Determinants of anxiety in elite athletes: a systematic review and meta-analysis

Mental health and well-being of elite youth athletes: a scoping review

BACKGROUND

There is increasing recognition of the prevalence and risk factors for mental health symptoms and disorders among adult elite athletes, with less research involving elite youth athletes. This scoping review aimed to characterise the mental health and well-being of elite youth athletes who travel internationally and compete for their sport.

METHOD

Four databases were searched in March 2023. Inclusion criteria were studies with elite youth athlete populations (mean age 12-17 years) reporting mental health and well-being outcomes. Data from included studies were charted by outcome, and risk/protective factors identified.

RESULTS

Searches retrieved 3088 records, of which 33 studies met inclusion criteria, encapsulating data from 5826 athletes (2538 males, 3288 females). The most frequently studied issue was disordered eating (k=16), followed by anxiety (k=7), depression (k=5) and mixed anxiety/depression (k=2). Caseness estimates (a symptom level where mental health treatment is typically indicated) for disordered eating were wide ranging (0%-14% for males; 11%-41% for females), whereas only two studies estimated caseness for depression (7% in a mixed-sex sample; 14% for males, 40% for females) and one for anxiety (8% for males, 28% for females). Common risk factors for mental ill-health included sex, athlete status (compared with non-athletes) and social/relationship factors (with coaches/parents/peers). Contradictory evidence was observed for elite/competition level, which was associated with higher and lower rates of disordered eating.

CONCLUSION

Further representative research into the mental health and well-being of elite youth athletes is needed to enhance understanding and guide prevention and intervention measures.

The influence of competitive anxiety of Chinese elite swimmers

Background

Competitive anxiety is a common stress response in competitive environments, influencing sports performance, particularly among elite swimmers.

Purpose

This study aims to examine how the characteristics of competitive anxiety impact sports performance across different phases of competitive preparation, alongside its correlation with trait anxiety.

Methods

A longitudinal research design, integrating quantitative and qualitative approaches, was employed with 20 swimmers from the Chinese national swimming team participating in both the 2023 Fukuoka World Championships and the Hangzhou Asian Games. The mental readiness form-3 (MRF-3) scale was employed at four time points during the preparation period for longitudinal tracking, complemented by the trait anxiety inventory (T-AI) scale to assess trait anxiety.

Results

The study identified a negative correlation between cognitive anxiety and somatic anxiety among elite swimmers, with confidence demonstrating a positive correlation. Additionally, there was a significant between trait anxiety and competitive anxiety (p < 0.05). Variations in competitive anxiety were found at different stages of the preparation cycle (F = 15.074; 11.627; 19.552, p < 0.05), impacting sport performance.

Conclusion

To optimise performance, tailored psychological intervention programs should be developed and implemented to address the distinct characteristics of competitive anxiety experienced by elite swimmers throughout the preparation phases.

A study on the relationship and path between mental health and burnout of Chinese athletes

Background

This study aims to explore the relationship and influencing pathways between mental health indicators and athlete burnout among Chinese competitive athletes.

Methods

A cross-sectional study was conducted on 501 elite Chinese athletes from several national and provincial sports teams. Generalized Anxiety Disorder Scale (GAD-7) was used to measure anxiety, Patient Health Questionnaire (PHQ- 9) was used to measure depression, Athlete Psychological Strain Questionnaire (APSQ) was used to measure perceived stress, and Athlete Burnout Questionnaire (ABQ) was used to measure burnout. The results were derived using reliability testing, descriptive statistics, correlation analyses, and structural equation modeling.

Results

The following results were obtained: (a) the clinical detection rates of anxiety and depression in this sample were within normal levels, but the detection rate of perceived stress (78.64%) was relatively high; (b) all three mental health indicators were significantly correlated with athlete burnout; (c) in our model, there was a direct path with APSQ directly contributing to 69.95% of the variance in athlete burnout, and two indirect paths with APSQ exerting an indirect effect through depression or/and anxiety accounting for 30.05% of the variance.

Conclusion

The findings revealed the psychological characteristics of Chinese competitive athletes and the direct and indirect effects of the APSQ on burnout. Future research should actively promote the international development and application of burnout assessment tools, conduct more comprehensive studies on athlete mental health monitoring, and intensify efforts in athlete education, treatment, and support services, as well as strategies for athlete's coping stress.

Anxiety, eating disorders and menstrual disturbances risk in Spanish elite female paddlers

Affiliated athletes are frequently subject to higher levels of anxiety due to the intensity of training, competition and many other factors. This anxiety can cause alterations in their health, both physically and mentally, such as menstrual irregularities, eating disorders, etc. In this work we have analysed the anxiety levels of a population of female affiliated paddlers and the possible consequences for their health. The results showed that a third of the female paddlers analysed have a moderate/high risk of suffering from anxiety; and within this group, the less sporting experience the athlete has, the greater the probability is of suffering from anxiety. Moreover, almost half the total of the female paddlers suffers from menstrual dysfunction before an important competition, with this number rising among high performance athletes, even though three out of every four adjust their training schedule to their menstrual cycle. Less-experienced female athletes, who show higher anxiety levels, also present a greater risk of suffering from eating disorders.

Neuropsychological analysis of anxiety and executive control of motor patterns in athletes and non-athletes

Introduction

Even simple tapping tasks require cognitive processes. Some variants of the Finger Tapping Test (FTT) may reveal cognitive aspects associated with frontal processing, including executive functions such as inhibition, or emotional aspects such as anxiety. A context of particular interest for the application of cognitive-motor-anxiety interactions is sports. Although athletes generally exhibit better anxiety levels, they may experience heightened anxiety before important competitions. The problem lies in determining whether the application of anxiety control techniques can be useful in pre-competition situations, given the lack of quick and easy methods to detect if an athlete is experiencing anxiety at a particular moment.

Methods

This exploratory study evaluated anxiety using online versions of questionnaires (ISRA, the Competitive State Anxiety Inventory-2, and STAI) and applied a variant of the FTT to 204 participants, both athletes and non-athletes. The scores were compared and correlated.

Results

Athletes exhibited lower general anxiety and greater cognitive resistance to interference (better cognitive inhibition). Non-athletes displayed a particular parameter in the FTT variant that differed from the one obtained by athletes and exhibited higher anxiety levels. In the athletes' group only, anxiety was correlated with a specific parameter of the FTT task.

Discussion

Our conclusion is that this parameter holds potential relevance in elite sports performance to detect if an athlete is experiencing anxiety. It could be of particular interest in psychological interventions in sports. Further investigation is warranted to fully explore this potential.

The prevalence of menstrual cycle symptoms and their association with mental health and sleep in German exercising women and athletes

OBJECTIVES

Menstrual cycle symptoms are very common in female athletes. However, more evidence about the association between menstrual cycle characteristics and symptoms with sleep and mental health in athletes needs to be gathered. This study aimed to examine this association in German exercising women and athletes.

DESIGN

322 women (mean age: 23.13 ± 4.36) participated in a cross-sectional study. The survey included the Menstrual Symptom index (MSi), the Depression Anxiety Stress Scales (DASS-21), the Pittsburgh Sleep Quality Index (PSQI), and the Athletes Sleep Behavior Questionnaire (ASBQ). Additionally, demographic, sport-specific data and further menstrual cycle characteristics were examined. Multiple regression models were used for the statistical analyses.

RESULTS

The MSi score demonstrated a highly significant (p < 0.001) positive association with Depression, Anxiety, Stress, PSQI, and ASBQ. The most prevalent menstrual cycle symptoms were cravings/increased appetite, mood changes/anxiety, and tiredness/fatigue. A difference between individual and team sport athletes could not be found. Moreover, there was no association between the constructs and menses length, irregularity, or heaviness of bleeding.

CONCLUSIONS

Menstrual cycle symptoms occur very frequently in female athletes. In this study, they were related to mental health, sleep quality, and sleep behavior, regardless of the cycle phase. This evidence demonstrates the relevance of considering the menstrual cycle and menstrual symptoms in future studies with female athletes and in sport practice.

Mental Health in First- and Second-Division Soccer Players: A Cross-Sectional Study

BACKGROUND

The benefits of sport in mental health have been broadly studied. However, few studies have examined these outcomes in high-performance athletes. We aimed to analyze the state of the mental health of the Villarreal Soccer Club's first- (FD) and second-division (SD) players and the possible mediating effects of sex and professional category.

METHODS

This was a cross-sectional study with an initial sample of 108 soccer players (final sample n = 54). Data from MINI, HARS, HDRS, BARRAT-11 and SCSRQ questionnaires were analyzed.

RESULTS

The mean age was 23.41 years (SD = 4.56) and 61.1% (n = 33) were men. A proportion of 24.1% (n = 13) stated that they had undergone mental health treatment, 7.4% (n = 4) had taken psychotropic drugs, and 2.1% (n = 1) had made a suicide attempt. Differences were observed between the FD and SD players in terms of the sensitivity to punishment (t = -2.2; p = 0.033), overall impulsivity (t = -3.1; p = 0.003), unplanned impulsivity (t = 3.4; p = 0.001), and the HDRS (U = -110.5; p = 0.004), HARS-Total (U = -104.0; p = 0.006) and HARS-Psychological subscale scores (U = -104.0; p = 0.001). Differences were also observed between the female and male SD players for the HARS-Somatic subscale (U = 136.5; p = 0.028).

CONCLUSION

The low values obtained in the clinical scales, together with the reported psychopathological histories, suggested that the Villareal players showed better mental health than the general population.

Factors associated with the Single Leg Squat test in female soccer players: a cross-sectional study

BACKGROUND

The Single Leg Squat (SLS) test is widely used in the clinical setting to examine and evaluate rehabilitation goals. It is simple to perform and is proposed to have biomechanical and neuromuscular similarities to athletic movements. The aim of the present study was to investigate whether demographics, previous injuries, and biomechanical and psychosocial factors are associated with the outcome of the SLS, assessed as a total score for all segments and as a separate knee segment in elite and sub-elite female soccer players.

METHODS

We conducted a cross-sectional study involving 254 female soccer players (22 yrs; SD ± 4, height 1.69 m; SD ± 0.1, weight 64 kg; SD ± 6) from divisions 1-3 of the Swedish Soccer League. During the preseason, we assessed the participants using the SLS and tested their hip strength and ankle mobility. Demographics, previous injury, sleep quality, fear of movement, anxiety, and perceived stress were assessed with questionnaires. Logistic regression models were built to analyse the association between the outcome of the SLS and the independent variables for the dominant and non-dominant leg.

RESULTS

Significantly more participants failed the SLS on the dominant leg compared with the non-dominant leg (p < 0.001). The outcome of the SLS associated with various biopsychosocial factors depending on if the dominant or non-dominant leg was tested. The total score associated with hip strength for the dominant (OR 0.99, 95% CI 0.98-0.99, p = 0.04) and the non-dominant leg (OR 0.99, 95% CI 0.97-0.99, p = 0.03). The knee segment associated with division level for the dominant (div 2; OR 2.34, 95% CI 1.01-5.12, p = 0.033. div 3; OR 3.07, 95% CI 1.61-5.85, p = 0.001) and non-dominant leg (div 2; OR 3.30, 95% CI 1.33-8.00, p = 0.01. div 3; OR 3.05, 95% CI 1.44-6.43, p = 0.003).

CONCLUSIONS

This study identified that leg dominance, division level, hip strength, and psychosocial factors were associated with the outcome of the SLS when assessed as a total score and as a separate knee segment. This indicates that clinicians need to understand that movement control is associated with factors from several domains. Whether these factors and, the results of the SLS are related to injury need to be studied prospectively.

TRIAL REGISTRATION

Clinical Trials Gov, date of registration 2022-03-01.

CLINICAL TRIALS IDENTIFIER

NCT05289284A.

Depression, anxiety and stress among female student-athletes: a systematic review and meta-analysis

OBJECTIVE

To identify, quantify and analyse determinants of depression, anxiety and stress symptoms among female student-athletes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Five online databases (PubMed, CINAHL, PsychInfo, SportDiscus and Web of Science) searched from inception through 14 September 2023. Hand-searches and contacting authors for eligible studies.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Articles were included if they were published in English, included female student-athletes competing at National Collegiate Athletic Association institutions, and measured symptom-level depression, anxiety and/or stress.

RESULTS AND SUMMARY

We screened 2415 articles; 52 studies (N=13 849) were included in the systematic review with 13 studies qualifying for meta-analysis. Seventeen determinants were identified including injury (eg, concussions), health (eg, sleep hygiene) and social factors (eg, social support). As data specific to female student-athletes was delineated from studies that included other populations, we observed 16 studies (30.7%) reported that identifying as female was a meaningful determinant of depression, anxiety and stress in athletes. Results of the meta-analysis (k=13, N=5004) suggested a small but significant association (r=0.15, 95% CI 0.05 to 0.24, p=0.004) between other determinants and depression, anxiety, and stress among female student-athletes.

CONCLUSION

Coaches, trainers and clinicians are key contributors in supporting female student-athlete mental health, with responsibilities for integrating mental skill training, sleep hygiene education and regular assessments. Comprehensive mental health and tailored education programmes considering determinants such as injury, health and social factors specific to female student-athletes are needed to enhance mental health equity in sport.

PROSPERO REGISTRATION NUMBER

CRD42022362163.

Inequities in the Training Environment and Health of Female Golfers Participating in the 2022 International Golf Federation World Amateur Team Championships

OBJECTIVE

To assess health problems and training environment of female golfers participating in the 2022 World Amateur Team Championships (WATC) and to compare golfers (a) with and without health problems prior the WATC and (b) living and training in countries ranking in the upper versus lower 50% of the team results at the 2022 WATC.

DESIGN

Cross-sectional cohort study using an anonymous questionnaire.

SETTING

International Golf Federation WATC.

PARTICIPANTS

One hundred sixty-two female golfers from 56 countries.

INTERVENTIONS

N/A.

MAIN OUTCOME MEASURES

Golfers' answers on the presence and characteristics of health problems, their training environment, and to the Oslo Sport Trauma Research Centre Questionnaire.

RESULTS

Almost all golfers (n = 162; 96%) answered the questionnaire. In the 4 weeks before the WATC, 101 golfers (63.1%) experienced 186 musculoskeletal complaints, mainly at the lumbar spine/lower back, wrist, or shoulder. Just half of the golfers (50.6%) performed injury prevention exercises always or often. More than a third (37.4%) of the golfers reported illness complaints and 32.5% mental health problems in the 4 weeks preceding the WATC. General anxiety, performance anxiety, and low mood/depression were the most frequent mental health problems. Golfers with injury complaints rated their daily training environment poorer. Golfers ranking in the lower 50% at the WATC had significantly less support staff, rated their training environment poorer, and had a higher prevalence of illness complaints and mental health problems.

CONCLUSIONS

Effective illness and injury prevention programs should be implemented and better access to education and health support in the daily training environment provided.

Voices from the field: exploring practitioners' experiences and perceptions of the voices of athletes (VOA) in the pacific islands

This exploratory study aims to gain insights into practitioners' experiences and perceptions of the "Voices of Athletes" (VOA), a specialized athlete support program, developed and implemented in the Pacific Islands. Semi-structured interviews enabled participants to share detailed experiences, with 14 practitioners participating. Thematic analysis of the data identified five key themes: "Fostering Athlete Empowerment", "Impact of Sport on Education and Social Change", "Expanding VOA's Reach and Impact", "VOA's Role in Preparing Athletes for Post-Sport Life", and "Optimizing VOA Implementation and Experience". The findings demonstrated that the VOA plays a critical role in empowering athletes and assisting them in becoming leaders within their societies. Practitioners emphasized the power of sport as an effective channel for education and inspiration, and the potential for the VOA framework to be applied in various contexts and regions. The study also revealed that the VOA helps athletes prepare for life after sport, contributing to increased self-esteem, development of transferable skills, and awareness of their social roles. The findings also emphasized the need for VOA improvements, including enhanced interactivity, larger spaces, and financial support. Recognition from sport governing bodies and coaches could broaden the program's reach and impact. Incorporating internship schemes within the VOA or related programs could address life after sport more effectively. Developing written VOA guidelines would ensure consistent, sustainable delivery, supporting its potential for wider implementation and adaptation, contributing to holistic development for athletes and young people globally.

The Psychology of ACL Injury, Treatment, and Recovery: Current Concepts and Future Directions

CONTEXT

Interest in the relationship between psychology and the outcomes of anterior cruciate ligament (ACL) reconstruction (ACLR) continues to grow as variable rates of return to preinjury level of activity continue to be observed.

EVIDENCE ACQUISITION

Articles were collected from peer-reviewed sources available on PubMed using a combination of search terms, including psychology, resilience, mental health, recovery, and anterior cruciate ligament reconstruction. Further evaluation of the included bibliographies were used to expand the evidence.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

General mental health and wellbeing, in addition to a host of unique psychological traits (self-efficacy, resilience, psychological readiness and distress, pain catastrophizing, locus of control, and kinesiophobia) have been demonstrated convincingly to affect treatment outcomes. Moreover, compelling evidence suggests that a number of these traits may be modifiable. Although the effect of resilience on outcomes of orthopaedic surgical procedures has been studied extensively, there is very limited information linking this unique psychological trait to the outcomes of ACLR. Similarly, the available information related to other parameters, such as pain catastrophizing, is limited with respect to the existence of adequately sized cohorts capable of accommodating more rigorous and compelling analyses. A better understanding of the specific mechanisms through which psychological traits influence outcomes can inform future interventions intended to improve rates of return to preinjury level of activity after ACLR.

CONCLUSION

The impact of psychology on patients' responses to ACL injury and treatment represents a promising avenue for improving low rates of return to preinjury activity levels among certain cohorts. Future research into these areas should focus on specific effects of targeted interventions on known, modifiable risk factors that commonly contribute to suboptimal clinical outcomes.

STRENGTH-OF-RECOMMENDATION TAXONOMY (SORT)

B.

Mental health problems, sleep quality and overuse injuries in advanced Swedish rock-climbers - the CLIMB study

OBJECTIVES

To examine the prevalence of mental health problems (depression, anxiety, and stress), sleep quality, and disability due to overuse injuries in advanced and elite rock-climbers. The rock-climbers were compared to a group of non-climbing controls.

METHODS

A self-selected sample of advanced and elite Swedish rock-climbing athletes was recruited through the Swedish Rock-climbing Federation, local rock-climbing gyms and through social media. A control group, matched in size was recruited. Participants in the control group answered an online survey of validated questionnaires, examining symptoms of stress, anxiety, depression, sleep quality. The climbing participants answered the same survey as the non-climbing controls but with additional questions regarding musculoskeletal problems and disabilities related to these. Outcome measures used were the Depression Anxiety Stress Scale, Pittsburgh Sleep Quality Index and The Oslo Sports Trauma Research Center Overuse Injury Questionnaire.

RESULTS

A total of 183 participants were included in the rock-climbing group, and 180 participants in the control group. In the rock-climbing group the mean age (SD) was 28.2 (8.3) years among women and 30.5 (9.6) years in men. The mean BMI of women was 21.2 (2.2) and 22.8 (2.1) in men. A total of 30.6% of the rock-climbing group (26.7% of men, 35.9% of women) reported at least moderate levels of symptoms of depression and 23.1% (17.2% men, 30.8% women) at least moderate levels of symptoms of anxiety. A total of 48.4% of rock-climbers (39.1% men, and 61.6% women) reported at least moderate levels of symptoms of stress. Among the rock-climbers, 45.0% reported having poor sleep quality. There were no statistical significant differences (p = 0.052-0.96) in mental health problems or sleeping problems between the rock-climbers and the controls. Among rock-climbers, reports of one-week prevalence of injury related problems was: Finger and hand (49.5%), Shoulder (35.2%), Knee (29.1%), Lumbar back (26.4%), Arm (25.3%), Thoracic back and neck (17.0%), and Foot and lower leg (12.1%).

CONCLUSION

The overall results indicate high levels of symptoms of mental health problems and poor sleep quality in both rock-climbers and controls. Although no significant differences between the climbing group and the control group was displayed, symptoms that warrant clinical attention is high. Overuse injuries were commonly reported among the rock-climbers in all examined injury locations. Previous studies reporting mental health problems to be more prevalent among athletes were contradicted in this study. The results display the need for a broader perspective regarding climbers general health and the need to provide structured care and adequate support in order to come to terms with these concerns.

Relationship Between Athletes' History of Stressors and Sport Injury: A Systematic Review and Meta-Analysis

A history of stressors in athletes represents psychosocial factors that may lead to sport injury. However, empirical studies have provided varying results for the relationship between stress history and sport injury. We examined prior literature on the stress history - sport injury relationship within a systematic review and, by meta-analysis, we offered a pooled estimate of the strength of this relationship. We searched seven major academic databases (Sportdiscus, Psyinfo, Academic Search Premier, Ovid, Scopus, Web of Science, and PubMed) from January 2000 to September 2023 and identified 19 empirical studies that examined injuries in sports contexts for meta-analysis. In 19 empirical studies of moderate to high publication quality, we found moderate heterogeneity (Q(17) = 98.61; p < .001), low sensitivity (I2 77.82-83.77), and low publication bias (Z-value = 7.74; p < .001). Further, using a random effect estimate-r, we found a low but significant correlation between stress history and sport injury, yielding a small overall effect size (ES) of r = .12. Furthermore, moderation analyses found adolescents (r = .14), contact-sport athletes (r = .09), non-elite athletes (r = .13), and non-European athletes (America r = .16; Asia r = .14; Oceania r = .14) to have a relatively higher ES than their counterparts in this stress history/sport injury relationship. We concluded that inevitable life stressors may lead to many negative consequences for athletes, such that sports professionals should provide stress management educational programs to enhance athletes' health and well-being.

The Epidemiology of Mental Health Symptoms and Disorders Among Elite Athletes and the Evolution of Mental Health Literacy

Within elite sport, epidemiological evidence is needed concerning the incidence and prevalence of mental health symptoms and disorders in relation to athlete demographic factors such as (dis)ability, race, ethnicity, sexual orientations, and different genders. Mental health promotion campaigns are often based on mental health literacy strategies. Such strategies aim to increase knowledge of mental health symptoms and disorders, address aspects of self- and public stigma, and promote help-seeking behaviors. Sporting organizations need to take responsibility to ensure that policies, practices, and services reflect organizational values concerning mental health. Organizational mental health literacy ensures that information is culturally competent and responsive, easy to find, straightforward, and offers simple, legitimate opportunities to access support.

A moderated mediation analysis on the influence of social support and cognitive flexibility in predicting mental wellbeing in elite sport

The purpose of this study was to examine the mechanism by which social support influences mental wellbeing. Using the thriving through relationships model to provide a theoretical underpinning, cognitive flexibility was hypothesised as a mediator. Additionally, the research examined the consistency of this pathway between elite athletes, retired athletes, and non-athletes. Survey responses from a sample of 247 participants (n = 49 elite athletes, n = 61 retired athletes, n = 137 convenience sample; of which 127 (51.4%) were males were included in the analysis. Initial mediation analysis revealed a significant indirect pathway from social support to mental wellbeing through cognitive flexibility. Moderated mediation analysis revealed this pathway was significant for retired athletes and the convenience sample, but not for elite athletes. Results provide additional insight into the mechanisms by which social support influences wellbeing. Cognitive flexibility interventions may not be as effective for elite athletes.

Epidemiology of Anterior Cruciate Ligament Tears in National Collegiate Athletic Association Athletes: 2014/2015-2018/2019

PURPOSE

This study aimed to describe the epidemiology of ACL tears in NCAA men's and women's sports.

METHODS

Injury and exposure data collected within the NCAA Injury Surveillance Program from 2014/2015 to 2018/2019 were analyzed. ACL tear frequencies, injury rates (IR), and injury proportions were used to describe injury incidence by sport, event type, injury mechanism, and injury history. Injury rate ratios (IRR) were used to examine differential injury rates, and injury proportion ratios (IPR) were used to examine differential distributions.

RESULTS

A total of 729 ACL tears were reported from 8,474,401 recorded athlete exposures (AE) during the study period (IR = 0.86 per 10,000 AE), and the competition-related ACL tear rate was higher than the practice-related rate (IRR = 5.52, 95% confidence interval [CI] = 4.75-6.39). Among men's sports, the highest overall ACL tear rate was observed in men's football (IR = 1.44 per 10,000 AE), whereas among women's sports, the highest overall rate was observed in women's soccer (IR = 2.60 per 10,000 AE). Among sex-comparable sports, ACL tear rates were higher in women's basketball, softball, and soccer, as compared with their men's counterparts. ACL tears were more prevalently attributed to player contact mechanisms in men's sports than women's sports (IPR = 1.73, 95% CI = 1.37-2.19), but more prevalently attributed to noncontact mechanisms in women's sports than men's sports (IPR = 1.17, 95% CI = 1.01-1.35).

CONCLUSIONS

ACL tear risk in women's sports continues to warrant attention and prevention efforts. Given the differential rates by event type, future research efforts may also evaluate initiatives to reduce competition-related injury burden in NCAA sports.

Anxiety Disorders in Athletes

Athletes and non-athletes experience many anxiety-related symptoms and disorders at comparable rates. Contributory factors may include pressure to perform, public scrutiny, sporting career dissatisfaction, injury, and harassment and abuse in sport. Anxiety may negatively impact sport performance. Specific types of anxiety may have unique presentations in athletes. It is important to rule out general medical and substance-related causes of anxiety symptoms. Psychotherapy and pharmacology treatment options should be considered, bearing in mind athletes' environmental circumstances and physiologies.

Mental Health of Elite Sport Coaches and Entourage

There is growing understanding of the extent of mental health problems, and related mental health needs, among elite athletes. However, far less attention has been paid to mental health among elite coaches and high-performance support staff, the latter including strength and conditioning coaches, physiotherapists, sport psychologists, and other allied health workers in the daily training environment (high-performance support staff are referred to collectively as "entourage" throughout this article). The scarcity of research examining mental health among elite coaches and entourage warrants urgent attention, particularly given these individuals share similar performance demands and role-related stressors as elite athletes. This article reviews the available literature on this topic, including (1) an empirical study conducted by the authors with a sample of coaches and entourage from Australia's national high-performance sport system and (2) a case example to illustrate sport-specific and general risk factors that are likely to impact mental health in elite sporting environments. Avenues for supporting mental health among coaches and entourage are discussed.

Evaluating workforce well-being: an investigation of healthcare professionals' mental health and burnout symptoms at the Tokyo 2020 and Beijing 2022 Paralympic Games

OBJECTIVE

To explore the prevalence of symptoms of mental health conditions and burnout of healthcare professionals (HCPs) working during the Tokyo 2020 Paralympic Games and the Beijing 2022 Paralympic Winter Games.

METHODS

In this cross-sectional, observational study, HCPs working during the Tokyo 2020 and Beijing 2022 Paralympic Games were asked to complete an online, anonymous survey, which included demographic questions and questions regarding mental health symptoms including depression (Patient Health Questionnaire 9-item depression scale) and anxiety (Generalized Anxiety Disorder 7-item scale) as well as burnout (Maslach Burnout Inventory-Human Services Survey: depersonalisation, emotional exhaustion, personal accomplishment). Correlation coefficients (r) were calculated between demographic characteristics and mental health symptoms.

RESULTS

In total, 256 HCPs (of 857 HCPs; 30%) completed the surveys. Twelve and eight per cent of HCP scores fell within the moderate to severe depression and moderate to severe anxiety categories, respectively. More than 30% reported moderate to high burnout (depersonalisation: 36%; emotional exhaustion: 36%; personal accomplishment: 58%). In addition, thoughts of self-harm and/or suicidality were reported by some HCPs (8%). Weak correlations were observed between age and depression (r=-0.13, p=0.046), anxiety (r=-0.16, p=0.010) and burnout (emotional exhaustion: r=-0.14, p=0.032; personal accomplishment: r=0.27, p<0.001).

CONCLUSION

Although most HCPs reported good mental health, this study suggests that a subset of HCPs experienced symptoms of depression, anxiety, burnout or thoughts of self-harm during the Tokyo 2020 and Beijing 2022 Paralympic Games. While the generalisability of these findings outside of COVID-19 restrictions should be tested, appropriate guidance and mental health support of HCPs leading up to the Paralympic Games should be prioritised.

Psychometric properties of the Chinese version of Sport Anxiety Scale-2

Introduction

The Sport Anxiety Scale-2 (SAS-2) is a validated measure of sports trait anxiety, with promising psychometric properties. However, its cross-cultural applicability in Chinese samples remains unexplored. Thus, the primary objectives of this study were twofold: to translate the SAS-2 into Chinese and assess the psychometric properties of the Chinese version.

Methods

In Study 1, we initiated the translation of the SAS-2 into Chinese. This assessment involved bilingual Chinese students proficient in both English and Chinese. Additionally, we conducted a cross-linguistic measurement invariance analysis. In Study 2, we delved into the psychometric properties of the Chinese SAS-2 using a sample of Chinese student athletes. This examination encompassed an evaluation of its factor structure, convergent and discriminant validity, and measurement invariance across genders.

Results

Our findings in Study 1 indicated no significant differences in item scores between the Chinese SAS-2 and the English version, and measurement invariance across languages. In Study 2, we uncovered that the Chinese SAS-2 and its factors exhibited excellent reliability, with Cronbach's alpha values exceeding 0.80. Confirmatory factor analyses upheld the original three-factor model, demonstrating acceptable model fit indices (CFI = 0.96, TLI = 0.93, RMSEA = 0.08). Furthermore, all three factors of the Chinese SAS-2 displayed significant and positive correlations with athlete burnout and State-Trait anxiety. Additionally, this study elucidated the mediating role of Concentration Disruption (Somatic anxiety and Concentration Disruption) in the relationship between the Trait (State) anxiety, and athlete burnout. Moreover, we identified measurement invariance of the Chinese version of the SAS-2 across genders. Finally, female college athletes exhibited significantly higher scores in somatic anxiety and worry compared to their male counterparts.

Discussion

In sum, our findings affirm that the Chinese version of the SAS-2 demonstrates robust reliability and correlates effectively with related criteria, thus validating its suitability for use in a Chinese context.

Anxiety and Depression in British Horseracing Stud and Stable Staff Following Occupational Injury

Horseracing has identified several factors influencing staff wellbeing; however, the relationship between injury, anxiety, and depression is yet to be established. This study investigated anxiety and depression scores and their association to pain management, coping, and help-seeking behaviour in injured British horseracing staff. An online retrospective survey was completed by 175 participants, identifying injury prevalence, coping strategies, occupational risk factors, and Hospital Anxiety and Depression Scale (HADS) scores. Analysis identified 65.14% (n = 114) of staff reported anxiety scores above the threshold (≥8) and 59.52% (n = 104) of staff reported depression scores ≥8. Median anxiety and depression scores were higher for staff who viewed their employer as unhelpful (anxiety p = 0.001; depression p = 0.020). Heightened anxiety and depression were associated with an increased likelihood to use pain medication to manage at work, including non-steroidal anti-inflammatory drugs (NSAID's), alcohol, nicotine, and prescription drugs (p < 0.05). Implications for staff wellbeing is evident; anxiety and depression risks are high following injury, which may influence help-seeking behaviour, perceived job security, and coping mechanisms. This paper suggests it is vital to continue to investigate poor mental health and injury in racing staff and the implications for equine welfare.

Psychometric properties of the Sport Anxiety Scale-2 for Chinese adolescent athletes taking the National Sports College Entrance Examination

Background

This study aims to evaluate the psychometric properties of the Sport Anxiety Scale-2 (SAS-2) in Chinese adolescent sports exam candidates.

Methods

One day before the National Sports College Entrance Examination, 965 Chinese athletes rated the Chinese-language SAS-2. Confirmatory factor analysis was performed to test the three-factor structure. Factorial invariance was tested by comparing the configural invariance model to three more constrained models. Construct validity and reliability were determined.

Results

Fit indices meet the critical values: CFI = 0.953, TLI = 0.943, RMSEA = 0.048 [90% CI, 0.041-0.054], and SRMR = 0.042. All path factor loadings exceed 0.5. The changes in CFI and RMSEA across the configural, metric, scalar, and uniqueness invariance are within the critical values, demonstrating strict measurement invariance across gender, years of training, and type of sports. The average variance extracted of the worry sub-scale is above the cutoff criteria, and McDonald's omega coefficients are over 0.70. Significant correlations exist between the SAS-2, SCAT, and CSAI-2. Factor correlations are all below 0.8. The measurement also distinguishes the known gender effect, with females showing a probability of 58.6% higher anxiety levels. The intraclass correlation coefficient ranges from 0.706 to 0.801.

Conclusion

This study validated the Chinese-language SAS-2 in measuring competitive anxiety among Chinese adolescent athletes taking the National Sports College Entrance Examination. The development of the scale's applicability in China is discussed.

Behind the Curtain: Prevalence of Symptoms of Depression, Generalised Anxiety and Eating Disorders in 147 Professional Dancers from Six Opera Houses or State Theatres

BACKGROUND

Mental health problems cover a wide spectrum. Depression and anxiety disorders are the most frequent mental health problem in the general population and in elite athletes. The aim of the present study was to assess the prevalence of symptoms of depression, generalised anxiety disorder and eating disorders in professional dancers, to compare the results between genders and to the general population and to analyse potential determinants.

METHODS

During a pre-season health screening, professional dancers of six German companies answered a comprehensive questionnaire on personal and dancer-specific characteristics, medical history and the Patient Health Questionnaire (PHQ-9), Generalised Anxiety Disorder Questionnaire (GAD-7) and Eating-Disorder-Examination-Questionnaire (EDE-QS).

RESULTS

A total of 82 (55.8%) female and 65 (44.2%) male dancers answered the questionnaire. One in five (20.8%) dancers had at least moderate symptoms of either depression, generalised anxiety disorder or eating disorders. The prevalence of at least moderate symptoms of depression was 11.1% in female and 6.4% in male dancers, of generalised anxiety disorder 16.0% in female and 6.4% in male dancers and of eating disorders 14.8% in female and 6.1% in male dancers. Compared to the general population of the same gender and similar age, the prevalence of at least moderate symptoms of generalised anxiety disorder was significantly higher in both genders. About one in four dancers (26.9%) reported a subjective need for support from a psychotherapist at the time of the screening. The PHQ-9, GAD-7 and EDE-QS sum scores were not related to the size or type of the companies, the age or rank of the dancers, but the PHQ-9 and GAD-7 sum score were significantly related to severity of musculoskeletal pain in the past seven days and to chronic or recurrent symptoms of low mood and generalised anxiety.

CONCLUSION

The prevalence of symptoms of depression, generalised anxiety and eating disorders was high in professional dancers. Routine screening and low-threshold interventions to improve mental health of professional dancers are recommended.

The psychological effects of sports disruptions in NCAA Division I and II athletes during the COVID-19 pandemic: a mixed methods analysis

BACKGROUND

Improving mental health outcomes in college athletics requires better understanding of how student-athletes respond to stress-inducing events.

METHODS

Using a cross-sectional design, this study aimed to assess student-athletes' mental health status during the COVID-19 pandemic. Eligible participants (N.=489) included Division I and II student-athletes at least 18 years of age with plans to compete in the 2020-2021 sport season. Participants completed an online battery of psychological health surveys.

RESULTS

Survey results suggested high psychological strain (APSQ: 20.58±8.08), mild symptoms of anxiety (GAD-7: 7.66±5.51) and depression (PHQ-9: 7.51±5.65), and burnout (ABQ: 2.37±0.96).

CONCLUSIONS

A subset of student-athletes reported symptoms of psychological strain, depression, and anxiety warranting follow-up clinical evaluation and/or treatment according to scoring guidelines. Findings encourage psychological screening, particularly during sport-disrupting events, to better support athletes' mental health during high-stress conditions.

Clinical Commentary: Depression and Anxiety in Adolescent and Young Adult Athletes

Mental health (MH) symptoms and disorders are common in adolescents and young adults, and athletes may be at risk due to sport-specific triggers such as injury or illness as well as stressors related to performance, transition, or retirement from sport. Anxiety and depression are reported frequently in this age group, and early recognition and treatment can improve outcomes. The medical team (eg, athletic trainers or therapists, team physicians) should be familiar with the symptoms of depression and anxiety, recognize "red flags" for these symptoms and disorders, and seek to provide screening assessments and develop MH plans and MH emergency action plans. As a part of their scope of practice, team physicians should have the initial assessment and management of patients with these MH conditions and appreciate the importance of referrals to other MH providers with expertise caring for athletes. Athletic trainers are often the first point of contact for athletes who may be experiencing MH symptoms and therefore play a key role in early recognition and referrals to team physicians for early diagnosis and treatment. Additional resources that provide more in-depth information regarding the treatment and management of anxiety and depression are provided herein.

Prevalence of symptoms of depression and generalized anxiety disorder in field hockey players of German first and lower leagues

BACKGROUND

While several studies on mental health of elite athletes were published in recent years, few compared the prevalence with the general population and none included field hockey players.

AIMS

To analyze the prevalence of symptoms of depression and generalized anxiety disorder in field hockey players of different skill levels and to compare it to the general population.

METHODS

Male and female hockey players from different leagues were asked to answer questions on player characteristics, the Centre of Epidemiologic Studies Depression Scale (CES-D) and the Generalized Anxiety Disorder-7 (GAD-7).

RESULTS

One hundred and eighty-seven players (incl. 54 first and 28 second league players) participated in the study (response rate 97.4%). More than a third (n = 64; 35.0%) reported to be affected by an injury/health complaint, but 157 (86.3%) were able to train and play without limitations. The CES-D score indicated depression symptoms in more female (n = 15; 18.3%) than male (n = 5; 4.8%) players (χ2=8.8; p < 0.01). No male and one female player had symptoms of generalized anxiety disorder. Players who played 60 or more matches in the previous 12 months had on average significantly higher depression (t = 2.3; p < 0.05) and generalized anxiety scores (t = 4.2; p < 0.001) than players who played fewer matches. The prevalence of depression and of generalized anxiety symptoms was similar to or lower than in the general population. Although 20 (10.7%) players had depression symptoms, only 4 (2.2%) received psychological counseling or psychotherapy.

CONCLUSION

It is recommended to provide routine screening of mental health problems and low-threshold access to adequate treatment for elite athletes.

Fear of falling in women: A psychological training intervention improves climbing performance

The main purpose of this study was to determine the effect of a psychological training intervention based on emotional regulation on anxiety and climbing ability in women climbers with fear of falling. A secondary aim was to compare the outcomes of climbing ability, anxiety, self-confidence and interoceptive awareness (IA) between the psychological group (PG), a training (TG) and a control group. Self-reported climbing ability, anxiety and IA were assessed using Competitive State Anxiety Inventory-2 and the Multidimensional Assessment of Interoceptive Awareness questionnaire. Results indicated a significant improvement in climbing ability for both PG and TG. The PG showed a significant reduction in cognitive and somatic anxiety, while the TG only exhibited a reduction in cognitive anxiety. Moreover, the PG demonstrated a greater significant increase in self-confidence compared to the TG. IA improved in five subscales for the PG, whereas the TG changed in only two subscales. In conclusion, a psychological training intervention focusing on emotional regulation might contribute to improvements in IA, reduced anxiety levels, and enhancements in climbing ability and self-confidence among women climbers facing fear of falling.

The Impact of a Psychological Skills Training and Mindfulness-Based Intervention on the Mental Toughness, Competitive Anxiety, and Coping Skills of Futsal Players-A Longitudinal Convergent Mixed-Methods Design

Despite the sport's popularity, there is a paucity in futsal psychological interventional research. This study analysed the impact of a ten-session psychological skills training and mindfulness-based intervention (PSTMI) on the mental toughness, competitive anxiety, and athletic coping skills of national league futsal players (n = 13). It also analysed whether these variables were predicted by playing experience. Pre-/post-intervention questionnaires were filled in and analysed (Competitive State Anxiety Inventory-2, Sport Mental Toughness Questionnaire, and Athletic Coping Skills Inventory-28). Semi-structured interviews were also conducted with seven athletes; quantitative and qualitative data were integrated in a convergent parallel mixed-methods design. Results revealed significant medium-to-large improvements in mental toughness, cognitive anxiety, and coping skills following the PSTMI. Years of playing experience positively and significantly predicted better self-confidence and coping skills. Thematic analysis generated five themes: (1) post-intervention enhancement in athletic performance and well-being; (2) the non-athletic commitments of futsal players; (3) diverse views on how to improve the intervention; (4) instilling social identity through sport psychology sessions; and (5) the impact of years of experience on skill learning. Results mirrored those from other sporting disciplines. The PSTMI was well-received and equipped athletes with beneficial psychological skills, stressing the need for more sport psychology resources in futsal.

Psychological Aspects of Return to Sport for the Female Athlete

Female athletes represent a unique population of competitors who face distinct stressors when compared with male athletes. These include sport inequities, violence, abuse, body image concerns, disordered eating, relative energy deficiency, family planning challenges, hormonal challenges, and mental distress. When combined with sports injuries, these stressors can negatively impact the mental health of female athletes as well as their injury recovery and return to sports. It is essential for orthopaedic surgeons to be familiar with the unique aspects inherent to being a female athlete, along with the psychological aspects of sports injuries. By integrating questions about female athletes' psychological well-being into their routine practice and collaborating with a multidisciplinary team, orthopaedic surgeons can better address these unique stressors, support female athletes in achieving optimal outcomes, and enhance return to sport rates.

Level of Evidence

V, expert opinion.

Elite youth athletes' mental health and its relationship with the talent development environment: A variable- and person-centred approach

The present research sought to examine the prevalence of elite youth athletes' mental health and its relationship with talent development environments (TDEs). A sample of 248 Chinese elite youth athletes completed a self-report survey measuring demographic variables, TDE factors, and mental health outcomes including generalised anxiety disorder (GAD), depression, and athlete burnout. The results revealed moderate levels of burnout, with 19% of the participants meeting the diagnostic cut-off of GAD, and similar numbers for depression. The multiple regression analysis revealed alignment of expectations was the only TDE factor to significantly predict GAD and depression. Holistic quality preparation was the only significant TDE predictor of burnout. The results of cluster analysis suggested a three-cluster solution: cluster 1-"slightly below average TDE", cluster 2-"high TDE", and cluster 3-"very low TDE". Among the three clusters, cluster 2 had the lowest levels of GAD, depression, and burnout. Cluster 3 reported a higher burnout level than cluster 1, and the two clusters showed no differences in other two mental health outcomes. These findings suggest a need to manage mental health symptoms of elite youth athletes, and the roles of TDE could be considered in the management of mental health.

Athletes with Eating Disorders: Analysis of Their Clinical Characteristics, Psychopathology and Response to Treatment

Eating disorders (ED) have frequently been described among athletes. However, their specific features and therapy responses are lacking in the literature. The aims of this article were to compare clinical, psychopathological and personality traits between ED patients who were professional athletes (ED-A) with those who were not (ED-NA) and to explore differences in response to treatment. The sample comprised n = 104 patients with ED (n = 52 ED-A and n = 52 matched ED-NA) diagnosed according to DSM-5 criteria. Evaluation consisted of a semi-structured face-to-face clinical interview conducted by expert clinicians and a psychometric battery. Treatment outcome was evaluated when the treatment program ended. ED-A patients showed less body dissatisfaction and psychological distress. No differences were found in treatment outcome among the groups. Within the ED-A group, those participants who performed individual sport activities and aesthetic sports presented higher eating psychopathology, more general psychopathology, differential personality traits and poor therapy outcome. Individual and aesthetic sports presented more severity and worse prognosis. Although usual treatment for ED might be similarly effective in ED-A and ED-NA, it might be important to develop preventive and early detection programs involving sports physicians and psychologists, coaches and family throughout the entire athletic career and afterwards.

Mental health help-seeking preferences and behaviour in elite male rugby players

Objectives

Mental health symptoms and mental illnesses are common in elite athletes. There is an urgent need to develop care systems to support the mental health of elite athletes. Understanding elite athletes' preferences in mental health help seeking can help explore strategies to develop such systems. Therefore, this study aims to investigate with whom/where elite athletes feel comfortable discussing mental health concerns and seeking help.

Methods

We analyse data from 219 Japanese male rugby players out of 612 players (565 Japanese, 47 foreigners) aged 18 and over who belong to the Japan Rugby Players Association using a cross-sectional design and an anonymous, web-based, self-administered questionnaire. In the questionnaire, the players are asked to rate on a 5-point Likert scale how comfortable they feel talking about their mental health concerns with affiliation/team staff, family/relatives, friends, mental health professionals, rugby-related seniors and teammates. Analysis of variance and Dunnett's test are performed to detect differences in their preferences for sources of help.

Results

Dunnett's test shows that the mean scores for preferring to consult affiliation/team staff are significantly lower than for all the other groups (p<0.001), indicating that players are reluctant to seek help for mental health concerns from affiliation/team staff. Fewer players sought help from affiliation/team staff or mental health professionals than from other groups.

Conclusion

Regarding mental health concerns, for elite male rugby players as elite athletes, it can be difficult to ask for help or talk to team staff.

Burnout Syndrome in Selectable Athletes for the Brazilian Handball Team-Children Category

To investigate the presence of burnout syndrome in child athlete tryouts for the Brazilian Handball Team, before and after the National Development and Technical Improvement Camp is of great interest. A correlational study, with longitudinal design of the before-and-after type, carried out with 64 male athletes in the children's category, immersed in the National Camp for Development and Improvement of Handball Technique, in the municipality of São Bernardo do Campo, São Paulo, Brazil, in December 2018. To evaluate burnout syndrome, we used the Athlete Burnout Questionnaire (ABQ). There was a statistically significant increase of the mean scores for burnout and dimensions (Physical and Emotional Exhaustion = 1.5 to 1.6; p-value < 0.001; Reduced Sense of Accomplishment = 2.7 to 2.9; p-value < 0.001; Sports Devaluation = 1.4 to 1.6; p-value < 0.001; and General Burnout = 1.9 to 2.0; p-value < 0.001). The athletes selected for the national team had lower mean scores for general burnout and dimensions (Physical and Emotional Exhaustion = 1.5; Reduced Sense of Accomplishment = 2.7; Sports Devaluation = 1.5; General Burnout = 1.9). The National Camp for Development and Technical Improvement can have a negative impact on the mental health of athletes. This event is important to select the competitors with greater ability to face the pressure and adversities present in the sport environment.

Risk factors of lower extremity injuries in youth athletes

Objective

Lower extremity sports injuries frequently occur during an individual's growth period. The object of the current study was to analyse the risk factors for lower extremity sports injuries for youth athletes. The secondary objective was to clarify the factors related to new injuries after a lower extremity injury.

Methods

We extracted information on youth athletes (aged 10-15 years) with sports-related disorders. Background data and injury situations were collected via a specific application. During the follow-up period, new injuries were also recorded. The athletes were divided into two groups according to injury location (lower extremity or other). We performed a multiple logistic regression analysis to clarify the association between injury location and background data.

Results

1575 complaints of lower extremity disorders and 328 complaints in other body parts were registered. According to the multiple regression analysis, practice time per week was significantly shorter for the lower extremity group than the other locations group (OR 0.98; 95% CI 0.963 to 0.999). Athletes whose future goal was at the recreational level had a significantly low incidence of new injuries after experiencing lower extremity disorders.

Conclusion

The practice environments and psychological factors should receive more attention to prevent lower extremity injuries.

Sports psychiatry: a desideratum on sports arena!

The emerging field of sports psychiatry has been developing steadily in recent years. This is not just a health concern but is likely to impact sporting performance and achievement significantly. An overview of sports psychiatry is provided. Psychiatric disorders of all varieties can and do present in sporting populations. Sports psychiatry keeps evolving to drive forward the importance of good mental health in sport as in life.

EVALUATION OF ANXIETY AND DEPRESSION SYMPTOMS AMONG U-20 SOCCER ATHLETES IN RECIFE-PE: A CROSS-SECTIONAL STUDY

ABSTRACT Introduction Being a soccer player is one of the dreams most present in the popular imagination of Brazilian children. However, the path to professionalization is arduous and several reasons can be pointed out for this difficulty: a very competitive environment, few chances, and poor career counseling, among others. In competitive soccer, the athlete must be ready for all the demands that will be made, as well as accept the demand for the best possible performance. Furthermore, athletes from the youth system are still adolescents and youths in development, usually up to 21 years of age, who are often forced to choose soccer and its demands, at the expense of their studies and family lives, to become professional players. In this scenario, a still little-debated topic is mental health among soccer players. Objectives To verify the frequency of anxiety and depression symptoms among soccer players of the under-20 youth categories of Pernambuco clubs and to assess its association with sociodemographic, athletic, and health data. Methods The Hospital Anxiety and Depression Scale (HADS) was applied and socio-demographic, athletic, and health data were collected. A marginal descriptive analysis was conducted, as well as categorical and numerical assessments of anxiety- and depression-related variables. Finally, a linear regression study of the anxiety and depression scores was conducted. Results A statistically significant association was found between income received and an increase in anxiety symptoms. An increase in depressive symptoms as income decreased was also identified. Conclusion Further research with larger numbers of participants is needed, as well as with a greater variety of clubs, to better understand the relationship observed. Level of Evidence II; Prognostic study – Investigation of the effect of a patient characteristic on the outcome of their illness.

Effect of mindfulness-based programmes on elite athlete mental health: a systematic review and meta-analysis

OBJECTIVE

To determine the effectiveness of mindfulness-based programmes (MBPs) on the mental health of elite athletes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Eight online databases (Embase, PsycINFO, SPORTDiscus, MEDLINE, Scopus, Cochrane CENTRAL, ProQuest Dissertations & Theses and Google Scholar), plus forward and backward searching from included studies and previous systematic reviews.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies were included if they were randomised controlled trials (RCTs) that compared an MBP against a control, in current or former elite athletes.

RESULTS

Of 2386 articles identified, 12 RCTs were included in this systematic review and meta-analysis, comprising a total of 614 elite athletes (314 MBPs and 300 controls). Overall, MBPs improved mental health, with large significant pooled effect sizes for reducing symptoms of anxiety (hedges g=-0.87, number of studies (n)=6, p=0.017, I ²=90) and stress (g=-0.91, n=5, p=0.012, I ²=74) and increasing psychological well-being (g=0.96, n=5, p=0.039., I ²=89). Overall, the risk of bias and certainty of evidence was moderate, and all findings were subject to high estimated levels of heterogeneity.

CONCLUSION

MBPs improved several mental health outcomes. Given the moderate degree of evidence, high-quality, adequately powered trials are required in the future. These studies should emphasise intervention fidelity, teacher competence and scalability within elite sport.

PROSPERO REGISTRATION NUMBER

CRD42020176654.

Athlete Identity and Mental Health of Student Athletes during COVID-19

The purpose of our study is to evaluate athletic identity (AI) and mental health measures of youth and young adult athletes during the COVID-19 pandemic. This cross-sectional study recruited athletes aged 11-25 years from universities, high schools, and middle schools in California and New York. Participants were emailed a link to an anonymous, cross-sectional electronic survey. The measure included the athletic identity measurement scale (AIMS), the Patient Health Questionnaire-4 (PHQ-4), and demographic variables. Chi-square, Fisher's Exact Test, and linear regression were used to examine the relationships between AI, symptoms of anxiety, and symptoms of depression by age, gender, and race. The survey was completed by 653 participants. AI was stratified by tertiary percentiles. The odds of positively scoring for symptoms of anxiety were 60% higher for participants in college compared with high school (OR: 1.60, 95% CI: [1.09, 2.35]). Conversely, the odds of scoring positively for symptoms of depression were 68% higher for participants in high school compared to college (OR: 1.68, 95% CI: [1.09, 2.59]). The odds of scoring positively for symptoms of depression were higher for athletes who scored as high AI, compared to those who scored as moderate (OR: 1.72, 95% CI: [1.11, 2.68]) or low (OR: 1.93, 95% CI: [1.20, 3.12]). The odds of scoring positively for symptoms of anxiety on the PHQ-4 were 3.2 times higher for participants who identified as female (OR: 3.19, 95% CI: [2.31, 4.41]), and the odds of scoring positively for symptoms of depression were 2.4 times higher for participants who identified as female (OR: 2.35, 95% CI: [1.56, 3.54]). Female athletes experienced symptoms of depression and anxiety at significantly higher rates than male athletes during the COVID-19 pandemic. High school students experienced fewer symptoms of anxiety, but greater symptoms of depression as compared to the collegiate group, while college students experienced greater odds of symptoms of anxiety. Athletes in the high AI group were more likely to report symptoms of depression than moderate or low identity groups. Female athletes reported lower AI than male athletes, but still had greater symptoms of anxiety and depression.

Analysis of Progressive Muscle Relaxation on Psychophysiological Variables in Basketball Athletes

The purpose of this study was to evaluate the effects of a progressive muscle relaxation program on psychological (stress levels, anxiety, and mood states) and physiological (blood pressure and heart rate) variables in basketball athletes. Fifty-nine basketball players, aged 14 to 19 years, and members of Bauru Basket team, were recruited for this study and grouped into control group (CG, n = 30) and intervention group (IG, n = 29). The participants were evaluated, before and after the intervention, by the following means: Competitive State Anxiety Inventory-2 (CSAI-2), to measure the pre-competitive anxiety state, i.e., how anxious each athlete felt just before the competition; Brunel Mood Scale (BRUMS), an instrument for early detection of overtraining syndrome; Recovery-Stress Questionnaire for Athletes (RESTQ-Sport), to identify the extent to which each athlete was physically or mentally stressed and the athlete's current capability for recovery; Athlete Burnout Questionnaire (ABQ), specifically developed for athletes. The IG athletes participated in 12 progressive muscle relaxation sessions, a practice for tensing or tightening a specific muscle until an ideal state of relaxation is reached. Each participant had blood pressure and heart rate measured before and after every session. The CG athletes were evaluated similarly to those in the IG but without relaxation. The results showed statistically significant differences in cognitive anxiety (p = 0.039) and specific stress (p = 0.016) between CG and IG before the intervention; in addition, a significant heart rate decrease (p < 0.01) between IG and CG was noted.

Competing against COVID-19: what about the mental health problems of athletes with disabilities?

OBJECTIVES

Although there is growing interest in athletes' mental health (MH), there is a paucity of research exploring MH in athletes with disabilities (AWD). The purpose of this study was to evaluate the impact of the COVID-19 pandemic on the psychological state of AWD.

MATERIALS AND METHODS

An online survey including demographic questions, SARS-CoV-2-related questions, and standardized scales assessing depression, anxiety, stress, coronavirus anxiety (CAS), and nonspecific psychological distress was distributed to AWD.

RESULTS

A total of 362 athletes (183 AWD) participated in the study (response rate 31.2%). AWD infected with SARS-CoV-2 reported higher depression, anxiety, and CAS scores than AWD not infected with SARS-CoV-2 (Z = -2.10, ES = 0.15 Z = -3.45, ES = 0.25; Z = -2.43, ES = 0.18; respectively). Female AWD reported higher anxiety scores compared to males (Z = -2.25, ES = 0.16). Depression (Z = -2.80, ES = 0.20), stress (Z = -2.12, ES = 0.15) and K-10 (Z = -2.02, ES = 0.14 scores of individual sport AWD were higher than team sports AWD.

CONCLUSION

MH problems in AWD were associated with a wide range of variables such as being infected with SARS-CoV-2, female gender, competing in an individual sport, and having performance concerns. In light of these results, MH assessment should be undertaken for AWD to ensure appropriate and timely intervention.

National vs. Non-National Soccer Referee: Physiological, Physical, and Psychological Characteristics

Purpose: The objectives of the present study were to analyze the relationship between psychological variables (self-esteem, anxiety and self-confidence) assessed before the competition and physical and physiological responses demonstrated during the competition in soccer referees and to compare these psychophysical and physiological responses by category (CAT; national and non-national). Method: A total of 153 soccer referees participated (age Mage = 23.2; SD = 4.8 years; experience Mage = 6.0; SD = 4.5 years) in the study. The CSAI-2 and Rosenberg questionnaires were conducted before the match, and match performance data were collected using GPS devices. Results: The results showed significant differences in self-esteem and self-confidence across CATs (p < .001; d > .84). The national referees had higher psychological and physical-physiological responses (mean and maximum heart rate) Some correlations were observed among the psychophysical and physiological responses, CAT and age, demonstrating that the age could explain up to 48.4% of the variance the referee CAT (p < .001) and this CAT could explain self-esteem, anxiety and self-confidence by up to 20% of the variance. Conclusions: national referees presented better psychological responses prior to the competition, and also obtained greater physical and physiological records, which could be translated into a better position on the pitch in conflicting plays in order to make a right and just decision.

Perceptions of Concussion and Associated Anxiety in Irish Collegiate Athletes

BACKGROUND

Concussion nondisclosure and poor management after a concussion are a concern in Irish collegiate sports. How athletes perceive concussions and appraise their own concussion may affect their decisions and behaviors after a suspected concussion. However, this has yet to be examined in an Irish context. This study aimed to (1) establish concussion perceptions and associated anxiety in Irish collegiate athletes; (2) examine how sex, concussion, and mood disorder history influenced their perceptions; and (3) investigate factors associated with higher anxiety perceptions.

HYPOTHESIS

Irish collegiate athletes will display negative concussion perceptions and anxiety related to concussion, especially in female athletes and those without a concussion history.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 3.

METHODS

Irish collegiate athletes [n = 268 (141 women,127 men), mean age = 21.5 ± 2.2 years] from high-risk sports completed a survey including the Perceptions of Concussion Inventory for Athletes (PCI-A), demographics, diagnosed concussion history, self-reported mood disorder history, and a concussion knowledge assessment. Differences in concussion perceptions by sex, concussion history, mood disorder history were examined using Mann-Whitney U tests, and factors associated with anxiety-related concussion perceptions were identified using multivariate logistic regression.

RESULTS

Over half (53.0%, n = 142) of participants reported concerns regarding concussion. The thoughts of sustaining a concussion made participants feel upset (63.4%, n = 170), fearful (47.7%, n = 128), and anxious (35.1%, n = 94). Women reported significantly higher anxiety (P < 0.01, r = 0.23), effects (P = 0.04, r = 0.12), and clarity (P = 0.01, r = 0.16) perception scores. Participants with a diagnosed concussion history displayed greater symptom variability perception scores (P = 0.04, r = 0.12), but lower anxiety (P = 0.03, r = 0.13) and treatment (P < 0.01, r = 0.19) beliefs on the PCI-A. No differences were observed for those with a history of a mood disorder (P > 0.05). A significant multivariate model was established (χ² = 55.44, P < 0.01), with female sex [odds ratio (OR) = 1.53], concussion history (OR = 0.63), effects (OR = 1.31), and treatment (OR = 1.15) subscales associated with greater anxiety.

CONCLUSION

Concerns about sustaining a concussion are prevalent in Irish collegiate athletes. Women displayed more negative perceptions and those with a concussion history displayed fewer perceived benefits of treatment.

CLINICAL RELEVANCE

The findings support the need for concussion awareness campaigns to provide accurate concussion information to mitigate anxiety-related concussion perceptions and injury belief misconceptions.

Influence of Competition on Anxiety and Heart Rate Variability in Young Tennis Players

The aim of this study was to analyze the effect of competition on anxiety and heart rate variability (HRV) in tennis players. Thirty tennis players (15 boys and 15 girls) were included in the study. In boys, the mean age was 14.53 years, mean height was 169.20 cm and mean weight was 60.60 kg. In girls, the mean age was 13.60 years, mean height was 164.07 cm and mean weight was 53.33 kg. Competitive anxiety was measured using the Competitive Anxiety Inventory-2 (CSAI-2) and the State Trait Anxiety Inventory (STAI). HRV was also analyzed using a validated HR chest band (Polar H7). These measurements were performed at two different times, before training and before competing, both times maintaining the same conditions for the participants. In addition, a gender differentiation was carried out. Somatic anxiety and state anxiety were significantly higher at the pre-competition time compared to the pre-training time (p < 0.05). On the contrary, the rest of the variables did not present significant differences between conditions (p > 0.05). On the other hand, no correlation was observed between anxiety and heart rate variability either before competition or before training. As for gender differentiation, significant differences were obtained between males and females in state anxiety and heart rate, identifying higher values in females.

Anxiety, insomnia, and depression during COVID-19 lockdown in elite individual and team sport athletes

PURPOSE

Pandemic-induced lockdowns disrupted sport training and competition. We aimed to identify the impact on the mental health of high-level athletes and clarify whether the effects differ for team-based and individual athletes.

METHODS

This cross-sectional survey, stratified by sex and sport type, collected demographic data and mental health measurements from 274 Brazilian high-performance athletes (142 from team sports and 132 from individual sports) involved with the Brazilian Olympic Committee program for the Tokyo Olympics 2021. Depression, disturbed sleep, and anxiety were assessed by the 9-Item Patient Health Questionnaire, 7-Item Insomnia Severity Index, and 7-Item Generalized Anxiety Disorder scale respectively. Responses were analyzed dichotomously according to published threshold values, characterizing the relative frequency distribution of prevalence (PCRS) or non-prevalence of clinically relevant symptoms (NPCRS).

RESULTS

Out of all participants, 47 [17.1%], Z(274) = 15.38, p = .001, 32 [11.7%], Z(274) = 17.94, p = .001, and 49 [17.9%], Z(274) = 15.04, p = .001 had PCRS of anxiety, insomnia, and depression, respectively. There were no significant differences in the PCRS among genders. Compared with individual sport athletes, team sport athletes were more likely to report PCRS of insomnia (12 [37.5%] vs 20 [62.5%], Z(274) = -2.00, p = .046), and depression (18 [36.7%] vs 31 [63.3%], Z(274) = -2.63, p = .009) but not for anxiety.

CONCLUSION

Athletes reported high levels of mental health problems during the lockdown. Team sport athletes reported worse symptoms of insomnia and depression than individual sport athletes, possibly due to the impact of unaccustomed social isolation and lack of social team activity. Therefore, it becomes relevant to consider psychological support to team sport athletes who for some reason, such as a pandemic, enduring crisis even injury rehabilitation needs to be isolated.

COVID-19-related impact on mental health and career uncertainty in student-athletes—Data from a cohort of 7,025 athletes in an elite sport high school system in Sweden

Objectives

Mental health consequences and behavior change has been described in elite athletes following the vast impact of the COVID-19 pandemic on the world of sports. However, most study samples have been of limited size, and few studies have assessed student-athletes. This study aimed to analyze perceived mental health impact, measured as clinical degree of depression and anxiety, worry about one's sport and about one's career, and behavioral change with respect to video gaming behavior, in high-school athletes in Sweden.

Methods

Data on anxiety and depression as well as on perceived behavioral changes during COVID-19 were collected from students at sports high schools in Sweden (N = 7,025) in February 2021, during the ongoing COVID-19 pandemic.

Results

Sixteen and 14% met criteria of moderate/severe depression and anxiety, respectively. Many respondents reported feeling mentally worse during the pandemic (66%), and were worried about the future of their sport (45%) or about their own future in sports (45%). Increased gaming behavior during COVID-19 was reported by 29%. All mental health variables were significantly more common in women, except increased gaming (more common in men). Being worried about one's career was less common in winter sports, more common in team sports and more common in older student-athletes, and associated with both depression and anxiety in regression analyses.

Discussion

Self-reported mental health impact of COVID-19 is substantial in student-athletes, and even more so in women and in team sports. The lower impact in winter athletes suggests a moderating effect of the seasons in which the COVID-19 outbreak occurred.

Risk and protective factors for mental ill-health in elite para- and non-para athletes

Objective

To apply a socioecological approach to identify risk and protective factors across levels of the “sports-ecosystem,” which are associated with mental health outcomes among athletes in para-sports and non-para sports. A further aim is to determine whether para athletes have unique risks and protective factor profiles compared to non-para athletes.

Methods

A cross-sectional, anonymous online-survey was provided to all categorized (e.g., highest level) athletes aged 16 years and older, registered with the Australian Institute of Sport (AIS). Mental health outcomes included mental health symptoms (GHQ-28), general psychological distress (K-10), risky alcohol consumption (AUDIT-C) and eating disorder risk (BEDA-Q). Risk and protective factors across multiple levels of the socioecological model, including individual, microsystem, exosystem and macrosystem level factors were assessed via self-report.

Results

A total of 427 elite athletes (71 para and 356 non-para athletes) participated in the study. No significant differences in the rates of mental health problems were observed between para and non-para athletes. Both differences and similarities in risk and protective factor profiles were found across the multiple levels of the sports-ecosystem. Weak evidence was also found to support the hypothesis that certain risk factors, including experiencing two or more adverse life events in the past year, sports related concussion, high self-stigma, inadequate social support and low psychological safety conferred a greater risk for poorer mental health outcomes for para athletes in particular.

Conclusion

Risk factors occurring across various levels of the sports ecosystem, including individual, interpersonal and organizational level risk factors were found to be associated with a range of poorer mental health outcomes. The association between mental ill-health and certain risk factors, particularly those at the individual and microsystem level, appear to be greater for para athletes. These findings have important implications for policy and mental health service provision in elite sports settings, highlighting the need for more nuanced approaches to subpopulations, and the delivery of mental health interventions across all levels of the sports ecosystem.

Demographic, psychosocial, and physical fitness predictors of successful graduation from U.S. Army Ranger School

U.S. Army Ranger School is an arduous 64-day leadership training course designed to simulate the stressors of combat. Although physical fitness has been shown to be an important predictor of successful graduation for Ranger School, psychosocial characteristics like self-efficacy and grit have not been examined. The purpose of this study is to identify personal, psychosocial, and fitness characteristics associated with successful completion of Ranger School. This study was a prospective cohort examining the association of baseline characteristics of Ranger School candidates with a primary outcome of graduation success. Multiple logistic regression was performed to determine the contribution of demographics, psychosocial, fitness and training characteristics to graduation success. Out of 958 eligible Ranger Candidates, this study obtained graduation status for 670 students, 270 (40%) of which graduated. Soldiers who graduated were younger, more likely to come from units with a higher proportion of previous Ranger School graduates, had higher self-efficacy and faster 2-mile run times. The results from this study suggest that Ranger students should arrive in optimal physical conditioning. Furthermore, training programs that optimize student self-efficacy and units with a high proportion of successful Ranger graduates may confer advantage for this challenging leadership course.

COVID-19 Lockdown: A Global Study Investigating the Effect of Athletes' Sport Classification and Sex on Training Practices

PURPOSE

To investigate differences in athletes' knowledge, beliefs, and training practices during COVID-19 lockdowns with reference to sport classification and sex. This work extends an initial descriptive evaluation focusing on athlete classification.

METHODS

Athletes (12,526; 66% male; 142 countries) completed an online survey (May-July 2020) assessing knowledge, beliefs, and practices toward training. Sports were classified as team sports (45%), endurance (20%), power/technical (10%), combat (9%), aquatic (6%), recreational (4%), racquet (3%), precision (2%), parasports (1%), and others (1%). Further analysis by sex was performed.

RESULTS

During lockdown, athletes practiced body-weight-based exercises routinely (67% females and 64% males), ranging from 50% (precision) to 78% (parasports). More sport-specific technical skills were performed in combat, parasports, and precision (∼50%) than other sports (∼35%). Most athletes (range: 50% [parasports] to 75% [endurance]) performed cardiorespiratory training (trivial sex differences). Compared to prelockdown, perceived training intensity was reduced by 29% to 41%, depending on sport (largest decline: ∼38% in team sports, unaffected by sex). Some athletes (range: 7%-49%) maintained their training intensity for strength, endurance, speed, plyometric, change-of-direction, and technical training. Athletes who previously trained ≥5 sessions per week reduced their volume (range: 18%-28%) during lockdown. The proportion of athletes (81%) training ≥60 min/session reduced by 31% to 43% during lockdown. Males and females had comparable moderate levels of training knowledge (56% vs 58%) and beliefs/attitudes (54% vs 56%).

CONCLUSIONS

Changes in athletes' training practices were sport-specific, with few or no sex differences. Team-based sports were generally more susceptible to changes than individual sports. Policy makers should provide athletes with specific training arrangements and educational resources to facilitate remote and/or home-based training during lockdown-type events.

Non-Cardiac Conditions that Mimic Cardiac Symptoms in Athletes

When considering the variety of complaints an athlete can present with, chest pain is arguably the most concerning given the potential for catastrophic outcomes. Luckily, these do not comprise the majority of cases, and indeed, are quite rare. The bulk of presentations of athletes with chest pain are due to musculoskeletal, gastrointestinal, and pulmonary causes. Each and every healthcare provider who works closely with athletes must have a thorough understanding of contributing conditions that present as chest pain. Here, we explore some of the more prevalent causes of non-cardiac chest pain, classic presentations, and management considerations.