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During 2013, the World Players' Union (FIFPro) – the voice of more than 65,000 professional footballers worldwide – conducted an international study of mental illness in professional football. Results of this preliminary FIFPro study were published in April 2014, showing that 26 % of active professional footballers reported symptoms related to depression/anxiety, compared to 39 % of retired players.

Besides exploration of the rate of players suffering from symptoms related to mental illness, the FIFPro study also sought an insight into what factors (stressors) might play a role in the incidence of these health conditions. After a brief summary of the background and methodology of the study and an examination of the results published a few months ago, the following document gives an insight into the factors that might play a role in the incidence of symptoms related to mental illness.

1. Background and objectives

Potential stressors during a professional football career

During their career, professional footballers have a high risk of injuries, especially hamstrings, knee and ankle injuries (Aoki 2012; Eirale 2012; Gouttebarge 2014). While mild acute injuries do not prevent recovery and a quick return to sport, severe injuries can cause long periods without training or competition, and may even lead to surgery (Chen 2005). In the worst cases, severe injuries may even cause early and forced retirement from football, involuntary retirement having been recognised as a potential risk for post-sports life mental health problems (Kerr 2000; Warriner 2008). Consequently, severe injuries and related surgeries are considered as major physical and psychological stressors that may induce mental illness, both during and after a football career (Shuer 1997; Walker 2007; Wiese-Bjornstal 2010). In addition, current and retired players may also experience mental health problems as a consequence of more traditional stressors such as life events and low social support (Karasek 1190).

Objectives of the FIFPro study

The aim of FIFPro's study was to explore the rate of players suffering with symptoms related to mental illness and to get an insight into what factors (stressors) might play a role in the incidence of the health conditions under study.

2. Outline of the FIFPro study

The national unions involved

Six national unions collaborated in the study: the Professional Footballers Australia (PFA), the Professional Footballers' Association of Ireland (PFAI), the Vereniging van Contractspelers (VVCS), the New Zealand Professional Footballers' Association (NZPFA), the Professional Footballers' Association (PFA) Scotland, and the Major League Soccer Players Union (MLSPU).

Measurement of symptoms related to mental illness

In the study, the following outcome measures (symptoms related to mental illness) were included: distress, burnout, anxiety/depression, low self-esteem, and adverse health behaviour (alcohol, smoking, nutrition). To assess these outcome measures, well-recognised and validated questionnaires i.e. scales were used.

Measurement of stressors

Several stressors were explored in the study: severe injuries (training or competition absence for more than 4 weeks), surgery, life events (death of a family member etc.) and (social) support from trainer/supervisor and teammates/colleagues. All these stressors were self-reported by the players.

Procedures

Based on the different outcome measures and stressors involved in the study, a paper and electronic survey was set up, both in English and Dutch. Then in 2013 the participating national unions sent by e-mail and/or post an information letter about the study to some of their members. Those willing to participate in the study filled in their questionnaire (20 to 25 minutes needed) which was subsequently returned.

3. The occurrence of symptoms related to mental illness

Current professional footballers

Of the 180 active professional footballers who participated to the study, 3 to 26 % reported some symptoms related to mental illness. In particular, symptoms of anxiety/depression and adverse nutritional behaviour were the most reported, namely by 1 out of 4 players. By contrast, only a few current players reported symptoms of burnout (5 %) or had a low self-confidence (3 %). Symptoms related to distress were reported by fewer players (10 %). Nearly 20 % of the current footballers reported adverse alcohol behaviour, while only 7 % were smoking.

Retired professional footballers

Of the 121 retired professional footballers who participated in the study, 5 to 42 % reported symptoms related to mental illness. In particular, symptoms of anxiety/depression and adverse nutritional behaviour were the most reported, namely by 2 out of 5 players. By contrast, only a few retired players reported a low self-confidence (5 %). Symptoms related to distress and burnout were reported by 15 to 20 % of the retired players. More than 30 % of the retired footballers reported adverse alcohol behaviour, while 12 % were smoking.

4. Relation between stressors and symptoms related to mental illness

Current professional footballers

Current professional footballers reported a total of 174 severe injuries occurring (so far) during their career (1 injury: 32 %; 2 injuries: 20 %; 3 or more injuries: 17 %), of which 31 % were related to the knee joints and 12 % to the ankle joints. Also, the current players reported that they underwent a total of 170 surgeries (1 surgery: 22 %; 2 surgeries: 13 %; 3 surgeries or more: 18 %), of which more than 50 % were related to knee or ankle injuries. Not all assumptions made prior to the study about the relationship between stressors and symptoms related to mental illness were confirmed but the following were:

Stressors   Symptoms related to mental illness
Higher number of life events related to distress
Higher number of life events related to burnout
Higher number of life events related to anxiety/depression
Lower social support from trainer/coach related to burnout
Lower social support from teammates related to anxiety/depression

 

Retired professional footballers

More than 60 % of these players had retired from football voluntarily, and 85 % had a paid job (38 hours a week on average) at the time of the study. During their career, 80 % of the former players had had one or more severe injuries, while 70 % reported having had one or more surgeries. As in the group of current players, not all assumptions made prior to the study about the relationship between stressors and symptoms related to mental illness were confirmed but the following were:

Stressors   Symptoms related to mental illness
Higher number of life events related to anxiety/depression
Lower social support from supervisor related to distress
Lower support from supervisor related to burnout
Higher number of severe injuries related to smoking behaviour

 

5. Conclusions and FIFPro's next steps

Occurring more often among retired professional footballers than in current players, mental illness symptoms were found to be related in both study groups with recently occurring life events and with low social support. However, because of the research design applied in our study, the relationships are difficult to interpret and additional studies based on a stronger research design (prospective) are needed in order to get an insight in the causality between stressors and the incidence of symptoms related to mental illness. Consequently, FIFPro, in collaboration with the St Marianna University School of Medicine (FIFA Medical Centre of Excellence), is currently conducting a larger international (prospective cohort) study in several countries (including Finland, France, Japan, Norway, Paraguay, Peru, Spain, Sweden and others) of mental illness in current and retired professional footballers. Subsequently, the results might make it possible for FIFPro to develop and implement optimal (preventive) strategies in order to protect and promote the sustainable mental health of professional footballers, both during and after their careers.

 

Sources:
Gouttebarge et al. (2014) Severe time-loss injuries and surgeries in relation to mental health in professional football. 23rd International Conference on Sports Rehabilitation and Traumatology, Milan, Italy.
Gouttebarge et al. (2013) Prevalence of mental health complaints and psychosocial implications in current and former professional football players, 9th Sport-medical Scientific Congress, Ermelo, the Netherlands.

 

 

Factors contributing to mental illness in professional football
By Dr. Vincent Gouttebarge PhD
Former professional footballer, Chief Medical Officer FIFPro
(+31621547499; v.gouttebarge@fifpro.org)

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