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NO TIME TO WASTE DURING THE COVID-19 PANDEMIC AND BEYOND: SCREENING FOR MENTAL HEALTH SYMPTOMS AND DISORDERS IN PROFESSIONAL FOOTBALL FEATURE / VINCENT GOUTTEBARGE Within the context of professional football, the mental health of players has been legitimately the subject of increasing scrutiny over the past years. The available body of scientific evidence suggests that the prevalence of mental health symptoms among professional footballers is substantial, or at least similar to the prevalence of the general population. Due to the ongoing COVID-19 pandemic and its related adverse consequences, professional footballers have reported recently higher rates of mental health symptoms. Regardless of how long the professional football industry will remain affected by COVID-19, there is no time to waste anymore and a systematic screening programme for mental health symptoms among players should be introduced in any professional football clubs. Definition of mental health symptoms Mental health symptoms refer to selfreported adverse or abnormal thoughts, feelings, and/or behaviours that do not meet specific diagnostic criteria and do not necessarily cause significant distress or functional impairment.1 By contrast, mental health disorders are typically defined as conditions causing clinically significant distress or functional impairment that meet certain diagnostic criteria such as in the Diagnostic and Statistical Manual of Mental Disorders 5 or the International Classification of Diseases.1 In professional football, nearly all available body of scientific evidence is directed towards mental health symptoms such as psychological distress, anxiety, depression, sleep disturbance, or alcohol misuse. Any professional footballer (as any individual) can occasionally experience sadness, anger, stress, irritability, and anxiety. However, if persistent over a long period of time and/or if impacting the player’s performance or daily life, then it may be that this player is experiencing mental health symptoms. Common experiences of mental health symptoms can include the following adverse thoughts, feelings, behaviours, and/or physical changes:2
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Thoughts: excessive self-criticism, low self-esteem, pessimism, hopelessness, problems with focus, concentration, and memory; Feelings: irritability, anger, mood swings, sadness, extreme disappointment that you just cannot shake, depression, loneliness, emptiness, lack of passion and sense of purpose, lack of motivation; Behaviours: aggression, withdrawal from others / not going outside as much, being much more quiet than usual, an unexpected drop of performance (e.g., in sport, school, work); Physical changes: low energy, poor sleep, changes in appetite, changes in weight and appearance, evidence of alcohol or other substance misuse.
Mental health symptoms in professional football during the COVID-19 pandemic Professional footballers report several mental health symptoms at rates at least similar to those of the general population. In a twelvemonth prospective cohort study conducted in 2015 among 607 male professional players, the prevalence of mental health symptoms found at baseline was 38% for anxiety/depression, 23% for sleep disturbance and 9% for adverse alcohol use.3 From March 2020, several public health measures were implemented to reduce human-to-human transmission of COVID-19, for instance, travel restrictions, mass homeconfinement directives, social distancing, and postponement or cancellation of most ongoing football competitions. Such an unprecedented COVID-19 pandemic created new strains on players, increasing potentially their vulnerability to mental health symptoms. Therefore, an observational comparative cross-sectional survey study was conducted.4 The validated Generalised Anxiety Disorder 7 (GAD-7) was used to assess anxiety symptoms and the validated Patient Health Questionnaire 9 (PHQ-9) for depressive symptoms. Data were collected from March to April 2020 in the COVID-19 study group (468 female and 1,134 male professional footballers), and from December 2019 to January 2020 in the non-COVID-19 comparison group (132 female and 175 male professional footballers). The
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prevalence rates were significantly higher during the COVID-19 pandemic than before (p<·01): • Anxiety symptoms: 18% versus 8% before in female players and 16% versus 4% in male players; • Depressive symptoms: 22% versus 11% before in female players and 13% versus 6% in male players. Similar results were found among 191 players in the top Swedish football league surveyed in May 2020.5 The extent of mental health symptoms among players, either prior or since the COVID-19 pandemic, warrants systematic screening for mental health symptoms in professional football, just as other conditions (e.g., musculoskeletal, cardiovascular) are screened. The IOC Sport Mental Health Assessment Tool 1 (SMHAT-1) In the International Olympic Committee (IOC) consensus statement on mental health in elite athletes published in 2019, one principal caveat formulated was the lack of specific tools to assess mental health symptoms and disorders in elite athletes.1 Consequently, the IOC established its Mental Health Working Group aiming in part to develop an assessment tool for the context of elite sports. Therefore, from April 2019 to March 2020, the IOC Mental Health Working Group (i) conducted narrative and systematic reviews of the scientific literature, (ii) explored through an electronic questionnaire the views of elite athletes, (iii) selected the approach and content for a provisional version of the assessment tool, (iv) evaluated and finalised the assessment tool via a modified Delphi consensus process among licensed mental health professionals, and (v) assessed the appropriateness and preliminary reliability and validity of the assessment tool.2 This exercise led to the IOC Sport Mental Health Assessment Tool 1 (SMHAT-1) published in September 2020 in the British Journal of Sports Medicine.2 The SMHAT-1 (Figure 1) is developed for sports medicine physicians and other licensed/ registered health professionals to assess elite athletes (including professional footballers) potentially at risk for or already experiencing mental health symptoms and disorders to facilitate timely management and/or referral to adequate support and/or treatment. The SMHAT-1 relies on a three-step approach: triage step (step 1) based on an existing validated
