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

Implementing a scoping review to explore sport officials' mental health

Introduction

Sport officials are tasked with applying rules, maintaining fairness, and ensuring athlete safety. However, sport officials experience anxiety, burnout, and non-accidental violence, with the incidence of these events increasing worldwide. This has led to rising attrition rates among sport officials, with many sport organizations concerned for their operational capacity. The effects of anxiety, burnout, and non-accidental violence might contribute to or be indicative of sport officials' negative mental health outcomes. To develop a clear understanding of how sport officials' mental health is affected by their occupation, it is necessary to identify the mental health outcomes and predictors they experience, and to what extent. The purpose of this scoping review was to identify and examine the empirical research and policy documents surrounding sport officials' mental health.

Method

One thousand, two hundred six articles were identified across four databases: PubMed, Web of Science, SportDiscus, and PsycINFO. Next, a policy search was conducted on the respective international governing body websites from English-speaking countries for the 60 included sports. Following screening, 18 studies and one policy document met the inclusion criteria for exploring sport officials' mental health.

Results

Participants (N = 7,941) in the studies were mainly European male soccer and basketball referees. Most studies utilized quantitative inquiry (n = 15) rather than qualitative methods (n = 2) or framework development (n = 1). The research demonstrated that sport officials frequently experienced negative mental health outcomes and predictors including anxiety, depression, burnout, lower mental health literacy, and high levels of stigmatization towards mental health.

Discussion

These outcomes were influenced by gender/sex, age, and experience. There is a need to explore personal and environmental (including occupational) factors that cause or contribute to sport officials' mental health symptoms and disorders.

A systematic review, meta-analysis, and meta-regression of the prevalence of self-reported disordered eating and associated factors among athletes worldwide

BACKGROUND

The purpose of this meta-analysis was to provide a pooled prevalence estimate of self-reported disordered eating (SRDE) in athletes based on the available literature, and to identify risk factors for their occurrence.

METHODS

Across ten academic databases, an electronic search was conducted from inception to 7th January 2024. The proportion of athletes scoring at or above predetermined cutoffs on validated self-reporting screening measures was used to identify disordered eating (DE). Subgroup analysis per country, per culture, and per research measure were also conducted. Age, body mass index (BMI), and sex were considered as associated/correlated factors.

RESULTS

The mean prevalence of SRDE among 70,957 athletes in 177 studies (132 publications) was 19.23% (17.04%; 21.62%), I2 = 97.4%, τ2 = 0.8990, Cochran's Q p value = 0. Australia had the highest percentage of SRDE athletes with a mean of 57.1% (36.0%-75.8%), while Iceland had the lowest, with a mean of 4.9% (1.2%-17.7%). The SRDE prevalence in Eastern countries was higher than in Western countries with 29.1% versus 18.5%. Anaerobic sports had almost double the prevalence of SRDE 37.9% (27.0%-50.2%) compared to aerobic sports 19.6% (15.2%-25%). Gymnastics sports had the highest SRDE prevalence rate, with 41.5% (30.4%-53.6%) while outdoor sports showed the lowest at 15.4% (11.6%-20.2%). Among various tools used to assess SRDE, the three-factor eating questionnaire yielded the highest SRDE rate 73.0% (60.1%-82.8%). Meta-regression analyses showed that female sex, older age, and higher BMI (all p < 0.01) are associated with higher prevalence rates of SRDE.

CONCLUSION

The outcome of this review suggests that factors specific to the sport affect eating behaviors throughout an athlete's life. As a result, one in five athletes run the risk of developing an eating disorder. Culture-specific and sport-specific diagnostic tools need to be developed and increased attention paid to nutritional deficiencies in athletes.

Sleep Profiles in Eating Disorders: A Scientometric Study on 50 Years of Clinical Research

Sleep and diet are essential for maintaining physical and mental health. These two factors are closely intertwined and affect each other in both timing and quality. Eating disorders, including anorexia nervosa and bulimia nervosa, are often accompanied by different sleep problems. In modern society, an increasing number of studies are being conducted on the relationship between eating disorders and sleep. To gain a more comprehensive understanding of this field and highlight influential papers as well as the main research domains in this area, a scientometric approach was used to review 727 publications from 1971 to 2023. All documents were retrieved from Scopus through the following string "TITLE-ABS (("sleep" OR "insomnia") AND ("anorexia nervosa" OR "bulimia nervosa" OR "binge eating" OR "eating disorder*") AND NOT "obes*") AND (LIMIT-TO (LANGUAGE, "English"))". A document co-citation analysis was applied to map the relationship between relevant articles and their cited references as well as the gaps in the literature. Nine publications on sleep and eating disorders were frequently cited, with an article by Vetrugno and colleagues on nocturnal eating being the most impactful in the network. The results also indicated a total of seven major thematic research clusters. The qualitative inspection of clusters strongly highlights the reciprocal influence of disordered eating and sleeping patterns. Researchers have modelled this reciprocal influence by taking into account the role played by pharmacological (e.g., zolpidem, topiramate), hormonal (e.g., ghrelin), and psychological (e.g., anxiety, depression) factors, pharmacological triggers, and treatments for eating disorders and sleep problems. The use of scientometric perspectives provides valuable insights into the field related to sleep and eating disorders, which can guide future research directions and foster a more comprehensive understanding of this important area.

The Association between Occupational Stress and Mental Health among Chinese Soccer Referees in the Early Stage of Reopening Soccer Matches during the COVID-19 Pandemic Outbreak: A Moderated Mediation Model

BACKGROUND

The sudden and unpredictable changes caused by the COVID-19 pandemic are a serious threat to the occupational stress and mental health of referees worldwide, which has not attracted widespread attention. The mental health of football referees has a certain influence on their job satisfaction or the accuracy of judgments.

METHODS

This study constructed a moderated mediation model to explore the buffer factors between occupational stress and mental health in Chinese soccer referees in the early stage of reopening soccer matches during the COVID-19 pandemic outbreak. Data from 317 Chinese soccer referees (aged 19-45) were collected through an online questionnaire in September-October 2022. Occupational stress, mental health, job burnout and perceived social support were measured, and moderated mediation model was analyzed.

RESULTS

The results of this study showed that occupational stress was negatively correlated with mental health through the mediating effect of job burnout and the moderated effect of perceived social support after controlling for demographic variables. Specifically, the association between occupational stress and mental health was weaker when perceived social support was higher and stronger.

CONCLUSIONS

The results demonstrate that job burnout and perceived social support played important roles in buffering the negative effects of occupational stress on the mental health of Chinese soccer referees in the early stage of reopening soccer matches during the COVID-19 pandemic outbreak. The findings provide implications for mental health interventions in soccer referees during the public health crises.

Examining the mental health status of referees in the turkish professional football league

OBJECTIVE

The purpose of the study was to evaluate the mental health (MH) status of referees who officiate in the Turkish professional football leagues.

METHOD

An online survey was sent to all referees in the Turkish professional football leagues (n = 630) incorporating standardized scales assessing depression, anxiety, and stress.

RESULTS

A total of 433 referees participated in the study, yielding a response rate of 68.7%. Younger referees (18-27 years) reported higher depression (p = 0.01), anxiety (p < 0.01), and stress (p < 0.01) scores than older (>38 years) refereees. Depression, anxiety, and stress scores of single referees were higher compared to married referees (all p < 0.01). Lower-level referees reported higher depression (p < 0.01), anxiety (p = 0.01), and stress (p < 0.01) scores than their higher-level counterparts. Higher depression, anxiety, and stress scores were also associated with less income, performance concerns, severe injury history, and inadequate social support.

CONCLUSION

MH problems in referees were associated with a wide range of variables including younger age, being single, refereeing at lower-levels, performance concerns, and inadequate social support. In light of these results, MH assessments should be undertaken with referees to detect which officials are at greater risk of MH problems. Doing so will help to enable appropriate and timely MH interventions.

Prevalence and burden of health problems in top-level football referees

BACKGROUND

Top-level football referees take decisions during strenuous physical activity, and often under great mental pressure. Despite their central role in a football match, little is known about referees' health problems, particularly in female referees.

AIM

To investigate the prevalence and burden of health problems in female and male top-level referees.

STUDY DESIGN

Prospective cohort study.

METHOD

Fifty-five Norwegian male and female top-level referees reported health problems (injuries and illnesses) in pre-season and during the 2020 competitive season, using the Oslo Sports Trauma Research Center Questionnaire on Health Problems (OSTRC-H2).

RESULTS

We recorded data for 49 weeks with a compliance of 98%. On average, 34% (95% CI 31-36%) of referees reported at least one health problem each week, and 20% (95% CI 19-22%) reported substantial health problems. Female referees reported more health problems than male referees, and on-field referees reported more health problems than assistant referees. Gradual-onset injuries were most prevalent and caused the greatest absence from training and matches, whereas illnesses represented only a small portion to the overall burden of health problems. The injury incidence was three injuries per athlete-year (95% CI 2.5-3.5) and 11 injuries per 1000 match hours (95% CI 7-18). The illness incidence was 1.4 illnesses per athlete-year (95% CI 1.1-1.8). Injuries to the lower legs and feet represented the highest burden of health problems.

CONCLUSION

Top-level referees, especially females, reported a high prevalence of health problems. Gradual-onset injuries to the lower leg and foot represented the highest injury burden.

Training and development in sport officials: A systematic review

Sport officials make significant contributions to organized sport, yet scientific evidence to inform their specialized training and education at various levels has lagged. While psychological and performance demands of expert sport officials have been well documented, the extent of research about talent and expertise development, training efficacy, and broader developmental trajectories is unclear. This systematic review summarizes 30 years of published findings on the study of training and development of sport officials, including areas of research interest, study designs, and sport official characteristics. A PRISMA systematic review was conducted, utilizing three scientific databases (Web of Science, SportsDiscus, PsycInfo) to identify relevant studies (N = 27). Female participants were generally underrepresented in studies (17%), while football officials were most often represented (79%). Training intervention (59%), retrospective (37%), and cross-sectional comparison (22%) were the main study designs. Expert and near-expert sport officials' training histories and responses to empirically driven isolated-skills training represented the predominant areas of study. Sport-specific, video-based infraction detection tasks were the most frequently used training methods to improve perceptual-cognitive skills for on-field decision-making, however, studies lacked retention measures to on-field performance. Psychological skills training programs were found to have mixed effects and used varied criteria for measuring training efficacy. Physical training showed mainly significant effects on physiological measures and aging influences for on-field performance. More rigorous sport-specific evidence, assessments of training transfer, program efficacy, and macro-developmental trajectory and milestone data are needed to inform training programs and developmental plans.

Mental Health Symptoms of Amateur Association Football Referees: A Cross-Sectional Study

Although referees who officiate in the amateur football leagues are exposed to various stressors that can negatively affect their mental health (MH), little is known about their MH symptoms. The purpose of the study was to evaluate MH symptoms of referees who officiate in the Turkish amateur football leagues. An online survey was sent to all referees in the Turkish amateur football leagues (n = 4,900) incorporating standardized scales assessing depression, anxiety, and stress. A total of 1,279 referees participated in the study. Female referees reported higher depression (p < .01) and anxiety (p = .02) scores than males. Younger referees (23–27 years) reported higher depression (p = .01) and anxiety (p < .01) scores than older (>38 years) referees. Results showed that symptoms of depression, anxiety, and stress scores were associated with marital status (being single), lower incomes, severe sports injury history, and inadequate social support. In light of these results, MH assessments should be undertaken to detect which referees are at greater risk of MH problems and facilitate appropriate and timely MH interventions. Further study is needed to inform MH risk reduction strategies and/or programming.

Incidence of injury and pain in referees in German national handball leagues: a cohort study

Background

Handball referees play an important role during a handball match. Surprisingly, not much is known about their sports-related injuries and resulting pain, therefore the purpose of our study was to focus on injuries and sports-related pain in referees in German handball leagues.

Methods

During the 2018/19 national German handball season, referees of the German Federation of Handball (DHB) were contacted and asked to complete an injury and pain questionnaire on the penultimate matchday of the first and the second round of the season.

Results

Seventy referees participated in the study. One in three referees reported an injury during the last year and perceived some form of pain. Of those suffering from pain, 16.7% referees reported chronic pain disorders. During the season, 31.4% of referees incurred an injury and the majority of the 70 referees officiated despite pain (n = 43). Prospectively-enrolled data suggested an incidence of 11.6 (95% CI: 10.3 to 13.0) injuries per 1000 match hours, and 19.0 (95% CI: 16.8 to 21.3) sports-related pain events per 1000 match hours. The most common injuries were foot and knee injuries and a substantial number of the referees (n = 25) reported taking analgesics for the pain.

Conclusion

German handball referees are at risk of sports-related injuries with subsequent pain. Considering the injury profile, the incidence of sports-related pain events, and the high physiological demands of refereeing, it appears that prevention programs should be developed and integrated into the routine of the referee.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13102-021-00320-1.

Effects of Physical Activity and Training Routine on Mental Health During the COVID-19 Pandemic and Curfew

This research aimed to explore the effects of physical activity and training routine on mental health during the COVID-19 pandemic and the proclaimed emergency state and curfew. To measure the mental health components of psychological distress and subjective well-being, two studies were conducted on different samples: Study 1 during the beginning of curfew in Serbia (N = 678) and Study 2 during the ending phase (N = 398). The results of Study 1 showed that elite athletes as well as those with high level of physical activity experienced the lowest distress. Furthermore, effects of the changes in the training routine on distress among physically active individuals depended on the level of sports participation with elite athletes who reduced trainings showing lower anxiety compared to recreational athletes who reduced trainings as well or kept the same training routine. Thus, we could conclude that in the early stage of the pandemic, elite athletes showed better mental health and adaptability to the crisis situation. Results of Study 2 showed that although all the participants had decreased well-being during the curfew, compared to the period before the pandemic and the curfew, there were no differences in well-being between elite and recreational athletes, who had higher well-being compared to non-athletes. However, this effect held both before and during the curfew showing that physically active individuals did not additionally benefit from this decrease compared to the non-active. Furthermore, athletes who became physically inactive showed lower well-being compared to those who kept the same training routine. Thus, in the later stage of the pandemic, prolonged physical inactivity had negative effects on mental health.

Examining Negative Emotional Symptoms and Psychological Wellbeing of Australian Sport Officials

Sports officials are exposed to numerous performance and personal stressors, however little is known about their mental health and psychological wellbeing. This study investigated levels of mental health and psychological wellbeing of sports officials in Australia, and the demographic, officiating, and workplace factors associated with these outcomes. An online survey consisting of demographic and officiating questions, and measures of work engagement, mental health and psychological wellbeing was completed by 317 officials. A negative emotional symptoms score was computed. Associations between key demographic, officiating, and workplace factors with negative emotional symptoms and psychological wellbeing were assessed using univariate and multivariate analyses. Officials who were younger, not in a committed relationship, having lower levels of education, and less officiating experience reported higher levels of negative emotional symptoms, while males, older than 50 years, in a committed relationship and more officiating experience had higher levels of psychological wellbeing. The ability to self-manage workload and demonstrate professional autonomy were strongly associated with negative emotional symptoms and psychological wellbeing. Officials reported high negative emotional symptoms, but also high levels of psychological wellbeing. The ability to manage workload and to express professional autonomy are important determinants of mental health and wellbeing levels of sports officials.

The Relationship Between Personality Traits and Muscle Injuries in Swedish Elite Male Football Players

CONTEXT

The physical and mental demands of an elite football player are complex, which may explain why injuries are common in football. At elite level, muscle injuries of the lower-extremity are the most common among male football players, and the research hitherto is limited.

OBJECTIVE

To investigate whether personality traits affect the incidence of muscle injuries among male football players from the first league in Sweden.

DESIGN

Prospective cohort study.

PARTICIPANTS

A male football team from the first league in Sweden was prospectively followed, in terms of muscle injuries of the lower-extremity during 8 seasons, between 2007 and 2015.

INTERVENTION

All muscle injuries included in this study were evaluated and diagnosed with ultrasonography. Players from the team filled out the Swedish Universities Scales of Personality questionnaire. Swedish Universities Scales of Personality questionnaire consists of 91 items and is divided into 13 categories.

MAIN OUTCOME MEASURES

The raw values of each scale were linearly transformed to T scores, having a mean (SD) of 50 (10). All variables were summarized with standard descriptive statistics, such as frequency, mean, and SD. As data were of interval scale and no variable distribution was severely skewed, differences between noninjured players, rarely injured players, and frequently injured players were analyzed with 1-way analysis of variance with post hoc tests by Tukey honestly significant difference test.

RESULTS

No significant difference in personality traits were observed between noninjured players, rarely injured players, and frequently injured players regarding number of muscle injuries (P > .05). However, a trend (P = .07) was seen, where frequently injured players scored higher on stress susceptibility than rarely injured players.

CONCLUSION

A player's stress susceptibility should be taken into consideration by the player, coaches, and medical staff when assessing the risk of a muscle injury. Also, preventive measures available for these players may need to be considered.

Elite coaches have a similar prevalence of depressive symptoms to the general population and lower rates than elite athletes

Objective

The primary aim of this study was to estimate the prevalence of depressive symptoms and life stress in elite coaches. The secondary aim was to explore the associations of depressive symptoms and life stress with demographic and lifestyle variables.

Methods

National-level coaches were invited to participate in an online survey. Depressive symptoms were measured by the Centre for Epidemiological Studies Depression Scale-Revised (CESD-R). Life stress was measured using daily life hassle frequency and severity scores calculated from the Daily Hassles Questionnaire, with associations evaluated using linear regression.

Results

Of 110 potential participants, 69 completed and two partially completed surveys were received. The majority of respondents were male (77%), coaching individual sports (70%) and aged under 50 (71%). Overall, 14% of coaches reported at least moderate depressive symptoms according to the CESD-R. Those contemplating retirement were more likely to show depressive symptoms. Reported life stress was higher in females and in those contemplating retirement. There was a strong association between life stress and the odds of experiencing depressive symptoms (p=0.006).

Conclusions

Depressive symptoms are as prevalent in elite coaches as in general population, with potential risk factors including high levels of life stress and impending retirement.

Impact of concussion and severe musculoskeletal injuries on the onset of mental health symptoms in male professional rugby players: a 12-month study

Objective

This study explored the association between concussion or musculoskeletal injuries, and the onset of mental health symptoms (MHS) in male professional rugby players over a 12-month period.

Methods

Observational prospective cohort study with three measurements over a follow-up period of 12 months. At baseline, 573 participants provided informed consent. A total of 327 male professional rugby players (62% forwards, 38% backs) completed all follow-up assessments at baseline, 6 months and 12 months. The mean (±SD) age, height and weight of the participants at baseline was 25.9 (±4.4) years, 184.9 (±8.7) cm and 101.5 (±14.6) kg, respectively. Number of musculoskeletal injuries and number of confirmed concussions were assessed through single questions. Symptoms of distress, anxiety/depression, sleep disturbance, adverse alcohol use and eating disorders were assessed using validated questionnaires.

Results

Professional rugby players who sustained a concussion within 12 months of baseline were more likely to develop MHS with ORs ranging from 1.5 (95% CI 1.0 to 2.1) for distress to 2.0 (1.2 to 3.6) for adverse alcohol use. Players who sustained a severe injury within 12 months of baseline were more likely to develop symptoms anxiety/depression with an OR of 1.5 (1.1 to 2.0). There was no significant association in both groups for other MHS.

Conclusions

Rugby players who sustained concussion or severe injuries are up to two times more likely to develop symptoms of distress, adverse alcohol use or anxiety/depression.

Which parameters to use for sleep quality monitoring in team sport athletes? A systematic review and meta-analysis

Background

Sleep quality is an essential component of athlete's recovery. However, a better understanding of the parameters to adequately quantify sleep quality in team sport athletes is clearly warranted.

Objective

To identify which parameters to use for sleep quality monitoring in team sport athletes.

Methods

Systematic searches for articles reporting the qualitative markers related to sleep in team sport athletes were conducted in PubMed, Scopus, SPORTDiscus and Web of Science online databases. The systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. For the meta-analysis, effect sizes with 95% CI were calculated and heterogeneity was assessed using a random-effects model. The coefficient of variation (CV) with 95% CI was also calculated to assess the level of instability of each parameter.

Results

In general, 30 measuring instruments were used for monitoring sleep quality. A meta-analysis was undertaken on 15 of these parameters. Four objective parameters inferred by actigraphy had significant results (sleep efficiency with small CV and sleep latency, wake episodes and total wake episode duration with large CV). Six subjective parameters obtained from questionnaires and scales also had meaningful results (Pittsburgh Sleep Quality Index (sleep efficiency), Likert scale (Hooper), Likert scale (no reference), Liverpool Jet-Lag Questionnaire, Liverpool Jet-Lag Questionnaire (sleep rating) and RESTQ (sleep quality)).

Conclusions

These data suggest that sleep efficiency using actigraphy, Pittsburgh Sleep Quality Index, Likert scale, Liverpool Jet-Lag Questionnaire and RESTQ are indicated to monitor sleep quality in team sport athletes.

PROSPERO registration number

CRD42018083941.

Exposure to physical and psychosocial stressors in relation to symptoms of common mental disorders among European professional football referees: a prospective cohort study

Objectives

The study aim was to explore the association of physical and psychosocial stressors (severe injuries, surgeries, recent life events, social support) with one-season onset of symptoms of common mental disorders (CMDs) among European professional football referees.

Methods

An observational prospective cohort study over a follow-up period of one season (2015-2016) was conducted among professional football referees from Belgium, Finland, France, Germany, Norway, Russia, Scotland and Sweden. Based on physical and psychosocial stressors as well as symptoms of CMD, an electronic questionnaire in English and French was set up and distributed by eight football federations involved.

Results

The prevalence of symptoms of CMD ranged from 5.9% for distress to 19.2% for eating disorders. A higher number of severe injuries and a lower degree of satisfaction about social support were significantly related to the occurrence of symptoms of CMD with an OR of 2.63 and an OR of 1.10, respectively.

Conclusion

A higher number of severe injuries and a lower degree on satisfaction about social support were found to be significantly associated with the onset of symptoms of CMD among European professional football referees. Referees suffering from severe injuries were nearly three times more likely to report symptoms of anxiety and depression. Referees who reported a low satisfaction of social support were significantly more likely to report symptoms of eating disorder.