32) was determined using Receiver Operating Characteristic (ROC) analyses to assist appropriate mental health referrals.

Discussion

Results suggest the MHSIA is a reliable, valid, and relatively quick and easy to interpret screen for the broad spectrum of mental health disorders in collegiate athletes. As expected, NCAA athletes reported lower MHDSIA scores than club and intramural athletes, while males reported similar severity scores as females.

Current trends and perspectives in the exploration of anorexia athletica-clinical challenges and therapeutic considerations

Elite athletes are exposed to a considerable amount of physical and psychological stress throughout their entire professional life, but the exploration of the consequences of this stressful regimen on mental health is still in its early stages. Eating disorders (EDs), substance use disorders, and behavioral addictions represent only several domains that are worth more investigation in this vulnerable population, in order to find preventative and therapeutic strategies. The exploration of EDs in athletes is important because this population is very vulnerable to the impact that weight and body shape may have on their professional performances, and epidemiological studies support this concern, i.e., the prevalence of EDs in athletes is significantly higher than in the general population. This article is dedicated to the synthesis of available data regarding a specific pathology reported in elite athletes, i.e., anorexia athletica (AA), based on a narrative reviewing methodology. The information about risk factors, pathophysiology, positive and differential diagnosis, epidemiology, structured evaluation, and treatment of AA have been summarized and future research directions have been highlighted. While tentative diagnostic criteria for AA and a self-administered questionnaire exist, its pathophysiology is still insufficiently explored, and the treatment is not based on good-quality trials. According to the retrieved data, more research targeting the physical and mental health of elite athletes, especially those practicing esthetic sports, is needed, in order to implement adequate screening and early intervention programs. Future studies targeting various sub-populations of elite athletes, i.e., esthetic vs. non-esthetic sports, individuals presenting a history of ED vs. those without such a history, and those practicing individual sports vs. team sports are needed to reach the objective of improving the quality of life in this population.

Implementation of the International Olympic Committee Sport Mental Health Assessment Tool 1: Screening for Mental Health Symptoms in a Canadian Multisport University Program

OBJECTIVE

To apply the International Olympic Committee Sport Mental Health Assessment Tool 1 (SMHAT-1) to determine the prevalence of mental health symptoms in a cohort of university student athletes over an academic year. A secondary objective was to explore the internal consistency of the screening tools from the SMHAT-1.

DESIGN

Cross-sectional design with 3 repeated measurements over an academic year.

SETTING

A large university multisport program.

PARTICIPANTS

Five hundred forty-two university-level student athletes from 17 sports.

INTERVENTION

N/A.

MAIN OUTCOME MEASURES

On 3 occasions, the participants completed the SMHAT-1, which consists of the Athlete Psychological Strain Questionnaire. If an athlete's score was above the threshold (≥17), the athlete completed step 2, consisting of (1) Generalized Anxiety Disorder-7; (2) Patient Health Questionnaire-9; (3) Athlete Sleep Screening Questionnaire; (4) Alcohol Use Disorders Identification Test Consumption; (5) Cutting Down, Annoyance by Criticism, Guilty Feeling, and Eye-openers Adapted to Include Drugs; and (6) Brief Eating Disorder in Athletes Questionnaire. Internal consistency of the SMHAT-1 was also measured.

RESULTS

Participants reported mental health symptoms with prevalence of 24% to 40% for distress, 15% to 30% for anxiety, 19% to 26% for depression, 23% to 39% for sleep disturbance, 49% to 55% for alcohol misuse, 5% to 10% for substance use, and 72% to 83% for disordered eating. Female athletes were more likely to suffer psychological strain, depression, and sleep disturbance; male athletes were more likely to report substance use.

CONCLUSIONS

The SMHAT-1 was feasible to implement with good internal consistency. University-level athletes suffer from a variety of mental health symptoms underscoring the necessity for team physicians to have the clinical competence to recognize and treat mental health symptoms.

The Athlete's Paradox: Adaptable Depression

We proposed that an athlete's depressive symptoms may be different from the general population in etiology if considered from the context of a depressive disorder. By shifting focus from a limited notion of symptoms onto a comprehensive model of depression, the full scope of the phenomenon becomes clearer. This paper investigated the relationship between neurotransmitters and allostatic load to explain the incidence of depression among elite athletes. This literature review extensively analyzed exercise-induced neurohormonal imbalance resulting in depressive states among athletes. The research revealed that 5-HTTLPR polymorphism, brain-derived neurotrophic factor (BDNF), extensive psychological demands, social stigma, and overtraining syndrome (OTS) may all contribute to a unique version of depression. The research revealed that the biological standards of athletes differ from those of non-athletes, to the point that the new model may be useful, thereby introducing the new term "Adaptable Depression (AD)" to the literature. This framework suggests a new direction for future research to precisely measure the neurotransmitter-related brain changes that result in "Adaptable Depression" in athletes and to establish a better understanding of the depressive tipping point.

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

BACKGROUND

Interventions designed to increase mental health awareness in sport have grown substantially in the last 5 years, meaning that those involved in policy, research and intervention implementation are not fully informed by the latest systematic evaluation of research, risking a disservice to healthcare consumers. Hence, our aim was to update a 2017 systematic review that determined the effect of sport-specific mental health awareness programmes to improve mental health knowledge and help-seeking among sports coaches, athletes and officials. We extended the review to incorporate parents as a source of help-seeking and report the validity of outcome measures and quality of research design that occurred since the original review.

METHODS

Sport-specific mental health awareness programmes adopting an experimental or quasi-experimental design were included for synthesis. Five electronic databases were searched: Psychinfo, Medline (OVID interface), Scopus, Cochrane and Cinahl. Each database was searched from its year of inception to June 2020. As all of the outcomes measured were derived from psychometric scales, we observed statistically significant quantitative effects on the basis of p < .05, and a small, medium or large effect size as d = .2, .5 or .8, respectively. Risk of bias was assessed using the Cochrane and QATSQ tools.

RESULTS

Twenty-eight articles were included from the 2048 retrieved, eighteen additional articles since the original review. Eighteen studies targeted athletes, five with coaches, one sport officials (i.e. referees), one 'at-risk children' and three with parents. One of the studies was a combination of athletes, coaches and parents. In terms of study outcomes, health referral efficacy was improved in seven studies; twelve studies reported an increase in knowledge about mental health disorders. Proportionally, higher quality research designs were evident, as three of ten studies within the previous review did not demonstrate a high risk of bias, whereas thirteen of the eighteen additional studies did not display a high risk of bias. However, only one study included a behaviour change model in both the programme design and evaluation.

CONCLUSIONS

Our updated systematic review provides evidence of the benefits of mental health awareness interventions in sport; these benefits are mainly for athletes and show improvements in the methodological design of recent studies compared to the first review. There was also evidence of the extension of programme delivery to parents. In conclusion, researchers, practitioners and policy makers should consider methodological guidance and the application of theory when developing and evaluating complex interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016040178.

Elite Sport and Sustainable Psychological Well-Being

There is conflicting evidence that sport plays a protective role in the development of psychopathological disorders and contributes to the sustainability of mental health. The aim of the present study was to determine the prevalence of mental disorders among elite Slovenian athletes. We were interested in the prevalence of depression, anxiety, suicide risk, substance abuse, and eating disorders among athletes of both sexes and among athletes of individual and team sports aged 18 years or older. A total of 97 elite athletes participated in the study. We used PAI and EDI-3 questionnaires, and the study also included a control group of 90 non-athletes, matched in gender and age to the target group of elite athletes. Testing was conducted in 2020 and 2021. The comparison between elite athletes and the normative group showed a similar expression of depressive and anxious symptomatology. The athletes have a more pronounced drive for thinness and are more expansive, self-confident, and confident of their abilities compared to the control group. A total of 14% of the athletes show self-confidence to the point of self-grandiosity. Male athletes are more likely to use alcohol and other psychoactive substances and are also more impulsive and risk-taking, while female athletes are at higher risk of developing eating disorders. The study suggests that the prevalence of mental disorders in elite athletes is as high as in the general population. There is an urgent need to sustainably ensure the psychological well-being of athletes.

What Is Behind Disordered Eating Behaviors? An Exploratory Study With Female Adolescents From Individual Esthetic and Nonesthetic Sports

This study explored the differences in shame, perception of performance, the need to present a perfect body image, and disordered eating among 223 female athletes from esthetic (n = 114; Mage = 14.30; SDage = 1.65; Myearsofpractice = 6.62) and nonesthetic (n = 109; Mage = 14.75; SDage = 1.87; Myearsofpractice = 4.56) individual sports. Descriptive, t test, and correlational analyses were performed. Moreover, path analyses were conducted to examine the link between the variables. The two groups did not present significant differences in variables, except in perception of performance. The path model analyses explained 47% of disordered eating. Results suggested that individual characteristic of sports practice seems relevant in shame. This study suggests that female athletes from individual sports who experience inferiority tend to adopt perfectionist defensive strategies and engage in disordered eating behaviors. This study highlights the relevance of intervention and educational programs that promote more adaptative emotional regulation strategies in female athletes from individual sports.

Exercise Addiction in the Sports Context: What Is Known and What Is Yet to Be Known

Exercise addiction (EA) involves excessive concerns for exercise routines, an abusive practice, and the inability to control one’s own behavior, as well as the presence of psychological processes that are typical of behavioral addictions such as abstinence. EA is further associated with an alteration of the individual’s personal, social, and professional functioning and a higher risk for several pathologies, including physical injury, psychological distress, and eating disorders. The present work presents a narrative scoping review of the state of the art and the main findings of the research on EA, with a focus in the athletic population. The prevalence of EA risk, between 1 and 52% and up to 80% when co-occurring with eating disturbances, is also reviewed. Additionally, some of the explanatory models proposed to date and their power and limitations in terms of their capacity for a consensual operationalization and characterization of EA, and thus for the optimal exploration and management of this condition, are discussed. Finally, some deficiencies in the research on EA are noted which are to be addressed to successfully respond to the intervention and prevention needs that occur both in the general context of exercise-sports practice and the specific context of competitive athletes.

A Systematic Review on Exercise Addiction and the Disordered Eating-Eating Disorders Continuum in the Competitive Sport Context

Exercise addiction (EA) affects a considerable number of individuals who regularly perform exercise-sport activities. The co-occurrence of EA manifestations and the continuum of disordered eating-eating disorders (EDs) is so common in sports that a deeper understanding of them as comorbidities is warranted. The aim of this review is to provide an up-to-date overview and synthesis of the research on the relationship between maladaptive exercise and dysfunctional eating in the sport context. A systematic review was conducted following the PRISMA guidelines. A total of 22 empirical studies (23 articles) with young and adult female and male athletes from several sports and competition levels was included. EA in conjunction with eating disturbances is frequent among athletes, yet the prevalence rates are inconsistent. Existing evidence suggests that EA is a relevant outcome of ED pathology among athletes, supporting the classical secondary type of EA. However, research also reveals that excessive exercising plays a central role in the psychopathology of disordered eating. There is a need for further quantitative research addressing the features and correlates of the EA-EDs dyad, qualitative research on the subjective experiences of athletes with disordered exercise and eating, longitudinal and experimental research to establish possible causal paths and attempts to develop comprehensive conceptual models of EA and its co-occurrence with EDs, in order to improve the identification, prevention, and management of this dyadic condition in the sport context.

Let's Talk About Mental Health and Mental Disorders in Elite Sports: A Narrative Review of Theoretical Perspectives

The objective of this article is to discuss: (a) the various theoretical perspectives on mental health and mental health disorders adopted in sport psychology, and (b) how the adoption of these various theoretical perspectives in studies might impact upon the interpretations and conclusions in research about the mental health of participants in elite sports. Well-being as a target construct, holistic models, the single continuum or stage models, and Keyes' dual-continuum model of mental health are described, together with a sports psychiatric view of mental health. The strengths and limitations of various mental health perspectives are discussed. We conclude that mental health is a complex construct and that the sport psychology literature, much like the clinical psychology literature, has struggled to reach a consensus regarding a definition or a feasible approach to investigating mental health. For the researcher, it becomes important to make explicit the underlying theoretical perspective adopted and the operationalization upon which conclusions about elite athletes' mental health are based so that an increased knowledge base with high scientific credibility can be established and consolidated over time.

Influence of Anxiety on Baseline Cognitive Testing and Symptom Reporting in Adolescent Student Athletes

Anxiety symptoms are commonly endorsed by student athletes. This study examined the possible influence of anxiety on baseline cognitive testing and symptom reporting in a large sample of adolescent student athletes. Participants were 37,945 adolescent student athletes from the state of Maine who completed baseline testing using ImPACT^®. ImPACT includes an evaluation of cognitive functioning and a questionnaire assessing the presence and severity of common post-concussion symptoms. Participants were divided into high and low anxiety groups based on endorsement of anxiety-like symptoms. Student athletes in the high anxiety group were more likely to be girls and to have a greater lifetime history of treatment for mental health problems and headaches (ps < 0.001). The high anxiety group scored slightly lower on cognitive tests (Cohen ds = 0.15-0.26) and reported a much greater amount of baseline pre-season symptoms (Cohen d = 3.38). More than eight of 10 youth in the high anxiety group (82.7%) met International Statistical Classification of Diseases and Related Health Problems-10th Revision (ICD-10) symptom criteria for at least a mild form of the postconcussional syndrome compared with less than two of 10 (18.4%) in the low anxiety group. Students in the high anxiety group had slightly lower scores on neurocognitive testing, but the differences were not practically meaningful; however, they endorsed dramatically more physical, cognitive, and emotional symptoms. Anxiety can mimic the ICD-10 postconcussional syndrome in adolescent student athletes at baseline, when they have not been injured.

Likelihood of suffering from an eating disorder in a sample of Spanish cyclists and triathletes

BACKGROUND

During recent years, there has been increasing interest in the study of eating disorders within sports practitioners, with prevalence being reported to be higher than in the general population. The aim of this study was to describe and predict eating disorders according to sex, body mass index, age and sport discipline within a sample of athletes.

METHODS

A sample of 4037 cyclists and triathletes from across Spain was selected. Athletes self-reported demographic characteristics and completed the revised restraint scale, SCOFF questionnaire and Mediterranean diet adherence screener. To be eligible for inclusion, participants had to be over eighteen years old.

RESULTS

Males were significantly less likely than females (p < 0.001; OR = 0.33), and triathletes (p < 0.01; OR = 0.76) were less likely than cyclists to suffer from an eating disorder. Possibility of suffering from an eating disorder increased with increasing body mass index (p < 0.001; OR = 1.38) and decreasing age (p < 0.001; OR = 0.97).

CONCLUSION

Findings suggest that the roles of sex, sport discipline, age and body mass index predict risk factors for eating disorders in a sample of Spanish athletes. Clinical diagnosis seems necessary to better understand the factors and mechanisms at play when Spanish athletes develop an eating disorder.

TRIAL REGISTRATION

Ethics Committee of the University of Granada (N°883) data: 16/11/2015.

Mutual Interactions among Exercise, Sport Supplements and Microbiota

The adult gut microbiota contains trillions of microorganisms of thousands of different species. Only one third of gut microbiota are common to most people; the rest are specific and contribute to enhancing genetic variation. Gut microorganisms significantly affect host nutrition, metabolic function, immune system, and redox levels, and may be modulated by several environmental conditions, including physical activity and exercise. Microbiota also act like an endocrine organ and is sensitive to the homeostatic and physiological changes associated with training; in turn, exercise has been demonstrated to increase microbiota diversity, consequently improving the metabolic profile and immunological responses. On the other side, adaptation to exercise might be influenced by the individual gut microbiota that regulates the energetic balance and participates to the control of inflammatory, redox, and hydration status. Intense endurance exercise causes physiological and biochemical demands, and requires adequate measures to counteract oxidative stress, intestinal permeability, electrolyte imbalance, glycogen depletion, frequent upper respiratory tract infections, systemic inflammation and immune responses. Microbiota could be an important tool to improve overall general health, performance, and energy availability while controlling inflammation and redox levels in endurance athletes. The relationship among gut microbiota, general health, training adaptation and performance, along with a focus on sport supplements which are known to exert some influence on the microbiota, will be discussed.

Mental Health in Equestrian Sport

Equestrian media is showing an increasing interest in the impact of mental health on performance and general wellbeing of equestrian athletes. This study explores the awareness of mental health difficulties and psychological wellbeing within equestrian sport from the perspectives of equestrian athletes, instructors/coaches and parents. The exploratory nature of the research offered opportunity to use a dual approach including e-surveys and semi-structured interviews. Analysis of the qualitative data identified five key themes (Emotional WellbeinginBalance; Emotional WellbeingImbalance; WellbeingImbalance—Impact on Equestrian Sportspeople; Impact of Equestrian Sport on Wellbeing; Regaining Balance) and 22 sub-themes. The findings determine a compelling need for education, promotion of sharing experiences, facilitation of specialist (clinical and sport) professional training and intervention as well as a review of regulations from equestrian Governing Bodies.

Canadian Centre for Mental Health and Sport (CCMHS) Position Statement: Principles of Mental Health in Competitive and High-Performance Sport

The brave decision made by many Canadian athletes to share their experience with mental illness has fed a growing dialogue surrounding mental health in competitive and high-performance sport. To affect real change for individuals, sport culture must change to meet demands for psychologically safe, supportive, and accepting sport environments. This position statement addresses mental health in competitive and high-performance sport in Canada, presenting solutions to current challenges and laying a foundation for a unified address of mental health by the Canadian sport community. The paper emerged from the first phase of a multidisciplinary Participatory Action Research (PAR) project, in which a sport-focused mental health care model housed within the Canadian Centre for Mental Health and Sport (CCMHS) is currently being designed, implemented, and evaluated by a team of 20 stakeholders, in collaboration with several community partners and advisors.

Maladaptive Coping Strategies and Neuroticism Mediate the Relationship Between 5HTT-LPR Polymorphisms and Symptoms of Anxiety in Elite Athletes

OBJECTIVE

Previous studies have suggested that genetic factors, personality traits and coping strategies might play both independent and interacting roles when influencing stress-related anxiety symptoms. The aim of this study was to examine whether Neuroticism and maladaptive coping strategies mediate the association between the serotonin transporter gene-linked polymorphic region (5HTT-LPR) and symptoms of anxiety and depression in elite athletes who experience high levels of competitive stress.

METHOD

One hundred and thirty-three participants were genotyped for the 5-HTTLPR polymorphism and then asked to complete the Cope Orientation to Problems Experienced Inventory and the NEO Five-Factor Inventory. A path analysis was used to test this hypothesis.

RESULTS

The 5HTT-LPR was significantly associated with Neuroticism, the coping strategy of Focus on and Venting of Emotions' (FVE) and symptoms of anxiety. FVE and Neuroticism mediated the association between the 5HTT-LPR and symptoms of anxiety (i.e., Cognitive Anxiety and Emotional Arousal Control). Also, Neuroticism was a mediator of the association between the 5HTT-LPR and FVE. Finally, FVE also mediated effects on the relationship between Neuroticism and symptoms of anxiety.

CONCLUSIONS

The 5HTT-LPR may affect the susceptibility to develop symptoms of anxiety in elite athletes indirectly through mediation by maladaptive coping strategies and Neuroticism.

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.

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.

Life on an Emotional Roller Coaster: NFL Players and Their Family Members’ Perspectives on Player Mental Health

This qualitative study examined how NFL players and their family members characterized the impact of an NFL career on the mental and emotional health of NFL players. We interviewed 25 NFL players (23 former and 2 current) and 27 family members (24 wives and 3 others) to elicit players’ experiences during and following their time in the NFL. While players experienced positive outcomes from their careers, they also described important mental health challenges including feelings of depression, loneliness, and stress. Many of their concerns during their careers were linked to anxiety about job performance and job security. Post-career concerns were linked to loss of social identity and connections. Players had difficulty finding help for their concerns. We conclude with eight recommendations, including improved resources, confidentiality, and support.

Epidemiology of mental health conditions in incoming division I collegiate athletes

OBJECTIVES

The purpose of this study is to examine the epidemiology of mental health conditions in incoming American Division I collegiate athletes.

METHODS

Pre-participation physical questionnaires from 1118 incoming student athletes at a Division I Institution were collected retrospectively from 2011-2017. Data collected included lifetime history of any mental health condition, musculoskeletal injuries, concussions, and post-concussion depression. History of any mental health condition was evaluated by gender and sport played. It was also evaluated in comparison to musculoskeletal injuries and concussions.

RESULTS

The lifetime prevalence of any mental health condition was 14.0% for all athletes, 14.2% for male athletes, and 13.6% for female athletes. Individual sports reported a greater prevalence (17.2%) than did team sports (11.8%) (p = 0.010). The prevalence was also higher in contact sports (16.4%) than in non-contact sports (12.5%), although this difference was not statistically significant (p = 0.072). There was a significant association between mental health condition and all four major groups of injuries examined: upper extremity (p = 0.043), lower extremity (p = 0.007), axial skeletal (p < 0.001), and concussions (p = 0.039). Post-concussion depression occurred in 2.0% of all athletes reporting a concussion.

CONCLUSION

The lifetime prevalence of mental health conditions in this population (14.0%) is far less than estimates in the general population. This observation may be due to a combination of factors including exercise/athletic participation mitigating depressive symptoms, competitive selection, and underreporting. History of a mental health condition may be associated with injury, although causation cannot be determined.

Exercise addiction in adolescents and emerging adults - Validation of a youth version of the Exercise Addiction Inventory

Background Behavioral addictions often onset in adolescence and increase the risk of psychological and social problems later in life. The core symptoms of addiction are tolerance, withdrawal symptoms, lack of control, and compulsive occupation with the behavior. Psychometrically validated tools are required for detection and early intervention. Adolescent screening instruments exist for several behavioral addictions including gambling and video gaming addiction but not for exercise addiction. Given recent empirical and clinical evidence that a minority of teenagers appear to be experiencing exercise addiction, a psychometrically robust screening instrument is required. Aims The aim of this study was to develop and test the psychometric properties of a youth version of the Exercise Addiction Inventory (EAI) - a robust screening instrument that has been used across different countries and cultures - and to assess the prevalence of exercise addiction and associated disturbed eating. Methods A cross-sectional survey was administered to three high-risk samples (n = 471) aged 11-20 years (mean age: 16.3 years): sport school students, fitness center attendees, and patients with eating disorder diagnoses. A youth version of the EAI (EAI-Y) was developed and distributed. Participants were also screened for disordered eating with the SCOFF Questionnaire. Results Overall, the EAI-Y demonstrated good reliability and construct validity. The prevalence rate of exercise addiction was 4.0% in school athletes, 8.7% in fitness attendees, and 21% in patients with eating disorders. Exercise addiction was associated with feelings of guilt when not exercising, ignoring pain and injury, and higher levels of body dissatisfaction.

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.

Vulnerability to exercise addiction, socio-demographic, behavioral and psychological characteristics of runners at risk for eating disorders

BACKGROUND

Excessive exercise is frequently associated with eating disorders and may degenerate into exercise addiction. We still don't know whether runners at risk for eating disorders are at risk for exercise addiction. Our aim is to assess: 1) risk for exercise addiction in runners at risk for eating disorders and 2) socio-demographic, behavioral and psychological characteristics distinguishing runners at-risk from not-at-risk for eating disorders.

METHODS

We assessed risk for eating disorders and exercise addiction using the SCOFF questionnaire and the Exercise Addiction Inventory personality traits with the Big-Five Inventory Test, socio-demographic data, eating and training habits in a sample of 154 healthy runners.

RESULTS

Twenty five subjects had a score of ≥2 at the SCOFF and were included in the group "at risk for eating disorders". In this group, we found a higher percentage of subjects at risk for exercise addiction (p=0.01) and higher average scores at the Exercise Addiction Inventory (p=0.01) than runners not at risk (N=136). Runners at risk were statistically younger (p=0.03), women (p=0.001), started running to lose weight more often (p=0.03), lost more kilos since affiliation in their running club (p=0.04), and were characterized by neurotic traits using the Big-Five-Inventory Test (p=3.10^-6).

CONCLUSIONS

Screening for exercise addiction and mood disorders could lead to a more accurate management of runners at risk for eating disorders. Identifying vulnerable individuals will facilitate the prevention of eating disorders and preserve the benefits of sport practice.

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.

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.

Is Elite Sport (Really) Bad for You? Can We Answer the Question?

Elite athletes are not immune to mental health issues. Yet, quality research on mental health in elites has so far been limited. Thus, while research on mental health emphasises the prevalence and nature of disorders in the general population, its extent in elite performers remains unclear. Indeed, the prevalence of mental conditions cannot be accurately calculated in elite athletes due to a lack of diagnostic criteria and screening tools specifically adapted to this unique population. Researchers and practitioners are, therefore, confronted with biases reflecting the use of clinical norms and instruments initially developed for the general population. Furthermore, without considering the athlete persona as well as the sport culture in which elites play, there is a risk of under- or over-estimating the prevalence of mental health issues in high-performance environments. Due to the unique characteristics surrounding an elite athlete's life, we therefore suggest a change of perspective: moving from the usual normal-versus-pathological to a functional-versus-dysfunctional approach. Implications for future research and practice are discussed, most notably examining practitioners' expertise in diagnosing and treating elite performers.

Disordered eating in French high-level athletes: association with type of sport, doping behavior, and psychological features

PURPOSE

Over the last few years, disordered eating in athletes has received increasing attention. According to several studies, athletes could be more vulnerable to disordered eating and some characteristics specific to the athletic community could be in favour of an increased risk of poor body image and disturbed eating habits in athletes. However, the literature is sparse and some methodological issues in studies have been pointed out. In this context, we aimed at determining the prevalence of disordered eating in French high-level athletes using clinical interviews of three different clinicians and identifying what are the factors associated with disordered eating in athletes.

METHODS

In France, all athletes registered on the French high-level list have to undergo a yearly evaluation. Data collected during the somatic assessment, the dietary consultation, and the psychological of the yearly evaluation were used. Multivariate analysis was performed for identification of factors associated with disordered eating.

RESULTS

Out of the 340 athletes included, 32.9% have been detected with a disordered eating. They were difficult to detect by clinicians, as usual criteria did not seem to be reliable for athletes. Competing in sports emphasizing leanness or low body weight was associated with disordered eating; however, gender was not.

CONCLUSION

These results highlight the need for the development of specific screening tools for high-level athletes. Furthermore, the identification of factors associated with disordered eating could improve early detection and prevention program effectiveness.

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.

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.

Cumulative Head Impact Exposure Predicts Later-Life Depression, Apathy, Executive Dysfunction, and Cognitive Impairment in Former High School and College Football Players

The term "repetitive head impacts" (RHI) refers to the cumulative exposure to concussive and subconcussive events. Although RHI are believed to increase risk for later-life neurological consequences (including chronic traumatic encephalopathy), quantitative analysis of this relationship has not yet been examined because of the lack of validated tools to quantify lifetime RHI exposure. The objectives of this study were: 1) to develop a metric to quantify cumulative RHI exposure from football, which we term the "cumulative head impact index" (CHII); 2) to use the CHII to examine the association between RHI exposure and long-term clinical outcomes; and 3) to evaluate its predictive properties relative to other exposure metrics (i.e., duration of play, age of first exposure, concussion history). Participants included 93 former high school and collegiate football players who completed objective cognitive and self-reported behavioral/mood tests as part of a larger ongoing longitudinal study. Using established cutoff scores, we transformed continuous outcomes into dichotomous variables (normal vs. impaired). The CHII was computed for each participant and derived from a combination of self-reported athletic history (i.e., number of seasons, position[s], levels played), and impact frequencies reported in helmet accelerometer studies. A bivariate probit, instrumental variable model revealed a threshold dose-response relationship between the CHII and risk for later-life cognitive impairment (p < 0.0001), self-reported executive dysfunction (p < 0.0001), depression (p < 0.0001), apathy (p = 0.0161), and behavioral dysregulation (p < 0.0001). Ultimately, the CHII demonstrated greater predictive validity than other individual exposure metrics.

The Relationship between Personality Traits, the 5HTT Polymorphisms, and the Occurrence of Anxiety and Depressive Symptoms in Elite Athletes

The purpose of this study was to determine the relationship between personality, the serotonin transporter (5HTT) polymorphisms and the occurrence of anxiety and depressive symptoms in elite athletes. 133 healthy participants completed the NEO Five-Factor Inventory (NEO-FFI). The mood states were assessed using the Profile of Mood States (POMS) questionnaire. The athlete's mental skills were assessed through the Sport Performance Psychological Inventory (IPPS-48). The occurrence of psychiatric and personality disorders was assessed using the Clinical Interview for DSM-IV Disorders. A polymerase chain reaction was employed to identify genotypes at the 5HTTLPR polymorphism. The 5HTTLPR s/s genotype was associated with both neuroticism (p< 0.001) and tension/anxiety symptoms according to the POMS (p<0.02), cognitive anxiety and emotional arousal control according to the IPPS-48 (p<0.01). Significant correlations were proved between neuroticism and symptoms of anxiety and depression (p<0.05). Neuroticism mediates the association between the 5HTTLPR polymorphism and symptoms of cognitive anxiety and emotional arousal control (p<0.05). These results suggest a significant interaction between the 5HTTLPR polymorphism, neuroticism and sport related stress that predict adverse mental health outcomes in athletes. Identification of homogeneous groups of athletes having predispositions to anxiety and depressive symptoms may help to implement early prevention programs.

Symptoms and risk factors of depression during and after the football career of elite female players

Background

The mental health of elite athletes has received increasing attention in recent years, but no study has evaluated the career–time prevalence of depression, and very few have analysed risk factors of mental health problems during or after the career.

Methods

157 (response rate 64.1%) female players who played in the German First League answered an anonymous online survey on details of their football career, stressful and helpful conditions, depression and need of psychotherapeutic support during and after the football career.

Results

The career–time prevalence of depression symptoms was 32.3%. Significant differences in the average depression score were observed for playing positions (F=2.75; p<0.05) and levels of play (F=3.53; p<0.01). About half of the players (49.7%) stated ‘conflicts with coach/management’ as an important reason for their low in moods, followed by ‘low in performance/injury’ (48.4%) and ‘too little support/acknowledgement by the coach’ (40.0%). ‘Psychological strain/stress’ (46.5%) was (after injury) the second most important reason for lows in performance. During their career, almost 40% of players wanted or needed psychological support, but only 10% received it. After their career, the percentage of players wanting or needing psychological support decreased to 24%, of whom 90% received it.

Conclusions

The high prevalence of depression symptoms in combination with low use of psychotherapy during the career shows the need for de-stigmatisation of mental health issues in elite football. Furthermore, it seems very important to educate coaches, physicians, physiotherapists and club managers to recognise and prevent mental health problems of their players.

Examining the Role of Mental Health and Clinical Issues within Talent Development

Although significant research supports the association between physical activity and mental wellbeing, current literature acknowledges that athletes are no less susceptible to mental illness than the general population. Despite welcomed initiatives aimed at improving mental health within elite sport, these programs often fail to target young athletes; an important concern given that the genesis of many mental illnesses are recognized to occur during this critical period. Given the importance of early intervention and effective treatment, and the potentially devastating consequences of clinical issues going undiagnosed, the implications for talent identification and development (TID) become obvious. With this in mind, this study sought to examine the range of mental health issues that may impact upon developing athletes and potential consequences for the development process, specific risk and protective factors associated with talent development, along with an examination of current practices concerning the identification of mental health issues in such environments. Qualitative interviews were conducted with purposively sampled clinicians (n = 8) experienced in working with adolescents and/or young athletes. Inductive content analysis was undertaken, identifying four main themes: key behavioral indicators; associated risk factors; associated protective factors; and issues around identification and diagnosis. Key behavioral indicators included behavioral change, along with behaviors associated with eating disorders, anxiety and depression. Risk factors centered on family background, the performance environment, and issues surrounding adolescence. Protective factors were primarily social in nature. Finally, a lack of awareness and understanding of clinical issues, multiple causes of symptoms, non-disclosure and the need for triangulation of assessment were identified. The need for improved identification and intervention strategies was apparent, with coaches identified as well placed to detect general “warning signs” such as behavioral change. Short of integrating trained clinicians into talent development environments, as part of a triangulation process, ecologically validated assessment tools—coupled with appropriate training and signposting—could offer a practical way of flagging potential issues in developing athletes. The need for the development of such an instrument is therefore apparent. Finally, education around the influential role of family is also recommended in order to promote the protective elements and mitigate risk factors.

The mental health of Australian elite athletes

OBJECTIVES

Currently, little is known about the prevalence of mental disorders in athletes. This study aims to investigate Australian elite athletes' symptoms of general psychological distress and common mental disorders.

DESIGN

A cross-sectional survey design was employed to assess self-reported symptom prevalence.

METHODS

A total of 224 elite athletes (118 female, 106 male) from national sporting organisations in Australia were administered a self-report internet-based survey comprising measures of demographic status and mental health symptoms.

RESULTS

Overall, 46.4% of athletes were experiencing symptoms of at least one of the mental health problems assessed. Percentages meeting criteria for mental disorders were similar to previous epidemiological studies of both international athlete and community samples: depression (27.2%), eating disorder (22.8%), general psychological distress (16.5%), social anxiety (14.7%), generalised anxiety disorder (7.1%), and panic disorder (4.5%). Injured athletes had higher levels of both symptoms of depression (t=3.23, p=.001) and generalised anxiety disorder (t=2.26, p=.025).

CONCLUSIONS

The level of symptoms of mental health problems reported by elite athletes appears similar to that observed in the community. However, caution must be exercised in interpreting the findings, as possible demographic differences between athletes and comparison population datasets may exist. Furthermore, self-selection of respondents in the present study may have reduced the representativeness of the sample and the validity of the comparisons. Athletes, particularly those currently injured, should be well-supported to seek help for mental disorders through access to mental health professionals.