Sports psychiatry: Discipline, areas of activity, collaboration, and training

Participants

Participants were recruited between February 1, 2022, and May 13, 2022. They were contacted and recruited via e-mail, newsletters, and social media (Twitter account of the SSSPP). Those contacted included members of the sports psychiatry networks (including the national societies) in Switzerland, Germany, and Austria, as well as the authors of the first German textbook of sports psychiatry [17], and members of the professional societies for sports medicine and sports psychology in the three countries mentioned and for physiotherapy in Switzerland. In addition, child and adolescent psychiatrists, psychiatrists, and general practitioners in local physician networks in Switzerland were contacted. There was no financial compensation for the participants. The survey was offered only in German.

Questionnaire

The questionnaire was developed by Malte Christian Claussen and reviewed and pre-tested by three SSSPP board members. The questions consisted of 6 parts: (i) participant information, such as gender, age, country of residence, discipline and specialization, workplace and patient care activity; specific questions with regard to sports psychiatry, including (ii) familiarity with sports psychiatry and views on the classification of sports psychiatry, the areas of activity of sports psychiatry, and the importance of interdisciplinary and interprofessional collaboration in the areas of activity; (iii) the importance of sports and exercise for the prevention of and as therapy for mental disorders and as a therapeutic in psychiatric care; (iv) mental health and disorders in competitive and elite sport and the need for specific psychiatric care; (v) sport-specific mental health problems and disorders in popular sport and additional benefits through sports psychiatrists in the prevention of and as therapy for these disorders; and (vi) need, setting, and access to specific sports psychiatry education and training.

The results presented here are only a part of the complete online survey; they cover the topics of classification and areas of activity of sports psychiatry (part ii), sport-specific mental health problems and disorders in popular sport (part v), and education and training in sports psychiatry (part vi). The parts of the survey that specifically address the importance of sport and exercise for mental disorders (part iii) and mental health and disorders in competitive and elite sport (part iv) will be published elsewhere, since they will have to be presented in a different context.

Data collection and analysis

Data were collected through a REDCap-based online survey hosted at the Psychiatric University Hospital Zurich and University of Zürich, Switzerland [18, 19]. The data were analyzed according to the six parts mentioned above. If the participant information (part i) and/or classification and areas of activity of sports psychiatry (part ii) were missing, the respondent was excluded from analysis completely. Only complete datasets of the subsequent four parts of the questionnaire were used for analysis. Thus, the number of answered parts of the questionnaire decreased by the end. To ensure data validity, the participants who dropped out due to missing data were compared with the other participants. We used the data already provided to check if participants were missing at random or if they had dropped out systematically and could have introduced bias. The data are presented in the results section in the order in which they were collected.

To avoid assigning one person to several disciplines and/or specializations in the data analysis and description, an arbitrary hierarchy was established according to which the participants were assigned only to one professional group (Table 1). Disciplines and/or specializations were grouped together and ranked by their thematical proximity to sports psychiatry: psychiatry/psychosomatic medicine (P/PM) → child and adolescent psychiatry (CAP) → other medical specialty (OMS) → psychology (PSY) → physiotherapy (PHY) → other professionals (OP).

Table 1 Participants: Gender, age, country of residence, discipline and specialization, and workplace

	All
	n = 183
Notes. Due to rounding errors, percentages may add up to more than 100%. *Multiple selection: The groups are shown according to the procedure described in the text for participants who have indicated multiple training and/or specializations. Multiple answers are not shown. **Multiple selection: In case of multiple answers, the second number in the row represents all the answers given in that category. Multiple answers are shown. 1No clusters or additional relevant information were found in these groups. 2With and without completed further specialization/postgraduate training. 3Including 10 participants who indicated psychosomatic medicine as their discipline and specialization. 4Psychologists with or without completed further specialization/postgraduate training in different fields/specializations.
Gender
Male	90	49%
Female	92	50%
Other	1	1%
Age
25–34	26	14%
35–44	44	24%
45–54	60	33%
55–64	42	23%
> 65	11	6%
Country of residence
Switzerland	142	78%
Germany	23	13%
Austria	14	8%
1Other	4	2%
Discipline and specialization*
2Child and adolescent psychiatry (CAP)	17	9%
2,3Psychiatry/1psychosomatic medicine (P/PM)	79	43%
2Other medical specialty (OMS)	18	10%
4Psychology (PSY)	25	14%
2Physiotherapy (PHY)	20	11%
1Other professionals (OP)	24	13%
Workplace**
University hospital	25/39	14%
Public hospital	35/56	19%
Private hospital	20/29	11%
Institute	5/14	3%
Practice	78/88	43%
1Other place of work	20/25	11%
Patient care activity**
Outpatient care	93/155	51%
Partial inpatient care	8/27	4%
Inpatient care	52/62	28%
1Other patient care activity	11/15	6%
No activity in patient care	19/27	10%

Table 1 Participants: Gender, age, country of residence, discipline and specialization, and workplace

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Data were analyzed in these six occupational groups and simultaneously in three groups of subjective knowledge about sports psychiatry (possible answers: known, partially known, unknown).

Although the aim of this paper was to describe the data, we checked for differences between groups to evaluate if the disciplines and/or specializations differed from each other significantly. To check for differences between groups, the χ² test was used for tables with more than four fields, one-way analysis of variance was used for continuous variables, and the Kruskal–Wallis rank test was used for nonmetric variables. A two-sided p < 0.05 was considered statistically significant. If no difference was found, data were presented as such, and non-significant p-values were not displayed in the tables. Stata Statistical Software Release 13 (College Station, TX) was used to analyze the data.

Participants provided informed consent for participation in this survey; no research ethics committee approval was necessary, since the data were collected fully anonymously, and no identifying data were collected.

Participant flow

A total of 243 professionals participated in the survey. Sixty were excluded a priori from analysis due to missing participant information (part i) and/or not fully completing questions on the classification and areas of activity of sports psychiatry (part ii). Since only partial or no data were collected on the dropouts, no further analysis was possible. The remaining 183 professionals have been included in the descriptive analysis.

Participant demographics

At the beginning of the survey, we determined the extent to which the subject of sports psychiatry was known to the participants (Table 2) so that the results could be analyzed for (i) all participants as well as divided into (ii) disciplines and specialization (Table 1) and (iii) knowledge about sports psychiatry. Eighteen participants indicated multiple areas of training and/or specializations.

Table 2 Familiarity with sports psychiatry: Differentiation by discipline

		Discipline
	All	CAP	P/PM	OMP	PSY	PHY	OP
	n = 183	n = 17	n = 79	n = 18	n = 25	n = 20	n = 24
Notes. CAP: child and adolescent psychiatry; P/PM: psychiatry/psychosomatic medicine; OMS: other medical specialty; PSY: psychology; PHY: physiotherapy; OP: other professionals. There were no significant differences between groups.
Known	113	10	45	11	18	11	18
	62%	59%	57%	61%	72%	55%	75%
Partially known	51	3	24	4	5	9	6
	28%	18%	30%	22%	20%	45%	25%
Unknown	19	4	10	3	2	0	0
	10%	24%	13%	17%	8%	0%	0%

Table 2 Familiarity with sports psychiatry: Differentiation by discipline

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Sports psychiatry: Discipline, areas of activity, and collaboration

Tables 3 and 4 show the results in relation to sports psychiatry as a discipline, its areas of activity, and the importance of interdisciplinary and interprofessional collaboration within its various fields.

Table 3 Sports psychiatry: Classification of sports psychiatry as a medical discipline and field of child and adolescent psychiatry, psychiatry, sports medicine, and/or another field

		Discipline						Familiarity with sports psychiatry
	All	CAP	P/PM	OMP	PSY	PHY	OP	Yes	Partially	No
	n = 183	n = 17	n = 79	n = 18	n = 25	n = 20	n = 24	n = 113	n = 51	n = 19
Notes. Multiple selection. Differentiation by (i) discipline and (ii) familiarity with psychiatry knowledge. There were no significant differences between groups. CAP: child and adolescent psychiatry; P/PM: psychiatry/psychosomatic medicine; OMS: other medical specialty; PSY: psychology; PHY: physiotherapy; OP: other professionals. 1 No clusters or additional relevant information were found in these groups.
Children and adolescent psychiatry	89	14	34	12	8	8	13	55	25	9
	49%	82%	43%	67%	32%	40%	54%	49%	49%	47%
Psychiatry	162	14	76	17	24	17	14	102	45	15
	89%	82%	96%	94%	96%	85%	58%	90%	88%	79%
Sports medicine	112	12	43	14	9	16	18	65	36	11
	61%	71%	54%	78%	36%	80%	75%	58%	71%	58%
1Other field	5	0	1	1	1	0	2	3	2	0
	3%	0%	1%	6%	4%	0%	8%	3%	4%	0%

Table 3 Sports psychiatry: Classification of sports psychiatry as a medical discipline and field of child and adolescent psychiatry, psychiatry, sports medicine, and/or another field

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Table 4 Sports psychiatry: Areas of activity and importance of interdisciplinary and interprofessional collaboration by areas of activity

		Discipline						Familiarity with sports psychiatry
	All	CAP	P/PM	OMP	PSY	PHY	OP	Yes	Partially	No
	n = 183	n = 17	n = 79	n = 18	n = 25	n = 20	n = 24	n = 113	n = 51	n = 19
Notes. Multiple selection. Differentiation by (i) discipline and (ii) familiarity with psychiatry knowledge. There were no significant differences between groups. CAP: child and adolescent psychiatry; P/PM: psychiatry/psychosomatic medicine; OMS: other medical specialty; PSY: psychology; PHY: physiotherapy; OP: other professionals. 1No clusters or additional relevant information were found in these group.
Field of activity
Sport and exercise in the prevention of and as therapy for mental disorders	153	15	72	15	21	15	15	96	43	14
	84%	88%	91%	83%	84%	75%	62%	85%	84%	74%
Mental health and disorders in competitive and elite sport	172	17	73	16	24	20	22	108	47	17
	94%	100%	92%	89%	96%	100%	92%	96%	92%	89%
Sport-specific mental health problems and disorders in popular sport	146	14	65	17	21	15	14	96	39	11
	80%	82%	82%	94%	84%	75%	58%	85%	76%	58%
1Other/further field of activity	4	1	1	0	1	0	1	3	1	0
	2%	6%	1%	0%	4%	0%	4%	3%	2%	0%
Importance of interdisciplinary collaboration
Sport and exercise in the prevention of and as therapy for mental disorders	159	13	73	16	21	17	19	99	46	14
	87%	76%	92%	89%	84%	85%	79%	88%	90%	74%
Mental health and disorders in competitive and elite sport	167	15	71	16	24	20	21	107	47	13
	91%	88%	90%	89%	96%	100%	88%	95%	92%	68%
Sport-specific mental health problems and disorders in popular sport	146	13	65	14	21	17	16	98	38	10
	80%	76%	82%	78%	84%	85%	67%	87%	75%	53%
1Other/further field of activity	16	1	5	2	3	3	2	9	6	1
	9%	6%	6%	11%	12%	15%	8%	8%	12%	5%
In no field of activity	1	1	0	0	0	0	0	0	0	1
	1%	6%	0%	0%	0%	0%	0%	0%	0%	5%
Importance of interprofessional collaboration
Sport and exercise in the prevention of and as therapy for mental disorders	163	14	74	16	22	17	20	100	46	17
	89%	82%	94%	89%	88%	85%	83%	88%	90%	89%
Mental health and disorders in competitive and elite sport	166	15	72	15	24	9	21	106	47	13
	91%	88%	91%	83%	96%	95%	88%	94%	92%	68%
Sport-specific mental health problems and disorders in popular sport	141	13	64	16	21	16	11	94	37	10
	77%	76%	81%	89%	84%	80%	46%	83%	73%	53%
1Other/further field of activity	13	0	4	2	3	2	2	7	6	0
	7%	0%	5%	11%	12%	10%	8%	6%	12%	0%
In no field of activity	1	1	0	0	0	0	0	1	0	0
	1%	6%	0%	0%	0%	0%	0%	1%	0%	0%

Table 4 Sports psychiatry: Areas of activity and importance of interdisciplinary and interprofessional collaboration by areas of activity

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Sports psychiatry was most frequently classified as a field of psychiatry by the participants (89%). The majority of those who stated that they were not familiar with sports psychiatry also classified it as a field of psychiatry (79%), albeit less frequently. Of all the participants, 61% classified sports psychiatry as an area of sports medicine and 49% as a field of child and adolescent psychiatry. The psychiatrists (and experts in psychosomatic medicine) and psychologists groups were the least likely of all the participants to classify sports psychiatry as a field of sports medicine (54% and 36%, respectively). The child and adolescent psychiatrists who participated in the survey classified sports psychiatry in equal numbers as a field of psychiatry and child and adolescent psychiatry (both 82%).

The mental health and disorders in competitive and elite sport category was classified by 94% of the participants as one of sports psychiatry’s fields of activity, followed by sport and exercise in the prevention of and as therapy for mental disorders (84%) and sport-specific mental health problems and disorders in popular sport (80%) as further areas of activity. Certain differences were found between the disciplines as well as the groups, depending on the respondents’ knowledge of sports psychiatry. Concerning the popular sport category, 94% of the members of the other medical discipline group, but only 58% of the other professional group, rated this as a field of sports psychiatry.

Very few participants denied that sports psychiatry was an interdisciplinary (3/183) or an interprofessional (5/183) specialty. The importance of interdisciplinary and interprofessional collaboration was most frequently reported in terms of mental health and disorders in competitive and elite sport (91% interdisciplinary vs. 91% interprofessional), followed by sport and exercise in mental disorders (87% vs. 89%) and sport-specific mental health problems and disorders in popular sport (80% vs. 77%). In particular, psychologists and physiotherapists rated interdisciplinary and interprofessional collaboration as most important in the category of mental health and disorders in elite sport (more important than in the other categories).

Sport-specific mental health problems and disorders in popular sport

The answers to the questions about sport-specific mental health problems and disorders in popular sport and the benefits of sports psychiatry in the prevention of and as treatment for these disorders were available from 159 participants and are shown in Tables 5 and 6. The 24 dropouts did not significantly differ in age, gender, discipline, or specialization, nor with familiarity with sports psychiatry, compared with those who completed the questionnaire.

Table 5 Significant sport-specific mental health problems and disorders in popular sport

		Discipline						Familiarity with sports psychiatry
	All	CAP	P/PM	OMP	PSY	PHY	OP	Yes	Partially	No
	n = 159	n = 14	n = 69	n = 17	n = 24	n = 15	n = 20	n = 101	n = 43	n = 15
Notes. Multiple selection. Differentiation by (i) discipline and (ii) familiarity with psychiatry knowledge. There were no significant differences between groups. CAP: child and adolescent psychiatry; P/PM: psychiatry/psychosomatic medicine; OMS: other medical specialty; PSY: psychology; PHY: physiotherapy; OP: other professionals. 1No clusters or additional relevant information were found in these group.
Substance use to improve appearance and performance	132	13	64	15	19	11	10	85	35	12
	83%	93%	93%	88%	79%	73%	50%	84%	81%	80%
Body image disorders	128	12	57	12	21	13	13	86	32	10
	81%	86%	83%	71%	88%	87%	65%	85%	74%	67%
Disturbed eating behavior and eating disorders	137	13	59	13	22	15	15	87	39	11
	86%	93%	86%	76%	92%	100%	75%	86%	91%	73%
Addictive sports and exercise behavior	134	12	63	12	21	13	13	85	38	11
	84%	86%	91%	71%	88%	87%	65%	84%	88%	73%
1Other	5	0	3	1	1	0	0	3	1	1
	3%	0%	4%	6%	4%	0%	0%	3%	2%	7%
Sport-specific mental disorders and disorders in popular sport are not significant	14	1	6	2	1	0	4	8	4	2
	9%	7%	9%	12%	4%	0%	20%	8%	9%	13%

Table 5 Significant sport-specific mental health problems and disorders in popular sport

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Table 6 Prevention and treatment of sport-specific mental health problems and disorders in popular sport: Can the expertise of sports psychiatrists bring additional benefits?

		Discipline						Familiarity with sports psychiatry
	All	CAP	P/PM	OMP	PSY	PHY	OP	Yes	Partially	No
	n = 159	n = 14	n = 69	n = 17	n = 24	n = 15	n = 20	n = 101	n = 43	n = 15
Notes. Differentiation by (i) discipline and (ii) familiarity with psychiatry knowledge. There were no significant differences between groups. CAP: child and adolescent psychiatry; P/PM: psychiatry/psychosomatic medicine; OMS: other medical specialty; PSY: psychology; PHY: physiotherapy; OP: other professionals.
Prevention
Agree	85	7	40	8	14	5	11	58	21	21
	53%	50%	58%	47%	58%	33%	55%	57%	49%	49%
Agree somewhat	46	5	21	5	4	7	4	24	15	15
	29%	36%	30%	29%	17%	47%	20%	24%	35%	35%
Neither agree nor disagree	23	1	7	4	5	3	3	17	5	5
	14%	7%	10%	24%	21%	20%	15%	17%	12%	12%
Disagree somewhat	5	1	1	0	1	0	2	2	2	2
	3%	7%	1%	0%	4%	0%	10%	2%	5%	5%
Disagree	0	0	0	0	0	0	0	0	0	0
	0%	0%	0%	0%	0%	0%	0%	0%	0%	0%
Treatment
Agree	101	8	41	11	19	9	13	70	24	7
	64%	57%	59%	65%	79%	60%	65%	69%	56%	47%
Agree somewhat	39	5	22	2	1	4	5	20	14	5
	25%	36%	32%	12%	4%	27%	25%	20%	33%	33%
Neither agree nor disagree	17	1	5	4	3	2	2	10	4	3
	11%	7%	7%	24%	12%	13%	10%	10%	9%	20%
Disagree somewhat	2	0	1	0	1	0	0	1	1	0
	1%	0%	1%	0%	4%	0%	0%	1%	2%	0%
Disagree	0	0	0	0	0	0	0	0	0	0
	0%	0%	0%	0%	0%	0%	0%	0%	0%	0%

Table 6 Prevention and treatment of sport-specific mental health problems and disorders in popular sport: Can the expertise of sports psychiatrists bring additional benefits?

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Significant sport-specific mental health problems and disorders in popular sport were indicated by all the participants, namely substance use to improve appearance and performance (83%), body image disorders (81%), disturbed eating behavior and eating disorders (86%), and addictive sports and exercise behavior (84%) – and thus by more than 80% of the participants for each of the mental health problems and disorders available for selection. Of the participants, 9% stated that sport-specific mental health problems and disorders were not important in popular sport. Certain differences appeared between the different groups.

Cumulative 82% (prevention) and 89% (treatment) of the participants selected the categories “Agree” or “Agree somewhat” concerning the question of whether sports psychiatry expertise could have a significant additional benefit for sport-specific mental health problems and disorders in popular sport.

Education and training in sports psychiatry

The answers to the questions about the need for specific training in sports psychiatry, the need of independent training in sports psychiatry, or integration with postgraduate training in psychiatry or sports medicine are shown in Table 7.

Table 7 Education and training in sports psychiatry: Need, setting, and access to sports psychiatry training (in addition to child, adolescent, and adult psychiatrists)

		Discipline						Familiarity with sports psychiatry
	All	CAP	P/PM	OMP	PSY	PHY	OP	Yes	Partially	No
	n = 159	n = 14	n = 69	n = 17	n = 24	n = 15	n = 20	n = 101	n = 43	n = 15
Notes. *Responses of participants who stated that there was a need for specific sports psychiatry training (n = 134). Multiple selection. Differentiation by (i) discipline and (ii) familiarity with psychiatry knowledge. There were no significant differences between groups. CAP: child and adolescent psychiatry; P/PM: psychiatry/psychosomatic medicine; OMS: other medical specialty; PSY: psychology; PHY: physiotherapy; OP: other professionals. 1No clusters or additional relevant information were found in these group.
Need for specific sports psychiatry training?
No	25	2	16	1	6	0	0	17	7	1
	16%	14%	23%	6%	25%	0%	0%	17%	16%	7%
*The sports psychiatry training should be:
Independent	62	7	26	8	6	7	8	46	13	3
	39%	50%	38%	47%	25%	47%	40%	46%	30%	20%
Integrated with postgraduate training in the two psychiatric specialties	69	5	34	7	9	7	7	40	19	10
	43%	36%	49%	41%	38%	47%	35%	40%	44%	67%
Integrated with the postgraduate training in sports medicine	72	3	28	12	8	12	9	39	26	7
	45%	21%	41%	71%	33%	80%	45%	39%	60%	47%
1Other	5	1	0	0	1	0	0	3	1	1
	3%	7%	0%	0%	4%	0%	0%	3%	7%	2%
*Access to sports psychiatry training is/would be important for the following professionals (in addition to child, adolescent, and adult psychiatrists):
Specialists in general medicine and/or internal medicine	86	9	41	11	11	4	10	55	18	13
	54%	64%	59%	65%	46%	27%	50%	54%	42%	87%
Specialists in pediatrics and adolescent medicine	89	10	38	10	14	9	8	58	19	12
	56%	71%	55%	59%	58%	60%	40%	57%	44%	80%
Specialists in orthopedics and/or trauma surgery	59	7	27	7	9	4	5	39	12	8
	37%	50%	39%	41%	38%	27%	25%	39%	28%	53%
Specialists in neurology	40	5	15	2	9	2	7	29	9	2
	25%	36%	22%	12%	38%	13%	35%	29%	21%	13%
Sports physicians	101	9	41	11	13	13	14	67	27	7
	64%	64%	59%	65%	54%	87%	70%	66%	63%	47%
Psychologists specialized in psychotherapy	86	9	39	10	15	4	9	56	22	8
	54%	64%	57%	59%	62%	27%	45%	55%	51%	53%
Psychologists specialized in sports psychology	105	9	44	10	16	13	13	67	28	10
	66%	64%	64%	59%	67%	87%	65%	66%	65%	67%
Mental trainers	58	4	17	7	10	12	8	36	16	6
	36%	29%	25%	41%	42%	80%	40%	36%	37%	40%
1Other professionals	19	0	3	2	1	8	5	13	5	1
	12%	0%	4%	12%	4%	53%	25%	13%	12%	7%

Table 7 Education and training in sports psychiatry: Need, setting, and access to sports psychiatry training (in addition to child, adolescent, and adult psychiatrists)

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Of the 159 participants, 25 (16%) denied the need for specific sports psychiatry training and thus were not prompted to answer subsequent questions. These participants did not significantly differ in age, gender, discipline, or specialization, nor familiarity with sports psychiatry, compared with those who completed the questionnaire.

The groups of psychiatrists and experts in psychosomatic medicine (23%) and psychologists (25%) most frequently indicated that no specific sports psychiatry training was needed. All participants who believed specific training was needed most often indicated that it should be integrated with postgraduate training in sports medicine (45%) and psychiatry (43%) and less often (39%) offered the opinion that training in sports psychiatry should be independent.

Furthermore, the psychiatrists (and experts in psychosomatic medicine; 38%) and psychologists (25%) groups were the least likely to state that there was a need for independent training in sports psychiatry. A higher proportion of the psychiatrists and experts in psychosomatic medicine groups were in favor of integration with postgraduate training in psychiatry (49%) and sports medicine (41%), compared with participants from the psychologists group (38% and 33%, respectively). Physical therapists (80%) most often indicated that training in sports psychiatry should be integrated with postgraduate training in sports medicine. Besides physical therapists, members of other medical disciplines (71%) and of the other professionals group (45%) also preferred integrating sports psychiatry training with postgraduate training in sports medicine, in contrast to psychologists and especially child and adolescent psychiatrists (21%).

Aside from child, adolescent, and adult psychiatrists, participants indicated that the following disciplines in particular should have access to the sports psychiatry training: sports psychologists (66%), sports physicians (64%), child and youth physicians (56%), general practitioners and internists (54%), and psychological psychotherapists (54%). There were also differences between the individual disciplines and according to their respective level of knowledge of sports psychiatry.

Limitations

The main limitation of this survey is that the recruitment did not lead to a representative sample, as, for example, most of the participants were psychiatrists. It would also have been desirable if more participants (also from neighboring disciplines) had taken part. Therefore, the results can be considered only on a descriptive level as exploratory and as providing an initial view of opinions. Furthermore, the survey was designed in German and thus only included participants from German-speaking countries, and especially those from German-speaking Switzerland. Therefore, the data show a regional selection and perspective on sports psychiatry.