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Lundqvist C, Schary DP, Jacobsson J, Korhonen L, Timpka T. Aligning categories of mental health conditions with intervention types in high-performance sports: A narrative cornerstone review and classification framework. J Sci Med Sport 2024; 27:525-531. [PMID: 38796375 DOI: 10.1016/j.jsams.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/16/2024] [Accepted: 05/07/2024] [Indexed: 05/28/2024]
Abstract
Epidemiological studies suggest that psychiatric disorders are as prevalent amongst high-performance athletes as in general populations, challenging the myth of invulnerability. Despite efforts of sport organisations to highlight the significance of athletes' mental health, it is still many times tough to combine the sport performance ethos with a discourse on mental health. This narrative cornerstone review examines challenges related to definitions and classifications of athlete mental health in high-performance sports and how these influence assessments and the implementation of interventions. We discuss challenges with concept creep and psychiatrisation and outline their consequences for sport healthcare professionals. Based on this, we present a framework that aligns different categories of athlete mental health conditions (from the reduction of wellbeing to psychiatric disorders) with intervention types (from the provision of supporting environments to pharmacotherapy). We conclude that researchers and sport practitioners need to carefully consider conceptual creep and the risk of pathologising normal and healthy, albeit emotionally aversive, reactions to athlete lifeworld events when assessing athlete mental health. A clear separation of terminology denoting the athlete's resources to handle the lifeworld (including salutogenic factors) and terms describing psychiatric conditions and their management is necessary to avoid misguidance in intervention planning.
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Affiliation(s)
- Carolina Lundqvist
- Department of Behavioural Sciences and Learning, Linköping University, Sweden; Athletics Research Center, Linköping University, Sweden.
| | - David P Schary
- Department of Physical Education, Sport and Human Performance, Winthrop University, USA. https://twitter.com/DrDavidSchary
| | - Jenny Jacobsson
- Athletics Research Center, Linköping University, Sweden; Department of Health, Medicine and Caring Sciences, Division of Society and Health, Linköping University, Sweden
| | - Laura Korhonen
- Barnafrid and Department of Biomedical and Clinical Sciences, Linköping University, Sweden
| | - Toomas Timpka
- Athletics Research Center, Linköping University, Sweden; Department of Health, Medicine and Caring Sciences, Division of Society and Health, Linköping University, Sweden; Regional Executive Office, Region Östergötland, Sweden
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2
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Ahmad CS, Hellwinkel JE, Ahmed R, Alexander FJ, Reynolds AW, Piasecki DP, Bottiglieri TS, Lynch TS, Popkin CA, Saltzman BM, Trofa DP. Impacts of the Early COVID-19 Pandemic on Depressive Symptoms and Mental Health Among Student-Athletes. Open Access J Sports Med 2024; 15:19-28. [PMID: 38523629 PMCID: PMC10959820 DOI: 10.2147/oajsm.s392977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 07/06/2023] [Indexed: 03/26/2024] Open
Abstract
Objective Social distancing protocols due to the COVID-19 pandemic resulted in premature ending of athletic seasons and cancellation of upcoming seasons, placing significant stress on young athletes. Inability to play or forced early retirement has significant consequences on athlete's mental health, as demonstrated by an extensive body of injury literature. We hypothesize that premature suspension and cancellation of athletic events due to the COVID-19 pandemic leads to higher incidence of depressive symptoms among high-school and collegiate athletes. Further, athletes who strongly derive their sense of self-worth centered around athletics would have higher rates of depressive symptoms. Methods High school and collegiate athletes were evaluated for depressive symptoms, emotional health and athletic identity measures through validated assessment instruments from May 2020 through July 2020. The Patient-Reported Outcomes Measurement Information System Depression Computer Adaptive Test (PROMIS-10 Depression CAT), Veterans RAND-12 (VR-12), which comprises both a physical and mental health component, and Athletic Identity Measurement Scale (AIMS) were utilized. Results Mental health assessments were completed by 515 athletes (52.4% male, 47.6% female; .84.5% collegiate, 15.5% high school). Female athletes scored significantly worse than males on VR-12 mental health assessments, as well as PROMIS-10 Depression scores; however, males scored significantly lower than females on VR-12 physical health assessments, irrespective of education level. Athletes who had strong associations with athletics as central to their personal identity exhibited worse psychologic impact on VR-12 mental health and PROMIS-10 Depression measures and female athletes in this cohort reported greater depressive symptoms than males. Conclusion Social distancing protocols due to the COVID-19 pandemic have limited athlete's ability to participate in sports at the training and competition level. Higher rates of depressive symptoms in high school and college athletes have resulted among female athletes and those who identify strongly as an athlete.
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Affiliation(s)
- Christopher S Ahmad
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Justin E Hellwinkel
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Rifat Ahmed
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Frank J Alexander
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Alan W Reynolds
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Dana P Piasecki
- Sports Medicine Center, OrthoCarolina, Charlotte, NC, 28207, USA
- Musculoskeletal Institute, Atrium Health, Charlotte, NC, 28207, USA
| | - Thomas S Bottiglieri
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - T Sean Lynch
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Charles A Popkin
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, 10032, USA
| | - Bryan M Saltzman
- Sports Medicine Center, OrthoCarolina, Charlotte, NC, 28207, USA
- Musculoskeletal Institute, Atrium Health, Charlotte, NC, 28207, USA
| | - David P Trofa
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, 10032, USA
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3
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Reardon CL, Gorczynski P, Hainline B, Hitchcock M, Rice S. Anxiety Disorders in Athletes. Clin Sports Med 2024; 43:33-52. [PMID: 37949513 DOI: 10.1016/j.csm.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
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.
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Affiliation(s)
- Claudia L Reardon
- Department of Psychiatry, University of Wisconsin School of Medicine and Public Health, 6001 Research Park Boulevard, Madison, WI 53719, USA.
| | - Paul Gorczynski
- Psychology and Counselling, School of Human Sciences, University of Greenwich, Old Royal Naval College, Park Row, Greenwich SE10 9LS, UK
| | - Brian Hainline
- National Collegiate Athletic Association, 700 West Washington Street, PO Box 6222, Indianapolis, IN 46206, USA
| | - Mary Hitchcock
- University of Wisconsin-Madison, Ebling Library for the Health Sciences, 2339 Health Sciences Learning Center, 750 Highland Avenue, Madison, WI 53705, USA
| | - Simon Rice
- Orygen, 35 Poplar Road, Parkville, Melbourne, Australia; Centre for Youth Mental Health, The University of Melbourne, Locked Bag 10, Parkville, Melbourne, Australia
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4
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Edwards CD. Management of Mental Health Challenges in Athletes: Screening, Pharmacology, and Behavioral Approaches. Clin Sports Med 2024; 43:13-31. [PMID: 37949507 DOI: 10.1016/j.csm.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Athletes are incredibly motivated and perpetually pursuing dominance in skill, strength, endurance, and execution-often while balancing many additional responsibilities. Despite the appearance of living fun, luxurious, care-free lifestyles, they are vulnerable to exceptional stressors and the same mental health challenges as the general population. The use of screening tools and assessment guided by a biopsychosocial framework can assist in understanding the factors that contribute to the athlete's mental health status. This can facilitate the development of a targeted management approach to mental health challenges.
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Affiliation(s)
- Carla D Edwards
- Department of Psychiatry and Behavioural Neurosciences, McMaster University, St. Joseph's Healthcare Hamilton West 5th Campus, Administration B3, 100 West 5th Street, Hamilton, Ontario L8N 3K7, Canada. https://twitter.com/Edwards10Carla
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5
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Beable SE. Depressive Disorders in Athletes. Clin Sports Med 2024; 43:53-70. [PMID: 37949514 DOI: 10.1016/j.csm.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Depressive disorders in athletes are thought to be at least as common as the general population. However, athletes have a unique set of risk factors that can affect the likelihood of developing depression. Screening tools have been developed specifically for athletes such as the Sport Mental Health Assessment Tool (SMHAT). The management of the depressed athlete should involve an individualized approach, with methods such as counseling, interpersonal therapy, or cognitive behavioral therapy being used. Some may require antidepressant medication. Depressive disorders are also linked to sucidality in athletes, and the team physician and sporting organisation should have a crisis management plan in place for mental health emergencies. Tackling the stigma that remains in sport is a key part to improving mental wellbeing for all athletes.
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Affiliation(s)
- Sarah E Beable
- High Performance Sport New Zealand, Axis Sports Medicine Specialists, 15/5 Hawthorne Drive, Queenstown 9304, New Zealand.
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6
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Myall K, Montero-Marin J, Gorczynski P, Kajee N, Syed Sheriff R, Bernard R, Harriss E, Kuyken W. Effect of mindfulness-based programmes on elite athlete mental health: a systematic review and meta-analysis. Br J Sports Med 2023; 57:99-108. [PMID: 36223914 DOI: 10.1136/bjsports-2022-105596] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2022] [Indexed: 01/07/2023]
Abstract
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.
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Affiliation(s)
- Kearnan Myall
- Department of Psychiatry, Oxford University, Oxford, UK
| | - Jesus Montero-Marin
- Department of Psychiatry, Oxford University, Oxford, UK .,Teaching, Reseach and Innovation Unit, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, Spain
| | - Paul Gorczynski
- School of Human Science, University of Greenwich, London, UK
| | - Nabeela Kajee
- Department of Psychiatry, Oxford University, Oxford, UK
| | - Rebecca Syed Sheriff
- Department of Psychiatry, Oxford University, Oxford, UK.,Oxford Health NHS Foundation Trust, NHS, Oxford, UK
| | - Robert Bernard
- Department of Education, Concordia University, Montreal, Quebec, Canada
| | - Eli Harriss
- Bodleian Health Care Libraries, Oxford University, Oxford, UK
| | - Willem Kuyken
- Department of Psychiatry, Oxford University, Oxford, UK
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7
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Vella SA, Schweickle MJ, Sutcliffe J, Liddelow C, Swann C. A Systems Theory of Mental Health in Recreational Sport. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:14244. [PMID: 36361123 PMCID: PMC9656761 DOI: 10.3390/ijerph192114244] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 09/24/2022] [Accepted: 09/28/2022] [Indexed: 06/16/2023]
Abstract
The focus on mental health outcomes in sport, including the ways in which mental health can be protected and promoted, has become a major international priority for all sports, including the recreational sports system. The aim of this paper is to outline a systems theory of mental health care and promotion that is specific to needs of the recreational sport system so that context-specific, effective policies, interventions, and models of care can be articulated and tested. Based on general systems theory, we offer a preliminary theory and accompanying postulates that outline the general principles that explain mental health in recreational sports. Namely: one of the purposes of the recreational sport system is to protect and promote the mental health of all involved; the recreational sport system is comprised of components (individuals, groups, organisations, communities, society); the role and function of those components vary by context; the purpose of the system is achieved through coordinated and reciprocal relationships between its components; and, the system should be regulated from within to ensure that mental health is protected and promoted. We have also outlined the ways in which the subcomponents of the system interact, their potential influence on mental health in recreational sports, and the ways in which they may be regulated. This information provides a theoretical foundation upon which research, programming, and policy can be based to protect and promote the mental health of all involved in recreational sports.
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Affiliation(s)
- Stewart A. Vella
- School of Psychology, University of Wollongong, Wollongong, NSW 2522, Australia
- Global Alliance for Mental Health and Sport, University of Wollongong, Wollongong, NSW 2500, Australia
| | - Matthew J. Schweickle
- School of Psychology, University of Wollongong, Wollongong, NSW 2522, Australia
- Global Alliance for Mental Health and Sport, University of Wollongong, Wollongong, NSW 2500, Australia
| | - Jordan Sutcliffe
- School of Psychology, University of Wollongong, Wollongong, NSW 2522, Australia
- Global Alliance for Mental Health and Sport, University of Wollongong, Wollongong, NSW 2500, Australia
| | - Caitlin Liddelow
- School of Psychology, University of Wollongong, Wollongong, NSW 2522, Australia
- Global Alliance for Mental Health and Sport, University of Wollongong, Wollongong, NSW 2500, Australia
| | - Christian Swann
- Physical Activity, Sport, and Exercise Research Theme, Faculty of Health, Southern Cross University, Coffs Harbour, NSW 2450, Australia
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8
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Psychosocial aspects of sports medicine in pediatric athletes: Current concepts in the 21 st century. Dis Mon 2022:101482. [PMID: 36100481 DOI: 10.1016/j.disamonth.2022.101482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Behavioral aspects of organized sports activity for pediatric athletes are considered in a world consumed with winning at all costs. In the first part of this treatise, we deal with a number of themes faced by our children in their sports play. These concepts include the lure of sports, sports attrition, the mental health of pediatric athletes (i.e., effects of stress, anxiety, depression, suicide in athletes, ADHD and stimulants, coping with injuries, drug use, and eating disorders), violence in sports (i.e., concepts of the abused athlete including sexual abuse), dealing with supervisors (i.e., coaches, parents), peers, the talented athlete, early sports specialization and sports clubs. In the second part of this discussion, we cover ergolytic agents consumed by young athletes in attempts to win at all costs. Sports doping agents covered include anabolic steroids (anabolic-androgenic steroids or AAS), androstenedione, dehydroepiandrostenedione (DHEA), human growth hormone (hGH; also its human recombinant homologue: rhGH), clenbuterol, creatine, gamma hydroxybutyrate (GHB), amphetamines, caffeine and ephedrine. Also considered are blood doping that includes erythropoietin (EPO) and concepts of gene doping. In the last section of this discussion, we look at disabled pediatric athletes that include such concepts as athletes with spinal cord injuries (SCIs), myelomeningocele, cerebral palsy, wheelchair athletes, and amputee athletes; also covered are pediatric athletes with visual impairment, deafness, and those with intellectual disability including Down syndrome. In addition, concepts of autonomic dysreflexia, boosting and atlantoaxial instability are emphasized. We conclude that clinicians and society should protect our precious pediatric athletes who face many challenges in their involvement with organized sports in a world obsessed with winning. There is much we can do to help our young athletes find benefit from sports play while avoiding or blunting negative consequences of organized sport activities.
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9
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Ekelund R, Holmström S, Stenling A. Mental Health in Athletes: Where Are the Treatment Studies? Front Psychol 2022; 13:781177. [PMID: 35859831 PMCID: PMC9289539 DOI: 10.3389/fpsyg.2022.781177] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
In recent years, athletes’ mental health has gained interest among researchers, sport practitioners, and the media. However, the field of sport psychology lacks empirical evidence on the effectiveness of psychotherapeutic interventions for mental health problems and disorders in athletes. Thus far, intervention research in sport psychology has mainly focused on performance enhancement using between-subject designs and healthy athlete samples. In the current paper, we highlight three interrelated key issues in relation to treating mental health problems and disorders in athletes. (i) How are mental health and mental health problems and disorders defined in the sport psychology literature? (ii) How are prevalence rates of mental health problems and disorders in athletes determined? (iii) What is known about psychotherapeutic interventions for mental health problems and disorders in athletes? We conclude that the reliance on different definitions and assessments of mental health problems and disorders contributes to heterogeneous prevalence rates. In turn, this limits our understanding of the extent of mental health problems and disorders in athletes. Furthermore, knowledge of the effectiveness of psychotherapeutic interventions for athletes with mental health problems and disorders is scarce. Future research should include athletes with established mental health problems and disorders in intervention studies. We also propose an increased use of N-of-1 trials to enhance the knowledge of effective psychotherapeutic interventions in this population.
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Affiliation(s)
- Rebecka Ekelund
- Department of Psychology, Umeå University, Umeå, Sweden
- Umeå School of Sport Sciences, Umeå University, Umeå, Sweden
- *Correspondence: Rebecka Ekelund,
| | - Stefan Holmström
- Department of Psychology, Umeå University, Umeå, Sweden
- Umeå School of Sport Sciences, Umeå University, Umeå, Sweden
| | - Andreas Stenling
- Department of Psychology, Umeå University, Umeå, Sweden
- Umeå School of Sport Sciences, Umeå University, Umeå, Sweden
- Department of Sport Science and Physical Education, University of Agder, Kristiansand, Norway
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10
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Forys WJ, Tokuhama-Espinosa T. The Athlete’s Paradox: Adaptable Depression. Sports (Basel) 2022; 10:sports10070105. [PMID: 35878116 PMCID: PMC9320389 DOI: 10.3390/sports10070105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 06/22/2022] [Accepted: 06/27/2022] [Indexed: 02/01/2023] Open
Abstract
We proposed that an athlete’s depressive symptoms may be different from the general population in etiology if considered from the context of a depressive disorder. By shifting focus from a limited notion of symptoms onto a comprehensive model of depression, the full scope of the phenomenon becomes clearer. This paper investigated the relationship between neurotransmitters and allostatic load to explain the incidence of depression among elite athletes. This literature review extensively analyzed exercise-induced neurohormonal imbalance resulting in depressive states among athletes. The research revealed that 5-HTTLPR polymorphism, brain-derived neurotrophic factor (BDNF), extensive psychological demands, social stigma, and overtraining syndrome (OTS) may all contribute to a unique version of depression. The research revealed that the biological standards of athletes differ from those of non-athletes, to the point that the new model may be useful, thereby introducing the new term “Adaptable Depression (AD)” to the literature. This framework suggests a new direction for future research to precisely measure the neurotransmitter-related brain changes that result in “Adaptable Depression” in athletes and to establish a better understanding of the depressive tipping point.
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Affiliation(s)
- Weronika Jasmina Forys
- Division of Continuing Education, Harvard University, 51 Brattle Street, Cambridge, MA 01238, USA
- Correspondence:
| | - Tracey Tokuhama-Espinosa
- Faculty of Arts and Sciences, Extension School, Harvard University, 51 Brattle Street, Cambridge, MA 01238, USA;
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11
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Ojio Y, Matsunaga A, Kawamura S, Horiguchi M, Yoshitani G, Hatakeyama K, Amemiya R, Kanie A, Fujii C. Anxiety and Depressive Symptoms in the New Life With COVID-19: A Comparative Cross-Sectional Study in Japan Rugby Top League Players. Int J Public Health 2022; 66:1604380. [PMID: 35115903 PMCID: PMC8803632 DOI: 10.3389/ijph.2021.1604380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 12/16/2021] [Indexed: 11/23/2022] Open
Abstract
Objectives: The primary objective is to compare the prevalence of mental health problems, including psychological distress, anxiety and depressive symptoms in Japan Rugby Top League players in the new life with COVID-19 with those evaluated before COVID-19. Methods: An observational comparative web-based cross-sectional study was employed for Japan Rugby Top League players. We compared the data from 220 Japanese and 7 foreign players during the new life with COVID-19 with the data from before COVID-19, which was obtained from 233 Japanese and 18 foreign players. We measured anxiety and depression symptoms with the validated Kessler-6, which has been widely used in clinical and research settings among different populations. To investigate the distribution of K6 score and whether there are discrete clusters or not, we conducted the two-step cluster analysis. Results: In the new life with COVID-19, 15.0% of players reported mild symptoms, which was significantly lower than the 32.3% of players before COVID-19. The prevalence of moderate and severe symptoms was 6.7 and 3.5%, respectively, in the group during the new life with the COVID-19, and 4.8 and 5.2% in the pre-COVID-19 group, with no significant difference. A two-step cluster analysis supported the existence of these two qualitatively different clusters in both groups. Conclusions: With the spread of new lifestyles related to COVID-19, some rugby players may have improved mental health status due to changes in their daily living environment. Such environmental adjustments alone may not have been sufficient to change the mental health status of others. Rugby players or their teams may require mental health professionals and systems that ensure rest, adjust the environment, and sustainably provide more professional care.
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Affiliation(s)
- Yasutaka Ojio
- Department of Community Mental Health and Law, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
- *Correspondence: Yasutaka Ojio,
| | - Asami Matsunaga
- Department of Community Mental Health and Law, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
| | | | | | | | | | - Rei Amemiya
- Faculty of Health and Sports Sciences, University of Tsukuba, Tsukuba, Japan
| | - Ayako Kanie
- National Center for Cognitive Behavioral Therapy and Research, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Chiyo Fujii
- Department of Community Mental Health and Law, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
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12
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Abstract
ABSTRACT Athletes at all levels of competition are susceptible to mental health symptoms and disorders, and this has been a topic of increased research attention in recent years. The most common such conditions will be highlighted in this article, with a clinical focus on unique aspects of presentation, diagnosis, and management among athletes. Conditions addressed include depression, anxiety and related disorders, eating disorders, sleep concerns, attention-deficit/hyperactivity disorder, bipolar and psychotic disorders, and substance use disorders and behavioral addictions. Athletes experience particular physiologic and psychosocial demands that impact how they present symptomatically and how treatment modalities, including psychotherapy and pharmacologic treatments, impact them.
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Affiliation(s)
- Claudia L Reardon
- Department of Psychiatry, University of Wisconsin School of Medicine and Public Health, Madison, WI
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13
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Abstract
Athletes commonly experience mental health symptoms. However, prevalence estimates require refinement so that symptoms are interpreted in context and diagnostic labels are accurately applied. Further prevalence studies are also needed in subgroups within sport, in particular female athletes, athletes with disabilities, and coaches. Existing consensus-based and evidence-based therapies must be adapted not only to the individual athlete but also to the ecology of sports. Filling the gaps in our knowledge on what treatment modifications may be required for the individual athlete and how services should be designed to deliver treatment most effectively will require well-designed studies that use standardized terminology and defined outcome measures.
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14
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Currie A, Blauwet C, Bindra A, Budgett R, Campriani N, Hainline B, McDuff D, Mountjoy M, Purcell R, Putukian M, Reardon CL, Gouttebarge V. Athlete mental health: future directions. Br J Sports Med 2021; 55:1243-1244. [PMID: 34344708 DOI: 10.1136/bjsports-2021-104443] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Alan Currie
- Regional Affective Disorders Service, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Cheri Blauwet
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Medical Committee, International Paralympic Committee, Bonn, Germany
| | - Abhinav Bindra
- Athletes' Commission, International Olympic Committee, Lausanne, Switzerland
| | - Richard Budgett
- Medical and Scientific Department, International Olympic Committee, Lausanne, Switzerland
| | - Niccolo Campriani
- Sports Department, International Olympic Committee, Lausanne, Switzerland
| | - Brian Hainline
- National Collegiate Athletic Association (NCAA), Indianapolis, Indiana, USA
| | - David McDuff
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Margo Mountjoy
- Family Medicine, McMaster University Michael G DeGroote School of Medicine, Waterloo, Ontario, Canada.,Sport Medicine, FINA, Lausanne, Switzerland
| | - Rosemary Purcell
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Knowledge Translation, Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia
| | - Margot Putukian
- Major League Soccer, New York, New York, USA.,Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey, USA
| | - Claudia L Reardon
- Department of Psychiatry, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Vincent Gouttebarge
- Sports Medicine, University of Pretoria, Pretoria, South Africa.,Amsterdam UMC, University of Amsterdam, Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam, The Netherlands
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15
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Hooper NR, Reiber C, Cheatham SA. The psychological effects of event cancellation in Olympic-level swimmers: preliminary findings and mental health screening recommendations. J Sports Med Phys Fitness 2021; 62:732-739. [PMID: 33871239 DOI: 10.23736/s0022-4707.21.12206-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Mental health screening of elite athletes is not routinely practiced following the cancellation of an athletic event. Though sporting event cancellation has negative career and training impacts on elite athletes, little is known about its psychological impact. To determine the extent to which sporting event cancellation might warrant psychological screening practices in elite athletics, this study evaluated elite-level swimmers' response to the cancellation of the 2020 Olympic Games through psychological assessment and qualitative interviewing. METHODS A cross-sectional study design was implemented. Online psychological assessment included self-report scales to measure anxiety, burnout, psychological strain, and optimism/pessimism. Follow-up semi-structured telehealth interviews were conducted to assess appraisals of and coping responses to the cancellation. RESULTS Of the 14 participants assessed for mental health symptoms, 12 were available for interview procedures. Results (mean ± SD) indicated 'very high' psychological strain (22.71 ± 4.83) and 'mild' anxiety (6.29 ± 4.87). All swimmers exhibited levels of psychological strain that warranted clinical evaluation per established cut-off scores. Thematic content analysis of interviews generated four themes: pre-cancellation evaluations, primary appraisals, coping responses, and coping outcomes. Most swimmers exhibited maladaptive coping (75%); however, adaptative coping was as prevalent (92%), particularly through use of support networks. Most swimmers achieved positive coping outcomes (75%) and maintained strong 2021 Olympicqualifying confidence (93%). In contrast, swimmers with poor coping outcomes (25%) employed more frequent maladaptive coping strategies and exhibited higher psychological distress. CONCLUSIONS Findings urge sports medicine clinicians to implement psychological screening protocols in elite athletes following the cancellation of a major sporting event to attend to symptoms of psychological distress and to direct appropriate psychological intervention.
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Affiliation(s)
- Nicholas R Hooper
- School of Medicine, Virginia Commonwealth University, Richmond, VA, USA -
| | - Curtis Reiber
- School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Seth A Cheatham
- Department of Orthopedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
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16
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Glick ID, Stillman MA, McDuff D. Update on integrative treatment of psychiatric symptoms and disorders in athletes. PHYSICIAN SPORTSMED 2020; 48:385-391. [PMID: 32298189 DOI: 10.1080/00913847.2020.1757370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Primary objective: In this review, we detail the issues and disorders athletes present with, guidelines for making diagnostic formulations and treatment goals, and strategies for delivering integrated treatment attuned to the athlete and their team and/or sport. In addition, we highlight special issues associated with athletes and their families. Reasoning: Data suggests athletes experience comprable incidence and prevalence rates to the general population of psychiatric disorders. The mental and physical demands placed on athletes are unique and may increase their susceptibility to certain mental health problems. The current literature regarding integrative interventions in athletes is sparse and largely anecdotal. We provide a summary of the scientific evidence from a literature review conducted by the IOC Consensus Committee on Mental Health in Elite Athletes, reviews and expert clinical strategies recommended by the authors of four books on sports psychiatry written since 2012, and our own review of the literature related to psychotherapy with elite and non-elite- athletes. Main outcomes and results: At the moment there are no randomized controlled trials assessing the use of psychotherapy or medication for mental illness in athletes to guide treatment. Controlled studies examining psychological interventions in collegiate athletes have demonstrated improvements in mental health symptomology. Although these studies were limited to collegiate athletes they assist in providing a foundation for elite athletes as well. For the assessment and management of the mental health needs of athletes' to be on a par with their physical needs, more high-quality scientific epidemiological and treatment intervention studies are needed. Conclusions: Development of specific models of psychiatric intervention for athletes with significant psychopathology and impairment appears to be warranted. These interventions should include individual, family/marital, and group psychotherapy with or without medication using evidence-based treatments.
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Affiliation(s)
- Ira D Glick
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine , Stanford, CA, USA
| | - Mark A Stillman
- Department of Clinical Psychology, College of Health Professions, Mercer University , Atlanta, GA, USA
| | - David McDuff
- Department of Psychiatry, University of Maryland School of Medicine , Baltimore, MD, USA
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17
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Bu D, Chung PK, Zhang CQ, Liu J, Wang X. Mental Health Literacy Intervention on Help-Seeking in Athletes: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17197263. [PMID: 33020448 PMCID: PMC7579198 DOI: 10.3390/ijerph17197263] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 09/21/2020] [Accepted: 09/28/2020] [Indexed: 12/26/2022]
Abstract
Mental health literacy (MHL) is recognised as a major factor in whether athletes seek help when they experience mental health difficulties. Therefore, the current study aimed to provide a systematic review of the effectiveness of MHL training programmes in improving mental health knowledge and help-seeking and reducing stigma among athletes. To identify intervention studies of MHL programmes, five electronic databases were systematically searched for articles published before May 2020. The selection procedure was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All kinds of study designs were included. Effect sizes were calculated for mental health knowledge, stigma reduction and help-seeking attitudes, intentions and behaviours. Risk of bias was assessed for each study using the Cochrane tool and the Newcastle–Ottawa quality assessment scale. Five studies (1239 participants in total) were selected for review. Overall, either small or medium effects were found for mental health knowledge, stigma reduction, help-seeking attitudes, and intentions for post- and follow-up interventions, whereas a null effect was found in help-seeking behaviours for both post- and follow-up interventions. Furthermore, three studies had a low risk of bias, and two had a high risk of bias. MHL interventions can enhance help-seeking attitudes and intentions and mental health knowledge and reduce stigma but do not increase help-seeking behaviours for now. Further studies should evaluate interventions to enhance help-seeking behaviours. Furthermore, the methodological quality of studies, including randomized controlled trials and other designs, should be improved in future research.
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Affiliation(s)
- Danran Bu
- Department of Sport, Physical Education and Health, Hong Kong Baptist University, Hong Kong, China; (D.B.); (C.-Q.Z.)
- HuBei Institute of Sport Science, Wuhan 432025, China
| | - Pak-Kwong Chung
- Department of Sport, Physical Education and Health, Hong Kong Baptist University, Hong Kong, China; (D.B.); (C.-Q.Z.)
- Correspondence:
| | - Chun-Qing Zhang
- Department of Sport, Physical Education and Health, Hong Kong Baptist University, Hong Kong, China; (D.B.); (C.-Q.Z.)
- Department of Psychology, Sun Yat-Sen University, Guangzhou 510275, China
| | - Jingdong Liu
- Department of Physical Education, Sun Yat-Sen University, Guangzhou 510275, China;
| | - Xiang Wang
- Graduate School, Wuhan Sports University, Wuhan 430079, China;
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18
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Reardon CL, Bindra A, Blauwet C, Budgett R, Campriani N, Currie A, Gouttebarge V, McDuff D, Mountjoy M, Purcell R, Putukian M, Rice S, Hainline B. Mental health management of elite athletes during COVID-19: a narrative review and recommendations. Br J Sports Med 2020; 55:bjsports-2020-102884. [PMID: 32967853 DOI: 10.1136/bjsports-2020-102884] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2020] [Indexed: 12/18/2022]
Abstract
Elite athletes suffer many mental health symptoms and disorders at rates equivalent to or exceeding those of the general population. COVID-19 has created new strains on elite athletes, thus potentially increasing their vulnerability to mental health symptoms. This manuscript serves as a narrative review of the impact of the pandemic on management of those symptoms in elite athletes and ensuing recommendations to guide that management. It specifically addresses psychotherapy, pharmacotherapy and higher levels of care. Within the realm of psychotherapy, crisis counselling might be indicated. Individual, couple/family and group psychotherapy modalities all may be helpful during the pandemic, with novel content and means of delivery. Regarding pharmacotherapy for mental health symptoms and disorders, some important aspects of management have changed during the pandemic, particularly for certain classes of medication including stimulants, medications for bipolar and psychotic disorders, antidepressants and medications for substance use disorders. Providers must consider when in-person management (eg, for physical examination, laboratory testing) or higher levels of care (eg, for crisis stabilisation) is necessary, despite potential risk of viral exposure during the pandemic. Management ultimately should continue to follow general principles of quality health care with some flexibility. Finally, the current pandemic provides an important opportunity for research on new methods of providing mental health care for athletes, and consideration for whether these new methods should extend beyond the pandemic.
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Affiliation(s)
- Claudia L Reardon
- Department of Psychiatry, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- University Health Services, University of Wisconsin, Madison, Wisconsin, USA
| | | | - Cheri Blauwet
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Richard Budgett
- Medical and Scientific Department, International Olympic Committee, Lausanne, Switzerland
| | - Niccolo Campriani
- Sports Department, International Olympic Committee, Lausanne, Switzerland
| | - Alan Currie
- Regional Affective Disorders Service, Northumberland Tyne and Wear NHS Foundation Trust, Newcastle, UK
- Department of Sport and Exercise Sciences, University of Sunderland, Sunderland, Tyne and Wear, UK
| | - Vincent Gouttebarge
- Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- AMC/VUmc IOC Research Center of Excellence, Amsterdam Collaboration on Health & Safety in Sports (ACHSS), Amsterdam, The Netherlands
| | - David McDuff
- Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland, USA
- MD Sports Performance, Ellicott City, Maryland, USA
| | - Margo Mountjoy
- Family Medicine, McMaster University Michael G DeGroote School of Medicine, Waterloo, Ontario, Canada
- Bureau, FINA, Lausanne, Switzerland
| | - Rosemary Purcell
- Department of Research and Translation, Orygen The National Centre of Excellence in Youth Mental Health, Parkville, Victoria, Australia
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Margot Putukian
- Athletic Medicine, Princeton University, Princeton, New Jersey, USA
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - Simon Rice
- Centre for Youth Mental Health, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Research and Translation, Orygen The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia
| | - Brian Hainline
- National Collegiate Athletic Association (NCAA), Indianapolis, Indiana, USA
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19
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Gouttebarge V, Bindra A, Blauwet C, Campriani N, Currie A, Engebretsen L, Hainline B, Kroshus E, McDuff D, Mountjoy M, Purcell R, Putukian M, Reardon CL, Rice SM, Budgett R. International Olympic Committee (IOC) Sport Mental Health Assessment Tool 1 (SMHAT-1) and Sport Mental Health Recognition Tool 1 (SMHRT-1): towards better support of athletes' mental health. Br J Sports Med 2020; 55:30-37. [PMID: 32948518 PMCID: PMC7788187 DOI: 10.1136/bjsports-2020-102411] [Citation(s) in RCA: 113] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2020] [Indexed: 01/28/2023]
Abstract
Objectives To develop an assessment and recognition tool to identify elite athletes at risk for mental health symptoms and disorders. Methods We conducted narrative and systematic reviews about mental health symptoms and disorders in active and former elite athletes. The views of active and former elite athletes (N=360) on mental health symptoms in elite sports were retrieved through an electronic questionnaire. Our group identified the objective(s), target group(s) and approach of the mental health tools. For the assessment tool, we undertook a modified Delphi consensus process and used existing validated screening instruments. Both tools were compiled during two 2-day meeting. We also explored the appropriateness and preliminary reliability and validity of the assessment tool. Sport Mental Health Assessment Tool 1 and Sport Mental Health Recognition Tool 1 The International Olympic Committee Sport Mental Health Assessment Tool 1 (SMHAT-1) was developed for sports medicine physicians and other licensed/registered health professionals to assess elite athletes (defined as professional, Olympic, Paralympic or collegiate level; aged 16 years and older) potentially at risk for or already experiencing mental health symptoms and disorders. The SMHAT-1 consists of: (i) triage with an athlete-specific screening tool, (ii) six subsequent disorder-specific screening tools and (iii) a clinical assessment (and related management) by a sports medicine physician or licensed/registered mental health professional (eg, psychiatrist and psychologist). The International Olympic Committee Sport Mental Health Recognition Tool 1 (SMHRT-1) was developed for athletes and their entourage (eg, friends, fellow athletes, family and coaches). Conclusion The SMHAT-1 and SMHRT-1 enable that mental health symptoms and disorders in elite athletes are recognised earlier than they otherwise would. These tools should facilitate the timely referral of those athletes in need for appropriate support and treatment.
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Affiliation(s)
- Vincent Gouttebarge
- Amsterdam UMC, Univ of Amsterdam, Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam, The Netherlands .,Amsterdam Collaboration on Health & Safety in Sports (ACHSS), Amsterdam UMC IOC Research Center of Excellence, Amsterdam, The Netherlands
| | - Abhinav Bindra
- Athletes' Commission, International Olympic Committee, Lausanne, Switzerland
| | - Cheri Blauwet
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Niccolo Campriani
- Sports Department, International Olympic Committee, Lausanne, Switzerland
| | - Alan Currie
- Regional Affective Disorders Service, Northumberland Tyne and Wear NHS Foundation Trust, Newcastle, UK.,Department of Sport and Exercise Sciences, The University of Sunderland, Sunderland, UK
| | - Lars Engebretsen
- Orthopedic Clinic, University of Oslo, Oslo, Norway.,Medical and Scientific Department, International Olympic Committee, Lausanne, Switzerland
| | - Brian Hainline
- National Collegiate Athletic Association (NCAA), Indianapolis, Indiana, USA
| | - Emily Kroshus
- Department of Pediatrics, University of Washington, Seattle, Washington, USA.,Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington, USA
| | - David McDuff
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Margo Mountjoy
- Department of Family Medicine - Sport, McMaster University, Hamilton, Ontario, Canada
| | - Rosemary Purcell
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia.,Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Margot Putukian
- Athletic Medicine, University Health Services, Princeton University, Princeton, New Jersey, USA
| | - Claudia L Reardon
- Department of Psychiatry, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Simon M Rice
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia.,Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Richard Budgett
- Medical and Scientific Department, International Olympic Committee, Lausanne, Switzerland
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20
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Psychische Erkrankungen bei Leistungssportlern. PSYCHOTHERAPEUT 2020. [DOI: 10.1007/s00278-020-00420-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Walton CC, Purcell R, Rice S. Addressing mental health in elite athletes as a vehicle for early detection and intervention in the general community. Early Interv Psychiatry 2019; 13:1530-1532. [PMID: 31264781 DOI: 10.1111/eip.12857] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 02/28/2019] [Accepted: 06/09/2019] [Indexed: 12/22/2022]
Abstract
Recent scientific literature in addition to increased media attention has highlighted the important role of mental health in elite athletes. Often defined by terms such as "mental toughness", athletes are now becoming more open to discussing the role of anxiety, depression and other psychologically distressing processes that are intertwined with their time both during and after elite sport. In line with this, recent international position statements regarding the mental health of athletes have been released. The current New Hypothesis article follows on from these statements and proposes that further work must be performed to better understand this aspect of elite sport in addition to developing sport-specific interventions for athletes, their families, and support staff. Furthermore, we propose that by better understanding and treating the mental health of elite athletes a follow-on effect may occur, whereby help-seeking in the general community will increase. In particular, young adults who were previously hesitant to seek help may take strength from this shift, maximizing the success of early intervention occurring.
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Affiliation(s)
- Courtney C Walton
- School of Psychology, The University of Queensland, Brisbane, Queensland, Australia
| | - Rosemary Purcell
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia.,Centre for Youth Mental Health, The University of Melbourne, Melbourne, Victoria, Australia.,Orygen Youth Health Clinical Program, Melbourne, Victoria, Australia
| | - Simon Rice
- Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia.,Centre for Youth Mental Health, The University of Melbourne, Melbourne, Victoria, Australia.,Orygen Youth Health Clinical Program, Melbourne, Victoria, Australia
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