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Activities to improve early detection, assessment, and management of mental health symptoms and mental disorders in competitive sports has to be supported, and the basic concept of “The International Olympic Committee (IOC) Sport Mental Health Assessment Tool 1 (SMHAT-1)” is excellent . However, there are various aspects in the SMHAT-1, that need critical discussion according to standards and guidelines for mental disorders [e.g., 2,3].
Mental health assessment and management
The SMHAT-1 was developed for sports medicine physicians and other licensed/registered health professionals, e.g. psychiatrists and psychologists . At step 1 (triage) the Athlete Psychological Strain Questionnaire (APSQ) assesses sport-related psychological distress. Athletes with a APSQ Score ≥ 17 are being referred to step 2 (screening) and evaluated based on six disorder-specific screening questionnaires. Taking into consideration the athlete’s history/record and the information provided, the administrator might refer the athlete to step 3a for a brief intervention and monitoring. If one or more of the screening questionnaires are positive, the athlete proceeds to step 3b. In this step a sport medicine physician and/or mental health professional will conduct a comprehensive clinical assessment, in order to identify a clinical diagnosis.
Questionnaires are useful in early detection and assessment of psychiatric symptoms and disorders, as part of the clinical assessment und...
Questionnaires are useful in early detection and assessment of psychiatric symptoms and disorders, as part of the clinical assessment und diagnostic process . However, Self-reports (questionnaires) usually are limited in sensitivity and specificity.
Clinical assessment and diagnosis as well as treatment of mental health symptoms and disorders should ideally be conducted by licensed/registered mental health professionals and require education and clinical training in psychiatry . The coordination of the integrated psychiatric management is a core competence of psychiatrists [2,4]. Following the same argument, children and adolescents should be treated by licensed/registered mental health professionals and psychiatrists for children and adolescents. However, there is still limited access to mental health professionals in sports settings, especially to psychiatrists and specialized psychiatrists (sports psychiatrists) . Psychiatrists and (clinical) psychologists differ in their education and expertise in the management of mental disorders. They complement each other, but the differences in their expertise should be clearly identified.
The authors believe there is a need to complement the SMHAT-1 with these fundamental standards of clinical practice in order to further enhance the management of mental health problems in elite sports.
Furthermore, step 3 describes various actions of the SMHAT-1 : (i) treatment/support provided by a sports medicine/primary care physician; (ii) additional screening questionnaires, including attention-deficit/hyperactivity disorder (ADHD), bipolar disorder, post-traumatic stress disorder (PTSD), gambling disorder and/or psychosis, prior to definitive diagnosis and to create an management/intervention plan; (iii) for severe, complex, diagnostically uncertain, even after additional screening and/or nonresponsive, treatment through licensed/registered mental health professionals is recommended.
Sports physicians and other health professionals are important specialists to improve and maintain mental health in competitive sports. Ideally, elite athletes should have access to the best interdisciplinary care . Nevertheless, the role of health professionals without specific expertise in mental health needs to be discussed. Only the inclusion of mental health professionals with expertise in sports psychiatry into athlete’s health teams provides the requirement to further improve interdisciplinary care. Moreover, certain mental disorders, e.g., ADHD and PTSD, require additional training and disease-specific expertise, even for mental health professionals .
We also strongly encourage the regular use of SMHAT-1 whenever any significant event for an athlete occurs . At the same time major injury/illness and suspected harassment/abuse often require a clinical consultation and assessment by mental health professionals. Screening questionnaires can be of help in detecting major mental health problems but usually do not address the specific need of athletes in such difficult situations. Hence, in some situations important psychological problems might be missed initially, increasing the danger of later mental disorders. The authors therefore propose an individual interdisciplinary approach in all cases of suspected harassment/abuse of (especially young) athletes.
Mental health in competitive sports
Questionnaires and clinical assessment through trained sports physicians in sports psychiatry could be a valuable part of the sports-medical examination. Additionally, we propose examination by sports psychiatrists as a routine in competitive sports. There is a strong need for mental health professionals, and a qualified medical discipline for mental health in competitive sports . Therefore, a corresponding coordinating office for sports psychiatry and sports psychiatry expertise is required in every association and club .
Education and training in sports psychiatry are essential in improving mental health in competitive sports. To impart information on mental disorders for athletes and their entourage is also an important action. A strong collaboration between all professionals is recommended.
Education and training in sports psychiatry. The International Society for Sports Psychiatry (ISSP) released a first curriculum for additional training in sports psychiatry in 2018 . In 2020, the Swiss Society for Sports Psychiatry and Psychotherapy (SSSPP) released a three-part curriculum for qualification in sports psychiatry . Part 1 imparts basic knowledge for psychiatrists as well as sports physicians and psychologists.
Education about mental health symptoms and disorders in competitive sports should complement the specialised qualification in sports psychiatry.
Mental health and mental disorders require qualified clinical and medical competence, irrespectively of the nature or severity, a psychiatric expertise and in the case of minors, expertise in child and adolescent psychiatry is required.
The basic concept of SMHAT-1 is excellent and following versions should consider these fundamental standards of clinical practice.
There is a need for psychiatrists and clinical psychologists in competitive sports; it is the hope of the authors that more mental health professionals will engage in these settings.
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