Suicidal thoughts (ideation) among elite athletics (track and field) athletes: associations with sports participation, psychological resourcefulness and having been a victim of sexual and/or physical abuse

Abstract

Objective
To examine associations between suicidal ideation and sexual and physical abuse among active and recently retired elite athletics (track and field) athletes.

Methods
The study population consisted of all athletes (n=402) selected for a Swedish Athletics team between 2011 and 2017. Data on suicidal ideation, suicidal events (estimated through the 1 year non-sports injury prevalence), lifetime abuse experiences, sociodemographics, sense of coherence and coping strategies were collected using a cross-sectional survey. The data were analysed using binary logistic regression with suicidal ideation and non-sports injury as outcomes.

Results
192 athletes (47.8%) returned data. The prevalence of suicidal ideation was 15.6% (men 17.4%; women 14.2%) and the non-sports injury prevalence was 8.0% (men 11.6%; women 5.7%). Among women, suicidal ideation was associated with having been sexually abused (OR 5.94, 95% CI 1.42 to 24.90; p=0.015) and lower sense of coherence (OR 0.90, 95% CI 0.85 to 0.96; p=0.001) (Nagelkerke R ² =0.33). Among men, suicidal ideation was only associated with use of behavioural disengagement for coping (OR 1.51, 95% CI 1.18 to 1.95; p=0.001) ( R ² =0.25). Among women, non-sports injury prevalence was associated with having been sexually abused (OR 8.61, 95% CI 1.34 to 55.1; p=0.023) and participating in an endurance event (OR 7.37, 95% CI 1.11 to 48.9; p=0.039 ( R ² =0.23), while among men, having immigrant parents (OR 5.67, 95% CI 1.31 to 24.5; p=0.020) ( R ² =0.11) was associated with injury outside sports.

Conclusions
About one out of six international athletics athletes reported having experienced suicidal ideation. World Athletics and National Olympic Committees need to include suicide prevention in their athlete protection programmes.

Full text

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TimpkaT, etal. Br J Sports Med 2020;0:1–9. doi:10.1136/bjsports-2019-101386
Suicidal thoughts (ideation) among elite athletics
(track and field) athletes: associations with sports
participation, psychological resourcefulness and
having been a victim of sexual and/or physicalabuse
Toomas Timpka ,1,2,3 Armin Spreco,1,2,3 Orjan Dahlstrom ,1,4
Jenny Jacobsson ,1,2 Jan Kowalski,1,2 Victor Bargoria,1,2,5 Margo Mountjoy ,6
Carl Göran Svedin1,2,7
Original research
To cite: TimpkaT, SprecoA,
DahlstromO, etal.
Br J Sports Med Epub ahead
of print: [please include Day
Month Year]. doi:10.1136/
bjsports-2019-101386
►Additional material is
published online only. To view,
please visit the journal online
(http:// dx. doi. org/ 10. 1136/
bjsports- 2019- 101386).
1Athletics Research Center,
Linköping University, Linköping,
Sweden
2Department of Health,
Medicine, and Caring Sciences,
Linköping University, Linköping,
Sweden
3Unit for Health Analysis, Centre
for Healthcare Development,
Region Östergötland, Linköping,
Sweden
4Department of Behavioural
Sciences and Learning,
Linköping University, Linköping,
Sweden
5Department Orthopaedics and
Rehabilitation, Moi University,
Eldoret, Kenya
6Department of Family Medicine,
McMaster University, Hamilton,
Ontario, Canada
7Ersta Sköndal Bräcke University
College, Stockholm, Sweden
Correspondence to
Professor Toomas Timpka,
Health and Society, Linkoping
University, Linkoping 581 83,
Sweden; toomas. timpka@ liu. se
Accepted 10 February 2020
© Author(s) (or their
employer(s)) 2020. Re- use
permitted under CC BY- NC. No
commercial re- use. See rights
and permissions. Published
by BMJ.
ABSTRACT
Objective To examine associations between suicidal
ideation and sexual and physical abuse among active
and recently retired elite athletics (track and field)
athletes.
Methods The study population consisted of all
athletes (n=402) selected for a Swedish Athletics team
between 2011 and 2017. Data on suicidal ideation,
suicidal events (estimated through the 1 year non-
sports injury prevalence), lifetime abuse experiences,
sociodemographics, sense of coherence and coping
strategies were collected using a cross- sectional survey.
The data were analysed using binary logistic regression
with suicidal ideation and non- sports injury as outcomes.
Results 192 athletes (47.8%) returned data. The
prevalence of suicidal ideation was 15.6% (men 17.4%;
women 14.2%) and the non- sports injury prevalence
was 8.0% (men 11.6%; women 5.7%). Among women,
suicidal ideation was associated with having been
sexually abused (OR 5.94, 95% CI 1.42 to 24.90;
p=0.015) and lower sense of coherence (OR 0.90, 95%
CI 0.85 to 0.96; p=0.001) (Nagelkerke R2=0.33). Among
men, suicidal ideation was only associated with use of
behavioural disengagement for coping (OR 1.51, 95%
CI 1.18 to 1.95; p=0.001) (R2=0.25). Among women,
non- sports injury prevalence was associated with having
been sexually abused (OR 8.61, 95% CI 1.34 to 55.1;
p=0.023) and participating in an endurance event (OR
7.37, 95% CI 1.11 to 48.9; p=0.039 (R2=0.23), while
among men, having immigrant parents (OR 5.67, 95% CI
1.31 to 24.5; p=0.020) (R2=0.11) was associated with
injury outside sports.
Conclusions About one out of six international
athletics athletes reported having experienced suicidal
ideation. World Athletics and National Olympic
Committees need to include suicide prevention in their
athlete protection programmes.
INTRODUCTION
‘Suicide, drugs, darkness’1 has been used to describe
the aftermath of the sexual abuse scandal in the USA
Gymnastics, where the physician Larry Nassar for
at least 14 years abused hundreds of young female
athletes.2 In addition to being at risk of sexual (and
physical) abuse, athletes competing at the highest
level also have to manage multiple other pressures
affecting their mental health and these pressures
can be aggravated by injury or failure to meet
performance goals.3 4
This mental load can lead to suicide ideation
(thinking about, considering or planning suicide)
and even suicidal behaviour, for example, a
suicide attempt (a non- fatal, self- inflicted destruc-
tive act with the explicit or inferred intent to die)
(Box 1).5 6 The incidence of suicidal ideation and
suicidal behaviour peaks among adolescents and
young adults, with a global prevalence of lifetime
suicidal ideation between 12% and 33% and lifetime
suicidal behaviour between 4% and 9%.5 Suicidal
events denote the worsening of suicide ideation
into, for instance, a suicide attempt, an emergency
referral for ideation or suicidal behaviour.5 Emer-
gency room visits for injury are one example of
events indicating increased suicide risk.7
Globally, the overall suicide rate is estimated to
11/100 000 per year.5 For collegiate sports in the
USA, the suicide rate of 1/100 000 per year8–10
represents about 7% of all- cause mortality among
student athletes.9 Studies of suicidal ideation,
suicidal events and suicide in non- collegiate elite
athletes are scarce.10 The occupational category
identified with the highest women’s suicide rates
(16/100 000) in 2015 in the USA included profes-
sional athletes, while among men in this occupa-
tional category showed the largest increase (47%)
in suicide rates from 2012.11 Participation in
football, repeated concussions and chronic trau-
matic encephalopathy have been associated with
increased risk of suicide among male elite athletes
in the USA.10 12 There are few studies of suicidal
ideation among elite athletes,13 but having been
sexually and/or physically abused is a risk factor for
suicidal ideation in the general population.14 We
have previously reported correlates between having
been sexually and physically abused and injury risk
among female athletics (track and field) athletes.15
We aimed to explore the determinants of suicidal
ideation and suicidal events among elite athletics
athletes by investigating associations with lifetime
abuse victimisation, aspects of sports participation
and the athlete’s mental and behavioural resources.
The motivational- volitional theory of suicidal
behaviour16 was used for structuring the analysis.
This theory conceptualises suicide as a behaviour
that develops through a motivational phase that
comprises development of suicidal ideation and
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Original research
Box 1 Definitions
Suicidal ideation: thoughts about taking action to end one’s life,
including identifying a method, having a plan or having intent to
act.
Suicidal events: events suggesting the worsening of suicide
ideation to suicidal behaviour, eg, emergency room visits or
suicide attempts.
Suicide attempt: a potentially self- injurious behaviour associated
with at least some intent to die.
Suicide: a fatal self- injurious act with some evidence of intent to
die.
Figure 1 Conceptual model of suicidal ideation and risky behaviour developed from the motivational- volitional theory.16 The theory conceptualises
suicide as a behaviour that develops through a motivational phase where suicidal ideation and intent develop, and a volitional phase that determines
whether the ideation leads to suicidal events.
intent, and a volitional phase that determines whether the
ideation leads to suicidal events. We hypothesised that when indi-
vidual athletes encounter situations of defeat and entrapment,
the likelihood that suicidal ideation will emerge is increased
when negative motivational elements are present. Physical and
sexual abuse victimisation have been connected with negative
effects long after the abuse has stopped in long- term studies
outside of sport.17–19
METHODS
The study used a cross- sectional design. Suicidal ideation was
used as the primary outcome measure, while suicidal events were
used as a secondary outcome measure (figure 1). Recording of
suicidal events was limited to the 1- year period prevalence of
emergency room- treated non- sports injuries. The explanatory
variables were the athlete’s personal and sociodemographic char-
acteristics, athletics participation, lifetime experience of sexual
and/or physical abuse, sense of coherence and coping strategies.
The data were collected in January 2018 using an anonymous
web- questionnaire (BriteBack AB, Norrköping, Sweden). Two
reminders were sent to non- responders during a 2- week period.
Participants
The study population consisted of all Swedish international
athletics athletes who had participated in a national team
between 2011 and 2017 in the event categories sprints (60–400
metres), hurdles, throws, jumps, middle- distance and long-
distance running (800–42.125 metres), combined events and
race walks. Athlete listing was obtained from Swedish Athletics
for each event category.
Patient and public involvement
The study was supported by an advisory group consisting of
athletes and coaches representing Swedish Athletics. This advi-
sory group partnered with us for the design of the study and
construction of the survey questions. At the end of the study, the
advisory group commented on the findings and contributed to
the dissemination plan.
Definitions and data collection
A web questionnaire based on the theoretical model was devel-
oped. Initial data collected in the questionnaire were regarding
demographics and athletics background. Second, data on sexual
orientation, lifetime sexual and physical abuse victimisation
including perpetrators and suicidal ideation were gathered. The
point in time of the abuse was specifically determined. There-
after, data from two standardised scales, the Brief COPE and
Sense of Coherence instruments were collected. The concept of
sense of coherence (SOC) was put forward by Aaron Antonovsky
to explain why some people become ill under stress and others
stay healthy.20 The respondents were finally asked whether they
had suffered a significant non- sports injury (cut, contusion,
concussion, etc) during the past year (1 year injury prevalence)
that required emergency room treatment.
Suicidal ideation was defined as lifetime thoughts about
committing suicide. Suicidal events indicating progress to the
volatile phase of suicidal behaviour16 were recorded using non-
sports injury as proxy measure. A non- sports injury was defined
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Table 1 Principal Component Analysis of Brief COPE items
Brief COPE items
Brief COPE components
1
r
2
r
3
r
4
r
Component
categorisation
1. Active coping 0.58 0.39 1
2. Planning 0.60 0.32 0.42 1
3. Positive reframing 0.64 3
4. Acceptance 0.43 0.50 3
5. Humour 0.74 3
6. Religion 0.84 4
7. Using emotional support 0.87 1
8. Using instrumental support 0.89 1
9. Self- distraction 0.54 3
10. Denial 0.56 2
11. Venting 0.58 2
12. Substance use 0.66 2
13. Behavioural disengagement 0.76 2
Rotated component matrix (Pearson’s correlations r>0.30 are displayed) (n=192).
*Brief COPE components: component 1 (exploiting support to take action) includes
items 1, 2, 7, 8; component 2 (behavioural disengagement) includes items 10, 11,
12, 13; component 3 (humour and positive reframing) includes items 3, 4, 5, 9;
component 4 (turning to religion) includes items 6. Item 14 (Brief COPE) was not
included in any component, but used separately, based on empirical groundings.
as a physical injury sustained outside sports requiring treatment
at an emergency medical facility.
Sexual abuse was defined as any sexual interaction involving
physical contact with person(s) of any age that was perpetrated
against the victim’s will, without consent or in an aggressive,
exploitative, manipulative or threatening manner. Precisely, the
variable used to collect data on sexual abuse was derived from
the statement and questions originally developed by Mossige21
and used in earlier Swedish studies22 23: “Sometimes people are
persuaded, pressed, or forced to do sexual activities they cannot
protect themselves from. The following questions are about such
situations. Have you been exposed to any of the following against
your will?” (it is possible to choose several alternatives): (a) “Some-
body exposed himself or herself indecently toward you, (b) Some-
body has pawed (touched your body in an indecent way) you, (c)
You masturbated somebody else, (d) You have had sexual inter-
course, (e) You have had oral sex, and (f) You have had anal sex”.
Physical abuse was defined as being deliberately hurt by an
adult person causing injuries such as bruises, broken bones, burns
or cuts.24 The questionnaire asked whether it had happened
that an adult had done any of the following to the athlete: “(a)
Pushed, shoved or shook you up, (b) Thrown something at you,
(c) Hurt you with her/his hands, (d) Kicked, bit or hit you with
her/his fists, (e) Hurt you with a weapon, (f) Burned or scalded
you, (g) Tried to smother you (took stranglehold) and (h) Phys-
ically attacked you otherwise”. Bullying was defined as being
deliberately verbally or physically hurt as a child or adolescent
by another child or adolescent. The survey asked whether it
had happened that a child or adolescent had done any of the
following to the athlete: “(a) repeated abused you verbally, (b)
Pushed, shoved or shook you up, (c) Thrown something at you,
(d) Hurt you with her/his hands, (e) Kicked, bit or hit you with
her/his fists, (f) Hurt you with a weapon, (g) Burned or scalded
you, (h) Tried to smother you (took stranglehold) and (i) Physi-
cally attacked you otherwise”.
The athlete’s mental and behavioural resources were measured
by estimating their sense of coherence and personal coping strat-
egies. The SOC-13 instrument was used to measure the athletes’
sense of coherence.25 A person’s sense of coherence is built on
the components of comprehensibility, manageability and mean-
ingfulness and is expected to reflect a person’s ability to handle
stressful life situations.26 This instrument consists of 13 ques-
tions estimated on a 7- grade scale from 1 (very seldom or never)
to 7 (very often). High scores indicate a high sense of coherence.
The Brief COPE instrument was used to measure the athletes’
coping strategies (ie, practices used to manage life chal-
lenges).27 28 The Brief COPE instrument cover two concepts,
adaptive or maladaptive coping strategies. Adaptive strategies
cover items for active coping, emotional support, instrumental
support, positive reframing, planning, mood, acceptance and
religion while maladaptive strategies are covered by the items
self- distraction, denial, substance, behavioural disengagement,
venting and self- blame. Each item is scored on a 4- point Likert
scale from 1 (I have not been doing this at all) to 4 (I have been
doing this a lot).
Data analysis
The SOC-13 data were compiled into a total summary score
ranging from 13 to 91. The items included in the Brief COPE
instrument, except self- blame, were analysed using Principal
Component Analysis (PCA), where items were combined into
four components (behavioural disengagement, exploiting
support to take action, humour and positive reframing and
turning to religion) that thereafter were investigated separately.
The item self- blame was retained in its original form (table 1).
To explore possible dependencies between the explanatory vari-
ables, correlations (Pearson’s r) between SOC-13 scores, Brief
COPE component scores and age were investigated. T- tests were
used to analyse differences in SOC-13 scores with regard to sex
and between abuse victims and non- victims.
For the analyses of determinants of suicidal ideation and non-
sports injury, the data collected for the variables characterising
the athlete were recoded into binary format: lifetime sexual
abuse victimisation involving physical contact (yes/no), lifetime
physical abuse victimisation (yes/no), both parents (each of them)
≤12 years formal education (yes/no), at least one parent immi-
grant (yes/no), family perceived by athlete as financially disad-
vantaged (yes/no), age >13 years when commencing training
athletics (yes/no), training load >20 hours/week (yes/no) and
sports injury (yes/no). Athletics events were recoded into speed/
power (sprints, hurdles, throws, jumps, combined events) and
endurance events (middle- distance and long- distance running,
race walking). We first performed analyses with simple models
(logistic regression analyses with one explanatory variable)
and thereafter analyses with multiple models (logistic regres-
sion analyses with several explanatory variables) using suicidal
ideation (yes/no) and non- sports injury (yes/no) as outcomes.
The explanatory variables were abuse types (sexual/physical/
bullying), the Brief COPE components, SOC-13 and the binary
athlete characteristic variables. The multiple models were fitted
using backward elimination of non- significant variables (ie, vari-
ables with p≥0.05 were stepwise eliminated). Nagelkerke R2
was obtained for all multiple models to estimate their account-
ability levels.29 The Statistical Package for the Social Sciences for
Windows V.25.0 was used for the analyses. All statistical tests
were two- sided and outcomes with p<0.05 were considered to
be statistically significant.
RESULTS
Of 402 eligible athletes, 192 (47.8%) returned complete data
sets. Twenty- eight per cent of the respondents had retired from
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Table 2 Description of study sample (n=192)
At- peak and postpeak athletes (January 2018) from the Swedish Athletics team 2011–17.
Male athletes (n=86) Female athletes (n=106) All athletes (n=192)
Personal characteristics
Age, mean (SD) 29.1 (6.9) 28.8 (6.6) 28.9 (6.7)
Sexual orientation—homosexual/bisexual, n (%) 0 (0.0) 7 (6.6) 7 (3.6)
Childhood
Financially disadvantaged (athlete self- report), n (%) 17 (19.8) 16 (15.1) 33 (17.2)
Parents <12 years formal education, n (%) 20 (23.3) 28 (26.4) 48 (25.0)
Parents immigrants (at least one parent), n (%) 12 (14.0) 4 (3.8) 16 (8.3)
Athletics
Commencing >12 years of age, n (%) 28 (32.6) 32 (30.2) 60 (31.3)
Endurance athlete (middle- distance/long- distance running), n (%) 35 (40.7) 31 (29.2) 66 (34.4)
Speed/power athlete (jump, throw, sprints, combined), n (%) 51 (59.3) 75 (70.8) 126 (65.6)
At- peak athlete, n (%) 71 (82.6) 67 (63.2) 138 (71.9)
Training load >14 hours/week, n (%) 45 (52.3) 41 (38.7) 86 (44.8)
Athletics injury previous year, n (%) 43 (50.0) 45 (42.5) 88 (45.8)
Suicidal ideation and non- sport injury
Lifetime suicidal ideation, n (%) 15 (17.4) 15 (14.2) 30 (15.6)
Hospital- treated injury previous year, n (%) 10 (11.6) 6 (5.7) 16 (8.3)
Abuse victimisation
Sexual abuse, n (%) 4 (4.7) 16 (15.1) 20 (10.4)
Sexual abuse in athletics, n (%) 1 (1.2) 4 (3.8) 5 (2.6)
Physical abuse, n (%) 12 (14.0) 9 (8.5) 21 (10.9)
Bullying, n (%) 54 (62.8) 36 (34.0) 90 (46.9)
Sense of coherence
SOC-13 (score 13–91), mean (SD) 68.3 (11.1) 65.8 (11.7) 67.0 (11.5)
Coping strategies (Brief COPE)
Self- blame (score 0–6), mean score (SD) 3.2 (1.5) 3.4 (1.6) 3.3 (1.6)
‘Exploiting support to take action’* (score 0–24), mean score (SD) 15.6 (4.5) 16.5 (4.0) 16.1 (4.3)
‘Behavioural disengagement’† (score 0–24), mean score (SD) 3.0 (2.5) 3.9 (2.7) 3.5 (2.7)
‘Humour and positive reframing’‡ (score 0–24), mean score (SD) 12.3 (3.8) 12.4 (3.6) 12.4 (3.7)
‘Turning to religion’§ (score 0–6), mean score (SD) 0.5 (1.3) 0.5 (1.2) 0.5 (1.2)
*Includes items active coping, planning, using emotional support, using instrumental support.
†Includes items denial, venting, substance use, behavioural disengagement.
‡Includes items positive reframing, acceptance, humour, self- distraction.
§Includes item religion.
participation in elite sport at the time of the study. The propor-
tion of responders was similar among women (51.8%) and
men (48.2%) and between active (45.5%) and retired (54.5%)
athletes. The mean age of the respondents was 28.9 years (SD
6.7 years); males 29.1 years (SD 6.9 years) and females 28.8
years (SD 6.6 years) (table 2). Ninety- six per cent of the athletes
reported their sexual orientation as heterosexual. A majority
of athletes stated that during their childhood and adolescence
they had been living in families with stable finances (82.8%) and
at least one parent/custodian having had >12 years of formal
education (75.0%).
Lifetime suicidal ideation and non-sports injury prevalence
The prevalence of suicidal ideation among the participating
athletes was 15.6% (men 17.4%; women 14.2%) (table 2). Eight
per cent of the athletes (men 11.6%; women 5.7%) reported
having sustained a non- sports related injury in the previous year
that required emergency medical care.
Being subjected to sexual and physical abuse
Twenty (10.4%) of the participating athletes reported having
sustained sexual abuse (table 2), 15.1% among women and 4.7%
among men. Five athletes (2.6%) reported sexual abuse in the
athletics setting. The perpetrators of sexual abuse in athletics
were all male and were coaches, other adults and other athletes;
10.9% of participants had suffered physical abuse at some point
in their life (14.0% of men, 8.5% of women). The perpetrators
of physical abuse were predominantly parents/custodians; three
athletes reported having been physically abused by a coach. All
abuse episodes had occurred more than 1 year before the data
collection.
Relationship among related determinants (eg, coping, abuse,
etc)
The athletes’ sense of coherence did not differ by sex in unad-
justed analyses (SOC-13 mean scores 65.8 for females and 68.3
for males; p=0.130), but there was a small correlation between
the sense of coherence and age in both females (r=0.22;
p=0.040) and males (r=0.23; p=0.020). Sense of coherence
did not differ with regard to sexual abuse victimisation in
female (SOC-13 mean scores 65.1 for victimised and 66.0 for
non- victimised) or male athletes (SOC-13 mean scores 67.0 for
victimised and 68.4 non- victimised). Regarding physical abuse
victimisation, the sense of coherence was slightly lower among
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Original research
victimised than among non- victimised female athletes (SOC-13
mean scores 58.0 for non- victimised and 66.5 for victimised;
p=0.036), but not among male athletes (SOC-13 mean scores
69.0 for victimised and 68.4 for non- victimised).
Among female athletes, the sense of coherence displayed a
strong negative correlation (r=–0.52; p<0.001) with the Brief
COPE component ‘behavioural disengagement’ and a moderate
negative correlation (r=–0.36; p<0.001) with the item ‘self-
blame’ (online supplementary table 1). No statistically signifi-
cant correlations were observed with the remaining Brief COPE
components. Among male athletes, only a moderate negative
correlation (r=–0.44; p<0.001) between the sense of coherence
and the Brief COPE component ‘behavioural disengagement’
was observed.
Suicidal ideation models
The simple model analyses showed among female athletes that
lifetime suicidal ideation was associated with sexual abuse victi-
misation (OR 4.85, 95% CI 1.45 to 16.3; p=0.011), lower
sense of coherence (OR 0.90, 95% CI 0.85 to 0.96; p<0.001), a
financially disadvantaged childhood (OR 5.40, 95% CI 1.59 to
18.4; p=0.007) or using self- blame (OR 1.84, 95% CI 1.19 to
2.82; p=0.006) and behavioural disengagement (OR 1.26, 95%
CI 1.06 to 1.51; p=0.011) for coping (table 3). Among male
respondents, athletes reporting suicidal ideation showed a lower
sense of coherence (OR 0.92, 95% CI 0.87 to 0.97; p=0.004)
or used behavioural disengagement as coping strategy (OR 1.51,
CI 1.18 to 1.95; p=0.001).
In the multiple model for female athletes, suicidal ideation was
associated only with sexual abuse victimisation (OR 5.94, 95%
CI 1.42 to 24.9; p=0.015) and a lower sense of coherence (OR
0.90, 95% CI 0.85 to 0.96; p=0.001) (Nagelkerke R2=0.33),
while suicidal ideation among male athletes was only associated
with the use of behavioural disengagement for coping (OR 1.51,
95% CI 1.18 to 1.95; p=0.001) (Nagelkerke R2=0.25).
Suicidal event models
With regard to the secondary outcome measure the simple
model analyses showed that among female athletes, the 1- year
non- sports injury prevalence was associated only with sexual
abuse victimisation (OR 6.14, 95% CI 1.13 to 33.5; p=0.036),
while among male athletes, the 1- year non- sports injury preva-
lence was associated only with having immigrant parents (OR
5.67, 95% CI 1.31 to 24.5; p=0.020) (table 4).
Among female athletes, the 1- year non- sports injury preva-
lence was associated with sexual abuse victimisation (OR 8.61,
95% CI 1.34 to 55.1; p=0.023) and having competed in an
endurance event (OR 7.37, 95% CI 1.11 to 48.9; p=0.039)
(Nagelkerke R2=0.23). The multiple model for male athletes
was represented by a simple model, since only having immigrant
parents (OR 5.67, 95% CI 1.31 to 24.5; p=0.020) was included
(Nagelkerke R2=0.11).
DISCUSSION
We report a 15.6% lifetime prevalence of suicidal ideation
among Swedish athletics athletes competing at the international
level. This compares with a 13.9% lifetime prevalence reported
from Army servicemen,30 but is lower than the 32.7% lifetime
prevalence recently observed among college students.31 Sports-
related factors such as sports injuries and retirement from elite
level competitions did not correlate with suicidal ideation.
Determinants of suicidal ideation and suicidal events
Among female participants, having been sexual abused and
perceiving daily life as less comprehensible, manageable and
meaningful were the strongest determinants of both suicidal
ideation and suicidal events. Among male participants, the main
determinant for suicidal ideation was using an avoidant strategy
for coping with life challenges, and for suicidal events, having
immigrant parents. However, the accountability level for the
latter model among male athletes was low (Nagelkerke R2=0.11).
The single aspect of sport participation found to be relevant
was an increased likelihood of suicidal events in female athletes
participating in an endurance event. These findings correspond
with present aetiological theories of suicide, which typically
suggest that negative consequences of pre- existing vulnerability
factors are pronounced when challenged by stress.16 32 33
Sexual abuse history
A history of sexual abuse was thus a central determinant of
suicidal ideation and suicidal events among the female athletes.
The prevalence (15.1%) corresponds to previous reports from
research among competitive athletes.15 34 Several large studies in
the general population have documented associations between
sexual abuse and the subsequent experience of suicidal ideation
and suicidal events.35 36 However, these associations have also
been found to diminish with age.36 In this study, we observed a
correlation between the psychological resource sense of coher-
ence and increasing age, and an inverse correlation between
sense of coherence and avoidant coping strategies. These find-
ings indicate that although there exists intrusive and distressing
traumatic memories from previous sexual abuse, the athlete’s
capacity to manage this experience may improve with increasing
age. This finding also implies that negative consequences of
abuse may even be more prevalent in younger elite athletes than
in the sample of experienced elite athletes (mean age 28.9 years)
in this study.
Use of avoidant coping strategies
Among the male athletes in this study, the only determinant for
suicidal ideation was the use of an avoidant coping strategy, that
is, behavioural disengagement involving denial, venting and
substance use. Sexual abuse was not a risk factor among males,
possibly due to the relatively low life- time prevalence (4.7%)
compared with females (15.1%). Coping with life challenges
may be achieved by directly solving the problem or avoiding the
concern without reaching a solution.37 According to the notions
of affect regulation,16 38 the use of avoidant or maladaptive
coping strategies to handle stressful life situations increases the
probability of experiencing feelings of entrapment (no escape,
no rescue) and, subsequently, of suicidal ideation. The fact
that individuals who contemplate suicide have difficulties with
problem solving and coping is not surprising, and studies in non-
sports settings have consistently shown a link between suicidal
behaviour and deficits in these abilities.39 40
Implications for suicide prevention
We found that about one out of six elite athletes had experi-
ences of suicidal ideation. Conversion to suicide attempts was
not included in the present study, but a meta- analysis of studies
among college students estimated that about one- half (53.4%)
of lifetime ideators transition to a suicide plan and 22.1% of
lifetime planners transition to an attempt, while attempts among
lifetime ideators without plan are less frequent (3.1%).31 No
suicides among Swedish elite athletics athletes were publicly
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6TimpkaT, etal. Br J Sports Med 2020;0:1–9. doi:10.1136/bjsports-2019-101386
Original research
Table 3 Determinants associated with suicidal ideation among athletes (n=192) having participated in the Swedish Athletics team 2011–17 (ORs (95% CI) established by binary logistic regression
analyses)
Male athletes (n=86) Female athletes (n=106) All athletes (n=192)
Simple models
Multiple model
Nagelkerke R2=0.25 Simple models
Multiple model
Nagelkerke R2=0.33 Simple models
Multiple model
Nagelkerke R2=0.25
Personal characteristics
Financially disadvantaged childhood n.s. 5.40 (1.59 to 18.4) (p=0.007) 2.46 (1.01 to 6.02) (p=0.048)
Parents immigrants n.s. n.s. n.s.
Endurance athlete n.s.* n.s. n.s.
At- peak athlete n.s. n.s. n.s.
Training load n.s. n.s. n.s.
Abuse victimisation
Sexual abuse n.s. 4.85 (1.45 to 16.3) (p=0.011) 5.94 (1.42 to 24.9) (p=0.015) 3.22 (1.17 to 8.82) (p=0.023)
Physical abuse n.s. n.s. n.s.†
Bullying n.s. n.s.‡ 2.63 (1.16 to 5.97) (p=0.021)
Athletics
Athletics injury previous year n.s. n.s. n.s§
Sense of coherence
SOC-13 0.92 (0.87 to 0.97) (p=0.004) 0.90 (0.85 to 0.96) (p<0.001) 0.90 (0.85 to 0.96) (p=0.001) 0.91 (0.88 to 0.95) (p<0.001) 0.92 (0.88 to 0.96) (p<0.001)
Coping strategies (Brief COPE)
Self- blame n.s.¶ 1.84 (1.19 to 2.82) (p=0.006) 1.60 (1.21 to 2.11) (p=0.001) 1.40 (1.05 to 1.87) (p=0.023)
‘Exploiting support to take action’ n.s. n.s. n.s.
‘Behavioural disengagement’ 1.51 (1.18 to 1.95) (p=0.001) 1.51 (1.18 to 1.95) (p=0.001) 1.26 (1.06 to 1.51) (p=0.011) 1.33 (1.16 to 1.52) (p<0.001)
‘Humour and positive reframing’ n.s. n.s. n.s.
‘Turning to religion’ n.s. n.s. n.s.
*(0.30 (0.08 to 1.17) (p=0.084).
†(2.45 (0.87 to 6.93) (p=0.091).
‡(2.57 (0.85 to 7.79) (p=0.095).
§(1.97 (0.89 to 4.36) (p=0.094).
¶(1.46 (1.00 to 2.13) (p=0.051).
n.s, not significant at 5% level.
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Original research
Table 4 Determinants associated with having suffered a non- sports injury previous year among athletes (n=192) having participated in the
Swedish Athletics team 2011–17 (ORs (95% CI) established by binary logistic regression analysis)
Male athletes (n=86) Female athletes (n=106) All athletes (n=192)
Simple models
Multiple model
Nagelkerke R2=0.11 Simple models
Multiple model
Nagelkerke R2=0.23 Simple models
Multiple model
Nagelkerke R2=0.05
Personal characteristics
Financially disadvantaged childhood n.s. n.s. n.s.
Parents immigrants 5.67 (1.31 to 24.5)
(p=0.020)
5.67 (1.31 to 24.5)
(p=0.020)
NA NA 4.56 (1.27 to 16.3)
(p=0.020)
4.56 (1.27 to 16.3)
(p=0.020)
Endurance athlete n.s. n.s.* 7.37 (1.11 to 48.9)
(p=0.039)
n.s.
At- peak athlete n.s. n.s. n.s.
Training load n.s. n.s. n.s.
Abuse victimisation
Sexual abuse NA NA 6.14 (1.13 to 33.5)
(p=0.036)
8.61 (1.34 to 55.1)
(p=0.023)
n.s.
Physical abuse n.s. n.s. n.s.†
Bullying n.s.‡ n.s. n.s.§
Sense of coherence
SOC-13 n.s. n.s. n.s.
Coping strategies (Brief COPE)
Self- blame n.s. n.s. n.s.
‘Exploiting support to take action’ n.s. n.s. n.s.
‘Behavioural disengagement’ n.s. n.s. n.s.
‘Humour and positive reframing’ n.s. n.s.
‘Turning to religion’ n.s. n.s. n.s.
*(5.41 (0.94 to 31.2) (p=0.059).
†(3.12 (0.91 to 10.7) (p=0.072).
‡(2.70 (0.90 to 8.10) (p=0.076).
§(6.20 (0.75 to 51.5) (p=0.091).
NA, not available; n.s, not significant at 5% level.
reported during the time period for the study (2011–17), but
such events were reported from other sports, for example,
ice hockey.41 Internationally, several suicides among athletes
competing at the highest level have been reported during recent
years, for example, from figure skating in association with
sexual abuse accusations.42 Practical implications of our results
are that suicide prevention strategies43 among female athletics
athletes should include targeting sexual abuse victimisation and
strengthening the athletes’ personal psychological resources,
while among male athletes the corresponding interventions
should comprise coping strategies and problem solving skills.
Female athletes with a sexual abuse history should be provided
an opportunity to discuss what they have experienced, and indi-
vidual care plans should be developed.44 At the societal level,
efforts should be made to detect sexual abuse early and sports
federations should formulate action plans for suicide prevention.
In parallel, sports clinicians must increase their general attention
on improving the mental health of athletes.45
Study strengths and weaknesses
This is the first study to address the topic of suicidal ideation in
sport with a specific paucity of research on correlates to suicidal
ideation and suicidal events in elite athletes. It was designed
as a cross- sectional analysis using best- practice procedures
adjusted for the research topic. All multiple models of determi-
nants displayed satisfactory accountability levels (Nagelkerke R2
>0.20), except for non- sports injury among males. An important
limitation of the study is that >90% of the participating athletes
were living with a Swedish lifestyle, social background and bene-
fiting from national education and health systems. The results
obtained cannot therefore be immediately generalised to the
international population of elite athletics athletes. Also, use of
hospital- treated non- sports injuries as proxy for suicidal events
has limitations, due to the fact that not all hospital- treated injuries
are associated with suicidal events, that is, no- fault car accidents.
Moreover, the population was relatively small (n=404) and the
participation was 49%. Even though no difference in participa-
tion was observed with regard to sex or current international-
level competition status, the possibility of bias cannot be ruled
out. Finally, not all relevant determinants of suicidal ideation
were included in the study, for example, previous episodes of
clinically treated psychiatric disorders and the athlete’s ethnicity
were not assessed.
CONCLUSION
Among elite athletics athletes, sexual abuse victimisation
combined with a low sense of coherence were the main deter-
minants of suicidal ideation and suicidal events among female
athletes, while among male athletes, suicidal ideation was
primarily associated with avoidant strategies for coping with
stressful life events. Sports injury history and retirement from
international competitions were not identified as determinants.
In other words, mental harm resulting from abuse and the
athletes’ psychological resources and behavioural traits, respec-
tively, appeared to be the leading influences on susceptibility for
suicidal thoughts and actions. Given that about one out of six
athletes had experienced suicidal ideation, these results should
be used to plan how to prevent suicidal ideation, suicide attempts
and suicide for top- level athletes in the sport of athletics.
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8TimpkaT, etal. Br J Sports Med 2020;0:1–9. doi:10.1136/bjsports-2019-101386
Original research
What are the findings?
►The prevalence of suicidal ideation among elite athletics
athletes appears similar to that in general populations of
young adults.
►Having been victims of sexual abuse combined with having
decreased psychological resources to deal with life stress
(low sense of coherence) predicted suicidal ideation in female
elite athletics athletes.
►Among male elite athletes, suicidal ideation was associated
with use of avoidant strategies for coping with challenging
life events, for example, substance use and denial.
How might it impact on clinical practice in the future?
►Sport medicine clinicians should be aware of determinants
for suicidal ideation among athletes—women who have a
history of having been sexually abused and who have signs
of psychological vulnerability and men who display avoidant
coping behaviours.
Twitter Jenny Jacobsson @Jenny_Jacobsson and Margo Mountjoy @margo.
mountjoy
Contributors TT was the lead investigator. TT, OD and CGS conceived the study. All
authors were involved in the study design and reviewed the draft of the report. TT,
OD and AS coordinated the data management, and TT drafted the report. AS carried
out the statistical analysis, reviewed by OD and JK. All authors approved the final
version of the report. TT is the guarantor.
Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not- for- profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in
the design, conduct, reporting or dissemination plans of this research. Refer to the
’Methods’ section for further details.
Patient consent for publication Not required.
Ethics approval Ethical approval for the study was obtained from the Research
Ethics Board in Linköping, Sweden (Dnr 2017/601-32).
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement No data are available.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non- commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non- commercial. See:http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.
ORCID iDs
ToomasTimpka http:// orcid. org/ 0000- 0001- 6049- 5402
OrjanDahlstrom http:// orcid. org/ 0000- 0002- 3955- 0443
JennyJacobsson http:// orcid. org/ 0000- 0002- 1551- 1722
MargoMountjoy http:// orcid. org/ 0000- 0001- 8604- 2014
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