No Time to Waste During the COVID-19 Pandemic and Beyond: Screening for Mental Health Symptoms and Disorders in Professional Football

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 • 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 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

Figure 1 - The IOC Sport Mental Health Assessment Tool 1 (SMHAT-1)

screening instrument; screening step (step 2) based on six existing validated screening instruments related to the most prevalent mental health symptoms in elite sports; intervention and (re)assessment step (step 3) including in some cases a clinical assessment. It is important to mention that physical therapists, athletic trainers and not clinically-trained sports psychologists working with a sports medicine physician can use the SMHAT-1, but any clinical assessment, guidance or intervention should remain the responsibility of their sports medicine physician.

Because the athletes themselves and all members of their entourage (e.g. friends, fellow athletes, family, coaches) are essential to support athletes’ mental health, the IOC Mental Health Working Group developed the IOC Sport Mental Health Recognition Tool 1 (SMHRT-1). The SMHRT-1 (Figure 2) aims to facilitate early detection of mental health symptoms in elite athletes (including professional footballers) to promote help-seeking for those athletes in need of assistance from a sports medicine physician or other licensed/registered health professional and to facilitate further assessment and subsequent treatment as applicable.

Both the SMHAT-1 and SMHRT-1 are the first versions of the IOC tools. Analogous to sports concussion and its assessment (SCAT) and recognition (CRT) tools, the IOC Mental Health Working Group intends to revise the SMHAT-1 and SMHRT-1 in the future as needed.

No time to waste within professional football

The SMHAT-1 should be part of regular screening programmes within professional football: there is no justification why players would be screened systematically for musculoskeletal or cardiovascular conditions but not for mental health symptoms and disorders. Therefore, the SMHAT-1 should be used at least within the precompetition period (i.e. ideally a few weeks after the start of training), as well as when a player experiences any significant life event (e.g. major injury/illness, surgery, unexplained performance concern). In Box 1, a representative but a fictional case of a player with mental health symptoms and disorders is presented by Professor Alan Currie (Consultant Psychiatrist). The triage and screening steps of the SMHAT-1 are designed to ideally be embedded in any existing privacysecured online platforms that most professional football clubs already used. Thanks to the IOC and its SMHAT-1, there is thus no time to waste within professional football: mental health symptoms and disorders should be screened among players.

Vincent Gouttebarge Affiliations:

1. FIFPRO (Football Players Worldwide), Hoofddorp, the Netherlands 2. Amsterdam UMC, Univ of Amsterdam, Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, the Netherlands

Box 1. Case presentation by Professor Alan Currie, Consultant Psychiatrist at Regional Affective Disorders Service, Cumbria, Northumberland Tyne and Wear NHS Foundation Trust, Newcastle, United Kingdom

Jamie is 21 and plays in central midfield in the second-tier of his country’s national league. He developed groin pain during a training session but did not disclose this. The following Saturday he played with mild pain. This became much worse during a midweek match a few days later and he had to be substituted. An acute adductor longus injury was suspected and an MRI scan was confirmatory (grade 2 tear). He was out for 3 weeks and when fit again had lost his place in the team.

He was determined to regain his place but re-injured with a more severe tear during training. He was despondent, which made it hard to commit to rehabilitation. The physiotherapist became concerned about his mood and he opened up during a treatment session. He told of his deep unhappiness. He was lacking in motivation, energy and enthusiasm. He and the physiotherapist agreed to meet confidentially with the team doctor. During this consultation, he mentioned how bleak the future seemed and berated himself for his failure to recover. He was sleeping badly, couldn’t concentrate and had lost weight. He had no suicidal thoughts. Screening tools for anxiety and depression were completed and compared with his scores from the pre-season SMHAT-1. His PHQ9 score had been 4 and was now 21 (severe depression). His GAD7 score had increased from 3 to 7 (mild anxiety).

He reported feeling relieved at opening up and agreed to a consultation with a sports psychiatrist when reassured that the club had worked with this psychiatrist before and that he had a good understanding of the sport. Sessions of Cognitive Behavioural Therapy (CBT) were recommended and the therapist was able to work with Jamie and the sports medicine team to incorporate elements of behavioural therapy into the injury rehabilitation program e.g. setting realistic injury recovery goals and addressing concerns about re-injury. Anti-depressant medication was also recommended. Jamie was initially reluctant but agreed after an explanation and the psychiatrist took careful account of the tolerability and side-effect profile when prescribing.

Jamie’s mood and motivation improved slowly as rehabilitation progressed. He had some matches with the reserves before returning to the first team. He completed 12 sessions of CBT followed by ‘top-up’ work with his therapist throughout the next season. He continued medication for six months before it was reduced and stopped under psychiatric medical supervision.

1. Reardon CL, Hainline B, Miller Aron C, et al. International Olympic Committee consensus statement on mental health in elite athletes. Br J Sports Med 2019;53:667-99. 2. Gouttebarge V, Bindra A, Blauwet C, et al. International Olympic Committee (IOC) Sport Mental Health Assessment Tool 1 (SMHAT-1) and Sport Mental Health Recognition Tool 1 (SMHRT-1): towards better support of athletes’ mental health. Br J Sports Med 2020 Sep 18;bjsports-2020-102411. 3. Gouttebarge V, Aoki H, Kerkhoffs G. Symptoms of Common Mental Disorders and Adverse Health Behaviours in Male Professional Soccer Players. J Hum Kinet 2015;49:277-86. 4. Gouttebarge V, Ahmad I, Mountjoy M, et al. Anxiety and Depressive Symptoms During the COVID-19 Emergency Period: A Comparative Cross-Sectional Study in Professional Football. Clin J Sport Med 2020 Sep 15. doi: 10.1097/ JSM.0000000000000886. 5. Håkansson A, Jönsson C, Kenttä G. Psychological Distress and Problem Gambling in Elite Athletes during COVID-19 Restrictions-A Web Survey in Top Leagues of Three Sports during the Pandemic. Int J Environ Res Public Health 2020;17:6693.

Figure 2 - The Sport Mental Health Recognition Tool 1 (SMHRT-1)