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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 [2–7]. 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.
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Gouttebarge V, Aoki H, Verhagen EA et al (2017) A
12-month prospective cohort study of symptoms of
common mental disorders among European profes-
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Gouttebarge V, Aoki H, Ekstrand J et al (2016) Are
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