Psychiatry and Sports Medicine
POSITION PAPER
Complementing Existing Care Provision Strucutres and Promoting Mental Health in Competitive Sports

Position Paper: Sports Psychiatric Care Provision in Competitive Sports

Positionspapier: Sportpsychiatrische und -psychotherapeutische Versorgung im Leistungssport

Summary

Mental stress and illness are common health problems in competitive sports that can reduce performance and have effects beyond the end of a career as sport-specific and unspecific disorders.

The promotion of mental health and safe handling of mental problems and illnesses require appropriate education and train-ing. However, child, adolescent and adult psychiatrists with specific expertise in competitive sports (sports psychiatrists) are not yet an integral part of the structure of medical care provision in competitive sports.

This position paper gives an overview about existing care structures in competitive sports for the promotion of mental health, and investigated them with proposals for the further development of sports psychiatric care in competitive sports. Sports physicians, sports psychiatrists, as well as interdisci-
plinary and interprofessional collaboration, are at the center of mental health efforts in competitive sports.

Further aspects that will be discussed are the education and training of athletes and the environment in competitive sports, as well as the promotion of coaches’ health.

Key Words: Elite sports, Prevention, Mental health problems and disorders, Sports psychiatry, Sports Medicine 

Zusammenfassung

Psychische Belastungen und Erkrankungen sind häufige Gesundheitsprobleme im Leistungssport, die die Leistung mindern und sich als sportartenspezifische und -unspezifische Störungen bis über das Karriereende hinaus auswirken können.

Die Förderung der psychischen Gesundheit und ein sicherer Umgang mit psychischen Beschwerden und Erkrankungen erfordern eine entsprechende Aus- und Weiterbildung. Kinder-, Jugend- und Erwachsenenpsychiater und -psychotherapeuten mit einer spezifischen Expertise im Leistungssport (Sportpsychiater und -psychotherapeuten) sind bisher aber nicht fester Bestandteil in den Versorgungsstrukturen im Leistungssport.

Das Positionspapier gibt eine Übersicht über bestehende Versorgungsstrukturen zur Förderung der psychischen Gesundheit im Leistungssport, die durch Vorschläge zur Weiterentwicklung hinsichtlich der sportpsychiatrischen Versorgung ergänzt werden. Sportmediziner, Sportpsychiater und -psychotherapeuten sowie die interdisziplinäre und interprofessionelle Zusammenarbeit sollten dabei im Zentrum der Bemühungen um die psychische Gesundheit im Leistungssport stehen.

Weitere Aspekte, die diskutiert werden, sind die Aufklärung und Schulung von Athleten und des Umfeldes im Leistungssport, wie auch die Förderung der Trainergesundheit.

Schlüsselwörter: Spitzensport, Prävention, Psychische Belastungen und Erkrankungen, Sportpsychiatrie und -psychotherapie, Sportmedizin

Introduction

Mental health problems and illnesses are common health problems in competitive sports (24). The promotion of mental health and safe management of mental problems and illnesses require professionals with appropriate education and training. However, child, adolescent and adult psychiatrists and psychotherapists [hereafter psychiatrists] with specific expertise in competitive sports (sports psychiatrists) have not been an integral part of the medical care provision structures in competitive sports (6, 17).

In the scientific literature and public reporting, mental health and mental illness in competitive sports have received increasing attention in recent years. A consensus statement on the mental health of competitive athletes was published in 2019 by a working group of the International Olympic Committee (24).

Position papers on mental health in competitive sport have meanwhile been developed by various institutions and professional societies; for example, by the American Medical Society for Sports Medicine, the International Society of Sport Psychology, and the Swiss Society for Sport Psychiatry and Psychotherapy (5, 10, 19, 26, 31). A comprehensive model for mental health promotion and the management of mental health problems and illness in competitive sport was also proposed by Purcell and collaborators in 2019 (23).

Understanding the complexity of competitive sports, the high time commitment of athletes, and the already considerable amount of care, with increasingly busy schedules, it is the purpose of this position paper is to propose and discuss additions to medical care provision structures for mental health promotion in competitive sports from a psychiatrist and sports physician perspective. Considering the standards of psychiatric care, the proposal build on existing structures, incorporates past mental health efforts in competitive sports, and is intended to be practicable.

Mental Health and Illness in Competitive Sports

Mental strength is not the same as mental health (15). Athletes can be mentally strong and at the same time mentally unhealthy. This became widely known, not least through the brave interviews of successful athletes, in which athletes reported their mental health stresses and illnesses. "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" [World Health Organization WHO; (32)].

Physical and mental health, as integral dimensions in competitive sport, are significant for well-being and performance. The two cannot be considered separately (24): mental health problems and illness in sport can be associated with injury and reduced performance. Both, in turn, together with other factors such as certain personality traits (e.g., perfectionism), pose risks to mental health.

Addressing violence and abuse in competitive sport should always be considered in mental health care provision and support structures. Violence and abuse can occur within and outside of sport and has been described as a blind spot for many sport organizations. Concerns about reputational damage, ignorance, silence, or even tacit acquiescence are cited as reasons for this (20). Appropriate measures to deal with violence and abuse have been described by the International Olympic Committee consensus statement: harassment and abuse (non-accidental violence) in sport at the level of sports organizations, athletes, sports medicine, related disciplines and research (20). These levels also find their way into the additions to the medical care provision structures in competitive sport proposed here.

In competitive sports, mental health management and access to appropriate health care services should be as commonplace as the rest of medical care. Ideally, competitive athletes should have access to the best possible interdisciplinary and interprofessional care. This conclusion from the Mental health in elite athletes: International Olympic Committee consensus statement (2019) (24) also implicitly refers to current practice in competitive sport.

Competitive sports care without internists or orthopedists with advanced training in sports medicine is unthinkable. Dealing with mental health and illness in competitive sports requires, as with physical health and illness, qualified medical professionals, i.e. psychiatrists with further and advanced training in sports psychiatry and sports medicine (7).

One reason for the absence of psychiatrists in the concepts of medical care provision in competitive sports could be seen in the long time lack of initiative of psychiatry in competitive sports.

Other reasons, however, also lie in the often-varying ways in which protagonists in competitive sport deal with mental and physical health. "Barriers" for athletes in competitive sports to seek psychiatric-psychotherapeutic treatment have been discussed in detail elsewhere (4, 24): The stigmatization of mental complaints and illnesses by the public as well as by the athletes and their environment themselves, the lack of knowledge, negative previous experience, and tight schedules are often mentioned in this context. Cultural differences must be considered here, as well as the fact that many athletes come from countries where they do not have access to high-level health care (4, 24).

The promotion of mental health through prevention, diagnosis, therapy and aftercare of mental health problems and illnesses requires an interdisciplinary and interprofessional exchange and cooperation. In this context, the integration and cooperation of specialists such as sports physicians, clinical psychologists, sports psychologists, mental coaches and sports psychiatrists as well as other disciplines in particular must meet the demand for the best possible handling of mental health and illnesses in competitive sports.

It is important to utilize all available possibilities; the principle of empirically founded and guideline-compliant action should always be decisive. For sports psychiatry, however, this essentially means momentarily the orientation to the general recommendations and guidelines for mental illnesses. Therefore, there is a need for initiatives and efforts to establish sports psychiatric evidence and guidelines regarding competitive sports (25). Such initiatives should include from the beginning, the expertise from neighbouring disciplines, such as sports medicine, clinical psychology, sports psychology and sports science.

Promoting Mental Health in Competitive Sports

The following section includes and identifies potential additions to existing mental health care provision structures and efforts in competitive sports.

Environment: Education and Training

Athletes and parents as well as coaches in federations and clubs should be educated about the importance of mental health in competitive sports (17). This education should convoy that sustained athletic performance requires a healthy environment and health for athletes. This would also involve empowering and supporting athletes themselves to take responsibility for their mental health, for example through education.

Sports psychiatrists in associations and clubs, together with sports physicians and clinical psychologists, could be assigned this task. Associations and clubs without such a specialized unit would find appropriate support in the network of qualified sports psychiatrists (Table 1).

Education and training should be offered to athletes and parents, as well as to all specialists in associations and clubs, and should be geared to the specific circumstances of the sport and the type of sport. For example, certain sports such as endurance, weight class and antigravity sports or disciplines in the aesthetic field require a special focus on the prevention of disordered eating behavior and eating disorders (2).

The prevention of violence and abuse is also imperative for all athletes with special attention to be paid to risk groups, elite athletes, minors, para-athletes and LGBTQIA* athletes (20).

Coaches: Promoting Health

The training and support of coaches is of particular importance with regard to the promotion of health (11, 16). Coaches’ behavior has a direct influence on athletes’ physical and mental health (18, 30). However, coaches, like athletes, are themselves exposed to mental health burdens and risks in competitive sports and are under great pressure to succeed (3). In this regard, they play a very important role in promoting athletes’ mental health. Too often, they are still left alone with their stresses and forgotten (27).

The recent public reporting in many countries on the topic of violence and abuse in competitive sports shows the importance for this topic. Coaches may also have been victims of violence and abuse themselves and become perpetrators in their role as coaches, which must be taken into account in coaches’ education and care concepts. In addition to education and training on the importance of mental health in competitive sports and violence and abuse, regular sports medicine and sports psychiatry examinations should be offered to the predominantly volunteer coaches, which would make sense that such assessments could be guided by the sports medicine examination and the proposed baseline psychiatric assessment of athletes (13).

Qualified experts, psychiatrists, as well as psychologists with further clinical training, should be available in associations and clubs as contacts when needed. This would enable early and thus also preventive counseling and support for coaches to maintain or restore their mental health.

It should be noted that simultaneous treatment of coaches and athletes by the same therapists leads to bias due to conflicts of interest and role, so that two independent therapists are needed for this purpose.

The cooperation with coaches should include the possibility of qualified supervision, as a further contribution to the promotion of the health of the coaches and indirectly also of the athletes.

Interdisciplinarity and Interprofessionalism

The promotion of mental health and the handling of mental problems and illnesses, as well as the prevention of violence and abuse, require a high degree of interdisciplinarity and interprofessionalism, to which all specialist disciplines involved in competitive sport should feel committed. The disease- and disorder-specific expertise is decisive and should determine the actions. It should also be taken into account that underage athletes should be cared for by child and adolescent psychiatrists and not primarily consulted by psychiatrists specialized in adult psychiatry.

Sports psychologists and mental trainers should develop recommendations to prevent mental illnesses from being mistakenly treated with mental training techniques. Sport psychologists contribute to prevention and early detection of mental complaints (e.g. 21, 22). In competitive sports, both have an important role, in terms of optimizing performance and in their role as a reference and confidant. This is also true when participation in competitive sports is limited or temporarily suspended for athletes due to mental health problems or illness. Some athletes do not want to relinquish the support of the aforementioned caregivers even in the event of a break from competitive sports. A "tandem model" of cooperation between sports psychologists and mental trainers on the one hand and psychiatrists and clinically trained psychologists on the other, could represent a future model for this.

Tandem Treatment

Many athletes depend on mental skills training. Qualified mental skills training (competitive personality) should be provided by mental coaches or sports psychologists. Safe management of mental health and illness (overall personality) should be provided by qualified psychiatrists and clinically trained psychologists. In more severe cases, it is mandatory that treatment be provided by psychiatrists – and optimally in collaboration with sports medicine specialists. The continuity of support by mental coaches or sports psychologists can thus be guaranteed, as can the assurance of qualified psychiatric-psychotherapeutic and medical treatment.

In tandem, support from sports psychologists or mental coaches is maintained, while from the treatment side, therapeutic support continues for as long as circumstances require. Athletes can also count on the continuity of performance sport-related support if participation in competition or training is not possible. The exchange of information on the status of treatment or the next possible steps for resuming or intensifying competitive sports activity are an essential part of the tandem concept in order to achieve the best possible care for athletes – taking into account the sports medicine perspective.

For optimal interdisciplinary and interprofessional exchange, appropriate forums such as sports medicine, sports psychiatry and sports psychology boards, quality circles or inter- or supersessions are desirable.

Sports Medicine Examination (SME)

The regularly scheduled SME should be supplemented by a sports psychiatric screening, i.e., basic psychiatric assessment (BPA) (13). Like the SME, the BPA should be performed by sports physicians.

In case of abnormalities in the basic psychiatric assessment, a sports psychiatric evaluation (SPE) should follow for further assessment by psychiatrists (13). This should also be done at the direct request of the athlete and recommended if there is a relevant history or otherwise high risk of developing a mental illness. Mental health should also be kept in mind during contacts in sports medicine consultations, outside of the annual SME.

In the manuscript by Gonzalez Hofmann et al. in this issue of the German Journal of Sports Medicine, the screening and diagnosis of mental problems and illnesses in the sports medicine and sports psychiatry setting is discussed in more detail (13).

Sports Psychiatrists

In addition to sports medicine and sports psychiatry examinations, the integration of sports psychiatrists is desirable. Their special expertise lies in prevention, diagnosis, therapy and aftercare of mental health complaints and illnesses, as a supplement and extension of sports medicine care.

Gouttebarge et al. published the International Olympic Committee Sport Mental Health Assessment Tool 1 (SMHAT-1) and Sport Mental Health Recognition Tool 1 (SMHRT-1) in the British Journal of Sports Medicine in 2021 (14). Although the development of appropriate screening tools is generally to be welcomed, it must be noted that the reliable exclusion or diagnosis of a mental illness is to be performed by a specialist, psychiatric-psychotherapeutic competence and requires specialist expertise (from specialists in child, adolescent and adult psychiatry) (1).

SMHAT-1 allows non-specialists in the two psychiatric specialties a high level of competence and responsibility in the diagnosis and treatment of mental illness and the coordination of the same. This clearly contrasts the basic recommendations in the management of mental illness, for example, from the American Psychiatric Association (1). Sports physicians have a very important function in a care model for mental health in competitive sports. The qualified and safe handling of mental health or the threat to its integrity requires, in addition to specialist medical competence, specific expertise in competitive sports and, in the case of certain mental illnesses, such as trauma sequelae, expertise that builds on specialist medical competence (9). For this purpose, a network of psychiatrists as well as clinically trained psychologists must be established.

A special focus in the concepts for promoting mental health in competitive sports should be on sport-specific risks. Key words here include the increased risk of developing disordered eating behavior and eating disorders, head injuries, overtraining syndrome, and the prevention of violence and abuse.

Moreover, these specific aspects of competitive sport, as well as, for example, certain sport-specific phenotypes of mental disorders and illnesses, often go beyond the classic, specialist psychiatric knowledge – and make a specific qualification in sports psychiatry necessary for psychiatrists.

Special Units for Sports Psychiatry

Thus, it would be desirable to have qualified medical mental health professionals in the larger federations and clubs. Associations and clubs that are unable to integrate such specialists into their structures could find appropriate support in a network of sports psychiatrists (Table 1). In addition to providing low-threshold contact and advice from sports psychiatrists, the task of these specialist units could be to develop and implement prevention concepts in competitive sports.

The bridging function between athletes, coaches, support staff and federations can help to develop protective concepts, comparable to the discussion of lower weight limits in sports that are associated with a high risk of developing disordered eating behavior and eating disorders, changes to the game rules, sports equipment and gear in sports that are associated with a high risk of head injuries, or age limits in certain sports, for example aesthetic sports. The specialized units must be certified and awarded. Here, in turn, the societies are called upon to develop appropriate guidelines and to enable quality assurance as well as to monitor the Quality.

Networks of Sports Psychiatry

A very helpful network of sports psychiatrists in Germany was established by the Department of Sports Psychiatry and Psychotherapy of the German Association for Psychiatry and Psychotherapy, Psychosomatics and Neurology e. V. (Deutsche Gesellschaft für Psychiatrie und Psychotherapie, Psychosomatik und Nervenheilkunde e. V., DGPPN) with its DGPPN Centers "Mental Health in Sport" and the expert list "Sports Psychiatry" (Table 1). Within the German Society for Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy (Deutsche Gesellschaft für Kinder- und Jugendpsychiatrie, Psychosomatik und Psychotherapie e.V., DGKJP), a working group on sports psychiatry in childhood and adolescence was also recently formed in October 2020.

In Switzerland, the Swiss Society for Sports Psychiatry and Psychotherapy (SSSPP; Schweizerische Gesellschaft für Sportpsychiatrie und -psychotherapie, SGSPP) functions as such a network and lists sports psychiatrists (child, adolescent, and adult psychiatrists).

In Austria, the Austrian Society for Sports Psychiatry and Psychotherapy (Österreichische Gesellschaft für Sportpsychiatrie und -psychotherapie, ÖGSPP), which was founded last year, should be mentioned, which functions as a corresponding network of sports psychiatrists in addition to the Section for Sports Psychiatry and Psychotherapy within the Austrian Society for Psychiatry and Psychotherapy (Österreichische Gesellschaft für Psychiatrie und Psychotherapie, ÖGPP).

These efforts and networks must be further expanded. On one hand, this is to further optimize medical care provision, but also to advance research in the still young field of sports psychiatry in competitive sports. This should create the evidence to place the recommendations on a broad scientific footing.

Systematic education and training, and thus also quality assurance, is central to every specialist discipline. First efforts in this direction were made in the German-speaking countries by the Swiss Society for Sports Psychiatry and Psychotherapy. The SSSPP has developed a three-stage curriculum, which is the first of its kind to enable systematic continuing education and quality assurance in sports psychiatry (8).

The German Society for Sports Psychiatry and Psychotherapy (Deutsche Gesellschaft für Sportpsychiatrie und -psychotherapie, DGSPP) – and a further network of sports psychiatrists in Germany – has also developed a three-stage continuing education curriculum in sports psychiatry. It would be desirable to coordinate these curricula and to establish uniform continued education in sports psychiatry in Germany and Switzerland and, if possible, also with the Austrian colleagues, as well as colleagues from further countries.

Further discourse should occur regarding continuing education in sport psychiatry to build on these initial considerations of continuing education within sport psychiatry networks, but then in conjunction with sports medicine (7).

Conclusions

Sporting success and mental health must not be a contradiction of terms. The risks and burdens for mental health associated with the practice of competitive sports must be perceived and not seen or accepted as an unavoidable side effect of competitive sports. The goal is to support athletes. Sports psychiatrists can make a valuable contribution to this, but their initiative must in no way be understood as a "psychiatrization" of competitive sport.

Athletes must not be exposed to avoidable mental health risks through regulations or agreements. Federations and clubs should strive to make the best possible use of the opportunities available to promote and maintain physical and mental health, including the prevention of violence and abuse. For example, the implementation of diagnostics for mental health problems and illnesses and the integration of sports psychiatry into care provision structures. Athletes should be supported in making use of these expanded structures.

Training for athletes, coaches and trainers should help to break down barriers and avoid stigmatization on the one hand and raise awareness of mental health and the connections with performance on the other.

An open communication culture is to be promoted in order to be able to address and tackle any grievances at an early stage. In the case of underage athletes, this also includes the parents or guardians. Independent contact points, such as the aforementioned specialized sports psychiatry units, can help in particular where internal club or association structures are part of the problem.

Athletes, like all other humans, have the right to medical care and participation, in scientific progress (29). This is especially true for underage athletes, whose best interests must be given priority (28). At the same time, there is the right to free development of the personality. This includes risky or unhealthy behavior, which in its extreme form is reflected in the so-called Goldman dilemma (12).

Although competitive sports involve particular risks to physical and mental health, it is the responsibility of all those involved to minimize these as far as possible. In particular, the right of children to be supported in their development and to be protected from violence and abuse are non-negotiable and should always be given top priority. This has already found its way into sports regulations in the form of weight and age limits, as well as ethical codes, among other things, but is not yet an integral part of the culture of competitive sports.

Further efforts are still needed in the development of a medical discipline for mental health in competitive sports, as well as scientific data, e.g. on the relationships between
performance sport-related risks and stresses and mental health. With an increase in knowledge, sports psychiatric standards need to be developed and refined, including evidence-based guidelines. This calls for comprehensive research.

The self-determination of athletes in the sense of "informed consent" and participatory decision-making should contribute to athletes being able to take responsibility for their mental and physical health in an informed manner. Ultimately, all
suggestions serve to ensure that competitive sports can be practiced in harmony with mental health in the long term and to preserve the fascination of competitive sports.

Concluding remarks: This position paper is part of a Special Issue titled "Psychiatry and Sports Medicine" within the German Journal of Sports Medicine; Dtsch Z Sportmed. 2021; 72 (6). Psychiatrists and sports physicians contributed to this position paper. It would be desirable, if further discussions, regarding mental health promotion and mental health care models in competitive sports will be conducted together with all the clinical and non-clinical disciplines mentioned in the position
paper.

Conflict of Interest

Disclosures of financial interests and relationships, such as patents, royalties, or corporate support: The translation of the German version of the Manuscript was conducted by Ian Needham and financially supported by the Swiss Society for Sports Psychiatry and Psychotherapy (SSSPP).

Contribution Statement

Board members from the Swiss, Austria and German societies for sports psychiatry (MCC, CGH, ES, AS, TF), plus the deputy head of the Department of Sports Psychiatry and Psychotherapy of the German Association for Psychiatry and Psychotherapy, Psychosomatics and Neurology e. V. (FH), together with sports physicians, e.g. from the University of Salzburg (JN) and the University of Zurich (SF, JS), and further psychiatrists (ARS, MA) and sports physicians (JH, EK), contributed to the position paper. In addition, we refer to the author list and affiliations.

MCC proposed the idea of the paper in discussion with CGH and JS. MCC wrote the original draft. All authors reviewed and edited the manuscript.

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Malte Christian Claussen, MD
Department of Psychiatry, Psychotherapy
and Psychosomatics
Psychiatric University Hospital Zurich
Lenggstrasse 31, 8032 Zurich, Switzerland
malte.claussen@pukzh.ch