Objectives To present an overview of the existing epidemiological evidence regarding the occurrence of mental health symptoms and disorders among current and former elite athletes. Design Systematic review and meta-analysis. Data sources Five electronic databases were searched from inception to November 2018: PubMed (MEDLINE), SportDiscus via EBSCO, PSycINFO via ProQuest, Scopus and Cochrane. Eligibility criteria for selecting studies We included original quantitative studies that were written in English, were conducted exclusively among current or former elite athletes, and presented incidence or prevalence rates of symptoms of mental disorders. Results Twenty-two relevant original studies about mental health symptoms and disorders among current elite athletes were included: they presented data especially on symptoms of distress, sleep disturbance, anxiety/depression and alcohol misuse. Meta-analyses comprising 2895 to 5555 current elite athletes showed that the prevalence of mental health symptoms and disorders ranged from 19% for alcohol misuse to 34% for anxiety/depression. Fifteen relevant original studies about mental health symptoms and disorders among former elite athletes were included: they similarly presented data especially about symptoms of distress, sleep disturbance, anxiety/depression and alcohol misuse. Meta-analyses comprising 1579 to 1686 former elite athletes showed that the prevalence of mental health symptoms and disorders ranged from 16% for distress to 26% for anxiety/depression. Conclusions Our meta-analyses showed that the prevalence of mental health symptoms and disorders ranged from 19% for alcohol misuse to 34% for anxiety/depression for current elite athletes, and from 16% for distress to 26% for anxiety/depression for former elite athletes.

Objectives To develop an assessment and recognition tool to identify elite athletes at risk for mental health symptoms and disorders. Methods We conducted narrative and systematic reviews about mental health symptoms and disorders in active and former elite athletes. The views of active and former elite athletes (N=360) on mental health symptoms in elite sports were retrieved through an electronic questionnaire. Our group identified the objective(s), target group(s) and approach of the mental health tools. For the assessment tool, we undertook a modified Delphi consensus process and used existing validated screening instruments. Both tools were compiled during two 2-day meeting. We also explored the appropriateness and preliminary reliability and validity of the assessment tool. Sport Mental Health Assessment Tool 1 and Sport Mental Health Recognition Tool 1 The International Olympic Committee Sport Mental Health Assessment Tool 1 (SMHAT-1) was developed for sports medicine physicians and other licensed/registered health professionals to assess elite athletes (defined as professional, Olympic, Paralympic or collegiate level; aged 16 years and older) potentially at risk for or already experiencing mental health symptoms and disorders. The SMHAT-1 consists of: (i) triage with an athlete-specific screening tool, (ii) six subsequent disorder-specific screening tools and (iii) a clinical assessment (and related management) by a sports medicine physician or licensed/registered mental health professional (eg, psychiatrist and psychologist). The International Olympic Committee Sport Mental Health Recognition Tool 1 (SMHRT-1) was developed for athletes and their entourage (eg, friends, fellow athletes, family and coaches). Conclusion The SMHAT-1 and SMHRT-1 enable that mental health symptoms and disorders in elite athletes are recognised earlier than they otherwise would. These tools should facilitate the timely referral of those athletes in need for appropriate support and treatment.

Currently, there is no overview of the incidence and (volleyball‐specific) risk factors of musculoskeletal injuries among volleyball players, nor any insight into the effect of preventive measures on the incidence of injuries in volleyball. This study aimed to review systematically the scientific evidence on the incidence, prevalence, aetiology and preventive measures of volleyball injuries. To this end, a highly sensitive search strategy was built based on two groups of keywords (and their synonyms). Two electronic databases were searched, namely Medline (biomedical literature) via Pubmed, and SPORTDiscus (sports and sports medicine literature) via EBSCOhost. The results showed that ankle, knee and shoulder injuries are the most common injuries sustained while playing volleyball. Results are presented separately for acute and overuse injuries, as well as for contact and non‐contact injuries. Measures to prevent musculoskeletal injuries, anterior knee injuries and ankle injuries were identified in the scientific literature. These preventive measures were found to have a significant effect on decreasing the occurrence of volleyball injuries (for instance on ankle injuries with a reduction from 0.9 to 0.5 injuries per 1000 player hours). Our systematic review showed that musculoskeletal injuries are common among volleyball players, while effective preventive measures remain scarce. Further epidemiological studies should focus on other specific injuries besides knee and ankle injuries, and should also report their prevalence and not only the incidence. Additionally, high‐quality studies on the aetiology and prevention of shoulder injuries are lacking and should be a focus of future studies.

Mental health symptoms and disorders amongst elite athletes have attracted a great deal of discussion recently. Current epidemiological evidence illustrates that mental health symptoms and disorders in elite athletes are prevalent and a concern for athletes, coaches, and sport organizations. Recently, seven consensus, expert, or position statements have been written on the topic of mental health in elite sport. A strategy suggested by each of the seven statements – aimed at preventing and treating mental health symptoms and disorders in elite athletes, both individually and systemically – is to employ education interventions, specifically those based on increasing mental health literacy. Mental health literacy has come to include concepts related to knowledge of effective self-management strategies, challenging mental disorder stigma, awareness and use of mental health first-aid to assist others, and the facilitation of help seeking behaviors. In elite sport, questions remain about how mental health literacy can address the unique needs of the individual athlete, but also factor in their culture and their environment to identify how to prevent and treat mental health symptoms and disorders. The purpose of this commentary is twofold: 1) to explore the evolving concept of mental health literacy within elite sport which addresses individuals, their culture, and their environment, and 2) to propose strategies for best practice and research in mental health literacy within elite sport relying on collaboration between sports psychiatry, sport psychology, and clinical psychology. Lay Summary: Expert statements on mental health in elite sport have suggested the use of educational strategies to address poor mental health in elite athletes. This commentary explores the concept of mental health literacy within elite sport which addresses individuals, their culture, and their environment, and proposes strategies for best practice.

Objectives To examine the sensitivity/specificity of the Athlete Psychological Strain Questionnaire (APSQ) in both male and female elite athletes, and also assess internal consistency and convergent/divergent validity, and determine discriminative validity relative to current injury status. Methods Data were provided by 1093 elite athletes (males n=1007; females n=84). Scale validity and reliability values were benchmarked against validated measures of general psychological distress and well-being. ROC curve analysis determined a range of optimal severity cut-points. Results Bias-corrected area under curve (AUC) values supported three APSQ cut-points for moderate (AUC=0.901), high (AUC=0.944) and very high (AUC=0.951) categories. APSQ total score Cronbach coefficients exceeded those observed for the Kessler 10 (K-10). Gender ×injury status interactions were observed for the APSQ total score and K-10, whereby injured female athletes reported higher scores relative to males and non-injured female counterparts. Conclusion By providing a range of cut-off scores identifying those scoring in the marginal and elevated ranges, the APSQ may better facilitate earlier identification for male and female elite athletes vulnerable to mental health symptoms and developing syndromes. Use of the APSQ may support sports medicine practitioners and allied health professionals to detect early mental ill health manifestations and facilitate timely management and ideally, remediation of symptoms.