Injury Associated with Higher Prevalence of Psychological Distress and Depressive Symptoms Among South African Female Athletes: Findings from the Female Athlete Lifestyle and Mental Health Evaluation I (FLAME I) study

Technical Summary: Injury Associated with Higher Prevalence of Psychological Distress and Depressive Symptoms Among South African Female Athletes

Problem Statement
While mental health symptoms (MHS) are a recognized public health concern globally and among elite athletes, there is a significant evidence gap regarding the mental health status of female athletes in South Africa. Existing literature indicates that female athletes generally face higher risks of MHS compared to males due to unique biological, psychological, and sport-related stressors, including gender-based violence and pay disparities. However, no prior research has explored the prevalence of MHS among South African female athletes across different participation levels (elite vs. amateur) and sport types (team vs. individual). This study addresses the need to quantify the mental health burden in this underrepresented population and identify demographic and sport-related risk indicators.

Methodology
The study employed an observational, cross-sectional design using an online convenience sampling approach.

• Participants: A total of 376 female athletes (aged 18+) from South Africa participated, comprising both elite (National level/First Division) and amateur (Club/Division Two and lower) athletes in team and individual sports.
• Data Collection: Data was collected via a two-part questionnaire programmed in Qualtrics.
  • Part A: Captured demographic and sport-related variables (age, employment, residence, sport type, training hours, injury history).
  • Part B: Utilized the Sports Mental Health Assessment Tool-1 (SMHAT-1). Unlike the standard stepwise administration, all participants completed all components to ensure comprehensive surveillance and minimize false negatives, given concerns about the cross-cultural validity of the initial Athlete Psychological Strain Questionnaire (APSQ) cut-off in this population.
• Screening Instruments: The study assessed six domains:
  1. Psychological Distress (APSQ)
  2. Anxiety (GAD-7)
  3. Depression (PHQ-9)
  4. Sleep Disturbances (ASSQ)
  5. Alcohol Misuse (AUDIT-C)
  6. Disordered Eating (BEDA-Q)
     Note: Drug misuse was excluded from analysis due to a prevalence of <5%.
• Statistical Analysis: Descriptive statistics were calculated for prevalence. Generalized linear models with a Poisson distribution and log link were used to examine associations between MHS and demographic/sport variables. Prevalence Ratios (PR) with 95% confidence intervals were reported.

Key Results
The study revealed a high prevalence of mental health symptoms across the cohort, with specific patterns emerging based on sport type and participation level:

• Overall Prevalence: Disordered eating (DE) was the most prevalent symptom cluster (75%), followed by psychological distress (67%) and sleep disturbances (45%). Lower rates were observed for alcohol misuse (36%), anxiety (27%), and depression (25%). Only 33% of participants reported no symptoms of psychological distress.
• Sport Type Differences:
  • Anxiety: Team sport athletes reported significantly higher anxiety symptoms (33%) compared to individual sport athletes (20%) (PR: 1.6; p=0.02).
  • Other Symptoms: No statistically significant differences were found between team and individual athletes for distress, depression, DE, or sleep disturbances, though team athletes consistently showed slightly higher prevalence rates.
• Participation Level: No significant differences were found between elite and amateur athletes for most symptoms. However, elite athletes showed slightly higher distress (72% vs. 64%) and anxiety (31% vs. 24%), while amateur athletes showed higher DE (78% vs. 71%).
• Risk Indicators:
  • Injury: Recent injury (past four weeks) was significantly associated with higher prevalence of psychological distress (PR: 1.34) and depression (PR: 2.02).
  • Age: Athletes aged 18–24 exhibited significantly higher anxiety (PR: 2.6) and depression (PR: 1.8) compared to those >34 years.
  • Academic Status: Athletes who were studying had significantly higher anxiety symptoms (PR: 2.04) compared to employed athletes.
  • Non-Significant Factors: No significant associations were found for area of residence, training hours, or years of participation.

Key Contributions
This paper provides the first empirical data on the prevalence of mental health symptoms among South African female athletes. Its primary contributions include:

1. Baseline Data: Establishing that psychological distress and disordered eating are highly prevalent in this population, with rates potentially exceeding those of the general South African female population for distress.
2. Risk Identification: Identifying specific risk indicators, namely recent injury, younger age (18–24), and academic commitments, which correlate with increased vulnerability to specific MHS.
3. Contextual Nuance: Highlighting that team sport athletes in this context may be at higher risk for anxiety than individual athletes, a finding that contrasts with some international literature suggesting individual athletes are more prone to MHS.
4. Methodological Adaptation: Demonstrating the utility of administering full SMHAT-1 batteries rather than stepwise screening in specific cultural contexts to avoid under-detection.

Significance and Claims
The authors position this study as a critical step toward understanding the mental health landscape of South African female athletes. They claim that the findings underscore the necessity for:

• Targeted Screening: The implementation of routine, athlete-centered mental health screenings across all sporting levels (elite and amateur) and disciplines.
• Context-Specific Interventions: The development of support services tailored to specific risk groups, such as student-athletes and those recovering from injury.
• Systemic Support: The integration of mental health professionals into high-performance teams and the establishment of referral pathways for amateur athletes who lack institutional support.
• Holistic Care: Addressing the intersection of physical injury and psychological well-being, as well as the normalization of restrictive eating behaviors in sporting environments.

The paper concludes that while the cross-sectional design limits causal inference, the identified correlates provide a foundation for future longitudinal research and the development of targeted prevention strategies to improve the well-being and performance of South African female athletes.