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Determinants of anxiety in elite athletes: a systematic review and meta-analysis
  1. Simon M Rice1,2,
  2. Kate Gwyther1,2,
  3. Olga Santesteban-Echarri3,
  4. David Baron4,
  5. Paul Gorczynski5,
  6. Vincent Gouttebarge6,7,
  7. Claudia L Reardon8,9,
  8. Mary E Hitchcock10,
  9. Brian Hainline11,
  10. Rosemary Purcell1,2
  1. 1 Research and Translation, Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia
  2. 2 Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
  3. 3 Department of Psychiatry, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
  4. 4 Center for Health and Sport, Western University of Health Sciences, Pomona, California, USA
  5. 5 Department of Sport and Exercise Science, University of Portsmouth, Portsmouth, UK
  6. 6 Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam UMC, University of Amsterdam, Meibergdreef, The Netherlands
  7. 7 AMC/VUmc IOC Research Center of Excellence, Amsterdam Collaboration on Health and Safety in Sports (ACHSS), Amsterdam, The Netherlands
  8. 8 Department of Psychiatry, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
  9. 9 University Health Services, University of Wisconsin, Madison, Wisconsin, USA
  10. 10 Ebling Library for the Health Sciences, University of Wisconsin–Madison, Madison, Wisconsin, USA
  11. 11 National Collegiate Athletic Association (NCAA), Indianapolis, Indiana, USA
  1. Correspondence to Dr Simon M Rice, Research and Translation, Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, VIC 3052, Australia; simon.rice{at}


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.

  • anxiety
  • athlete
  • elite performance
  • injury
  • meta-analysis

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  • Contributors All authors conceived the study. MEH conducted the search, and SMR, RP and KG screened the articles. KG abstracted the data and performed the statistical analysis. SMR and OS-E reviewed the data for consistency. SMR and KG drafted the manuscript. All authors critically reviewed the manuscript and approved the final version.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.