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Mental Health in Professional Football Players

Authors:
  • Amsterdam University Medical Centers / University of Pretoria

Abstract and Figures

Symptoms of common mental disorders describe a mental and emotional state of adverse thoughts and/or abnormal or maladaptive behaviour that impair activities either in daily life, work or sport. Examples of symptoms of common mental disorders are often related to distress, burnout, anxiety, depression or sleep disturbance. Among professional footballers, 4-week prevalence of symptoms of common mental disorders ranges from 9% for adverse alcohol use to 38% for anxiety/depression and 12-month incidence from 12% for distress to 37% for anxiety/depression. Symptoms of common mental disorders are generally multifactorial, occurring as a consequence of the interaction between biological, psychological, social, sport-specific and career-related stressors. Especially, severe time-loss (28 days or more) injuries during a football career can be considered as a major stressor. Professional footballers who have sustained one or more severe time-loss injuries during their career are two to four to nearly four times more likely to report symptoms of a mental disorder than professional footballers who have not suffered from similar time-loss injuries. Most of professional footballers mention that symptoms of common mental disorders influence football performance negatively, while those symptoms are likely to interfere with return to play, especially in terms of concentration, focus, emotion, reaction time, coordination, power, strength and endurance. This emphasises the importance of applying a multidisciplinary approach to the clinical care and support of professional footballers, especially when a player faces severe time-loss injuries and related return to play process.
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V. Musahl et al. (eds.), Return to Play in Football, https://doi.org/10.1007/978-3-662-55713-6_65
Mental Health in Professional
Football Players
Vincent Gouttebarge and Gino M.M.J. Kerkhoffs
Contents
65.1 Introduction ............................................. 851
65.2 Definition of Symptoms of Common
Mental Disorders ..................................... 852
65.3 Prevalence and Incidence of Symptoms
of Common Mental Disorders
in Professional Football .......................... 852
65.4 Aetiology of Symptoms of Common
Mental Disorders ..................................... 853
65.4.1 Psychosocial Stressors .............................. 853
65.4.2 Sport-Specific Stressors ............................ 854
65.4.3 Developmental Model of Transitions ........ 855
65.5 Prevalent Mental Health Problems
in Professional Football .......................... 856
65.5.1 Depression ................................................. 856
65.5.2 Anxiety ...................................................... 856
65.5.3 Sleep Disturbance ..................................... 857
65.5.4 Adverse Alcohol Use ................................ 857
65.6 Potential Influence on Performances
and Return to Play .................................. 858
References .............................................................. 859
65.1 Introduction
In professional football, most of the epidemio-
logical studies have been directed towards the
physical health of players, principally towards
the occurrence of musculoskeletal injuries and
more recently towards the prevention of these
injuries. By contrast, scientific information about
the mental health of professional footballers
remains scarce. This is surprising because play-
ers are (cumulatively) exposed during their career
to specific and non-specific stressors that might
lead to symptoms of common mental disorders
(CMD). These symptoms of CMD are likely to
influence the performances of players but also
their quality of life negatively.
This chapter focuses on the symptoms of
CMD (self-reported and not clinically diagnosed)
that might occur during a career in professional
football. After its definition, the magnitude of the
symptoms of CMD among professional foot-
ballers is presented. Subsequently, the non-
specific and football-specific stressors that play a
role in the occurrence of symptoms of CMD are
V. Gouttebarge (*)
World Players’ Union (FIFPro),
Hoofddorp, The Netherlands
Academic Center for Evidence based Sports
Medicine (ACES), Academic Medical Center,
Amsterdam, The Netherlands
Department of Orthopaedic Surgery, Academic
Medical Center, University of Amsterdam,
Amsterdam Movement Sciences, Amsterdam,
The Netherlands
e-mail: v.gouttebarge@fifpro.org
G.M.M.J. Kerkhoffs
Academic Center for Evidence based Sports
Medicine (ACES), Academic Medical Center,
Amsterdam, The Netherlands
Department of Orthopaedic Surgery,
Academic Medical Center, University of
Amsterdam, Amsterdam Movement Sciences,
Amsterdam, The Netherlands
65
852
presented. Finally, a concise overview of the
symptoms of CMD that are most frequently
reported by players is given.
65.2 Definition of Symptoms
of Common Mental
Disorders
Someone suffers from symptoms of CMD when
he or she experiences adverse feelings or
thoughts or when he or she shows some abnor-
mal or maladaptive behaviour that impair his or
her activities either in daily life, work or sport
(Fact Box 1). Examples of symptoms of CMD
are related to distress, burnout, anxiety, depres-
sion or sleep disturbance. In contrast to symp-
toms of CMD that are self-reported, mental
disorders are clinically diagnosed and refer to
the combination of more severe symptoms. In
accordance with the standard classification of
mental disorders used by mental health profes-
sionals in the USA (Diagnostic and Statistical
Manual of Mental Disorders), mental disorders
are divided into different categories such as
depressive disorders (e.g. major depressive dis-
order), anxiety disorders (excessive fear and
anxiety and related behavioural disturbances),
sleep-wake disorders (e.g. insomnia disorder,
hypersomnolence disorder), substance-related
and addictive disorders (e.g. alcohol, caffeine,
cannabis) and feeding and eating disorders
(anorexia nervosa, bulimia nervosa) [1].
Symptoms of CMD are often comorbid (several
symptoms occurring simultaneously).
65.3 Prevalence and Incidence
of Symptoms of Common
Mental Disorders
in Professional Football
In recent years, several studies have been con-
ducted about the occurrence of symptoms of CMD
among professional footballers [27]. In 2013, a
preliminary study on symptoms of CMD was con-
ducted in a sample of 149 male professional foot-
ballers (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 the USA
[2]. In this cross-sectional study, the 4-week preva-
lence of symptoms of CMD was 10% for distress,
26% for anxiety/depression and 19% for adverse
alcohol use [2]. Subsequently to this preliminary
study, a 12-month prospective cohort study on
symptoms of CMD 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 symptoms of CMD were used as in the
preliminary study. The 4-week prevalence of
symptoms of CMD 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 symptoms of CMD
were quite similar across five European countries,
ranging from 6% in Sweden for adverse alcohol
use to 43% in Norway for anxiety/depression [4].
Based on the longitudinal data collected during the
12-month follow-up period (follow-up rate of
68%), incidence of symptoms of CMD among
professional footballers was 12% for distress, 37%
for anxiety/depression, 19% for sleep disturbance
and 14% for adverse alcohol use [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 disor-
der [7]. 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 [7].
Fact Box 1
Symptoms of common mental disorders
include feelings and thoughts of psycho-
logical disturbance—such as feelings and
thoughts of distress, anxiety, depression or
sleep disturbance—and describe a mental
and emotional state that affects signifi-
cantly the way of thinking, feeling and
behaving to such an extent that important
areas of life such as learning, living, work-
ing, exercising and socialising are impaired.
V. Gouttebarge and G.M.M.J. Kerkhoffs
853
In other professional sports, recent studies
found similar prevalence rates than those among
football players (Table 65.1). In 2015, a cross-
sectional study involving 224 Australian elite ath-
letes showed that 45% of them had experienced
symptoms of at least one mental health problem
such as anxiety, depression or distress in the previ-
ous few weeks [8]. In another recent study involv-
ing more than 2000 young and adult French
Olympics athletes, 17% of them reported having
encountered mental problems in the past [9].
Among 203 Dutch elite athletes, 4-week preva-
lence of symptoms of CMD ranged from 6% for
adverse alcohol use to 45% for anxiety/depression,
while 17% reported two simultaneous symptoms
of CMD [10]. Among 204 elite Gaelic athletes, a
prospective cohort study (2016) showed a 4-week
prevalence of symptoms of CMD reaching up to
48% for anxiety/depression, while around 24% and
16% reported two and three simultaneous symp-
toms of CMD, respectively [11]. In South African
professional cricket (N = 78), 4-week prevalence of
symptoms of CMD ranged from 26% for adverse
alcohol use to 38% for distress and anxiety/depres-
sion [12]. Among 990 (semi-)professional rugby
players, 4-week prevalence of symptoms of CMD
was 18% for distress, 30% for anxiety/depression,
13% for sleep disturbance, 23% for eating disor-
ders and 15% for adverse alcohol use [13].
65.4 Aetiology of Symptoms
of Common Mental
Disorders
The occurrence of symptoms of CMD is not
caused by a single stressor but is usually multi-
factorial. Among professional footballers, symp-
toms of CMD can occur as a consequence of the
interaction between psychosocial, sport-specific
and career-related stressors.
65.4.1 Psychosocial Stressors
As indicated in the biopsychosocial model
(Fig. 65.1), biological (genetic, biochemical,
etc.), psychological (mood, personality, behav-
iour, etc.) and social (cultural, familial, socioeco-
nomic, medical, etc.) stressors play a role in the
occurrence of symptoms of CMD (as well as
physical health problems) [14]. The biopsycho-
social model is a general framework arguing that
the complex and dynamic interaction between
Table 65.1 Prevalence of symptoms of common mental disorders among professional footballers and professional
athletes from other sport disciplines
Distress Anxiety/depression Sleep disturbance Adverse alcohol use
Footballers 10–15 26–38 23 9–19
Cricketers 38 37 38 26
Dutch athletes 27 45 22 6
Gaelic athletes 38 48 33 23
Handball 20 26 22 3
Ice hockey 9 17 9 6
Rugby players 17 30 13 15
Physical health problems Mental health problems
Long-lasting stress
Vulnerability
Life events
Family, friends, home, work,
school, cultural traditions...
Personality, perceptions,
beliefs, emotions, coping...
Genetic predisposition,
physiological reactions...
Social factorsPsychological factorsBiological factors
Fig. 65.1 Biopsychosocial
model
65 Mental Health in Professional Football Players
854
these three types of stressors determines the
course of health-related outcomes, and not one
type of stressors in isolation.
Especially, vulnerability due to potential pre-
disposition, combined with environmental stress-
ors or life events, can lead to symptoms of
CMD. Because of the exposure to many life
changes and related stressors between the 18th
and 25th year of someone’s life, symptoms of
CMD occur especially in young adulthood, with
some symptoms being clearly gender related
[15]. As any human being, professional foot-
ballers are likely to develop symptoms of CMD
as a consequence of potential biological, psycho-
logical and social stressors. In addition, profes-
sional footballers are also exposed during their
career to sport-specific stressors.
65.4.2 Sport-Specific Stressors
Recently, the scientific literature has shown that
professional footballers as well as competitive
athletes might be confronted during their career
(including transitioning out of sport) with up to
640 distinct stressors that could induce symp-
toms of CMD (Fact Box 2) [16].
These sport-specific stressors are divided into
four main categories: (1) leadership and person-
nel issues (adverse coach’s behaviour and atti-
tudes, conflict with coach, dealing with media
and spectators, governing bodies, etc.), (2) logis-
tical and environmental issues (poor travel and
accommodation arrangements, adverse weather
conditions, poor facilities and equipment, etc.),
(3) cultural and team issues (adverse teammates’
behaviour and attitudes, lack of support, poor
communication, etc.) and (4) performance and
personal issues (decreased performances, inju-
ries, etc.) [16].
Especially injuries that lead to a long layoff
period can be considered as a major stressor that
might induce symptoms of CMD. Cross-
sectional analyses within the aforementioned
12-month prospective cohort study showed that
the total number of severe time-loss (28 days or
more) injuries during a football career was posi-
tively correlated with distress, anxiety and sleep-
ing disturbance (Fact Box 3) [6]. These analyses
showed that professional footballers who had
sustained one or more severe time-loss injuries
during their career were 2–4 times more likely to
report symptoms of CMD than professional foot-
ballers who had not suffered from severe time-
loss injuries [6].
These sport-specific stressors, combined with
more traditional biological, psychological and
social stressors, form a complex dynamic to
Fact Box 3
The number of severe musculoskeletal
injuries during a football career is corre-
lated with distress, anxiety and sleeping
disturbance. Professional footballers who
have sustained one or more severe muscu-
loskeletal injuries (time-loss >4 weeks)
during their career are two to nearly four
times more likely to report symptoms of
common mental disorders than profes-
sional footballers who have not suffered
from severe musculoskeletal injuries.
Fact Box 2
Four main categories of sport-specific
stressors:
Leadership and personnel issues:
adverse coach’s behaviour and attitudes,
conflict with coach, dealing with media
and spectators, governing bodies, etc.
Logistical and environmental issues:
poor travel and accommodation arrange-
ments, adverse weather conditions, poor
facilities and equipment, etc.
Cultural and team issues: adverse team-
mates’ behaviour and attitudes, lack of
support, poor communication, etc.
Performance and personal issues:
decreased performances, injuries, etc.
V. Gouttebarge and G.M.M.J. Kerkhoffs
855
which professional footballers are exposed from
their young adulthood until the end of their
career. The interaction between all these stressors
can lead to symptoms of CMD among profes-
sional footballers but can also impair their devel-
opment as players [17].
65.4.3 Developmental Model
of Transitions
The developmental model of transitions
(Fig. 65.2) shows that the development of an ath-
lete (such as a professional footballer) can be
characterised by different developmental transi-
tions that occur on four levels [17]: (1) stages and
transitions related to sport development (for
instance from the years within the academy of a
football club to the transition out of competitive
football), (2) stages and transitions occurring at
psychological level (childhood, adolescence and
(young) adulthood), (3) stages and transitions
occurring in the athlete’s psychosocial develop-
ment relative to her or his sport involvement (ath-
lete family, peer relationships, coach-player
relationships, marital relationships and other
interpersonal relationships significant to players)
and (4) stages and transitions related to the aca-
demic and vocational level (primary education/
elementary school, secondary education/high
school, higher education (college/university),
vocational training and/or an professional
occupation).
To continue to develop and thus continue to
achieve the required level of performance, ath-
letes should be able to successfully cope with
these stages and transitions within and across
all four developmental levels. Inadequate cop-
ing, for example, when there is insufficient
social support within the athlete’s environment
or when an athlete does not concur with the
requirements of a first-year senior athlete
(being no longer the strongest, competing with
mature and experienced athletes), can lead to a
transitional crisis that might be associated with
symptoms of CMD. The developmental model
of transitions (Fig. 65.2) underlines not only
the interactive nature of transitions in different
domains of life of athletes but also that nonath-
letic transition may affect, aside their mental
health, the development of athletes’ sports
career.
Note: A dotted line indicates that the age at which the transition occurs is an approximation
Academic
vocational
level
Psycho-
social
level
Psycho-
logical
level
Athletic
level
Age 10 15 20 25 30 35
Primary
education
Parents
Siblings
peers
Childhood
Initiation
Secondary
education
Higher
education
Vocational training
Professional occupation
Peers
Coaches
Parents
Partner
Coach
Family
(Coach)
Adolescence Adulthood
Development Mastery Discontinuation
Fig. 65.2 The developmental model of transitions
65 Mental Health in Professional Football Players
856
65.5 Prevalent Mental Health
Problems in Professional
Football
The next sections present some basic information
(definition, symptoms and signs, assessment and
screening, treatment approach) about the symp-
toms of CMD being prevalent among profes-
sional footballers, namely, anxiety/depression
(prevalence up to 38%), sleep disturbance (preva-
lence up to 23%) and adverse alcohol use (preva-
lence of up to 19%) [1, 18]. These symptoms can
have some negative influence for the perfor-
mances of players but also for their return-to-play
process.
65.5.1 Depression
Depression is a common, but often serious, mood
disorder causing severe symptoms that affect
how you feel, think and handle activities of daily
life, work and/or sport. Depression is character-
ised by persistent and long-lasting symptoms
such as:
Low or sad moods, often with crying
episodes
Irritability and anger
Thinking negatively and feeling worthless,
helpless and hopeless
Appetite and sleeping disturbance
Decrease in energy and activity levels with
feelings of fatigue or tiredness
Decreases in concentration, interest and
motivation
Social withdrawal or avoidance
Unexplained aches and pains (increased in
physical complaints such as headaches, back
pain, aching muscles and stomach pain)
In severe cases: thoughts of death or suicide
To be diagnosed with depression, a person
must have experienced during more than 2
weeks a major depressive episode including a
combination of symptoms. To establish such a
diagnosis, information is collected through
medical history about the presence of symptoms
and the level of impairment (daily life, work
and/or sport). In addition, reproducible and
valid screening instruments can be used such as
Hospital Anxiety and Depression Scale (HADS),
General Health Questionnaire (GHQ) and
Profile of Mood States (POMS). While a short
depressive episode can resolve naturally, treat-
ment is warranted when the depression becomes
more severe, lasts longer, occurs more fre-
quently and impairs functioning significantly
(Fact Box 4).
65.5.2 Anxiety
Anxiety is a normal part of everyday life: every-
one is likely from time to time to experience
symptoms of anxiety, either in the cognitive (e.g.
worries), emotional (e.g. feelings of nervous-
ness), behavioural (e.g. pacing) or physiological
(e.g. muscle tension) domain. Anxiety is charac-
terised by feelings of abnormal, e.g. extreme fear,
panic and/or worry, that lead to sustainable irra-
tional or to impairment in social context.
Difference should be made between panic disor-
der, social anxiety disorder, generalised anxiety
disorders and phobias.
Being often comorbid with depression, anxi-
ety includes symptoms such as:
Feelings of panic, fear and uneasiness
Sleeping disturbance
Cold or sweaty hands or feet
Shortness of breath
Heart palpitations
Not being able to be still and calm
Dry mouth
Numbness or tingling in the hands or feet
Nausea
Muscle tension
Dizziness
Anxiety can be diagnosed using structured and
semi-structured interviews (Diagnostic Interview
Schedule, Anxiety Disorders Interview Schedule)
as well as with (behavioural) observations. In
addition, reproducible and valid screening instru-
ments can be used such as Symptom Checklist-90
V. Gouttebarge and G.M.M.J. Kerkhoffs
857
(SCL-90), Hospital Anxiety and Depression Scale
(HADS), General Health Questionnaire (GHQ)
and Profile of Mood States (POMS). Depending
on the type of anxiety disorder, several therapy
strategies can be applied (Fact Box 4).
65.5.3 Sleep Disturbance
Sleep disturbance includes complaints that affect
the ability to sleep well on a regular basis. While
occasionally experiencing difficulties to sleep is
normal, it is abnormal to regularly have problems
getting to sleep at night, to wake up feeling
exhausted or to feel sleepy during the day.
Insomnia might be the most known type of sleep
disturbance, being defined as having poor sleep
at least three times a week that may lead to daily
life impairments (e.g. fatigue, irritability,
decreased concentration). Depending on its
severity and type, sleep disturbance includes
symptoms such as:
Difficulty falling or staying asleep
Daytime fatigue
Strong urge to take naps during the day
Irritability or anxiety
Lack of concentration
Depression
Information collected through medical history
is generally sufficient to establish the diagnosis
of sleep disturbance. During the anamnesis, sev-
eral issues need to be addressed, among which
(1) nature, duration, course and frequency of the
symptoms, (2) impairments in daily living, (3)
potential causes, (4) sleep patterns (including
evening activities disturbing sleep) and (5) physi-
cal symptoms and disorders (pain, cough, dys-
pnoea, nasal congestion, night sweats,
palpitations). Physical examination is not often
necessary, only in case of the presence of physi-
cal symptoms and disorders. In addition to the
use of a sleep diary, reproducible and valid
screening instruments can be used such as Sleep
Disorders Questionnaire (SDQ), Epworth
Sleepiness Scale (ESS) and Holland Sleep
Disorders Questionnaire.
Depending on the type and underlying cause,
the treatment for sleep disturbance generally
includes a combination of medical treatments
and lifestyle adjustments. Medical treatments
might include sleeping pills, melatonin supple-
ments, medications for any underlying health
problems, breathing device and a dental guard.
Lifestyle adjustments aim at improving the qual-
ity of sleep, for instance, by reducing stress and
anxiety through exercising, having a regular
sleeping schedule, limiting the consumption of
caffeine, decreasing tobacco and alcohol use and
eating smaller meals before bedtime.
65.5.4 Adverse Alcohol Use
Adverse alcohol use and alcohol dependence are
characterised by either a persistent pattern of
inappropriate alcohol use or of adverse conse-
quences. While alcohol dependence is typically
considered to be synonymous with alcoholism,
adverse alcohol use can be defined as a recurring
pattern of high-risk drinking that results in
adverse outcomes such as personal problems (e.g.
memory and cognition, job, family and friends),
problems to others (e.g. injuries, violence) and
problems for society (e.g. underage drinking,
health care costs). Depending on the type and
amount of alcohol consumed and an individual’s
Fact Box 4
Treatment strategies for depression
(depending on duration and severity):
Self-management and education (with
minimal support) or counselling
Forms of physical activity such as walk-
ing, running, cycling or swimming
Evidence-based psychotherapy
approach such as cognitive behavioural
therapy, interpersonal therapy and
problem-solving therapy
e-Health interventions
Medication including especially (mod-
ern) antidepressants
65 Mental Health in Professional Football Players
858
personality, several (physical) signs might occur
as a consequence of adverse alcohol use, for
instance, decreased involvement and interest in
social activities, work or school, lack of interest
in family or friends, depression, restlessness,
erratic and violent behaviour and redness of the
face during or after periods of consumption.
Moderate drinking can be defined as consum-
ing (1) up to one drink (10 g of alcohol, which is
around 100 ml of wine) per day for women and
(2) up to two drinks per day for men. Excessive
(binge) drinking can be defined as consuming (1)
four or more drinks during a single occasion for
women and (2) five or more drinks during a sin-
gle occasion for men. Heavy drinking can be
defined as consuming (1) 8 or more drinks per
week for women and (2) 15 or more drinks per
week for men. Adverse alcohol use (and depen-
dence) can be screened with the following repro-
ducible and valid instruments: Michigan
Alcoholism Screening Test (MAST), Alcohol
Use Disorders Identification Test (AUDIT), Cut
down, Annoyed by criticism, Guilty about drink-
ing, Eye-opener (CAGE-test).
The first step of any treatment is to go through
detoxification, being the process of removing
alcohol from the body and eliminate any physical
dependency to the substance. Such a process is
associated with developing withdrawal symp-
toms such as nausea, trembling and sweating. In
addition to medication (such as benzodiazepines
or naltrexone), various interventions can be used
such as motivational interviewing, cognitive
behavioural therapy, teaching social skills and
self-control training.
65.6 Potential Influence
on Performances
and Return to Play
Symptoms of CMD reported by professional foot-
ballers are likely to influence negatively their per-
formances. Most of professional footballers believe
that symptoms of CMD influence football perfor-
mances negatively, while a large majority (65%)
mentioned that they had been impaired during their
own career because of symptoms of CMD. Because
of their nature and consequences, a logical assump-
tion is that symptoms of CMD are likely to inter-
fere within the return-to-play process, especially
with regard to the following aspects:
• Concentration and focus
• Coordination
• Power
• Emotion
• Reaction time
• Strength
• Endurance
Take-Home Message
Four-week prevalence of symptoms of com-
mon mental disorders among professional
footballers ranges from 9% for adverse alco-
hol use to 38% for anxiety/depression and
12-month incidence from 12% for distress to
37% for anxiety/depression.
Professional footballers who have sustained
one or more severe time-loss injuries during
their career are two to four to nearly four times
more likely to report symptoms of a mental dis-
order than professional footballers who have
not suffered from similar time-loss injuries.
Symptoms of common mental disorders are
likely to influence football performance nega-
tively and to interfere with return to play.
Top Five Evidence-Based References
Gouttebarge V, Aoki H, Kerkhoffs G (2015) Symptoms of
common mental disorders and adverse health behav-
iours in male professional soccer players. J Hum Kinet
49:277–286
Gouttebarge V, Backx F, Aoki H et al (2015) Symptoms
of common mental disorders in professional football
(soccer) across five European countries. J Sports Sci
Med 14:811–818
Gouttebarge V, Aoki H, Verhagen EA et al (2017) A
12-month prospective cohort study of symptoms of
common mental disorders among European profes-
sional footballers. Clin J Sport Med 27:487–492
Gouttebarge V, Aoki H, Ekstrand J et al (2016) Are
severe joint and muscle injuries related to symptoms
of common mental disorders among male European
professional footballers? Knee Surg Sports Traumatol
Arthrosc 24:3934–3942
Junge A, Eddermann-Demont N (2016) Prevalence
of depression and anxiety in top-level male
and female football players. BMJ Open Sport
Exerc Med 2:e000087. https://doi.org/10.1136/
bmjsem-2015-000087
V. Gouttebarge and G.M.M.J. Kerkhoffs
859
References
1. American Psychiatric Association (2013) Diagnostic
and statistical manual of mental disorders, Fifth Edition
(Dsm-5). American Psychiatric Publishing, Arlington
2. Gouttebarge V, Frings-Dresen MHW, Sluiter JK
(2015) Mental and psychosocial health among current
and former professional football players. Occup Med
65:190–196
3. Gouttebarge V, Aoki H, Kerkhoffs G (2015)
Symptoms of common mental disorders and adverse
health behaviours in male professional soccer players.
J Hum Kinet 49:277–286
4. Gouttebarge V, Backx F, Aoki H et al (2015)
Symptoms of common mental disorders in profes-
sional football (soccer) across five European coun-
tries. J Sports Sci Med 14:811–818
5. Gouttebarge V, Aoki H, Verhagen EA et al (2017) A
12-month prospective cohort study of symptoms of
common mental disorders among European profes-
sional footballers. Clin J Sport Med 27:487–492
6. Gouttebarge V, Aoki H, Ekstrand J et al (2016) Are
severe joint and muscle injuries related to symptoms
of common mental disorders among male European
professional footballers? Knee Surg Sports Traumatol
Arthrosc 24:3934–3942
7. Junge A, Eddermann-Demont N (2016) Prevalence
of depression and anxiety in top-level male
and female football players. BMJ Open Sport
Exerc Med 2:e000087. https://doi.org/10.1136/
bmjsem-2015-000087
8. Gulliver A, Griffiths KM, Mackinnon A et al (2015)
The mental health of Australian elite athletes. J Sci
Med Sport 18:255–261
9. Schaal K, Tafflet M, Nassif H et al (2011) Psychological
balance in high level athletes: gender-based differ-
ences and sport-specific patterns. PLoS One 6:e19007
10. Gouttebarge V, Jonkers R, Moen M et al (2017) The
prevalence and risk indicators of symptoms of com-
mon mental disorders among current and former
Dutch elite athletes. J Sports Sci 35(21):2148–2156.
https://doi.org/10.1080/02640414.2016.1258485
11. Gouttebarge V, Tol J, Kerkhoffs G (2016)
Epidemiology of symptoms of common mental disor-
ders among elite Gaelic athletes: a prospective cohort
study. Phys Sportsmed 44:283–289. https://doi.org/10
.1080/00913847.2016.1185385
12. Schuring N, Kerkhoffs, G, Gray J et al (2017) The
mental wellbeing of current and retired professional
cricketers: an observational prospective cohort
study. Phys Sportsmed, pp. 1–7. https://doi.org/
10.1080/00913847.2017.1386069
13. Gouttebarge V, opley P, Kerkhoffs G et al (2017)
Symptoms of common mental disorders in profes-
sional rugby: an international observational descrip-
tive study. Int J Sports Med 38:864–870
14. Engel GL (1977) The need for a new medical model:
a challenge for biomedicine. Science 196:129–136
15. Krueger RF, Caspi A, Moffit TE et al (1998) The
structure and stability of common mental disorders
(DSM-III-R): a longitudinal – epidemiological study.
J Abnorm Psychol 107:216–227
16. Arnold R, Fletcher D (2012) A research synthesis and
taxonomic classification of the organizational stress-
ors encountered by sport performers. J Sport Exerc
Psychol 34:397–429
17. Wylleman P, Reints A, De Knop P (2013) A devel-
opmental and holistic perspective on athletic career
development. In: Sotiaradou P, De Bosscher V
(eds) Managing high performance sport. Routledge,
New York
18. Barlow DH (2008) Clinical handbook of psychologi-
cal disorders. The Guilford Press, New York
65 Mental Health in Professional Football Players
... While the aforementioned transactional model (Lazarus & Folkman, 1984) offers an excellent description of the psychological mechanisms, which can lead to maladaptive coping and potentially result in the adaptational outcome depression (Folkman, Lazarus, Dunkel-Schetter et al., 1986;Lazarus & Folkman, 1984), scholars frequently adopt a broader perspective and hypothesize a multifactorial (i.e., biological, psychological, and social) cause for depression, described as the biopsychosocial perspective (e.g., Frank et al., 2015;Gouttebarge & Kerkhoffs, 2018;Reardon et al., 2019). Gouttebarge and Kerkhoffs (2018), for example, argue that the complex and dynamic interaction between these three types of factors, and not one factor in isolation, determines the course of mental health-related outcomes like depression. ...
... While the aforementioned transactional model (Lazarus & Folkman, 1984) offers an excellent description of the psychological mechanisms, which can lead to maladaptive coping and potentially result in the adaptational outcome depression (Folkman, Lazarus, Dunkel-Schetter et al., 1986;Lazarus & Folkman, 1984), scholars frequently adopt a broader perspective and hypothesize a multifactorial (i.e., biological, psychological, and social) cause for depression, described as the biopsychosocial perspective (e.g., Frank et al., 2015;Gouttebarge & Kerkhoffs, 2018;Reardon et al., 2019). Gouttebarge and Kerkhoffs (2018), for example, argue that the complex and dynamic interaction between these three types of factors, and not one factor in isolation, determines the course of mental health-related outcomes like depression. The biopsychosocial perspective was first introduced with the biopsychosocial model of health and disease (Engel, 1977). ...
Thesis
Depression is a common mental health disorder among competitive athletes that can have detrimental consequences including performance-decline, premature career-dropout, and even suicide. Athletes have been found to be as susceptible to depressive symptoms as non-athletes, and stress has repeatedly been linked to depression in the context of competitive sports. Based on the serious potential consequences of depression in competitive sports, the present dissertation explores depression and stress, and factors associated therewith, in German competitive athletes. An overview of the current body of literature reveals that existing prevalence studies on depression report a broad range of prevalence rates and inconsistent findings regarding the association between depressive symptomatology and demographic variables (e.g., age, level of sport performance). Several of the existing prevalence studies are further characterized by methodological limitations, such as small and unrepresentative sample sizes, and the disregard of the adolescent athlete population. With the intention of addressing the aforementioned limitations of, and research gaps in, prior studies, the aim of study I of this dissertation is the investigation of the prevalence of depressive symptoms in a comprehensive sample of German competitive athletes. A special focus is placed on the examination of the association between the demographic variables age, gender, and level of sport performance and the prevalence of depressive symptomatology. Study I reveals that of 1,799 German competitive athletes, 13.4% were screened positively for depression and 10.2% for impairments in psychological well-being. Adolescent age, female gender, and junior national team status were identified as risk factors for depressive symptoms. For the general population, empirical support for the relationship between depression, stress, and back pain is extensive. Despite the fact that back pain is a widespread issue in competitive sports with adverse performance and (mental) health outcomes for athletes, the relationship between the factor back pain and the psychosocial variables depression and stress has hardly received any scientific attention in competitive sports. To close this research gap, study II of this dissertation investigates the relationship between depression, stress, and back pain in German competitive athletes. Study II reveals that depression and stress are associated with back pain parameters in a population of 154 competitive athletes with back pain. In particular, stress could be linked to pain intensity and depression to pain-related disability. A multitude of empirical findings supports the assumption that adolescence is a sensitive period for the experience of stress and stress-related mental (e.g., depression) and physical (e.g., back pain) health outcomes. In order to transfer knowledge derived from empirical findings and theoretical frameworks to the applied work with competitive athletes, the aim of study III is to develop, implement, and evaluate a theory-based stress-prevention intervention for 92 adolescent soccer players through a randomized controlled trial. The intervention was evaluated on its effectiveness regarding stress, coping, and depression parameters and on its perceived usefulness according to the athletes. No intervention effects on stress, coping, and depression emerged. Notwithstanding, the athletes perceived the stress-prevention intervention to be useful, especially with regard to the improvement of their performance and well-being. This dissertation provides new insights into depression, stress, and factors associated therewith in competitive sports by means of basic research via cross-sectional designs (study I and study II) and a longitudinal preventive intervention study (study III). Considering the average prevalence rate across all three studies, every 10th German competitive athlete was screened positively for depressive symptoms. This observed prevalence rate of depressive symptoms in competitive athletes is akin to the prevalence rate detected in the general German population. This dissertation further indicates that adolescent athletes seem to be more vulnerable to depressive symptomatology than other age groups. Forthcoming studies should consider investigating the mechanisms of stress and stress-related conditions in competitive sports to improve the understanding of their etiology and to deduce effective preventive interventions for the context of competitive sports in general, and for the adolescent athlete population in particular.
... The occurrence of CMD symptoms are usually multifactorial and not caused by a single stressor (Gouttebarge and Kerkhoffs, 2018). This section will categorize the multiple stressors that adolescent academy footballers encounter. ...
... The current study also recognised multiple stressors interlinked and impacted a player's mental health and stated how a solitary stressor wasn't a factor. These findings agree with those obtained by Gouttebarge and Kerkhoffs (2018) who established that CMD's are not caused by a single stressor and are often multifactorial. ...
Thesis
Full-text available
Background Adolescents are experiencing increasing amounts of depression and anxiety disorders, especially for those involved in a competitive sporting environment (Wylleman, Alfermann and Lavallee, 2004). Adolescent athletes fall within an age range that Common Mental Disorders are deemed most prevalent (Gulliver et al., 2015) and due to the sporting environment, are exposed to multiple competitive mental health stressors (Reeves, Nicholls and McKenna, 2009). The aim of this study was to assess the various psychological stressors for adolescents within professional football academies and to determine what mental health frameworks are in place to support them. Design : A qualitative study using semi-structured interviews and exploratory email interviews was chosen. Four participants who worked within four different organisations involved in professional sport, in particular football, agreed to take part in the study. The participants' backgrounds were from sport psychology, player welfare and professional sport mental health charities. Results The findings revealed that contractual issues were a major stressor for middle to late adolescent athletes due to the anxiety of not gaining further employment as a professional footballer. Adequate coach and club staff mental health education and support networks were considered integral to provide an adolescent athlete with sufficient mental health support. Conclusions Further research is recommended to address the implications of contractual issues, its stress on middle to late adolescent athletes and explore frameworks to support athletes psychologically during this career stage.
... Furthermore, factors related to performance and health (e.g., psychomotor speed, sleep, heartrate variability) are closely monitored in players of soccer youth academies, exerting additional pressure on the young athletes (Heidari et al., 2019). Although the plethora of soccer-specific stressors and negative stress-related outcomes has been well documented (e.g., Gouttebarge & Kerkhoffs, 2018;Jensen et al., 2018;Junge & Feddermann-Demont, 2016), the importance of sport psychology services for youth academies is not always acknowledged by professional soccer clubs (Heidari et al., 2019;Nesti, 2010). Instead, knowledge about sport psychology is sometimes vague or even nonexistent, and skepticism in regard to sport psychology frequently prevails in the clubs (Johnson, Andersson, & Fallby, 2011). ...
Article
Adolescent soccer players experience many stressors and negative stress-related outcomes. Short-term stress-prevention programs are frequently implemented in youth sports, although there is limited evidence of their usefulness and effectiveness. Thus, the present study evaluated the usefulness and effectiveness of a stress-prevention workshop for adolescent soccer players. Ninety-two soccer players (age: M = 15.5 years, SD = 1.43; 31.5% female) were randomly allocated to either an intervention group or an intervention control group. To evaluate effectiveness, stress, coping, and depression were assessed at baseline (t1) and 4 weeks postworkshop (t2). To investigate usefulness, the perceived quality of results was assessed at t2. No intervention effects on stress, coping, and depression emerged, but both groups exhibited high values regarding perceived quality of results. Although one workshop might not be enough to modify stress-related parameters, it may be useful for adolescent soccer players and pave the way for long-term interventions.
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This study explored the influence of athletic identity and sports participation on the psychological well-being of athletes during a pandemic. The objective of the study was to understand the psychological impact of the coronavirus lockdown measure on athletes who were not able to carry out their normal daily routine. Athletes from nine different sports completed an online survey during the sixth week of the total lockdown in Nigeria. The online survey consists of an athletic identity scale and the Kessler Psychological Distress Scale (K10). Data collected were analyzed using Multiple regression and the Mann-Whitney test at 0.05 level of significance. The result of the findings revealed that category of sports (individual and team) (M = 0.73, β = −6.116) and athletic identity (M = 59.16, β = −0.166) predicts psychological distress to some degree. Few individual sports athletes and athletes with low athletic identity are prone to higher levels of psychological distress than team sports athletes and athletes with high athletic identity during the coronavirus pandemic lockdown. Individual sports athletes reported elevated levels of psychological distress compared to team sports athletes (z = −2.186, p = 0.03, r = 0.27). In conclusion, the results have confirmed that some athletes competing in individual sports experience elevated levels of psychological distress during the coronavirus pandemic, therefore they need the support of a sports psychologist during such periods to help in maintaining their psychological well-being.
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Objective: Scientific knowledge about symptoms of common mental disorders in professional cricket is non-existent. Consequently, the aims of the study were to determine the prevalence and the six-months incidence of symptoms of common mental disorders (CMD: distress, anxiety/depression, sleep disturbance, adverse alcohol use) among current and former professional cricketers and to explore the association of potential stressors (significant injury, surgery, adverse life events, career dissatisfaction) and CMD. Methods: An observational prospective cohort study with a follow-up period of six months was conducted among current and former professional cricketers from South Africa. Using validated questionnaires to assess symptoms of common mental disorders as well as several stressors, an electronic questionnaire was set up and distributed by the South African Cricketers Association (SACA). Results: A total of 116 participants enrolled at baseline (overall response rate of 33%) and 76 of those participants completed the 6-month follow-up (follow up rate of 66%). The prevalence of symptoms of CMD in current professional cricketers was 38% for distress, 38% for sleep disturbance, 37% for anxiety/depression and 26% for adverse alcohol use. Among former professional cricketers, baseline prevalence as was 26% for distress, 24% for anxiety/depression, 21% for sleep disturbance and 22% for adverse alcohol use. Career dissatisfaction led to an increased risk of distress, anxiety/depression and sleep disturbance in current professional cricketers. Surgeries and adverse life events led to an increase in reported symptoms of distress and anxiety/depression in current professional cricketers. Conclusions: It was concluded that symptoms of CMD are prevalent in both current and former professional cricketers and the association with surgery, adverse life events and cricket career dissatisfaction may provide some insight into possible mechanisms.
Article
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Objective: Scientific knowledge about symptoms of common mental disorders among elite Gaelic athletes is lacking. Consequently, this study aimed to (i) determine the prevalence, comorbidity and 6-month incidence of symptoms of common mental disorders (distress, anxiety/depression, sleep disturbance, adverse alcohol use) among elite Gaelic athletes and (ii) evaluate their association with potential stressors (severe musculoskeletal injuries, surgeries, recent life events, career dissatisfaction). Methods: An observational prospective cohort study by means of questionnaires was conducted over six months among elite Gaelic athletes (N=204). Using validated questionnaires to assess symptoms of common mental disorders as well as several stressors, an electronic questionnaire was set up and distributed by the Gaelic Players' Association. Results: Prevalence ranged from 23% for adverse alcohol use to 48% for anxiety/depression. Around 24% of the participants reported at baseline two symptoms. Six-month incidence ranged from 11% for sleep disturbance to 21% for anxiety/depression. Severe musculoskeletal injury, surgery, recent life events and career dissatisfaction led to an increased risk for common mental disorders. Conclusion: Our findings indicate that raising the self-awareness of all stakeholders in Gaelic sports about common mental disorders should be prioritized, as well as the evidence-based development and application of adequate preventive and supportive measures.
Article
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Background Scientific studies on the prevalence of mental health problems in elite athletes are rare, and most have had considerable methodological limitations, such as low response rate and heterogeneous samples. Aims To evaluate the prevalence of depression and anxiety in top-level football players in comparison to the general population, and to analyse potential risk factors. Methods Players of all first league (FL) and of four U-21 football teams in Switzerland were asked to answer a questionnaire on player's characteristics, the Centre of Epidemiologic Studies Depression Scale (CES-D) and the Generalized Anxiety Disorder (GAD-7) scale. Results All 10 women's FL teams, 9 of 10 men's FL teams and 4 male U-21 teams (n=471 football players) took part in the study. The CES-D score indicated a mild to moderate depression in 33 (7.6%) players and a major depression in 13 (3.0%) players. The GAD-7 score indicated an at least moderate anxiety disorder in 6 (1.4%) players. Compared to the general population, the prevalence of depression was similar and the prevalence of anxiety disorders was significantly (χ2=16.7; p<0.001) lower in football players. Significant differences were observed with regard to player characteristics, such as age, gender, player position, level of play and current injury. Conclusions Swiss FL football players had the same prevalence of depression as the general population, while male U-21 players had a higher prevalence of depression. It is important to raise awareness and knowledge of athletes’ mental health problems in coaches and team physicians, and to provide adequate treatment to athletes.
Article
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To present time, scientific knowledge about symptoms of common mental disorders and adverse health behaviours among professional soccer players is lacking. Consequently, the aim of the study was to determine the prevalence of symptoms of common mental disorders (distress, anxiety/depression, sleep disturbance) and adverse health behaviours (adverse alcohol behaviour, smoking, adverse nutrition behaviour) among professional soccer players, and to explore their associations with potential stressors (severe injury, surgery, life events and career dissatisfaction). Cross-sectional analyses were conducted on baseline questionnaires from an ongoing prospective cohort study among male professional players. Using validated questionnaires to assess symptoms of common mental disorders and adverse health behaviours as well as stressors, an electronic questionnaire was set up and distributed by players’ unions in 11 countries from three continents. Prevalence of symptoms of common mental disorders and adverse health behaviours among professional soccer players ranged from 4% for smoking and 9% for adverse alcohol behaviour to 38% for anxiety/depression and 58% for adverse nutrition behaviour. Significant associations were found for a higher number of severe injuries with distress, anxiety/depression, sleeping disturbance and adverse alcohol behaviour, an increased number of life events with distress, sleeping disturbance, adverse alcohol behaviour and smoking, as well as an elevated level of career dissatisfaction with distress, anxiety/depression and adverse nutrition behaviour. Statistically significant correlations (p
Article
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Evidence on the prevalence of symptoms related to distress, anxiety/depression or substance abuse/dependence, – typically referred to as symptoms of common mental disorders (CMD) – is lacking in European professional football (soccer). The aims of the present study were to investigate the prevalence of symptoms related to CMD (distress, anxiety/depression, sleeping disturbance, adverse alcohol behaviour, and adverse nutrition behaviour) in professional footballers from five European countries , and to explore associations of the outcome measures under study with life events and career dissatisfaction. A cross-sectional design was used. Questionnaires were distributed among professional footballers by the national players' unions in Finland, France, Norway, Spain and Sweden. The highest prevalence of symptoms related to common mental disorders were 18% for distress (Sweden), 43% for anxiety/depression (Norway), 33% for sleeping disturbance (Spain), 17% for adverse alcohol behaviour (Finland), and 74% for adverse nutrition behaviour (Norway). In Finland, France and Sweden, both life events and career dissatisfaction were associated with distress, anxiety/depression, adverse alcohol behaviour, and adverse nutrition behaviour. Results suggest the need for self-awareness in professional football about common mental disorders and a multidisciplinary approach by the medical team.
Article
The aim of the study was to determine the prevalence of symptoms of common mental disorders among professional rugby players across countries. A cross-sectional analysis of the baseline questionnaires from an ongoing prospective cohort study was conducted. Nine national players’ associations and three rugby unions distributed questionnaires based on validated scales for assessing symptoms of common mental disorders. Among the whole study sample (N=990; overall response rate of 28%), prevalence (4-week) of symptoms of common mental disorders ranged from 15% for adverse alcohol use to 30% for anxiety/depression. These findings support the prevalence rates of symptoms of common mental disorders found in previous studies among professional (i. e., elite) athletes across other sports, and suggestions can be made that the prevalence of symptoms of anxiety/depression seems slightly higher in professional rugby than in other general/occupational populations. Awareness of the prevalence of symptoms of common mental disorders should be improved in international rugby, and an interdisciplinary approach including psychological attention should be fostered in the medical care of professional rugby players. Adequate supportive measures to enhance awareness and psychological resilience would lead not only to improved health and quality of life among rugby players but arguably to enhanced performance in rugby.
Article
The aim of the study was to determine the prevalence and comorbidity of symptoms of common mental disorders (distress, anxiety/depression, sleep disturbance, eating disorders, adverse alcohol use) among current and former Dutch elite athletes, and to explore the inference between potential risk indicators (severe injury, surgery, life events, sport career dissatisfaction, social support) and the outcomes measures under investigation. Cross-sectional analyses were conducted on baseline questionnaires from an ongoing prospective cohort study among 203 current and 282 former elite Dutch athletes (response rate: 28% among current athletes and 95% among former athletes). Based on validated scales, an electronic questionnaire was set up and distributed. Prevalence (4-week) ranged from 6% for adverse alcohol use to 45% for anxiety/depression among current elite athletes, and from 18% for distress to 29% for anxiety/depression among former elite athletes. A higher number of past severe injuries, higher number of past surgeries, higher number of recent life events, higher level of career dissatisfaction and lower level of social support were related to the occurrence of symptoms of common mental disorders among both current and former elite athletes. On average, the 4-week prevalence of common mental disorders as shown in our study among current and former Dutch elite athletes were similar to the ones found among athletes from other sports disciplines and does compare with the lifetime prevalence estimates in the general population of the Netherlands.
Article
Objective: To determine the 12-month incidence and comorbidity of symptoms of common mental disorders (CMD) among European professional footballers and to explore the association of potential stressors with the health conditions under study among those European professional footballers. Design: Observational prospective cohort study with a follow-up period of 12 months. Participants: Male professional footballers from 5 European countries (n = 384 at baseline). Assessment of risk factors: Adverse life events, conflicts with trainer/coach, and career dissatisfaction were explored by using validated questionnaires. Main outcome measures: Symptoms of distress, anxiety/depression, sleep disturbance, and adverse alcohol use were assessed using validated questionnaires. Results: A total of 384 players (mean age of 27 years old; mean career duration of 8 years) were enrolled, of which 262 completed the follow-up period. The incidence of symptoms of CMD were 12% for distress, 37% for anxiety/depression, 19% for sleep disturbance, and 14% for adverse alcohol use. Over the follow-up period of 12 months, approximately 13% of the participants reported 2 symptoms, 5% three symptoms, and 3% four symptoms. Professional footballers reporting recent adverse life events, a conflict with trainer/coach, or career dissatisfaction were more likely to report symptoms of CMD, but statistically significant associations were not found. Conclusions: The 12-month incidence of symptoms of CMD among European professional footballers ranged from 12% for symptoms of distress to 37% for symptoms of anxiety/depression. A professional football team typically drawn from a squad of 25 players can expect symptoms of CMD to occur among at least 3 players in one season.