Discussion
The prevalence of MHS among the participants within this study was up to 69%. The most prevalent MHS among active male and female professional footballers was sport-related psychological distress with, respectively, 52% and 63%. The most common MHS among former footballers was 69% for alcohol misuse. Overall, the prevalence of MHS such as global psychological distress, sleep disturbance, alcohol misuse and other substance misuse were significantly lower in the group of active male players vs former professional footballers. Injury in the 6 months prior to the survey was a salient risk factors for both genders, but was associated with a higher odds of gambling in males, and greater sleep disturbance in females. Higher psychological resilience was associated with lower sports-related and global psychological distress, anxiety and depression in males and a decrease in symptoms of depression in females. There was no significant association in both groups for other symptoms of MHS.
Comparison with other studies
Compared with prior meta-analytic research by Gouttebarge et al (that included various sport types (eg, cricket, football, handball, ice hockey, rugby, boxing, judo, gymnastics, rowing, swmiming)), the results of our study show somewhat higher prevalence of MHS.2 The prevalence of MHS among current and former elite athletes (males and females) in the review by Gouttebarge et al ranged from 19% for alcohol misuse to 34% for anxiety/depression among current players and 16% for distress to 26% for anxiety/depression among former athletes.2 In the present study, MHS reached up to 63% for sports related psychological distress among active players as for retired players the prevalence of MHS reached op to 69% for alcohol misuse. Cautiousness is warranted as the population characteristics and representativeness in both studies may differ, as in this study only football players are involved. Also, the association between injuries and MHS, as shown in previous studies (eg, distress, anxiety, sleeps disturbance) was not in accordance with the results of this study as injury in the previous 6 months was only associated with gambling.2 4 Junge et al showed a 13% and 7% prevalence of depressive symptoms in first Swiss league female footballers (average age of 21) and male footballers (average age of 25), respectively.26 The presence of depressive symptoms in our study was 11% and 7% among female and male footballers respectively, showing somewhat similar results. Among female players from the German First League, Prinz et al found a higher prevalence of depression symptoms, namely 32%.27 This could be explained potentially by the use of different instruments to assess MHSs or different characteristics of each sample.
Compared with other elite-level sports Drew et al showed a substantial prevalence of sleep disturbances (49% poor sleep, 22% sleepiness) and poor mental health among Olympic athletes, male and female combined (average age 26 and 24 respectively). They also stated that good mental health, resilience and sleep quality appear to be important factors involved in remaining healthy.28 Even though the present study involves a different population of only football players, it does shows also a substantial prevalence of MHS, wherein sleep disturbance presents a prevalence range (95% CI) of 12.2% (7.8% to 18.5%) to 35.6% (25.2% to 41.0%) among active male and female footballers, respectively.
Slade et al assessed the mental health well-being of the Australian general populations through a self-report survey (age 18 years and older).29 Even though Slade et al used different screening tools to assess mental health status among the Australian general population, they also used the K10 scale to assess distress corresponding with the present study.29 The prevalence of GADs was 2% and 4% for both male and females.29 The prevalence of depression was 3% and 5% for male and females, respectively.29 Drug use disorder was prevalent among 1% of males and 0.5% of females while alcohol use disorder was, respectively, 4% and 2%.29 Any substance use disorder was 7% and 3% for male and females respectively.29 The active and former athlete population in the present study shows higher prevalence rates of symptoms of anxiety, depression, alcohol-use disorders and drug-use disorder.
In our study, we found that previous injury was a contributing factor to problem gambling among active male footballers and to disordered eating among active female footballers. Our findings are in line with the scientific literature showing that injury and MHS might intersect.1 Gouttebarge et al concluded that the number of severe musculoskeletal injuries and surgeries during a career was positively correlated and associated with MHS among male European professional footballers.3 Even more, Kiliç et al showed that previous severe injuries were associated with the onset of MHS during the subsequent season (relative risks up to 7).4 This confirms that injury leads to cognitive, emotional and behavioural responses among elite athletes, including disordered gambling, changes in appetite and disordered eating.1
Limitations
Measurement of MHS through self-report might be a potential limitation as it measures only symptoms being consistent with mental health disorders and as it can lead to recall bias. Also for the collection of injury data, the method of self-report is not in accordance with the Fuller et al consensus statement.24 In our study, non-response analysis could not be conducted, because potential participants were invited for the study by the PFA with the procedure being blinded to the research team for privacy and confidentiality reasons. This might have led to selection bias and thus have influenced the external validity of our results. Another potential source of bias might be that football players with a particular interest in MHS were more prone to participate. The present study was done through anonymous recruitment and validated scales in order to improve the objectivity of the participants towards their own mental health, as MHS are a rather taboo subject in professional sports such as football.30 However a possible bias may arise from this ongoing taboo surrounding MHS among elite athletes, which could lead to a possible underestimation in the extent of MHS. An additional limitation is that there was no reference or comparison group from the general population included in the present study. In addition to a group of former players, a reference or comparison group from a non-athlete population, matched for age and gender, might have provided the possibility to appreciate potential differences and make other interpretations. Furthermore the number of participants within the former players group did not meet the power criteria (N=130 per group). The low number of former female participants in particular precluded further analyses with this group. A specific explanation for the low number of former female players could be that the female football industry is only just starting to develop and to be unionised, making them more difficult to track and approach for participation. Also the cross-sectional set up of this study does not allow to assess any causal relationship between the variables. Nonetheless, the results of this study provides a foundation for future research.
Recommendations
In several past studies different tools and populations were used to assess the symptoms of MHS, creating heterogeneity and complexity in the ability to easily compare between studies.2 A recommendation for further studies is to use the IOC Consensus Statement on mental health in elite athletes as a more evidence based and standardised approach to this subject is warranted.1 30 Future studies should have a longitudinal design of several years making it possible to assess causalities. Furthermore, there should be more attention to enrolling female participants in studies about MHS among active and retired athletes.
The prevalence of MHS among footballers have shown to be common, meaning that support and a multidisciplinary approach by mental health professionals as well as sport medicine physicians should be standard care. The IOC SMHAT-1 and The IOC Sport Mental Health Recognition Tool 1 (SMHRT-1) should be used to identify and help athletes that are at risk for developing MHS as well as increasing their psychological resilience.21 The SMHAT-1 identifies athletes that are in need for mental health treatment. This tool should be used by the sports medicine physician and/or licensed and registered mental health professionals in order to set up a multidisciplinary approach in tackling the MHS of the footballers.21 Psychological resilience is a significant protective factor against MHS according to this study. Family, teammates, coaches and friends known as the footballer players’ entourage have been identified as essential support in the mental well-being. With the SMHRT-1 the footballers’ entourage can facilitate in the early detection of MHSs and support early help-seeking by footballers from their sports medicine physician or psychologist.21 Education about the negative effects of alcohol misuse should be given to football players.31 32 This might help improving coping behaviour as it is also shown that sleeping problems or anxiety may lead to alcohol misuse and vice versa.31 32 Early detection and if needed treatment of MHS can serve to improve the athletes psychological resilience, performance and quality of life.
In professional football, an after career consultation has recently been introduced.33 In an earlier pilot study, such an intervention was positively evaluated by former players.2 34 In particular, athletes forced into early retirement, but also voluntarily retired athletes, could benefit from programmes preparing them for post-elite sport times (eg, seminars, mental and life skills training about career transition).2 33 A smooth transition into retirement could prevent the development of MHS among retired athletes and improve their psychological resilience.