2Steps4Health project: Promotion of mental health in junior professional sports

Mental disorders in young elite athletes

Overall, it can be assumed that mental disorders have similar prevalence rates in young elite athletes as in the general population [7, 9, 10, 11]. Some studies found particularly high levels of psychological distress in young elite athletes compared to adults [12, 13, 14, 15]. Specifically, one study evaluated the prevalence of depression and anxiety in top-level football players of first league and U21 football teams in Switzerland [16]. Based on self-reports, male U21 players had significantly higher average depression and anxiety scores than male first league players. Similar results were found for Danish and Swedish male elite football players [17]. Here significant negative correlations between age and anxiety as well as higher levels of depression, competitive anxiety, and social phobia in U19 players compared to A-squad professionals were found. These results are in line with studies conducted with German elite athletes [13], showing depressive symptoms in 20% in young athletes versus 15 % in adult athletes.

In so-called critical phases, such as long-lasting breaks due to injury or the premature, involuntary end of a career, young elite athletes often reported high levels of stress (i.e., depressive or anxiety symptoms) [15]. Further, manifested mental disorders (e.g., depression) may be maintained by certain factors which contribute to symptomatology. In addition to behaviors that are typical for maintaining depression such as social withdrawal or inactivity, negative impacts on athletic performance are particularly severe in competitive sports. Failures and setbacks lead to further self-doubt, self-deprecation, and increased pressure [18, 19]. This vicious cycle impacts athletic performance, resulting in a downward spiral from which young athletes usually cannot escape without professional support [20].

While physical stresses associated with competitive sports are routinely treated as a matter of course, few specific programs target mental health issues and specific needs of young elite athletes. Due to specific stressors in competitive sports (e.g., double burden of school and sports, performance pressure, high expectations), young elite athletes need to learn coping strategies for these stressors (e.g., reduce everyday stress) and acquire skills to manage crises and therefore to increase subjective well-being in the long-term [21]. Although the demands for pedagogical-psychological intervention programs were made more than 10 years ago by the EU expert group to support dual careers in professional sports [21], and awareness of the mental stress in competitive sports is therefore increasing, there are still hardly any well-evaluated universal or indicated prevention programs to protect mental health in elite young athletes.

Theoretical background

The underlying model of the 2Steps4Health program is the vulnerability-stress-model [24] adapted to the junior professional sports context (Figure 1). This model asserts that mental illness may be the result of contributing factors such as individual vulnerability, developmental and social influences, as well as stress and social strains. Individual vulnerability to mental disorders may result from the interaction of genetic and neurobiological factors as well as psychosocial development, including early childhood experiences. Genetic and neurobiological factors in turn affect personality development, coping styles, and cognitive variables [25]. Over the lifespan, particular strains, stress, and critical life events lay the conditions for the development of mental disorders [26]. Additionally, young elite athletes must cope with age-typical developmental and social influences, and strains that increase the risk for a mental disorder [7].

Participants

The program is directed at all young elite athletes aged 12–21 years, regardless of squad status, type of sport, and current mental stress or well-being status. Athletes are recruited through the project’s collaborations with various clubs and federations in Germany as well as sports schools and boarding houses. For both prevention levels – universal and indicated level – a minimum of 60 athletes (30 per intervention and control group, hereafter referred to as IG and CG) is pursued (for G*Power sample size calculation see below).

Study design and procedure

A longitudinal (quasi-)randomized intervention study with a waiting CG (no intervention during waiting time) and three main measurement time points (pre, post, follow-up) is used to test the program’s effectiveness. For the universal prevention level, a (quasi-)randomization procedure will be used with randomization of entire training groups to ensure feasibility for participating sports clubs and training groups. For the indicated prevention level, a full randomization approach will be applied. After the waiting period, the CG will also be given the opportunity to participate in the prevention program. The study was approved by the university’s ethics committee (2022.07.29_eb_165). Participants are informed about the aims of the study and provide written consent, whereby underaged athletes’ parents provide written informed consent. Participation in is free and voluntary.

The universal prevention level is offered to all young elite athletes, regardless of reported mental stress, whereas the indicated prevention level addresses athletes who have reported clinically conspicuous internal symptoms or are exposed to special risk situations (e.g., injury, dropout, personal crisis). An a priori sample size calculation using G*Power 3 [27] (with α = .05, and power = .95 for 2 groups, 3 measurement time points and medium effect size) suggested a sample size of 58. Anticipating a dropout rate of 20 percent, we aim to recruit for both prevention levels 74 participants (37 individuals each for IG and CG).

Prevention levels

A summary of the content and framework of both prevention levels is shown in Table 1.

Table 1 Summary of content and framework of both prevention levels in the 2Steps4Health project

	Universal prevention	Indicated prevention
Note:aClinically significant internal distress symptoms are assessed using the Youth Self Report (Scale of Internalizing Problems) [29].
Group	10–20 young elite athletes (e.g., training groups), sport homogeneous	4–5 young elite athletes from different sports, if possible homogeneous in age
Indication	No specific indication, free for every young elite athlete	Clinically significant internal distress symptomsa and/or critical periods (e.g., prolonged injury, dropout, personal crisis)
Scope	3 workshops, one in a week, each workshop 3 hours	14 sessions, one in a week, each session 100 minutes
Objectives	Basics of (sports) psychology and competencies regarding stress, communication and lifestyle, learning strategies and techniques (e.g., self-talk, resource analysis, mindfulness), promotion of self-reflection and increasing well-being	Reduction of psychological, internal stress symptoms (e.g., anxiety, depressiveness, stress, sadness, self-doubt), learning to cope better with stress, increasing well-being, self-confidence and self-esteem
Methods and didactical approach	Psychoeducation and tools of sports psychology and positive psychology (e.g., resource analysis, guided meditation, positive self-talks), group work and discussions, individual work, role play, team quiz, inductive and deductive method for theoretical input	Psychoeducation and tools of sports psychology and cognitive behavioral therapy (e.g., cognitive restructuring, relaxation, mindfulness, resource activation, group discussions, and role plays), inductive and deductive method for theoretical input
Content and Goals	Workshop 1 – Mind Gym • fundamental skills for mental health based on the bio-psycho-social model and tips for healthy use of social media • athletes are capable of coping with stressors and able to prevent them through positive psychological tools	Sessions 1–4 – Tactical briefing • getting to know each other, stresses in competitive sports, individual stresses, life path to date, and resources of each athlete in the group, psychoeducation about stress and mental illness, (athletic) identity
	Workshop 2 – Communication and Conflict Management • basics of communication and conflict management (e.g., 4-ears-model, conflict types and solutions, need-oriented communication) • athletes are capable of building healthy relationships not only with peers but also with coaches and parents	Session 5 – Just a number in the system • self-worth, self-confidence, see the person behind the athlete
		Session 6 – School, training, little free time and a lot of stress • relaxation, mindfulness, positive activities
	Workshop 3 – Sleep and Nutrition • foundational knowledge on sleep and nutrition (e.g., sleep phases, importance for regeneration, healthy sleep hygiene, macro/micronutrients, water intake, implementing a healthy diet in daily life) • athletes can develop lifelong healthy habits	Sessions 7–9 – Failures in sports and self-doubt • connections between emotions, thoughts, and behavior • reality check for negative thoughts and self-doubt • finding positive thoughts to improve negative emotions
		Session 10 – Expectations and personal standards for peak performance • dealing with the inner critic, self-compassion, self-acceptance
		Session 11 – Dependency on coaches and conflicts within the training group • learning confident behavior, conflict-management, self-confidence
		Session 12 – Pre-competition excitement • preparing for competition
		Sessions 13–14 – Future plan • mental health crisis plan, relapse prevention, farewell from the group

Table 1 Summary of content and framework of both prevention levels in the 2Steps4Health project

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Measures

The following empirically validated questionnaires are employed to assess effectiveness. Both prevention levels: KIDscreen [14], Rest-Q-Sport-36 [28] and Youth Self Report/11-18R [29]; indicated prevention level: Short Recovery and Stress Scale [30], Rosenberg Self-Esteem Scale (RSES) [31], Dysfunctional Attitude Scale (DAS-18) [32] and Affective Style Questionnaire (ASQ) [33]. Additionally, questions on quality management are used for evaluation purposes. Table 2 provides an overview of the instruments as well as the measurement time points for each prevention level. Questionnaires that have not been validated for our age range (>12 years) will be used due to the lack of available alternatives, checked for age appropriateness, and linguistically adapted if necessary.

Table 2 Questionnaires and time of assessment for universal and indicated prevention level

	Time of measurement (1 = pre, 2 = post, 3 = follow-up)
	Universal level			Indicated level3
Questionnaires	1	21	32	1	2	32	Weekly	Number of items	Example item	Answer format	Psychometric properties
Note:1The YSR is used to identify athletes showing clinically conspicuous stress after participation in universal prevention level 1 and requiring the indicated prevention level. Here, the Internal Stress Symptoms scale serves as a guide. 2Follow-up: six weeks after end of universal prevention level and 12 weeks after indicated prevention level. 3Athletes exhibiting critical psychological symptoms after participating in the indicated prevention level, may opt for individual psychotherapeutic treatment at the psychotherapeutic outpatient clinic for children and adolescents at the University of Leipzig or another psychotherapeutic practice. However, this is not part of the present prevention program.
Sociodemographic and sports biography
Sociodemographic	X			X				10	Age, gender.	Free text
Sporty biography	X			X				6	Type of sport, squad.	Free text
Quality of life
KIDscreen Index-10 [14]	X	X	X	X	X	X		10	Have you physically felt fit and well?	5-point Likert-scale (1 = not at all to 5 = extremely)	Internal consistencies: α = .77 to α = .89, intraclass correlation r = .56 to r = .77.
Symptoms screening, affective styles, and dysfunctional attitudes
Youth Self Report (YSR/11-18R) [29]1		X		X	X	X		112	I would rather be alone than with other kids.	3-point Likert-scale (0 = not true, to 2 = very true or often true)	Internal consistency: α =.86
Affective Style Questionnaire (ASQ) [33]				X	X	X		20	I can tolerate having strong emotions.	5-point Likert-scale (1 = not true of me at all to 5 = extremely true of me)	Internal consistency: α = .84
Dysfunctional Attitude Scale (DAS-18) [32]				X	X	X		18	It is difficult to be happy, unless one is good looking, intelligent, rich and creative.	7-point Likert-scale (1 = fully disagree to 7 = fully agree)	Internal consistencies: α = .86 to α = .94
Self-Esteem
Rosenberg Self-Esteem Scale (RSES) [31]				X	X	X		9	On the whole, I am satisfied with myself.	4-point Likert-scale (1 = strongly agree to 4 = strongly disagree)	Internal consistencies: α = .85 to α = .88
Recovery and stress
Short Recovery and Stress Scale (SRSS; KEB) [30]				X	X	X	X	8	General state of stress, e.g., exhausted, overloaded, physically flat.	7-point Likert-scale (0 = does not apply at all, 6 = fully applies)	Internal consistencies: α = .78 to α = .84
Recovery-Stress Questionnaire Sport (REST-Q-Sport-36) [28]	X	X	X	X	X	X		36	In the past 3 days/nights, I felt physically fit.	7-point Likert-scale (0 = never, 6 = always)	Internal consistencies: α = .61 to α = .90
Quality management
Evaluation of content and structure		X			X			7	How satisfied were you with the today’s session?	5-point Likert-scale (1 = not at all to 5 = totally)

Table 2 Questionnaires and time of assessment for universal and indicated prevention level

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Hypotheses

After universal prevention, we expect that young elite athletes will show significantly higher scores in measures for life satisfaction [14], less stress, and improved recovery [28] at post and follow-up assessment compared to CG.

For the indicated prevention level, we expect that young elite athletes will show significantly higher scores for life satisfaction [14] and self-esteem [31], less stress and improved recovery [28], less internal distress symptoms [29], and less maintaining factors (e.g., dysfunctional attitudes [32] and unfavorable emotion regulation styles [33]) at post and follow-up assessment compared to CG.

Statistical analyses

All data will be analyzed by an intention-to-treat analysis using a 2 (group: IG vs. CG) × 3 (time: pre, post, follow-up) mixed ANOVA. For indicated prevention, we will also analyze the data from the weekly-assessed Short Recovery and Stress Scale [30] using a one-way repeated measures ANOVA (rmANOVA) with the within-subject factor being time. Furthermore, we will conduct an attrition analysis to prevent any imbalance resulting from loss to follow-up [34].

Long-term implementation

Both prevention levels of the 2Steps4Health project are envisioned for long-term implementation. Following evaluation, we aim to standardize the implementation of the workshops and group program with a manual/guide accompanying exercise booklets and presentation slides and make these documents available to (sport) psychologists practicing in competitive sports. Thus, 2Steps4Health will improve the psychological care of young elite athletes nationwide. Furthermore, the workshops for universal prevention are intended to be adapted in content and structure to the school context, facilitating the implementation of prevention in sports schools. A possible transfer to other international countries is envisaged.