Professional team athletes experience a range of mental health problems, both sports and non-sports related. However, there is limited information available for those charged with responsibility for managing these mental health conditions, particularly within the context of professional sporting clubs. This paper reports on consensus findings from a study of club doctors, who are primary care providers for professional team athletes within a specific code, the Australian Football League (AFL). Drawing on findings from a systematic literature search, a two-round Delphi procedure was used to develop a consensus on best practice for managing mental health conditions for club doctors as primary care providers for professional team athletes. Participants in this study were current and former club doctors employed in professional AFL clubs across Australia, with 28 doctors participating across two survey rounds. Overall, 77 statements were presented, with 50 endorsed as essential or important by ≥ 80% of the participants across the two rounds. Primary themes across nine domains include: (1) Prevention and Mental Health Promotion Activities; (2) Screening; (3) Engaging External Specialists; (4) Duty of Care; (5) Treatment: Assessment, Treatment and Case Coordination; (6) Communication; (7) Confidentiality; (8) Sleep Management and (9) Substance Use Management. This study is the first to offer club doctors working in professional team settings consensus guidelines for the management of mental health conditions, and the opportunity for greater clarification and consistency in role delivery.
- consensus statement
- Australian football
- sports and exercise medicine
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Elite athletes are not immune to developing mental health problems, with research indicating that they experience comparable rates of mental health disorders as the general population.1 2 Like the general community, athletes experience non-sport-related risks for the development of mental health disorders, such as adverse life events, age, gender and inadequate social support.3 However, participation in elite sport confers a unique combination of both sport and non-sport-related risk factors associated with mental health disorders, such as injuries including concussion,4 performance failure,5 overtraining,6 social pressures to perform and stigmatisation and denial of mental health disorders.7 Moreover, years of active participation in elite competition commonly overlap with peak age of onset for most mental health disorders.8 Together, these factors suggest that tailored and context-specific approaches are required to effectively respond to and manage the mental health of elite athletes.
Despite increasing research into elite athlete mental health and well-being, evidence regarding best practice management of mental health disorders remains limited. A recent review by the International Olympic Committee (IOC)9 highlighted a need for more standardised, evidence-based approaches to elite athlete mental health diagnosis and management. While research into professional team-based athletes’ mental health has increased,10 the majority of existing empirical studies focus on collegiate teams and their athletes11 whose roles differ substantially from professional athletes with respect to their performance context, public profile and media scrutiny. As such, evidence-based guidelines into the management of mental health disorders in professional, team-based athletes are needed, to inform responses of team-based healthcare staff and to ultimately improve the management of mental health disorders in professional athletes.12
The Australian Football League (AFL) is the pre-eminent professional league for Australian rules football, with 18 men’s and 14 women’s teams across mainland Australia. AFL club doctors are front-line providers of all aspects of player healthcare, including mental health. Although club doctors are not expert mental health clinicians, they have a duty of care for players’ mental health and well-being. This is particularly important given the significant interplay between mental and physical health outcomes.9 Club doctors are well positioned to play a leadership role in the recognition, initial management and co-ordination of players’ mental healthcare. However, there is an absence of consensus guidelines on how best to achieve this. This has resulted in inconsistent industry responses to important domains relevant to mental health identification and management, including use of screening and assessment tools, risk identification and management, treatment provision, case coordination, sleep management and addressing substance use. Moreover, management of player mental health within the broader context of a professional team elicits a host of additional considerations. These include managing confidentiality, navigating public and media scrutiny, involving multiple stakeholders in management planning including families, coaching and performance staff, and remaining aware of the implications for team performance and well-being.
There is thus a need to establish consensus about best practice and the role and responsibilities of club doctors in the mental health management of professional athletes in the AFL, which this study set out to achieve.
Methodology and survey development
This study employed a modified Delphi methodology13 14 to develop consensus on the role of club doctors in addressing and managing professional player mental health.
A systematic search of relevant databases (ie, Medline, PsycINFO, Embase and SportDiscus) was conducted in December 2019 using the following search terms: mental health (“mental health”) OR (“addict*”) AND elite athletes (“elite athlete*”) OR (“team sport*”) OR (“elite sport*”) AND treatment/management (“intervention*”) OR (“treatment*”) OR (“screen*”) OR (“management”). No date exclusions were applied, but only English-language papers were reviewed. This yielded a total of 279 studies, of which 257 were excluded based on title and/or abstract, resulting in a total of 22 papers which were reviewed for relevant content.
Using findings from the above literature review, alongside author expertise, an initial list of potential club doctor actions and roles were generated by the authors. Statements were reviewed to ensure clarity, limiting each statement to a single idea and providing alternatives where relevant. Statements were clustered thematically to reflect mental health promotion, screening and risk identification, treatment of mental health disorders, communication and information management. Additional items were added in a second-round survey, based on first-round participant suggestions. A full list of survey items is provided in table 1.
Eligible participants for this study were registered club doctors currently or previously working with professional men’s and women’s AFL teams. To preserve anonymity, information regarding club affiliation, age and gender was not requested. A sample of 20 participants has been deemed sufficient in prior literature.15 This was exceeded, with 35 participants consenting and 28 participating in this study across two survey rounds. This represents 56% of the estimated 50 AFL club doctors currently affiliated with teams.
After obtaining ethical approval from (blinded for review) University’s Ethics in Human Research Committee, the initial survey was sent in April 2020 to participants via their professional group, the AFL Doctors Association (AFLDA). For all statements, participants were asked to rate the importance of the item on a 5-point Likert scale. Response options were essential (1), important (2), depends (3), not important (4), should not be included (5), with an option to nominate ‘do not know’. Participants could also add additional items via free-text response options, if they felt important areas were unaddressed.
After the first-round survey was completed, statements endorsed as ‘essential’ or ‘important’ by more than 80% of respondents were retained, while statements endorsed as ‘essential’ or ‘important’ by less than 60% of respondents were rejected. The remaining statements, in addition to newly proposed items, were presented to participants, again via the AFLDA, in a second-round survey in June 2020. The same criteria for retention and/or rejection were applied. As such, consensus represents the view of more than 80% of respondents across two survey rounds.
Characteristics of participants
A total of 28 participants completed the first-round survey; of these, 22 (79%) completed the second-round survey. The majority of participants were currently working as AFL club doctors (96%) and reported considerable breadth of experience, with 39% having worked for more than ten years, 11% having worked for 5–10 years, 25% between 2–5 years and 25% for less than 2 years.
The responses provided by club doctors fell within nine domains: (1) prevention and mental health promotion activities; (2) screening and risk identification; (3) engaging external specialists; (4) duty of care; (5) assessment, treatment and case coordination; (6) communication; (7) confidentiality; (8) sleep management and (9) substance use management. Table 1 details specific activities included under each domain and the level of agreement.
This study used a modified Delphi procedure to establish consensus about the role of club doctors in the mental health management of elite athletes in professional teams. Prevention and mental health promotion activities as well as regular mental health screening were identified as within the scope of the club doctor role. The participants strongly endorsed that club doctors should be aware of and engaged in whole-of-club mental health promotion activities, which should be evidence based, multidisciplinary and delivered by those with relevant expertise. In line with these views, a comprehensive mental health framework has been proposed3 for promotion of athlete mental health and well-being. This framework suggests that preventative components, such as mental health literacy training and screening tools are essential components within any elite or professional sporting context.
There was consensus that valid, reliable and standardised screening tools should be used at specific time frames in the athlete’s career, namely, recruitment, preseason, end of season and end of contract or retirement, as well as critical life events or stressors. These views align with recommendations for standardised mental health screening tools by the IOC, who have developed the Sport Mental Health Assessment Tool and the Sport Mental Health Recognition Tool. This standardised assessment tool is one example of an athlete specific screening tool that could be implemented in sporting programmes for early identification of mental health symptoms.16 It was noted that additional mental health screening in the case of concussion was not sufficiently endorsed to meet acceptance criteria (78.3%). Existing AFL concussion protocols mandate use of the SCAT517 which incorporates brief screening for psychological symptoms, and may be deemed sufficient. However, we also note emerging evidence of associations between concussion and mental health symptoms,18 19 and this result may suggest a need for further training for club doctors in this area.
The participants strongly agreed that club doctors ultimately held the duty of care for player mental health; however, it was also agreed that within each club, a nominated health professional could be embedded to manage treatment coordination and ease administrative burdens on club doctors. This nominated treatment coordinator would liaise closely with the club doctor, ensuring overall integrated management, while bringing relevant additional expertise. This view is consistent with recommendations12 that appointed mental health officers could be a positive addition to multidisciplinary athlete support.
Regarding treatment, the participants agreed that if club doctors had relevant clinical expertise, they could conduct mental health assessments, manage pharmacotherapy and deliver initial evidence-based treatment. Club doctors who did not have relevant experience were still acknowledged to hold a duty of care and responsibility for oversight of treatment progress. As such, club doctors would hold responsibility for treatment coordination, which could be delegated to a nominated club professional, while the club doctor maintained oversight. Such an approach could facilitate the best use of professional expertise, while embedding consistent processes within the club and ideally contributing to an athlete-centred culture of care.20 When engaging external specialists, the participants agreed that club doctors should be responsible for referrals to external mental health professionals, while again maintaining oversight. They also endorsed a recommendation that concurrent referrals to mental health professionals should be considered when the principal injury is physical, given significant overlap between injury and mental health decline.4 They noted that physical injury specialists, such as orthopaedic surgeons or neurosurgeons, should not be assumed responsible for managing psychological sequalae of physical injuries.
The participants agreed that it was not the role of the club doctor to communicate with media, family or friends about a player’s mental health disorder, nor did they believe that club doctors should be responsible for providing regular updates to coaching staff about a player’s mental health. Such roles may create a conflict of interest for club doctors,21 and could potentially jeopardise athlete-centred focus of care.20 However, the participants agreed that club doctors should be involved in decisions to notify the media about a player’s mental health disorder and be aware of the club’s social media policy, so that actions can be taken in the best interests of the player’s well-being. The participants endorsed standard protocols around patient confidentiality, following existing local legal and ethical protocols.
There was also agreement for a focus on building mental health literacy for all club staff, particularly those in coaching roles or other direct player contact, to understand mental health disorders and encourage help seeking, as supported by other experts.3 12 As expected, the participants agreed that club doctors must be familiar with and follow legal and professional protocols around privacy of medical information, basing all decisions to disclose information on consideration of well-being of the player, seeking consent for disclosure, and complying with legislative requirements.
Lastly, with respect to illicit drug policies, the participants agreed that the only role of the club doctor was to coordinate evidence-based treatments for alcohol use disorders, whereas directly providing treatment for alcohol, gambling and substance use was beyond the scope of their role. This last point highlighted the potential need for greater training in the management of gambling and substance use disorders for club doctors.
To date, support for elite athlete mental health has focused on building mental health literacy and awareness3; however, such an approach is insufficient without a comprehensive mental health system that can respond effectively to athlete needs, at the right time, the right place and with the right support. Findings from this study provide a starting point for club doctors to address the varied mental health needs of professional team athletes which has been lacking in published literature, and supports existing calls to action.3 This also supports investment in the critical role of club doctors to ensure quality provision of mental health programme delivery across prevention, early identification and intervention.3
Investment in primary prevention and early intervention are an important part of stepped care approaches to mental health, and are an important part of a whole-of-club approach to ensure the club is capable of preventing athlete mental health disorders. We note that while club doctors hold a duty of care, they cannot be solely responsible for player mental health and well-being. Within a stepped care approach,22 23 engagement of expert tertiary resources is a valuable and efficient use of relevant expertise.
Within a given team or club, coaches, allied health staff, teammates and support staff, and external agencies such as the sport governing body, also have critical roles in management of player mental health within an integrated team. To achieve this, a focus on professional clubs as mentally healthy workplaces,24 where risk factors are identified and addressed, and protective factors maximised, requires input from all organisational levels. Such an approach includes a culture of mental health literacy and awareness, stigma reduction and increased capacity for individuals other than club doctors, such as teammates, coaches and other support staff, to intervene and promote early help seeking.25 26 Nonetheless, it is noted that club doctors still hold a duty of care for the player’s mental health, regardless of who performs day-to-day coordination roles. Therefore, specific and continuing mental health training should be a priority for club doctors in professional sporting contexts. While all medical practitioners receive mental health and psychiatry training during their medical degree, postgraduate training in mental health is limited. For sports and exercise registrars, the Australasian College of Sport and Exercise Physicians has recently developed a specific module, Sports Psychology for Sports Medicine,27 in which non-trainees can also enrol. However, regular, scheduled and ongoing professional mental health training for existing sports and exercise physicians may be helpful.
A second noteworthy implication concerns the need for access to both internal and external mental health expertise. Embedding mental health clinicians within a professional team can reduce stigma associated with needing to seek ‘outside help’.28 They may also be best placed to hold responsibility for screening; a role which club doctors believed was needed, yet felt uncertain about who would hold primary responsibility. Crucially, should an athlete require intervention due to emergent concerns, including deteriorating pre-existing mental health disorders, it is imperative that the club has a critical incident response plan for how to best assess the situation, bring together relevant and suitably qualified professionals (especially in regard to lower prevalence conditions), formulate the planned strategy and implement a response, as per stepped care models.22 Additionally, specialist services and treatment for specific conditions, particular alcohol, substance use and gambling disorders, may require skills and expertise which are unlikely to be held by club doctors, and external providers would be necessary in such situations.
Regardless of specific screening tools used, there was consensus on the importance of screening, as part of a comprehensive early identification and intervention model of care,29 again consistent with recommended best practice in mental health management for Olympic and other elite athletes. This offers the opportunity to triage athletes into levels of mental health risk, and then ensure access to services and resources based on their current profile, enabling the earliest and most effective mental health management.
Lastly, issues of confidentiality within the professional club setting remain challenging for club doctors. To support this, education for coaching staff and developing a psychologically safe workplace within the club, are likely to create a climate in which athletes feel that such information can be safely shared.30
While our findings are of interest, we note some study limitations. First, although the sample size was within recommended guidelines for a Delphi procedure,15 it may not reflect the experiences and perspectives of all club doctors. Second, information regarding the club doctors’ education, training and experience in mental health was not obtained due to the ethical requirements for non-identifiable information to be collected. In addition, participants were limited to club doctors and did not include primary mental health clinicians. Although this privileges the opinion of club doctors, with varying levels of expertise in mental health, this research attempts to provide an initial consensus on the roles and responsibilities of the club doctor as determined by their own peer group. Further research is warranted to broaden the scope of opinion on the role of the club doctor through a multidisciplinary lens. Third, participants surveyed work within a professional team sport operating in a single nation, in well-resourced clubs, where there are strong regulatory frameworks around mental health treatment provision. As such, implications for other sports, or non-professional teams in less well-resourced environments, should be evaluated for applicability, as other professional team sports will have cultural-specific context and nuances. Lastly, this study is based on consensus, which means that if new information becomes available, suggested domains may need to be amended accordingly. Ideally, future research will enable these questions to be further explored.
Our findings identify the important role that club doctors play in the management of athlete mental health in professional Australian Rules football teams. Our consensus recommendations outline the ways in which club doctors can effectively address the mental health needs of their athletes, while acknowledging their limitations. A multidisciplinary team and a whole-of-club approach are needed to optimise prevention, early identification and treatment strategies to manage player mental health.
Patient consent for publication
The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Human Research Ethics Committee of Deakin University, Reference HEAG-H 155-2019, Approval dated November 2019.
The authors gratefully acknowledge the contributions and time of those club doctors who responded to and completed our surveys.
Contributors Conceptualisation: BW, KH and EMC; methodology: BW, KH and EMC; formal analysis: JB and EMC; investigation: BW, EMC, KH and TC, RM: data curation: JB and EMC; writing—original draft preparation: EMC, BW, JB; writing—review and editing, BW, EMC, JB, KH, TC and RM; supervision, KH and RM; project administration, EMC; funding acquisition: BW and EMC. All authors have read and agreed to the submitted version of the manuscript.
Funding This study was supported with funding from the AFL’s Research Board and participant engagement was facilitated through the AFLDA.
Competing interests KH and RM were employed by the AFL as the Head of Mental Health and Wellbeing (KH) and AFL Chief Psychiatrist (RM) during this study, and have no other conflicts of interest to report. BW and TC are present and past medical doctors (respectively) at football clubs within the AFL competition, and have no other conflicts of interest to report. EMC and JB have no conflicts of interest to declare relevant to this paper. As such, only JB and EMC had access to the raw data and analyses to minimise any conflicts due to the roles of AFL staff and club staff.
Provenance and peer review Not commissioned; externally peer reviewed.
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