Sport Health Volume 38 Issue 2 - Mental Health by Sports Medicine Australia

Sport

health Mental Health

VOLUME 38 ISSUE 2 2021

PLUS

• COVID-19 and Mental Health in Athletes • New Directions in Athlete Mental Health • Nutrition for optimising Mental Health in Athletes

Contents REGULARS

No time to waste during the COVID-19 pandemic and beyond In this feature, Dr Vincent Gouttebarge sheds light on the process of screening for mental health disorders in professional footballers.

From the Chair SMA Board Chair, Professor Gregory Kolt discusses the prevalence of mental health issues throughout the year of 2020.

3 From the CEO In this edition of Sport Health, Interim CEO Michael Kenihan welcomes new board members and gives an update on what is to come for SMA in 2021.

22 New Directions in Athlete Mental Health This feature shows a shift in focus on mental health in sport – a topic that has been a blind spot for some time.

14 Cultural influencers and barriers to elite athletes seeking treatment for mental health disorders

Professor Rosemary Purecell (BA, M.Psych, PhD), Associate Professor Simon Rice (BBSc, Grad Cert Clin epi, MPsych, PhD).

Professor João Maurício Castaldelli-Maia and Clinical Associate Professor Todd Stull share aspects of cultural influence on athlete’s mental health.

FEATURES

4 The Bases Expert Statement on Burnout in Sport

Dr Daniel J. Madigan and colleagues discuss the physical and mental effects of athlete burnout in sport.

What We Know – Physical Activity and Mental Health in Australian Athletes

Dr Daniel J. Madigan, Dr Henrik Gustafsson, Professor Alan L. Smith, Professor Thomas D. Raedeke, Professor Andrew P.Hill. Opinions expressed throughout the magazine are the contributors’ own and do not necessarily reflect the views or policy of Sports Medicine Australia (SMA). Members and readers are advised that SMA cannot be held responsible for the accuracy of statements made in advertisements nor the quality of goods or services advertised. All materials copyright. On acceptance of an article for publication, copyright passes to the publisher.

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Dr Catherine Sabiston shares the mental health benefits that come along with regular exercise.

Publisher Sports Medicine Australia Sports House, 375 Albert Rd Albert Park VIC 3206 sma.org.au ISSN No. 1032-5662 PP No. 226480/00028

Copy Editor Kristen Butterworth Manager – Marketing and Communications Cohen McElroy Design/Typesetting Perry Watson Design Cover Photography Gettyimages/wavebreakmedia Content Photography Author supplied; www.gettyimages.com.au

Volume 38 • Issue 2 • 2021

Nutrition for optimising Mental Health in Athletes

People Who Shaped SMA: Tim Pain Tim Pain reflects on his career and time as a valued person in the SMA community.

Accredited Dietitian Holly Edstein discusses the ever-growing research on nutrition and mental health.

36 Sports Medicine Around the World: Israel

NEWS

SMA Members News

Sports Trainer Spotlight: Kenneth Whitehill

INTERVIEWS

Promoting Good Mental Health: From the Weekend Warrior to the Elite Athlete – Review

Kenneth Whitehill looks back on his time as a Sports Trainer with SMA and shares the highlights of his sporting career.

5 Minutes with: Dr John Orchard

Read all about our key take aways from SMA’s Mental Health in Sport webinar held in October 2020.

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FROM THE CHAIR

Navigating wellbeing after a year of uncertainty SMA BOARD CHAIR, PROFESSOR GREGORY KOLT INTRODUCES THE TOPIC OF MENTAL HEALTH IN SPORT, AND OUTLINES THE IMPORTANT AREAS OF FOCUS FOR SPORTS MEDICINE AUSTRALIA IN THE COMING MONTHS.

elcome to the first issue of Sport Health for 2021! This issue covers a topic that, as a society, we are increasingly having to navigate â&#x20AC;&#x201C; mental health and wellbeing. Reflecting on the year of 2020, and as a psychologist, I have been acutely aware of the increasing prevalence of mental health issues across the globe. Whilst a critical part of the work of psychologists, others involved in sports medicine can also play an important role in identifying mental health issues and ensuring appropriate management is put in place. This issue focuses on Mental Health in Sport. Whilst there is extant evidence supporting the important role of sport and physical activity in managing mental health, this issue will address a range of specific areas including athlete burnout in sport, mental health in the wake of a global pandemic, cultural influences on the health and wellbeing of elite athletes, and much more.

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Reflecting on the year of 2020, and as a psychologist, I have been acutely aware of the increasing prevalence of mental health issues across the globe.

As we bring in a new year, at Sports Medicine Australia a significant focus early in 2021 is the appointment of our new Chief Executive Officer. Recruitment for this critical role is underway and we hope to have this completed in February. The Board is excited to work with the incoming CEO on the plans for the future of SMA and the many projects and benefits that can be delivered to our members. The CEO will lead our committed and

passionate staff, bring greater stability to our budget following the COVID-19 disruption, and work closely with the Board in advancing the organisation in a range of ongoing and new activities. I hope that you enjoy this issue of Sport Health, and that it serves a reminder that mental health is at the forefront of health and wellbeing. Professor Gregory Kolt

FROM THE CEO

An exciting year to come HAPPY NEW YEAR AND WELCOME TO THE NEWEST EDITION OF SPORT HEALTH.

s we welcome a new year, we also welcome Michelle Bergeron, Dr Anita Green and Gary Nicholls who were appointed directors to the SMA Board at the 2020 SMA AGM. Our internal team here at SMA have been busily preparing for the launch of our new online community SMA Connect – SMA Connect will allow you to access member-only content, post questions and share opinions with your peer network, profile your practice or research, expand your industry contacts, share links, documents and events and find partners or collaborators from anywhere in the world at any time, all in one place. We can’t wait to share it with you. We are thrilled to announce that the 2021 SMA Conference will be back, taking place from October 7-9. In more exciting event news, 2021 will also see the Eminent Member Speaker Series begin with Dr Peter Brukner (February), Professor Wendy Brown (March), Dr Peter Larkins (April)

After a year of loss, illness and uncertainty for many it is no surprise that there is increased risk for significant anxiety and distress among individuals, particularly those that are reliant on sport in their everyday lives.

and Professor Jill Cook (May) as the keynote speakers, all four of these events will have face to face and online viewing opportunities with free attendance for SMA members.

lives. Throughout the last year our members have shown extreme resilience by adapting as needed and cultivating a sense of community during such an isolating time.

This edition of Sport Health focuses on mental health. After a year of loss, illness and uncertainty for many it is no surprise that there is increased risk for significant anxiety and distress among individuals, particularly those that are reliant on sport in their everyday

I would like to thank every person who contributed to this edition of Sport Health. I hope that you enjoy this edition and find it informative and helpful. Interim CEO, Michael Kenihan

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FEATURE: BURNOUT IN SPORT

The

BASES Expert Statement on Burnout in Sport BURNOUT IS AN EXTREME AND PERSISTENT FORM OF SPORT DISILLUSIONMENT THAT CAN AFFLICT BOTH ATHLETES AND COACHES. IT IS COMPRISED OF THREE SYMPTOMS, NAMELY, A REDUCED SENSE OF ACCOMPLISHMENT, DEVALUATION OR CYNICISM DIRECTED AT SPORT, AND PHYSICAL AND EMOTIONAL EXHAUSTION (MASLACH ET AL., 1986; RAEDEKE & SMITH, 2001). THESE SYMPTOMS ARE SIGNIFICANT CONTRIBUTORS TO DIMINISHED PHYSICAL AND PSYCHOLOGICAL WELL-BEING. AS SUCH, OUR AIM IN THE PRESENT EXPERT STATEMENT IS TO INCREASE AWARENESS OF BURNOUT AND PROVIDE ATHLETES, COACHES AND SPORT SCIENTISTS WITH RECOMMENDATIONS TO HELP PREVENT ITS OCCURRENCE.

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FEATURE: BURNOUT IN SPORT

BACKGROUND AND EVIDENCE Researchers have invested substantial time and resources into understanding burnout in sport (Goodger et al., 2007; Smith et al., 2019). This research has provided us with considerable insight into its consequences. For athletes, burnout is associated with underperformance, compromised physical and psychological wellbeing and possible dropout from sport (Gustafsson et al., 2017). For coaches, there is evidence that it reduces work capacity, negatively affects coach-athlete relationships and can result in coaches leaving the profession (Goodger et al., 2007). Although few studies have directly assessed burnout prevalence, estimates suggest that up to 10% of athletes may regularly experience moderate levels of burnout symptoms. In coaches, rates are likely to be comparable to those found in similar professions (e.g. ~15% of teachers; García-Carmona et al., 2019). Research has also provided us with a great deal of information about burnout development. This research suggests that burnout stems from both stress and motivation-related processes. Consequently, factors that place the individual at risk of stress or motivation difficulties are particularly relevant in understanding burnout development. These factors can relate to the structure of sport (i.e. organisation/ environment) and the individual themselves. For the structure of sport, perceived incongruence of personally desired and organisationally provided resources (e.g. workload, control, reward, community, fairness and value), a lack of social support, and negative social interactions have all been found to positively correlate with burnout (Gustafsson et al., 2017; Pacewiczet al., 2019). For individual factors, a large body of evidence has shown that certain aspects of personality and elements of self-determination are

RECOMMENDATIONS

For athletes, burnout is associated with underperformance, compromised physical and psychological wellbeing and possible dropout from sport

important. For example, perfectionistic concerns (overly critical evaluations of one’s behaviour and performance) positively correlate with burnout and predict increases in athlete burnout over time (Hill & Curran, 2016). In addition, thwarting of psychological needs of autonomy, competence and relatedness positively correlates with burnout. This thwarting corresponds with more external motives and less internal motives for sport involvement, which also tie with greater burnout (Li et al., 2013). The preceding discussion highlights the importance of protecting athletes and coaches from burnout. To provide athletes, coaches and sport scientists with the means to do so, we offer recommendations for how to monitor, intervene and further our understanding of burnout in sport. Intervention What can athletes and coaches do to address burnout? The aforementioned risk factors are helpful in terms of organising possible interventions. That is, we can target (1) the structure of sport (organisation/environment) and/or (2) the individual.

Monitoring Monitoring athletes and coaches for burnout symptoms is an important component of burnout prevention. Burnout is typically measured using self-report questionnaires. The Athlete Burnout (1) The structure of sport Questionnaire is a 15-item questionnaire capturing the three symptoms of athlete burnout (Raedeke & Smith, 2001). Similarly, the Maslach Burnout Inventory-General Scale (Schaufeli et al., 1996) is a 16-item questionnaire capturing burnout symptoms in coaches. We provide example items and the response format in Table 1. Higher scores indicate more frequent symptoms. Research shows that these questionnaires are useful for ongoing monitoring and detection of burnout in athletes and coaches (Smith et al., 2019). Coaches and support staff can be taught to provide athletes with environments that are less likely to lead to burnout. There is evidence that offering more autonomy support (e.g. acknowledging athlete perspectives, providing athletes with the opportunity to make choices and decisions, and valuing independent problem solving and initiative taking), social support, and positive feedback can buffer the likelihood of burnout (Smith et al., 2019). ٚ Organisational changes that reduce exposure to stressors (e.g. reduced workload), improve role clarity, and increase congruence between desired and provided resources (e.g. increased reward, organisational support) may help mitigate burnout risk for coaches. The individual Interventions targeting the individual should aim to reduce the potential for chronic stress and equip athletes and coaches with coping resources and strategies. There is evidence that Cognitive Behavioural Therapy-based interventions are particularly effective in these regards and can combat VOLUME 38 • ISSUE 2 2021

FEATURE: BURNOUT IN SPORT

The

BASES Expert Statement on Burnout in Sport burnout directly (Gustafsson et al., 2017). Psychological skills training (e.g. goal-setting, self-talk, imagery) is also likely to be effective and is often part of routine support provided by sport psychologists to athletes and coaches. Whereas more studies examining interventions for burnout prevention and treatment in sport are required, evidence outside of sport suggests interventions that simultaneously target the sport structure and the individual will be most effective (West et al., 2016). Future research Sport scientists play an important role in advancing our understanding of burnout so as to increase our capacity to assist athletes and coaches. Accordingly, we close this expert statement by providing recommendations for future research.

1. We recommend developing behavioural observation measures of burnout symptoms. This would provide an additional means to monitor athletes and coaches for burnout symptoms (and may act as early warning for these individuals). 2. We highlight the need for research identifying the epidemiological and public health significance of burnout given its potential prevalence and impact on health-related outcomes. 3. We have little understanding of the psychophysiology of burnout, both in terms of aetiology and its markers. Future research should therefore adopt a multidisciplinary approach that aims to identify endocrine (e.g. cortisol) and immunological (e.g. Salivary IgA) markers associated with burnout. 4. We also believe it is important to understand how social dynamics potentially catalyse or mitigate the processes involved in burnout development. This includes how

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burnout manifests amongst coach-athlete dyads and within organisations (e.g. teams of athletes and support staff). 5. We call for further intervention research that ensures we are able to practice in an evidence-based manner. Conclusions Burnout consists of three core symptoms that have a negative impact on athletes and coaches. Burnout is known to stem from both stress and motivation-related processes and can be monitored using selfreport questionnaires. Prevention should focus on addressing the sport structure and individual in ways that reduce exposure to stress, promote autonomy support and increase coping resources and strategies. Taken together, we hope that this expert statement will enable athletes, coaches and sport scientists to better recognise burnout and its risk factors so as to help prevent its development and intervene when necessary.

FEATURE: BURNOUT IN SPORT

About the Authors Dr Daniel J. Madigan is a Senior Lecturer in Sport and Exercise Psychology at York St John University, UK. He is also Co-Editor of the International Journal of Sport Psychology and a BASES accredited sport and exercise scientist. Dr Henrik Gustafsson is an Associate Professor at Karlstad University, Sweden and a Sport Psychologist with the Swedish Olympic Committee. Professor Alan L. Smith is Professor and Chairperson of the Department of Kinesiology at Michigan State University, USA. Professor Thomas D. Raedeke is a Professor and Graduate Program Director for the Kinesiology Department at East Carolina University, USA. Professor Andrew P. Hill is a Professor of Sport and Exercise Psychology at York St John University, UK. He is also Senior Section Editor of the Scandinavian Journal of Medicine & Science in Sports and a BASES accredited sport and exercise scientist.

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FEATURE: SCREENING FOR MENTAL HEALTH

No time to waste during the COVID-19 pandemic

Screening for mental health disorders in football

Author: 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

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ithin the context of professional football, the mental health of players has been legitimately subject of increasing scrutiny in the past years. The available body of scientific evidence suggests that the prevalence of mental health symptoms among professional footballers is substantial, at least similar to the prevalence from the general population. Because of the ongoing COVID-19 pandemic and its related adverse consequences, professional footballers have reported recently higher rates of mental health symptoms. Regardless 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 self-reported adverse or abnormal thoughts, feelings and/or behaviour 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

FEATURE: SCREENING FOR MENTAL HEALTH

Because of the ongoing COVID-19 pandemic and its related adverse consequences, professional footballers have reported recently higher rates of mental health symptoms.

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.

ٚ Thoughts: excessive self-criticism, low self-esteem, pessimism, hopelessness, problems with focus, concentration and memory;

ٚ Physical changes: low energy, poor sleep, changes in appetite, changes in weight and appearance, evidence of alcohol or other substance misuse.

ٚ 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;

Mental health symptoms in professional football before and during the COVID-19 pandemic Professional footballers report several mental health symptoms at rates at least similar to those of the general population. In 2013, a preliminary study was conducted in a sample of 149 male professional footballers (mean age of 27 years; mean career duration of nine years; 60% playing in the highest professional league) from Australia, Ireland, The Netherlands, New Zealand, Scotland and United States. 3 In this

ٚ Behaviours: aggression, withdrawal from others/not going outside as much, being much more quiet than usual, unexpected drop of performance (e.g., in sport, school, work);

Any professional footballers (as any individuals) 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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FEATURE: SCREENING FOR MENTAL HEALTH

No time to waste during the COVID-19 pandemic Screening for mental health symptoms in football cross-sectional study, the four-week prevalence of mental health symptoms was 10% for distress, 26% for anxiety/ depression and 19% for adverse alcohol use. 3 Subsequently to this preliminary study, a twelve-month prospective cohort study was conducted among 607 male professional players (mean age of 27 years; mean career duration of eight years; 55% playing in the highest professional league) recruited in 11 countries.4 In that study, the same scales for measuring mental health symptoms were used as in the preliminary study. The fourweek prevalence of mental health symptoms found at baseline was 15% for distress, 38% for anxiety/ depression, 23% for sleep disturbance and 9% for adverse alcohol use.4 A sub-analysis of these baseline data showed that the prevalence rates of mental health symptoms were quite similar across five European countries, ranging from 6% in Sweden for adverse alcohol use to 43% in Norway for anxiety/depression. 5 A study among 471 top-level football players from Switzerland found a prevalence of 8% for mild to moderate depression, 3% for major depression, and around 1% for an at least moderate anxiety disorder. In that study (using different scales for measuring depression and anxiety than those used in the studies aforementioned), male players had a lower prevalence of depression and anxiety than female players.6 From March 2020, several public health measures were implemented in order to reduce human-tohuman transmission of COVID-19, for instance travel restrictions, mass home-confinement directives, social distancing, and postponement or cancellation of most ongoing football competitions. Such an unprecedent COVID-19 pandemic created new strains on players, increasing potentially their vulnerability to mental health 10

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symptoms. Therefore, an observational comparative cross-sectional survey study was conducted.7 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 was 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<Âˇ01): 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 findings were found among 191 players in the top Swedish football league surveyed in May 2020.8 Stressors for mental health symptoms in professional football In professional footballers or elite athletes, the occurrence of mental health symptoms is usually multifactorial rather than caused by a single stressor. The complex and dynamic interaction between biological (genetic, biochemical, etc.), psychological (mood, personality, behavior, etc.) and social (cultural, familial, socioeconomic, medical, etc.) stressors play a role in the occurrence of mental health symptoms (as well as physical health problems).9 This interaction can create a potential predisposition and/or vulnerability, which can be strengthened by adverse life events or sport-specific stressors. Recently, the scientific literature has shown that professional footballers

FEATURE: SCREENING FOR MENTAL HEALTH

as well as competitive athletes might be confronted with up to 640 distinct sport-specific stressors that could induce mental health symptoms.10 Especially injuries that lead to a long layoff period can be considered as a major stressor for most players. The total number of severe time-loss (28 days or more) injuries during a football career was shown to be positively correlated with distress, anxiety and sleeping disturbance, revealing that professional footballers who had sustained one or more severe time-loss injuries during their career were two-four times more likely to report mental health symptoms than those who had not suffered from severe time-loss injuries.11,12 The IOC Consensus Statement on Mental Health in Elite Athletes, Mental health symptoms are common in professional football but also in other elite sports.13 Therefore, the

Figure 1: The IOC Sport Mental Health Assessment Tool 1 (SMHAT-1) and Sport Mental Health Recognition Tool 1 (SMHRT-1)

International Olympic Committee (IOC) selected an international expert panel in order to thoroughly review the available scientific literature, which led to the IOC Concensus Statement of Mental Health in Elite Athletes published in 2019.1 This consensus statement emphasises that 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. It addresses all relevant facets related to mental health symptoms and disorders in elite athletes, from diagnostic to treatment.1 In the IOC consensus statement, one principal caveat formulated was the lack of specific tools to assess mental health symptoms and disorders in elite athletes.1 This is peculiar because the prevalence of mental health symptoms among elite athletes, among which professional footballers, either prior or since the COVID-19

pandemic, warrants systematic screening just as other conditions (e.g., musculoskeletal, cardiovascular) are screened. To overcome this lack of specific tools, the IOC established its Mental Health Working Group aiming in part to develop an assessment tool for the context of elite sports. The IOC Sport Mental Health Assessment Tool 1 (SMHAT-1) In the IOC Consensus Statement on Mental Health in Elite Athletes, 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 VOLUME 38 â&#x20AC;˘ ISSUE 2 2021

FEATURE: SCREENING FOR MENTAL HEALTH

No time to waste during the COVID-19 pandemic Screening for mental health symptoms in football

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 (https://bjsm.bmj.com/ content/early/2020/09/18/ bjsports-2020-102411.long).2 The SMHAT-1 (Figure 1) is developed for sports medicine physicians and other licensed/registered health professionals to assess elite athletes that are potentially at risk for or already experiencing mental health symptoms and disorders in order to facilitate timely management or referral to adequate support or treatment. The SMHAT-1 relies on a three-step approach: triage step (step one) based on an existing validated screening instrument; screening step (step two) based on six existing validated screening instruments related to the most prevalent mental 12

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health symptoms in elite sports; intervention and (re)assessment step (step three) including in some cases a clinical assessment. It is important to mention that physical therapists, athletic trainers and non-clinicallytrained sport 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 athletesâ&#x20AC;&#x2122; mental health, the IOC Mental Health Working Group developed the IOC Sport Mental Health Recognition Tool 1 (SMHRT-1). The SMHRT-1 (Figure 1) aims to facilitate early detection of mental health symptoms in elite athletes in order 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 sport 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 pre-competition 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). The triage and screening steps of the SMHAT-1 are designed to ideally be embedded in any existing privacy-secured online platforms that most professional football clubs already use. As part of its commitment to supporting the health and performance of

FEATURE: SCREENING FOR MENTAL HEALTH

elite athletes and to the continuing professional development of those who care for them, the IOC Medical and Scientific Commission offers a postgraduate-level Diploma program in Mental Health in Elite Sport for sports medicine physicians and other qualified health professionals, as well as a Certificate in Mental Health in Elite Sport for other members of the athlete entourage (https://www.sportsoracle. com/Mental+Health/Home/). Thanks to the IOC and its SMHAT-1, there is no time to waste within elite sports and in particular within professional football: mental health symptoms and disorders should be screened among players. References 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, Frings-Dresen MHW, Sluiter JK. Mental and psychosocial health among current and former professional football players. Occup Med 2015;65:190-6.

football players. BMJ Open Sport Exerc Med 2016;2:e000087.

encountered by sport performers. J Sport Exerc Psychol 2012;34:397-429.

7. 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.

11. Gouttebarge V, Aoki H, Ekstrand J et al. Are severe joint and muscle injuries related to symptoms of common mental disorders among male European professional footballers? Knee Surg Sports Traumatol Arthrosc 2016;24:3934-42.

8. 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.

12. Kiliç Ö, Aoki H, Goedhart E, et al. Severe musculoskeletal time-loss injuries and symptoms of common mental disorders in professional soccer: a longitudinal analysis of 12-month follow-up data. Knee Surg Sports Traumatol Arthrosc 2018;26:946-54.

9. Engel GL. The need for a new medical model: A challenge for biomedicine. Science 1977;196:129-36.

13. Gouttebarge V, Castaldelli-Maia JM, Gorczynski P et al. Occurrence of mental health symptoms and disorders in current and former elite athletes: a systematic review and meta-analysis. Br J Sports Med 2019;53:700-6.

10. Arnold R, Fletcher D. A research synthesis and taxonomic classification of the organisational stressors

About the Author Dr. Vincent Gouttebarge is a former professional footballer who played 14 seasons in France and The

4. 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.

Netherlands. He is currently working as A/Professor at the Orthopaedic Surgery department of the Amsterdam University Medical Centers and as Chief Medical Officer at FIFPRO (Football Players Worldwide). Dr. Gouttebarge’s work focuses on a wide range of sports medicine domains

5. Gouttebarge V, Backx F, Aoki H et al. Symptoms of common mental disorders in professional football (soccer) across five European countries. J Sports Sci Med 2015;14:811-8.

being relevant in elite sports, striving to protect and promote the physical, mental and social health of active and former professional athletes. He is Chair of the International Olympic Committee (IOC) Mental Health Working Group and co-director of the IOC Programs on Mental Health in Elite Sport. Dr. Gouttebarge is

6. Junge A, Eddermann-Demont N. Prevalence of depression and anxiety in top-level male and female

also member of the Concussion Expert Group of the International Football Association Board (The IFAB).

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FEATURE: CULTURAL INFLUENCERS AND BARRIERS

Cultural influencers and barriers

to elite athletes seeking treatment for mental health disorders

ental health symptoms and disorders are prevalent in elite athletes, occurring in 5% to 35% of elite athletes in a year. Anxiety, depression, sleeprelated problems, alcohol misuse, and eating disorders are highly prevalent in screening studies of elite athletes. Elite athletes appear to experience levels of many mental health symptoms and disorders similar to the general population, while some conditions such as eating disorders are more common in elite athletes. However, mental health treatment-seeking is low among elite athletes. Media portrayals convey some challenges with mental health treatment-seeking that elite athletes face: the image of the “strong, winning athlete” contrasts with the image of the “weak, depressed human being”. Despite such portrayals, increasing numbers of studies are emerging that investigate factors related to recognition of mental health symptoms and disorders and mental health treatment-seeking

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among elite athletes. However, no systematic reviews to date have summarised barriers to mental health treatment-seeking in elite athletes and negative cultural influencers of mental health in this population. Many factors place the athlete at increased risk for mental health symptoms and disorders. The demands of a heavy training schedule, both physically and mentally, and a constant push to improve performance can be stressful. Many elite athletes live near or at training sites with other athletes and are often separated from their families and friends. They often follow strict regimens with diet, schedules, and habits, striving to improve performance. Coaches and others push athletes to improve skills and abilities while closely monitoring their activities. Some subgroups, such as women and minorities, may experience lack of acceptance from their culture of origin or training environment. Unexpected events (e.g.,

death of a family member, health/ injury-related problems) can trigger mental health symptoms and disorders. Furthermore, increased risks of mental health symptoms and disorders occur in those who experience involuntary and/or undesired retirement from sport because of de-selection or injury. Former athletes are also at risk for mental health and substance use-related symptoms and disorders. Lack of retirement planning, high levels of athletic identity, lower educational attainment, post-sport unemployment, chronic pain, and adverse life events can impair the lives of former athletes and lead to mental health symptoms and disorders. Within this context, the present systematic review aims to summarise the findings of studies that investigated barriers to treatment-seeking among elite athletes, and cultural influencers that impact mental health symptoms and disorders in this population.

FEATURE: CULTURAL INFLUENCERS AND BARRIERS

Media portrayals convey some challenges with mental health treatment-seeking that elite athletes face: the image of the “strong, winning athlete” contrasts with the image of the “weak, depressed human being.

Original studies of elite athletes (defined here as those competing at professional, Olympic, or collegiate/ university levels), published in any language, reporting (i) barriers to elite athletes accessing mental health resources and/or (ii) cultural considerations (e.g., gender, sexual orientation, race, ethnicity, socioeconomic status, religion) on elite athlete mental health were included in the search. Excluded from this review were: meeting proceedings; reviews; commentaries; letters; opinion articles; case reports; position statements; book chapters; editorials; non peer-reviewed articles; articles focusing on the general population; articles focusing on subgroups in the general population (e.g., just men or just women, youth, college students); articles focusing on other specific populations (e.g., minorities, individuals with mental health disorders, individuals with a specific disease); articles focusing on professional dancers; articles focusing on elite drivers; articles investigating sport as a treatment; articles focusing on non-mental health issues or problems in elite athletes (e.g., nutrition, performance, orthopedics, cardiovascular, respiratory, other health issues); articles focusing on performance sports psychology; articles focusing on elite athlete staff (e.g., coaches, managers, other professionals); and articles not focusing on barriers or cultural considerations. VOLUME 38 • ISSUE 2 2021

FEATURE: CULTURAL INFLUENCERS AND BARRIERS

Cultural influencers and barriers

to elite athletes seeking treatment for mental health disorders One author (MH) searched databases to identify articles that discussed treatment-seeking behavior, or the barriers thereof, of elite athletes seeking mental health services. The first search was completed in February 2018; duplicated citations from the multiple databases were removed, resulting in a total of 254 unique articles. The search did not limit to a specific date range. A second search conducted in October 2018, using the same terms and databases, resulted in 139 additional articles. A third and final search was conducted in November 2018, resulting in no additional articles specifically focusing on athletes. A total of 393 unique studies were identified in the searches. The initial search string used within PubMed was: ((((“Mental Health Services”[Mesh] OR “mental health services” OR counselling[tw] OR “psychiatric help” OR “psychiatric assistance”)) AND (((((“HelpSeeking Behavior”[Mesh]) OR (“Attitude”[Mesh] OR “Attitude to Health”[Mesh] )) OR “mental toughness” OR “Social Stigma”[Mesh]) OR “Stereotyping”[Mesh] OR stigma[tw] OR “help-seeking” OR “Athletes/ psychology”[Mesh] OR “barrier to” OR “refusal for” OR aversion OR attitude OR perception[tw]))) AND (athlete OR sport OR athletic)). However, additional terms such as “Health Knowledge, Attitudes, Practice”[Mesh] or “Athletic Performance/psychology”[Mesh] could also be used interchangeably. Using this set of terms as the base search string, each subsequent search within separate databases was modified slightly to allow for controlled vocabulary and keyword searching. In the screening phase, the first and the last author independently read the abstracts of all studies found in the search (n = 393). After applying the inclusion and exclusion criteria, 16

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333 articles were excluded. Around 80% of exclusions were based on the following 9 exclusion criteria: reviews (n = 33); commentary/ letter/ opinion/ case/ position statement/ book chapter (n = 27); general population (n = 34); general young population (n = 22); other specific populations (n = 20); other problems/issues in athletes (n = 48); no focus on barriers (n = 22); no focus on health seeking (n = 33); and focus on sport psychology to improve performance (n = 24). Articles recommended for exclusion by one author at this stage were included for further evaluation in the next phase. In the eligibility phase, the first, second, and third authors assessed the fulltext articles (n = 60) for eligibility. The first author determined inclusion or exclusion in cases of disagreement between the second and third authors. Eight articles were excluded based on the inclusion/exclusion criteria. Eventually, 52 studies were included in the present systematic review. The first, second, third, and last authors read all 52 included studies, independently. The second and third authors tabulated data from half of the studies each. Then the tabulated data were evaluated by the other three authors. After reading the full text of the 52 articles included in the present systematic review, the first and last author identified the most relevant topics for data collection. These topics were presented to and discussed with a panel of experts during the International Olympic Committee Consensus Meeting on Mental Health in Elite Athletes in Lausanne, Switzerland in November 2018. The panel included psychiatrists, psychologists, primary care sports medicine physicians, a neurologist, a neurosurgeon, a exercise scientist, a social worker, elite athletes, and

members of the panel represented geographical diversity (Australia, Brazil, Canada, China, India, Italy, the Netherlands, South Africa, South Korea, Turkey, the United Kingdom, and the United States). Based on expert consensus during this discussion of findings from the 52 articles, this review aims to summarise the literature with respect to: ٚ Barriers, facilitators, influencing factors, preferred characteristics of counsellors, and interventions regarding elite athletes accessing mental health resources; ٚ Cultural issues that impact the mental health of elite athletes, including gender, gender identity, sex, sexual orientation, race, ethnicity, socioeconomic status, and religion. No method of handling data and combining results of studies was carried out because of high

FEATURE: CULTURAL INFLUENCERS AND BARRIERS

Elite athletes often believe mental health symptoms and disorders are a sign of weakness, or report stigma associated with mental health symptoms and disorders.

heterogeneity among the included studies, as follows: different types of studies; non-similar measures; intervention heterogeneity; and sampling and design heterogeneity. Among the 52 included studies, the majority were published in the last 10 years (n = 40), with almost half of the studies published in the last 5 years (n = 24). There were 35 quantitative, 12 qualitative, and 5 mixed-method studies. The majority were crosssectional (n =43). Four randomised controlled trials were included among the 9 prospective studies. Intervention studies were few (n = 7). More than half of studies were from North America (n = 28), followed by Europe (n = 11), Oceania (n = 5), and Asia (n = 3). The five remaining studies were cross-national multi-continent studies. Almost all studies were from high-income countries, except for two studies from Malaysia and India. No studies were found from Africa or South/Central

America. In total, the studies included 13,255 elite athletes, with more than 90% of those athletes from quantitative studies (n = 12,596). Elite athletes from at least 71 sports were included in the review. Football (soccer) was the most common sport, being included in 18 studies. The instruments used most often were: the Attitudes Toward Seeking Professional Psychological Help Scale72; the Athletic Identity Measurement Scale73; the Expectations about Counselling Questionnaire74; the Attitudes Toward Seeking Sport Psychology Consultation Questionnaire29; and the Sport Psychology Attitudes â&#x20AC;&#x201C; revised form. The present review identified barriers for elite athletes seeking mental health treatment. Stigma attached to mental health symptoms and disorders appears to be the strongest barrier in quantitative and qualitative studies in sports, supported by 18 studies in the present systematic review. Elite

athletes often believe mental health symptoms and disorders are a sign of weakness, or report stigma associated with mental health symptoms and disorders. They also report a lack of knowledge and understanding of mental health symptoms and disorders. Elite athletes appear to have higher levels of stigma compared to non-athlete peers. Lower openness and lower conscientiousness predicted greater stigma towards sport psychology consulting. Public stigma (stigma endorsed by the general public) and self-stigma (individualsâ&#x20AC;&#x2122; own stigmatised attitudes related to internalisation of public stigma) predict a significant detrimental impact on treatment-seeking by athletes for mental health symptoms and disorders. Greater perceived public stigma than self-stigma was found in elite athletes. However, public stigma appears to be less of a deterrent for collegiate athletes to seek treatment than in the past. A study of collegiate athletes showed that they had a significantly lower mean score than non-athlete peers on scales assessing attitudes toward mental health, reflecting less willingness to seek mental health treatment. Concerns regarding how elite athletes will be perceived by their peers, coaches, and sport managers could be a barrier even for those with VOLUME 38 â&#x20AC;˘ ISSUE 2 2021

FEATURE: CULTURAL INFLUENCERS AND BARRIERS

Cultural influencers and barriers

to elite athletes seeking treatment for mental health disorders positive attitudes toward mental health treatment-seeking who express a willingness to seek treatment. Other reported barriers include lack of mental health literacy, negative past experiences with mental health treatment-seeking, and busy schedules. Lack of mental health literacy (knowledge and beliefs about mental health disorders that aid their recognition, management, or prevention) was a barrier in different levels and types of sports in qualitative and qualitative studies. Time constraints also influenced many elite athletes, especially collegiate athletes, in not seeking mental health care. Several additional factors are associated with negative attitudes about mental health treatmentseeking, including: identification as male; hypermasculinity; younger age; Black (versus Caucasian) race; United States (versus European) nationality; lower measures of openness and higher measures of conscientiousness (personality factors); gender role conflicts; and participation in physical contact sports..

Conversely, other factors can facilitate elite athletes seeking mental health care, including: availability of individual mental health treatment services inside the university or training facilities; positive previous interactions with mental health providers; having an established relationship with a mental health provider; perception of benefits to seeking treatment; strong positive coping skills; higher neuroticism, higher conscientiousness, and higher openness (personality factors); a sense of self-efficacy to seek treatment; and positive attitudes of others, especially coaches and family members, regarding seeking mental health treatment. Coach support for mental health treatment-seeking is an important facilitator for elite athletes. Moreover, athletes with stronger positive coping skills generally are more supportive of seeking mental health treatment. Finally, athletes have strong preferences for counsellor characteristics, such as familiarity with their sport, same gender, older but still close enough in age to understand their lives, and geographic proximity to the sports facility.

We identified seven intervention studies designed to decrease barriers to athlete mental health treatmentseeking. Despite improving mental health knowledge and decreasing stigma attached to mental health disorders, these studies reported no effects on mental health treatmentseeking. Generally, the interventions were short-term, aiming to increase awareness and understanding of mental health, decrease stigma attached to it, and reduce overall barriers to accessing mental health supports and services for athletes. Bapat et al.65 tested an 8-hour training program. Beauchemin et al.66 tested an integrative outreach model, which consisted of a one session workshop, as well as three or five-session components of a larger class focusing on overall wellness. Donohue et al.67 tested two semi-structured interview formats: one interview focused on discussing the athleteâ&#x20AC;&#x2122;s experiences in sports, and the other focused on describing sport psychology and its potential benefits to the athlete. Donohue et al.69 conducted a subsequent study to determine interest in participating in one of two goaloriented programs. Donohue, et al.67 also tested a sport-specific optimisation approach to concurrent mental health and sport performance, which consisted of a longer intervention, with 12 performance meetings of 60 to 90 minutes within four months. Gulliver et al.70 conducted a study with three brief, fully-automated, internet-based mental health treatment-seeking interventions. Kern et al.71 tested an internet-based intervention, which consisted of nine presentations and two videos. Several cultural influencers that are both associated with and impact the mental health of elite athletes have been described. Gender issues were reported in five studies. Specifically, discrimination and segregation

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FEATURE: CULTURAL INFLUENCERS AND BARRIERS

involving female athletes have been reported. Hammermeister & Burton found that sex role stereotypes and role expectations predispose men and women to cope with stress differently. Women are socialised to use more emotion-focused coping strategies, particularly seeking emotional social support, while men are socially reinforced for using more problemfocused approaches to coping. Generally, male athletes are more prone to doping. However, female elite football (soccer) players have reported higher likelihood of doping than male elite football players. Recent studies report less homophobia within sport than earlier studies did. Some athletes argue that an athlete’s ability to play is the only criterion on which they are judged, and their sexuality is of little consequence. However, professional football (soccer) players suspect that there are no openly gay players in their sport because of financial considerations (i.e., the sport would be perceived as less marketable with openly gay players). Regarding race and ethnicity as cultural factors within elite sport, a qualitative study found that younger, largely non-white team members appeared to feel more pressure to fit in by hiding aspects of themselves that diverge from the perceived “norm”. British athletes had lesser stigma towards mental health treatment-seeking, greater personal openness, and lesser preference for a consultant of the same race or culture than Singaporean athletes. Lawrence found a fairly broad representative distribution of race and wealth in summer Olympic athletes. However, some sports have important race differences. Participants in equestrian, modern pentathlon, road cycling, rowing, and sailing were more likely to be white. Conversely, non-white athletes were more likely to participate

Increasing mental health literacy, including among elite athletes, is a global challenge. Increased knowledge about the most prevalent mental health symptoms and disorders (e.g., anxiety, sleep disorders, depression, eating disorders, and alcohol and other substance misuse) would be important for current and former elite athletes. in athletics (track and field), basketball, gymnastics, taekwondo, table tennis, and judo. Lawrence found that sports associated with white athletes were also associated with the athletes having a private education. Torres Colon et al. 56 reported that those more dependent on financial benefits of sport have different attitudes towards concussion (i.e., more willingness to risk multiple concussions). Walseth found that sports can play an important role for social capital accumulation in young female athletes in the Middle East. Blodgett et al. and Harkness reported on religion as a factor in elite sport. Despite its importance as a cultural dimension for some athletes, especially non-white and Muslims, religion is not usually disclosed among teammates, while it is common for teammates to share other aspects of their culture. Religious convictions also predicted lower likelihood of doping. This review aimed to systematically review the barriers to elite athletes

seeking mental health treatment and the main cultural influencers that may impact their mental health symptoms and disorders. As in the general population, stigma emerged as the most commonly reported barrier to treatment-seeking for elite athletes, along with low mental health literacy, negative past experiences with mental health treatment-seeking, busy schedules, and other factors such as hypermasculinity. Lack of acceptance of women as athletes emerged as a commonly reported cultural influencer of mental health in elite athletes, as did race and ethnicity, religiosity, and socioeconomic status. Although elite athletes report more stigma to mental health treatmentseeking than the general population, stigma is declining in younger cohorts, which accompanies a similar trend in discrimination against people with mental health symptoms and disorders in the general population. However, elite athletes continue to have more difficulty in disclosing apparent signs of “weakness”, which is how some perceive mental health symptoms and disorders; this attitude can be an important barrier to any antistigma intervention in this population. Athletes fear, possibly rightly so, that disclosing mental health symptoms or disorders would reduce their chances of maintaining or signing a professional team contract or an advertising campaign. In addition, athletes fear negative reactions from their teammates and coaches if mental health symptoms or disorders were to be disclosed. Although brief anti-stigma interventions in collegiate athletes did not impact long-term mental health treatmentseeking behavior, brief anti-stigma interventions reported good initial results, and may be an important initial step to overcome barriers.

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FEATURE: CULTURAL INFLUENCERS AND BARRIERS

Cultural influencers and barriers

to elite athletes seeking treatment for mental health disorders Increasing mental health literacy, including among elite athletes, is a global challenge. Increased knowledge about the most prevalent mental health symptoms and disorders (e.g., anxiety, sleep disorders, depression, eating disorders, and alcohol and other substance misuse) would be important for current and former elite athletes. In addition, access to confidential mental health services geographically close to elite athletes, and with counsellors familiar with the type of sport and associated stressors experienced by target athletes, could help to minimise barriers. The preference of athletes for counsellors of the same gender and closer age should be carefully evaluated. It is important to optimise the comfort level of athletes seeking mental health treatment, but not to create stigma regarding mental health providers of a different sociodemographic background and thus further limit availability of providers. Broad-reaching cultural influencers impact elite athletes in different ways. Their own cultural identities – which include gender, gender identity, sex, sexual orientation, race, ethnicity, socioeconomic status, and religion – can play a role. Some athletes may experience performance disadvantage and higher likelihood of mental health symptoms or disorders associated with cultural influences; importantly, there is no evidence that this is because of any inherent vulnerability associated with certain cultural identities, but rather, it likely relates to discrimination based on cultural factors. While not meeting our strict criteria for inclusion in this systematic review, some reports suggest that female athletes engaged in progressively higher levels of elite sport face varying degrees of cultural acceptance. Moreover, women participating in traditional “male” sports may face being marginalised 20

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certain coaches or teams. Some professional female athletes must train outside their native countries and may struggle to find a support network and cultural understanding from teammates in their new location.

Some professional female athletes must train outside their native countries and may struggle to find a support network and cultural understanding from teammates in their new location. and stereotyped and may experience unequal training opportunities and resources. Elite sport opportunities for women are influenced by ethnic beliefs, religion, sexualisation, and traditional gender roles. Considering religious rules about the body and presentation in public, combining more traditional roles with being an elite athlete can be problematic. For example, tension may exist between what is functionally optimal attire for elite women athletes and what is deemed culturally acceptable. Gender stereotyping in the media may influence how women athletes view themselves. Women athletes may be stereotyped as “lesbian” to keep them from playing certain sports, or from playing for

Masculinity and sexuality are also common issues for male athletes. Like women, men may be excluded and patronised. Gay men and lesbian women athletes face various degrees of acceptance, which can negatively impact performance. Despite apparent improvements in ease of disclosing gender identity and gender expression within sport, other studies (not meeting our strict criteria for inclusion in the systematic review) attest to negative experiences of non-heterosexual athletes in sport, specifically including worse mental health relative to heterosexual athletes. Transgender athletes often have negative experiences in sports and struggle to be accepted. Religion is a taboo subject of conversation among elite athletes, contributing to social isolation of athletes from minority religious backgrounds. Racial disparities – including those related to exploitation, player-coach tension, and prejudicial treatment – along with socioeconomic inequities form barriers that prevent equal opportunities. Finally, coaches were identified as having an important role for supporting elite athletes in mental health treatment-seeking. They are in frequent contact with athletes, and thus can support and encourage acknowledgement and treatment of mental health symptoms and disorders by creating a destigmatising environment wherein mental health treatment-seeking is a core function of training and self-care. This kind of support could be especially important in adolescent athletes, who might be even more vulnerable to coaches’ positive

FEATURE: CULTURAL INFLUENCERS AND BARRIERS

or negative attitudes regarding mental health treatment-seeking than adult athletes. Parents and other caregivers might also promote positive attitudes toward mental health treatmentseeking and toward those affected by mental health symptoms and disorders. There was great heterogeneity among the studies we included (e.g., quantitative versus qualitative, crosssectional versus prospective, sampling differences, and different measures and endpoints). As a result, we did not perform meta-analyses. Additionally, many athletes come from countries where there are few, if any, mental health services, and where there may also be ways of understanding and treating mental health symptoms and disorders outside evidence- and biomedically-based ones. The present review did not aim to summarise evidence on the role of these alternative methods in overcoming barriers to mental health treatment-seeking. Future studies in low- and middleincome countries using and/or validating the most important scales from studies included in the present review (e.g., Attitudes Toward Seeking Professional Psychological Help Scale, the Athletic Identity Measurement Scale, the Expectations about counselling Questionnaire, the Attitudes Toward Seeking Sport Psychology Consultation Questionnaire, and the Sport Psychology Attitudes – revised form) are needed to generate greater understating of barriers to mental health seeking at a global level. In addition, intervention programs to decrease discrimination against those with mental health symptoms and disorders should focus on the most problematic subgroups of elite athletes, such as those with marginalised cultural identities within elite sport. Studies testing longer interventions, supported by already-piloted brief interventions,

in select subpopulations might be a helpful next step. Non-collegiate elite athletes should also be the focus of such interventions, considering that previous studies were carried out in collegiate athletes. Additionally, already-tested brief interventions could be tested in larger samples. Stigma, low mental health literacy, negative past experiences with mental health treatment-seeking, busy schedules, and hypermasculinity are important barriers to mental health treatment-seeking for elite athletes. The lack of acceptance of women as athletes, lower acceptability of mental health disorders among non-white athletes, non-disclosure of religious beliefs, and higher dependence on economic benefits are also

important features to be considered regarding vulnerability to mental health symptoms and disorders in elite athletes. More effective strategies for overcoming stigma and increasing mental health literacy for elite athlete populations are needed. Focused and tailored interventions on problematic subgroups identified by the present systematic review would be an important next step. Coaches could be important agents for supporting positive mental health attitudes within the elite athlete environment, including fostering an environment of mental health treatment-seeking. A better understanding of sport as a sub-culture within society is needed, including which elements of that sub-culture are particularly conducive to positive mental health outcomes.

About the Author Todd Stull, M.D is a Clinical Associate Professor at the University of California Riverside. In his present role, he is the Director of the Sports Psychiatry Fellowship in the Department of Psychiatry and Neuroscience. He was the first full-time sports psychiatrist in the NCAA where he served as the Senior Associate Athletic Director for Performance at the University of Nebraska in the Athletic Department. He is the President of the International Society for Sports Psychiatry. Stull has been on several NCAA workgroups to write guidelines for mental health, substance use, sleep, pain, gender, diversity, and sports wagering. He has served on the NCAA Competitive Safeguards and Medical Aspects of Sports Committee. He was one of 22 experts from six continents on the International Olympic Committee to write mental health and substance use guidelines. João Maurício Castaldelli-Maia is an Auxiliary Professor of Psychiatry, in the Department of Neuroscience, at the ABC Foundation, in Santo André, Brazil. As well as, this he is a Brazil Postgraduate Supervisor, in the Department of Psychiatry, at the University of São Paulo, São Paulo, Brazil President of the ABC Center for Mental Health Studies and Editor-in-Chief, of the Argentina Review of Clinical Psychology. VOLUME 38 • ISSUE 2 2021

FEATURE: NEW DIRECTIONS IN ATHLETE MENTAL HEALTH

New Directions in Athlete Mental Health 22

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FEATURE: NEW DIRECTIONS IN ATHLETE MENTAL HEALTH

he preceding decade has witnessed an explosion of interest into elite athlete mental health and wellbeing. Prior to this, mental health was largely a blind spot within the field of sports medicine. This appeared to correspond to assumptions that elite athletes, by virtue of their physical attributes and sporting success, were somehow protected or immune from mental health problems. We now know this not to be the case. Around one in three professional or elite athletes will experience mental health symptoms throughout their career, even if they haven’t spoken about it, with former or retired athletes also at-risk. Athletes speaking openly and publicly about their struggles and experiences with mental illness is increasingly occurring both during competitive years, and in retirement, leading to a growing acceptance of mental health concerns. Mental health refers to how a person feels, thinks and behaves. There are a range of mental health disorders that athletes are susceptible to, and the most common reflect what are referred to as high prevalence disorders such as major depression, generalised anxiety disorder or substance use disorders. Warning signs for athlete mental health problems also vary, but may include noticeable changes in mood or personality (e.g. increased irritability), losing interest or pleasure in sport, having a low self-esteem, and a drop in performance, including difficulties concentrating or paying attention. If an athlete expresses that life is hopeless, or even not worth living, a formal mental health assessment and support should be arranged promptly. Mental health is influenced by a range of factors, such as genetics, our life experiences, social relationships, and how we process or interpret our thoughts. The focus on athlete mental health is long overdue, and governing bodies are actively working to support increased knowledge and access to

Around one in three professional or elite athletes will experience mental health symptoms throughout their career, even if they haven’t spoken about it, with former or retired athletes also at-risk.

care. In 2019, the International Olympic Committee (IOC) Expert Consensus Statement on Elite Athlete Mental Health distilled current knowledge and clinical opinion in the management of mental health problems in this population. Here in Australia, the work of Orygen – the world’s largest translational youth mental and early intervention research centre – has significantly contributed to the field more broadly, and the work of the IOC. In this article we summarise

areas of progress to date relevant to the field of sports medicine and highlight areas for development. Orygen’s work in the elite sports sector has highlighted the lack of athlete mental health assessment tools calibrated to the sporting context. Improved assessment sensitivity and specificity is a key advantage of using specialised, standardised selfreport tools designed for athletes. In partnership with the Australian Football League, Cricket Australia and Professional Footballers Australia, we have recently published a series of studies on the Athlete Psychological Strain Questionnaire (APSQ), validated with >1,000 Australian elite athletes. The APSQ enquires about early manifestations of sport-specific indictors of mental health issues and is designed to assist early identification (and intervention) efforts. Whereas a non-athlete sensitised assessment tool may enquire about extended periods or severity of low mood or noncompetitive nervousness, the APSQ items are tailored to context. VOLUME 38 • ISSUE 2 2021

FEATURE: NEW DIRECTIONS IN MENTAL HEALTH

New Directions in Athlete Mental Health

For examples, APSQ items enquire about being unable to stop worrying about injury or performance or finding it hard to cope with selection pressures. With validated cut-off scores benchmarked against indices of general psychological distress, the APSQ offers an efficient assessment and is the recommended triage scale for the IOC’s recently published Sports Mental Health Assessment Tool-1 (SMHAT-1). The SMHAT-1 is analogous to the Sports Concussion Assessment Tool, providing broad guidance to sports-based clinicians regarding management of mental health symptoms in athletes. The accompanying Sports Mental Health Recognition Tool-1 (SMHRT-1) is designed to assist athletes and their entourage (coaches, family and friends) to recognise key mental health symptoms in order to facilitate early help-seeking and professional support. While early identification and assessment are essential in providing timely care to athletes, the broader environment or eco-system also yields an influence on athlete mental health outcomes. Elite athletes are exposed to intense mental and physical demands that may increase their vulnerability to certain mental health problems. However, athletes are less likely than the general population to seek support for such 24

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problems, for reasons including a lack of understanding about mental health, stigma and the perception of help seeking as a sign of weakness. Building a psychologically safe environment in elite sporting contexts may contribute to increased motivation to discuss and address difficulties related to mental wellbeing, as well as increased learning and development opportunities. We have advocated for the need for approaches to go beyond merely developing mental health literacy, which is necessary but not sufficient for addressing the level of need in relation to mental health in elite sports. In particular, cultures within sports settings need to be built and maintained that acknowledge that an athlete’s mental health needs are just as important as their physical health needs, and that both are likely to contribute to optimising the athlete’s overall wellbeing in conjunction with performance excellence. Key components of this include (i) supporting athletes to develop a range of self-management skills for periods of psychological distress, (ii) equipping key stakeholders in the elite sporting environment (including coaches, sports medicine and high-performance support staff) to better recognise and respond to concerns regarding an athlete’s mental health and (iii) highlighting the need for specialist multi-disciplinary teams or skilled

mental health professionals to manage athletes with severe or complex mental disorders, including selfharm or suicidal thinking. Although, not without their resourcing (e.g. funding) challenges, the integration of these three components will help ensure that elite athletes receive timely intervention and support in the right place, with the right person. There are a number of areas likely to see significant developments in the coming decade. Research is yet to assess club-level or system-level factors that may contribute to mental health and wellbeing. There is a need to explore the views of athletes, coaches, high performance and executive staff regarding the systems-level influencers and organisational strategies that help underpin psychological safety or mental wellbeing programs in elite sporting organisations. Policies and actions that support psychological safety will lead to heathier environments for both athletes, and those involved in coaching or auxiliary roles. Currently, there is limited evidence to guide best-practice in mental health and wellbeing strategies in elite sporting club environments. We recently conducted a systematic review on this topic and found that cognitive behavioural therapy (e.g., helping athletes understand how their characteristic ways of thinking and

FEATURE: NEW DIRECTIONS IN MENTAL HEALTH

behaving contribute to mental health difficulties) was the only approach with at least two high quality studies that the intervention works in sports. Tailoring and evaluating existing mental health interventions within the sports setting is an area of pressing need. There is promising evidence from the University of Nevada that athlete-specific mental health intervention focusing on performance optimisation across domains valued by the athlete (rather than simply treating or minimising psychopathology) may promote better engagement than nonspecific (e.g., treatment as usual) counselling approaches. As the field develops, these kinds of interventions are likely to develop a compelling evidence base, supporting scaling efforts.

About the Authors Professor Rosemary Purcell (BA, M.Psych, PhD) Rosie is the Director of Research & Translation at Orygen, Australia’s centre of excellence in early intervention and youth mental health. She is a registered psychologist and leads the Elite Sports and Mental Health research and consulting program at Orygen. She is also the Deputy Head of Department for the Centre for Youth Mental Health at The University of Melbourne. Rosie’s research focuses on understanding the prevalence and nature of mental health problems in high

A final area warranting investigation is the interface between the elite sporting content and health anxiety. Health anxiety refers to excessive concern or worry about a threat to health, which triggers an anxiety response. For example, in collision sports, risk of concussion or repeated sub-concussive blows is ever present. Protocols for the detection and management of concussion have seen return to play guidelines, and in severe instances or complicated recovery, medical recommendations have seen a minority of athletes discontinue sporting careers. For vulnerable athletes (e.g., those with a significant history of concussion or complicated recovery), worry may develop that they may experience a career-ending concussive impact. Little is known about the ways in which health anxiety impacts other domains of athlete wellbeing, as well as athletic performance, and more research is needed.

performance sport, and optimal strategies for improving and maximising mental health and wellbeing in both elite and community sporting environments. She is interested in whole of organisation (‘systems’) approaches to improving mental health in sport and has worked with a number of elite and professional sports in Australia to support their work in developing early intervention frameworks for mental health. She has over 140 publications and is Deputy Editor of the Journal of Early Intervention in Psychiatry. Associate Professor Simon Rice (BBSc, Grad Cert Clin Epi, MPsych, PhD) Associate Professor Simon Rice is a Principal Research Fellow and Clinical Psychologist. He leads Orygen’s Young Men’s Mental Health research stream and has worked in the field of elite sports and

The increasing focus on athlete mental health provides a major opportunity for the field of sports medicine. Enhanced athlete wellbeing will have a range of positive impacts, and could feasibly be expected to support career longevity and performance outcomes. Beyond that however, once sporting ecosystems value the mental health of their cohorts in the same manner as physical health and conditioning, psychologically safe environments are likely to evolve, leading to improved working environments for everyone engaged in high-performance sports settings.

mental health since 2014. He leads a number of international collaborative research projects and is a member of the International Olympic Committee’s Elite Athlete Mental Health Consensus Group. His work is supported by a range of competitive national and international research grants, and he was recognised for research excellence through the 2020 Dame Kate Campbell Fellowship, and the 2020 Society for Mental Health Research Epidemiological Award for Teambased Research for his contributions to Orygen’s Elite Sports Mental Health research program.

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FEATURE: PHYSICAL ACTIVIT Y AND MENTAL HEALTH

What We Know Physical Activity and Mental Health in Austra T

he World Health Organisation (WHO) describes many different mental disorders that are generally characterised by abnormal thoughts, perceptions, emotions, behaviours, and relationships with others. Depression and anxiety are the most prevalent mental illnesses, with one in 16 Australians currently experiencing depression and one in seven Australians experiencing anxiety. Depression symptoms include negative or low mood and a lack of interest in all or most activities (called anhedonia), along with extreme feelings of guilt, worthlessness, difficulties concentrating, and low motivation. Anxiety symptoms include unpleasant feelings of uncertainly, overwhelmed, irrational fears, muscle tension, 26

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obsessions, compulsions, vigilance, and avoidance of situations. Finding ways to reduce the prevalence and burden of depression and anxiety symptoms is a health priority. Luckily, there is emerging evidence that sport participation has both anti-depressant and anti-anxiolytic effects. Now we just have to make sure that more of us start and stay involved in sport! There is strong evidence that physical activity at moderate-to-vigorous intensities is important for (i) improving mental health; (ii) preventing depression and anxiety, (iii) helping individuals who are diagnosed with depression and/or anxiety to improve their quality of life, and (iv) treatment of mental illness. Clinical programs tend to focus

on structured and supervised physical activity at moderate-to-vigorous intensities, yet there is also consistently evolving evidence on the benefits of sport participation. And these benefits are realised in-the-moment and short term, while also lingering for years. Sport participation protects from depression and anxiety symptoms, and this is important since mental illness accounts for more than ten percent of the global disease burden, and mental illness is a leading cause of disability. Complimenting emergent research findings from all over the World, research in the Mental Health and Physical Activity Research Centre at the University of Toronto has been focused on the protective effects of sport participation

FEATURE: PHYSICAL ACTIVIT Y AND MENTAL HEALTH

Depression and anxiety are the most prevalent mental illnesses, with 1 in 16 Australians currently experiencing depression and one in seven Australians experiencing anxiety.

alian Athletes for several years. The evidence is clear that individuals who participate in sport during adolescence report less symptoms of depression and anxiety into adulthood. Youth who are involved in sports for longer, and stay involved, report better mental health. All is not lost if you didn’t participate in sport participation during childhood and adolescence – across many of our research studies, we also find that current sport participation in adults is related to better mental health. All told, sport participation reduces the risk for depression and anxiety and it is never too late to start gaining mental health benefits from sport. You may now be wondering if the type of sport matters? We have found clear

positive benefits from team sport, and less profound benefits from individual sports – although still protective effects. Team sports emphasise group goals, social support, and a sense of connection. These social features provide more opportunity for learning adaptive coping strategies that can be essential for long-term mental health. Also, many individual sports (such as dance, gymnastics, swimming to name a few) tend to be dependent on scoring from others, and emphases on appearance and weight. The culture of these types of sports may perpetuate mental health problems even with the benefits of the physical movement. So, we may be seeing a bit of a tradeoff when it comes to mental health outcomes among athletes involved in individual sports. This is very early research, and further efforts are needed to understand the nuances between team and individual sport. Regardless of team or individual sport context, it is important to highlight that there are mental health

benefits with any consistent sport participation. There are a number of proposed reasons to help explain why sport protects from mental illness. Sport may reduce symptoms of depression and anxiety because it elicits actual changes to the body. Being active improves fitness, muscular strength, and heart health that together help the body function better physically and mentally. Also, moderate-to-vigorous intensity activity can stimulate molecular and cellular brain functions and even structural changes in the brain as well as blood flow that may be protective of depression symptoms. Consistent sport participation may also improve inflammatory responses, and may stimulate adaptive stress responses (i.e., blunting stress responses) that decrease depression symptoms. Also, participating in sport can release endorphins that help enhance positive mood and emotions. At a more “in the moment” level, playing sports can also increase our body temperature VOLUME 38 • ISSUE 2 2021

FEATURE: PHYSICAL ACTIVIT Y AND MENTAL HEALTH

What We Know Physical Activity and Mental Health in Australian Athletes which makes us feel warmth and elicits positive emotions as well as a sense of comfort that is linked to lower anxiety symptoms. There is also some thought that the evolution of humans, from being active “hunters and gatherers” to now leading much more sedentary lives has disrupted our homeostasis (i.e., the body’s desired state of efficient functioning). And so, when we lead active lives, we are engaging in movement that the human body needs, and this balance is good for mental health. Finally, we have found that sport participation may be most beneficial for panic anxiety symptoms. Panic attacks are characterised by heightened arousal of the sympathetic nervous system––increased heartbeat, rapid breathing, and increased sweating. Because sports participation can result in these exact same responses, it could act as a form of exposure therapy explaining why sport participation may reduce these specific panic symptoms.

There is consistent evidence that sport can improve self-esteem as well as body image, which can both lead to improvements in mental health.

In addition to the physical changes in our bodies when we are active, changes in perceptions and beliefs are also elicited in sport and are broadly associated with lower depression and anxiety symptoms. For example, there is consistent evidence that sport can improve self-esteem as well as body image, which can both lead to improvements in mental health. Positive perceptions of both what the body can do and how the body looks are important to protect from depression symptoms. Also, sport participation can provide more opportunity for building mastery and confidence that are also important for mental health. There is also some evidence that playing sport is a distraction that can help reduce or manage anxiety symptoms. As was already alluded to earlier, there are also social reasons for the anti-

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FEATURE: PHYSICAL ACTIVIT Y AND MENTAL HEALTH

depressant and anti-anxiolytic effects of sport. Specifically, sport participation can enhance feelings of connectedness to others, and can increase social networks that help build coping resources. It is possible that by providing opportunities for socialisation, sport can enhance social support to create a buffer against symptoms of mental illness. Specifically, sport is inherently social – there are always others involved as teammates, opponents, coaches, judges, officials, administrators, and spectators – and this very nature of sport can help people feel connected and supported. Also, this exposure may help ward off symptoms of agoraphobia (characterised as having a fear of being in crowds or public places) and social (characterised by a constant sense of fear of judgment by others, fear of embarrassment, and/ or fear of social situations) anxiety symptoms simply by being in sport. As you can see, sport participation is beneficial for reducing symptoms of depression and anxiety. There are three caveats to this message. First, sport participation has also been associated with increased substance use (e.g., alcohol and cigarette and marijuana smoking) that could lead to worsened symptoms of mental illness. In fact, substance use and mental illness are highly connected across the lifespan. Second, sport participation is not always ‘good’. There are certainly sub-groups of people who have poor experiences in sport because of maltreatment, heightened comparisons to others, and negative feelings of self that lead to extreme feelings of failure and worthlessness. Third, it is important to keep in mind that the very symptoms that sport helps to protect athletes from may also limit participation. Individuals who experience symptoms

of depression and anxiety are less likely to participate in sport (and physical activity more broadly), and need much more personalised attention and care to reap the benefits. Achievable goals, a focus on progress, and multiple opportunities for accomplishment and success are important considerations for improving mental health through sport. Notwithstanding these caveats, sport has many positive mental health benefits that are often overshadowed by the physical benefits. With the current circumstances of sport – limited opportunities and participation

brought about by restrictions and safety precautions of COVID-19 on a global scale – it is more important than ever to keep people engaged with their teams, connected with their sport identity, practicing skills and strategies, and moving at moderate-to-vigorous intensities. Encourage activity that is enjoyable and keep moving. Based on our research, focus on youth because setting up participation early not only helps protect from longer term mental illness at a time that is opportune (70% of mental health problems surface in childhood or adolescence) but is also a starting point for a more active life.

About the Author Dr. Catherine Sabiston is a Professor in the Faculty of Kinesiology and Physical Education at the University of Toronto and the Director of the Mental Health and Physical Activity Research Centre. As a leading Canadian researcher, Catherine holds a Canada Research Chair in physical activity and mental health. Her research broadly examines the interrelations among mental health, physical selfperceptions, social influences, and sport and exercise motivation and behaviour. Dr. Sabiston has over 250 peer-reviewed publications, has delivered over 400 presentations, and she has held over $20 million dollars in funding for her research. Dr. Sabiston’s research has been extensively featured in the media, has been used to inform evidence-based practice, and has advanced theory and methods in sport and exercise psychology.

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FEATURE: NUTRITION AND MENTAL HEALTH

Nutrition & Mental Health THE WAY WE EAT HAS THE POWER TO INFLUENCE MENTAL HEALTH. WHILE THE LINK BETWEEN DIET AND PHYSICAL HEALTH HAS BEEN STUDIED FOR DECADES, THE RELATIONSHIP BETWEEN NUTRITION AND MENTAL HEALTH IS A MORE RECENT RESEARCH AREA BUT ONE THAT IS RAPIDLY EVOLVING.

Context The World Health Organisation reports mental disorders like depression and anxiety to be one of the leading causes of disability worldwide. Within sport specifically, elite athletes have an equal if not greater prevalence of mental illhealth than the rest of the population. With a recent survey of 750 Australian athletes finding athletes were significantly more likely to report ‘high to very high’ psychological distress than their nonathlete counterparts when compared to published community norms (Purcell et al. 2020). Furthermore, the International Olympic Committee released a consensus statement in 2019 regarding mental health of elite athletes, reporting the prevalence of mental health disorders 30

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FEATURE: NUTRITION AND MENTAL HEALTH

are linked to poorer mental health. In one of the first studies of its kind, Jacka et al. (2010) observed a link between traditional-style diets and a lower risk of depression, with the key characteristics of these diets including a high intake of fruit, vegetables, whole grains, fish, lean protein and healthy fats. Conversely, poorer mental health was found in individuals who followed more of a Western-style diet, consisting of a greater portion of ultraprocessed foods that were relatively high in saturated and trans fat, salt and added sugar while also being low in fibre. Since this study, more and more research from around the world has found similar observations. The mechanisms There are several mechanisms thought to be responsible for the link between nutrition and mental health, including inflammation, the gut microbiota and neuroplasticity.

in athletes to be between 5-35%. Much like the rest of the population, COVID-19 has created further stress for athletes, including the subsequent disruption and cancellation to training and competitions. Therefore, it is imperative that alongside appropriate psychological support and intervention, we also consider how and what we eat to enhance and support the mental health of all individuals. The link Research demonstrates that certain dietary patterns are associated with better mental health, while others

Inflammation refers to the chronic activation of the immune system, with low-grade inflammation linked to mental illness. While there are many factors that can lead to systemic inflammation in the body including stress, obesity, substance use, vitamin D status and sleep, we also know that diet can strongly influence inflammation. Diets deemed to have a lower dietary inflammatory index have been linked to reduced risk of depression (Lassale 2018), with a longitudinal study of over 3500 participants observing a 24% higher risk of developing depressive symptoms in those following a proinflammatory diet (Western-style diet) compared to those on an antiinflammatory diet (Mediterraneanstyle diet) (Shivappa et al, 2018). Another key mechanism understood to influence mental illness is the twoVOLUME 38 â&#x20AC;˘ ISSUE 2 2021

FEATURE: NUTRITION AND MENTAL HEALTH

way relationship between the gut and the brain known as the gut-brain axis, whereby each organ can influence the other. For example, athletes may experience gastrointestinal symptoms like nausea or diarrhoea when nervous before an important competition, demonstrating the brain’s influence on the gut. We now know that this relationship also goes the other way, with the state of the gut also influencing emotional health and wellbeing. The gut consists of 100 trillion microorganisms known as the gut microbiota, which is influenced by a variety of factors including birth mode, pets, sleep, hygiene, disease and diet. Every individual’s microbiota is 32

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different, with some bacteria eliciting health benefits via the production of metabolites like short-chain fatty acids, while other bacteria can play a role in disease and poorer health outcomes. How and what we eat has the potential to influence the richness and diversity of different bacteria in the gut, and it is an abundance of beneficial bacteria in the gut that is linked to better mental health. For example, unsaturated fat and plant proteins have been linked to improved diversity and richness of beneficial bacteria in the gut, while saturated fat and animal proteins have been linked to the opposite (Singh 2017). It is this dysbiosis of bacteria in the gut that is thought to be linked to disease.

The other mechanism involved in diet’s impact on mental health is neuroplasticity – the ability of the brain to make new connections. Neuroplasticity is important for learning and adaptability as well as mental health (Kays 2012). A diet rich in whole foods including a variety of plants with a low intake of sugarsweetened beverages was associated with greater brain tissue volumes, including the hippocampus (Croll 2018). Diet as treatment An intervention study known as the SMILES trial (Jacka et al. 2017) assessed the impact of specific nutrition interventions on those diagnosed with depression. The dietary intervention used a modified Mediterranean diet,

FEATURE: NUTRITION AND MENTAL HEALTH

Nutrition & mental health in sport Within sport, key messages around nutrition often surround optimising fuelling, recovery, hydration and training adaptation, and minimising the risk or assisting in treatment of illness/injury. While these are important for maximising performance, it is important that these focus areas are not approached at the expense of other areas, including eating to optimise mental health.

which had a strong focus on intake of fruit, vegetables, whole grains, omega3-rich fish, legumes, nuts, seeds and extra virgin olive oil, with a reduction in ultra-processed discretionary foods like confectionary, refined grains, processed meats, sugar-sweetened beverages and fast food. The results showed the modified Mediterranean diet was able to improve mental health, with almost a third of the participants demonstrating a significant reduction in depressive symptoms following three months of dietary intervention. A meta-analysis by Firth et al. (2019) assessed sixteen randomised control trials and further supported the results from the SMILES trial, with the dietary interventions having a clear link to reduced depressive symptoms.

For example, carbohydrate loading is a performance nutrition strategy used in endurance events to maximise glycogen storage, with the goal to delay fatigue during the event that comes with glycogen depletion. The process involves up to 6-12 grams of carbohydrates per kilogram of body weight in the day/s leading into the event, which in reality can end up being a lot of food. Due to the satiating nature of fibre, athletes are often advised to consume low-fibre options during this time to enable them to reach the carbohydrate quantities advised. With a high-fibre diet being key for optimising mental health, it is important these athletes work with an accredited sports dietitian to ensure gut health isn’t chronically compromised around competition.

Key dietary recommendations ٚ Eat a wide variety of fruit and vegetables, every day. Aiming for three different colours in every meal is a good start. ٚ Choose whole grain options ٚ Incorporate fatty fish regularly e.g. salmon, tuna, mackerel, sardines, trout ٚ Make extra virgin olive oil the oil of choice ٚ Make nuts and/or seeds a staple as a snack or an addition to meals e.g. in salads ٚ Include fermented foods like yoghurt, kefir, sauerkraut, kimchi and sourdough bread Summary The research linking nutrition and mental health is only getting stronger. With the prevalence of mental illness increasing across the globe, nutrition is another area that we should consider alongside all other appropriate psychological intervention to prevent and treat mental illness.

Biography Holly Edstein is

Furthermore, the evidence points to diets with lower intakes of red meat being linked to better mental health due to the impact of red meat on the gut. However, red meat is a key source of dietary iron, and athletes generally have higher iron requirements than their non-athlete counterparts, especially for female and endurance athletes. Therefore, education around timing and nutrient combinations is crucial in assisting athletes to optimise iron absorption from their diet, without needing to consume excessive amounts of red meat.

an Accredited Practising Dietitian and Accredited Sports Dietitian. She is passionate about supporting individuals to utilise their diet for both optimal health and performance and is fortunate enough to do this with elite athletes at the New South Wales Institute of Sport and Sydney Roosters. She also works in private practice where she works with a range of clients, both athletes and non-athletes. VOLUME 38 • ISSUE 2 2021

REVIEW: MENTAL HEALTH IN SPORT

Promoting Good Mental Health

From the Weekend Warrior to the Elite Athlete â&#x20AC;&#x201C; Review

ON THURSDAY 29 OCTOBER 2020 SPORTS MEDICINE AUSTRALIA HELD A LIVE PANEL DISCUSSION ON MENTAL HEALTH IN SPORT HOSTED BY SPORT & EXERCISE PHYSICIAN DR ADAM CASTRICUM.

The panel included world renowned Sports Medicine professionals with AFL Chief Psychiatrist Dr Ranjit Menon, Australian Institute of Sport Mental Health Manager Matthew Butterworth, American Physical Therapist Dr Karen Litzy, Psychical Activity and Mental Health Senior Lecturer, Deakin University Dr Megan Teychenne and Sport and Exercise Psychologist Dr Michael Noetel. A feature of the expert panel was their ability to cover such a broad range of perspectives on mental health in sport, combining their multi-disciplinary 34

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skills and experience to share valuable insights into many different areas. These areas included attitudes and stigma around mental health in sporting communities, positive and negative relationships with exercise, how communities can support their athletes when mental health struggles arise, as well as providing advice and resources to those who know someone struggling with mental health or may be struggling themselves. It is widely known that sport and exercise have a strong positive

influence on overall health and wellbeing as well as quality of life. Individuals who partake in regular exercise often see benefits such as improved memory and brain function, lower blood pressure and improved heart health, better quality of sleep, reduced symptoms of anxiety and depression and improvement of joint movement. While the panel advocated for sport and exercise as a direct link between improved mental health, the effects of a negative relationship with exercise was also brought to light. For some,

REVIEW: MENTAL HEALTH IN SPORT

the panel advocated for sport and exercise as a direct link between improved mental health

exercise can be addictive causing some athletes to train excessive amounts leading to stress on the body such as poor sleep and eating habits and obsessing over their performance. The panel emphasised that while exercise is generally seen as inherently positive, there are many grey areas and issues to consider regarding exercise and mental health. To add to providing valuable insight to the topics addressed above, the panel also fielded 22 questions from the live audience, offering advice and options for those who

are working in the field or who have experienced mental health issues. The panel discussion significantly emphasised that mental health is just as important as physical health and should be treated as such. It was an insightful discussion that shared valuable understanding into the correlation between sports and mental health, and the idea that the two are more connected than we may think.

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SPORTS MEDICINE AROUND THE WORLD

Sport and Exercise Medicine in

Israel Atzmon (Atzi) Tsur MD

Regional rehabilitation physician in Meuhedet Mutual Service Counsellor of Israel Ministry of Health regarding sport medicine clinics Former director of rehabilitation department, Galilee Medical Center Former senior lecturer in the faculty of medicine of Bar-Ilan University at Safed.

IN ISRAEL, THERE ARE SIX SCHOOLS OF MEDICINE: THE OLDER ONE IN JERUSALEM, AND THE OTHERS, IN TEL-AVIV, IN HAIFA, IN BEER-SHEBA, AT SAFED AND AT ARIEL. THE LAST TWO ARE NEW MEDICAL SCHOOLS AND THEY ACCEPT STUDENTS ONLY FROM THE FOURTH YEAR OF STUDIES.

he medical studies in Israel take six years and after that, every student is obliged to do one year of practice in different hospitals’ departments in order to obtain the licence as a general practitioner in medicine. Sport medicine is not included in the ordinary six years of studies, but in some medical schools the students receive lectures about this theme. Currently, sport medicine is not recognised as a medical speciality in Israel, but a licentiate medical doctor, you have the possibility to do three academic years (six semesters) of postgraduate studies at either the Sackler school of medicine at TelAviv University or at the Technion medical school in Haifa in order to obtain a diploma in sport medicine.

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The academic program includes exercise physiology, kinesiology and biomechanics, traumatology and rehabilitation, cardiology, pulmonology, paediatrics, disability, genecology, psychology, and nutrition, all of them are sports related. The frequency of the sport medicine studies is once a week, for total of 360 hours. At the end of every academic year, there is a final examination. After three years of theoretical studies, the physician has to do a practical activity in a sports medicine centre recognised by our Ministry of Health during 350 (for specialists in other medical branch) or 700 hours (for general practitioners) in order to obtain the official certification in sport medicine, and to be able to do pre-participation examinations (PPEs) for sportsmen. During this period

of education, all the physicians who study sport medicine are requested to practice many PPEs, orthopaedic clinics, physiotherapy, cardiology, nutrition and psychology. The sport medicine courses include part of practice in the third year of the theoretical studies, in order to abbreviate the period of education. These sport doctors are not considered as specialists in sport medicine, but they are the only who have the authorisation from the Israeli Ministry of Health to do the PPEs. Currently, every physician, with or without a diploma in sport medicine, is authorised to provide medical care for all level of athletes, competitive and others, but not to give them medical certification for participation in sports activities.

SPORTS MEDICINE AROUND THE WORLD

When the physician obtains the diploma in sport medicine and has a specialisation in other medical branch, since 1998 there was a possibility (suspended at this moment) to make one year of “fellowship” in sport medicine in different departments of general hospital (as orthopaedics surgery, physical and rehabilitation medicine, cardiology, and others). Since 2013 exist a “fellowship” also in orthopaedic sport medicine, destined only for physician specialists in orthopaedic surgery. Actually, “fellow” is the supreme title to obtain in the domain of sport medicine in Israel. More than 80 clinics of sport medicine are located all over the state of Israel. Most of them are in private hands and the others, in general hospitals

More than 80 clinics of sport medicine are located all over the state of Israel or in public institutes. All the clinics have a physician with full education in sport medicine, but only few of these clinics have the authorisation to train future sports’ doctors. The Israel Society of Sport Medicine (ISSM) renewed her activity in 1985. The ISSM organises congresses and scientific conferences every year, but those do not contribute to the academic status of the participants.

Since 1988 exist in Israel sports’ law that among the other subjects, includes also a chapter regarding the domain of sport medicine. According this law, every athlete is obliged to do a periodical PPE in an authorised sport medicine clinic, generally before the beginning of the season. In order to supervise the current activity of the sports’ clinics and doctors, and in this way, to keep high level of the PPEs, the Israeli Ministry of Health established a committee of physicians, some of them are qualified in sport medicine. Beside them, acts the sports’ doctor counsellor from the Ministry of Health who visits the sport medicine clinics, check their equipment and examine the medical records in each of them. VOLUME 38 • ISSUE 2 2021

COMMUNIT Y NEWS

Sports Medicine @SMA_News sma.org.au • SMA appoints three new board members • Save the date – 2021 SMA Conference dates announced • SMA launches brand new online member community – SMA Connect - launching early 2021 • Concussion in Sport with Associate Professor Andrew Gardner – Webinar Review • Infection Control in Community Sport – Workshop Review • New Evidence and Guidance for Safe Sport in Extreme Heat Conditions – Webinar Review • Dr Peter Brukner – We are getting fatter and sicker. What are we going to do about it? Live presentation and Q&A February 17 • Professor Wendy Brown – New global guidelines on Physical Activity and Health – what has changed and why? Live Presentation and Q&A March 23

@ACSEP_ acsep.org.au • Save the date ACSEP 2021 Annual Scientific Conference

@SportsDietAus sportsdietitians.com.au • Gaye Rutherford announced as SDA President of the Board • Latest SDA blog • Latest SDA Recipes • SDA Resource Hub

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COMMUNIT Y NEWS

Community News APS • Mental illness shouldn’t be a rite-of-passage for older Australians says peak body for psychologists

@ESSA_News essa.org.au • Register for Research to Practice 2021 • Webinar – Non-Operative ACL Management – February 4 • ESSA congratulates 2020 Industry Award Winners • ESSA announces its latest Fellows

@APAPhysio australian.physio • APA Podcast series • Physios welcome announcement of permeant telehealth funding • Physio perfectly positioned to address Productivity Commission report findings on Mental Health

@AICE Sports & Exercise www.chiro.org.au/membership/aice/sport (formerly Sports Chiro Australia) • 2021 Sports Chiropractic Symposium • Managing Workers Compensation Patients Workshop – February 21

View the online version of Sport Health to see links. VOLUME 38 • ISSUE 2 2021

5 MINUTES WITH: DR JOHN ORCHARD

5 minutes with

Dr John Orchard Tell us a little bit about your background I was the first registrar appointed to the Australasian College of Sport and Exercise Physicians (ACEP) training program in 1992. There is a generation of SEM physicians older and more experienced than me who self trained in the 1980s, but I am a part of the first generation who went through the formal full training program in the early 1990s. I did my first year of training in Melbourne, where I grew up and went to medical school, then a year at the Australian Institute of Sport in Canberra, then I completed my training in Sydney where I have lived ever since. Congratulations on being awarded a Member of the Order of Australia (AM) in January this year for significant service to sports medicine, how did it feel to be recognised on that scale? It certainly was a great thrill and honour, and I suppose it proves that I am not a complete radical in that I accepted the award rather than declined! (laugh emoji). Relative to our numbers, SEM physicians have been well represented in these awards. It is a paradox that individual SEM physicians have a high profile relative to most doctors, as we are treating celebrity athletes regularly, yet the specialty itself has a low profile and struggles to receive recognition by government and the rest of the medical profession Describe your role as the Cricket Australia Chief Medical Officer? Has the role changed a lot since you commenced in 2014? When I started in 2014, the expectation was that the role was primarily about athlete care and coordination of care, particularly for the Australian men’s squad. There is still some of that (fortunately) but the policy side of it has morphed into being the vast majority 40

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of the job. The big rocks in terms of policy since 2014 have been athlete safety (in reaction to the Phillip Hughes tragedy), the evolution of concussion policy, the evolution of cardiac screening policy, extreme heat policy, then coping with bushfire smoke issues and more recently biosecurity and prevention of coronavirus. Since 2014 also the female program at CA has gone from being a sideshow to a huge part of the organisation and that has been a thrill to have been part of. What does a typical day look like in the life of Dr John Orchard? In 2020 I have had more days working from home than at an office, and it

is not unusual to have half a dozen teleconferences on Zoom or Teams on any given day. Being a SEM physician I have to practice what I preach and make sure I get out for my 11,500 steps per day (on average, not that I count too obsessively) and do something with upper limb as well (housework, swimming, play with kids and very occasionally golf). Be like Goldilocks with physical activity, not too hot and definitely not too cold. How did you get involved at SMA? SMA was the first collegiate group I got involved with in the early 1990s. My biggest role was doing Dr J columns for over a decade in Sport

5 MINUTES WITH DR JOHN ORCHARD

Health. I tried to get the balance right between making a serious point, cracking jokes and having a sense of humour and trying to offend the establishment class rather than the lowly practitioner class. Hopefully I got the balance right, although occasionally I had to negotiate apologies. For you, what is the biggest benefit of being an SMA member? As a SEM physician, ACSEP is definitely my core collegiate body, but looking further afield I am a proud SMA member but not a member of the Australian Medical Association (AMA). This is an easy choice, because SMA recognises SEM physicians as the peak medical specialists in the sports medicine field, whereas the AMA has elected to not recognise sport & exercise medicine as a specialty. SEM is as much an “exercise-based” specialty than a “medical specialty”, and it serves a critical role in the health system as a bridge between the two. I would hope every ACSEP Fellow & Registrar would also be a member of SMA and equally I’d hope that – until they change their stance – no SEM physicians should be members of the AMA. Fortunately, I am no longer writing Dr J columns, as what I’d write about the AMA would probably lead to a debate about whether I owed them an apology for excessive slagging. I’d argue, of course, that no abuse I could write about the AMA could be more offensive than their organisation failing to recognise a specialty that has legitimately existed in Australia for over 30 years. Furthermore, campaigning against SEM physicians getting equal medicare rebates with other physician specialists. The AMA harms patient health by fighting against a specialty which can and should lead the musculoskeletal medical specialties out of mire of prescribing more net harmful medical treatment (opiates, arthroscopies, cortisone shots

I am a proud SMA member but not a member of the Australian Medical Association (AMA). This is an easy choice, because SMA recognises SEM physicians as the peak medical specialists in the sports medicine field, whereas the AMA has elected to not recognise sport & exercise medicine as a specialty

and NSAIDs) than helpful medical treatment (exercise therapy). SMA, by contrast, is on the side of good not evil in the musculoskeletal world!

What is the best piece of advice someone has given you? All of the haters in medicine early in my medical career who said I couldn’t possibly aim to specialise in sports medicine because the specialty didn’t exist. So, I ignored their advice and went into sports medicine anyway. Proving them wrong has been a constant motivation, and continues to be even though the sport & exercise medicine denialists haven’t gone away (see AMA above). I have a dream that one day the health system in Australia might fund exercise therapy more generously than it funds knee arthroscopy. It is apparently too radical an idea to fund something that helps over something that harms. We have to keep fighting this fight until we (eventually) win it. Musculoskeletal outcomes are getting worse in western countries every year because we are addicted to low value medical treatments, and in this bizarre context being a radical and disruptor is evidencebased and fighting the good fight! VOLUME 38 • ISSUE 2 2021

PEOPLE WHO SHAPED SMA

People Who Shaped SMA

Tim Pain

the summer. My preference was AFL and basketball, later I transitioned into distance running and now a days I mostly mountain bike. Can you describe your educational background? I grew up in Port Wakefield in South Australia where I went to the local primary school and then bused to the public secondary school 30 kilometres away at Balaklava. My tertiary studies in podiatry were at the University of South Australia. How and when did you start working in Sports Medicine? When I started work there were very limited opportunities for further education in the sports medicine field, post graduate university courses were nonexistent and the internet was yet to be invented. I was working in Ouyen, in regional Victoria when I joined SMA and my passion for working with sports injuries started.

What made you decide on a career in Sports Medicine? I grew up in country South Australia, where I was always involved in sport. I had a desire to continue to play sport and be involved as much as possible, hence a career in podiatry was born. Were you an athlete prior to commencing your career? If so what sport/sports did you play? The two main sports on offer when I was a growing up were AFL, hockey in the winter, cricket and basketball in

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How and when did you first join SMA? What was your initial role? In 1995 when I first joined SMA and shortly afterwards I moved to Hobart and attended the SMA National Conference. Within six months I joined the state council in Tasmania and have been involved with SMA in one way or another ever since. How did being part of SMA help your sports medicine career? The single best thing about joining SMA was the access it has provided to other like-minded health professionals. I quickly learnt who were the good practitioners to refer to that would help my patients the

PEOPLE WHO SHAPED SMA

most. Over time the diversity of SMA membership has been more valuable than I would have first anticipated, often the benefits go far beyond sports medicine specific information. Through my involvement on state councils and national boards I often get unexpected pearls of wisdom in the areas of marketing, human resources, finance, law, etc that I would never be exposed to in a normal clinical setting. What has been your biggest contribution to SMA? I have held a number of different positions within SMA over the years but working with the local SMA council members to organise local SMA multidisciplinary education events has been the most rewarding aspect of my involvement. What has been your career highlight? Presenting at state conferences and national conferences is something that that I have always found daunting but in retrospect these moments were both a highlight and also provided an opportunity to meet people that I would not have otherwise met. Do you have any career regrets? If I had one career regret it would be that early on in my career, I was a fixated with the desire to hold a position within a high-profile sporting team. It took a number of years for me to realise that whilst often these positions hold a level of prestige, it is rare that they provide a greater opportunity to manage and treat sports injuries than those experienced by lower tier athletes. What do you believe is your most important contribution to your industry? Working with younger colleagues and seeing them grow and develop their own careers in the area of podiatry is extremely rewarding.

What is your advice to those starting out in their sports medicine career? Former AFL coach, John Kennedy summed it up best, “Don’t think, do”. People spend so much time thinking about what they want to or should do, that they actually never get beyond the theory of an idea. If an opportunity arises always say yes. You will make lots of mistakes but this is truly how you develop and grow as a practitioner. The beauty is that when you are starting out in your career everyone actually expects you to make mistakes anyway so they are far more forgiving.

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SPORTS TRAINER SPOTLIGHT: KENNETH WHITEHILL

Sports Trainer Spotlight

Kenneth Whitehill KENNETH WHITEHILL HAS BEEN A SPORTS TRAINER FOR OVER 20 YEARS. HE BEGAN HIS CAREER AT THE CORIO FOOTBALL CLUB IN 1995 AND HAS CONTINUED TO SERVE AS A DEVOTED SPORTS TRAINER WITH SPORTS MEDICINE AUSTRALIA EVER SINCE. HIS WORK HAS SHOWN SOME GREAT ACHIEVEMENTS AND TAKEN HIM TO SOME AMAZING PLACES.

VOLUME 38 â&#x20AC;¢ ISSUE 2 2021

SPORTS TRAINER SPOTLIGHT: KENNETH WHITEHILL

How did you get involved at SMA? I used to be a Sports Trainer at the Corio Football Club, the head Sports Trainer at the time told me all about SMA and suggested that I become a member, so I signed up! How long have you been an SMA Sports Trainer? I became an SMA Sports Trainer at the Corio Football Club 25 years ago back in October 1995. During my time there I decided to expand my skills and knowledge in the field and became a qualified Massage Therapist. I was a trainer at Corio right up until 2005 until I moved to Anakie Football and Netball club as the head trainer from October 2005 until 2012. During my time at Anakie I had the opportunity to be a trainer at the Master’s Games held in Geelong. After that I moved to Bell Post Hill Football and Netball Club from October 2012 and have been there ever since.

What do you love most about being a Sports Trainer? I love meeting people from all different sports and backgrounds, helping players with their recovery, preventing injuries in athletes and educating players and their family members on their injuries to give them the best advice. What has been the highlight of your journey as a Sports Trainer so far? There have been so many highlights, it is difficult to name just one. Two years into being at my club, I took on the role of Head Trainer in 1998 which was a huge achievement. I became a trainer at Geelong District Football League and then went on to become the Head Trainer for both the football and netball league. I’ve had the opportunity to be a presenter for SMA, and trained athletes at the Commonwealth and the Deaflympic Games, not long after I received a

Don’t just think that you’ve learnt enough, there is always something more to learn.

service award from the GDFL. But overall, the best part of what I do is the people that I meet and work with. What tips/advice do you have for any new Sports Trainers who are just starting out? Join SMA! With everything and anything you do; you should always be learning. You should always be evolving and working on your skills. Don’t just think that you’ve learnt enough, there is always something more to learn. My key moto is “I keep learning new skills every day”.

VOLUME 38 • ISSUE 2 2021

Publisher Sports Medicine Australia PO Box 78 Mitchell ACT 2911 sma.org.au ISSN No. 1032-5662 PP No. 226480/00028