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.

Objective: To identify and quantify determinants of anxiety symptoms and disorders experienced by elite athletes.Design: Systematic review and meta-analysis.Data sources: Five online databases (PubMed, SportDiscus, PsycINFO, Scopus and Cochrane) were searched up to November 2018 to identify eligible citations.Eligibility criteria for selecting studies: Articles were included if they were published in English, were quantitative studies and measured a symptom-level anxiety outcome in competing or retired athletes at the professional (including professional youth), Olympic or collegiate/university levels.Results and summary: We screened 1163 articles; 61 studies were included in the systematic review and 27 of them were suitable for meta-analysis. Overall risk of bias for included studies was low. Athletes and non-athletes had no differences in anxiety profiles (d=−0.11, p=0.28). Pooled effect sizes, demonstrating moderate effects, were identified for (1) career dissatisfaction (d=0.45; higher anxiety in dissatisfied athletes), (2) gender (d=0.38; higher anxiety in female athletes), (3) age (d=−0.34; higher anxiety for younger athletes) and (4) musculoskeletal injury (d=0.31; higher anxiety for injured athletes). A small pooled effect was found for recent adverse life events (d=0.26)—higher anxiety in athletes who had experienced one or more recent adverse life events.Conclusion: Determinants of anxiety in elite populations broadly reflect those experienced by the general population. Clinicians should be aware of these general and athlete-specific determinants of anxiety among elite athletes.

Objective To summarise the literature on the barriers to athletes seeking mental health treatment and cultural influencers of mental health in elite athletes. Design Systematic review Data sources PubMed, Cochrane, Scopus, SportDiscus (Ebsco), and PsycINFO (ProQuest) up to November 2018. Eligibility criteria for selecting studies Qualitative and quantitative original studies of elite athletes (those who competed at the professional, Olympic, or collegiate/university levels), published in any language. Results Stigma, low mental health literacy, negative past experiences with mental health treatment-seeking, busy schedules, and hypermasculinity are barriers to elite athletes seeking mental health treatment. Cultural influencers of mental health in elite athletes include: (1) the lack of acceptance of women as athletes; (2) lower acceptability of mental health symptoms and disorders among non-white athletes; (3) non-disclosure of religious beliefs; and (4) higher dependence on economic benefits. Coaches have an important role in supporting elite athletes in obtaining treatment for mental illness. Brief anti-stigma interventions in elite athletes decrease stigma and improve literary about mental health. Conclusion There is a need for various actors to provide more effective strategies to overcome the stigma that surrounds mental illness, increase mental health literacy in the athlete/coach community, and address athlete-specific barriers to seeking treatment for mental illness. In this systematic review, we identified strategies that, if implemented, can overcome the cultural factors that may otherwise limit athletes seeking treatment. Coaches are critical for promoting a culture within elite athletes’ environments that encourages athletes to seek treatment.

This narrative review examines post-traumatic stress disorder (PTSD) and other trauma-related disorders—mental health conditions with complex diagnosis and treatment considerations—in elite athletes. Athletes may exhibit greater rates of PTSD (up to 13%–25% in some athlete populations) and other trauma-related disorders relative to the general population. We describe common inciting events leading to symptoms of PTSD in elite athletes, including trauma incurred in sports participation through direct physical injury, secondary/witnessed traumatic events, or abusive dynamics within sports teams. Symptoms of PTSD may significantly impact athletes’ psychosocial and sport-related function through avoidance, hypervigilance and dissociative behaviours, which, in turn, may delay recovery from musculoskeletal injury. While PTSD may be common among elite athletes, recognition by providers who do not routinely screen for trauma-related disorders may be challenging because of the tendency of athletes to mask symptoms of PTSD and other trauma-related disorders. Early identification of athletes suffering from trauma-related symptoms, including those of acute stress disorder, may prevent progression to PTSD, while treatment of athletes already meeting criteria for PTSD may improve life functioning and sports performance outcomes. Current evidence supports increasing awareness of PTSD in athletes and use of screening tools to identify athletes who may benefit from trauma-informed medical or psychotherapeutic interventions.

External change agents can play an essential role in healthcare organizational change efforts. This systematic review examines the role that external change agents have played within the context of multifaceted interventions designed to promote organizational change in healthcare—specifically, in primary care settings. We searched PubMed, CINAHL, Cochrane, Web of Science, and Academic Search Premier Databases in July 2016 for randomized trials published (in English) between January 1, 2005 and June 30, 2016 in which external agents were part of multifaceted organizational change strategies. The review was conducted according to PRISMA guidelines. A total of 477 abstracts were identified and screened by 2 authors. Full text articles of 113 studies were reviewed. Twenty-one of these studies were selected for inclusion. Academic detailing (AD) is the most prevalently used organizational change strategy employed as part of multi-component implementation strategies. Out of 21 studies, nearly all studies integrate some form of audit and feedback into their interventions. Eleven studies that included practice facilitation into their intervention reported significant effects in one or more primary outcomes. Our results demonstrate that practice facilitation with regular, tailored follow up is a powerful component of a successful organizational change strategy. Academic detailing alone or combined with audit and feedback alone is ineffective without intensive follow up. Provision of educational materials and use of audit and feedback are often integral components of multifaceted implementation strategies. However, we didn’t find examples where those relatively limited strategies were effective as standalone interventions. System-level support through technology (such as automated reminders or alerts) is potentially helpful, but must be carefully tailored to clinic needs.

Background Substances from various classes may be used for recreational purposes, self-treatment or to boost performance. When substance use shifts from occasional to regular, heavy or hazardous use, positive and negative effects can develop that vary by substance class and athlete. Regular use of recreational or performance enhancing substances can lead to misuse, sanctions or use disorders. Objective To review the prevalence, patterns of use, risk factors, performance effects and types of intervention for all classes of recreational and performance enhancing substances in elite athletes by sport, ethnicity, country and gender. Methods A comprehensive search was conducted to identify studies that compared the prevalence and patterns of substance use, misuse and use disorders in elite athletes with those of non-athletes and provided detailed demographic and sport variations in reasons for use, risk factors and performance effects for each main substance class. Results Alcohol, cannabis, tobacco (nicotine) and prescribed opioids and stimulants are the most commonly used substances in elite athletes, but generally used at lower rates than in non-athletes. In contrast, use/misuse rates for binge alcohol, oral tobacco, non-prescription opioids and anabolic-androgenic steroids are higher among athletes than non-athletes, especially in power and collision sports. Cannabis/cannabinoids seem to have replaced nicotine as the second most commonly used substance. Conclusions Substance use in elite athletes varies by country, ethnicity, gender, sport and competitive level. There are no studies on substance use disorder prevalence in elite male and female athletes and few studies with direct comparison groups.