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Abstract
Background Information on the prevalence of mental health problems of elite athletes is inconclusive, most probably due to methodological limitations, such as low response rates, heterogeneous samples.
Aims To evaluate the prevalence and risk factors of depression and anxiety symptoms in high-level female football players.
Methods Female football players of 10 German first league (Bundesliga) and 7 lower league teams were asked to answer a questionnaire on players’ characteristics, the Center of Epidemiologic Studies Depression Scale (CES-D) and the Generalised Anxiety Disorder (GAD-7) scale.
Results A total of 290 players (184 first and 106 lower league players) took part in the study. The CES-D score indicated mild to moderate symptoms of depression in 48 (16.6%) and severe symptoms in 41 (14.1%) players. The GAD-7 score indicated an at least moderate generalised anxiety disorder in 24 (8.3%) players. The prevalence of depression symptoms and generalised anxiety disorders was similar to the female general population of similar age. However, significantly more second league players reported symptoms of depression than first league players, and thus the prevalence of depression symptoms in second league players was higher than in the general population. Only a third of the 45 (15.7%) players who stated that they currently wanted or needed psychotherapeutic support received it.
Conclusion The prevalence of depression and generalised anxiety symptoms in elite football players is influenced by personal and sport-specific variables. It is important to raise awareness of athletes’ mental health problems in coaches and team physicians, to reduce stigma and to provide low-threshold treatment.
- soccer
- women in sport
- elite performance
- mental
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Introduction
Mental health of elite athletes has gained increasing attention in recent years.1–4 Several epidemiological studies have been published on depression, eating disorders, anxiety, abuse of alcohol, or unspecific mental health problems such as distress and burnout of active athletes5–7; however, conclusive information on the prevalence and risk factors of mental health problems of elite athletes is still lacking. For example, the prevalence of depression symptoms in active athletes varied from 3.6%8 to 68%,9 and anxiety symptoms from 1.0%10 to 37.3.11 This is most probably due to differences in the assessment methods, characteristics of the study populations and response rates of the studies.10 12
Depression was most frequently assessed using the Center of Epidemiologic Studies Depression Scale (CES-D)13 and a cut-off of 16 (see table 1). However, even if solely results based on the CES-D were regarded, the percentage of athletes classified as depressed varied from 6.6%10 to 37.7%.14 In most studies a higher prevalence of depression in female than in male players was reported.10 11 14–18 In three studies significantly higher average depression scores in individual than in team sport athletes were observed, but gender was not regarded in the analysis.14 18 19 Yang et al 17 and Wolanin et al 14 showed substantial differences between sports (see table 1). Further, differences in the prevalence rates of depression have been reported between professionals, junior and amateur athletes,18 between adult and U-17 football players,10 as well as between different playing positions10 20 and level of play.10 20 Injured players have usually higher depression rates than uninjured players.6 21 22 These differences in the athletes’ characteristics may have contributed to the heterogeneous results.
Studies on depression of active athletes (M, male; F, female) using the CES-D and a cut-off of 16
Moreover, some studies had a low response rate (eg, 25.1%16 and 29%23), and others did not even report it.9 11 15 18 24 This is a serious methodological limitation, since potential selection effects might have biased the reported prevalence. Comparing the studies in table 1, the prevalence of depression symptoms decreased with a higher response rate for both male and female athletes. This supports the hypothesis that athletes with mental health problems are more likely to participate in studies on this topic, and thus the true prevalence might be overestimated in studies with low response rates.
Therefore, the aim of the present study was to evaluate the prevalence of and risk factors for depression and generalised anxiety symptoms in a homogeneous group of top-level athletes with a high response rate. Based on the recommendation by Prinz et al,20 ‘A suitable study population should regard the following criteria: (1) one type of sport because of the differences in depression between sports, (2) a popular sport because of the relevance of the result, and (3) a high level of play because of the associated level of stress’.20 German female football players were selected as study population, since football is a popular sport worldwide,25 women are at higher risk for depression26 and generalised anxiety symptoms27 28 than men, and Germany is one of the top teams of the FIFA World Ranking list for women.29 First and lower league players were included in the present study to enable comparison between different levels of play.
Methods
The study population consists of players of the first and the second team of the 10 clubs that played in the first German Women’s Football League (Allianz Frauen-Bundesliga) in the current and the previous season (2014/2015 and 2015/2016). All clubs were contacted by the last author (BP) and visited during a training session of the team by a well-known former female football player in Fall 2015. The former player explained the study to all players, asked them for their informed consent and to fill in the anonymous questionnaire. She distributed the questionnaires to and collected them from the players. Participation was voluntary and confidentiality of the data was ensured.
The questionnaire was specially designed for the present study and included questions on personal and player characteristics, need and use of psychotherapeutic support, current injury, and current general health. Almost all questions had predefined answer choices and an option to insert free text. In addition the CES-D13 and the Generalised Anxiety Disorder (GAD-7)30 were included. The questionnaires were available in German26 31 32 and English.
The CES-D33 is a self-report scale used to measure severity of depression symptoms experienced in the past week. A depression score between 0 and 60 is calculated based on the answers to the 20 items on a 4-point Likert scale (0–3). The cut-off score for mild to moderate depression is 16, and for a major depression more than 21.13
The GAD-730 is a seven-item questionnaire on symptoms of a generalised anxiety disorder in the last 2 weeks. A sum score is calculated by adding the answers to the seven items on a 4-point Likert scale (0–3), with scores ranging from 0 to 21. Scores of 5, 10 and 15 represent cut-off points for mild, moderate and severe anxiety, respectively.30
A variable ‘match experience’ was computed based on the number and level of matches played:
top: >50 international or >100 first league matches
high: 11–50 international or 11–100 first league or >100 second league matches
moderate: 1–10 international or 1–10 first league or 11–100 second league matches
low: no international, no first league, 1–10 second league, other matches.
Three different levels of play were defined, since some players played in other leagues than their squad:
first league: players who belong to a first league squad and play in the first league
second league: players who belong to a second league squad and play in the second league
other level: players who belong to a lower league squad or of more than one squad, or play in a lower league or in more than one league, or in a league different from their squad.
All data were processed using Excel and SPSS (version 23). Statistical methods applied were means with SD, frequencies with percentage, correlation, t-test, analysis of variance and χ2 test. For analysis of risk factors for depression symptoms (CES-D >16) and generalised anxiety disorders (GAD-7 >10), binomial logistic regression analyses were performed. Significance was accepted at P<0.05.
Results
A total of 290 female players of all first (n=203) and seven second teams (n=87) of the 10 clubs that played in the first German Women’s Football League in two consecutive seasons participated in the study. No player declined participation in the study, but 14.0% of the first and 39.2% of second team players were absent for various reasons at the training session when they were asked to fill in the questionnaire.
The players were on average 21.5 years old (SD=4.2) and trained 6.1 (SD=1.7) sessions per week in the last 12 months. Almost all grew up in Germany (n=224, 77.2%) or another European country (n=47, 16.2%), and spoke German (n=234, 80.7%) or English (n=18, 6.2%) as first language. Playing positions were distributed as follows: 99 (34.5%) defenders, 100 (34.8%) midfielders, 48 (16.7%) attackers, 26 (9.1%) goalkeepers and 14 (4.9%) played in more than one position.
Almost two-thirds of the players (n=184, 64.2%) belonged to a first league squad and played in the first league, 65 (22.4%) belonged to a second league squad and played in the second league, and 41 (14.1%) in lower or multiple leagues/squads. Nearly half of the players (138, 48.6%) were (almost) always, 34 (12.0%) often, 47 (16.5%) sometimes and 65 (22.9%) rarely/never a starter for their team. Based on the number of international, first and second league matches (for details see Methods), 75 (26.3%) players were classified as having top match experience, 104 (36.5%) high, 61 (21.4%) moderate and 45 (15.8%) low level of experience. Fifteen players could not be classified due to missing values.
More than 80% of the players described their general health as very good (n=72, 25.2%) or good (n=159, 55.6%), 47 (16.4%) as average and 4 (2.8%) as poor. About one in six players (n=47, 16.4%) was currently injured.
Almost 40% of the players stated that they wanted or needed psychotherapeutic support previously (n=68, 23.7%) or currently (n=45, 15.7%). Thirty-nine (13.6%) players received counselling or treatment from a psychologist or psychotherapist previously, and 15 (5.2%) were in such counselling at the time of the survey (‘current’). Thus, only a third of the players who currently wanted or needed psychological support received it.
Prevalence of depression and generalised anxiety symptoms
The depression score of the entire group (response rate 97.6%) was on average 13.96 (SD=7.27, range 2–48), and indicated mild to moderate symptoms of depression in 48 (16.6%) players and severe symptoms of depression in 41 (14.1%) players. The highest prevalence of depression symptoms was observed in the second league, with one in five players (20.6%) reporting symptoms of a severe depression (see table 2). Compared with the first league, about twice as many second league players had mild to moderate (χ2=7.71, P<0.01) and severe symptoms (χ2=5.31, P<0.05) of depression. Compared with a female general population of similar age,32 no difference was observed for all players or first league players, but significantly (χ2=5.85, P<0.05) more second league players had symptoms of depression.
Number and percentage of different degree of depression (CES-D) and generalised anxiety (GAD-7) symptoms in different leagues, the total group and the general population
The generalised anxiety score of the entire group (response rate 99.0%) was on average 4.65 (SD=3.29, range 0–17), and indicated a moderate generalised anxiety disorder in 20 (6.9%) players and a severe generalised anxiety disorder in 4 (1.4%) players. Three (75.0%) of the four players with a severe generalised anxiety disorder had also severe symptoms of depression. The depression and generalised anxiety scores correlated significantly (r=0.692, P<0.001). The prevalence of generalised anxiety symptoms was similar in three levels of play and to a female population of similar age (see table 2).
Risk factors for depression and generalised anxiety symptoms
Significant differences in the average depression and/or generalised anxiety score were observed among groups of different ages, country the player grew up, match experience, league, frequency of starting for their team, need for psychotherapeutic support and rating of general health (see table 3). Players younger than 20 years, with low match experience, who belonged to a second league squad and played in the second league, who were rarely/never a starter of their team, as well as players who reported a need for psychotherapeutic support and who rated their general health as average or poor were at higher risk for depression and generalised anxiety symptoms. No significant differences were found with regard to first language, number of training sessions, playing position or current injury.
Comparison of average scores of depression symptoms (CES-D) and generalised anxiety disorder (GAD-7) in different groups
Binary logistic regression analyses on the effects of different risk factors on the likelihood of symptoms of depression and anxiety (table 4) confirmed most of the univariate results.
OR and 95% CI of predictors for symptoms of depression (CES-D <16 vs ≥16) and anxiety (GAD-7 <10 vs ≥10)
The logistic regression model for depression symptoms was statistically significant (χ2(17)=44.93, P<0.001), explained 22.1% (Nagelkerke R2) of the variance of depression symptoms and correctly classified 73.8% of cases. Match experience and the subjective need for psychotherapy were significant predictors of depression symptoms. Players who stated that they never needed psychotherapy reported three to four times fewer symptoms of depression than players who needed psychotherapy previously or currently. Compared with players with the highest match experience, less experienced players were more likely to present with depression symptoms, and especially players in the second highest group were three times more likely to present with depression symptoms. No significant effect of age, playing position, current injury, being a starter, level of play or training volume on depression symptoms was found. However, subgroup differences of level of play and frequency of starting for the team were approaching significance with second league players and players who rarely or never started for their team being at a higher risk for depression symptoms.
The logistic regression model for generalised anxiety disorders was statistically significant (χ2(17)=28.817, P<0.05), explained 22.7% (Nagelkerke R2) of the variance of generalised anxiety symptoms and correctly classified 90.8% of cases. Specifically match experience and age were significant predictors of generalised anxiety symptoms. Compared with players with the highest match experience, players in the second highest group were four times more likely to present with generalised anxiety symptoms, and younger age was associated with an increased likelihood of exhibiting generalised anxiety symptoms. Further, the effects of level of play and subjective need of psychotherapy on generalised anxiety symptoms are approaching significance. Second league players were seven times more likely to exhibit symptoms of generalised anxiety than first league players. Players who stated to currently need psychotherapy reported four times more symptoms of generalised anxiety. No significant effect of playing position, current injury, being a starter or training volume was found.
Discussion
We evaluated the prevalence of depression and generalised anxiety symptoms in German first and lower league female football players. The study had a high response rate, with almost all players (97%) answering the depression and the anxiety questionnaires.
Prevalence
The prevalence of depression symptoms in the present study was similar to a female German general population of similar age.32 However, second league players reported symptoms of depression at a significantly greater rate than both first league players and counterparts in the general population.32 Compared with female football players from other countries, the prevalence of depression in the present study (31%) was much higher than in Swiss first league players (13%)10 but similar to American National Collegiate Athletic Association players (31%).14
We speculate that the country’s level of performance in women’s football may influence the prevalence of depression. Germany and the USA have been in the top places on the FIFA World Ranking list for women for many years,29 whereas Switzerland generally occupies a lower position. In countries where women’s football is very popular and successful, players of the top leagues might be under greater psychological pressure due to more competition among teams as well as within teams to maintain a place on the roster than players from countries where football is played on a less professional level.
The prevalence of generalised anxiety disorders (8.3%) was similar in the three levels of play and did not differ statistically from a female German general population of similar age.31 It was higher than in Swiss female first league players (1.1%)10 but similar to a mixed group of Australian elite athletes (7.1%).16 Symptoms of depression and generalised anxiety disorders correlated significantly (r=0.692, P<0.001) as reported previously from other groups of athletes.8 10 17
In the present study, differences in the prevalence of depression and generalised anxiety symptoms were found with regard to match experience. Players with the highest match experience had lower average depression and anxiety rates, and this extends previous reports by Prinz et al 20 for former elite female football players, and by Junge and Feddermann10 for active elite male and female football players. Multivariate regression analysis showed that match experience was a predictor for depression and generalised anxiety symptoms independent of level of play. Younger players had on average more depression and anxiety symptoms.10 This effect was confirmed in regression multivariate analysis for generalised anxiety but not for depression symptoms.
In contrast to Prinz et al 20 and Junge and Feddermann-Demont10 but in agreement with Gouttebarge et al,34 no effect of playing position on the prevalence of depression symptoms was observed in the present study. In the present study injured and uninjured players had similar depression and generalised anxiety rates. This is contrary to previous studies,6 10 16 22 but most probably explained by the fact that severely injured athletes did not attend the training session when players were asked to fill in the questionnaire. The data for this study were collected in the first half of the season, and it is possible that the prevalence of depression and anxiety symptoms varies over the course of the season.9
Clinical implications
Prinz et al 20 reported that almost 40% of former elite female football players stated that they wanted or needed psychotherapeutic support during their career. In the present study a similar percentage of active players stated that they wanted or needed psychotherapeutic support previously or currently. Based on the data of the present study, about three to four players in each team currently wanted or needed psychotherapeutic support, but only a third of these players received it. In contrast, Gulliver et al 16 reported that 62.7% of active Australian female athletes saw a psychologist and 5.9% a psychiatrist ‘to get help for personal or emotional problems’. This indicates low barriers and good facilitators of help-seeking in Australian elite athletes.35 In addition to stigma and denial,36 poor mental health literacy, attitudes and personal characteristics, as well as practical barriers, are important barriers to help-seeking of athletes.35
‘ Destigmatisation, improvement of mental health literacy and provision of low-threshold counselling and treatment could increase help-seeking of athletes in need, and thus, help to reduce mental health problems. ’
Conclusion
The prevalence of depression symptoms in second leagues players was higher than in the general population. Routine screening of mental health problems and especially depression has been recommended to identify players at risk.4 14
Players with the highest match experience had the lowest average depression and anxiety rates, independent of their level of play. Additional risk factors were young age for generalised anxiety disorders and being rarely/never a starter of their team for depression symptoms. An important finding is that only a third of the players who wanted or needed psychotherapeutic support received it. This could be due to mental health stigma, low help-seeking behaviour, low mental health literacy of the athletes and/or the support staff (coaches, team physician and others), as well as due to low availability and/or accessibility of related healthcare resources. It is recommended to reduce stigma and denial, to improve mental health literacy, and to provide low-threshold counselling and treatment for athletes with mental health problem.
What are the findings?
First league female football players had a similar prevalence of depression symptoms and generalised anxiety disorders than a female general population of similar age.
Second league female football players had a higher prevalence of depression symptoms than first league players and than a female general population of similar age.
On average 14% of the players had severe symptoms of depression, equivalent to two to four players in a team of 18–26 players.
About 16% of the players stated that they currently wanted or needed psychotherapeutic support, but only a third of them were receiving counselling or treatment from a psychologist or psychotherapist.
How might it impact on clinical practice in the future?
Awareness, knowledge and literacy of mental health problems should be raised in coaches, team physicians and other support staff to reduce stigma and improve referral of athletes with mental health problems to adequate treatment.
Awareness, knowledge and literacy of mental health problems should be raised in athletes to reduce stigma and improve their help-seeking behaviour.
Screening for depression and other mental health problems should be included in the regular medical examinations to identify athletes at risk.
Low-threshold counselling and access to adequate treatment should be provided for athletes with mental health problem.
Acknowledgments
The authors highly appreciate the cooperation of all players who volunteered their time to fill in the questionnaire. We express our gratitude to the former players for distributing the questionnaire and helping to achieve the high response rate. We thank Annika Prien, MSc, for performing the regression analyses.
References
Footnotes
Contributors AJ: first author, substantial contributions to the conception and design of the study, analysis and interpretation of data, drafting, writing and revising of the manuscript, and final approval of the version to be published. BP: second/last author, substantial contributions to the conception and design of the study, collection and interpretation of data, drafting of the manuscript, and final approval of the version to be published.
Funding The study was funded by the Fédération Internationale de Football Association (FIFA).
Competing interests None declared.
Patient consent Obtained.
Ethics approval The study has ethics approval (PV4734) from the Medical Association of Hamburg, Germany.
Provenance and peer review Not commissioned; externally peer reviewed.