Determinants of Anxiety in Elite Athletes

Systematic review Br J Sports Med: first published as 10.1136/bjsports-2019-100620 on 16 May 2019. Downloaded from Determinants of anxiety in elite athletes: a systematic review and meta-analysis Simon M Rice,‍ ‍ 1,2 Kate Gwyther,‍ ‍ 1,2 Olga Santesteban-Echarri,‍ ‍ 3 David Baron,4 Paul Gorczynski,5 Vincent Gouttebarge,6,7 Claudia L Reardon,‍ ‍ 8,9 Mary E Hitchcock,10 Brian Hainline,‍ ‍ 11 Rosemary Purcell1,2

4 ►► Additional material is Abstract (GAD) or social anxiety disorder. Additionally, published online only. To view Objective To identify and quantify determinants of anxiety can be a situationally or event-dependent please visit the journal online transitory state (eg, state anxiety), or a relatively (http://dx. doi.org/ 10.1136/ anxiety symptoms and disorders experienced by elite bjsports-2019- 100620). athletes. stable personality characteristic (eg, trait anxiety). Design Systematic review and meta-analysis. State anxiety symptoms are more likely to occur in For numbered affiliations see Data sources Five online databases (PubMed, situations perceived as threatening.6 end of article. SportDiscus, PsycINFO, Scopus and Cochrane) were Athlete-specific factors may precipitate or exac- searched up to November 2018 to identify eligible erbate anxiety disorders, including pressures to Correspondence to citations. perform and public scrutiny,7 career uncertainty or Dr Simon M Rice, Research 8 9 10–12 and Translation, Orygen, The Eligibility criteria for selecting studies Articles dissatisfaction, and injury. General psychoso- National Centre of Excellence were included if they were published in English, were cial factors are also strongly implicated in the onset in Youth Mental Health, quantitative studies and measured a symptom-level and maintenance of anxiety disorders within the Melbourne, VIC 3052, Australia; anxiety outcome in competing or retired athletes at the general population. These include behavioural inhi- simon. rice@orygen. org.au professional (including professional youth), Olympic or bition, social withdrawal or avoidance, and cogni- 13 Received 22 January 2019 collegiate/university levels. tive patterns of rumination. A recent meta-analysis Revised 13 March 2019 Results and summary We screened 1163 articles; 61 found that female gender, younger age and lower Accepted 14 March 2019 studies were included in the systematic review and 27 of athletic experience were associated with higher them were suitable for meta-analysis. Overall risk of bias competitive anxiety in athletes14; however, the for included studies was low. Athletes and non-athletes specific determinants of anxiety disorders in elite had no differences in anxiety profiles (d=−0.11, p=0.28). athlete populations has not yet been reported. Pooled effect sizes, demonstrating moderate effects, Identification of putative subgroup differences may were identified for (1) career dissatisfaction (d=0.45; assist with early identification and indicated preven- higher anxiety in dissatisfied athletes), (2) gender tion efforts in this population, improving the timely (d=0.38; higher anxiety in female athletes), (3) age management of anxiety disorders among elite (d=−0.34; higher anxiety for younger athletes) and (4) athletes. The objective of this study was to perform

musculoskeletal injury (d=0.31; higher anxiety for injured a systematic review and meta-analysis to identify, http://bjsm.bmj.com/ athletes). A small pooled effect was found for recent quantify and analyse determinants of anxiety symp- adverse life events (d=0.26)—higher anxiety in athletes toms experienced by elite athletes. who had experienced one or more recent adverse life events. Method Conclusion Determinants of anxiety in elite The study was conducted in accordance with the populations broadly reflect those experienced by the Preferred Reporting Items for Systematic Reviews general population. Clinicians should be aware of these

and Meta-Analyses guidelines. on September 26, 2021 by guest. Protected copyright. general and athlete-specific determinants of anxiety among elite athletes. Search strategy A systematic search strategy was developed by an experienced academic librarian (MEH). The Introduction search was executed in the PubMed, SportDiscus, Combined anxiety disorders affect the general PsycINFO, Scopus and Cochrane databases from population at an estimated (past 12 month) rate inception until November 2018. The search strategy of 10.6%–12.0%,1 2 with broadly similar rates and MeSH terms are presented in online supple- suggested among elite athlete populations (8.6%),3 mentary table 1. Citations were independently defined as those competing at professional, Olympic screened by SMR, RP and KG. or collegiate/university levels. Anxiety disorders are © Author(s) (or their characterised by emotional responses associated with Study inclusion employer(s)) 2019. Re-use permitted under CC BY-NC. No fear, apprehension, worry and tension in response Studies were selected if they included (1) data on 4 commercial re-use. See rights to an actual or perceived threat. Anxiety modu- elite athletes, including para-athletes, defined by and permissions. Published lates attentional networks, resulting in compro- standard of performance level,15 competing at the by BMJ. mised executive function, stimulus processing and professional (and professional youth, ie, members 5 To cite: Rice SM, Gwyther K, information selection —all important domains of elite sports schools), Olympic and collegiate/ Santesteban-Echarri O, for elite competition. While commonalities are university levels; (2) a symptomatic or diagnostic et al. Br J Sports Med present, diagnostic systems differentiate anxiety anxiety outcome measure (as per the Diagnostic and 2019;53:722–730. subtypes, such as generalised anxiety disorder Statistical Manual of Mental Disorders [DSM-5]4

Rice SM, et al. Br J Sports Med 2019;53:722–730. doi:10.1136/bjsports-2019-100620 1 of 10 Systematic review Br J Sports Med: first published as 10.1136/bjsports-2019-100620 on 16 May 2019. Downloaded from criteria) in relation to GAD, specific phobia, social anxiety, (current vs former). As subgroup analysis calculates an estimated panic disorders or obsessive-compulsive disorder (OCD); and effect size for each subgroup, a minimum of two subgroups with (3) currently competing or retired athletes (authors adopted a two contributing studies each were required to conduct a statis- maximum mean retirement length of 10 years to allow investi- tically sound analysis for a determinant.22 Additionally, sensi- gation of effects between anxiety and longer-term sport-specific tivity analysis was conducted when significant heterogeneity was outcomes [eg, concussion],16 and account for, yet limit the effect observed. Sensitivity analysis is a repeat of the initial analysis of retirement).17 which substitutes alternate inclusion or exclusion decisions to assess robustness of the results.24 Sensitivity analysis was calcu- Study exclusion lated by removing any visual outliers or studies with dissimilar Studies were excluded if they were not published in English, characteristics. were a case study or case report, used a qualitative design, were review articles or were not refereed journal articles (confer- Interpretation of forest plots ence abstracts were excluded), or focused solely on state-based A forest plot is a visual representation of the effect size for each performance or competitive anxiety (ie, included studies needed study, represented by squares, and the overall estimated effect to report on a measure/diagnosis of symptom-level anxiety as size, represented by a diamond. The side of the forest plot on per DSM-5). which the effect size estimate falls indicates a higher anxiety score in that group. For plots with subgroup analysis, overall Assessment of study quality effect size estimates are reported in the text. We assessed quality of studies with the Joanna Briggs Institute’s critical appraisal tools for systematic reviews.18 These tools are validated appraisal checklists specific to study design, capturing Heterogeneity and publication bias aspects of design quality, analysis and reporting. KG assessed The Q statistic measured the presence or absence of heteroge- studies using checklists for randomised controlled trials (RCTs), neity by testing the null hypothesis of no variation in true effect cohort studies, prevalence studies, cross-sectional studies and size across studies.25 Heterogeneity was assumed when the Q quasi-experimental studies. The appraisal score reported is the statistic was significant, as the null hypothesis of no variation proportion of ‘yes’ responses on the total number of criteria. If a is rejected. The I2 statistic describes the proportion of variance criterion was not applicable (N/A) to a given study, that item was in observed effects due to variance in true effects and can be not counted in the total number of criteria. interpreted as the percentage of variance that would remain if there was no sampling error.26 Low I2 scores indicate lower Data extraction heterogeneity. Publication bias was assessed using the Duval and 27 A standard template was designed for data extraction of study Tweedie trim-and-fill funnel plot method. A funnel plot is a and sample characteristics including study design, aim, loca- graphical representation of study size as a function of effect size; tion, gender ratio, sport population, anxiety outcome and key large studies generally appear at the top of the graph, close to findings. KG extracted the data and SMR reviewed them for the mean effect size, and small studies typically appear at the consistency. For the meta-analysis, KG extracted a list of deter- bottom of the graph, spread broadly around the mean effect 28 minants of anxiety (associated variables) in each study to assess size. Asymmetry in funnel plots (more studies falling to one http://bjsm.bmj.com/ viability for meta-analysis. Once a determinant was identified, side of the graph) indicates potential publication bias. To assess KG extracted the relevant quantitative data, while OS-E and the scope of bias, the trim-and-fill method estimates the number SMR reviewed for consistency. of missing studies in an asymmetrical plot, balances it with the ‘fill’ of additional study points and recalculates the estimated 27 Data analysis (meta-analysis) effect size using the filled estimates. Pooled effect sizes were estimated using Comprehensive 19 Meta-Analysis (CMA) software V.3.3.070. Raw data (mean, Results on September 26, 2021 by guest. Protected copyright. SD and n) were sourced for determinants of anxiety. When raw Literature search data were unavailable, we used effect size data (r, OR, t, and β The database search returned 1163 articles (figure 1). After F values). Overall effect sizes were estimated using the stan- removal of duplicates, 1111 articles were screened for eligibility. dardised difference in means (d) because this could be calculated Of the resulting 145 eligible articles, 61 were included in the for all types of extracted data. When we could not enter effect narrative synthesis after full-text assessment. These articles are size data directly into CMA (eg, , F and t statistics), transfor- β listed and grouped by anxiety outcome measure in table 1. mations were made into an r statistic.20 21 All meta-analyses used the random-effects model to account for within-study error and between-study variation. Though a minimum of two studies are Description of included studies 22 needed to perform a meta-analysis, CMA software requires Table 2 summarises the study characteristics of the reviewed arti- 23 at least three studies to perform publication bias analysis, cles (see online supplementary table 2 for a detailed summary hence we required three studies for inclusion in the overall (eg, of study characteristics for each article). Of the 61 studies, 46 non-subgroup) meta-analyses. An initial population compar- (75%) were published from 2014 onwards. Samples typically ison (elite athletes compared with non-athletes) was conducted, represented athletes from multiple countries (n=16, 26.2%). followed by analysis of the determinant variables. For single-location samples, the most common country was the USA (n=13, 21.3%), followed by Australia, France, Germany Subgroup and sensitivity analysis and Ireland with three studies each (5.0%). Italy, Korea, Spain, Where applicable, we conducted subgroup analysis to assess Sweden and Switzerland appeared twice (3.3%), and Canada, effect sizes across different anxiety outcomes (generalised, trait, China, Denmark, Egypt, Israel, Netherlands, Norway, Tunisia, diagnosis and global anxiety/depression) and playing status Turkey and the UK appeared once (1.6%).

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Table 1 Included articles grouped by anxiety measure State/trait Global anxiety/ Diagnosis (any Generalised anxiety anxiety depression anxiety disorder) Brand et al 201329 Bartholomew Brown et al 201756 Eissa et al 201867 200374 Byrd et al 201843 Filaire et al Foskett and Schaal et al 20113 199930 Longstaff 201841 Çelebi et al 2015105 Gerber et al Gouttebarge et al. Weber et al. 2018c34 201131 2015a52 Drew et al 2017106 Gomez-Piqueras Gouttebarge et al. et al 2018107 2015b47 Du Preez et al 201655 Gleeson et al Gouttebarge et al. Tension/anxiety 1999108 2016a53 Fiorilli et al 201332 Guillén and Gouttebarge et al. Moore et al 201669 Sánchez 200962 2016b109 Gross et al 201894 Guo et al Gouttebarge et al. Petito et al 201670 2018110 2016c54 Gulliver et al 201435 Halvari and Gouttebarge et al. Selmi et al 2018111 Gjesme 199573 2016d48 Houltberg et al Han et al 201465 Gouttebarge et al. 2018112 2017a44 Junge and Ivarsson et al Gouttebarge et al. Obsessive- Feddermann-Demont 201336 2017b57 compulsive disorder 201633 63 Figure 1 PRISMA study selection flow chart. Junge and Prinz Johnson and Gouttebarge et al. Cromer et al 2017 201842 Ivarsson 201149 2017c58 Lancaster et al 201637 Kang et al Gouttebarge et al. 201664 2017d50 Meta-analysis Liu et al 2018113 Levit et al Gouttebarge et al. Of the 61 articles, 27 (44%) were suitable for meta-analysis. After 201876 2017e51 screening for determinants of anxiety, seven variables were iden- Weber et al. 2018a38 Millet et al Gouttebarge et al tified: one population comparison (athletes vs non-athletes) and 200495 201859 six determinant variables (gender, age, concussion, musculoskeletal Weber et al. 2018b45 Morgan et al Kilic et al 2017114 injury, career dissatisfaction—typically measured as a dichotomous 198872 ‘yes/no’ variable, and recent adverse life events such as ‘death of Wilson and Madrigal Sheehan et al. Kilic et al 201812 close friend’ or ‘change in financial state’ within the past 6 months). 201771 2018a66 29–33 Five studies examined athletes compared with non-athletes. Sheehan et al. Schuring et al http://bjsm.bmj.com/ 39 60 No differences in anxiety symptomology were observed between 2018b 2017 Turner and Van Ramele et al athletes and non-athletes (d=−0.11, p=0.28; see figure 2). Sepa- 75 115 rate subgroup analysis of anxiety outcomes found no differences Raglin 1996 2017 in generalised anxiety (d=−0.04, p=0.36) or trait anxiety scores Yang et al 200740 (d=0.07, p=0.74). There was significant heterogeneity (p<0.01), Yang et al which became non-significant after removal of two studies that had 46 2015

mixed sport samples (Q=5.810, p=0.06; d=−0.06, p=0.798). on September 26, 2021 by guest. Protected copyright. There was no evidence of publication bias.

Concussion and musculoskeletal injury Demographic determinants Four articles examined anxiety by concussion frequency and symp- Ten articles measured anxiety by gender.3 31 33–40 Overall, female tomology.43–46 Figure 5 denotes a non-significant effect of concus- athletes reported higher anxiety scores compared with male sion (d=0.33, p=0.053). There was significant heterogeneity that athletes (d=0.38, p<0.001). Moderate effect sizes were found became non-significant after visual inspection advocated removal across all anxiety measurement types (see figure 3). Homoge- of an outlier study.43 The removal of the study also led to a small neity was upheld for the overall analysis and trait anxiety anal- significant effect (d=0.17, p=0.023), where athletes with concus- yses, but not the general anxiety (p=0.047) or diagnosis analyses sion history showed higher anxiety symptoms. There was no (p=0.045). Homogeneity was achieved for general anxiety after evidence of publication bias in the initial analysis, though there was removing the only single-sport sample (Q=1.658, p=0.437; evidence after the outlier study was removed. Accordingly, these d=0.28, p<0.001),33 though could not be reached for diagnosis results should be interpreted cautiously. as there were only two contributing studies. No publication bias Nine studies measured anxiety by musculoskeletal injury prev- was detected. alence.33 35 40 41 47–51 An overall significant small-moderate effect Three articles analysed anxiety by age.36 41 42 Younger athletes indicated injured athletes reported higher levels of anxiety (d=0.31, (<25 years) had higher anxiety levels compared with older athletes p<0.001). Subgroup analyses indicated significant effects across all (>25 years; d=−0.34, p=0.003; figure 4). There were insuffi- anxiety outcomes (see figure 6). Homogeneity was upheld across cient studies to perform subgroup analysis for anxiety outcomes. all analyses. There was evidence of publication bias, marginally Heterogeneity and publication bias were not detected. adjusting the estimated effect size (d=0.29).

Rice SM, et al. Br J Sports Med 2019;53:722–730. doi:10.1136/bjsports-2019-100620 3 of 10 Systematic review Br J Sports Med: first published as 10.1136/bjsports-2019-100620 on 16 May 2019. Downloaded from

Comorbidities Table 2 Summary of included article characteristics Diagnosed comorbidity was found for GAD occurring with depres- Types of athletes Sample characteristics sion,42 and for multiple anxiety disorders occurring together, for National level* 17 (27.8%) Mean sample size (n) 444 example GAD occurring with OCD, with agoraphobia or with Collegiate/university 15 (24.6%) Median sample size (n) 217 panic disorder.3 For symptomatology, higher anxiety scores were Professional 15 (24.6%) Mean age of sample (years) 24.5 commonly associated with higher depressive symptoms.40 46 Self-re- Mixed levels 7 (11.5%) Median age of sample 23.9 ported history of mental health disorders was also associated with (years) higher self-reported generalised anxiety symptoms in rugby players Professional youth 4 (6.6%) Mean retirement length 5.9 55 (years) during a competitive season and training season. Comorbidity Olympic 3 (4.9%) Aggregate sample size 27 515 of common mental health symptoms (including global anxiety/ Types of sports Aggregate male athletes 16 547 (60%) depression) was examined across multiple studies; however, due to Multiple 29 (48%) Aggregate female athletes 7964 (28.9%) non-specific reporting, it cannot be determined if indicated comor- 12 44 48 50 51 56–61 Soccer 13 (21%) Study design bidity encompassed anxiety symptoms. Rugby 5 (8%) Cross-sectional 36 (59%) Basketball 3 (5%) Cohort 17 (28%) Competitive level and experience Track and field 3 (5%) Longitudinal 2 (3%) Elite athletes playing at higher competitive levels typically reported Gaelic sports (eg, hurling) 2 (3%) Experimental 2 (3%) fewer symptoms of anxiety than athletes in lower competitive American football 1 (2%) Quasi-experimental 2 (3%) ranks,42 62 63 for instance, first-league compared with second- Baseball 1 (2%) Randomised clinical trial 1 (2%) league soccer and basketball players.42 62 Similarly, basketball and Golf 1 (2%) Mixed design 1 (2%) soccer players with more years of playing experience exhibited Ice hockey 1 (2%) lower anxiety scores than athletes with less experience.42 62 Lastly, Swimming 1 (2%) trait anxiety scores were lower in high-ranked compared with *One sample included national rookies. low-ranked professional golfers,64 although not in high-ranked and low-ranked baseball players.65 Career dissatisfaction and recent adverse life events Six articles analysed anxiety by career dissatisfaction.41 48 50–53 Motivation and coping Athletes with higher ratings of career dissatisfaction reported Two studies measuring team-sport athletes (eg, football, hurling) higher global anxiety/depression scores compared with career-sat- reported a negative correlation between trait anxiety and several isfied athletes (d=0.45, p<0.01; figure 7). Heterogeneity was measures of motivation, including autonomy, integrated regulation observed, though became non-significant after the removal of the (behaviours congruent with one’s value system) and intrinsic moti- only study with a retired athlete sample (Q=6.348, p=0.175; 39 66 53 vation (actions that produce satisfaction from participation). d=0.55, p<0.001). Publication bias was detected, slightly Trait anxiety was also positively correlated with non-regulated reducing the estimated effect size (d=0.45). 66 50–54 motivation (lack of intention to perform an action). Combined Five studies examined anxiety by recent adverse life events. team and individual sport athletes with panic disorder were less Figure 8 shows a small effect of recent adverse life events on global likely to use social support coping, positive reinterpretation (reap- anxiety/depression, where higher anxiety scores were found in

praising an adverse situation in an optimistic way) and information http://bjsm.bmj.com/ athletes who had experienced one or more recent adverse life seeking compared with athletes without that diagnosis.67 Athletes events (d=0.26, p<0.001). There was no evidence of heteroge- with GAD also reported low social support coping and informa- neity or publication bias. Exploratory subgroup analysis of current tion seeking, while athletes with specific phobias indicated high versus former athletes found a small effect for former athletes self-blame, helplessness and emotion-focused coping (eg, regu- (d=0.26, p<0.001, k=2),53 54 but not current athletes (d=0.23, lating distress with relaxation techniques).67 p=0.113, k=3).50–52

Neurological and biological factors on September 26, 2021 by guest. Protected copyright. Narrative results 68 Online supplementary table 3 summarises key findings of each of Tension/anxiety, exemplified by uneasiness and nervousness, the 61 articles. The following sections summarise other results not was negatively correlated with frontal alpha-asymmetries detected included in the meta-analysis. on electroencephalography (EEG) in soccer and American football players with concussion history who had returned to play.69

Figure 2 Forest plot for anxiety in athletes and non-athletes.

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Figure 3 Subgroup analyses for anxiety outcomes in male and female athletes.

Tension/anxiety was also higher in team-sport athletes with an (eg, gymnastics, figure skating) had the highest rates of GAD, l/l genotype compared with an s/s genotype for the 5-HTTLPR while risk sports (eg, aerial sports, motor sports) had the lowest serotonin transporter.70 Symptoms of generalised anxiety were rates in both male and female athletes.3 One study found handball negatively correlated with several markers of omega-3 polyunsat- players had higher state and trait anxiety compared with volley- urated fatty acids, including blood levels of eicosapentaenoic acid, ball players.30 Lastly, no differences in state and trait anxiety were docosapentaenoic acid and HS-omega-3 indices, in athletes across found between team-sport and individual-sport athletes.76 a range of sports (basketball, soccer, rifle, and golf).71 Quality appraisal (risk of bias) Performance For full quality appraisal, see online supplementary files 4–9e. Trait anxiety was negatively associated with performance in two The overall appraisal score (as a proportion) for all studies was studies, one regarding race times for long-distance runners72 and 0.8. Articles were typically of high quality, with 41 articles (67%) the other regarding performance errors following a competitive scoring 0.8 and above. Nineteen articles (31%) were of moderate motor task in collegiate athletes.73 For state anxiety, accurate methodological quality (0.5–0.79), and one article (2%) was of http://bjsm.bmj.com/ performance feedback from an experimenter was associated with poor methodological quality (<0.5). No studies were excluded lower anxiety shortly after a competitive task, whereas low feed- based on these analyses. back was associated with a short-term increase in state anxiety for rowing and cross-country athletes.74 Similarly, ‘optimal’ state Discussion anxiety (dependent on an athlete’s recollection) was associated The present study sought to identify determinants of anxiety 75 with high performance in track and field athletes. symptoms and disorders among elite athletes, in addition to summarising the extant literature on this population to date. Sport type As noted by others,77 findings of this review highlight a rapid on September 26, 2021 by guest. Protected copyright. Comparisons across sport types were rarely reported in the increase in this research domain, with 75% (n=46) of included included literature. One study found that aesthetic sport athletes studies published within the last 5 years. The meta-analysis

Figure 4 Forest plot for anxiety among athletes older and younger than 25 years.

Rice SM, et al. Br J Sports Med 2019;53:722–730. doi:10.1136/bjsports-2019-100620 5 of 10 Systematic review Br J Sports Med: first published as 10.1136/bjsports-2019-100620 on 16 May 2019. Downloaded from

Figure 5 Forest plot for anxiety in athletes with and without concussion history. outcomes indicated several general factors as being salient to was associated with higher global anxiety/depression in former symptomatic anxiety in elite athletes, including female gender, but not current athletes. Established support services for athletes younger age and recent experience of adverse life events. These that have transitioned out of elite sport should consider the pres- factors are consistent with findings from a recent meta-analysis ence and impact of recent adverse life events in this population for competitive anxiety in athletes,14 and trends in the general as a potential risk factor of symptomatic anxiety. population.14 78 79 Meta-analysis also indicated the role of two Meta-analysis of the five studies that also reported data from athlete-specific factors, namely current musculoskeletal injury a non-athlete control group29–33 indicated that athletes report and sporting career dissatisfaction, as being associated with anxiety symptoms at comparable severity with the general popu- anxiety symptoms. This is the first meta-analysis to highlight lation. Similarly, a recent meta-analysis identified that high-per- these domains as potential risk factors for symptomatic anxiety formance athletes were no more likely than non-athletes to among elite athletes. report mild to severe symptoms of depression.82 This is consistent Considering the athlete-specific factors, musculoskeletal with assertions that elite athletes are not necessarily protected injury and career dissatisfaction can be understood as promi- from mental health symptoms by virtue of their sporting role,83 nently biopsychosocial influencers of mental health.80 Attention strengthening the rationale for an increased focus on the mental to these factors, when present for elite athletes, may assist sports health of this population, and the broader development of the medicine practitioners in planning for the psychological manage- field of sports mental health.84 85 Anxiety disorders (especially ment needs of athlete cohorts. While individual intervention may GAD and social anxiety) are relatively prevalent in the general be required for affected athletes (eg, psychotherapy, pharmaco- population, and may be similarly so in elite athletes, although http://bjsm.bmj.com/ therapy), sport administrators and officials may also wish to research into diagnosed disorders (relative to symptoms) in this consider the broader environmental factors that may contribute population is lacking. to athlete injury or career dissatisfaction. For example, systemic This study also examined a range of broader outcomes that approaches may involve challenging once normative attitudes were not suitable for inclusion in the meta-analysis. Unsurpris- about the need for athletes to play or train though pain or injury ingly, it was found that anxiety symptoms in elite athletes were in order to demonstrate resilience or ‘toughness’.81 associated with symptoms of depression,40 46 or a depression diag- 42

Additionally, retirement status as an athlete-specific subgroup nosis, in addition to other concurrent anxiety disorder diag- on September 26, 2021 by guest. Protected copyright. analysis indicated that experiencing recent adverse life events noses.3 Anxiety symptoms were lower among more experienced

Figure 6 Subgroup analyses for anxiety outcomes in injured and uninjured athletes.

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Figure 7 Forest plot for anxiety in athletes with and without career dissatisfaction. athletes,42 62 63 and may have a negative relationship with both role-related barriers including concerns about stigma and the motivation39 66 and discrete aspects of sporting performance.72 73 impact of disclosure and help-seeking on team selection.90 The These findings further support the role of preventative or early development of youth-specific models of mental healthcare for intervention approaches in the management of anxiety disor- those under 25 years has resulted in decreased stigma and service ders in elite athletes, as this may lower the likelihood of devel- barriers, improving access to evidence-based intervention.91 oping comorbid mental health problems (such as depression), Athlete-specific models of care are emerging,92 and efforts to and increase the likelihood of motivation and performance consolidate and expand such initiatives warrant the support of remaining intact. Psychological factors considered essential for governing bodies, codes, and competitions. elite athletes successful at the highest levels include affect and self-regulation, maintaining motivation, self-confidence and adaptive coping strategies, alongside supportive interpersonal Limitations and future directions relationships.86 Development of and attention to such factors We acknowledge several limitations. In general, the quality of will almost certainly assist athletes in managing anxiety (either study reporting was relatively high, suggesting an overall low at the symptom or diagnostic level), and coupled with evidence- risk of bias in the included studies. Nonetheless, a wide range based intervention (eg, cognitive behavioural therapy), should be of anxiety symptom rating scales were employed in the studies considered by sports medicine practitioners and sports officials included in the meta-analysis. Where possible, we conducted in supporting the mental health of athlete populations. subgroup analyses for measures differentiating trait, gener- The overall mean age for participants in the included studies alised, global and diagnosed anxiety. Heterogeneity was initially was 24.5 years, which is inclusive of several studies that incor- observed for the gender, concussion and career dissatisfaction http://bjsm.bmj.com/ porated recently retired athletes. For most Olympic and analyses, though resolved after inspection of sample-specific professional sports, the years of competitive elite competition differences (eg, differences between sports). Additionally, only directly overlap with the peak ages of onset for mental disor- a small proportion of the included studies reported a confirmed ders, with 75% of all mental disorders shown to emerge prior clinician-rated or interviewer-rated diagnosis of anxiety, with to age 25.87 As anxiety disorders account for a large proportion most studies employing self-reported symptoms. Distinguishing of the burden of disease among all mental health problems,88 anxiety symptoms from diagnostic disorders is important given

their presence among and impacts on elite athlete populations functional impairment and associated distress is likely to be on September 26, 2021 by guest. Protected copyright. affords greater attention and action where needed. Younger more severe in the latter. Studies examining outcomes of athletes populations are also known to experience particular barriers to within the clinical range for anxiety disorders are currently accessing mental healthcare,89 and elite athletes have additional lacking, and as the field progresses, future reviews should look

Figure 8 Forest plot for anxiety in athletes with and without adverse life events within six months.

Rice SM, et al. Br J Sports Med 2019;53:722–730. doi:10.1136/bjsports-2019-100620 7 of 10 Systematic review Br J Sports Med: first published as 10.1136/bjsports-2019-100620 on 16 May 2019. Downloaded from to examine potential group differences according to clinician or not yet well understood. As an extension, it is unclear whether interviewer-rated diagnoses of anxiety versus self-report symp- athlete-specific interventions that provide remission of anxiety toms, given there may be bias in self-report measures, either in symptoms may be associated with changes in performance. terms of under-reporting or over-reporting.93 Further, attention Furthermore, while GAD and generalised anxiety symptoms should be given to patterns of symptom onset, duration, severity were well addressed in this review, at present we know far less and associated distress4 in order to distinguish anxiety disorders about other anxiety disorders (eg, OCD, panic disorder, social from competition-based performance anxiety. phobia) and a related personality disorder (ie, obsessive-com- While a relatively large number of studies were included in pulsive personality disorder; OCPD) in elite athletes. Ritualistic this review, only one study reported on the effects of an inter- behaviours or routines are common among elite athletes,86 and vention, and there were only a handful of studies using a longitu- potential overlap between such behaviours and anxiety disor- dinal design. The single included intervention study was a small ders, especially OCD and OCPD, remains poorly understood. RCT testing a mindfulness-acceptance–based approach.94 While Finally, additional research is needed on neurological or other groups have developed athlete-specific mental health biological aspects of anxiety in elite athletes. There was a rela- interventions (eg, the athlete optimisation approach for college tive lack of attention to this among included studies, and such athletes of Donohue et al),92 anxiety outcomes of these inter- research could consider EEG profiles,69 or imaging approaches, ventions are yet to be explored. The present results highlight the effects of biotherapeutic agents such as omega-3 polyun- the urgent need for well-conducted intervention-based RCTs, saturated fatty acids71 or cannabidiol, which is currently not a and specific attention towards the acceptability and efficacy of prohibited substance for athletes,104 and genomics and related psychotherapy approaches among elite athletes is needed. Simi- hereditary analytic approaches.104 larly, longitudinal studies in elite athlete populations are needed to shed light on anxiety symptom patterns according to temporal Conclusions factors. Related to this, the present study was unable to conclude Factors associated with anxiety symptoms among elite athletes whether time in competitive season impacted outcomes. It is provide useful information for preventative intervention or possible that a seasonal effect of athlete anxiety may exist in acute phase management. While there are research gaps related line with peak training loads, recovery and proximity to major to particular subtypes of anxiety in elite populations (eg, OCD, competition.95 panic disorder), this review highlights both general factors and The present review discovered markedly higher symptom- athlete-specific factors associated with symptom burden. Though atic anxiety among female athletes than their male counter- data are lacking, it seems feasible that focused and acceptable parts. Emerging research suggests that younger males, who can interventions for anxiety symptoms among athlete populations be socialised to deny or suppress perceived vulnerabilities in may enhance career longevity and improve role satisfaction. sport settings,96 may exhibit mental health symptoms through a Youth-specific models of mental healthcare that have been estab- constellation of behaviours beyond those included in diagnostic lished internationally are likely to be useful for those aiming to criteria for internalising disorders such as anxiety.97 98 Research develop innovative athlete-specific services. While it remains attention to anxiety symptoms (which are known to be higher to be seen whether such approaches will improve sporting or in females), in the context of broader comorbidity domains athletic performance, the next decade is certain to see major of risk-taking, problematic anger or aggression, and substance investment into the mental health of athletes and expansion of misuse (which are known to be higher in males),99 100 may be an sports mental health as a discipline. http://bjsm.bmj.com/ important step in recognising athletes at risk of mental health Author affiliations symptoms or disorders who may otherwise go unidentified via 1 existing anxiety rating scales or diagnostic criteria. Research and Translation, Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia Further, the present study identified an under-representa- 2Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, tion of female athletes and para-athletes. The ratio of males to Australia females was roughly double, and only one article reported data 3Department of Psychiatry, Hotchkiss Brain Institute, University of Calgary, Calgary, 32 for para-athletes. Future research should aim to explore these Alberta, Canada on September 26, 2021 by guest. Protected copyright. 4Center for Health and Sport, Western University of Health Sciences, Pomona, samples. Additionally, some factors pertinent to mental health California, USA are yet to be examined, including athlete sexuality and ethnicity. 5Department of Sport and Exercise Science, University of Portsmouth, Portsmouth, UK Future studies should consider these factors given consistent 6Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef, The Netherlands findings that minority sexuality and ethnicity differently impact 7 mental health.101 102 AMC/VUmc IOC Research Center of Excellence, Amsterdam Collaboration on Health and Safety in Sports (ACHSS), Amsterdam, The Netherlands To date, studies are yet to conclusively determine cross-sport 8Department of Psychiatry, University of Wisconsin School of Medicine and Public comparisons for anxiety disorders in elite athletes. The main Health, Madison, Wisconsin, USA exceptions to this are work by Schaal and colleagues,3 who found 9University Health Services, University of Wisconsin, Madison, Wisconsin, USA 10 higher rates of GAD among elite athletes competing in aesthetic Ebling Library for the Health Sciences, University of Wisconsin–Madison, Madison, 76 Wisconsin, USA sports, and work by Levit and colleagues, who found no 11National Collegiate Athletic Association (NCAA), Indianapolis, Indiana, USA differences in anxiety symptoms between team-based and individual athletes. Comparatively, growing literature of depression Acknowledgements The authors thank the other participants in the 2018 in elite athletes suggests that individual-sport athletes exhibit International Olympic Committee Consensus Meeting on Mental Health in Elite higher depressive symptoms than team-sport athletes.3 103 Future Athletes, including Cindy Miller Aron, Antonia Baum, Abhinav Bindra, Richard comparisons are needed, particularly taking account of the rela- Budgett, Niccolo Campriani, Joao Mauricio Castaldelli-Maia, Alan Currie, Jeff Derevensky, Lars Engebretsen, Ira Glick, Michael Grandner, Doug Hyun Han, David tive contribution of general versus athlete-specific factors in this McDuff, Margo Mountjoy, Aslihan Polat, Margot Putukian, Allen Sills, Torbjorn regard. Future studies using meta-regression techniques may Soligard, Todd Stull, Leslie Swartz and Li Jing Zhu, for their input on the development help quantify the unique contribution of athlete-specific factors. and interpretation of this research. Any link between the presence of an anxiety disorder or Contributors All authors conceived the study. MEH conducted the search, and anxiety symptoms and competitive performance impacts is SMR, RP and KG screened the articles. KG abstracted the data and performed the

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