Navigating athlete mental health: Perspectives from performance directors within elite sport

Performance directors lead high-performance programmes within elite sport and where they opt to invest resources has implications for athletes. This study explores performance directors' perspectives on mental health and illness and their experiences of managing these within elite sport. We conducted semi-structured interviews with 11 performance directors, resulting in 18 h of data. Interviews were transcribed verbatim and analysed using reflexive thematic analysis. We constructed three themes: 1) making sense of mental health: legitimacy vs. scepticism; 2) mental health as athlete responsibility; and 3) simplifying and sanitising mental health. Performance directors used physical health analogies to make sense of mental health, sometimes describing unrealistic expectations regarding mental health management. They also positioned athletes as responsible for finding solutions to their mental health concerns, at times overlooking the impact of the elite sport environment. Some performance directors shared over-simplified perceptions of mental health, often focusing on 'the positive' and neglecting to talk about the more challenging aspects of mental health and illness. Educating performance directors, as well as others in leadership positions, on the complexities of mental health and illness is recommended. This should include how mental illness differs from physical illness and injury, how to respond when athletes disclose mental health concerns, and how mental illness recovery is often nonlinear and subjectively defined.

Athlete mental health help-seeking: A systematic review and meta-analysis of rates, barriers and facilitators

Athletes are vulnerable to a range of mental health symptoms, in part due to stressors within the sport environment. An early intervention framework suggests the benefits of routine screening and referral for mental health, however, greater understanding around athlete help-seeking is needed to support referral uptake. This review examined rates of formal help-seeking behaviour as well as barriers and facilitators to help-seeking in sport settings. Relevant studies were retrieved from SportDiscus, PubMed and PsycInfo, with unpublished studies identified through contacting authors. Help-seeking rates were meta-analysed and barriers and facilitators were meta-synthesised. Twenty-two studies were included. Help-seeking rates were reported in 11 studies (N = 3415) and the pooled proportion of help-seeking was 22.4 % (95 % CI 16.2-30.2, I2 = 95.7 %). Barriers were reported in 13 studies and facilitators in six, highlighting a range of sporting-specific factors, such as stigma in relation to athlete identity and sport culture, fear of deselection, and concerns around confidentiality in sport settings, in addition to lack of awareness, low mental health literacy, and negative attitudes to services. Normalising experiences of mental health in sport settings, including through role models, was a key facilitator to help-seeking. Results provide implications for sport organisations to promote help-seeking and athlete mental health, such as through the use of role models, ensuring clarity around confidentiality, stigma reduction interventions, and fostering team cultures that promote mental health. Findings also support the value of sport staff in facilitating help-seeking, and organisational culture changes to foster wellbeing.

Mood Lifters for college athletes: a biopsychosocial approach to improving mental health for student-athletes

Objective: Mood Lifters, a biopsychosocial mental wellness program, has been shown to improve mental health in adults and senior citizens. This study examines the efficacy of the adaptation of the original program, hypothesizing that the Mood Lifters - Athlete version would improve collegiate athletes' anxiety and depression. Participants: Participants included fifty-two student-athletes recruited through The Invisible Opponent, an organization focused on student-athlete mental health awareness, and directly through an R1 University Athletic Department. Methods: Repeated-measures analysis of variance (ANOVAs) was conducted to evaluate the change in self-reported assessments of well-being at the start and end of the intervention. Results: Mood Lifters significantly improved participants' depression, anxiety, and self-esteem. Conclusion: Student-athletes showed improvements in mental well-being across several measures. The findings should be replicated in a larger trial with a more diverse sample to fully understand the impact of Mood Lifters.

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

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

Athletes are not at greater risk for death by suicide: A review

INTRODUCTION

Suicide represents a major mental and public health issue. Elite athletes share certain individual and environmental characteristics that may increase their risk for mental illnesses, ultimately leading to suicide. This notion conflicts with the general perception of athletes, being the healthiest representatives of society.

METHODS

A comprehensive literature search was carried out through PubMed and Embase databases for relevant publications.

RESULTS

Recent calls for investigating suicidality among athletes resulted in a considerable amount of literature providing some evidence regarding lower rates of suicide among professional and high-performance athletes as well as similar incidence and prevalence of mental conditions, which are known as risk factors for suicide. Nevertheless, special attention is required in this population as predisposing and precipitating factors might differ from classical features of suicidality in the general population. Sports physicians, sports psychiatrists, and other mental health professionals in elite sports should be aware of early signs of affective disorders, risk of recreational drug abuse, misuse of performance-enhancing medications, sport-specific environmental stressors, serious physical injuries, and presence of physical or mental illness, all of which may increase suicidality. Traumatic brain injury (TBI) is with suicide with higher severity correlated with increased risk. Compared to active athletes, former athletes may have higher rates of suicide due to common life stressors occurring after sports retirement.

CONCLUSIONS

The findings suggest a multidisciplinary approach to suicidality in elite athletes, the main goal of which should be the reduction of suicide-related morbidity and mortality. Further research is required to clarify the existing gaps in the current knowledge of the issue. While having lower rates of suicide, athletes share some similar (affective disorders, drug abuse, mental and physical illness) and unique factors (misuse of performance-enhancing substances, sports-related stressors, sports injuries, TBI) putting them at risk of suicide during active career and retirement.

How collaborative mental health care for competitive and high-performance athletes is implemented: A novel interdisciplinary case study

Introduction

Collaborative care is considered a best practice in mental health care delivery and has recently been applied in high-performance sport to address athletes' mental health needs. However, how the collaborative process unfolds in practice in the sport setting has not yet been well documented. The purpose of this illustrative case study was to investigate a novel interdisciplinary approach used within the Canadian Centre for Mental Health and Sport (CCMHS) to provide mental health care to clients. Focusing on 'how' the approach was implemented, the aim of the study was to provide insight into the collaboration that occurred between mental performance and mental health practitioners to provide care to a high-performance athlete over an 11-month period, as well as factors facilitating and impeding the team's collaboration. The case involved three practitioners and a 16-year-old female athlete experiencing chronic pain, low mood, and elevated anxiety.

Methods

In the first phase of the data collection process, each practitioner engaged in guided reflective journaling to describe the case and reflect on their practice and outcomes. During the second phase, practitioners co-created a case timeline to describe the collaborative process using clinical documents. Lastly, practitioners participated in collaborative reflection to collectively reflect more broadly on collaboration practice occurring within the CCMHS and Canadian sport system.

Results

The data depict a complex care process in which the necessity and intensity of collaboration was primarily driven by the client's symptoms and needs. A content analysis showed that collaboration was facilitated by the CCMHS' secure online platform and tools, as well as individual practitioner and team characteristics. Collaboration was, however, hindered by logistical challenges, overlapping scopes of practice, and client characteristics.

Discussion

Overall, there were more perceived benefits than drawbacks to providing collaborative care. While flexibility was required during the process, deliberate and systematic planning helped to ensure success. Factors such as interdependence of collaborative practice, complementarity of practice within care teams, compensation for collaboration, in-person versus virtual delivery, and intricacies of care coordination should be further examined in the future to optimize collaborative mental health care in sport.

Elite female football players' perception of the impact of their menstrual cycle stages on their football performance. A semi-structured interview-based study

OBJECTIVES

This study assesses how female footballers perceive how their menstrual cycle impacts their physical and psychological performance, informing future research and intervention.

METHODS

Semi-structured interviews, developed using piloting and peer review took place with fifteen elite female footballers from two English WSL clubs (age: 25.2 [18-33]). Data was audio recorded, transcribed verbatim, and analysed thematically using NVivo.

RESULTS

All players (100%) perceive their menstrual cycle to negatively impact performance. Analysing 27,438 words of data revealed five themes: A) symptoms, B) preparation, C) performance, D) recovery, and E) management. Over half (53%) of players experienced decreased appetite and sleep quality prior to performance during menstruation. Competitive performance was perceived to be most negatively impacted during menses (54 references) following by the pre-menstrual stage (23 references). During menstruation, the most impacted physical performance indicators were power (93%) and fatigue (87%). Psychologically, confidence, focus, and reaction to criticism were commonly affected (66.7%). Players reported missing training (13.3%) and matches (13.3%) due to severity of impact. Recovery was affected during the pre-menstrual (26.7%) and menstrual (66.7) stages. Players self-manage symptoms using over the counter (66.7%) and prescription (26.7%) medication, some prophylactically prior to competition (46.7%).

CONCLUSIONS

This first attempt to ascertain player perception in football exposes a clear negative impact on performance. The complex interplay of biopsychosocial and logistical factors, lack of awareness and education highlight the need for further research. Intervention is necessary and immediate initiation would be prudent, starting with simple measures such as basic self-management advice, education, and provision of sanitary products.

Sustaining optimal performance when the stakes could not be higher: Emotional awareness and resilience in emergency service personnel (with learnings for elite sport)

Emergency services personnel are a high stress occupation, being frequently confronted with highly consequential stressors and expected to perform: without fault; under high pressure; and in unpredictable circumstances. Research often invokes similarities between the experiences of emergency services personnel and elite athletes, opening up the possibility of transferring learnings between these contexts. Both roles involve genuine risks to emotional wellbeing because their occupations involve significant stress. Similarly, both roles face obstacles and injury, and their “success” is dependent on high-quality execution of their skills under pressure. As such, both occupations are required to have resilience and effective coping abilities to ensure psychological well-being. Researchers suggest emotional awareness may be a key variable in the management and maintenance of resilience. This study: (1) explored the experiences of emergency services personnel; (2) characterised connections between emotional awareness and resilience; and (3) reflected on the ways these findings can be extrapolated to elite athletes. We analysed 11 interviews with emergency services personnel. Participants identified resilience as crucial when coping with stress, however, many defined resilience as remaining unaffected by stress rather than, for example, managing and responding to it. Participants defined emotional awareness as understanding their emotions, and they recognised associated benefits for coping, resilience, and burnout. Nevertheless, most participants did not engage in practices to improve their emotional awareness. Barriers, such as maladaptive beliefs and help-seeking stigma, interfered with participants’ ability to cultivate emotional awareness, to promote resilience. In contrast, some participants described profound improvements in resilience and coping following the cultivation of emotional awareness. This finding illustrates that systemic change must target the individual, team, and organisation to correct misperceptions about resilience, emotional awareness, and psychological help-seeking. Developing emotional awareness may help emergency services personnel and other high stress occupations like elite athletes process difficult experiences and enhance their resilience, promoting well-being, and career longevity.

Men's Experiences of Mental Illness Stigma Across the Lifespan: A Scoping Review

The stigma of men's mental illness has been described as having wide-reaching and profound consequences beyond the condition[s] itself. Stigma negatively impacts men's mental health help-seeking and the use of services amid impeding disclosures, diminishing social connection and amplifying economic hardship. Although men often face barriers to discussing their struggles with, and help-seeking for mental illness challenges, research focused on men's lived experiences of mental illness stigma is, at best, emergent. This scoping review explores men's mental illness related stigmas synthesizing and discussing the findings drawn from 21 published qualitative articles over the last 10 years. Four thematic findings were derived: (a) the weight of societal stigma, (b) stigma in male-dominated environments, (c) inequity driven stigmas, and (d) de-stigmatizing strategies. Despite evidence that stigma is a common experience for men experiencing diverse mental illness challenges, the field remains underdeveloped. Based on the scoping review findings, research gaps and opportunities for advancing the field are discussed.

Mental Toughness, Sport-Related Well-Being, and Mental Health Stigma Among National Collegiate Athletic Association Division I Student-Athletes

Mental toughness has been associated with factors related to psychological well-being, but little is known about its relationship with stigma toward mental health and mental health help-seeking. This study investigated the relationship between mental toughness, sport-related well-being, and personal stigma toward mental health in a sample of 154 National Collegiate Athletic Association Division I student-athletes. The moderating effect of mental toughness on the relationship between public stigma and self-stigma toward mental health help-seeking was also explored. Mental toughness was significantly and positively associated with sport-related well-being, but not significantly related to personal stigma toward mental health. Moderation analysis indicated that mental toughness was not a significant moderator of the relationship between public stigma and self-stigma, but higher levels of mental toughness were significantly associated with lower levels of stigma toward mental health help-seeking. Building mental toughness may be a way to increase well-being and to reduce stigma toward help-seeking in student-athletes.

A Program to Reduce Stigma Toward Mental Illness and Promote Mental Health Literacy and Help-Seeking in National Collegiate Athletic Association Division I Student-Athletes

Student-athletes are susceptible to mental health problems that disrupt optimal functioning and well-being. Despite having many protective factors, student-athletes represent an at-risk subgroup of college students who experience mental health concerns due to the distress of balancing multiple obligations. However, many student-athletes underutilize psychological services. Stigma is the main barrier preventing student-athletes from seeking help, and mental health literacy (MHL) interventions addressing knowledge and beliefs about mental disorders have traditionally been used to destigmatize mental illness. This study investigated the impact of a 4-week program on stigma, MHL, and attitudes and intentions toward seeking help with 33 National Collegiate Athletic Association Division I student-athletes. The program was composed of four science-based interventions—MHL, empathy, counter stereotyping, and contact—delivered face-to-face within a group setting. MHL, attitudes toward seeking help, and intentions to seek counseling improved from preintervention to postintervention and to 1-month follow-up. Self-stigma was reduced from preintervention to postintervention.

Help-Seeking for Eating Pathology Among Collegiate Athletes: Examining Stigma and Perfectionism as Moderating and Mediating Mechanisms

Despite elevated risk of eating pathology (EP) among athletes, utilization of EP-treatment among athletes is low. Factors that may inhibit EP-help-seeking among athletes include perceived social stigma, self-stigma, and perfectionism. Heightened stigma associated with EP and sport climates may be exacerbated by negative perfectionism characteristic of athletes and decrease intentions to seek help for EP. We tested the following moderated-mediation model among a sample of collegiate athletes (N = 201) via online questionnaires: EP indirectly relates to EP help-seeking intentions through perceived and self-stigma and these relations are conditional on negative perfectionism. EP help-seeking intentions were negatively associated with EP severity, stigma, and negative perfectionism. EP was related to eating-specific help-seeking intentions through perceived social stigma, influencing self-stigma, but this was not moderated by negative perfectionism. Targeting mental-health treatment stigma among athletes may reduce risk of untreated EP among collegiate athletes.

Mental Health Services for Canadian University Student-Athletes: An Exploratory Survey

University student-athletes are equally vulnerable to mental health challenges compared to their non-athlete peers, but they access mental health services with less frequency. This study sought to explore the mental health issues experienced by Canadian student-athletes in order to address the question: how can Canadian universities better meet the mental health needs of student-athletes? An electronic survey was distributed to student-athletes at a large Canadian university. Data from 113 respondents were analyzed using descriptive statistics and content analysis. Stress and pressure were reported as the most prevalent contributors to mental health issues, and 47% of respondents indicated that there was a time in which they wanted to seek services for their mental health, but chose not to. Respondents identified mental health education for coaches and designating a healthcare professional within the athletic department as beneficial resources. Findings from this study can inform local and national mental health service planning for student-athletes.

The Relationships Among Self-Compassion, Stigma, and Attitudes Toward Counseling in Student-Athletes

Although factors involved with help-seeking have been widely studied in the general college population, college student-athletes have received less attention. The purpose of this study was to examine the moderating role of self-compassion on the relationship between public and self-stigma, and how self-stigma was associated with attitudes toward seeking counseling. A sample of 243 student-athletes from NCAA Divisions I and III participated in the study. Using structural equation modeling, self-compassion was not found to moderate the relationship between public and self-stigma. However, public stigma was positively associated with self-stigma, and self-stigma was negatively associated with attitudes toward counseling. A multigroup analysis did not find differences between males and females for the model. The results of this study have implications for professionals who work with college student-athletes and suggest that efforts should aim to reduce stigma and examine alternative factors that might improve attitudes toward mental health help-seeking.

Mental health in elite athletes: International Olympic Committee consensus statement (2019)

Mental health symptoms and disorders are common among elite athletes, may have sport related manifestations within this population and impair performance. Mental health cannot be separated from physical health, as evidenced by mental health symptoms and disorders increasing the risk of physical injury and delaying subsequent recovery. There are no evidence or consensus based guidelines for diagnosis and management of mental health symptoms and disorders in elite athletes. Diagnosis must differentiate character traits particular to elite athletes from psychosocial maladaptations.

Management strategies should address all contributors to mental health symptoms and consider biopsychosocial factors relevant to athletes to maximise benefit and minimise harm. Management must involve both treatment of affected individual athletes and optimising environments in which all elite athletes train and compete. To advance a more standardised, evidence based approach to mental health symptoms and disorders in elite athletes, an International Olympic Committee Consensus Work Group critically evaluated the current state of science and provided recommendations.

Mental health symptoms and disorders in elite athletes: a systematic review on cultural influencers and barriers to athletes seeking treatment

OBJECTIVE

To summarise the literature on the barriers to athletes seeking mental health treatment and cultural influencers of mental health in elite athletes.

DESIGN

Systematic review DATA SOURCES: PubMed, Cochrane, Scopus, SportDiscus (Ebsco), and PsycINFO (ProQuest) up to November 2018.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Qualitative and quantitative original studies of elite athletes (those who competed at the professional, Olympic, or collegiate/university levels), published in any language.

RESULTS

Stigma, low mental health literacy, negative past experiences with mental health treatment-seeking, busy schedules, and hypermasculinity are barriers to elite athletes seeking mental health treatment. Cultural influencers of mental health in elite athletes include: (1) the lack of acceptance of women as athletes; (2) lower acceptability of mental health symptoms and disorders among non-white athletes; (3) non-disclosure of religious beliefs; and (4) higher dependence on economic benefits. Coaches have an important role in supporting elite athletes in obtaining treatment for mental illness. Brief anti-stigma interventions in elite athletes decrease stigma and improve literary about mental health.

CONCLUSION

There is a need for various actors to provide more effective strategies to overcome the stigma that surrounds mental illness, increase mental health literacy in the athlete/coach community, and address athlete-specific barriers to seeking treatment for mental illness. In this systematic review, we identified strategies that, if implemented, can overcome the cultural factors that may otherwise limit athletes seeking treatment. Coaches are critical for promoting a culture within elite athletes' environments that encourages athletes to seek treatment.

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

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

Men, Mental Health and Elite Sport: a Narrative Review

Mental health in elite sport is receiving more publicity due to an increase in male athletes sharing their personal experiences. Sports injury is recognised as the major risk factor for psychological distress amongst male athletes, although anecdotally this may be that athletes are more likely to discuss their emotional wellbeing when related to the injury they are experiencing. Stress can be amplified within elite sport and the pressure they experience in relation to competition and performance can be exacerbated by adverse life events. This ongoing stress does not end when their sporting career does, it can follow them into retirement. The physical and psychological demands placed upon them by the sporting environment may predispose athletes to developing depression. As an athlete’s symptoms of mental illness intensify, their performance can be negatively affected leaving them vulnerable and exposed to further symptoms of common mental disorders. The pressure of performance can also expose male athletes to overtraining syndrome which can be difficult to distinguish from depression. Male athletes are more vulnerable to eating disorders compared with males in the general population and they do have anxieties, particularly around their bodies, but find it difficult to disclose their concerns. In addition to this, male athletes are more likely to use substances, including opioids to improve both sport and non-sport performance.

Despite the prevalence of common mental disorders in male athletes, stigma still exists, and although some athletes discuss their issues publicly after their career has ended, the majority of athletes prefer to remain silent. There remains a view that athletes who seek help for psychological problems may be seen as weak. Although there is an improvement in help-seeking attitudes within elite sport, further research and education is needed to encourage men to talk about their mental health, share their experiences and to enjoy a greater sense of emotional wellbeing.

Learning From Elite Athletes' Experience of Depression

Sport has become increasingly aware of the challenges associated with Mental Disorders and, to a greater extent, mental health issues (MHIs). This study sought to explore in depth the subjective experiences of elite athletes who suffered from a specific clinical MHI, namely depression. In addition, we explored their perceptions of the prevalence and stigma surrounding MHIs in elite sport environments. Data were collected from four elite athletes (1 female and 3 males; 2 team and 2 individual sports) using semi-structured interviews and analysed using Interpretative Phenomenological Analysis. Participants described both sport and non-sport related triggers in regard to their depression (e.g., institutional mistreatment and bullying, injuries, previous MHI, and miscarriage), as well as a range of behaviour, performance (e.g., decline), and personality changes compared to their normal functioning. Although the participants stressed the widespread prevalence of MHIs in elite sport, they also acknowledged the stigma associated with MHIs in high-level sport environments and its detrimental role for athletes. This study has important practical and diagnostic implications, and highlights the need for further research to assess the extent and scope of clinical MHIs in sport as well as to inform the care for this unique population.

Student-Athlete and Student Non-Athletes’ Stigma and Attitudes Toward Seeking Online and Face-to-Face Counseling

This study investigated differences in stigmatization by others, self-stigma, and attitudes (value and discomfort) toward online counseling (OC) and face-to-face counseling (F2F), and the relationships between these variables, in college student-athletes (n = 101) and non-athletes (n = 101). Results revealed no differences in levels of stigmatization by others and self-stigma between student-athletes and non-athletes. Furthermore, both groups reported higher value, and less discomfort, in F2F compared to OC, while non-athletes reported higher levels of value in F2F compared to student-athletes. A multiple group path analysis revealed no difference in the relationship of the stigma and attitudes variables between the two groups. Stigmatization by others was a significant positive predictor of self-stigma and value in OC. In addition, self-stigma was a significant negative predictor of value in F2F, and a significant positive predictor of discomfort in F2F. The current findings have implications for university counseling centers and athletic departments.

The Mental Health of Elite Athletes: A Narrative Systematic Review

Background

The physical impacts of elite sport participation have been well documented; however, there is comparatively less research on the mental health and psychological wellbeing of elite athletes.

Objective

This review appraises the evidence base regarding the mental health and wellbeing of elite-level athletes, including the incidence and/or nature of mental ill-health and substance use.

Methods

A systematic search of the PubMed, EMBASE, SPORTDiscus, PsycINFO, Cochrane and Google Scholar databases, up to and including May 2015, was conducted.

Results

The search yielded a total of 2279 records. Following double screening, 60 studies were included. The findings suggested that elite athletes experience a broadly comparable risk of high-prevalence mental disorders (i.e. anxiety, depression) relative to the general population. Evidence regarding other mental health domains (i.e. eating disorders, substance use, stress and coping) is less consistent. These results are prefaced, however, by the outcome of the quality assessment of the included studies, which demonstrated that relatively few studies (25 %) were well reported or methodologically rigorous. Furthermore, there is a lack of intervention-based research on this topic.

Conclusion

The evidence base regarding the mental health and wellbeing of elite athletes is limited by a paucity of high-quality, systematic studies. Nonetheless, the research demonstrates that this population is vulnerable to a range of mental health problems (including substance misuse), which may be related to both sporting factors (e.g. injury, overtraining and burnout) and non-sporting factors. More high-quality epidemiological and intervention studies are needed to inform optimal strategies to identify and respond to player mental health needs.

Electronic supplementary material

The online version of this article (doi:10.1007/s40279-016-0492-2) contains supplementary material, which is available to authorized users.