The official magazine of the Football Medicine & Performance Association
football medicine & performance
Issue 30 Autumn 2019
Feature
David Cotterill’s Road to Recovery FOCUS ON: Mental Health The Role of a Psychotherapist in a Football League Club Hidden in Plain Sight – Mental Health Challenges in Football Clubs Substance Abuse and Gambling in Professional Football Managing Mental Health Emergencies in Elite Football
Legal Ţ Education Ţ Recruitment Ţ Wellbeing
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CONTENTS WELCOME
8
Updates
FEATURES
10
Injury Mitigation in Team Sports. Part-1: A Review of Current Dogma Colin W. Fuller
13
The Role of Football Clubs in Supporting Community Mental Health Initiatives Dr Alan Pringle
15
David Cotterill’s Road to Recovery
16
The Role of a Psychotherapist in a Football League Club Gary Bloom
20
Mental Health Symptoms in Professional Football Vincent Gouttebarge, Gino Kerkhoffs
24
ABOUT
27
Golf. The Ultimate Mind Game? Dr Andrew Murray
28
Substance Abuse and Gambling in Professional Football Gary Souter
32
Mental Health of the Elite Young Athlete Manroy Sahni, Johnson Pok-Him Tam
34
Managing Mental Health Emergencies in Elite Football Tim Rogers
37
Getting Back in the Driving Seat: Taking Control of Your Work, Life and Wellbeing
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FMPA Register
Hidden in Plain Sight – Mental Health Challenges in Football Clubs Dr Misia Gervis, Lara Baker, Osimeiro Imoedemhe
Football Medicine & Performance Association 6A Cromwell Terrace, Gisburn Road, Barrowford, Lancashire, BB9 8PT T: 0333 456 7897 E: info@fmpa.co.uk W: www.fmpa.co.uk FMPA_Official Officialfmpa fmpa_official LinkedIn: Football Medicine & Performance Association FMPA_Register FMPARegister fmpa_register Chief Executive Officer Eamonn Salmon eamonn.salmon@fmpa.co.uk
Design Oporto Sports www.oportosports.com
Executive Administrator Lindsay Butler admin@fmpa.co.uk
Photography PA Images, FMPA, Getty Images
Administration Assistant Amie Hodgson amie.hodgson@fmpa.co.uk Project Manager Angela Walton angela.walton@fmpa.co.uk Marketing/Advertising Charles Whitney 0845 004 1040
Contributors Colin W. Fuller, Dr Alan Pringle, Gary Bloom, Vincent Gouttebarge, Gino Kerkhoffs, Dr Misia Gervis, Lara Baker, Osimeiro Imoedemhe, Dr Andrew Murray, Gary Souter, Manroy Sahni, Johnson Pok-Him Tam, Tim Rogers Print Media Village www.media-village.co.uk
COVER IMAGE Birmingham City’s David Cotterill. Birmingham City v Nottingham Forest - Sky Bet Championship - St Andrew’s. Dave Howarth / EMPICS Sport / PA Images
Football Medicine & Performance Association. All rights reserved. The views and opinions of contributors expressed in Football Medicine & Performance are their own and not necessarily of the FMPA Members, FMPA employees or of the association. No part of this publication may be reproduced or transmitted in any form or by any means, or stored in a retrieval system without prior permission except as permitted under the Copyright Designs Patents Act 1988. Application for permission for use of copyright material shall be made to FMPA. For permissions contact admin@fmpa.co.uk
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mental health
MENTAL HEALTH SYMPTOMS IN PROFESSIONAL FOOTBALL FEATURE / VINCENT GOUTTEBARGE & GINO KERKHOFFS
Affiliations 1. Amsterdam UMC, Univ of Amsterdam, Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, the Netherlands 2. FIFPRO (Football Players Worldwide), Hoofddorp, the Netherlands
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In professional football, most of the epidemiological studies have been directed towards the physical health of players, principally towards the occurrence of musculoskeletal injuries and more recently their prevention. By contrast, scientific information about the prevalence of mental health symptoms among active or former professional footballers remains limited. This is surprising because (i) anecdotal reports of active or former professional footballers with mental health symptoms have been released in the media for many years, and (ii) professional footballers are (cumulatively) exposed during and after their career to specific and non-specific stressors that might lead to mental health symptoms.
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Mental health symptoms versus mental health disorders Mental health disorders are typically defined as conditions causing clinically significant distress or impairment that meet certain diagnostic criteria such as in the Diagnostic and Statistical Manual of Mental Disorders 5 or the International Classification of Diseases.1 Mental health symptoms refer to self-reported adverse or abnormal thoughts, feelings and/ or behavior that do not meet specific diagnostic criteria and do not necessarily cause significant distress or functional impairment.1 In professional football, nearly all epidemiological evidence available is directed towards mental health symptoms. Examples of mental health symptoms are related to distress, burnout, anxiety, depression, sleep disturbance or adverse alcohol use.
football medicine & performance Prevalence of mental health symptoms in professional football In recent years, several studies have been conducted about the prevalence of mental health symptoms among active professional footballers. In 2013, a preliminary study was conducted in a sample of 149 male professional footballers (mean age of 27 years; mean career duration of 9 years; 60% playing in the highest professional league) from Australia, Ireland, The Netherlands, New Zealand, Scotland and United States.2 In this cross-sectional study, the 4-week prevalence of mental health symptoms was 10% for distress, 26% for anxiety/ depression and 19% for adverse alcohol use.2 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 8 years; 55% playing in the highest professional league) recruited in 11 countries.3 In that study, the same scales for measuring mental health symptoms were used as in the preliminary study. The 4-week 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.3 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.4 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.5 In that study (using different scales for measuring depression and anxiety than those used the studies aforementioned), male players had a lower prevalence of depression and anxiety than female players.5 In the preliminary and cohort study aforementioned, the prevalence of mental health symptoms among retired professional footballers was also explored. In a sample of 104 male professional footballers (mean age of 36 years; mean career duration of 12 years; mean retirement duration of 5 years), the 4-week prevalence of mental health symptoms was 18% for distress, 39% for anxiety/depression and 32% for adverse alcohol use.2 The subsequent cohort study conducted among 219 male professional players (mean age of 35 years; mean career duration of 12 years; mean retirement duration of 4 years) showed similar prevalence rates, namely 18% for distress, 35% for anxiety/depression and 25% for adverse alcohol use.3 Stressors for mental health symptoms in professional football In professional footballers as in elite athletes from other sports, the occurrence
of mental health symptoms is usually multi-factorial rather than caused by a single stressor. The complex and dynamic interaction between biological (genetic, biochemical, etc), psychological (mood, personality, behaviour, 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).6 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 as well as competitive athletes might be confronted with up to 640 distinct sport-specific stressors that could induce mental health symptoms.7 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 2-4 times more likely to report mental health symptoms than those who had not suffered from severe time-loss injuries.8,9
In professional footballers as in elite athletes from other sports, the occurence of mental health symptoms is usually multi-factorial rather than caused by a single stressor.�
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mental health
football medicine & performance
Figure 1 After Career Consultation: information for retired professional footballers.
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, Frings-Dresen MHW, Sluiter JK. Mental and psychosocial health among current and former professional football players. Occup Med 2015;65:190-6. 3. Gouttebarge V, Aoki H, Kerkhoffs G. Symptoms of Common Mental Disorders and Adverse Health Behaviours in Male Professional Soccer Players. J Hum Kinet 2015;49:277-86. 4. Gouttebarge V, 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. 5. Junge A, Eddermann-Demont N. Prevalence of depression and anxiety in top-level male and female football players. BMJ Open Sport Exerc Med 2016;2:e000087. 6. Engel GL. The need for a new medical model: A challenge for biomedicine. Science 1977;196:129-36.
Special attention to transitioning out of professional football Transitioning out of elite sport such as professional football is a difficult period: the epidemiological evidence suggests that elite athletes transitioning out of sport are likely to develop mental health symptoms.1 Especially undesired and involuntary retirement from sport, for instance as a consequence of a severe injury, is associated with an increased risk of mental health symptoms among retired athletes.10 Other stressors such as high levels of sport identity, lack of retirement planning and lower educational level are associated with long-term mental health symptoms.1 Therefore, FIFPRO and the Amsterdam University Medical Centers developed the After Career Consultation in order to empower the physical, mental and social health of retiring professional footballers.11 This support measure focusses on several health domains that are particularly relevant once retired from professional football, among which the promotion of a healthy lifestyle and the prevention of mental and cognitive health problems.10 Based on awareness raising, a thorough medical examination and follow-up counseling if necessary, the After Career Consultation or any similar ‘exit health examination’ should be supported and implemented by
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all stakeholders within professional football in order to protect and promote the long-term health of transitioning professional footballers.12 The IOC consensus statement Mental health symptoms are common in professional football but also in other elite sports.13 Therefore, the International Olympic Committee (IOC) selected an international expert panel in order to thoroughly review the available scientific literature, which led to the IOC consensus statement on mental health in elite athletes.1 This consensus statement addresses all relevant facets related to mental health symptoms (and disorders) in elite athletes, from diagnostic to treatment.1 Subsequently, the IOC developed a screening assessment and recognition tool for the early identification of elite athletes potentially at risk for experiencing mental health symptoms and disorders (intended to be published in the upcoming weeks). This screening tool should be used in professional football (ideally embedded within the pre-competition medical assessment) in order to facilitate timely referral of those players in need to adequate support and/or treatment, as well as to allow the prospective monitoring of mental health symptoms among players.
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7. Arnold R, Fletcher D. A research synthesis and taxonomic classification of the organizational stressors encountered by sport performers. J Sport Exerc Psychol 2012;34:397-429. 8. 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;24:393442. 9. 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. 10. Brown J, Kerkhoffs G, Lambert M, et al. Forced retirement from professional rugby union is associated with symptoms of distress. Int J Sports Med 2017;38:582–7. 11. Gouttebarge V, Goedhart E, Kerkhoffs G. Empowering the health of retired professional footballers: the systematic development of an After Career Consultation and its feasibility. BMJ Open Sport Exerc Med 2018;4:e000466. 12. Carmody S, Jones C, Malhotra A, et al. Put out to pasture: what is our duty of care to the retiring professional footballer? Promoting the concept of the ‘exit health examination’ (EHE). Br J Sports Med 2019;53:788-9. 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 metaanalysis. Br J Sports Med 2019;53:700-6.
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