The Sports and Exercise Medicine community and other sport stakeholders are becoming increasingly aware of the mental health symptoms (eg, depression, anxiety, substance misuse) reported by athletes. In 2019, this led to the publication of the first International Olympic Committee (IOC) consensus statement on mental health in this cohort and the establishment of the IOC Mental Health Working Group.1 Over the past 2 years, the COVID-19 pandemic and related public health measures have presented additional challenges to the well-being of all populations, including athletes. This editorial reflects on how the COVID-19 pandemic has highlighted a growing need to protect and promote athlete mental health.http://bjsm.bmj.comhj2022Sports Medicin

Bindra, Abhinav

Drezner, Jonathan

Gouttebarge, Vincent

Mkumbuzi, Nonhlanhla

Patricios, Jon

Rao, Ashwin

Reardon, Claudia L.

Thornton, Jane S.

Watson, Andrew

Mental health symptoms are common among professional, Olympic/Paralympic and collegiate athletes, with prevalence rates (15%-35%) equivalent to or exceeding those of non-athletes.1 Mental health symptoms are also common among youth and adolescent athletes, with a prevalence of up to one-third in some samples.2 Recent epidemiological evidence collected during the COVID-19 pandemic suggests increased rates of mental health symptoms among athletes during lockdown.3 In professional football (soccer), the prevalence of anxiety and depression doubled during the COVID-19 emergency period compared with immediately prior in both females (N=600; 18% vs 8% for anxiety) and males (N=1309; 13% vs 6% for depression).4 A significant difference was also found in US professional endurance athletes (N=114; 27% vs 5% for feeling anxious; 22% vs 4% for feeling depressed),5 as well as in the top leagues of Swedish football, ice hockey and handball (N=327), all correlated with COVID-19 pandemic distress.3 In Norway, symptoms of insomnia (38.3%) and depression (22.3%) were common among female and male elite athletes during COVID-19 (n=378).3 Among US high school athletes, the prevalence of moderate to severe depression more than tripled during the COVID-19 emergency period compared with years prior in both female (N=1877; 37% vs 11%) and male athletes (N=1366; 27% vs 6%).6 Increased mental health symptoms among athletes in the aforementioned studies might be linked to a range of pandemic-associated factors.7 Of concern, while athletes who have been able to return to sports participation after the end of the emergency period have shown some improvement in mental health, in many cases their mental health has not fully recovered to prepandemic status.

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Minds matter: How COVID-19 highlighted a growing need to protect and promote athlete mental health

UPSpace at the University of Pretoria

   1 of 3Gouttebarge V, et al. Br J Sports Med September 2022 Vol 56 No 17Minds matter: how COVID- 19 highlighted a growing need to protect and promote athlete mental healthVincent Gouttebarge   ,1,2,3 Abhinav Bindra,4 Jonathan A Drezner   ,5 Nonhlanhla Mkumbuzi,6 Jon Patricios   ,7 Ashwin Rao,5 Jane S Thornton   ,8 Andrew Watson   ,9 Claudia L Reardon10The Sports and Exercise Medicine commu-nity and other sport stakeholders are becoming increasingly aware of the mental health symptoms (eg, depression, anxiety, substance misuse) reported by athletes. In 2019, this led to the publication of the first International Olympic Committee (IOC) consensus statement on mental health in this cohort and the establishment of the IOC Mental Health Working Group.1 Over the past 2 years, the COVID- 19 pandemic and related public health measures have presented additional challenges to the well- being of all populations, including athletes. This editorial reflects on how the COVID- 19 pandemic has highlighted a growing need to protect and promote athlete mental health.ATHLETE MENTAL HEALTH DURING THE COVID-19 PANDEMICMental health symptoms are common among professional, Olympic/Paralympic and collegiate athletes, with prevalence rates (15%–35%) equivalent to or exceeding those of non- athletes.1 Mental health symp-toms are also common among youth and adolescent athletes, with a prevalence of up to one- third in some samples.2 Recent epidemiological evidence collected during the COVID- 19 pandemic suggests increased rates of mental health symptoms among athletes during lockdown.3 In profes-sional football (soccer), the prevalence of anxiety and depression doubled during the COVID- 19 emergency period compared with immediately prior in both females (N=600; 18% vs 8% for anxiety) and males (N=1309; 13% vs 6% for depression).4 A significant difference was also found in US professional endurance athletes (N=114; 27% vs 5% for feeling anxious; 22% vs 4% for feeling depressed),5 as well as in the top leagues of Swedish football, ice hockey and handball (N=327), all correlated with COVID- 19 pandemic distress.3 In Norway, symptoms of insomnia (38.3%) and depres-sion (22.3%) were common among female and male elite athletes during COVID- 19 (n=378).3 Among US high school athletes, the prevalence of moderate to severe depres-sion more than tripled during the COVID- 19 emergency period compared with years prior in both female (N=1877; 37% vs 11%) and male athletes (N=1366; 27% vs 6%).6 Increased mental health symptoms among athletes in the aforementioned studies might be linked to a range of pandemic- associated factors.7 Of concern, while athletes who have been able to return to sports participation after the end of the emergency period have shown some improvement in mental health, in many cases their mental health has not fully recovered to prepandemic status.7COVID-19 SPECIFIC CONTRIBUTING FACTORSBeyond generic (eg, adverse life event) and sport- specific (eg, injury) factors, it is likely that COVID- 19 has specifically chal-lenged athlete mental health (figure 1).1 COVID- 19- specific experiences and related home- confinement directives were associ-ated with increased mental health symptoms among athletes, although these effects were somewhat attenuated by home conditioning programmes and quarantine training camps.3 In particular, social isolation (eg, with team and tournament ‘bubbles’), concerns about well- being and financial problems, a fear of body changes with altered training and dietary regimens, as well as uncertainty about their identity, career and future, have been mentioned as COVID- 19- specific mental health contributing factors.3–5 8 Loss of athlete motivation, meaning and identity may have also perpetuated depressive symp-toms in athletes, especially for those exposed to competition postponement.9CLINICIANS’ APPROACH TO ATHLETE MENTAL HEALTH DURING THE COVID-19 PANDEMICWith alarming rates of mental health symp-toms among athletes during the COVID- 19 pandemic, it has never been clearer that mental health of athletes is a significant concern.10 This highlights that while sport confers important mental health benefits, athletes are nonetheless vulnerable to life stressors and major events. The disruptions in sport that the pandemic has wrought can be likened to the mental health impacts that occur at the time of injury and (forced) retirement. Injury, retirement and the COVID- 19 pandemic alike bring important changes to athletes’ lives through impacts on daily structure, support systems, livelihood, career trajectories and identity. Clinicians have learnt the importance of checking in with their athletes at any time of transi-tion—whether pandemic related or not.10 Mental health must be discussed explicitly and screening undertaken systematically.11 All sport stakeholders and members of the athletes’ entourages (including coaches) should receive training and resources to be able to identify mental health ‘red flags’ so that appropriate referrals can be made.11 Clinicians should routinely ‘check in’ with all athletes and take prompt steps to intervene when warranted.10 The IOC Sport Mental Health Assessment Tool 1 (SMHAT- 1) provides one framework to screen athletes for mental health symptoms.11A CONSTANT NEED TO PROTECT AND PROMOTE ATHLETE MENTAL HEALTHAthletes’ mental health was a growing concern before the pandemic, and pandemic- related influences will likely continue to have an impact well into the future. Beyond the individual clinician’s work, stakeholders such as governing bodies, sports leagues and 1Amsterdam UMC location University of Amsterdam, Dpt of Orthopedic Surgery and Sports Medicine, Amsterdam, The Netherlands2Section Sports Medicine, University of Pretoria, Pretoria, South Africa3Amsterdam Collaboration on Health & Safety in Sports (ACHSS), AMC/VUmc IOC Research Center, Amsterdam, The Netherlands4Athletes’ Commission, International Olympic Committee, Lausanne, Switzerland5Department of Family Medicine, University of Washington, Seattle, Washington, USA6NtombiSport (PTY) Ltd, Cape Town, South Africa7Wits Sport and Health (WiSH), School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg- Braamfontein, South Africa8Fowler Kennedy Sport Medicine Clinic, Department of Family Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, Ontario, Canada9Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA10Department of Psychiatry, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USACorrespondence to Prof Vincent Gouttebarge, Dpt. of Orthopedic Surgery and Sports Medicine, Amsterdam University Medical Centres, Amsterdam, The Netherlands;  v. gouttebarge@ amsterdamumc. nlEditorialcopyright. on October 27, 2022 at University of Pretoria. Protected byhttp://bjsm.bmj.com/Br J Sports Med: first published as 10.1136/bjsports-2022-106017 on 4 July 2022. Downloaded from 2 of 3 Gouttebarge V, et al. Br J Sports Med September 2022 Vol 56 No 17Editorialevent management teams must take steps to improve the mental health of their athletes and to change the culture of sport for the better. This is even more important as the pandemic continues, enabling the mental resilience of athletes to be optimised when they confront an increase in stressors. Team clinicians and management should priori-tise steps to safeguard and monitor athlete mental health. High- profile sporting events should highlight the importance of mental health as the United States Tennis Associa-tion did during the 2021 US Open.12 Ulti-mately, mental health assessments, resources and treatment should be destigmatised and more widely available. Athletes should be made to feel that addressing mental health is a priority, and not a sign of weakness. Now more than ever, minds matter! As athletes and as humans, they deserve to be well in every respect.Correction notice This article has been corrected since it published Online First. An acknowledgement statement has been added.Twitter Vincent Gouttebarge @vgouttebarge, Jonathan A Drezner @DreznerJon, Jon Patricios @jonpatricios, Ashwin Rao @badash13 and Jane S Thornton @janesthorntonAcknowledgements This article is part of a series commissioned by the BJSM for the World Innovation Summit for Health (WISH) 2022. The BJSM peer reviewed, edited and made the decision to publish. The lead author(s) received a small honoraria for this work. The series, including open access fees and honoraria, is funded by WISH, which is an initiative of the Qatar Foundation.Contributors VG and CLR conceptualised and drafted the initial version of the manuscript, with critical review provided by all authors. All authors read and approved the final version of the manuscript.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 VG is Chair of the IOC Mental Health Working Group. JD, JP and JST are editors of the British Journal of Sports Medicine. Claudia Reardon is co- chair of the IOC Consensus Group on Mental Health in Elite Sport.Patient consent for publication Not applicable.Provenance and peer review Not commissioned; internally peer reviewed.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/.© Author(s) (or their employer(s)) 2022. Re- use permitted under CC BY- NC. No commercial re- use. See rights and permissions. Published by BMJ.To cite Gouttebarge V, Bindra A, Drezner JA, et al. Br J Sports Med 2022;56:953–954.Accepted 26 June 2022Published Online First 4 July 2022Br J Sports Med 2022;56:953–954.doi:10.1136/bjsports-2022-106017ORCID iDsVincent Gouttebarge http://orcid.org/0000-0002-0126- 4177Jonathan A Drezner http://orcid.org/0000-0003-3519- 9120Jon Patricios http://orcid.org/0000-0002-6829-4098Jane S Thornton http://orcid.org/0000-0002-3519-7101Andrew Watson http://orcid.org/0000-0001-5122-2197REFERENCES 1 Reardon CL, Hainline B, Miller Aron C. International Olympic Committee consensus statement on mental health in elite athletes. Br J Sports Med 2019;53:667–99. 2 Walton CC, Rice S, Hutter RI. Mental health in youth athletes: a clinical review. Advances in Psychiatry and Behavioral Health 2021;1:119–33. 3 Jia L, Carter MV, Cusano A, et al. The effect of the COVID- 19 pandemic on the mental and emotional health of athletes: a systematic review. Am J Sports Med 2022:3635465221087473. 4 Gouttebarge V, Ahmad I, Mountjoy M, et al. Anxiety and depressive symptoms during the COVID- 19 emergency period: a comparative cross- sectional study in professional football. Clin J Sport Med 2022;32:21–7. 5 Roche M, Sainani K, Noordsy D, et al. The impacts of COVID- 19 on mental health and training in US professional endurance athletes. Clin J Sport Med 2022;32:290–6. 6 McGuine TA, Biese KM, Petrovska L, et al. Changes in the health of adolescent athletes: a comparison of health measures collected before and during the COVID- 19 pandemic. J Athl Train 2021;56:836–44. 7 McGuine T, Biese K, Hetzel S, et al. A multi- year assessment of sport participation during the Covid- 19 pandemic on the health of adolescent athletes. J Athl Figure 1 Mental health symptoms in athletes before and through the COVID- 19 pandemic.copyright. on October 27, 2022 at University of Pretoria. Protected byhttp://bjsm.bmj.com/Br J Sports Med: first published as 10.1136/bjsports-2022-106017 on 4 July 2022. Downloaded from 3 of 3Gouttebarge V, et al. Br J Sports Med September 2022 Vol 56 No 17EditorialTrain 2022. doi:10.4085/1062-6050-0679.21. [Epub ahead of print: 05 Apr 2022]. 8 Lambert C, Schuetz L- M, Rice S, et al. Depressive symptoms among Olympic athletes during the Covid- 19 pandemic. BMC Sports Sci Med Rehabil 2022;14:36. 9 McGuine TA, M Biese K, Hetzel SJ, et al. High school sports during the COVID- 19 pandemic: the effect of sport participation on the health of adolescents. J Athl Train 2022;57:51–8. 10 Reardon CL, Bindra A, Blauwet C, et al. Mental health management of elite athletes during COVID- 19: a narrative review and recommendations. Br J Sports Med 2021;55:608–15. 11 Gouttebarge V, Bindra A, Blauwet C, et al. International Olympic Committee (IOC) sport mental health assessment tool 1 (SMHAT- 1) and sport mental health recognition tool 1 (SMHRT- 1): towards better support of athletes’ mental health. Br J Sports Med 2021;55:30–7. 12 US Open. USTA launches mental health Initiative at 2021 US open. Available: https://www.usopen.org/en_ US/news/articles/2021-08-24/usta_launches_mental_ health_initiative_at_2021_us_open.htmlcopyright. on October 27, 2022 at University of Pretoria. Protected byhttp://bjsm.bmj.com/Br J Sports Med: first published as 10.1136/bjsports-2022-106017 on 4 July 2022. Downloaded from 

Minds matter : how COVID-19 highlighted a growing need to protect and promote athlete mental health

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Minds matter : how COVID-19 highlighted a growing need to protect and promote athlete mental health

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