Surveillance of athlete mental health symptoms and disorders: a supplement to the International Olympic Committee's consensus statement on injury and illness surveillance.

In 2019, the International Olympic Committee (IOC) published a consensus statement outlining the principles for recording and reporting injury and illness in elite sport. The authors encouraged sport federations to adapt the framework to their sport-specific context. Since this publication, several sports have published extensions to the IOC consensus statement.In response to a paucity of epidemiological data on athlete mental health, the IOC mental health working group adapted the IOC consensus statement on injury and illness surveillance to improve the capturing of athlete mental health data. In addition to the members of the working group, other experts and athlete representatives joined the project team to address gaps in expertise, and to add stakeholder perspective, respectively. Following an in-person meeting, the authors worked remotely, applying the scientific literature on athlete mental health to the IOC injury and illness surveillance framework. A virtual meeting was held to reach consensus on final recommendations.Practical outcomes based on the analysis of the scientific literature are provided with respect to surveillance design, data collection and storage, data analysis and reporting of athlete mental health data. Mental health-specific report forms for athlete and health professional utilisation are included for both longitudinal and event-specific surveillance.Ultimately, this publication should encourage the standardisation of surveillance methodology for mental health symptoms and disorders among athletes, which will improve consistency in study designs, thus facilitating the pooling of data and comparison across studies. The goal is to encourage systematic surveillance of athlete mental health.

Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport-Amsterdam, October 2022.

For over two decades, the Concussion in Sport Group has held meetings and developed five international statements on concussion in sport. This 6th statement summarises the processes and outcomes of the 6th International Conference on Concussion in Sport held in Amsterdam on 27-30 October 2022 and should be read in conjunction with the (1) methodology paper that outlines the consensus process in detail and (2) 10 systematic reviews that informed the conference outcomes. Over 3½ years, author groups conducted systematic reviews of predetermined priority topics relevant to concussion in sport. The format of the conference, expert panel meetings and workshops to revise or develop new clinical assessment tools, as described in the methodology paper, evolved from previous consensus meetings with several new components. Apart from this consensus statement, the conference process yielded revised tools including the Concussion Recognition Tool-6 (CRT6) and Sport Concussion Assessment Tool-6 (SCAT6, Child SCAT6), as well as a new tool, the Sport Concussion Office Assessment Tool-6 (SCOAT6, Child SCOAT6). This consensus process also integrated new features including a focus on the para athlete, the athlete's perspective, concussion-specific medical ethics and matters related to both athlete retirement and the potential long-term effects of SRC, including neurodegenerative disease. This statement summarises evidence-informed principles of concussion prevention, assessment and management, and emphasises those areas requiring more research.

Structural and social determinants of mental health inequities among collegiate athletes during the COVID-19 pandemic.

OBJECTIVES: To characterise psychological distress during the COVID-19 pandemic among collegiate athletes and assess whether racial and ethnic differences in psychological distress are attenuated when accounting for inequitable exposure to structural and social determinants of health. METHODS: Participants were collegiate athletes on teams competing in the National Collegiate Athletic Association (n=24 246). An electronic questionnaire was distributed by email, open for completion 6 October to 2 November 2020. Multivariable linear regression models were used to assess the cross-sectional associations between meeting basic needs, death or hospitalisation due to COVID-19 of a close contact, race and ethnicity, and psychological distress. RESULTS: Athletes racialised as Black had higher levels of psychological distress than their white peers (B=0.36, 95% CI 0.08 to 0.64). Psychological distress was higher among athletes who had more difficulties meeting basic needs, and who had a close contact die or be hospitalised with COVID-19. After adjusting for these structural and social factors, Black athletes experienced less psychological distress than white peers (B=-0.27, 95% CI -0.54 to -0.01). CONCLUSIONS: The present findings provide further evidence of how inequitable structural and social exposures are associated with racial and ethnic differences in mental health outcomes. Sports organisations should ensure the mental health services available for their athletes are appropriate for meeting the needs of individuals experiencing complex and traumatic stressors. Sports organisations should also consider whether there are opportunities to screen for social needs (eg, related to food or housing insecurity), and to connect athletes with resources to help meet those needs.

Improving inclusion and well-being of trans and gender nonconforming collegiate student-athletes: foundational concepts from the National Collegiate Athletic Association Summit on Gender Identity and Student-Athlete Participation.

The National Collegiate Athletic Association (NCAA) Summit on Gender Identity and Student-Athlete Participation was convened to identify institutional/athletic department strategies that may support the well-being of trans and gender nonconforming (TGNC) collegiate student-athletes in the USA. The Summit's purview did not include policy-level changes to eligibility rules. A modified Delphi consensus process was used to identify strategies for supporting collegiate TGNC student-athlete well-being. Key steps included an exploration phase (learning, generating ideas), and an evaluation phase (rating ideas in terms of their utility and feasibility). Summit participants (n=60) included individuals meeting at least one of the following criteria: current or former TGNC athlete, academic or healthcare professional with topical expertise, collegiate athletics stakeholder who would be involved in implementing potential strategies, representative from leading sports medicine organisation, or representative from relevant NCAA membership committee. Summit participants identified strategies in the following domains: healthcare practices (patient-centred care and culturally sensitive care); education for all stakeholders involved in athletics; and administration (inclusive language, quality improvement processes). Summit participants also proposed ways that the NCAA, through its existing committee and governance structures, could help support the well-being of TGNC athletes. NCAA-focused concepts were in the following domains: policy making processes; eligibility and transfer processes; resource development and dissemination; and visibility and support for TGNC athletes. The strategies developed represent important and relevant approaches that member institutions, athletic departments, NCAA committees, governance bodies and other stakeholders might consider in their efforts to support TGNC student-athlete well-being.

Addressing mental health needs of NCAA student-athletes of colour: foundational concepts from the NCAA Summit on Diverse Student-Athlete Mental Health and Well-Being.

We sought to identify concepts that may facilitate National Collegiate Athletic Association efforts to assist member institutions in addressing the mental health needs of student-athletes of colour. A two-step process was followed to generate and refine concepts, guided by Delphi methodology. First, a scoping review was conducted, including original peer-reviewed research articles that quantified or qualitatively described determinant(s) of racial or ethnic differences in athlete mental health or mental healthcare. Next, a multiday virtual meeting was facilitated to review the results of the scoping review, discuss lived experiences and generate potential concepts. Participants included a racially and ethnically diverse group of student-athletes, medical and mental health professionals, athletics administrators, diversity, equity and inclusion experts, health educators and representatives from leading organisations involved in athlete mental health. Through the consensus process, participants identified 42 concepts that member institutions might consider implementing on their campuses. Concepts were largely focused on organisational policies and practices such as staffing diversity and inclusion, expanded options for clinical support (ie, identity-relevant support groups) and within-organisation accountability. Concepts related to specific areas for stakeholder education were also identified. Institutions have the potential to play an important role in supporting the mental well being of student-athletes of colour, and the present concepts can help inform institutional action. While concepts proposed are believed to be broadly relevant across athletics settings, they would need to be further considered and tailored to reflect setting-specific organisational structures, resources and needs.

Do varsity college athletes have a greater likelihood of risky alcohol and cannabis use than non-athletes? Results from a National Survey in Brazil

Objective: We examined the prevalence of risky alcohol and cannabis use among Brazilian varsity college athletes and whether this group had a greater likelihood of risky use than non-athletes. Methods: In 2009, Brazilian college students (n=12,711) were recruited for a national stratified random survey. Their sociodemographic characteristics, mental health, substance use, and participation in varsity sports were assessed. Binary logistic regression models were used to examine the association between varsity athlete status and moderate to high-risk alcohol and cannabis use. Results: Among varsity athletes, 67.6 and 10.7% reported risky alcohol and cannabis use, respectively. Varsity athletes had greater odds of risky alcohol consumption than non-athletes (aOR = 2.02, 95%CI 1.08-3.78). Varsity athletes also had greater odds of risky cannabis use than non-athletes in unadjusted analyses (OR = 2.57, 95%CI 1.05-6.28), although this relationship was attenuated after covariate adjustment. Conclusions: Among college students in Brazil, varsity athletes had a higher prevalence of risky alcohol and cannabis use than non-athletes. The rates were considerably higher than those observed among samples of U.S. college athletes. Future research should examine the use of these substances among varsity college athletes in other middle-income countries since these findings will likely guide prevention and treatment efforts.

Differences in career longevity before and after implementation of the Women's Tennis Association Tour Age Eligibility Rule and Player Development Programmes: a 25-year study.

OBJECTIVES: To assess differences in career longevity, as a potential marker of athlete well-being, before and after the 1995 implementation of the Women's Tennis Association (WTA) Age Eligibility Rule (AER) and Player Development Programmes (PDP), which focused on organisational, physical and psychosocial education, skill building and support for adolescent athletes (≤17 years). METHODS: Career longevity data were collected through 2019 on adolescent players who began professional tournament play between 1970 and 2014 and reached a WTA singles ranking of 1-150 for a minimum of 1 week during their careers. Players were separated into pre-AER/PDP and post-AER/PDP groups, consisting of those who played their first professional events (FPE) before or after 1 January 1995. Measures of career longevity included career duration and premature retirement. RESULTS: Eight-hundred and eleven players were included in this study (51% pre-AER/PDP). The median career duration was 14.2 years for the post-AER/PDP group compared with 12.1 years for the pre-AER/PDP group (p<0.001). Moreover, post-AER/PDP players had higher probabilities of 10-year and 15-year careers compared with pre-AER/PDP players. After adjusting for age at FPE, athletes in the pre-AER/PDP group had an increased risk of shorter career duration (HR 1.55; 95% CI 1.31 to 1.83) and increased odds of premature retirement (OR 5.39; 95% CI 2.28 to 12.75) than athletes in the post-AER/PDP group. CONCLUSIONS: Adolescent athletes participating on the WTA after the combined AER/PDP initiative had longer career durations, higher probabilities of 10-year and 15-year careers, and decreased risk of premature retirement compared with those participating prior to AER/PDP. Organisational practices that encompass both education and competition regulation can positively affect career longevity related to improving athlete well-being.

Do varsity college athletes have a greater likelihood of risky alcohol and cannabis use than non-athletes? Results from a National Survey in Brazil.

OBJECTIVE: We examined the prevalence of risky alcohol and cannabis use among Brazilian varsity college athletes and whether this group had a greater likelihood of risky use than non-athletes. METHODS: In 2009, Brazilian college students (n=12,711) were recruited for a national stratified random survey. Their sociodemographic characteristics, mental health, substance use, and participation in varsity sports were assessed. Binary logistic regression models were used to examine the association between varsity athlete status and moderate to high-risk alcohol and cannabis use. RESULTS: Among varsity athletes, 67.6 and 10.7% reported risky alcohol and cannabis use, respectively. Varsity athletes had greater odds of risky alcohol consumption than non-athletes (aOR = 2.02, 95%CI 1.08-3.78). Varsity athletes also had greater odds of risky cannabis use than non-athletes in unadjusted analyses (OR = 2.57, 95%CI 1.05-6.28), although this relationship was attenuated after covariate adjustment. CONCLUSIONS: Among college students in Brazil, varsity athletes had a higher prevalence of risky alcohol and cannabis use than non-athletes. The rates were considerably higher than those observed among samples of U.S. college athletes. Future research should examine the use of these substances among varsity college athletes in other middle-income countries since these findings will likely guide prevention and treatment efforts.

Participating in Two Video Concussion Education Programs Sequentially Improves Concussion-Reporting Intention.

Undiagnosed concussions increase the risk of additional concussion and persistent symptoms from concussion. Because there are no reliable objective markers of concussion, self-reporting of subjective and non-visible symptoms are critical to ensuring proper concussion management. For this reason, educational interventions target concussion reporting, but the majority of studies have examined the efficacy of single educational interventions or compared interventions to one another. This randomized crossover study sought to identify whether there was benefit to administering multiple concussion education programs in tandem, back to back. The study randomized 313 male high school football players to first receive CrashCourse concussion education (CC) or Centers for Disease Control and Prevention video concussion education (CDC) followed by crossover with the other education. Athlete concussion-reporting intention, attitudes, subjective norms, perceived behavioral control, and enjoyment of education were assessed at baseline and after each intervention. There were statistically significant improvements across all measures, both after single intervention and crossover (all p < 0.001). Secondary analyses examining differences between education found that athletes reported higher enjoyment of concussion education immediately after participating in CC, as compared to CDC (p < 0.001). These findings demonstrate an additive benefit to implementing CC and CDC education in tandem, without decrement in enjoyment of concussion education after experiencing dual educations; in fact, enjoyment of concussion education improved after receiving education programs back to back. These educational programs appear to complement one another, and the results support the use of multi-modal concussion education to differentially target and maximize concussion reporting.

Sexual violence in sport: American Medical Society for Sports Medicine Position Statement.

The American Medical Society for Sports Medicine (AMSSM) convened a group of experts to develop a Position Statement addressing the problem of sexual violence in sport. The AMSSM Sexual Violence in Sport Task Force held a series of meetings over 7 months, beginning in July 2019. Following a literature review, the Task Force used an iterative process and expert consensus to finalise the Position Statement. The objective of this Position Statement is to raise awareness of this critical issue among sports medicine physicians and to declare a commitment to engage in collaborative, multidisciplinary solutions to reduce sexual violence in sport.

Tennis-specific extension of the International Olympic Committee consensus statement: methods for recording and reporting of epidemiological data on injury and illness in sport 2020.

The IOC has proposed standard methods for recording and reporting of data for injury and illness in sport. The IOC consensus statement authors anticipated that sport-specific statements would provide further recommendations. This statement is the tennis-specific extension of the partner IOC statement. The International Tennis Federation Sport Science and Medicine Committee, in collaboration with selected external experts, met in June 2019 to consider athlete health monitoring issues specific to tennis. Once the IOC consensus statement was finalised, the tennis-specific consensus was drafted and agreed on by the members over three iterations. Compared with the IOC consensus statement, the tennis consensus contains tennis-specific information on injury mechanism, mode of onset, injury classification, injury duration, capturing and reporting exposure, reporting risk and study population. Our recommendations apply to able-bodied as well as wheelchair tennis players. Where applicable, specific recommendations are made for wheelchair tennis.

International Olympic Committee (IOC) Sport Mental Health Assessment Tool 1 (SMHAT-1) and Sport Mental Health Recognition Tool 1 (SMHRT-1): towards better support of athletes' mental health.

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.

Mental health management of elite athletes during COVID-19: a narrative review and recommendations.

Elite athletes suffer many mental health symptoms and disorders at rates equivalent to or exceeding those of the general population. COVID-19 has created new strains on elite athletes, thus potentially increasing their vulnerability to mental health symptoms. This manuscript serves as a narrative review of the impact of the pandemic on management of those symptoms in elite athletes and ensuing recommendations to guide that management. It specifically addresses psychotherapy, pharmacotherapy and higher levels of care. Within the realm of psychotherapy, crisis counselling might be indicated. Individual, couple/family and group psychotherapy modalities all may be helpful during the pandemic, with novel content and means of delivery. Regarding pharmacotherapy for mental health symptoms and disorders, some important aspects of management have changed during the pandemic, particularly for certain classes of medication including stimulants, medications for bipolar and psychotic disorders, antidepressants and medications for substance use disorders. Providers must consider when in-person management (eg, for physical examination, laboratory testing) or higher levels of care (eg, for crisis stabilisation) is necessary, despite potential risk of viral exposure during the pandemic. Management ultimately should continue to follow general principles of quality health care with some flexibility. Finally, the current pandemic provides an important opportunity for research on new methods of providing mental health care for athletes, and consideration for whether these new methods should extend beyond the pandemic.

Improving Concussion Education: Consensus From the NCAA-Department of Defense Mind Matters Research & Education Grand Challenge.

Early disclosure of possible concussive symptoms has the potential to improve concussion-related clinical outcomes. The objective of the present consensus process was to provide useful and feasible recommendations for collegiate athletic departments and military service academy leaders about how to increase concussion symptom disclosure in their setting. Consensus was obtained using a modified Delphi process. Participants in the consensus process were grant awardees from the National Collegiate Athletic Association and Department of Defense Mind Matters Research & Education Grand Challenge and a multidisciplinary group of stakeholders from collegiate athletics and military service academies. The process included a combination of in-person meetings and anonymous online voting on iteratively modified recommendations for approaches to improve concussion symptom disclosure. Recommendations were rated in terms of their utility and feasibility in collegiate athletic and MSA settings with a priori thresholds for retaining, discarding, and revising statements. A total of 17 recommendations met thresholds for utility and feasibility and are grouped for discussion in five domains: (1) content of concussion education for athletes and MSA cadets, (2) dissemination and implementation of concussion education for athletes and military service academy cadets, (3) other stakeholder concussion education, (4) team and unit-level processes, and (5) organizational processes. Collectively, these recommendations provide a path forward for athletics departments and military service academies in terms of the behavioral health supports and institutional processes that are needed to increase early and honest disclosure of concussion symptoms and ultimately to improve clinical care outcomes.

Improving concussion education: consensus from the NCAA-Department of Defense Mind Matters Research & Education Grand Challenge.

Early disclosure of possible concussive symptoms has the potential to improve concussion-related clinical outcomes. The objective of the present consensus process was to provide useful and feasible recommendations for collegiate athletic departments and military service academy leaders about how to increase concussion symptom disclosure in their setting. Consensus was obtained using a modified Delphi process. Participants in the consensus process were grant awardees from the National Collegiate Athletic Association and Department of Defense Mind Matters Research & Education Grand Challenge and a multidisciplinary group of stakeholders from collegiate athletics and military service academies. The process included a combination of in-person meetings and anonymous online voting on iteratively modified recommendations for approaches to improve concussion symptom disclosure. Recommendations were rated in terms of their utility and feasibility in collegiate athletic and military service academy settings with a priori thresholds for retaining, discarding and revising statements. A total of 17 recommendations met thresholds for utility and feasibility and are grouped for discussion in five domains: (1) content of concussion education for athletes and military service academy cadets, (2) dissemination and implementation of concussion education for athletes and military service academy cadets, (3) other stakeholder concussion education, (4) team and unit-level processes and (5) organisational processes. Collectively, these recommendations provide a path forward for athletics departments and military service academies in terms of the behavioural health supports and institutional processes that are needed to increase early and honest disclosure of concussion symptoms and ultimately to improve clinical care outcomes.

Consensus Recommendations on the Prehospital Care of the Injured Athlete With a Suspected Catastrophic Cervical Spine Injury.

INTRODUCTION: Sports participation is among the leading causes of catastrophic cervical spine injury (CSI) in the United States. Appropriate prehospital care for athletes with suspected CSIs should be available at all levels of sport. The goal of this project was to develop a set of best-practice recommendations appropriate for athletic trainers, emergency responders, sports medicine and emergency physicians, and others engaged in caring for athletes with suspected CSIs. METHODS: A consensus-driven approach (RAND/UCLA method) in combination with a systematic review of the available literature was used to identify key research questions and develop conclusions and recommendations on the prehospital care of the spine-injured athlete. A diverse panel of experts, including members of the National Athletic Trainers' Association, the National Collegiate Athletic Association, and the Sports Institute at UW Medicine participated in 4 Delphi rounds and a 2-day nominal group technique (NGT) meeting. The systematic review involved 2 independent reviewers and 4 rounds of blinded review. RESULTS: The Delphi process identified 8 key questions to be answered by the systematic review. The systematic review comprised 1544 studies, 49 of which were included in the final full-text review. Using the results of the systematic review as a shared evidence base, the NGT meeting created and refined conclusions and recommendations until consensus was achieved. CONCLUSIONS: These conclusions and recommendations represent a pragmatic approach, balancing expert experiences and the available scientific evidence.

Consensus Recommendations on the Prehospital Care of the Injured Athlete With a Suspected Catastrophic Cervical Spine Injury.

INTRODUCTION: Sports participation is among the leading causes of catastrophic cervical spine injury (CSI) in the United States. Appropriate prehospital care for athletes with suspected CSIs should be available at all levels of sport. The goal of this project was to develop a set of best-practice recommendations appropriate for athletic trainers, emergency responders, sports medicine and emergency physicians, and others engaged in caring for athletes with suspected CSIs. METHODS: A consensus-driven approach (RAND/UCLA method) in combination with a systematic review of the available literature was used to identify key research questions and develop conclusions and recommendations on the prehospital care of the spine-injured athlete. A diverse panel of experts, including members of the National Athletic Trainers' Association, the National Collegiate Athletic Association, and the Sports Institute at UW Medicine participated in 4 Delphi rounds and a 2-day nominal group technique meeting. The systematic review involved 2 independent reviewers and 4 rounds of blinded review. RESULTS: The Delphi process identified 8 key questions to be answered by the systematic review. The systematic review comprised 1544 studies, 49 of which were included in the final full-text review. Using the results of the systematic review as a shared evidence base, the nominal group technique meeting created and refined conclusions and recommendations until consensus was achieved. CONCLUSIONS: These conclusions and recommendations represent a pragmatic approach, balancing expert experiences and the available scientific evidence.

Sexual Violence in Sport: American Medical Society for Sports Medicine Position Statement.

The American Medical Society for Sports Medicine (AMSSM) convened a group of experts to develop a Position Statement addressing the problem of sexual violence in sport. The AMSSM Sexual Violence in Sport Task Force held a series of meetings over 7 months, beginning in July 2019. Following a literature review, the task force used an iterative process and expert consensus to finalize the position statement. The objective of this position statement is to raise awareness of this critical issue among sports medicine physicians and to declare a commitment to engage in collaborative, multidisciplinary solutions to reduce sexual violence in sport.