Surveillance of athlete mental health symptoms and disorders: a supplement to the International Olympic Committee's consensus statement on injury and illness surveillance.

In 2019, the International Olympic Committee (IOC) published a consensus statement outlining the principles for recording and reporting injury and illness in elite sport. The authors encouraged sport federations to adapt the framework to their sport-specific context. Since this publication, several sports have published extensions to the IOC consensus statement.In response to a paucity of epidemiological data on athlete mental health, the IOC mental health working group adapted the IOC consensus statement on injury and illness surveillance to improve the capturing of athlete mental health data. In addition to the members of the working group, other experts and athlete representatives joined the project team to address gaps in expertise, and to add stakeholder perspective, respectively. Following an in-person meeting, the authors worked remotely, applying the scientific literature on athlete mental health to the IOC injury and illness surveillance framework. A virtual meeting was held to reach consensus on final recommendations.Practical outcomes based on the analysis of the scientific literature are provided with respect to surveillance design, data collection and storage, data analysis and reporting of athlete mental health data. Mental health-specific report forms for athlete and health professional utilisation are included for both longitudinal and event-specific surveillance.Ultimately, this publication should encourage the standardisation of surveillance methodology for mental health symptoms and disorders among athletes, which will improve consistency in study designs, thus facilitating the pooling of data and comparison across studies. The goal is to encourage systematic surveillance of athlete mental health.

Does Increased Physical Activity Explain the Psychosocial Benefits of Sport Participation During COVID-19?

CONTEXT: Although the return to sports during COVID-19 has been associated with improvements in mental health and quality of life (QOL), whether these benefits are primarily due to increases in physical activity (PA) is unknown. OBJECTIVE: To determine whether PA increases were responsible for the improvements in mental health and QOL among adolescents who returned to sport during the COVID-19 pandemic. DESIGN: Cross-sectional study. SETTING: Wisconsin secondary schools. PATIENTS OR OTHER PARTICIPANTS: A total of 559 adolescent athletes (age = 15.7 + 1.2 years, females = 43.6%) from 44 schools completed a survey in October 2020. MAIN OUTCOME MEASURE(S): Demographic information, whether they had returned to sport participation, school instruction type, anxiety (Generalized Anxiety Disorder-7), depression (Patient Health Questionnaire-9), QOL (Pediatric Quality of Life Inventory 4.0), and PA (Hospital for Special Surgery Pediatric Functional Activity Brief Scale). Mediation analysis was used to assess whether the relationships between sport status and anxiety, depression, and QOL were mediated by PA. RESULTS: At the time of the study, 171 (31%) had returned to play and 388 (69%) had not. Athletes who had returned to play had less anxiety (3.6 ± 0.4 versus 8.2 ± 0.6, P < .001) and depression (4.2 ± 0.4 versus 7.3 ± 0.6, P < .001) and higher QOL (88.1 ± 1.0 versus 80.2 ± 1.4, P < .001) and more PA (24.0 ± 0.5 versus 16.3 ± 0.7, P < .001). Physical activity explained a significant, but small, proportion of the difference in depression (22.1%, P = .02) and QOL (16.0%, P = .048) but not anxiety (6.6%, P = .20) between athletes who had and those who had not returned to play. CONCLUSIONS: Increased PA was responsible for only a small portion of the improvements in depression and QOL among athletes who returned to sports. This suggests that most of the mental health benefits of sport participation for adolescents during the COVID-19 pandemic were independent of the benefits of increased PA.

High School Sports During the COVID-19 Pandemic: The Effect of Sport Participation on the Health of Adolescents.

CONTEXT: During the fall of 2020, some high schools across the United States allowed their students to participate in interscholastic sports while others cancelled or postponed their sport programs due to concerns regarding COVID-19 transmission. What effect this has had on the physical and mental health of adolescents is unknown. OBJECTIVE: To identify the effect of playing a sport during the COVID-19 pandemic on the health of student-athletes. DESIGN: Cross-sectional study. SETTING: Sample recruited via email. PATIENTS OR OTHER PARTICIPANTS: A total of 559 Wisconsin high school athletes (age = 15.7 ± 1.2 years, female = 43.6%, male = 56.4%) from 44 high schools completed an online survey in October 2020. A total of 171 (30.6%) athletes played (PLY) a fall sport, while 388 (69.4%) did not play (DNP). MAIN OUTCOME MEASURE(S): Demographic data included sex, grade, and sport(s) played. Assessments were the General Anxiety Disorder-7 Item for anxiety, Patient Health Questionnaire-9 Item for depression, the Hospital for Special Surgery Pediatric Functional Activity Brief Scale for physical activity, and the Pediatric Quality of Life Inventory 4.0 for quality of life. Univariable comparisons between the 2 groups were made via t tests or χ2 tests. Means for each continuous outcome measure were compared between groups using analysis-of-variance models that controlled for age, sex, teaching method (virtual, hybrid, or in person), and the percentage of students eligible for free or reduced-price lunch. RESULTS: The PLY group participants were less likely to report moderate to severe symptoms of anxiety (PLY = 6.6%, DNP = 44.1%, P < .001) and depression (PLY = 18.2%, DNP = 40.4%, P < .001). They also demonstrated higher (better) Pediatric Functional Activity Brief Scale scores (PLY = 23.2 [95% CI = 22.0, 24.5], DNP = 16.4 [95% CI = 15.0, 17.8], P < .001) and higher (better) Pediatric Quality of Life Inventory total scores (PLY = 88.4 [95% CI = 85.9, 90.9], DNP = 79.6 [95% CI = 76.8, 82.4], P < .001). CONCLUSIONS: Adolescents who played a sport during the COVID-19 pandemic described fewer symptoms of anxiety and depression and had better physical activity and quality-of-life scores compared with adolescent athletes who did not play a sport.

Bipolar disorder and eating disorders in sport: a case of comorbidity and review of treatment principles in an elite athlete.

OBJECTIVES: There is overlap between the typical age of onset of bipolar disorder (BD) and the age of peak athletic success. Additionally, eating disorders (EDs) are prevalent psychiatric disorders in athletes. Despite the relevance of both disorders in this population, there remains a need for treatment guidelines, especially when present as comorbidities given the complex interplay between them. METHODS: This report provides background information and utilizes a case report to explore the presentation and treatment of BD comorbid with an ED in an athlete. It specifically highlights the case of an elite female long-distance runner utilizing a multidisciplinary approach specific to the patient's unique needs as an athlete. RESULTS: Treatment of this elite athlete utilized strategic pharmacotherapy taking into consideration her training and competition cycles. At 16 week follow-up, the patient was psychiatrically stable, experienced improvement in her running and felt confident in choosing to stay on medication and continue her running career. CONCLUSION: It is important for providers who work with high-level athletes to provide treatment choices that allow athletes to safely and successfully continue their sport while adequately treating their mental illness. Treatment guidelines that increasingly take into consideration complex psychiatric comorbidities and nuanced pharmacologic approaches are needed in order to advance the field of sports psychiatry.

Bipolar Disorder and Athletes: A Narrative Review.

ABSTRACT: Bipolar disorder is a diagnosis with immense lifelong implications that affects 1% to 2% of the general population. It typically presents during late adolescence and early adulthood, which often coincides with the age of peak athletic performance and a limited window of opportunity to compete at the highest levels of sport. Understanding the nature and course of the illness, as well as the effects that pharmacological treatment can have on an athlete, can be extremely beneficial for sports medicine physicians, particularly as many young athletes may not yet be diagnosed and/or adequately treated. Bipolar disorder is an incredibly complex and challenging diagnosis, but the ability to identify symptoms and intervene early is invaluable. The aim of this review is to summarize the available evidence and to highlight relevant risk factors, diagnostic features, management, and potential complications pertaining to the athletic population.

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.

Changes in the Health of Adolescent Athletes: A Comparison of Health Measures Collected Before and During the COVID-19 Pandemic.

CONTEXT: In spring 2020, schools closed to in-person teaching and sports were cancelled to control the transmission of COVID-19. The changes that affected the physical and mental health among young athletes during this time remain unknown. OBJECTIVE: To identify changes in the health (mental health, physical activity, and quality of life) of athletes that occurred during the COVID-19 pandemic. DESIGN: Cross-sectional study. SETTING: Sample recruited via social media. PATIENTS OR OTHER PARTICIPANTS: A total of 3243 Wisconsin adolescent athletes (age = 16.2 ± 1.2 years, 58% female) were surveyed in May 2020 (During COVID-19). Measures for this cohort were compared with previously reported data for Wisconsin adolescent athletes (n = 5231; age = 15.7 ± 1.2 years, 47% female) collected in 2016 to 2018 (PreCOVID-19). MAIN OUTCOME MEASURE(S): Demographic information included sex, grade, and sport(s) played. Health assessments included the Patient Health Questionnaire-9 Item to identify depression symptoms, the Pediatric Functional Activity Brief Scale to gauge physical activity, and the Pediatric Quality of Life Inventory 4.0 to evaluate health-related quality of life. Univariable comparisons of these variables between groups were conducted via t or χ2 tests. Means and 95% CIs for each group were estimated using survey-weighted analysis-of-variance models. RESULTS: Compared with preCOVID-19 participants, a larger proportion of During COVID-19 participants reported moderate to severe levels of depression (9.7% versus 32.9%, P < .001). Scores of the During COVID-19 participants were 50% lower (worse) on the Pediatric Functional Activity Brief Scale (mean [95% CI] = 12.2 [11.9, 12.5] versus 24.7 [24.5, 24.9], P < .001) and the Pediatric Quality of Life Inventory 4.0 compared with the PreCOVID-19 participants (78.4 [78.0, 78.8] versus 90.9 [90.5, 91.3], P < .001). CONCLUSIONS: During the COVID-19 pandemic, adolescent athletes described increased symptoms of depression, decreased physical activity, and decreased quality of life compared with adolescent athletes in previous years.

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.

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.

A Quality Improvement Curriculum for Psychiatry Residents.

Introduction: Quality improvement (QI) is an increasingly important aspect of health care and residency education. There is relatively little research describing QI curricula for residents in psychiatry. Although QI curricula have been published in MedEdPORTAL, the current resource represents the first such curriculum specific to psychiatry residents. This resource aims to present a QI curriculum for psychiatry residents. Methods: The University of Wisconsin psychiatry residency program implemented a QI curriculum for our PGY 3 psychiatry residents in 2010. The initial version of the curriculum has undergone marked changes over the ensuing years, reflecting feedback received from learners and faculty instructors, as well as ongoing review of the literature, to ascertain best practices in this area of medical education. Steps taken have included faculty training, development of evaluation forms, and implementation of elements to increase accountability for successful, sustainable project development. Results: During the 8 completed years of this curriculum, 77 PGY 3 psychiatry residents have completed it. The Quality Improvement Knowledge Application Tool adapted for psychiatry was completed by PGY 3 residents in advance of and upon completion of the curriculum for the first 2 years of the curriculum; results demonstrated a significant improvement in scores as a measurement of QI knowledge and skills. Thirty-one of 32 resident teams (97%) have implemented a QI project. Discussion: Our QI curriculum for PGY 3 psychiatry residents has been successful in equipping residents with QI knowledge and having them implement QI projects.

American Medical Society for Sports Medicine Position Statement: Mental Health Issues and Psychological Factors in Athletes: Detection, Management, Effect on Performance, and Prevention-Executive Summary.

The American Medical Society for Sports Medicine convened a panel of experts to provide an evidence-based, best practice document to assist sports medicine physicians and other members of the athletic care network with the detection, treatment, and prevention of mental health (MH) issues in competitive athletes. This statement discusses how members of the sports medicine team, including team physicians, athletic trainers, and MH providers, work together in providing comprehensive psychological care to athletes. It specifically addresses psychological factors in athletes including personality issues and the psychological response to injury and illness. The statement also examines the athletic culture and environmental factors that commonly impact MH, including sexuality and gender issues, hazing, bullying, sexual misconduct, and transition from sport. Specific MH disorders in athletes, such as eating disorders/disordered eating, depression and suicide, anxiety and stress, overtraining, sleep disorders and attention-deficit/hyperactivity disorder, are reviewed with a focus on detection, management, the effect on performance, and prevention. This document uses the Strength of Recommendation Taxonomy to grade level of evidence.

Mental Health Issues and Psychological Factors in Athletes: Detection, Management, Effect on Performance, and Prevention: American Medical Society for Sports Medicine Position Statement.

The American Medical Society for Sports Medicine convened a panel of experts to provide an evidence-based, best practices document to assist sports medicine physicians and other members of the athletic care network with the detection, treatment, and prevention of mental health issues in competitive athletes. This statement discusses how members of the sports medicine team, including team physicians, athletic trainers, and mental health providers, work together in providing comprehensive psychological care to athletes. It specifically addresses psychological factors in athletes including personality issues and the psychological response to injury and illness. The statement also examines the athletic culture and environmental factors that commonly impact mental health, including sexuality and gender issues, hazing, bullying, sexual misconduct, and transition from sport. Specific mental health disorders in athletes, such as eating disorders/disordered eating, depression and suicide, anxiety and stress, overtraining, sleep disorders, and attention-deficit/hyperactivity disorder, are reviewed with a focus on detection, management, the effect on performance, and prevention. This document uses the Strength of Recommendation Taxonomy (SORT) to grade level of evidence.

Mental health issues and psychological factors in athletes: detection, management, effect on performance and prevention: American Medical Society for Sports Medicine Position Statement-Executive Summary.

The American Medical Society for Sports Medicine convened a panel of experts to provide an evidence-based, best practices document to assist sports medicine physicians and other members of the athletic care network with the detection, treatment and prevention of mental health issues in competitive athletes. This statement discusses how members of the sports medicine team, including team physicians, athletic trainers and mental health providers, work together in providing comprehensive psychological care to athletes. It specifically addresses psychological factors in athletes including personality issues and the psychological response to injury and illness. The statement also examines the athletic culture and environmental factors that commonly impact mental health, including sexuality and gender issues, hazing, bullying, sexual misconduct and transition from sport. Specific mental health disorders in athletes, such as eating disorders/disordered eating, depression and suicide, anxiety and stress, overtraining, sleep disorders and attention-deficit/hyperactivity disorder, are reviewed with a focus on detection, management, the effect on performance and prevention. This document uses the Strength of Recommendation Taxonomy to grade level of evidence.

Problem gambling and associated mental health concerns in elite athletes: a narrative review.

Opportunities to participate in gambling have dramatically changed during the past 20 years. Casinos have proliferated as have electronic gambling machines, lotteries, sports betting, and most recently online gambling. Gambling among the general population has moved from being perceived negatively to a socially acceptable pastime. As over 80% of individuals have reported gambling for money during their lifetime, governments recognise that regulating gambling-a multibillion dollar industry-is a significant source of revenue. While the vast majority of individuals engaged in some form of gambling have no or few gambling-related problems, an identifiable proportion of both adolescents and adults experience significant gambling-related problems. Elite athletes have not been immune to the lure of gambling nor its concomitant problems. Prevalence studies suggest higher rates of gambling problems among athletes than the general population. In this narrative review, we examine several risk factors associated with gambling problems among elite athletes and new forms of gambling that may be problematic for this population. Given the potential serious mental health and performance consequences associated with a gambling disorder for athletes, we aim to increase coaches', athletic directors' and health professionals' knowledge concerning the importance of screening and treatment referrals.