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Consensus statement
Surveillance of athlete mental health symptoms and disorders: a supplement to the International Olympic Committee’s consensus statement on injury and illness surveillance
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  1. Margo Mountjoy1,2,
  2. Astrid Junge3,
  3. Abhinav Bindra4,
  4. C Blauwet5,
  5. Richard Budgett6,
  6. Alan Currie7,8,
  7. Lars Engebretsen6,
  8. Brian Hainline9,
  9. David McDuff10,
  10. Rosemary Purcell11,
  11. Margot Putukian12,
  12. Claudia L Reardon13,
  13. Torbjørn Soligard6,
  14. Vincent Gouttebarge14,15,16
  1. 1 Family Medicine, McMaster University Michael G DeGroote School of Medicine, Waterloo, Ontario, Canada
  2. 2 Medical and Scientific Department—Games Group, International Olympic Committee, Lausanne, Switzerland
  3. 3 Center for Health in Performing Arts, MSH Medical School Hamburg, Hamburg, Germany
  4. 4 Olympic Champion and IOC Athletes Commission Member, Deharadun, Punjab, India
  5. 5 Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts, USA
  6. 6 Medical and Scientific Department, International Olympic Committee, Lausanne, Switzerland
  7. 7 Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
  8. 8 Exercise, Sport and Rehabilitation Therapies, University of Sunderland, Sunderland, UK
  9. 9 National Collegiate Athletic Association (NCAA), Indianapolis, Indiana, USA
  10. 10 Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland, USA
  11. 11 Elite Sport and Mental Health, Orygen, The National Centre of Excellence in Youth Mental Health, Melbourne, Victoria, Australia
  12. 12 Chief Medical Officer, Major League Soccer, Princeton, New Jersey, USA
  13. 13 Department of Psychiatry, University of Wisconsin Madison School of Medicine and Public Health, Madison, Wisconsin, USA
  14. 14 Orthopedic Surgery and Sports Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
  15. 15 Section Sports Medicine, University of Pretoria, Pretoria, South Africa
  16. 16 Amsterdam Collaboration on Health & Safety in Sports (ACHSS), IOC Research Center, Amsterdam, The Netherlands
  1. Correspondence to Margo Mountjoy, Family Medicine, McMaster University Michael G DeGroote School of Medicine, Waterloo, Canada; mountjm{at}mcmaster.ca

Abstract

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.

  • Athletes
  • Epidemiology
  • Psychology, Sports
  • Preventive Medicine
  • Prospective Studies

https://doi.org/10.1136/bjsports-2022-106687

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    Introduction

    Elite athletes, like anyone in the general population, can experience sadness, anger, stress, doubt, irritability and anxiety. However, if this persists over several weeks, is causing significant distress, and/or is negatively impacting sport performance or the ability to function in daily life, then the athlete may be experiencing mental health symptoms or disorders. Mental health symptoms are defined in the International Olympic Committee (IOC) mental health consensus statement as adverse/abnormal thoughts, feelings and/or behaviours that do not occur in a pattern meeting specific diagnostic criteria (eg, Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR)1) and do not necessarily cause significant distress or functional impairment.2 Conversely, mental health disorders refer to conditions causing clinically significant distress or impairment that meet specified diagnostic criteria in the DSM-5-TR.2 Mental health symptoms are common among professional, Olympic/Paralympic and collegiate athletes, with prevalence rates equivalent to or in some cases (eg, disordered eating) exceeding those of non-athletes.3–6 The severity of these mental health symptoms can vary longitudinally during a season.7 8 Among elite athletes, mental health symptoms and disorders can occur as a consequence of the dynamic interaction between generic (eg, adverse life events) and sport-specific contributing factors such as international travel, decrease in sport performance, severe time-loss injury and transitioning out of sport.2

    Thus, it is essential to initiate or strengthen efforts towards the protection of athletes’ mental health. The prevalence of mental health symptoms in elite athletes warrants the use of routine surveillance to help ensure that affected or at-risk athletes are identified and provided with the level of care they require as early as possible. Elite athletes exhibit higher mental health stigma than the general population9 and have a tendency to withhold disclosure of mental conditions10 underscoring the need for the explicit assessment of mental health symptoms and disorders in this population. Establishing and normalising mental health surveillance as an integrated component of athletes’ overall routine health assessment has the potential to reduce stigma, improve mental health literacy and help-seeking,11 contribute to greater psychological safety12 and generate preventative effects by identifying mental health concerns at an earlier stage when they are easier to resolve.2 13

    To uphold the duty to protect athletes’ health, epidemiological studies identifying sport-related health concerns are fundamental. In 2020, the IOC published a consensus statement on injury and illness surveillance in sport (hereafter referred to as the ‘IOC surveillance consensus statement’).14 Ensuring consistency regarding the definitions and methods used to collect and report data, this sports-generic statement was subsequently complemented by specific statements with recommendations tailored for several sports.15–20 These sports-generic and sports-specific statements focus on the collection and reporting of data related to general physical health, especially musculoskeletal injuries, and general medical illnesses, offering detailed options to classify and code those adequately. By contrast, the taxonomy related to mental health symptoms and disorders is generic and poorly detailed; only a single illness category is presented—namely ‘psychiatric/psychological’—and aetiological categories are not specific enough for mental health (eg, environmental).14 Such a lack of specificity does not align with the many categories defined as mental health symptoms and disorders (eg, depression, disordered eating, psychosis), nor with the various contributing factors potentially inducing these health conditions (eg, adverse life events, COVID-19 pandemic, injury).2 21–23 Furthermore, the injury and illness surveillance reports at the most recent Olympic Winter and Summer Games did not capture information about the different types of mental health symptoms and disorders.24–27 This does not comport with the increasing number of elite athletes speaking about their mental health during high-profile competitions, nor with the recent epidemiological literature.28–33 Moreover, this lack of mental health surveillance data ignores the reality that mental health symptoms and disorders—just like physical health conditions—can have substantial impact on sports performance.2

    This discrepancy between the low level of epidemiological data and the increasing vocal testimonies of athletes might reflect traditional barriers to the reporting of mental health symptoms and disorders including stigma and low mental health literacy in athletes and their health support staff.34 35 However, the discrepancy might also be attributable to limitations within the IOC surveillance consensus statement, such as lack of specific mental health symptom and disorder categories.14 Therefore, there is a need to compile a specific supplement to standardise the surveillance methodology for mental health symptoms and disorders among athletes. We encourage sport organisations to adapt the recommendations in this consensus statement to their own sporting contexts.

    Methods

    Following exploratory discussions about the development of a mental health supplement with the IOC surveillance consensus statement’s14 lead author, the conceptualisation and framework of the project, and the determination of the writing process occurred during an in-person meeting of the IOC Mental Health Working Group held in Lausanne, Switzerland, in April 2022. This group consists of experts from around the world representing sports psychiatry (AC, DM), sports science (RP, VG), sports medicine (CB, MM, MP), elite athletes (CB, AB) and the Director from the IOC’s Medical and Scientific Department (RB). The two lead authors of the IOC consensus statement on mental health in elite sport2 (CLR (sports psychiatry) and BH (sports medicine)) were included as co-authors to provide further expertise. To address an identified gap in knowledge and experience of surveillance epidemiology, an external expert (a psychologist who is a co-author of the IOC surveillance consensus statement14 as well as several sport-specific adaptations) was included in the author group (AJ). To represent the IOC surveillance project that occurs at the Olympic Games, two members of the IOC Science Department were invited to participate (LE, TS). CB also represents the para sport perspective, as a member of the Medical Committee of the International Paralympic Committee. MM, AJ, AB, RB LE and TS were original authors of the IOC surveillance consensus statement,14 and thus provided context and insight about the development of this publication.

    Via videoconference, the core group of lead authors (MM, AJ and VG) defined the methodology for reaching consensus based on published guidelines.36 37 They identified core elements of the manuscript by defining content sections to supplement the IOC surveillance consensus paper. Subgroups with identified section leads were formed and assigned to various content sections based on expertise and interest. The subgroups were tasked to explore several electronic databases (eg, PubMed, SportDiscus, PSycINFO) for relevant scientific literature related to the specific topic area and to formulate a summary of their findings along with recommendations based on the results and expert opinion. As the topic of mental health surveillance in sport is underdeveloped, there is a paucity of publications on the topic thus precluding the feasibility of formal systematic reviews. The subgroups worked remotely throughout the third and fourth quarters of 2022. A virtual meeting was held in December 2022 to finalise the content and recommendations. Consensus was reached by majority agreement, with all authors reviewing and approving all sections prior to submission. Dissentions were managed through group discussion and resolution.

    Athlete mental health surveillance

    Defining mental health terminology in sport

    The IOC surveillance consensus statement14 references a definition by Clarsen et al,38 that a health problem is ‘any condition that reduces an athlete’s normal state of full health, irrespective of its consequences on the athlete’s sports participation or performance or whether the athlete sought medical attention.’ According to this definition, we defined a mental health problem as any adverse thought, feeling, behaviour and/or psychosomatic symptom that reduces an athlete’s normal state of full mental health, irrespective of its cause or of its consequences on the athlete’s sports participation or performance or whether the athlete sought medical attention. Mental health problems can range from minor mental health symptoms to severe mental health disorders.

    To ensure consistency in surveillance methodology across sports and athlete populations, we have drawn on the IOC consensus statement on mental health in elite athletes as well as other resources and expert opinion to define the terms ‘mental health symptoms’ and ‘mental health disorders’ for the purposes of this manuscript. Mental health symptoms are defined as any adverse thought, feeling, behaviour and/or psychosomatic symptom that might lead to subjective distress or functional impairments in daily life, work and/or sport. Mental health disorders are syndromes characterised by clinically significant disturbance in an individual’s cognition, emotional regulation or behaviour that reflects a dysfunction in the psychological, biological or developmental processes that underpin mental and behavioural functioning. These disturbances are usually associated with distress or impairment in personal, family, social, educational, occupational or other important areas of functioning, and are diagnosed according to existing clinical criteria as outlined in the DSM-5-TR.1 We consider a mental health disorder to be synonymous with a mental illness (see box 1).

    Box 1

    Definitions adopted for mental health surveillance in sport

    • Mental health problem: any adverse thought, feeling, behaviour and/or psychosomatic symptom that reduces an athlete’s normal state of full mental health, irrespective of its cause or of its consequences on the athlete’s sports participation or performance or whether the athlete sought medical attention. Mental health problems cover the spectrum from minor mental health symptoms to severe mental health disorders.

    • Mental health symptoms: any adverse thought, feeling, behaviour and/or psychosomatic symptom that might lead to subjective distress or functional impairments in daily life, work and/or sport.

    • Mental health disorders: syndromes characterised by clinically significant disturbance in an individual's cognition, emotional regulation or behaviour that reflects a dysfunction in the psychological, biological or developmental processes that underpin mental and behavioural functioning. These disturbances are usually associated with distress or impairment in personal, family, social, educational, occupational or other important areas of functioning and are diagnosed according to existing clinical criteria such as the DSM-5-TR*.

    • Mental illness: a mental health disorder

    • *DSM5-TR: diagnostic and statistical manual of mental disorders (5th edition—text revisions)1

    To clarify the distribution of mental health problems, symptoms and disorders by consequence of time-loss from sport, we have adapted figure 1 of the IOC surveillance consensus statement14 in figure 1.

    Figure 1
    Figure 1

    Relationship of mental health problems, mental health symptoms and mental illness/disorder by consequence of time-loss from sport (not drawn to scale) (adapted from Bahr et al 14). MH, mental health.

    Classifying mental health diagnoses in athletes

    The IOC surveillance consensus statement14 identifies the limitations of the International Classification of Diseases (ICD-11)39 with respect to sports-related classifications and recommends the use of one of the revised sport-specific classification systems (Orchard Sport Classification of Injury and Illness System (OSCIIS) or the Calgary Sport Medicine Diagnostic Coding System)40; however, there are not classifications for many of the common mental health presentations in athletes in these systems. Traditionally, mental health disorders are classified by the DSM-5-TR.1 Table 1 illustrates the comparison between the ICD-11,39 DSM-5-TR1,OSCIIS40, and SMDCS classification systems as they pertain to some common mental health disorders in athletes, as well as a description and their symptom clusters (as per tables 5 and 9 in the IOC surveillance consensus statement14).

    View this table:
    Table 1

    Description, symptom cluster, ICD-11 codes, DSM-5-TR terminology, OSIICS 14, and SMDCS codes for the classification of mental health disorders prevalent in athletes1 39 40 51

    Recording athletes’ mental health symptoms

    As outlined in the IOC surveillance consensus statement,14 athletes and non-clinical recorders should report only symptoms, whereas health professionals can record diagnoses. For athletes’ health surveillance, usually either a sport health professional or the athlete themself will be reporting the athlete’s mental health symptom(s). To facilitate consistency between studies and the comparison of athlete populations, we developed a list of common mental health symptoms or symptom clusters for utilisation by health professionals and athlete/non-clinical individuals based on DSM-5-TR defined symptoms and other validated tools (eg, Patient Health Questionnaire (PHQ)-2 (depression),41 Generalized Anxiety Disorder)-2 (anxiety)42) (see table 2).

    View this table:
    Table 2

    Symptoms or symptom clusters to be recorded in athletes’ mental health surveillance

    Classifying mode of onset

    The IOC surveillance consensus statement authors identify that the mode of onset for injury and illness can have a mix of both acute and gradual onsets, with a variety of underlying mechanisms (see table 1 in IOC surveillance consensus statement14). Similarly, the onset of a mental health problem can be sudden, gradual or mixed (see table 3).

    View this table:
    Table 3

    Examples of mental health modes of onset

    Recording aetiology

    The IOC surveillance consensus statement14 emphasises the importance of recording the aetiology or mechanism of the index injury (see table 2 of IOC surveillance consensus statement14) or illness (see table 8 of the IOC surveillance consensus statement14). Identifying the underpinning contributing factor(s) or reason(s) for the health problem is the second step in the injury prevention sequence originally outlined by van Mechelen.43 Mental health symptoms and disorders are believed to be the ultimate result of a multitude of biopsychosocial factors. From a surveillance perspective, it is helpful to identify, if feasible, the most influential factor(s) for the mental health problem, for the purposes of developing targeted risk modification interventions. Table 4 is a collection of potential contributing factors for the athlete mental health problem for use by either athlete or health professional recording.

    View this table:
    Table 4

    Most influential contributing factor(s) or reason(s) for the index athlete mental health problem (multiple answers can apply)

    Measuring severity

    The IOC surveillance consensus statement14 states that the severity of health problems in sport can be described using various criteria, based on the duration of complaints, of limitations in performance or of time-loss from sport participation. In contrast to special grading systems developed for some diagnoses (eg, depression), measuring severity by duration facilitates comparison across different health problems.

    The IOC Sport Mental Health Assessment Tool-1 (SMHAT-1) measures severity of general psychological distress and of specific symptoms using the cut-off thresholds of the included questionnaires.34 The Oslo Sport Trauma Research Centre Questionnaire on Health Problems (OSTRC-H2, for details see below) calculates the severity of health problems based on the answers to four questions.38

    Multiple health problems

    Throughout a season, an athlete can encounter more than one health problem. Consistent with the concepts presented in the IOC surveillance consensus statement14 on multiple events, we have adapted figure 2 to include mental health problems.

    Figure 2
    Figure 2

    Recording of multiple health problems: examples of hypothetical prospectively collected injury/illness/mental illness data (adapted from Bahr et al 14). MH, mental health.

    Subsequent, recurrent and/or exacerbation of mental health problems

    The IOC mental health surveillance writing group also concurs that the injury and illness classification of subsequent, recurrent and/or exacerbation concepts are applicable to the mental health context for the purposes of surveillance. Modifications to figure 3 of the IOC surveillance consensus statement14 have been adapted to demonstrate mental health presentations.

    Figure 3
    Figure 3

    Classification tree for subsequent mental health problems (adapted from Bahr et al 14). Definitions: (1) index mental health problem=the first recorded mental health problem (2) subsequent mental health problem=any mental health problem occurring after the index mental health problem. (i) Subsequent mental health problem that is different than index mental health problem=new subsequent mental health problem or (ii) subsequent recurrent mental health problem that is the same as the index mental health problem. If not achieved remission*=exacerbation of index mental health problem. If achieved remission=repeat index mental health problem. *Remission is defined by DSM-5 as being without symptoms for 2 months (depression) or 3–12 months (addiction). DSM, diagnostic and statistical manual of mental disorders.

    Reporting exposure, expressing risk, burden of health problems, study population characteristics, data collection methods and reporting guidelines

    We recommend the implementation of the principles outlined in the IOC surveillance consensus statement14 for these various aspects of surveillance with no modifications relevant to mental health surveillance.

    Practical applications

    When should athlete mental health surveillance be conducted?

    In addition to the research applications of the proposed mental health surveillance recommendations, these tools can also be used to monitor athlete mental health symptoms clinically. Thus, ideally, for clinical applications, mental health surveillance should be conducted prospectively and systematically throughout the entire season including competitive and off-season periods. If prospective surveillance is not possible, then episodic mental health screening can occur around key timepoints, for example, during periodic health examinations (eg, pre-season, mid-season or post-season)8 or on occasions of significant injury, illness or mental health problem. Surveillance can also occur in response to a specific trigger for developing mental health symptoms or disorders from either (1) inside sport (eg, being cut from a team, after international competition, retiring from sport),44 or from (2) personal stressors from outside of sport. Mental health surveillance should also occur during large competitions or tournaments such as World Championships organised by International Sport Federations, or multi-sport events such as the Olympic and Paralympic Games, Commonwealth Games or Continental Championships (eg, Pan American, or Asian Games) when mental health symptoms such as anxiety and sleep disorders might be heightened.28 Athletes and coaches may consider mental health surveillance during competitive events as intrusive and/or unnecessary; thus, surveillance conducted during events must take into account this sensitivity.

    Who should conduct athlete mental health surveillance?

    Depending on the research question or the objective of the mental health surveillance, either the athlete or a health professional can record the data. For mental health surveillance that is designed to be reported by a health professional, we recommend that the individual is a qualified member of the athlete health entourage who has developed a trusting, professional relationship with the athlete such as the sports medicine physician, sports psychiatrist and/or licensed sport psychologist.45 46 These individuals should have the training, skills, ethical responsibility and experience to manage mental health problems in the sports context. Requiring these individuals to also have trauma-informed skills is recommended to assist with the diagnosis and support of athletes who are identified in the surveillance process as having mental health problem secondary to harassment and abuse (trauma) from within or outside of sport.47 If sport event-related mental health surveillance is being conducted in a single or multi-sport context where the investigators do not have a therapeutic relationship with the athlete, it is important that mental health support be available for any mental health concerns identified during the surveillance process.45 46

    How should mental health surveillance be conducted?

    It is important that athlete mental health information be treated with confidentiality and data security protection as other medical information. However, as MH data are perceived as more sensitive in nature and given the stigma around mental health that exists in sport, mental health information may require higher levels of protection to safeguard an athlete’s privacy, particularly in high profile, elite sport settings. Strict confidentiality is particularly important for sensitive information related to substance misuse and harassment and abuse. Individual mental health data should not be accessible to anyone outside of the defined circle of care (ie, those designated healthcare professionals responsible for this aspect of the athletes’ health), who are bound by professional codes of conduct with respect to confidentiality.48 If felt appropriate within a given setting, access to athlete mental health data can be coordinated within the electronic medical record or surveillance database by having either a separate section for mental health symptoms and disorders that can be viewed only by designated individuals, or by having limitations to access for specific files and/or notes.

    When working with athlete mental health, it is particularly important to recognise the duty of care to support and treat athletes who are identified as having mental health symptoms or disorders during the surveillance process. As such, sport health professionals conducting surveillance should be equipped with the clinical competence to recognise, diagnose, treat and/or refer for common mental health presentations in the sports context.2

    Tools to conduct mental health surveillance

    There are several tools that can be used to perform mental health surveillance in sport. The selection of a specific tool depends on the aim of the project, the study design (ie, how, who, where, when, frequency, etc.), the available resources and other parameters. Please see table 5 for a summary of the various mental health surveillance tools and the roles of athletes and the athlete healthcare team. Translation of the tools into other languages to improve end-user comprehension is recommended. We highly recommend using validated tools and questionnaires.

    View this table:
    Table 5

    A summary of the types of mental health surveillance tools, timing of data collection for each type, the recommended tools within each type, and the roles of the athlete and the health professional

    For athlete-based longitudinal monitoring of health problems, the OSTRC-O was recently enhanced to capture any health problem including injury, illness, pain and mental health conditions (OSTRC-H2).38 This questionnaire uses four questions to assess the impact of these problems on key sports-specific functional outcomes: (1) sport participation, (2) modifications to training and competition, (3) sport performance and (4) symptom severity. The authors state that additional questions must be used to classify health problems and provide additional information to researchers or clinicians but did not make any recommendations on these follow-up questions.38 A list of 13 mental health complaints in addition to the original version of this tool was used in a study on dance students and dance-teacher students.49 Of this list, we exclude six, as they are non-specific, reworded four, kept three and added 16. Thus, we have developed a list of 23 symptoms or symptom cluster that should be provided to athletes (see table 2). In addition, we recommend asking further questions about the date of onset, whether the problem is new, a recurrence or worsening, the subjective reason or most influential factor(s) (see table 3), the use of professional help and the duration of the problem. Our recommendation of an athlete-based report form for longitudinal monitoring of (mental) health problems is presented in online supplemental appendix 1.

    Supplemental material

    For longitudinal monitoring of health problems by a physician or the medical team, we have modified the IOC report form for during the season14 (see online supplemental appendix 2). We have also added a mental health section to the IOC report form for (multi-)sport events-related monitoring of health problems by a physician or the medical team (see online supplemental appendix 3). Due to their distinctiveness and importance, we recommend a specific, separate section for mental health data. Following the structure of the injury and illness sections of the IOC health surveillance form, we propose the documentation of (a) mental health symptoms/symptom clusters (table 2), (b) the most influential contributing factor(s) or reason(s) for the mental health problems (table 4), (c) mode of onset (table 3), (d) new, recurrent or exacerbation, (e) duration of time-loss in sport and (f) date of return to sport or reason for not returning to sport (with the new inclusion of retirement).

    Supplemental material

    Supplemental material

    For episodic screening of athlete mental health, the IOC’s Sports Mental Health Assessment Tool 1 (SMHAT-1)34 is recommended. First, all athletes complete Step 1, which contains a validated screening tool for sport-related psychological distress. Then those who score above threshold complete Step 2, which contains the validated screening tools for depression, anxiety, sleep disturbance, alcohol, drug misuse and eating disorders. In the case of diagnostic uncertainty, complexity, severity or treatment non-responsiveness, athletes can complete further validated screening measures (Step 3b) designed to screen for attention-deficit/hyperactivity disorder, bipolar disorder, post-traumatic stress disorder, problem gambling and psychosis.34

    Discussion and summary of consensus recommendations

    Mental health is an integral component of both athlete health and sport performance. This publication on mental health surveillance serves as a supplement to the IOC surveillance consensus statement14 by including and standardising surveillance principles specific to athlete mental health. Conducting systematic and methodologically robust mental health surveillance is key to identifying and defining mental health problems in athletes and is a critical component of the prevention and early intervention cycle. Mental health literacy education of athletes and the entourage is recommended to realise successful mental health surveillance. Implementation of the athlete mental health surveillance recommendations from this publication will also serve to improve the quality of surveillance research outcomes and facilitate comparison of results across studies. In addition, adoption of the principles outlined in this publication should improve clinical outcomes by facilitating earlier identification of athlete mental health problems.

    There are some limitations to this publication. Author membership on this manuscript does not include individuals from Africa or South America. In addition, a systematic review of the scientific literature was not undertaken due to the paucity of published scientific literature on the topic. We also acknowledge that the proposed additions to the surveillance forms have not yet been implemented in their current form (other than the SMHAT-1) and require piloting to assess feasibility and efficacy. As with all injury and illness surveillance studies, there may be inconsistencies of inter- and intra-athlete reporting, as well as unknown correlation between reporting athletes, and medical providers.

    A summary of the main additions to, and adaptions of, the IOC surveillance consensus statement14 related to the surveillance of athlete mental health can be found in table 6.

    View this table:
    Table 6

    A summary of the main additions to the IOC surveillance consensus statement on injury and illness surveillance related to the surveillance of athlete mental health

    Conclusions

    Sport has the duty of care to protect the health of athletes.50 We encourage the implementation of the surveillance principles outlined in this paper, and the adaptation of them to a variety of sporting contexts, including the Olympic Games. Adoption of the recommendations outlined above should not only stimulate mental health surveillance and promote mental health literacy,11 but also may decrease stigma, and improve the quality of mental health surveillance outcomes. The goal of mental health surveillance is to improve athlete health and well-being. ‘Mental health and other aspects of physical health are two halves of a whole, and care for both must be seen as a priority.’ AB, Olympic Champion and member of the IOC Mental Health Working Group.45

    Ethics statements

    Patient consent for publication

    Ethics approval

    Not applicable.

    Acknowledgments

    The authors would like to thank the International Olympic Committee for their prioritisation and support of athlete mental health.

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    Supplementary materials

    Footnotes

    • Twitter @margo.mountjoy, @Mputukian, @TSoligard

    • Contributors MM, AJ and VG are core lead authors responsible for design, development and collation of contributions. All authors were involved in conception, drafting, revising and approval of the final manuscript prior to submission.

    • Funding No external funding was obtained for this publication. The International Olympic Committee supported the logistics for the in-person meeting of the IOC Mental Health Working Group for this paper.

    • Competing interests MM is a Deputy Editor of the BJSM and a member of the BJSM IPHP Editorial Board. VG is Chair of the IOC Mental Health Working Group and MM, AB, CB, AC, DM, RP and MP are members. CLR and BH are co-Chairs of the IOC Consensus Group on Mental Health in Elite Athletes. RB is the IOC Medical and Scientific Director. LE is the IOC Head of Science Activities. TS is the IOC Scientific Manager. CB is an Associate Editor of the BJSM and a member of the BJSM IPHP Editorial Board. She is a member of the IOC Medical & Scientific Commission and the IPC Medical Committee. LE is an IPHP Editor of the BJSM.

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

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.