Research gaps in the correlation of anxiety and depression prevalence in former college athletes: a systematic review

Inclusion and exclusion criteria

The searches were conducted on December 11, 2023. The studies were first screened by title and abstract to include only studies that pertained to anxiety or depressive disorders in former collegiate athletes by two authors in a masked, duplicative fashion. The types of studies included were original research articles including letters and briefs, literature reviews, systematic reviews or meta-analyses, clinical trials, and case studies. We excluded conference posters or presentations, commentaries, and editorials. The studies were also limited to those published in English within the last 10 years.

Data extraction

Data extraction was performed by two authors – also in a masked, duplicative fashion. After the extraction was completed, the author reconciled data to reach 100 % inter-rater agreement. In instances when agreement between the two extractors (M.R. and B.E.) could not be reached, a third author (M.H.) acted as an arbiter. Data extracted from the studies included author, year of publication, title, location (country/state), journal, type of article, type of research, sport, age of participants, sex, enrollment, intervention, type of mental health disorder, symptomology, and duration of symptoms.

Search strategy results

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram (Figure 1) shows the search string results for our scoping review. There was a total of 180 articles from PubMed, Embase, and the Cochrane Library. After duplicates were removed, there were 169 articles left for screening. These articles were screened by both title and abstract for the inclusion criteria. We determined that 61 articles fit our criteria and were selected for full-text analysis. The articles not selected were excluded because they reported on the wrong target population or medical condition, had an excluded study design, or were a type of predetermined excluded article. From the 61 full-screen articles, an additional 52 were further excluded. These 52 articles were excluded for the following reasons: 21 had the wrong target population, 20 had the wrong medical condition, eight were a type of excluded article, two were not in English, and one was published 27 years ago. Therefore, a total of nine articles were included in this scoping review.

Figure 1:

Preferred reporting items for systematic reviews and meta-analyses (PRISMA) diagram for article inclusion in this review.

Article analysis

Two authors reviewed all nine included articles. The details of each article including author, publication year, type of research, sport, age of participants, sex, intervention, enrollment, and symptoms for each article are presented in Table 1. The included studies consisted of cross-sectional surveys, systematic/scoping reviews, literature reviews, and qualitative research. Most articles involved multiple sports. All included articles mentioned anxiety and/or depression in regard to former collegiate athletes. An interventional tool was analyzed in each article, and the most common type of intervention was staying active after retirement (n=4) followed by educational approaches for the transitioning athlete (n=2). Other interventional strategies observed were mental health screening before retirement (n=1), maintaining social groups (n=1), and having physicians be aware of athlete-specific determinants of anxiety symptoms (n=1).

Identified gaps in mental health research for former collegiate athletes

Our review also analyzes gaps listed in each article. Gaps identified in the selected articles encouraged future research to look at all divisions of semi-professional sports [9] and to compare how varying sports affect athletes differently [13]. Others pointed out that further research needs to be done without utilizing self-reporting surveys to eliminate bias or misunderstanding of symptoms [12]. None of the articles that utilized surveys to collect data followed up with the athlete after the initial survey. Shander and Petrie [11] pointed out the lack of longitudinal studies on athletes transitioning out of sport, which this review agrees with, especially for our target population. Most of the selected articles mentioned that future studies should include the effect of interventions or pretransition planning on this group of athletes [9], 12], 13].

Where these limitations are present in our target population, professional sports leagues in the United States can combat them. The National Football League (NFL) has programs in place through the Players Association (NFLPA) that allow athletes to access career-advising services and career counseling [18]. They have also started a program called AthleteAnd, which offers a variety of services to the players to grow their lives “outside the locker room [19].” Major League Baseball (MLB), the National Hockey League (NHL), and Major League Soccer (MLS) offer similar programs to their athletes. The NHL Players Association offers a mental health training course specifically designed to address issues faced by players and their families [20], whereas MLS offers players the chance to shadow the league office for a day to learn more about the business side of soccer [21]. Whereas these professional leagues have a multitude of money and resources compared to colleges, it would still be possible for colleges and universities to offer similar programs through existing resources through career development offices, student success, and athletic departments.

Implications and recommendations

The findings of this scoping review reveal important implications for both the understanding and treatment of mental health issues among college athletes, particularly during their transition into postathletic life. While a substantial body of research highlights high rates of anxiety and depression among professional athletes, particularly in leagues like the NFL [22], it is likely that similar mental health challenges are prevalent among competitive athletes at lower levels. Moreover, many existing studies focus predominantly on male professional athletes [23]. Studies included in our review show that the intense demands placed on student-athletes – balancing academics, athletic performance, and financial responsibilities – create an environment conducive to mental health disorders among all genders [23]. Among any athlete, however, the physical demands of the sport and related lifestyle changes, as well as the loss of athletic identity and the transition into retirement, especially involuntarily, can exacerbate mental health issues [23].

Given the disparity in funding for professional sports and college athletics, we support the recommendations and strategies put forth by Moore et al. and Voorheis et al., in utilizing existing infrastructure for mental health support at the collegiate level. This could be a collaborative effort across multiple sports at each institution to spread the costs associated with employing mental health professionals, conducting screenings, and making referrals when the need arises. Additionally, Voorheis et al., proposed a four-step framework to help athletes transition away from athletics to reduce the impact of retirement on mental health. These steps included: 1) preparation for retirement – seeing retirement as a transition rather than an ending; 2) curating self-identity – understanding strengths and identifying transferable skills; 3) gaining control of the process – preparing to adjust to a life without sports through shifting time management, being aware of grief, vocational planning, establishing a social support network, maintaining physical activity, and thinking about how to make money outside of sports; and 4) normalizing the transition – including former athletes, coaches, and mental health providers in sport in the process can show that all athletes can move into postsports life in a positive, effective way [13]. Given the long-term mental health impact on former athletes, the NCAA should consider requiring colleges to implement an exit training module as part of graduation or before the next semester for nongraduating athletes. This training module should include elements to support the eight dimensions of wellness – physical, intellectual, emotional, social, spiritual, vocational, financial, and environmental [24]. Schools could have their exercise science or kinesiology departments create workouts that are shorter and suited for public gym use available for download within the module. Nursing or dietitian programs could provide a brief overview of nutritional requirements and caloric intake for nonathletes. If athletes wish to continue their education postgraduation, the module could provide resources to potential programs that fit their skill set through continuing education programs on campus. The college or university’s career services department could provide something similar to the NFL program mentioned above that links athletes with potential career paths that fit their unique skills. All students are required to complete an exit counseling through Free Application for Federal Student Aid (FAFSA) when they graduate or drop below full-time enrollment. However, the financial services department at schools could provide additional counseling to athletes including how to manage Name, Image, and Likeness (NIL) funds as well as budgeting for food and other necessities. The community outreach and involvement departments could provide links to social groups – churches, adult sports leagues, etc – within the community so athletes could start to build their social networks outside of school. Finally, mental health screenings evaluated by the school’s mental health provider and the athletic training department can identify athletes at an increased risk for anxiety and depressive disorders and provide them with the resources they need for their transition. Overall, this transition module would require multi-departmental cooperation in order to best benefit the transitioning athlete.

Furthermore, we recommend that more research needs to be conducted in this field of study so that athletes can have access to the best resources during this transition time. Given that the included articles do not mention changes in the athletes’ relationships or dietary, career, and health changes, future studies should focus on these aspects of the postcollege athletic transition. Utilizing the increased research, the addition or expansion of educational courses could be implemented across all collegiate athletic departments, which would greatly benefit athletes during this transition period.

Strengths and limitations

A notable strength of the current review was that we searched the five largest databases to include a wide range of literature specific to anxiety and depression as medical conditions among athletes. While this allowed for an accurate depiction of the currently available medical research, literature that was not available through these databases may limit our findings, as databases emphasizing psychological research may yield research on other aspects of athlete mental health, particularly regarding psychosocial factors and career transition experiences. Additionally, the use of three reviewers optimized the selection process. A notable limitation of this study resulted from the use of articles only written in English within the last 10 years – possibly excluding articles that could have been beneficial to the study. Additionally, we did not search grey literature, nor clinical trial registries to retrieve nonpublished items.