CLINICAL REVIEW: SPORT MENTAL HEALTH ASSESSMENT

Vincent Gouttebarge, Abhinav Bindra, Cheri Blauwet, Niccolo Campriani, Alan Currie, Lars Engebretsen, Brian Hainline, Emily Kroshus, David McDuff, Margo Mountjoy, Rosemary Purcell, Margot Putukian, Claudia L Reardon, Simon M Rice, Richard Budgett.

Br J Sports Med 2020;0:1–9. doi:10.1136/bjsports-2020-102411

By Amanda O’Reilly

The prevalence of mental health symptoms and disorders in elite athletes is substantial, and similar to the prevalence in the general population. The risk of mental health symptoms and disorders can increase due to sport-specific stressors such as severe musculoskeletal injuries, surgeries with long recoveries, and transitioning out of elite sport. In 2017 the International Olympic Committee (IOC) established an expert panel to review the available literature regarding mental health symptoms and disorders among active and former elite athletes leading to a consensus statement. A recommendation from this statement was the need for an appropriate screening tool for elite athletes. This article describes the development, and preliminary reliability and validity of the tool.

The IOC established a Mental Health Working Group with 11 international experts (10 of whom were involved in the consensus statement). The group reviewed the literature, and assessed the views of current and former elite athletes on mental health symptoms and disorders. From that information they formulated a three-stepped approach to assessing elite athletes (defined as professional, Olympic, Paralympic or collegiate level; aged 16 years and older) potentially at risk for (ie, exposed to one or more stressors), or already experiencing, mental health symptoms and disorders to facilitate timely management and/or referral to adequate support and/or treatment.

This tool can be used by sports medicine physicians and other registered health professionals but the clinical assessment step (3B) must be conducted by a sports medicine physician or a registered mental health professional.

The Athlete Psychological Strain Questionnaire (APSQ) is a 10 item, self-reported rating (5-point) scale specific to the sport context. A score of 17 or more is indicative of a high risk for psychological distress. A positive triage leads onto the subsequent step.

The following six disorder-specific screening questionnaires are used: • General Anxiety Disorder-7 (GAD-7): assesses the presence of symptoms of anxiety. • Patient Health Questionnaire-9 (PHQ-9): assesses the presence of symptoms of depression. • Athlete Sleep Screening Questionnaire (ASSQ): assesses the presence of sleep disturbance. • Alcohol Use Disorders Identification Test

Consumption (AUDIT-C): assesses the presence of alcohol misuse. • Cutting Down, Annoyance by Criticism, Guilty

Feeling, and Eye-openers. Adapted to Include

Drugs (CAGE-AID): assesses the presence of substance misuse, being slightly adapted for the

SMHAT (no focus on alcohol use as already explored with the AUDIT-C; additional question to explore which substance was used). • Brief Eating Disorder in Athletes Questionnaire (BEDA-Q): assesses the presence of disordered eating.

If all screening questionnaires are negative, the administrator proceeds to step 3A (brief intervention and monitoring). If one or more screening questionnaires are positive or a positive answer is given on PHQ-9, item 9, the administrator proceeds to step 3B.

Based on the questionnaires and history of the athlete, the administrator might refer the athlete for interventions such as mindfulness, meditation, mental skills training and/or stress control. After the intervention the readministration should conduct the APSQ and another positive result will be a referral to step 3B.

A comprehensive clinical assessment is conducted by a sport medicine physician and/or registered mental health professional to obtain additional relevant information and identify a clinical diagnosis. Based on the information, one of three actions can be followed:

1. In cases that are neither severe nor complex and where there is no diagnostic uncertainty nor history of previous non-responsive to treatment, then treatment/support can be provided by a sports medicine/primary care physician. 2. In cases of diagnostic uncertainty or when further information might be useful, additional screening questionnaires for other mental health symptoms and disorders, including but not limited to attention-deficit/hyperactivity disorder, bipolar disorder, post-traumatic stress disorder, gambling disorder and/or psychosis, can be considered prior to definitive diagnosis and the creation of a management/intervention plan. 3. In cases that are severe, complex, diagnostically uncertain even after additional screening is completed and/or non-responsive to treatment, we recommend referral of the athlete to a registered mental health professional.

The tool can be used pre, mid and end-season periods. It should also be used when an athlete experiences any significant life event such as a major injury or illness, unexplained performance concern, suspected harassment/abuse and on transition out of sport.

The APSQ applied at step 1 (triage) identified 57.1% (N=160) of the sample requiring progression to step 2 (screening). Overall, the APSQ performed well in case detection for the six screening instruments at step 2. It detected all positive screened cases for the GAD -7, PHQ-9 and CAGE-AID, while only a small proportion of cases was misclassified for the AASQ (5%), AUDIT-C (16%) and BEDA-Q (11%).

Friends, family, coaches and fellow athletes are significant essential supports for elite athletes hence the IOC MHWG developed the SMHRT-1 to be used by these support networks and facilitate early detection of mental health symptoms or disorders in elite athletes. The SMHRT-1 relies on the observation of significant and/or persistent thoughts, feelings, behaviours and/or physical changes in athletes. In cases where those are observed, the athletes should be directed to a sports medicine physician or registered health professional for mental health screening with the SMHAT-1.

The questionnaires within the SMHAT-1 are selfreported so the external validity relies on the accuracy of the respondents' answers. The majority of the questionnaires have only been studied in nonathletic populations so more testing is required within different sporting populations and countries to gain further validation.

Whilst there is still a lot of further validation and analysis of practicality of the SMHAT-1 and the SMHRT-1; if used as part of routine screening like cardiovascular and musculoskeletal screening the awareness, assessment and management of mental health symptoms and disorders will improve within the elite athletic population. The questionnaires are self-reporting so easy to administer and the stepwise system provides the support networks for an athlete such as coaches, family, allied health and sports medicine practitioners a clear protocol for intervention or referral as required.

A full set of references are available on request