Mental health considerations for athlete removal from play and return to play planning

Primary physical health causation

The decision to remove an athlete from training and/or competition due to physical health reasons should be made by, or in consultation with, a medical doctor based on history and clinical examination findings. Suspicion and exploration of medical causes for symptoms may also require removal from play until results are received. Sport interruption due to physical health reasons, including injuries, can impact athlete mental health [1, 3, 6, 26] but will not be further explored in this paper.

Primary mental health causation

While there are no firm thresholds to direct removal from play due to mental health conditions, decisions can be based on the nature of symptoms that are present and the extent of their impact on cognitive, emotional, and behavioral elements as they impact safety, stability, and function. Exceptions include anorexia nervosa and bulimia nervosa, which are primary mental health conditions that have direct impacts on physical health and for which guidelines have been established for exclusion/withdrawal from, and return to, sport [13, 14, 15].

The following cases illustrate how mental health symptoms can impact safety, stability, and function and influence an athlete’s suitability to participate in training and competition. Names and specific sport details have been changed to anonymize the athletes.

Case 1

Lauren was a 22-year-old collegiate volleyball player in her final year of eligibility. She had an episode of depression and self injury (cutting) early in the season, was seen in the Emergency Department, and prescribed antidepressants. Throughout this time, she continued to train and compete, but was not referred for psychiatric support. She felt slightly better through November and December, then became more depressed and suicidal over the holidays. Her antidepressant dosage was increased by her primary care physician in January, and within one week she developed significant irritability, racing thoughts, pressured speech, paranoia, hypersexuality, poor concentration, increased energy, and was unable to sleep. She still did not have specialized mental health support and her mental health was not being monitored. At the conclusion of one practice, she “took over” the team locker room, would not allow the team to leave, and spoke rapidly about nonsensical and paranoid topics. She refused to go to the hospital, necessitating teammates to stay with her overnight. The following day she saw her family doctor and was sent to the Emergency Department for involuntary psychiatric assessment. She was hospitalized for three weeks and diagnosed with bipolar disorder type 1: current episode manic with psychotic features. She was discharged two weeks before playoffs and insisted that she be allowed to return to the team. Ongoing symptoms upon discharge included racing thoughts, hypersexuality, emotional lability, poor judgement, disinhibition, poor insight, suicidal thoughts, intrusive behavior, inability to return to classes due to racing thoughts, inability to focus, inattention to self hygiene, and psychomotor restlessness. Additional concerns on discharge included nonadherence to the treatment regimen; and the team and coach were scared and traumatized by her behaviour prior to hospitalization and were very resistant to her return to the team, particularly as they approached playoffs.

Case 2

Hilary was a 23-year-old collegiate lacrosse player who developed a restrictive eating disorder during the Covid-19 pandemic when she radically changed her nutritional intake in an effort to make it “clean and healthy.” Although she was previously a high-performance athlete who played with multiple teams at high levels, she believed she needed to be significantly lighter and thinner for improved performance. After two years of significant weight loss resultant from restrictive eating and excessive exercise, she required hospitalization on an inpatient eating disorder unit and was diagnosed with anorexia nervosa. She left the program against medical advice and pursued community supports, with the goal of returning to sport participation. A multidisciplinary support team was assembled, including a sports and exercise medicine physician, sports psychiatrist, dietician, and psychotherapist. Several elements of concern were identified:

General considerations

An overall clinical mental health assessment should be undertaken by a mental health professional to explore broad contextual, interactional, complex or risk elements (including the role of ongoing treatment). As a general guide, safety, function, and stability are essential elements that should be reviewed and established before RTP planning is initiated.

The decision about an athlete’s suitability to return to the sport environment is sometimes more difficult to make than the decision for removal from play (particularly when the decision to remove them was based on clear safety and behavioral concerns). Whereas RTP from physical injury has more predictable and controlled variables, such as measurement of strength, endurance, muscle symmetry and balance, mental health creates a landscape of much greater uncertainty.

Measures of relative mental health symptom intensity can be anchored in the use of rating scales, such as the Patient Health Questionnaire-9 (PHQ-9) [33] or Baron Depression Screen (BDS) [34] for depression, Generalized Anxiety Disorder-7 (GAD-7) [35] for anxiety, or Mood Disorder Questionnaire (MDQ) [36] for bipolar disorder. Several toolkits are available for screening of suicidal thoughts and intentions, including the Ask Suicide-Screening Questions toolkit [37] and the Suicide Screening Toolkit [38]. The PHQ-9 also has a question related to suicidal thoughts. These screening tools should be administered over defined intervals (i.e., biweekly) in combination with clinical assessment and monitoring, to observe the evolution of symptoms throughout the recovery phase as well as identify factors reflecting safety, stability, and function.

The special case of eating disorders

The presence of disordered eating or eating disorders can be explored with the use of a comprehensive preparticipation physical exam (PPE) [39], during periodic health examination (PHE) [40], or during assessment when the athlete presents for related concerns [41]. Several eating disorder questionnaires have been validated for the athlete population and care should be taken to select the most appropriate tool for the athlete [14]. The Eating Disorder Examination Questionnaire 6.0 (EDE-Q 6.0) is a short form screening tool based on the EDE 17.0 and should form part of a comprehensive assessment of the athlete [42, 43].

It is recommended that return to play planning involving athletes diagnosed with anorexia nervosa or moderate to severe bulimia nervosa should follow guidelines published by the Norwegian Olympic Committee [15, 44]. Clinical assessment tools that may assist RTP decision making in the context of eating disorders include the REDS Clinical Assessment tool [45, 46] and the 2014 Female Athlete Triad Cumulative Risk Assessment Tool [47]. The International Olympic Committee has developed a RTP model based on green light (low risk), yellow light (moderate risk), and red light (high risk) parameters [48]. The Female Athlete Triad: Cumulative Risk Assessment Tool provides numeric scores for key risk factors, which subsequently guide whether an athlete should receive full clearance, provisional/limited clearance or restriction from participation [13, 47]. It is also recommended that a written contract be utilized for athletes who fall in the moderate- to high-risk categories of risk, and signed by all members of the athlete care team [13, 47]. A template for a contract that can be used with athletes can be found in the Female Athlete Triad Coalition Consensus Statement [47]. In a clinical setting, the Safe Exercise at Every Stage (SEES) guideline may be a useful tool to facilitate progress review and guide RTP planning [49]. Athletes with active eating disorders should be referred to an eating disorder program to assist with the transition back to sport [13].

Eating disorders present mental health risks beyond the physical manifestations of illness that must also be explored. Eating disorders feature among the highest mortality rates of all psychiatric illnesses, and individuals diagnosed with eating disorders have a significantly elevated suicide risk [50, 51, 52]. Suicide accounts for one in five deaths among individuals with anorexia nervosa, and nearly one in four (23%) individuals with bulimia nervosa [51, 53]. Being aware of exercise tendencies in athletes with eating disorders is of particular importance, as over-exercising is the compensatory mechanism most strongly associated with suicide in this population [54].

Considerations following hospitalization

Following admission to hospital for mental disorder, self harm or suicidal behavior, individuals may feel shame and worry about what other people either know or think about their hospitalization. For mental disorders that necessitate acute hospitalization, the period of highest risk for suicide is in the first three months post discharge [55]. In a large meta-analysis, the suicide rate was approximately 100 times the global suicide rate during the first three months after discharge, and nearly 200 times the global suicide rate for patients who were admitted with suicidal thoughts or behaviors. A large Australian study reported that nearly 20% of all inpatients were readmitted to hospital within one month of discharge [56], and a UK study reported nearly 15% of readmissions within the first three months of discharge [57]. Readmissions may be related to incomplete illness remission, lack of appropriate follow up, or illness relapse. During this high-risk period in particular, assessment of safety, stability, and function should be a priority. Preparing an athlete for RTP following hospitalization for mental disorder should feature frequent follow up and assessment of symptom burden, intensity, stability, suicidal ideation and intent, and overall function–particularly during the first three months following discharge.

Long term management

In terms of longer-term management, it is important to consider prognostic indicators for relapse and recurrence to guide the pace of return to sport as well as monitoring throughout recovery and full reintegration to sport. Bipolar disorder is associated with a high recurrence rate and chronic burden of illness. It requires long term lifestyle management including appropriate sleep management, stress reduction, pharmacological treatment, and psychiatric monitoring. Major depressive episodes can be recurrent, persist for several months, and can cause significant functional impairment. Prognostic indicators for depression relapse or recurrence include history of childhood maltreatment, post-treatment residual symptoms, and a history of recurrence [58]. Athletes with these histories may require a more gradual RTP plan and closer monitoring. Athletes whose treatment regimens include pharmacotherapy should routinely be monitored for adherence and adverse effects. Goals for athlete treatment team should include the development of a sound (but fluid) RTP plan after assessment of the athlete’s safety, stability, and function. Reassessments during regular monitoring should always include these elements. A graduated RTP plan can proceed similarly to RTP post-injury, illness, or surgery – with gradual increased exposure to sport elements in terms of time, volume, and intensity – with reassessment of the key elements outlined above.

Thresholds for stress tolerance may significantly impact an athlete’s response to adversity. Adversity has the potential to further destabilize the mental health of athletes who are struggling, and thus the RTP plan must consider the type of stress and adversity the athletes will face at each stage of return. Athletes who have no safety concerns but struggle to maintain mental wellness and function when faced with increased pressure, stress, and adversity may need a more gradual RTP plan to mitigate risks of deteriorating mental health.

After return to sport has been established, it is vital that the athlete have regular follow-up with mental health specialists and members of the multidisciplinary team to facilitate adherence to the recommended guidelines.

Considering the sport ecosystem in RTP planning

It is critically important to understand the elements of the sport ecosystem surrounding the athlete when planning for RTP. Specific elements that are impacted by an athlete’s RTP include teammates, coaches, staff, the sport environment, and the athlete themselves. We must also consider the impact of the ecosystem on the athlete (i. e. a toxic or unsafe environment can have a perpetuating influence on an athlete’s mental health challenges, while a positive, safe environment may support reintegration). Additional consideration needs to be given to the potential risks associated with training and competing (both at home and on the road). These elements can be considered under the same three themes of safety, stability, and function [5].

Psychological considerations for return to sport are not always performance related. The more serious circumstances will likely involve safety and require appropriate resources to address stability and function. When mental health challenges are the primary contributors to the interruption in training or competition, essential issues that must be reviewed and addressed prior to the athlete returning to sport include athlete-, sport-, and environmental factors. These elements are described in Table 3.

Table 3 Framework of key considerations for RTP planning

Elements	General assessment	Safety considerations	Stability considerations	Functional considerations
Situation	• Did the team, coach, or environment contribute to the challenge? • How were the team, coach, or environment affected by the mental health episode?	• Is the athlete safe to return to the environment? • Is the environment safe for the athlete to return to?	• Is the environment stable and predictable?	• Can the athlete presently function in the athletic environment (consider training and/or competition)
Symptoms	• Presence or ongoing or residual symptoms • Impact on thoughts or behavior during the episode • Whether the symptoms were witness or experienced by others • Degree of insight • Attitude towards treatment. • Predominantly internal (i.e., affects the self) vs. external (i.e., affects others)	• The nature of the symptoms may place the individual or others at risk for physical harm (i.e., agitation, anger, aggression, suicidal or homicidal thoughts)	• Are the symptoms stable and remitting, or labile and relapsing? • Do increased stimulation, demands and stress make symptoms worse?	• Are symptoms resulting in functional impairment?
Safety	• Influence of active symptoms on current risk appraisal • Consideration of prognostic risk factors • Consideration of recent hospitalization • Past history of self harm, suicidal behavior, or violence • Is the athlete taking medications that may result in adverse effects or drug interactions?	• Are there active thoughts or intentions of self harm, suicide, or homicide? • Presence of disorganized behavior, paranoia, psychotic features • Active self injurious behavior • Safety should be considered both at home and in the context of travelling.	• Emotional or behavioral stability • Ability to maintain personal safety despite increased stress or adversity • Ability to adhere to a safety plan • Adherence to treatment and follow up.	• Is there preoccupation with thoughts of suicide, harming oneself, or harming someone else? • Has self-harm behavior led to impaired ability to function? (i.e., through injury, compromised health)
Sport-specific circumstances	• Individual vs. team sport • Role (i.e., starter vs. support player) • Timing in the season • Proximity to major events • Potential impact on career • Suitability to develop gradual RTP • Consider how the athlete’s return would potentially impact the group (if applicable)	• Are there symptoms that can place the athlete at risk in the sport setting (i.e., cognitive fogginess, poor concentration, emotional lability, impulsivity) ? • Risk of post-competition “crash” (low mood)	• Are there sport-specific elements that may compromise stability? (i.e., presence of hostile spectators, high pressure role) • Are there sport-specific factors that may support stability?(i.e., supportive team, confidence and success with role)	• Certain sports may require higher levels of recovery before return can be considered (i.e., returning to a collision sport while recovering from anorexia nervosa)
Systems	• Supports, including family, friends, formal mental health supports, other sport-based supports, organizational supports. • Consider who should be aware of key details to ensure appropriate monitoring and provision of safety. • Consider: supports at home as well as while traveling. • The process of developing the support system should begin prior to return, and its effectiveness should regularly be reviewed.	• Mental health supports are essential • Frequent monitoring and symptom review after hospitalization • Crisis plan with identification of available crisis services	• Consider developing a Mental Health Action Plan. • Plan for supporting the athlete if they relapse or encounter difficulty	• Appropriate supports should be established according to the level of impairment the athlete has experienced • Supports and monitoring should be continued throughout the recovery phase
Risk of Return	• Consider how the athlete would react to poor performance, peer conflict, pressure situations, feedback (including criticism), hostility on social media or from fans. • Consider: navigating these factors at home as well as while traveling. This needs to be addressed prior to return and should guide the timeline of return.	• Consider the potential for panic attacks, suicidal ideation, further emotional disturbance.	• Consider the potential that exposure to sport-specific adversity, pressure or stress related to sport will destabilize the athlete’s condition.	• A difficult or unsuccessful return could lead to withdrawal and deterioration; while successful reintegration could mitigate the risks of return. • The ability of the athlete to manage the load of return to sport concurrently with daily functional activities should be monitored.

Table 3 Framework of key considerations for RTP planning

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