International consensus statement on the psychosocial and policy-related approaches to mental health awareness programmes in sport.

BACKGROUND: Research focused on mental health in sport has revealed a need to develop evidence-supported mental health practices that are sensitive to sport culture, particularly for non-elite athletes. A consensus statement was produced to assist effective mental health awareness in sport and guide programme implementation in this rapidly emerging field.
METHOD: The AGREE Reporting Checklist 2016 was used in two international expert consultation meetings, followed by two online surveys. Experts from 10 countries and over 30 organisations contributed.
RESULTS: Six objectives were agreed: (1) to define mental health awareness and service implementation constructs for inclusion in programmes delivered in sporting environments; (2) to identify the need to develop and use valid measures that are developmentally appropriate for use in intervention studies with sporting populations, including measures of mental health that quantify symptom severity but also consider causal and mediating factors that go beyond pathology (ie, well-being and optimisation); (3) to provide guidance on the selection of appropriate models to inform intervention design, implementation and evaluation; (4) to determine minimal competencies of training for those involved in sport to support mental health, those experiencing mental illness and when to refer to mental health professionals; (5) to provide evidence-based guidance for selecting mental health awareness and implementation programmes in sport that acknowledge diversity and are quality assured; and (6) to identify the need for administrators, parents, officials, coaches, athletes and workers to establish important roles in the promotion of mental health in various sports settings.
CONCLUSION: This article presents a consensus statement on recommended psychosocial and policy-related approaches to mental health awareness programmes in sport. © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Objectives

There has been a rapid expansion of evidence-based public mental health awareness programmes in sport, revealing the need for improvements to mental health programme conception; design and measurement; delivery methods; use of theory; and evaluation approaches in sport.1 A review of current policy related to community sport, physical activity and mental health, and illness in England has also concluded that measurable and specific targets that can be used to track positive change related to mental health and illness have not been outlined in much government policy.2 Moreover, recently, published consensus statements have focused on elite athletes or elite athlete clinical service provision,3–6 overtraining,7 or have been specific to a disorder.8 Each statement on an individual basis is important, but collectively they do not address mental health awareness, implementation of programmes or evaluation among the wider sporting population beyond elite athletes. For instance, globally, while sports participation rates are high, elite athletes comprise only a very small proportion of total sport participants.9 Further, while elite athletes, typically, have access to a range of support systems including medical professionals, sport psychologists and/or professional coaches, such resources are not afforded to subelite or non-elite participants.

Guidelines for the implementation and evaluation of mental health programmes in a non-elite context are crucial because these programmes are also relevant to the vast majority of sport participants worldwide. All participants across the life course of sport would benefit from supporting mental health optimisation. Consensus is therefore required to assist programme designers and deliverers, policymakers and commissioners with respect to: (A) definitions and terminology that can be operationalised when promoting mental health awareness10; (B) key design principles including choice of theory, target populations, stakeholder involvement and delivery sites; (C) outcomes to measure programme efficacy and effectiveness; and (D) methods for conducting and reporting interventions with sporting population groups (eg, coaches, athletes and officials). Our consensus statement is intended to enhance these areas, and facilitate development of mental health programmes in controlled trials.

A recent Wellbeing in Sport Action Plan 2019-2025 for Northern Ireland11 highlighted the importance of sporting environments in improving mental health. Part of this policy action plan suggested the need for consensus in evaluating the evidence for mental health awareness programme implementation at all levels of sport.11 Indeed, the Northern Ireland Wellbeing in Sport Action Plan 2019-2025 and the UK Government Mental Health Action Plan for Elite Sport12 are the first of their kind internationally to either be supported or developed by governments. Given the current momentum in mental health in sport research, and the increased disclosure by high-profile athletes, it is anticipated that action plans will continue to emerge. We seek to build on previous consensus statements, adding a specific focus on determining effective reporting of mental health awareness and implementation programmes at all levels of sport and for all types of sports workers, and not just programmes which focus on elite athletes. This is necessary to ensure the effective implementation, translation and evaluation of mental health programmes in sport at all levels leading to meaningful benefits at a population level.

Stakeholder involvement

To assist in carrying out these objectives, the AGREE Reporting Checklist 2016 was adopted. The AGREE Reporting Checklist assists practice guideline developers to improve the completeness and transparency of reporting. The checklist includes six quality domains with 23 key items, providing a systematic process for reporting essential information.

In the development of this international consensus statement, a 2-day consultation meeting of experts was conducted. This included invited international stakeholders representing: research, policy, sporting organisations, practitioners, safeguarding and welfare practitioners, psychiatrists, psychologists and mental health charities. The first event took place at the European College of Sport Science Congress (ECSS) in Dublin, Ireland, on 4 July 2018.13 The second took place at the British Psychological Society’s (BPS) Division of Sport and Exercise Psychology (DSEP) Annual Conference on 4 December 2018 in Belfast, Northern Ireland.14 Both conferences were intentionally targeted as attendees were professionals representing various disciplines from across the field of mental health and sport. Invitations were sent to those who could bring expert knowledge to the discussion and who were not already planning on attending these events.

Consultation 1: ECSS

Prior to the first meeting, a rationale for the international consensus statement was made available to panel members for their preliminary input. Five presentations were provided by international researchers and policymakers with expertise in mental health and sport. Presentations highlighted: (1) the need for a consensus statement; (2) the available evidence and ongoing research; and (3) policy development needs internationally. Each presentation lasted 20 min, and were as follows: (1) Setting the Context and Rationale for Psychosocial and Policy-Related Approaches to Mental Health and Well-being in Sport—Chartering the Path Towards a Mental Health and Well-being Consensus Statement (GB, Northern Ireland); (2) Tackling the Blues: Designing a Theoretically Informed Sports-Based Mental Health Programme for Children and Young People (AS, England); (3) The Optimum Performance Programme in Sports: A Description of Its Components and Report of Its Randomized Controlled Clinical Trials in Collegiate Athletes (BD, USA); and (4) Integrating Mental Health and Well-being in Sport Into a Government Action Plan: Research to Policy (PD, Northern Ireland). Following the presentations, a discussion was facilitated between the panel and the audience on the content of the presentations and emerging objectives which could be incorporated into an initial draft summary consensus statement.

Four questions were presented: (1) Did delegates acknowledge the need for a consensus statement for psychosocial and policy-related approaches to mental health awareness in sport? (2) Would those involved want to help shape the consensus statement? (3) After reading the draft summary of potential objectives of the statement, what additional information would need to be included, for example, were the aims and methods appropriate? and (4) Were there any additional comments or suggestions? Contributors to the discussion were from eight countries (USA, Taiwan, Italy, Spain, Turkey, England, Northern Ireland and Republic of Ireland).

The summary statement along with a feedback questionnaire was made available online between July and October 2018 to increase the reach of the consultation and to account for the views of those who could not attend the meeting. The survey targeted organisations, policymakers, practitioners and researchers involved in mental health promotion in sport. Responses from the ECSS meeting and the online survey were summarised. Attendees were in broad agreement that an international consensus statement was required and identified seven reasons why (see box 1).

There has been increasing recognition of mental health issues in sport.

Growth of sport-based mental health awareness programmes.

Variation in programme content, design, theory and evaluation.

Uncertainty about the outcomes or impact of programmes.

Variations in measurement tools selected—validation and reliability of these tools.

Lack of agreement on the minimal training requirements for sport and exercise psychologists or mental health club officers in supporting or guiding awareness training programme content and development.

Necessity for evidence-based recommendations to shape policy.

In addition to formulating the above rationale, questions were raised about whether the consensus statement should recommend a standardised validated instrument to assess mental health outcomes. The merits of having a single standardised measure were discussed but considered to be too restrictive for both researchers and practitioners. A more robust and inclusive approach would be to determine what validated and useful tools are currently available.

It was agreed that the consensus statement should go beyond elite sport and include direction for promoting a positive sport environment, characterised as a climate that encourages mental health help seeking, self-disclosure of mental health-related concerns, stigma reduction specific to mental health and signposting to support those in need of mental health support. It was also acknowledged that promoting mental health and well-being in sport requires a shared mandate and is a shared responsibility.15 Consequently, there should be a focus on supporting all who participate and work in sport, including employees such as administrators, coaches, sport science support personnel, parents, officials and volunteers.

Findings from the online survey, completed by representatives of 26 organisations from seven countries (England, Northern Ireland, Republic of Ireland, USA, Scotland, Australia and Turkey), including those not at the meeting in July, showed that 100% of respondents either agreed or strongly agreed that there was a need for an international consensus statement to guide Psychosocial and Policy-Related Approaches to Mental Health Awareness in Sport. From this online survey and discussions at the ECSS meeting, it was confirmed that the consensus statement could inform policymakers and mental health in sport action plans internationally as they emerge.

All respondents indicated they would assist the development of the consensus statement and provided comments on the summary draft. Three key objectives were originally developed: (1) to define mental health awareness constructs for inclusion in programmes in sport; (2) to identify valid measures for use in intervention studies with the sporting population, and establish standards for data collection, analysis and reporting procedures; and (3) to provide policymakers with guidance for implementing awareness programmes in sport. These objectives were subsequently broadened to six, thereby encompassing the opinions of all those involved in the consultation process.

Further views from respondents extended the points addressed above and related to specific interventions, and challenged the importance of the focus of the statement. For instance, one respondent stated: ‘My main concern is that the initiative should not omit examination of mental health interventions. Awareness is a big part, but I believe insufficient in making significant change.’ This view was widely supported but considered outside the initial remit of the consensus statement on mental health awareness raising. A further comment highlighted the need to engage with those with lived experiences of mental illness. Due to the diversity of opinion expressed in discussions following the initial consultation and online survey it was acknowledged that additional changes to the initial consensus should be considered. This occurred during the second consultation meeting, held at the BPS’s DSEP Annual Conference in Belfast, Northern Ireland, in December 2018. This consultation event addressed the feedback from Consultation 1 and involved the suggested inclusion of: (A) those with lived experience of mental illness; and (B) organisations who support those with lived experience of mental illness.

Consultation 2: BPS’s DSEP Annual Conference

Prior to the consultation, the aims of the event were shared with delegates attending the conference via the programme and marketing on the conference website. An information leaflet describing the adapted consensus statement was also produced summarising the revised objectives that emerged from the initial consultation and survey results. At the DSEP conference the second consultation event was scheduled as a panel discussion rather than a traditional keynote address. Seven panel members representing interdisciplinary groups were selected as experts to discuss the six objectives defined in the updated consensus. The panel consisted of the Chair of the BPS DSEP (SC), Royal College of Psychiatrists Special Interest Group in Sport (TR), Clinical Research Trials Researcher (BD), DSEP Training Committee Chair (Dr Ruth Lowry), Childline (Geraldine McConaghy), CEO of Sport Northern Ireland (Antoinette McKeown) and Sociology and Mental Health in Sport Researcher (AS).

The session was independently chaired by Dr John Kremer, a rationale for the session was introduced by GB (Consensus lead) and response data were collected by SS and TJH. The agenda consisted of an update on what had been achieved so far in the development of the consensus statement.14 Three questions were posed to the panel and audience: (1) Did the six objectives capture all that is viewed as necessary in the consensus statement? (2) Was each objective fit for purpose? and (3) Were there any other factors that need to be considered? Table 1 outlines the responses that have been considered after Consultation 2 and integrated into the six original objectives.

Table 1

Do the six key objectives capture all that is viewed as necessary in the consensus statement?

Key objectives	Responses from the panel, audience and survey that were considered and integrated into the objectives
Objective 1	‘When defining awareness, consider the inclusion of sporting environments.’
Objective 2	‘Consider having correct measures in place to assess awareness.’‘The objective is symptom based, what about cause of mental health issues.’‘Young people should be included in the design of appropriate measures.’‘Make language of measurements of awareness age appropriate.’
Objective 3	‘Consider the inclusion of theory or models for evaluation.’
Objective 4	‘Coaches should know when to refer to a professional.’‘Competencies around mental health should be considered in training as a sport and exercise psychologist.’‘What is the minimal training required to be a sport and exercise psychologist, this should include mental health in sport?’‘If a coach is not trained they need to know who can help.’‘Quality assuring certification should be considered for awareness training programmes.’‘Make those involved in sport aware of what follow on care after referral is available.’
Objective 5	‘Public Health Agency quality assurance of mental health awareness trainers.’‘Training provided in resilience.’‘Training should be included in a curriculum for athletes, coaches and officials.’
Objective 6	‘Still work to be done here, survey of coaches, directors of governing bodies who look after the people.’ ‘Consider peer athlete support.’

Following the event, a second online survey was made available, until 15 February 2019, for those who attended the conference to feed back further recommendations on the content of the revised consensus statement. A key point to emerge from the survey was that the statement should be written using an inclusive non-discriminatory narrative against marginalised individuals, such as those with a disability or in greatest areas of financial need.

On addressing feedback, a draft of the consensus statement was prepared and circulated to all members who expressed an interest in being involved, with an invitation for edits and comments to be returned. All comments received were reviewed and, where applicable, incorporated into revisions of the final consensus statement. Where a suggested change was not incorporated, a written explanation was prepared. After the final iteration, all members of the group were asked to confirm their agreement with the content of the objectives. In total, this international consensus statement evolved from an initial three to six objectives through an 8-month consultation period. The final six consensus statement recommendations are detailed below.

Consensus recommendations

The six objectives are intended to: (1) inform those developing psychosocial or policy-related mental health awareness programmes; and (2) provide direction for researchers, policymakers and practitioners working in this emerging area (see table 2). As research and practice develops we intend to update the recommendations in the coming decade, and methodologically open the revisions to as wide an audience as possible through online mediums, events and debates.

Table 2

Finalised international consensus statement recommendations.

Recommendation 1	To define mental health awareness and the key-related constructs for inclusion in programmes delivered in sport environments.
Recommendation 2	To identify standards for data collection, analysis and reporting procedures, and valid measures that are age appropriate for use in intervention studies and implementation science with sporting populations. These may include assessments of mental health that measure symptoms, but also consider causal factors and mediators, and measures that go beyond pathology (eg, well-being, resilience, optimisation and team/organisational culture).
Recommendation 3	To provide guidance on the selection of appropriate theories or models and constructs to inform intervention design, implementation and evaluation.
Recommendation 4	To determine the minimal competencies of mental health awareness training for those involved in sport to support mental health, those experiencing mental illness and when to refer to professional services.
Recommendation 5	To provide evidence-based guidance for the selection of mental health awareness and implementation programmes in sport that acknowledge diversity (eg, age, gender, culture) and are quality assured.
Recommendation 6	To identify what role administrators, parents, officials, coaches, athletes and other workers/volunteers have in the cocreation of mental health promotion in various sport settings.

Discussion

Recommendations within this consensus statement highlight the need for action towards greater consistency in the development, evaluation and reporting of mental health awareness programmes in sport. First, suggestions were made for appropriately defining mental health awareness and implementation constructs appropriate to sport. We therefore propose that practitioners and policymakers view mental health from a perspective that comprises both mental illness and mental health as two independent, but related, factors through Keyes’ two continua model.16 Further, we outline a sport-sensitive definition of mental health that participants can relate to. We expanded the WHO’s definition, that is; mental health is not merely the absence of illness, but a state of well-being in which those involved in competitive sport realise their purpose and potential, can cope with competitive sport demands and normal life stressors, can work productively and fruitfully, can act autonomously according to their personal values, are able to make a contribution to their community and feel they can seek support when required. As a means of promoting mental health, we suggest that awareness constructs including mental health literacy,17 psychological literacy15 and mental health self-management18 that can be operationalised in the context of interventions should be considered.

Second, we suggest being selective by using psychometrically validated, theory-informed and context-appropriate measurement tools in the evaluation of awareness programmes.1 19 The measures should be aligned with the intended outcomes of the programme; assessing mental health literacy, stigma reduction, help-seeking behaviour, pathological symptoms, and those assessing wellness constructs. Statistical analyses during programme evaluation may consider recommended methodological practices, such as reporting effect sizes, determining adequate sample size and power, and emerging approaches for assessing mediating effects and modelling individual and collective behaviour change over time.20 Those involved in programme evaluation could also give consideration to the inclusion of robust longitudinal controlled trial research designs.

Third, programme designers should underpin the intervention components with appropriate theories and models, such that the design, implementation and evaluation of programmes are guided by theoretically derived mechanisms of change through which interventions are more likely to be effective.21 22 A number of theoretical models to be considered which to date have shown some success in raising mental health awareness with athletes are: the Theory of Planned Behaviour, Self-Determination Theory, Integrated Behaviour Change Model and Family-Based Behavioural Learning Theory.23 The integration of theories has also helped explain additional variance in mental health outcomes18 and related health behaviours24 and may be considered in the future when developing theory through programme design, implementation and analyses.

Fourth, those involved in the design of programmes should be cognisant of the appropriate level of training that is required for those delivering mental health awareness programmes,25 particularly given mental health is a sensitive area. We propose trainers should be aware of sport-specific theories underlying mental health, as Keyes outlines,16 including how athletes can function effectively in their sport and experience psychological well-being, while also having mental illness symptoms such as anxiety, depression, bulimia, schizophrenia, and so on. Moreover, trainers require competency in observation skills on how to detect observable changes in moods or behaviours in others; have knowledge of when, where and who to signpost a person if they require help; and finally be able to promote self-care. Adopting a public health approach to programme development, staff training and delivery in and of itself is not enough (ie, using an existing generalist mental health awareness programme), so we suggest that trainers are sensitive to sports cultures and environments and that awareness programmes include sporting case studies as a minimum.

Fifth, those involved in mental health service provision need to consider contextual (eg, culture, family, age, gender) and operational factors (eg, feasibility, length of time, service user experience), without which evidence-based programmes23 may not be sustainable or effective. For instance, recent evidence26 indicates that collegiate athletes’ family problems may predispose them to mental health distress, and therefore serve as a good screening method to assist referrals.

Finally, in recommendation 6, all of those involved in sport should consider the significant role that all stakeholders (eg, athletes, support staff, national governing bodies, sport associations, media, industry sponsors and clubs) have to play in developing and supporting an open, stigma-free environment in which mental health can be supported within and through sport at all levels.2 23 27 28 By implementing these recommendations, it is expected that improved methodological guidance will become available from researchers working alongside stakeholders. Overall, we argue that these approaches will enhance and encourage the creation of valid and reliable evidence base for underpinning future programmes that are designed to increase mental health awareness in sport, and in so doing better inform future psychosocial policy approaches to mental health awareness.

Future directions

A rigorous evidence-based implementation of mental health awareness programmes is required across countries to ensure equitable support is available for all involved in sport beyond elite athletes. This international consensus statement provides evidence-based strategies for programme implementation and research to stimulate the development of culturally sensitive mental health promotion efforts that are inclusive of all involved in sport. It is apparent that some plans are already in place,11 29 while developmental work is currently underway in other countries. Research into what works best in terms of increasing mental health awareness across cultures is also required, and a sharing of this knowledge would be beneficial to the global mental health promotion field. Overcoming the historical personal and social stigma of help seeking requires exploration within sports cultures that have typically lagged behind many other prominent cultural sectors in promoting and addressing mental health. Future work could therefore consider the recommended compatibility and practical guidance that can be provided to national associations on developing a balanced sport performance ethos as well as an open and inclusive environment for mental health help seeking. Finally, there is a relative lack of mental health awareness programmes that address the nuances of competing and working in sport in some countries; in some countries there is a reliance on using a public health model that is not sensitive to sports cultures without adaptation, and in others there is a complete absence of provision. Adopting the above guidance may help inform the future development of policy, practice and science which regards mental health as equally important as sports performance so that all involved in sport are mentally better off.