Screening and Assessment tool for sport
September saw an important development for the mental health care of elite athletes with the publication of a screening and assessment tool for use in elite sport.
The Sport Mental Health Assessment Tool (SMHAT) includes a general screening instrument for symptoms with more comprehensive screening for specific symptoms (disturbed sleep, anxiety, eating issues, depression and alcohol/substance misuse) available for those who score positive on the general measure. Guidance is also provided for practitioners on next steps including initial management and further assessment.
The SMHAT is complemented by a recognition tool that can be used by all members of the athletes entourage (the Sport Mental Health Recognition Tool or SMHRT).
Exercise for your mental health – but don’t overdo it!
A huge study of exercise and mental health has published data on almost 1.2 million subjects and demonstrated the relationship between exercise and improved better mental health for (almost) everyone.
One interesting finding was the ‘U’ shaped curve which shows that whilst limited exercise associates with worse mental health so too does large amounts of exercise. More isn’t always better!
The finding that large amounts of exercise don’t bring the same benefits as more moderate amounts is perhaps not surprising. Firstly the volumes of exercise necessary for the benefit to diminish are very large and we already know that ‘overtraining’ in elite athletes produces both physical and psychological symptoms. We also know that ‘compulsive exercise’ can be associated and even driven by symptoms of mental health problems. Allowing exercise to dominate your life might also bring damaging social effects by creating an exercise/life imbalance akin to the work/life imbalance that can harm mental health.
Yet more evidence of the mental health benefits of exercise
Benjamin Willis and his team in Texas have just published the results of a huge survey of ‘midlife fitness’. They collected retrospective data on a cohort of almost 18000 individuals – mostly (80%) men. After measuring fitness using a treadmill exercise test they found that high levels of midlife fitness were associated with a 16% reduced likelihood of developing depression. Perhaps a more significant finding was the relationship between depression and later cardiovascular morbidity. Those who have had an episode of depression are known to be at increased risk of cardiovascular disease (CVD) afterwards. Dr Willis’ team found a 56% reduction in deaths due to CVD after an episode of depression in those who had a high level of physical fitness. Yet more evidence of how important it is to look after both our physical and mental health.
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A 12-month prospective cohort study of symptoms of common mental disorders among professional rugby players
Gouttebarge, V., Hopley, P., Kerkhoffs, G. M. M. J., Verhagen, E. A. L. M., Viljoen, P. W., & Lambert, M. (2018). A 12-Month prospective cohort study of symptoms of common mental disorders among professional rugby players. European Journal of Sport Science, (April). http://doi.org/10.1097/JSM.0000000000000388
Male professional rugby players have significant and often enduring symptoms of common mental health problems according a recently published large survey published in the European Journal of Sport Science (Gouttebarge et al., 2018)
Unusually the study is a 12 month observational prospective cohort design rather than a simple point prevalence survey with symptoms being measured at 3 time points (baseline and then at 3 and 12 month follow-up). The subjects were players from all the major rugby playing nations and thus a sample across different cultures. Players came from both rugby codes (union and league) and also included rugby sevens specialists – although the results are reported in aggregate form. They had a mean age of 26, mean weight of 101kg and just over half had attended college or university.
Players were scored using a number of recognised tools for measuring mental health symptoms seen in athletes (e.g. PROMIS for sleep disturbance and the GHQ-12 for symptoms of anxiety and depression). Data was available at both follow-up points for 333 players allowing observations to be made on the longitudinal course of symptoms.
13% of participants reported symptoms at both 3 and 12 months suggesting a significant prevalence of enduring symptoms. Players who reported recent life events or career dissatisfaction were more likely to be symptomatic but this did not reach statistical significance. Almost all of those with symptoms suggested that this adversely affected their sporting performance and nearly half reported that specific support measures for players were inadequate.
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Exercise Leads to Better Clinical Outcomes in Those Receiving Medication Plus Cognitive Behavioral Therapy for Major Depressive Disorder.
Gourgouvelis, J., Yielder, P., Clarke, S. T., Behbahani, H., & Murphy, B. A. (2018). Exercise leads to better clinical outcomes in those receiving medication plus cognitive behavioral therapy for major depressive disorder. Frontiers in Psychiatry, 9(MAR). http://doi.org/10.3389/fpsyt.2018.00037
The ubiquitous BDNF has been suggested in several studies to have a role in directing the mental health benefits of exercise. This small but fascinating control study examines the benefits of exercise therapy in a subgroup of patients with major depressive disorder receiving medication and group CBT.
Vancampfort, D., Hallgren, M., Firth, J., Rosenbaum, S., Schuch, F. B., Mugisha, J., … Stubbs, B. (2018). Physical activity and suicidal ideation: A systematic review and meta-analysis. Journal of Affective Disorders, 225(August 2017), 438–448. http://doi.org/10.1016/j.jad.2017.08.070
Another comprehensive review from Davy Vancampfort and his team in Belgium. This time examining the relationship between physical activity and suicidal ideation. Higher levels of physical activity are associated with lower levels of suicidal ideation but as with all associations we need more prospective data to help us understand the relationship in more detail.
Mental disorder in elite sport has rightly attracted much media attention over the last decade however quantitative studies about the prevalence of common mental disorders in athletes are lacking. In this global study Gouttebarge and colleagues surveyed nearly 1000 elite rugby players across 12 countries. The 4-week prevalence rates of symptoms of common mental disorders ranged from 15% for adverse alcohol use to 30% for anxiety/depression. This indicates similar levels of morbidity compared to other elite sports and possibly higher rates than the general population. The authors emphasis the importance of mental health awareness across medical and support staff in rugby in order to identify mental disorders at an early stage.
Gouttebarge V, Hopley P, Kerkhoffs G, Verhagen E, Viljoen W, Wylleman P, et al. Symptoms Of Common Mental Disorders In Professional Rugby: An International Observational Descriptive Study. Int J Sports Med [Internet]. Georg Thieme Verlag; 2017 Oct 11 [cited 2018 Mar 14];38(11):864–70.
Physical activity in schizophrenia
Physical activity programmes for patients with schizophrenia are important yet dropout rates are high by comparison with similar programmes for other conditions such as depression and diabetes. Davy Vancampfort is one of the leading researchers and writers in this area. He and his team have concluded that ‘policymakers should make the inclusion of qualified professionals such as physical therapists and exercise physiologists a priority in order to improve adherence among people with schizophrenia’.
Vancampfort, D., Rosenbaum, S., Schuch, F. B., Ward, P. B., Probst, M., & Stubbs, B. (2016). Prevalence and predictors of treatment dropout from physical activity interventions in schizophrenia: A meta-analysis. General Hospital Psychiatry, 39(January), 15–23. http://doi.org/10.1016/j.genhosppsych.2015.11.008
Is elite sport really bad for you? Can we answer the question?
As we strive for more understanding of the nature and extent of mental health problems in elite sport a question remains for many researchers in this field – can we use existing diagnostic criteria in this unusual population?
The contribution of Florence Lebrun and Dave Collins is to suggest that a different dichotomy is applicable in sport. We should not consider whether an attribute is normal or pathological but rather consider whether it is functional or dysfunctional.
Is the latter really so different from how clinicians practice – whether or not they are working with athletes? Surely functional impairment is the hallmark of ‘pathology’, for without impairment where is the illness?
To read more clink the link for access to the complete article from Frontiers in Psychology in March 2017.
When the Best Therapy is at Your Feet
The sporting press can be a bit hit and miss when reporting on mental health issues. Runner’s World however regularly publishes scholarly, thoughtful and inspirational pieces on the link between running and mental health. Here is one of their most recent articles entitled When the Best Therapy is at Your Feet. Click the image to read more and find out why a ‘runner’s high’ is about more than endorphins.
Exercise and the treatment of depression
As yet we don’t know in detail what kind of physical activity, at what intensity and for how long is necessary to provide an anti-depressant effect. Nonetheless it is helpful to have this Australian review of 5 RCTs describing the effectiveness of regular (three times weekly) aerobic exercise programmes.
Stanton, R., & Reaburn, P. (2014). Exercise and the treatment of depression: A review of the exercise program variables. Journal of Science and Medicine in Sport.
Screening for depression
A 2016 paper by Professor Thomas Trojian (Philadelphia) in the British Journal of Sports Medicine makes some important points about depression in sport.
1. The sports physician’s responsibility to look after the whole athlete/patient including mental health and well-being.
2. Sporting stresses increase the risks for athletes especially where they lack social support and are under-performing in their sport. Poor sleep and low self-esteem also contribute and female athletes are at higher risk
3. Screening is helpful but there needs to be clarity about the response to positive results from screening – most importantly the availability of a more detailed assessment and appropriate treatment.
Depression, Anxiety, and Alcohol Use in Elite Rugby League Players Over a Competitive Season.
Du Preez, Etienne J.; Graham, Kenneth S.; Gan, Thomas Y.; Moses, Bassam; Ball, Chris; Kuah, Donald E.
Clinical Journal of Sport Medicine: Jan 2017.
This Australian study surveyed psychiatric morbidity over the course of an elite competitive season. Prevalence rates for anxiety and depression were in the low teens. Depression had an association with both past history of mental health problems and number of concussions. Around two-thirds of players were hazardous users of alcohol.
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Mental Health Literacy
Sebbens, J., Hassmen, P., Crisp, D., & Wensley, K. (2016). Mental Health In Sport (MHS): Improving the early intervention knowledge and confidence of elite sport staff. Frontiers in Psychology, 7(JUN), 1–9. http://doi.org/10.3389/fpsyg.2016.00911
Mental health problems are common in elite sporting populations. Among the barriers to accessing appropriate help are a lack of recognition and an unsupportive sports culture – not found in all sports but certainly in some.
Improving ‘mental health literacy’ is one way to address this. Literacy in this context means improving knowledge, understanding beliefs abut mental health problems and improving recognition, management and prevention.
Several programmes have been developed to improve this kind of literacy. Here the authors report a programme in sport designed to be brief (and therefore accessible) as well as specific to the culture of sport.
A 4-hour workshop was developed making use of case studies and role-play. The ‘four Rs’ of ‘recognise’, ‘reach out’, ‘refer’ and ‘remain supportive’ were emphasised. Participants were drawn from coaches and other support staff working in high-level sport.
Knowledge of signs and symptoms and confidence to provide support were all significantly enhanced by the programme and especially for anxiety disorders (which are particularly common in sport).
Petito, A., Altamura, M., Iuso, S., Padalino, F. A., Sessa, F., D’Andrea, G., … Bellomo, A. (2016). The relationship between personality traits, the 5HTT polymorphisms, and the occurrence of anxiety and depressive symptoms in elite athletes. PLoS ONE, 11(6), 1–13. http://doi.org/10.1371/journal.pone.0156601
Many different factors contribute to the presence of anxiety and stress in athletes. This study describes a fascinating interaction between biology, psychology and environment. The researchers recruited 133 athletes and examined not only serotonin transporter gene (5HTT) polymorphisms but also measures of emotional arousal, personality traits (including neuroticism), and mood states. Their conclusion is that ‘a significant interaction’ exists between polymorphism, neuroticism and sporting stresses and that this predicts mental health problems in athletes.
The ‘dark side’ – depressive experiences in elite sport
Newman, H. J. H., Howells, K. L., & Fletcher, D. (2016). Frontiers in Psychology, 7(JUN).
Therapists of all disciplines who work with elite athletes will recognise the themes that emerge from this interesting review of 12 sporting autobiographies. Themes such as how sport initially provides a relief from mental distress before itself becoming a contributory factor as sporting demands increase.
The mental health of college athletes
Rao, A. L., & Hong, E. S. (2016). British Journal of Sports Medicine, 50(3).
This review includes a comprehensive review of risk factors for mental ill-health within college athletics. It also provides another welcome call for mental health to be accorded parity with physical health in providing appropriate health care for college athletes.
The emotional impact of being dropped
Two established ‘hot-spots’ for athletes are injuries and transitions and both have been associated with psychiatric morbidity and psychological symptoms. A large study of elite German school athletes (aged 12-15) adds to our knowledge of these difficulties by comparing the mental health of athletes deselected from performance programmes with those maintained on such programmes (and a control group of non-athletes).
Deselected athletes perhaps unsurprisingly had higher levels of psychological symptoms and less positive mood scores.
Whilst it is tempting to see cause/effect relationships in these associations – deselection is bad for your psychological well-being – what if it were the other way round? Are athletes more likely to be deselected if their psychological health is poor?
In either case this is an important reminder of the need to provide psychological support for athletes at all stages in their development.
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Psychological Symptoms and Chronic Mood in Representative Samples of Elite Student-Athletes, Deselected Student-Athletes and Comparison Students. Brand R, Wolff W, Hoyer J. School Mental Health, vol. 5, issue 3 (2013) pp. 166-174
Cannabis Use in Sport
When we think of drugs in sport our first thought is usually a doping issue or use illegal performance drugs (PEDs). This intriguing study is a timely reminder that substance misuse is not uncommon in sports and in some subgroups there may be particular problems for the sports psychiatrist to address in helping athletes to better health and improved performances. Click the image for more.
Brisola-Santos, M. B., Gallinaro, J. G. de M. e, Gil, F., Sampaio-Junior, B., Marin, M. C. D., de Andrade, A. G., … Castaldelli-Maia, J. M. (2016). Prevalence and correlates of cannabis use among athletes-A systematic review. The American Journal on Addictions, 25(7), 518–528. http://doi.org/10.1111/ajad.12425
Dan Begel is one of the founding fathers of sports psychiatry. His work since the 1980s has encouraged many to pursue a career in that field and his 1992 publication was especially influential (An Overview of Sport Psychiatry in the American Journal of Psychiatry). His reflections 24 years later are definitely worth a read and he offers many useful insights into the current status of sports psychiatry and his hopes for the future. Click each image for more.
Many contact and collision sports are working hard to develop guidelines on the management of concussion. The focus is usually on the prevention of longer-term neurological sequelae. It seems that concussed athletes are also at risk of depression and this study describes some of the associations between concussion and subsequent depressive symptoms.
Gray Vargas, Amanda Rabinowitz, Jessica Meyer, and Peter A. Arnett (2015) Predictors and Prevalence of Postconcussion Depression Symptoms in Collegiate Athletes. Journal of Athletic Training: March 2015, Vol. 50, No. 3, pp. 250-255.