Variables and instruments to evaluate mental health in competitive swimmers: a narrative review

Introduction

Mental health problems are increasingly present among elite athletes and it was during the Tokyo 2020 Olympics when it was an urgent call for this issue. In particular, several athletes complained about their mental health situation regarding the highly demanding inquiries about their sports modalities. Moreover, the World Health Organization (WHO) defines “global health” as “a state of complete physical, mental, and social well-being,”. This definition explicitly stresses that mental health is vital to our ability to think, feel and interact among us (Jackson et al., 2022; World Health Organization, 2018). However, far from this definition in terms of health, in high-competition swimming, the athletes are exposed to different stressors in high competition due to the physical, technical and mental demands (Hooper et al., 2022; Salazar et al., 1997; Trinidad et al., 2021). Likewise, it was also corroborated that psychological preparation and sports psychologists are essential factors within the technical teams with a view to the optimal performance of swimmers (Rice et al., 2016). It was not until 2017 that the International Olympic Committee (IOC) began to take care of the mental health of athletes, creating a specific working group (MHWG), to develop an evaluation and early recognition tool on the possible risks of suffering from mental health symptoms and disorders (Gouttebarge et al., 2021).

Since the 1990s, the scientific literature has emphasised mental health’s role among competitive swimmers. This factor is as important as physical health in optimising the athlete’s performance and well-being. However, this concept has been unnoticed by sports coaches and psychologists, due to the limited literature on swimming and the benefits of this sport for mental health (Geamonond, 2018). The scarcity of research that has had competitive swimmers as an object of study has been a visible fact (Jackson et al., 2022; Rice et al., 2016). Even in a recent review study (Gouttebarge et al., 2019), the absence of these athletes is evidenced by not characterizing them specifically (Hughes & Leavey, 2012; Reardon & Factor, 2010). Similarly, high-quality systematic studies and intervention trials have been limited (Rice et al., 2016; Gouttebarge et al., 2021), as well as descriptive research on the extent of mental health symptoms and disorders (Gouttebarge et al., 2019). This evidence set off alarms among swimmers, coaches and technical teams, as high rates of highly prevalent mental disorders begin to appear (Rice et al., 2016). This is contrary to the statement that swimming causes the sensation of well-being and relaxation, as well as control of anxiety, stress and fatigue (Cordeiro et al., 2017). Some factors include intense physical activity, overtraining, injuries and exhaustion (Peluso & Andrade, 2005), proximity to sports retirement (Gouttebarge et al., 2016), a strict diet (Sundgot-Borgen & Torstveit, 2004), physical and competitive stress, along with pressure from the public, the media, and the social media (Bruner et al., 2008; Fletcher & Wagstaff, 2009; Hanton et al., 2005; Noblet & Gifford, 2002). Moreover, it should be added that athletes do not seek help for reasons such as a bad reputation, lack of understanding, the impact on performance and the perception that seeking help is a weakness (Reardon & Factor, 2010; Gulliver et al., 2012). This generates a high risk of mental illness that reduce sporting success (Rice et al., 2016).

Therefore, something must be fixed since the literature has warned us of the importance of psychological preparation and mental training (Nideffer, 1985; Ryan, 1982). Moreover, putting up with the high training loads does not only depends on physical, technical and tactical preparation in order to achieve high performance (Salazar et al., 1997). Subsequently, the novelty of this study is to review the different works that examine the mental health of swimmers and the tools displayed to examine those characteristics of mental health in this population. To date, it seems that no previous review has examined the different tools and measures to portray competitive swimmers’ mental health situation. Therefore, this study aimed to carry out an analysis of the scientific tests taken with mental health in the discipline of swimming, as well as to examine the type of instrument used to evaluate and diagnose this situation in highly competitive swimmers.

Methods

Results

Searches were made using titles, abstracts and keywords. The first comprehensive search yielded a total of 512 records. One additional article was identified by other means. After removing duplicates, 72 documents were identified, of which 41 were excluded as they were not directly related to the objective of the study. Finally, 59 articles were reviewed and, after applying the inclusion criteria, the 18 articles included in this review were selected (Figure 1).

Figure 1. Identified articles flow chart.

Discussion

This study aimed to carry out an analysis of the scientific tests taken in mental health in the discipline of swimming, as well as to examine the type of instrument used to evaluate and diagnose this situation in highly competitive swimmers. In competitive swimming, mental health has been assessed from different perspectives and with great scientific heterogeneity. One of the possible causes could be associated with the fact that swimming is related to other areas of knowledge (Navarro et al., 1990), among which is psychology. The range of variables studied in this area has generated some uncertainty and overlooked certain factors that may have influenced swimmers’ vulnerability to mental health symptoms and disorders (Bär & Markser, 2013). Likewise, some studies highlight that there are more than 640 different stressors (Arnold & Fletcher, 2012) and that together with the sports withdrawal, they could develop a high probability of suffering from symptoms and mental health disorders (Arnold & Fletcher, 2012; Wylleman & Reints, 2010). Therefore, it may be highlighted that mental health has not been analysed and evaluated in depth and rigour, according to the scientific literature. However, there are also controversies since other authors defend the idea that swimming positively affects general somatic health (Oja et al., 2015; Tanaka, 2009) and mental health (Cordeiro et al., 2017; Yfanti et al., 2014). On the contrary, these opinions differ from those other researchers give when discussing mental health in high-level sports and its stressors and conditioning factors (Henriksen et al., 2020). For this reason, this scientific diversity has generated some uncertainty among researchers, not knowing what to focus their studies on when evaluating and diagnosing due to the dimensional amplitude of variables.

The reviewed scientific literature shows how the concept of mental health could be clearer between the studies, since most of them have analysed different variables separately (Byrne & McLean, 2002; Didymus & Fletcher, 2014; Hammond et al., 2013; Hooper et al., 2022), to later refer to the term mental health in general. Likewise, most of these studies have focused mainly on variables such as: anxiety, coping, goal setting and depression (Abrahamsen et al., 2008; Nixdorf et al., 2013; Salazar et al., 1997; Simões et al., 2012), neglecting other factors (Arnold & Fletcher, 2012), which could also be analysed and give a more complete view in terms of mental health among swimmers. Therefore, it would be necessary to reach a consensus on mental health and work on these symptoms and disorders in an interconnected way with other factors (risk and recovery from injuries, sports performance, depression and anxiety) and relate them to other symptoms, injuries and physical illnesses (Jones & Hanton, 1996). This could further clarify what mental health is and how it could be extrapolated to swimming, since most of the studies analysed in the literature focus on the study of a reduced number of variables or in the analysis of aquatic disciplines displayed by FINA (Jackson et al., 2022).

Likewise, the scientific literature seems to have not found a consensual categorization of the term mental health. Authors such as Rice et al. (2016) related mental health with: anger and aggression, anxiety, eating disorder and image, general prevalence studies, seeking help, sleep, stress and coping, substance use and well-being. In contrast, Gouttebarge et al. (2019) linked it to terms such as: distress, sleep, anxiety/depression, and alcohol abuse. Purcell et al. (2019) and Reardon et al. (2019) linked it with: high prevalence disorders (e.g., anxiety and mood symptoms) and more complex mental health disorders (e.g., bipolar and eating disorders). However, the International Olympic Committee (IOC) and its mental health working group (MHWG) have proposed a confidential mental health support service “Mentally Fit”. This service could help to clarify the term and establish different categories of analysis (pressure management, physical or psychological exhaustion, harmony between sport and life at home, management of life or career changes, stress management, communication improvement, how to deal with injuries, anxiety control, depression, eating disorders, bullying, harassment and abuse, and parenting). Also, this service could explain all the edges that make up mental health for future research, given the lack of consensus among researchers when categorising mental health. Furthermore, even the International Swimming Federation (FINA) does not have a program similar to that of the International Olympic Committee (IOC) and delegates, according to its general medical regulations, to the members of the Olympic movement. It is therefore questionable whether there is any concern on the part of this competent body for its swimmers in the area of mental health according to its current regulations.

It even reinforces the opinion of some researchers on the lack of concern on the part of federations and institutions (Reardon & Factor, 2010), in the face of this situation in high-level swimmers. Therefore, it would be recommended that the International Swimming Federation (FINA) implement a health program that will help both coaches and athletes to improve their knowledge of mental health problems (Mountjoy et al., 2019), extending this to other aquatic disciplines under FINA conditions (Jackson et al., 2022).

Concerning the methodology used to detect mental health problems in swimmers, it has been shown that most cross-sectional, longitudinal and comparative studies do not correspond to high-quality research and intervention trials (World Health Organization, 2018). This situation also corroborates the need for more consensus among researchers when it comes to intervening, preventing and establishing action protocols, to which is added the scarcity of scientific literature (Trinidad et al., 2021; World Health Organization, 2018), being necessary the expansion in this field through specific studies. Furthermore, it would be necessary to increase the analysis sample for future comparative studies (Hainline & Reardon, 2019; Hammond et al., 2013; Purcell et al., 2019), since it was found that most research was at most 15 sample swimmers (Henriksen et al., 2020; Jackson et al., 2022; Oja et al., 2015; Tanaka, 2009).

Regarding the revised instruments for the measurement and diagnosis of mental health in swimmers, there is great heterogeneity since most of them have used between three and four measurement tools. First, for anxiety the following were mainly used: the modified CSAI-2 (Ning et al., 2022; Martens et al., 1990), the direction scale, the mental readiness form (MRF-3) (Krane, 1994) and different self-report scales (Hooper et al., 2022). Regarding coping, the following were used: the career information questionnaire, modified COPE (Carver et al., 1989) and MCOPE (Crocker & Graham, 1995), the performance strategies test (TOPS) (Hardy et al., 2010) and the semi-structured follow-up telehealth interviews (Ning et al., 2022). In order to establish goals, the following were used: the scale of expectations of achieving objectives, the mental training program (MTP) and the perception of success questionnaire (POSQ) (Roberts et al., 1998). Finally, for depression, the following were used: the semi-structured interview based on the DSM-IV-TR criteria, the BDI-II self-report instrument (Beck & Steer, 1993), center for Epidemiological Studies Depression Scale revised (CESD-R-10) (Jackson et al., 2022) and an online survey. This diversity of resources demonstrates, once again, the lack of consensus and the need to establish a more homogeneous protocol among researchers, in order to know what tools should be used in each aspect of mental health. Therefore, it would be necessary to lay the foundations to reach viable conclusions that can be extrapolated to swimmers to measure and diagnose mental health. All this evidence makes it necessary to carry out specific studies with swimmers and ex-swimmers, in order to carry out intervention protocols and prevention of mental health, rather than waiting for symptoms to appear during sports life or even waiting for the testimonies of retired swimmers.

In conclusion, mental health problems are a salient topic in sports since 1990s. Studies that have analysed mental health symptoms and disorders in competitive swimmers have been insufficient in the scientific literature. They have even valued it from different dimensions and tools, masking the problem or simply reporting data that have not helped to clarify what mental health is. Therefore, it is necessary to fill this gap with studies that work under the same consensus and in collaboration with specified technical teams, in order to supervise, evaluate and provide services, through detection tests and support to swimmers in their training, as well as before and after competitions. Moreover, there should be a direct involvement by the competent bodies and institutions to tackle, instead of ignoring or mismanaging this situation, in order to respond to the needs of swimmers. Finally, mental health is everyone’s responsibility, from the swimmer himself to the bodies and institutions involved, and interdisciplinary and collaborative work should be done, establishing specific programs based on the sport in order to guarantee efficient prevention and care.