Athlete mental health and the physicians’ role

The prevalence of mental disorders in Singapore is on the rise.[1] A significant subset of the population affected includes its growing number of athletes, from elite to school level. Athletes are exposed to not only stressors at work or in school, but also to stressors related to sport participation — from poor sleep arising from training and competition commitments selection pressure, injury, premature retirement and slumps in performance. Singapore’s athletes have become competitive on the world stage, winning World and Olympic titles. Along with this comes the pressure of professional sport. At the school level, the Direct School Admission scheme has raised the stakes for student-athletes who may not be ready to face such pressures. The Singapore Sports School, launched in 2004, offers an intensive training and competition schedule, with an academic curriculum wrapped around it. Another major stressor, widely publicised in international media, is non-accidental violence, namely harassment and abuse in sport. This may take the form of psychological, physical or sexual abuse, or neglect.[2] As physicians managing sports injuries, it is notable that an athlete’s physical and mental health are interlinked. Physical injuries increase the risk of mental disorders, which in turn, delay recovery and increase the risk of further physical injury. Sports injuries such as concussions and chronic traumatic encephalopathy (arising from repetitive head impacts) have more direct causal links to cognitive, behavioural and mood changes.[3] Hence, physicians need to be mindful of the signs and symptoms of mental disorders in athletes. These can be wide ranging and include depression, anxiety, eating disorders, burnout, substance abuse (including adverse alcohol use), post-traumatic stress disorder (e.g. from injury) and sport-related concussion. Extreme cases may result in suicide. The International Olympic Committee (IOC) consensus statement on mental health in elite athletes (2019) provides a comprehensive and structured approach to the management of mental health symptoms and disorders in athletes.[2] With the additional stressors faced by athletes, is the prevalence of mental disorders higher among athletes compared to the general population? Given the relative lack of awareness, diverse presentations and tendency to under-report, collecting reliable data is challenging. The general consensus is that there is no overwhelming evidence to suggest that mental disorders are more prevalent among athletes than in the general population. While athletes face additional stressors, their training may instil better coping strategies, and exercise has been demonstrated to be beneficial to mental health. Given the higher competitive levels, are senior athletes more prone to mental disorders compared to junior and youth athletes? Again, this is hard to gauge. It may be perilous to assume that junior-level competitions are not as intense, as young athletes often compete in a professional environment before their coping skills have had time to mature. The survey by Li et al.[4] on the prevalence of mental health symptoms in Singapore elite athletes provides insight into the size and nature of the problem locally. The survey found that 70% of respondents reported “high” to “very high” levels of athlete-specific psychological strain, 41% reported clinically significant depressive symptoms, 18% reported “moderate” to “severe” anxiety symptoms, and 16% were suspected to have disordered eating. These numbers are high enough to warrant that clinicians remain vigilant not only with elite athletes, but also across the broader athletic population, as school athletes face significant stressors yet often have less developed coping mechanisms. Along with early recognition of the signs and symptoms of mental disorders in athletes, there needs to be frameworks in place to protect athletes, especially from non-accidental violence, as well as referral pathways to better manage their mental health. The former is being addressed by the IOC through its toolkit of safeguarding policies and procedures for International Federations and National Olympic Committees, which will ultimately filter down to our National Sports Associations.[5] The latter is being addressed jointly by the Singapore Sports Medicine Centre and High Performance Sport Institute. Mental health screening has been woven into the biennial pre-participation screening for Singapore’s national athletes, and referral pathways are being established among physicians, sports psychologists, clinical psychologists and psychiatrists to direct athletes to the appropriate clinician.

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