Prevalence of symptoms of depression and generalized anxiety disorder in field hockey players of German first and lower leagues
Abstract
Background
While several studies on mental health of elite athletes were published in recent years, few compared the prevalence with the general population and none included field hockey players.
Aims
To analyze the prevalence of symptoms of depression and generalized anxiety disorder in field hockey players of different skill levels and to compare it to the general population.
Methods
Male and female hockey players from different leagues were asked to answer questions on player characteristics, the Centre of Epidemiologic Studies Depression Scale (CES-D) and the Generalized Anxiety Disorder-7 (GAD-7).
Results
One hundred and eighty-seven players (incl. 54 first and 28 second league players) participated in the study (response rate 97.4%). More than a third (n = 64; 35.0%) reported to be affected by an injury/health complaint, but 157 (86.3%) were able to train and play without limitations. The CES-D score indicated depression symptoms in more female (n = 15; 18.3%) than male (n = 5; 4.8%) players (χ2=8.8; p < 0.01). No male and one female player had symptoms of generalized anxiety disorder. Players who played 60 or more matches in the previous 12 months had on average significantly higher depression (t = 2.3; p < 0.05) and generalized anxiety scores (t = 4.2; p < 0.001) than players who played fewer matches. The prevalence of depression and of generalized anxiety symptoms was similar to or lower than in the general population. Although 20 (10.7%) players had depression symptoms, only 4 (2.2%) received psychological counseling or psychotherapy.
Conclusion
It is recommended to provide routine screening of mental health problems and low-threshold access to adequate treatment for elite athletes.
1 INTRODUCTION
In 2019, the International Olympic Committee (IOC) published a consensus statement on mental health in elite athletes to advance a more standardized, evidence-based approach to mental health symptoms and disorders in elite athletes.1 Based on their review of the literature, they stated that mental health symptoms and disorders are common among elite athletes, but most studies have lacked reference groups from the general population.1
A systematic review and meta-analysis on mental health problems in elite athletes summarized that 34% symptoms of anxiety/depression (not differentiated) with high heterogeneity between studies.2 The authors assumed that the prevalence of mental health symptoms and disorders in elite athletes might be slightly higher than in the general population but also stated that none of the studies included in their meta-analyses compared its results to the general population. Rice et al.3 concluded from their narrative review on 60 studies that elite athletes have a similar risk of depression and anxiety relative to the general population.
A recent review focusing on the depressive symptoms in high-performance athletes showed that the prevalence ranged from 6.7% to 34.0%.4 As most studies used the same questionnaire, the large range in results may be due to differences in the characteristics of the study populations. Differences in depression symptoms have been reported previously for gender,5-11 type of sports,10, 11 and level of play.7, 8, 12 Gorczynski et al.5 concluded from their comparative meta-analysis that male and female high-performance athletes were just as likely as non-athletes to report depressive symptoms. However, only five studies were included in this review, and three involved mixed types of sports or did not report the type of sports.
Prevalence rates of generalized anxiety disorder in elite athletes range from 6.0% to 14.6%.1 In their recent review Rice et al.13 found no differences in generalized anxiety between athletes and non-athletes. However, also in this review only five studies were included. The authors also reported that gender, age, and musculoskeletal injury were determinants of anxiety.13
While the mental health of elite athletes has gained increasing interest in recent years and several studies were conducted, there is still a lack of sound epidemiological studies in single sports using established, standardized questionnaires to compare results between studies and/or to the general population.1 Reviewing the literature, no study on the prevalence of mental health problems of field hockey players was found.
Field hockey is a summer Olympic sport, the first Olympic competition for men was introduced in 1908, and for women in 1980. This team sport is played in- and outdoor and has an exceptionally high training and competition load with matches often played on consecutive days.14 German field hockey teams consistently rank among the world's best. The men's team ranked sixth (2014) and fifth (2018) and the women's team fifth (2018) and fourth (2022) in the most recent World Cups.
Therefore, the aim of the present study was to analyze the prevalence of symptoms of depression and general anxiety disorder in male and female German field hockey players and compare it to the general population. The secondary aim was to analyze potential determinants of symptoms of depression and general anxiety disorder in this group.
2 METHODS
The data for this cross-sectional study were collected during the baseline examination of a prospective study on epidemiology and risk factors of injuries in field hockey players during the season 2015/2016.14-16 The setting, recruitment procedure, and inclusion criteria have been previously described.15, 16 All data were treated strictly confidential, and it was ensured that no individual data would be shared with anyone, including the coach or club management. Twenty-eight field hockey teams of the national, regional, and youth league were contacted via the regional hockey federation, and 17 teams agreed to participate. Ethical approval was obtained from the local ethics committee (PV Nr. 4893), and all participants or their parents/legal guardians gave written consent.
The baseline questionnaire was provided in German language and included questions on personal and player characteristics, need and use of psychotherapeutic support, current injury, and current general health as well as the German versions of the Center for Epidemiologic Studies Depression Scale (CES-D,17 German version18) and the Generalized Anxiety Disorder-7 (GAD-7,19 German version20).
The CES-D is a validated self-report questionnaire to measure severity of depression symptoms experienced in the past week. It is the most commonly used tool in studies to assess depression symptoms in athletes.4, 7, 8 It comprises 20 items to be answered on a four-point Likert scale. A depression score is calculated, and the cutoff score for mild to moderate depression is 16, and for major depression more than 21.17 A systematic review with meta-analysis including 22 studies reported a sensitivity of 0.87 (95% CI 0.82–0.91) and a specificity of 0.70 (95% CI 0.65–0.75) using the cutoff of 16 in the general population.21 Age- and gender-matched reference values from a general German population (n = 2005)22 were used for comparison.
The GAD-719 is a validated 7-item questionnaire to assess symptoms of generalized anxiety disorder in the last 2 weeks. It has been previously used in athletes,6-8, 23 and has recently been recommended as disorder-specific screening questionnaire by the IOC.24 The GAD-7 is to be answered on a four-point Likert scale. A sum score is calculated, and cutoff scores for mild, moderate, and severe anxiety are 5, 10, and 15, respectively.19, 20 The authors reported a sensitivity of 89% and a specificity of 82% using a cutoff of 10.19 For comparison with a general German population, age- and gender-matched data from a representative national survey (n = 5030)20 were used.
Four different levels of play were defined: First: first national league (first Bundesliga); Second: second national league (second Bundesliga); Regional or lower: third to fifth league (Regionalliga, Oberliga and Verbandsliga); Youth league: regional youth league.
“Match experience” was computed based on the number and level of matches played in the last 12 months reported by the players: Very high: at least one international match; High: 30 or more national club matches; Moderate: 15–29 national club matches; Low: less than 15 national club matches.
All data were processed using Excel (Version 16.67) and the statistical package for the social sciences (SPSS; Version 27). Methods applied included: frequencies, crosstabs, descriptives, means, chi-square test, t-test, and ANOVA. All statistical tests were two-sided, and results with p < 0.05 were regarded as statistically significant.
3 RESULTS
A total of 192 athletes filled in the baseline questionnaire but five did not complete the CES-D nor the GAD-7 and were excluded from the analysis (response rate 97.4%).
3.1 Player characteristics
The study group consisted of 82 (43.9%) female and 105 (56.1%) male players with an average age of 20.0 years (SD = 4.7, range 14–38 years). About a third of each were strikers (n = 63; 33.9%) and defenders (n = 58; 31.2%), 49 (26.3%) were midfielders, and 16 (8.6%) goalkeepers. Fifty-four (28.9%) players played in the first league, 28 (15.0%) in the second league, 56 (29.9%) in lower leagues, and 49 (26.2%) in a regional youth league. In the preceding 12 months, 27 (14.4%) players had played matches with the national team and 22 (11.8%) had played other international matches. Almost all players had played national club matches (n = 170; 92.2%) and friendly or training matches (n = 168; 89.8%). On average each player played 42.4 (SD = 22.7; range 0–111) matches; 39 (21.3%) players played 60 or more matches in the previous 12 months. Based on their number and level of matches, 44 (23.5%) players had very high match experience, 56 (29.9%) high, 53 (28.3%) moderate, and 34 (18.2%) low match experiences. Female and male players were similar in all characteristics described above.
3.2 Current injuries, general health and need for psychological support
At the time the players completed the questionnaire, more than a third (n = 65; 35.3%) reported being affected by an injury or a health-related complaint. However, 157 (86.3%) were able to train and play without limitations, 22 (12.1%) had some limitations, and 3 (1.6%) were not able to train or play. Only 2 (1.1%) players rated their general health as very good, 54 (29.7%) as good, half of the players (n = 97, 53.3%) as average, 27 (14.8%) as poor, and 2 (1.1%) as very poor. Seven (3.8%) players reported a subjective need for psychological counseling or psychotherapy, and 4 (2.2%) received such treatment. No significant difference between female and male players was found in these variables.
3.3 Prevalence of symptoms of depression and generalized anxiety disorder
The CES-D score indicated mild to moderate symptoms of depression in 17 (9.1%) and severe symptoms in 3 (1.6%) players. Significantly more female (n = 15; 18.3%) than male players (n = 5; 4.8%) had symptoms of depression (χ2=8.8; p < 0.01). The GAD-7 score indicated moderate symptoms of generalized anxiety disorder in one female (1.2%) player. This woman had also moderate symptoms of depression.
The prevalence of hockey players with symptoms of depression or of generalized anxiety disorder was lower than in the general German population of the same gender and similar age (Table 1). The difference reached statistical significance for symptoms of depression in male players (χ2=16.0; p < 0.001), and for symptoms of generalized anxiety disorder in female (χ2=4.9; p < 0.05) and in male players (χ2=6.3; p < 0.05).
| Female | Male | |||
|---|---|---|---|---|
| Field hockey players | General populationa | Field hockey players | General populationa | |
| CES-D | n = 82 | n = 127 | n = 105 | n = 122 |
| <16 | 67 (81.7%) | 91 (72%) | 100 (95.2%) | 93 (76%) |
| 16–21 | 12 (14.6%) | 18 (14%) | 5 (4.8%) | 11 (9%) |
| >21 | 3 (3.7%) | 18 (14%) | 0 | 18 (15%) |
| GAD-7 | n = 82 | n = 260 | n = 105 | n = 296 |
| <10 | 81 (98.8%) | 239 (91.9%) | 105 (100%) | 279 (94.4%) |
| 10–14 | 1 (1.2%) | 18 (6.9%) | 0 | 13 (4.4%) |
| >14 | 0 | 3 (1.2%) | 0 | 4 (1.2%) |
3.4 Determinants of symptoms of depression and generalized anxiety disorder
The depression score was on average significantly (F = 17.3; p < 0.001) higher in female (12.2; SD = 4.4) than male players (9.9; SD = 3.2), and also the generalized anxiety score was on average significantly (F = 19.6; p < 0.001) higher in female (3.1; SD = 2.5) than in male players (1.7; SD = 1.9). No statistically significant difference in the average depression or generalized anxiety scores was found between player groups of different age, playing position, league, match experience, and current ability to train and play for the whole group as well as when male or female players were analyzed separately (Table 2).
| Population | Female players n = 82 | Male players n = 105 | ||
|---|---|---|---|---|
| Variable | CES-D | GAD-7 | CES-D | GAD-7 |
| Group (n of female/male) | Mean (SD) | Mean (SD) | Mean (SD) | Mean (SD) |
| Age in years | ||||
| <18 years (32/36) | 12.1 (4.2) | 2.8 (2.4) | 10.4 (3.4) | 1.6 (2.2) |
| 18–20 years (22/29) | 12.0 (4.8) | 3.0 (2.3) | 10.2 (3.1) | 1.5 (1.7) |
| >20 years (28/40) | 12.5 (4.5) | 3.6 (2.8) | 9.2 (3.0) | 1.9 (2.0) |
| Playing position | ||||
| Defender (24/34) | 13.2 (4.0) | 3.4 (2.8) | 10.2 (3.3) | 1.7 (1.8) |
| Midfield (26/23) | 12.1 (5.1) | 2.9 (2.6) | 11.0 (2.9) | 2.0 (2.4) |
| Strikers (27/36) | 11.9 (4.0) | 3.2 (2.2) | 9.4 (3.4) | 1.6 (1.9) |
| Goalkeeper (4/12) | 10.0 (4.3) | 2.3 (2.1) | 8.6 (2.3) | 1.5 (1.6) |
| League | ||||
| First national (23/31) | 12.3 (4.2) | 3.6 (2.1) | 9.5 (2.7) | 1.9 (1.8) |
| Second national (12/16) | 12.4 (5.5) | 3.3 (3.2) | 8.8 (2.8) | 1.9 (1.4) |
| Regional or lower (19/37) | 11.2 (3.7) | 2.3 (2.1) | 10.2 (3.4) | 1.8 (2.4) |
| Youth (28/21) | 12.8 (4.6) | 3.3 (2.7) | 11.0 (3.6) | 1.0 (1.5) |
| Match experiencea | ||||
| Very high (15/19) | 11.6 (3.6) | 3.9 (2.3) | 9.6 (2.8) | 1.8 (2.1) |
| High (31/25) | 12.7 (4.7) | 3.3 (2.4) | 9.9 (3.6) | 1.7 (2.2) |
| Moderate (22/31) | 11.5 (4.1) | 2.2 (2.2) | 10.2 (3.1) | 1.8 (1.8) |
| Low (14/20) | 12.9 (5.1) | 3.4 (3.1) | 10.0 (3.4) | 1.4 (1.8) |
| Number of matches last 12 months | ||||
| <60 (57/87) | 11.4 (4.4) | 2.6 (2.4) | 9.9 (3.2) | 1.4 (1.7) |
| 60 or more (22/17) | 13.6 (4.0) | 4.3 (2.4) | 10.2 (3.1) | 3.1 (2.6) |
| Currently able to train/play | ||||
| Yes, without limitation (72/85) | 12.5 (4.5) | 3.3 (2.6) | 9.9 (3.1) | 1.6 (1.8) |
| Yes, with limitation (6/16) | 9.5 (2.7) | 1.8 (1.2) | 9.5 (3.6) | 1.7 (2.1) |
| No (2/1) | 9.0 (2.8) | 2.5 (3.2) | 14.0 (0) | 1 (0) |
| Currently affected by injury/complaint | ||||
| No (53/66) | 11.5 (4.2) | 2.8 (2.3) | 10.0 (3.0) | 1.8 (2.1) |
| Yes (28/37) | 13.5 (4.4) | 3.5 (2.7) | 9.8 (3.6) | 1.5 (1.7) |
| Current general health | ||||
| Very good (0/2) | - | - | 8.0 (2.8) | 2.0 (1.4) |
| Good (26/28) | 10.7 (4.3) | 1.8 (1.7) | 10.0 (2.3) | 1.3 (1.5) |
| Average (41/56) | 12.2 (3.7) | 3.3 (2.5) | 9.9 (3.6) | 1.8 (2.1) |
| Poor (14/13) | 15.4 (5.2) | 4.9 (2.8) | 9.7 (3.9) | 1.5 (2.0) |
| Very poor (0/2) | - | - | 10 (0.0) | 4.5 (3.5) |
| Need for psychotherapy | ||||
| No (58/86) | 11.6 (4.1) | 2.6 (2.2) | 9.7 (3.0) | 1.7 (2.0) |
| In the past (19/12) | 13.7 (5.0) | 4.3 (2.7) | 10.7 (3.1) | 1.7 (1.8) |
| Currently (4/3) | 15.5 (3.7) | 5.3 (3.0) | 13.0 (7.2) | 2.7 (1.5) |
| Use of psychotherapy | ||||
| No (63/86) | 12.0 (4.4) | 2.8 (2.5) | 9.6 (3.1) | 1.7 (2.0) |
| In the past (15/14) | 13.0 (4.8) | 3.8 (2.1) | 10.5 (2.7) | 1.9 (1.8) |
| Currently (3/1) | 14.0 (2.6) | 6.3 (2.5) | 21.0 (0.0) | 3.0 (0.0) |
- Abbreviations: CES-D, Centre of Epidemiologic Studies Depression Scale; GAD-7, Generalized Anxiety Disorder-7.
- a Very high: at least one international match; High: 30 or more national club matches; Moderate: 15–29 national club matches; Low: less than 15 national club matches.
Players who played 60 or more matches in the previous 12 months had on average significantly higher depression (t = 2.3; p < 0.05) and generalized anxiety scores (t = 4.2; p < 0.001) than players who played fewer matches. Among female players the difference was significant for depression (t = 2.0; p < 0.05) and generalized anxiety (t = 2.7; p < 0.01), among male players for generalized anxiety (t = 2.5; p < 0.05) (Table 2).
Female players with different rating of their current health (F = 5.8; p < 0.01) and of current impairment due to an injury or a health complaint (F = 4.1; p < 0.05) differed in the average depression scores (for details see Table 2). The average generalized anxiety score of female players differed significantly in groups with different rating of current health (F = 8.7, p < 0.001), subjective need for psychotherapy (F = 5.4, p < 0.01), and use of psychotherapy (F = 3.7, p < 0.05). In male players, only groups with different use of psychotherapy differed significantly in the average depression score (F = 7.3, p < 0.001). All significant differences were in the expected direction, for example, players who reported a current need for psychotherapy had higher depression scores (Table 2).
4 DISCUSSION
This is the first study evaluating the prevalence and determinants of symptoms of depression and generalized anxiety disorder in field hockey players using established, validated questionnaires. A total of 187 male and female players of different skill levels, including 54 (28.9%) first league players, participated in the study (response rate 97.4%).
4.1 Prevalence of depression symptoms
In the present study the overall prevalence of depression symptoms was 10.7%, which is within the range of depression symptoms in high-performance athletes reported before.4 It was significantly higher in female than in male players. A higher prevalence of depression symptoms in women than in men has previously been reported for various athlete populations5-7, 9-11 and for the general population.18, 22
The prevalence of depression symptoms in female field hockey players found in the present study was higher than in Swiss female football players,7 but lower than in German female football players8 and in female athletes from various sports.6, 9-11 The prevalence in male field hockey players was similar to Swiss male first league football players7 but lower than in male Swiss U-21 football players,7 male US American Division I baseball players,25 and male athletes from various sports.6, 9-11 It is possible that the popularity of a certain type of sport in a specific country and the associated pressure on the players contribute to the observed differences.
Few studies have compared the prevalence of depression symptoms in elite athletes with the general population.5 In the present study, the prevalence in female hockey players was similar to and the prevalence in male players was significantly lower than in a German general population of the same gender and similar age. In their meta-analysis Gorczynski et al.5 summarized the results of five studies and concluded that the prevalence of depressive symptoms was similar in high-performance athletes and non-athletes of the same gender. Also, Junge and Prinz8 found no significant difference between female football players and a female general population of similar age.
4.2 Prevalence of symptoms of generalized anxiety disorder
The prevalence of symptoms of generalized anxiety disorder in female hockey players was 1.2%, and no such disorder was observed in the male players in the present study. The higher prevalence in women than in men is in accordance with the literature on elite athletes6, 7, 13 and the general population.20
The prevalence of symptoms of generalized anxiety disorder in female and in male hockey players was similar to Swiss first league football players7 but lower than in elite rugby players26 and athletes from various sports.6, 27 The prevalence of symptoms of generalized anxiety disorder in female field hockey players was also lower than in German female football players.8 The differences are probably due to differences in the characteristics of the study populations and investigated sports as outlined above.
In the present study, the prevalence in female and male hockey players was significantly lower than in a German general population of the same gender and similar age. In their recent review, Rice et al.13 summarized the results of five studies and found no differences in generalized anxiety between athletes and non-athletes. Likewise, Junge and Prinz8 found no difference in elite female football players and the general population. The low prevalence of generalized anxiety disorder in the German field hockey population is in accordance with the relative low prevalence of depression symptoms in this group and leads to the conclusion that field hockey might be a beneficial sport for mental health. This is supported by the fact that just seven (3.8%) field hockey players stated to currently need psychological counseling or psychotherapy, while it was 15.7% in elite female football players8 and 15.9% in elite aquatic athletes of both genders.28 Another interpretation could be that the hockey players in the present study under-reported their mental health symptoms and need for support.1, 29 However, we regard this as unlikely, as the prevalence rates were within the range of other elite athletes of the same gender, for example, Swiss first league football players.7 We assume that German field hockey players profit from the positive effects of regular physical activity on mental health, but do not suffer from the pressures related to popular elite sports.
4.3 Determinants of depression and generalized anxiety disorder
Few studies have investigated potential determinants of depression and anxiety in elite athletes, except for gender.1, 13 Besides the female gender, injury has been frequently reported as risk factor.1, 6, 7, 10, 13, 30 In the present study, only female players who reported being currently affected by an injury or complaints had significantly higher depression scores, while no difference was found for generalized anxiety, or in male players. As only three players of the study population were unable to train or play but more than a third reported to be “currently affected by an injury or complaints”, it can be assumed most of these players had minor complaints that did not influence their mental health. An effect of younger age which has been reported from other populations8, 13 was not found in the present study, possibly because most of the younger players played in separate leagues, and thus, were not under high performance pressure. In contrast to study on football players,7, 8 playing position, league and match experience had no statistically significant effect on the average depression or generalized anxiety score in present study. However, players who played 60 or more matches in the previous 12 months had on average higher depression and generalized anxiety scores than players who played fewer matches. Negative effects of a very congested match schedule on performance31-33 and mood33 has been shown in professional football players. Longer periods of insufficient recovery may also induce mental health problems associated with the state of overtraining and burnout.3
At the time of the baseline examination, 7 (3.8%) players reported a subjective need for psychological counseling or psychotherapy, but just 4 (2.2%) received such treatment. However, with regard to the past, 31 of the 29 players who indicated a subjective need for psychotherapy have made use of it. Although a reporting bias cannot be excluded, it seems more likely that the availability of (or waiting time for) psychological support, rather than help-seeking behavior, is the problem in this group of players.
4.4 Strength and limitations
This is the first epidemiological study on symptoms of depression and generalized anxiety disorder in a large group of male and female field hockey players of different skill levels. The study received a very high response rate (97.4%). Players from various leagues (included 54 first and 28 second league players, representing 43.9% of the study population) participated, however, no significant difference (or trend) in the average gender-specific depression and generalized anxiety score was observed between leagues. The study used established, validated questionnaires that were most frequently used in elite sport8, 13 and in the general population. Results were compared to other sports as well as to the general population as recommended by the IOC consensus group.1 However, questionnaires should only serve as screening tools, and a diagnosis should be based on diagnostic interviews by qualified health care professionals. It cannot be ruled out that some players did not answer the questionnaires honestly, although confidentiality was assured, but this limitation also applies to almost all studies on mental health in elite sports. Further, results on the determinants of depression and generalized anxiety which were significant only at 0.5 level should be interpreted with caution because of multiple testing in this section. We reported these results because they were all in accordance with the literature.
5 CONCLUSION AND PERSPECTIVE
The prevalence of symptoms of depression and of generalized anxiety disorder was similar to or lower than in the general population and in other elite sports. However, 20 (10.7%) players had symptoms of depression, and only 4 (2.2%) received psychological counseling or psychotherapy. Therefore, mental health problems should be a part of routine pre-season screening, and low-threshold access to adequate treatment should be provided especially to players at higher risk. Studies on determinants and predictors of mental health problems in elite athletes are required to develop prevention strategies.
AUTHOR CONTRIBUTIONS
AJ and AZ designed the study in the design of the study conception. KW was responsible for data collection. AJ conducted the statistical analysis and wrote the first draft of the manuscript. AZ contributed to the interpretation of results. All authors read and approved the final manuscript.
ACKNOWLEDGEMENTS
The authors thank the Hamburg Hockey Association for their support of the study and all teams for participation. Open Access funding enabled and organized by Projekt DEAL.
FUNDING INFORMATION
This study was funded by the German Federal Institute for Sport Science (grant number 2515BI0111).
CONFLICT OF INTEREST STATEMENT
The authors have no conflict of interest to declare.
PATIENT CONSENT
All participants or their parents/legal guardians gave written informed consent.
Open Research
DATA AVAILABILITY STATEMENT
Data will not be shared due to confidentiality reasons.
