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From www.fifpro.org 

FIFPro Chief Medical Officer Dr. Vincent Gouttebarge PhD

FIFPro, the World Footballers' Association, announced results of an international study revealing the extent of Mental Illness in Professional Football. More than 300 current and former professional players and six national unions participated. The following summary is divided in five parts: 1) background and objective of the study 2) methodology; 3) findings among current professional footballers; 4) findings among former professional footballers; and 5) conclusions.

1. BACKGROUND AND OBJECTIVES

Mental Illness in Professional Sports

In professional i.e. elite sports, most of the scientific medical studies have been directed towards the occurrence of musculoskeletal injuries (bones, muscles, joints, ligaments...), showing an increased risk for injuries in the lower extremities (Alonso 2010; Hootman 2007; Junge 2008). While mild acute injuries do not impair recovery and return to sport on short notice, recurrent or severe injuries cause long periods of time without training or competition, and might even lead to surgeries (Chen 2005). Consequently, severe injuries and related surgeries are considered as major physical and psychological stressors that may induce mental illness during a sport career (Shuer 1997; Walker 2007; Wiese-Bjornstal 2010). In addition, severe injuries might even cause early and forced retirement from sports, involuntarily retirement having been recognized as a potential risk for post-sports life mental health problems (Kerr 2000; Warriner 2008).

Mental illness in Professional Football

Most of the scientific studies about footballers' health are related to the occurrence of musculoskeletal injuries: professional players have during their career a high risk for injuries, especially hamstrings, knee and ankle injuries (Aoki 2012; Eirale 2012; Gouttebarge 2014). Analogously to athletes from other sport disciplines, the expectation is that professional footballers might also experience, over the short and long term, mental health problems as a consequence of physical and psychological stressors such as severe injuries, surgeries or long-term physical problems (osteoarthritis). In addition, professional footballers have been exposed to other stressors such as match-fixing and non-payment of salary.

Objectives of the FIFPro study

Considering the lack of knowledge about mental illness, and with regard to the presence of several physical and psychological stressors during and after a career in professional football, FIFPro and six national unions supported an international scientific study to learn about mental illness among current and former professional footballers. With the information provided by such a study, FIFPro and related national unions have a basis to understand mental health problems that might occur during and/or after a professional football career. Subsequently, FIFPro and related national unions will be in a position to develop and implement optimal strategies in order to protect and promote the sustainable health of professional footballers.

2. OUTLINE OF THE FIFPRO STUDY

The involved national unions

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 mental illness

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

Measurement of mental physical and psychological stressors

Several physical and psychological stressors were explored in the study such as severe injuries (training or competition absence for more than 4 weeks), surgeries, life events (death of a family member) and (social) support from trainer and team mates. All these aspects were self-reported by the players.

Procedures

Based on the different questionnaires i.e. scales used to measure physical and psychological stressors and mental illness, a paper and electronic survey was set-up, both in English and Dutch. Then, the participating national unions (Australia, Ireland, Netherlands, New Zealand, Scotland and United States) sent in 2013 per e-mail and/or post an information letter about the study to some of their members. If willing to participate in the study, the members
filled in their survey (20-25 min needed) that was subsequently returned.

3. MENTAL ILLNESS AMONG ACTIVE PROFESSIONAL FOOTBALLERS

Participants

180 active professional footballers participated to the study (all male; goalkeeper: 11%; defender: 33%; midfielder: 33%; forward: 23%). From these players, 60% were playing at the time of the study for a club of the highest national league. Further characteristics of these current players were:

mean age: 27 years old;
mean height: 183 cm;
mean body weight: 79 kg;
mean duration of football career: 8.5 years.

This group reported a total of 174 severe injuries (so far) during their career (1 injury: 32%; 2 injuries: 20%; 3 or more injuries: 17%), from 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%), from which more than 50% related to knee or ankle injuries.

Results

Three to 26% of the current professional footballers reported to have some mental health problems. Especially, signs of anxiety/depression and adverse nutritional behavior were the most reported, namely by 1 out of 4 players. By contrast, only few current players reported some signs of burnout (5%) or have a low self-confidence (3%). Distress was reported by fewer players (10%). Nearly 20% of the current footballers reported to have some adverse alcohol behaviors, while only 7% were smoking.

Some perspectives about the findings

To put the findings of the study among current players in some perspective, comparison with other groups can be made. Mental problems encountered in the past were reported by 17% of young and adult French Olympics athletes, while mental health problems were reported by 5% to 25% of young and older general and working populations in several countries (Bültmann 2002; King 2008; Korten 2000; Schaal 2011). In these groups of individuals, mental health problems such as distress, anxiety, depression and substance abuse have an high impact on functioning (work and daily life) and quality of life. The results of the study show that mental illness occurs among current professional footballers as often as in other populations.

4. MENTAL ILLNESS AMONG FORMER PROFESSIONAL FOOTBALLERS

Participants

121 former professional footballers participated in the study (all male; goalkeeper: 12%; defender: 41%; midfielder: 32%; forward: 15%). Nearly 65% of these former footballers have had played during their career principally for a club of the highest national league. Further characteristics of these former players were:

mean age: 36 years old;
mean height: 184 cm;
mean body weight: 85 kg;
mean duration of football career: 12 years;
mean duration since retirement: 5 years.

More than 60% of these players had retired from football voluntarily, and 85% had at the time of the study a paid job for 38 hours a week on average. During their career, 80% of the former players have had one or more severe injuries, while 70% reported they have had one or more surgeries.

Results

Five to 42% of the former professional footballers reported to have some mental health problems. Especially, signs of anxiety/depression and adverse nutritional behavior were the most reported, namely by 2 out of 5 players. By contrast, only few former players reported to have a low self-confidence (5%). Distress and burnout were reported by 15-20% of the former players. More than 30% of the former footballers reported to have some adverse alcohol behaviors, while 12% were smoking. Comparison can be made in order to put these findings in some perspectives. Mental problems encountered in the past were reported by 17% of young and adult French Olympics athletes, while mental health problems were reported by 5% to 25% of young and older general and working populations in several countries.

Some perspectives about the findings

As acknowledged previously in relation to active professional footballers, mental problems encountered in the past were reported by 17% of young and adult French Olympics athletes, while mental health problems were reported by 5% to 25% of young and older general and working populations in several countries. In these groups of individuals, mental health problems such as distress, anxiety, depression and substance abuse have an high impact on functioning (work and daily life) and quality of life.

5. CONCLUSIONS

The results of our study show that mental illness seems to occur among former professional footballers more often than in current players and more often than in other populations. Consequently, mental illness among former professional footballers cannot be underestimated and should be a subject of interest for all stakeholders in football. Attention to career planning in an early stage of a football career might significantly help to prepare the post-sport life period and to avoid potential problems after retirement (Alfermann 2007).

The attention given to professional footballers' health by international governing bodies or clubs, and many researchers is principally directed towards the occurrence of injuries, which is peculiar as health involves not only the physical well-being but also mental and social well-being, both short and long term. When it comes to any health problem, physical or mental, the minimum standard is to raise self-awareness of players about these issues. Access to educational tools and support mechanisms covering all aspects of what might occur during and after a professional football career is vital.

The shift that occurs during the transition to life after professional football can have a dramatic impact. Players stop with their intensive physical activities, they lose their structured life, their social support by trainers and team mates diminishes, they need to find their place in 'regular' society, and find another occupation. Consequently, they are likely to experience some mental health problems during this period.

Support groups involving current and former players can have an important role. For example, moderate or self-selected intensity exercises (30-40 minutes per session, three times a week for a few months) are methods which have shown to be effective for the treatment of mental health issues such as depression.

We know that young individuals do not seek easily professional help for mental health problems. This might be even more the case in a population of young football players. Consequently, reducing the stigma about mental health in football should have the attention of all stakeholders to raise awareness and acceptance, while empowering and encouraging players to seek assistance. It is possible to learn optimal behaviours and coping skills to manage symptoms relating to mental illness.