Introduction
In recent years, mental health of athletes has received increasing attention in sports medicine, and several editorials,1–4 clinical overviews5–8 and empirical studies9–24 have been published on this topic. It is now accepted that elite athletes are under specific internal and external emotional pressures, and that these stressors may lead to an increased prevalence of mental health problems.3
However, sound epidemiological studies are still rare, and their results are inconclusive.5 ,9 ,25 Most studies investigated depression, and some assessed anxiety, eating disorders, abuse of alcohol or unspecific mental health problems such as distress and burnout in active athletes (for an overview, see ref. 25). A few studies examined the present mental health of athletes after the end of their sports career.22 ,26–29 Until now, no study has investigated the career–time prevalence of depression or other mental health concerns in elite athletes. Gulliver et al18 asked active athletes whether or not they ‘have ever seen a mental health professional to get help for personal or emotional problems’. This might give an indication of the size of the problem (overall 57.1%); however, the athletes were still within their career, and the study had a low response rate (25.1%).
Prior studies have reported a prevalence of depression in athletes ranging between 3.6%20 and 34%.23 These differences might be due to the study population (gender, type of sport, competition level), assessment methods and response rates.25 In the eight studies that used the Centre of Epidemiologic Studies Depression Scale (CES-D)30 and a cut-off of 15 for classification of depression,11–15 ,18 ,24 ,25 the prevalence rates of symptoms of depression varied between 6.6%25 and 33.5%,11 most probably due to the differences in characteristics of the study groups and in response rates.25
Risk factors for mental health problems have rarely been investigated in athletes. In most studies, a higher prevalence of depression was reported in female than in male athletes.11 ,12 ,17–19 ,24 ,25 Differences in the prevalence of depression were found for type of sport,24 level of play19 ,23 ,25 and player position.25 In general, injured players had higher scores of depression than uninjured players.10 ,25 ,31 Gouttebarge et al22 observed that mental health problems were significantly associated with low social support and recent life events. Nixdorf et al19 found a correlation of depression symptoms with chronic stress, coping strategies and stress recovery states. Hammond et al23 reported that twice as many athletes met criteria for a major depressive episode before a competition compared with after a competition.
Since almost all mental health questionnaires relate to a relatively short period of time (eg, CES-D to the past week), such evaluation of active athletes does not reflect the sports career, and might be biased by specific situational conditions. Another important aspect which needs to be considered when assessing mental health in active athletes is the stigma attached to this topic.2 It is possible that stigma leads to an under-reporting or denial of mental health problems in active athletes.6 ,32–34 A retrospective design allows evaluation of the prevalence of depression for the entire period of a sports career and might reduce potential bias or non-compliance expected in active athletes due to the stigma and denial attached to this topic.
A suitable study population should regard the following criteria: (1) one type of sport because of the differences in depression between sports,24 (2) a popular sport because of the relevance of the results and (3) a high level of play because of the associated level of stress.19 ,23
Thus, the aims of the present study were to evaluate depression symptoms during and after the career in former female football players of the German First League. Additional questions on stressful and helpful conditions were included to provide ideas for prevention or reduction of mental health problems. Information about reasons for and consequences of ending the sports career might help to improve the care for players beyond their football career.