Attention-deficit/hyperactivity disorder in elite athletes: a narrative review

Health status of senior netball players, their medication use and attitudes towards doping

Limited research exists on the health and injuries of South African senior netball players. Senior netball players may be at greater risk of injuries and chronic disease due to their age. To treat these conditions, they may use prescription and over-the-counter (OTC) medications and, therefore, may be more vulnerable to unintentional doping. The primary aim of this study was to determine the health status, medication use and attitudes towards doping of South African senior netball players. A cross-sectional descriptive design was employed to collect data by means of an online survey. The validated 8-item Performance Enhancement Attitudes Scale (PEAS) was used to gather information on the netball player's attitudes towards doping. Descriptive statistics were used to describe the data using proportions (categorical), means (normally distributed, continuous) and medians (non-normal distributed, continuous). Doping prevalence and accompanying 95% confidence interval were calculated. Sixty senior netball players consented and completed the self-report questionnaire. The prevalence of chronic disease was 11.67%. Asthma and other conditions such as depression and attention-deficit/hyperactivity (ADHD) had the highest prevalence of 3.33%. The prevalence of chronic prescription medication use was 8.33% and 66.67% of the netball players reported receiving prescription injections, medications or utilizing OTC medications for treating injury or illness suffered 1-6 weeks before or during competition. The netball players do not have a lenient attitude towards doping. The prescription and OTC medication use could put this cohort of netball players at risk of unintentional doping. Anti-doping education aimed at senior athletes may be beneficial to reduce the risk of unintentional doping due to prescription and OTC medication use for injury or illness.

The influence of ADHD on recovery from sport concussion among collegiate athletes in the United States: LIMBIC MATARS consortium investigation

OBJECTIVE

The present study aimed to assess the potential influence of a diagnosis of ADHD on concussion recovery among collegiate athletes.

DESIGN

Retrospective and cross-sectional.

METHODS

Data were extracted retrospectively from medical records across LIMBIC MATARS member institutions (n = 11), representing 1,044 concussion cases among collegiate athletes. After exclusions, 406 concussions were included in our analysis (ADHD: n = 38, age = 20.2 ± 1.67 years, 18.4% female; No ADHD: n = 368, age = 19.8 ± 1.39 years, 40.1% female). Mann-Whitney U tests were used to compare days from injury to diagnosis, symptom resolution, and return to sport among athletes with and without ADHD.

RESULTS

No differences were observed for days from concussion until diagnosis (z = -0.33, p = 0.74), until days to symptom resolution (z = -1.30, p = 0.19), or days until return to sport (z = -0.68, p = 0.49); among concussion cases with or without a previously reported diagnosis of ADHD.

CONCLUSION

Our findings further expand the literature that suggests ADHD is not strongly associated with recovery trajectory following sport concussion in collegiate athletes. Future research should extend these findings to be inclusive of additional preexisting health conditions and moderating effects related to medication usage among diverse athlete levels.

Attention-Deficit / Hyperactivity Disorder in Athletes

ADHD is common among the general population and may be slightly more common among athletes. Diagnosis requires six or more DSM-5-TR symptoms to have been present prior to age 12 and to have an effect on functioning in multiple settings. Different sporting organizations have varying requirements for documentation when making a diagnosis. Stimulant medications are the mainstay of treatment; psychosocial interventions, exercise, and non-stimulant medications can serve as adjuncts. Future directions in research on ADHD in sports include determining whether ADHD is overrepresented among the population of elite athletes and parsing out the relationship between ADHD and concussion risk and recovery.

A Critical Review of Existing Evidence-Based Sport Psychological Interventions for College Athletes with Comorbid Attention Deficit-Hyperactivity Disorder and Sport-Related Concussions

ABSTRACT

The preventive efficacy of mental skills in reducing the risk of sport-related concussions (SRC), facilitating rehabilitation post-SRC, and enhancing mental performance was assessed in individuals with comorbid attention deficit-hyperactivity disorder (ADHD) and SRC. ADHD, characterized by behavioral disruptions linked to hyperactivity and impulsivity, poses an increased risk of severe injuries among student-athletes. Annually, over 10,000 mild Traumatic Brain Injuries (mTBI), including SRC, are diagnosed in National Collegiate Athletic Association (NCAA) student-athletes. Despite the high incidence, there remains a limited understanding of how sport psychological interventions can effectively prevent and rehabilitate SRC in student-athletes with ADHD. This article explores the intricate relationship between ADHD and SRC in NCAA-affiliated student-athletes, focusing on identifying optimal sport psychological interventions for injury prevention, treatment, and performance improvement. The analysis aims to inform the integration of this knowledge into comprehensive services for student-athletes, encompassing prevention, rehabilitation, and performance enhancement strategies.

Is the deficit in attention-deficit/hyperactivity disorder a concentration deficit?

Attention-deficit/hyperactivity disorder (ADHD) is comprised of two behavioral clusters of symptoms, inattention and hyperactivity/impulsivity. Numerous studies have attempted to address the underlying neuropsychological mechanism of ADHD. However, there is still no uniform mechanism that can fully explain both inattention and hyperactivity/impulsivity symptoms. This review describes the research findings that have shifted the focus from cognitive selective attention to executive function deficits and notes that the prominence of the attention deficit remains unclear. As ADHD is not consistently explained by cognitive selective attention but rather with cognitive sustained attention/vigilance and executive function deficits, this review suggests that concentration deficit is likely the cause of inattention symptoms. Indeed, considering concentration deficit as the cause of inattention symptoms may better describe the underlying difficulties of maintaining and controlling attention in ADHD. In addition, as concentration, impulsivity, and hyperactivity may share a common cognitive deficit, this shift in focus may help in identifying a single mechanism for all ADHD symptoms.

Increased anxiety and depression among collegiate athletes with comorbid ADHD and history of concussion

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) is prevalent among student-athletes when compared to the general population. Mental health disruptions (i.e., depression or anxiety) are common among student-athletes, and risk of experiencing depressive and anxious symptoms may be even greater among student-athletes that have incurred concussion.

OBJECTIVE

To examine the influence of pre-existing ADHD and history of concussion on mental health in collegiate student-athletes.

DESIGN

Retrospective cross-sectional study.

SETTING

National Collegiate Athletic Association Division-I (NCAA) athletics.

PATIENTS

Between 2010 and 2017, student-athletes at a Southeastern NCAA Division-I institution were surveyed as part of a Performance, Health, and Wellness Program. Analyses were conducted using a sample of 324 student athletes (212 female) with either a prior diagnosis of ADHD, a prior history of a sport-related concussion, both prior diagnosis of ADHD and a history of sport-related concussion, or neither (controls).

MAIN OUTCOME MEASURE(S)

Symptomatology associated with ADHD was characterized using the Behavior Assessment System for Children Self-Report of Personality College Version. The State-Trait Anxiety Inventory and the Center of Epidemiological Studies-Depression Scale examined anxious and depressive symptomatology.

RESULTS

Student-athletes with ADHD and a history of concussion had 16.4 times greater odds of exhibiting clinically significant symptoms of state anxiety and 7.9 times greater odds of exhibiting clinically significant symptoms of depression, relative to control student-athletes. Every participant with both a diagnosis of ADHD and a history of concussion exhibited clinically significant attentional problems.

CONCLUSIONS

Having both ADHD and a history of concussion may have a synergistic effect on mental health beyond that of ADHD and/or concussion alone. Additional longitudinal research is necessary to verify current findings. However, athletic trainers and other health care professionals are encouraged to be mindful of student-athletes with ADHD, as they may be more vulnerable to experiencing symptoms of depression and state anxiety with elevated inattentive behaviors following a concussion.

Neurodiversity in elite sport: a systematic scoping review

The objective of this systematic scoping review is to understand the extent and scope of evidence regarding neurodiversity in elite sport. This systematic scoping review considered epidemiological studies, com mentary and viewpoints papers, systematic review and meta-analyses, and any intervention or clinical treatment, management and practice studies in relation to neurodiversity in elite sport. Case studies and grey literature were ineligible for review. Neurodivergence included neurodevelopmental disorders such as autism spectrum disorder, attention-deficit hyperactivity disorder (ADHD) and specific learning disorders. Elite sport was defined as Olympic, Paralympic, national, international, professional and semiprofessional sport. The final 23 studies included in this review comprised 10 observational studies, 4 systematic/narrative reviews, 6 commentary/position statements and 3 qualitative studies. The literature reflected a major focus on ADHD as a risk factor for concussion and prognosis for postconcussion recovery. Further, there was a focus on the medical management of ADHD, regarding adherence to sporting antidoping regulations. One study focused on the experience of autism in athletes in elite sport settings through qualitative interviews. One study focused on anxiety disorders in elite athletes, with ADHD emerging as a major risk factor. There is a strong rationale for future research to build on the evidence for neurodiversity in elite sport to foster supportive and inclusive elite sporting environments.

Athletes With Attention-Deficit/Hyperactivity Disorder: Position Statement of the American Medical Society for Sports Medicine

ABSTRACT

Athletes of all ages may be affected by medical and mental health issues. Sports medicine physicians should be familiar with common conditions that may affect the well-being of athletes, such as attention-deficit/hyperactivity disorder (ADHD). ADHD behaviors have the potential to affect a person's ability to concentrate. It is likely that social and cognitive therapies combined with pharmacotherapy will be the most effective way to treat ADHD in athletes. Medications used for ADHD, especially stimulant types, are known to improve alertness, reaction time, anaerobic performance, and endurance, which would potentially improve athletic performance. Furthermore, stimulant medications may enable student athletes with ADHD to focus on academic studies for longer periods of time, beyond usual levels of fatigue, important for those who may be exhausted after practices and games. The purported performance enhancement effects and potential adverse effects of stimulant medications have prompted many sports governing bodies to ban prescription stimulants or establish strict rules for their use. Athletes taking physician-prescribed stimulants to treat ADHD need to provide the appropriate documentation for approval before competition or risk punitive measures. Physicians should strive to provide a high quality of care to athletes with ADHD through early diagnosis, appropriate and careful multidisciplinary treatment, and complete and timely documentation to facilitate continued sports participation.

Impact of transcranial alternating current stimulation on working memory and selective attention in athletes with attention deficit hyperactivity disorder: randomized controlled trial

OBJECTIVE

The current study aimed to investigate the impact of transcranial alternating current stimulation (tACS) on working memory and selective attention in athletes with attention deficit hyperactivity disorder (ADHD).

METHODS

In total 45 athletes with attention deficit hyperactivity disorder were randomly divided into three equal groups (sham, control and experimental groups). All participants in the sham and experimental groups received stimulations on the F3 and SO with a current of (10 HZ) 1 mA for 15 min over 10 sessions ( P  ≤ 0.05), and after 10 sessions, each group was retested. After 2 weeks, a follow-up test was performed according to the post-test using the Stroop test and N-BACK- (working memory test) to test statistical hypotheses ( P  ≤ 0.05).

RESULTS

The results of repeated measures analysis of variance revealed that applying tACS proved effective in improving the working memory and selective attention of ADHD athletes.

CONCLUSIONS

The study's findings indicated that the protocol of applying tACS 1 MA with 10 HZ improved the working memory and selective attention of ADHD athletes.

Updated Blood Pressure Guidelines: Implications for Athletes

PURPOSE OF REVIEW

To review the prevalence, short- and long-term impact of exercise on blood pressure, and the evaluation and treatment of hypertension in competitive athletes.

RECENT FINDINGS

Due, in part, to inconsistencies in measurement and the definitions used, the true prevalence of hypertension is unknown as reports range from 0 to 83%. With recent changes in the blood pressure guidelines, the proportion of athletes that meet criteria for elevated blood pressure or stage 1 hypertension has increased dramatically with over one-third of collegiate and professional athletes meeting criteria for hypertension. Data consistently show that American-style football players, particularly linemen, display the highest rates of hypertension. These athletes typically have a larger body mass index, higher body fat percentage, and weight gain in serial follow-up. Many athletes with hypertension have traditional risk factors, and, to date, there is no evidence of a causal relationship between long-term sport participation and increased risk of developing hypertension. Many more athletes now meet criteria for hypertension, given the updated blood pressure guidelines. This should be taken as an opportunity for early intervention, as athletes are not immune to the development of cardiovascular risk factors and disease.

ADHD symptoms and use of anabolic androgenic steroids among male weightlifters

Use of anabolic androgenic steroids (AAS) is associated with adverse health effects. The factors that predispose to AAS use among athletes are poorly understood, but attention deficit/hyperactivity disorder (ADHD), which is known to occur among athletes more often than in the general population, is associated with risk behaviors, including substance abuse. We aimed to see if AAS use in male weightlifters was associated with ADHD symptoms, and test the link between ADHD symptoms and cognitive performance. Hundred and forty male weightlifters, 72 AAS users and 68 weightlifting controls (WLC), completed the Achenbach system of empirically based assessment (ASEBA) for ADHD symptoms and underwent cognitive examination. Self-reported ADHD symptom scores were significantly higher among AAS users compared to WLC, and scores in the range indicating clinically important ADHD was significantly more common in the AAS-using group. Age of onset of AAS use correlated inversely with ADHD scale score (r = - 0.35; p = 0.003). ADHD score correlated inversely with cognitive scores for working memory (r = - 0.25, p < 0.001), processing speed (r = - 0.24, p < 0.001), verbal learning and memory (r = - 0.19, p = 0.03), and problem solving (r = - 0.20, p = 0.02). AAS use among weightlifters is associated with ADHD symptoms and corresponding lower cognitive performance. Recognising a relationship between ADHD symptoms and AAS use may guide drug prevention strategies in sports.

Attention-Deficit/Hyperactivity Disorder-Related Self-Reported Symptoms Are Associated With Elevated Concussion Symptomatology

The aim of the present investigation was to provide insight into how postconcussion symptomatology may be altered in individuals exhibiting attention-deficit/hyperactivity disorder (ADHD)-related behaviors and examine factors that may be responsible for driving such relationships. A total of 99 individuals were assessed during the subacute phase of concussion recovery. Inattentive symptomatology, but not diagnosis of ADHD, was related to greater concussion-symptom severity and overall symptoms endorsed. Cluster and factor analyses highlighted that the relationship between ADHD symptomatology and concussion symptomatology was not a function of overlapping constructs being assessed (i.e., concussion-related symptomatology was not a proxy of ADHD-related symptomatology). These relationships were not mediated by parental observations of impairments in behaviors associated with executive functioning (i.e., executive dysfunction was not driving the greater concussion-related symptomatology associated with ADHD-related symptomatology). These findings highlight the importance of moving beyond categorical frameworks of ADHD to, instead, consider the continuum of underlying behaviors.

Do we over-diagnose ADHD in North America? A critical review and clinical recommendations

There has been a marked increase in the prevalence of attention-deficit/hyperactivity disorder (ADHD) in the last 25 years in North America. Some see this trend as positive and believe that it reflects a better identification of ADHD and even think that the disorder is still under-diagnosed. Others, however, contend that ADHD is over-diagnosed. To help mental health clinicians to maintain an informed and nuanced perspective on this debate, this critical review aims to (1) summarize empirical results on factors that might contribute to increase the number of ADHD diagnoses and (2) propose clinical recommendations coherent with these findings to improve clinical practices for ADHD assessment and treatment. We conclude that artifactual factors such as current formulation of diagnostic criteria, clinical practices, and inordinate focus on performance, which is rampant in North America, likely contribute to inflated prevalence rates.

ADHD Prescription Medications and Their Effect on Athletic Performance: A Systematic Review and Meta-analysis

BACKGROUND

Stimulant medications used for the treatment of Attention Deficit-Hyperactivity Disorder (ADHD) are believed to provide a physical advantage in athletics, but several of these medications are not regulated by the World Anti-Doping Association. Given the prevalence of ADHD among the athlete population and concern for abuse of ADHD medications, this review and meta-analysis aimed to evaluate effects of ADHD medications on athletic performance, thereby appraising the validity of claims of performance enhancement.

METHODS

A search of MEDLINE, Embase, CINAHL, and Cochrane Review databases was performed for all randomized controlled trials evaluating athletic performance after ingestion of placebo or ADHD treatment medications from August 2020 through November 2020. All RCTs identified from these search criteria were included for screening, with exclusion of any animal studies. Two reviewers (JB, CK) assessed methodological quality and risk of bias using CONSORT 2010 and Cochrane Collaboration tools. Study results were compiled with corresponding p values for each finding. Effect sizes (Cohen's D) for athletic performance and physiological changes were aggregated for each study. Studies were further screened for homogeneity that would allow for meta-analysis. Heterogeneity was calculated using I2.

RESULTS

A total of 13,033 abstracts evaluating amphetamine, methamphetamine, methylphenidate, and bupropion were screened. The final analysis included nine studies, six of which found significant improvement in athletic performance with use of stimulant medications (p < 0.05). Methylphenidate and amphetamine were consistently identified to have a performance effect. Secondary effects identified included significant increase in heart rate, core temperature, and elevation of various serum hormone levels (p < 0.05). Effect size evaluation found seven studies demonstrating small to large effects on physical performance, as well as in categories of cardiometabolic, temperature, hormone, and ratings of perceived exertion, to varying degrees. A meta-analysis was performed on two studies, demonstrating conflicting results.

CONCLUSIONS

Dopaminergic/noradrenergic agonist medications appear to have a positive effect on athletic performance, as well as effects on physiological parameters. Further consideration of medications currently not regulated, i.e. bupropion, is warranted given evidence of athletic performance enhancement. PROSPERO trial registration number: CRD42020211062; 10/29/2020 retrospectively registered.

The Mental Health of Athletes: Recreational to Elite

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.

Knowledge and attitude of Attention-Deficit and Hyperactivity Disorder (ADHD) among male primary school teachers, in Riyadh City, Saudi Arabia

Objective:

The aim of this study was to explore teachers' knowledge about the ADHD, its origin, causes, and identify the main demographic variables affecting their knowledge.

Methods:

The study was conducted among male school teachers of ten government primary schools that are found in different regions of Riyadh city, the Kingdom of Saudi Arabia. We used a stratified random sampling technique to collect our sample with inclusion criteria of being male teachers who currently working in male government primary school and are directly involved on teaching of students. Data analysis was performed using SPSS software statistical program version 21.

Results:

We received 400 response for our questionnaire, mostly younger than 40 years old. Most of teachers in this sample had a bachelor's degree, only 6% had diploma while 8% had a higher degree, while most of them had experience more than 5 years in teaching (74.2%). only 8%of teachers admitted that they had not heard about ADHD before. 78% of teachers had read about ADHD at least once before. This knowledge was more from reading books (32.8%) followed by reading internet websites (28.7%), TV/Media (14.6%) while magazine and social media represent (23.9%). Most of the teachers showed that they had attended courses/training about ADHD (76.7%) however only 40.4% of them thought that they had the enough information about the disease. 51.5% of teachers showed that they had already asked before to assess a child who was suspected to have ADHD and 65.3% had taught a child with the disease.

Conclusion:

From the results of this study, it is concluded that the knowledge regarding ADHD among elementary school teachers is suboptimal. Some teachers had misunderstanding about ADHD symptoms and general information, which indicated the further needing for courses to enhance this knowledge.

Do Athletes Have More of a Cognitive Profile with ADHD Criteria than Non-Athletes?

The current study investigates the possibility that athletes have more parallel ADHD symptoms than non-athletes. High-level youth sport athletes were compared with non-athletes in leisure time (i.e., sport) and in the school in ADHD symptoms. Athletes and students were evaluated by a trained psychotherapist using Adult ADHD Self-Report Scale (ASRS) on activities at school and during activities in leisure/sports time. They also filled in the Autism Spectrum Questionnaire (AQ) as a self-report assessment. Results showed significant differences in ASRS-scores for athletes in school and in their sport, with high scores in school and low scores in sport. No differences were found in AQ between the groups. The findings indicate that many athletes might display a cognitive profile of parallel of ADHD criteria. Future research needs to further investigate potential benefits of the cognitive profile in athletes and how they handle different contexts including sport and school settings.

Anxiety and depression in athletes assessed using the 12-item General Health Questionnaire (GHQ-12) - a systematic scoping review

Background

The poor mental health of athletes is a major concern in sport. Typically, the incidence/prevalence of mental health symptoms in athletes is studied using symptom-specific questionnaires. For symptoms of depression/anxiety, one such self-reporting questionnaire is the 12-item General Health Questionnaire (GHQ-12).

Objectives

The aim of this review was to synthesise and compare studies using the GHQ-12 in athletes to inform future research bodies by identifying trends and gaps in the literature.

Methods

A systematic search of five electronic databases (Google Scholar, PubMed, PsychINFO, Scopus and Web of Science) was conducted on all published studies up to 1 January 2019. Inclusion criteria: (1) participants were able-bodied athletes; (2) studies measured anxiety/depression using the GHQ-12; (3) studies were full original articles from peer-reviewed journals; (4) studies were published in English.

Results

Thirty-two studies were included in the review. The prevalence and incidence of symptoms of anxiety/depression ranged from 21-48% and 17-57%, respectively. The majority of studies screening anxiety/depression using the GHQ-12 were cross-sectional. Almost 70% of the studies used the traditional scoring method. The majority of study populations sampled all-male cohorts comprising football (soccer) players.

Conclusion

The traditional scoring of 0-0-1-1 should be used with the cut-off set at ≥3. Also, the mean GHQ-12 score should be reported. Potential risk factors for symptoms of anxiety/depression (i.e. recent adverse life events, injury and illness, social support, pressure to perform and career transitioning) and a lack of prospective studies were identified. Future research should also broaden the spectrum of athlete populations used and aim to improve response rates.

Self-Reported Physical Activity, Injury, and Illness in Canadian Adolescent Ski Racers

Youth ski racers spend a considerable amount of time on snow and this may detract from other activities known to influence fundamental movement skills and overall health related outcomes. Parents of racers (n = 52 F; n = 44 M; age range 9–14 years) registered in the Canadian club system completed a baseline medical questionnaire during preseason testing in 2017. We describe physical activity volume and sport participation outside of physical education classes over the previous 12 months and report on injuries, medication use and health care utilization. The mean number of activities participated was five (range 1–14) with cycling, hiking, and swimming as the preferred choice and a cumulative mean of just under 400 h of activity was reported (range F 27–1,015; M 62–869 h/year) in the past year. During the past 12 months 16% of the athletes reported being injured and injury severity impacted return to sport with range of reported days missed from 1 to 365 days. Thirteen non-concussive injuries were reported in alpine skiing and females (12%, 6/52) reported more lower limb injuries than males (7%, 3/44). More males were concussed over their lifetime, with alpine skiing accounting for 46% and mountain biking 15%. Most athletes (85%) did not take medication on a regular basis and those that did had a medical diagnosis. The frequency of respiratory conditions was 13% (12/96) with males reporting slightly more cases than females. No difference in emergency visits occurred (25%) between males and females in the past 12 months, however females reported more (n = 102) allied health care, sport medicine and x-rays appointments when compared to males (n = 65). In summary, a high volume of physical activity (an hour plus per day) over the previous 12 months was reported with racers participating in several activities outside of skiing, likely honing their fundamental movement skills. Close proximity to the mountains may have influenced their choices of activity outside of ski racing, and their injuries and a variety of health conditions were typical of their age group. Future research employing wearable technology to objectively quantify the volume and intensity of physical activity participation is recommended.

Update on integrative treatment of psychiatric symptoms and disorders in athletes

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.

Mental health management of elite athletes during COVID-19: a narrative review and recommendations

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.

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

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.