Abstract
Background:
Young adults report increased rates of anxiety and depression than other age groups. Furthermore, young adult athletes experience additional stressors that may negatively impact their mental health. The aim of this study was to investigate the prevalence of anxiety and depression symptoms among Division I collegiate athletes and the influences of sex, sport type, and distance from home.
Hypothesis:
It was hypothesized that self-reported levels of anxiety and depression would increase among this population during this timeframe.
Study Design:
Cross-sectional.
Level of Evidence:
Level 3.
Methods:
Participants included 792 incoming Division I collegiate athletes. The Generalized Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) scores were completed by all incoming student athletes at a single institution as part of their preparticipation examination over 5 years. Both survey scores were categorized into different levels of severity and separately compared with chi-square tests. Continuous scores were modeled separately using negative binomial regression models including year, sex, sport type, and home location as covariates.
Results:
Results showed consistent levels of anxiety and depression over time. Female athletes reported higher levels of both anxiety and depression than male athletes, and individual sport athletes reported higher levels of depression than team sport athletes. Distance from home was not associated with anxiety or depression levels.
Conclusion:
Overall, levels of anxiety and depression did not change in this population over this time period. However, differences in anxiety and depression were seen between sexes and depression between sport types.
Clinical Relevance:
Understanding anxiety and depression risk factors among collegiate athletes can enhance early identification and intervention to improve mental health and allow for better allocation of resources to at-risk groups among Division I collegiate athletes.
Keywords: GAD-7, mental health, PHQ-9
Adolescents and young adults in the United States are experiencing a mental health epidemic that began long before the COVID-19 pandemic. 3 Between 2007 and 2017, children and young adults experienced dramatic increases in suicide rates. 5 In addition, 18- to 25-year-olds have demonstrated the greatest increase in anxiety of any age-group in the last decade.3,7 Concurrently, depression among college-aged adults has also been on the rise, with prevalence rates reported as high as 21%. 23 Around this age, many young adults move from high school to college and feel the stressors related to this transition period. College students particularly internalize academic pressures, financial demands, sleep disturbances, and social networking, among other factors. 2
The National Collegiate Athletic Association (NCAA) has recognized the growing mental health concerns among collegiate athletes with the development of the Mental Health Task Force and Mental Health Best Practices.1,13 Among these best practices is screening for mental health issues. Nevertheless, rates of anxiety and depression among athletes remain poorly defined in the collegiate athlete population. Although 1 study found similar rates of anxiety disorders between collegiate athletes and nonathletes, athletes were less likely to seek treatment and mental illness is typically underreported in athletes due to stigmas in athletics. 21 In addition to the stressors that typical college students experience, including feelings of loneliness, homesickness, or financial burden,6,8,21 collegiate athletes internalize added stressors such as commitment to their team, performance, and injury concerns. 23 Furthermore, these factors may disproportionately affect athletes differently based on sex and sport-type. For example, female and individual sport athletes tend to report greater anxiety and depression than male and team sport athletes.2,14,22,23
Therefore, the purpose of this study was to quantify the changes in anxiety and depression outcome measures over 5 years among incoming NCAA Division I athletes. We hypothesized that anxiety and depression levels would increase among incoming student athletes each year, mirroring reported increases in this age group in the general population. In addition, a secondary aim of this study was to identify whether anxiety and depression were related to sex, sport type, or distance from home. We hypothesized that female athletes, individual sport athletes, and those farther from home would report greater anxiety and depression.
Methods
Subjects
Between 2017 and 2021, incoming athletes at a single Midwest, NCAA Division I institution were asked to complete surveys regarding demographic information, anxiety, and depression as part of their preparticipation examination. Preparticipation examinations occur once, before an athlete begins their career at the institution. This study was approved by the University of Wisconsin-Madison Health Sciences Institutional Review Board. Given the retrospective nature of the study, informed consent was not deemed necessary.
Outcome Measures
The Generalized Anxiety Disorder-7 (GAD-7) was used to quantify symptoms of anxiety and the Patient Health Questionnaire (PHQ-9) was used to quantify symptoms of depression. The GAD-7 is a 7-item measure of anxiety symptoms during the past 2 weeks that has been shown to be reliable and accurate among collegiate athletes for identifying generalized anxiety disorder. 20 GAD-7 scores were classified into 4 anxiety categories: 0 to 4, minimal; 5 to 9, mild; 10 to 14, moderate; and 15 to 21, severe. 19 The PHQ-9 is a 9-item measure of depressive symptoms during the past 2 weeks that has been validated in the general population 9 and has since been used in athletic populations to assess depression related to injury and changes in depression over time.4,11 The PHQ-9 has been shown to be reliable and accurate for identifying major depressive disorder in male and female adults ≥ 18 years. 9 The PHQ-9 has previously been used in collegiate athletes to determine depressive symptoms. 11 PHQ-9 scores were classified into 5 depression categories: 0 to 4, minimal; 5 to 9, mild; 10 to 14, moderate; 15 to 19, moderately severe; and 20 to 27, severe. 9
Procedures
Distance from home was defined as from the Midwest or not, such that home addresses from Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin were considered part of the Midwest. Team sports included basketball, American football, hockey, soccer, softball, and volleyball. Individual sport athletes were defined as those that can compete without another athlete other than the competitor, including cross country, golf, swimming, tennis, track, and wrestling. Survey results were included in the analysis if all of the following criteria were met: (1) the survey was completed during the preparticipation examination at the beginning of the athletic season, (2) the athlete was on 1 of the teams listed above, and (3) the preparticipation examination was completed between 2017 and 2021. Incomplete surveys were excluded.
Statistical Analysis
GAD-7 and PHQ-9 responses were grouped by academic year of survey completion (2017-2018, 2018-2019, 2019-2020, 2020-2021, 2021-2022), sex (male or female), sport type (individual or team), and home location (Midwest or not Midwest). Categorical outcomes were compared with chi-square tests. Separate negative binomial regression models using continuous scores were used to predict GAD-7 and PHQ-9 scores, including year, sex, sport type, and home location as covariates. Statistics were completed through R (Version 3.6.1). Significance level was set at alpha = 0.05 priori.
Results
Demographics
Survey responses from 792 athletes were included (Figure 1). There were no incomplete surveys identified. The distribution between academic years, sex, sport type, and distance from home are shown in Table 1.
Figure 1.
Survey responses from 792 athletes. (a) GAD-7 and (b) (PHQ-9) categories reported by incoming Division I collegiate athletes by year showing percentages in each category of all athletes’ responses included from that year. No athletes reported severe depression. GAD-7, Generalized Anxiety Disorder-7; PHQ-9, Patient Health Questionnaire-9; PPE, preparticipation examination.
Table 1.
Participant characteristics
| Year | Total | ||||||
|---|---|---|---|---|---|---|---|
| 2017-2018 | 2018-2019 | 2019-2020 | 2020-2021 | 2021-2022 | N | Percentage of total | |
| Total | 128 | 151 | 151 | 156 | 206 | 792 | |
| Sex | |||||||
| Female | 59 | 65 | 73 | 65 | 82 | 344 | 43.4 |
| Male | 69 | 86 | 78 | 91 | 124 | 448 | 56.6 |
| Sport | |||||||
| Individual | 51 | 77 | 67 | 66 | 70 | 331 | 41.8 |
| Team | 77 | 74 | 84 | 90 | 136 | 461 | 58.2 |
| Home location | |||||||
| Midwest | 94 | 110 | 99 | 100 | 156 | 559 | 70.6 |
| Non-Midwest | 34 | 41 | 52 | 56 | 50 | 233 | 29.4 |
Anxiety
Female athletes reported more severe levels of anxiety than male athletes (Table 2). There were no statistically significant differences in anxiety categories (minimal, mild, moderate, severe) between years, sex, or distance from home (Table 2). When analyzing GAD-7 scores as a continuous outcome in the fully adjusted model, female athletes reported a higher level of anxiety than male athletes, but no statistically significant associations were identified with respect to academic year, sport type, or home location (Table 3).
Table 2.
Differences in anxiety across academic year, sex, sport type, and home location among NCAA Division I collegiate athletes a
| GAD-7 | |||||
|---|---|---|---|---|---|
| Minimal | Mild | Moderate | Severe | P value | |
| Academic year | 0.06 | ||||
| 2017-2018 | 122 (95%) | 5 (4%) | 1 (1%) | 0 (0%) | |
| 2018-2019 | 142 (94%) | 7 (5%) | 2 (1%) | 0 (0%) | |
| 2019-2020 | 133 (88%) | 15 (10%) | 2 (1%) | 1 (1%) | |
| 2020-2021 | 146 (94%) | 5 (3%) | 3 (2%) | 2 (1%) | |
| 2021-2022 | 190 (92%) | 16 (8%) | 0 (0%) | 0 (0%) | |
| Sex | <0.01 | ||||
| Female | 301 (88%) | 34 (10%) | 7 (2%) | 2 (1%) | |
| Male | 432 (96%) | 14 (3%) | 1 (0%) | 1 (0%) | |
| Sport type | 0.08 | ||||
| Individual | 300 (91%) | 24 (8%) | 5 (2%) | 2 (1%) | |
| Team | 433 (94%) | 24 (5%) | 3 (1%) | 1 (0%) | |
| Home location | 0.56 | ||||
| Midwest | 518 (93%) | 34 (6%) | 6 (1%) | 1 (0%) | |
| Non-Midwest | 215 (92%) | 14 (6%) | 2 (1%) | 2 (1%) | |
GAD-7, Generalized Anxiety Disorder-7.
Chi-squared (and Fisher exact test where appropriate) results for categorical GAD-7 scoring.
Table 3.
Independent associations between anxiety (GAD-7 total score) and academic year, sport type, sex, and home location among NCAA Division I collegiate athletes a
| Estimate | Standard Error | P value | |
|---|---|---|---|
| 2018-2019 | 0.06 | 0.21 | 0.77 |
| 2019-2020 | 0.27 | 0.20 | 0.18 |
| 2020-2021 | 0.04 | 0.20 | 0.84 |
| 2021-2022 | 0.03 | 0.19 | 0.87 |
| Sport type (individual) | 0.001 | 0.13 | 1.00 |
| Sex (female) | -0.85 | 0.12 | <0.01 |
| Home location (Midwest) | 0.12 | 0.13 | 0.37 |
GAD-7, Generalized Anxiety Disorder-7; NCAA, National Collegiate Athletic Association.
Negative binomial regression results for continuous GAD-7 score.
Depression
Female and individual sport athletes reported more severe levels of depression than male and team sport athletes, respectively (Table 4). There were no statistically significant differences in depression categories between academic years or distance from home (Table 4). When analyzing depression as a continuous outcome in the full model, female athletes reported a higher level of depression, but no statistically significant associations were identified with respect to year, sport type, or home location (Table 5).
Table 4.
Differences in depression across academic year, sex, sport type, and home location among NCAA Division I collegiate athletes a
| PHQ9 | ||||||
|---|---|---|---|---|---|---|
| Minimal | Mild | Moderate | Moderately Severe | Severe | P value | |
| Across years | 0.20 | |||||
| 2017-2018 | 126 (98%) | 2 (2%) | 0 (0%) | 0 (0%) | 0 (0%) | |
| 2018-2019 | 144 (95%) | 6 (4%) | 1 (1%) | 0 (0%) | 0 (0%) | |
| 2019-2020 | 140 (93%) | 9 (6%) | 1 (1%) | 1 (1%) | 0 (0%) | |
| 2020-2021 | 152 (97%) | 4 (3%) | 0 (0%) | 0 (0%) | 0 (0%) | |
| 2021-2022 | 202 (98%) | 4 (2%) | 0 (0%) | 0 (0%) | 0 (0%) | |
| Sex | 0.01 | |||||
| Female | 324 (94%) | 17 (5%) | 2 (1%) | 1 (0%) | 0 (0%) | |
| Male | 440 (98%) | 8 (2%) | 0 (0%) | 0 (0%) | 0 (0%) | |
| Sport type | 0.01 | |||||
| Individual | 284 (94%) | 15 (5%) | 2 (1%) | 1 (0%) | 0 (0%) | |
| Team | 480 (98%) | 10 (2%) | 0 (0%) | 0 (0%) | 0 (0%) | |
| Location | 0.25 | |||||
| Midwest | 542 (97%) | 16 (3%) | 1 (0%) | 0 (0%) | 0 (0%) | |
| Non-Midwest | 222 (95%) | 9 (4%) | 1 (0%) | 1 (0%) | 0 (0%) | |
PHQ-9, Patient Health Questionnaire-9.
Chi-squared (and Fisher exact test where appropriate) results for categorical PHQ-9 scoring.
Table 5.
Independent associations between depression (PHQ-9 total score) and academic year, sport type, sex, and home location among NCAA Division I collegiate athletes
| Estimate | Standard Error | P value | |
|---|---|---|---|
| 2018-2019 | 0.02 | 0.20 | 0.90 |
| 2019-2020 | 0.30 | 0.20 | 0.13 |
| 2020-2021 | -0.30 | 0.20 | 0.15 |
| 2021-2022 | -0.19 | 0.19 | 0.32 |
| Sport type (individual) | -0.14 | 0.13 | 0.26 |
| Sex (female) | -0.44 | 0.12 | <0.01 |
| Home location (Midwest) | -0.19 | 0.13 | 0.14 |
NCAA, National Collegiate Athletic Association; PHQ-9, Patient Health Questionnaire-9.
Discussion
This study examined anxiety and depression levels among incoming NCAA Division I collegiate athletes during the course of 5 academic years leading up to, and including, the COVID-19 pandemic, as well as their associations with sex, sport type, and distance from home. We did not identify statistically different levels of anxiety and depression among incoming NCAA Division I collegiate athletes over the past 5 academic years. Given the increases that have been seen in this age-group in the general population,3,23 we hypothesized that anxiety and depression levels would increase during the study window.
Although our findings did not support our hypothesis, the inclusion of only first-year students may have had an effect on the results. Athletes completed this survey as they were about to transition to college. Incoming collegiate athletes in this study are representative of the benefits of high school athletics on anxiety and depression during this transition to college. The excitement of entering college athletics may overcome insecurities and trepidation of a new environment. Perhaps completing these surveys after fully integrating into their team, courses, and new living environment would show different results.
We found that female collegiate athletes demonstrated higher levels of anxiety and depression than male athletes. Specifically, 13% of female athletes reported mild-to-severe anxiety compared with 3% of male athletes, and 6% of female athletes reported mild-to-severe depression compared with 2% of male athletes. This agrees with a previous study looking at depression among collegiate athletes that found female athletes exhibited 1.8 times the risk of male athletes for experiencing depression symptoms. 22 Given this same-sex trend is seen in adolescent athletes, 12 the higher prevalence of mental illness among female collegiate athletes may begin in high school or earlier and continue into college. Therefore, mental health screening during the preparticipation examination may represent a vitally important means of identifying symptomatic persons to intervene in a timely manner during a period of significant potential stress.
We also found that individual sport athletes reported more mild-to-severe depression (6%) than athletes participating in team sports (2%). Previous research in adolescent athletes has suggested that athletes exclusively participating in individual sports may benefit from the physical activity sport involves but may not receive the same emotionally supportive relationships that team sports provide.14,22 This also agrees with previous evidence that college athletes participating in individual sports experienced more depression in their lifetime overall than team sport athletes. 16 Participation in sport is often sought out for social interaction, and team sports may facilitate the development of social skills more than individual sports do. 14 While the underlying mechanism is not clear from this current study, our findings nonetheless suggest that individual sport athletes may be at a relatively greater risk of anxiety and depression than team sport athletes. 14
Although home location did not appear to be associated with anxiety or depression in our study, this relationship may be more pronounced with greater distances from home than we evaluated. Previously, depression symptoms were reportedly higher in international college students than domestic college students, 2 while no difference was seen when comparing in- versus out-of-state student athletes. 23 Differentiating home location as in or outside of the region of our institution may not have incorporated a sufficiently large enough distance from home to identify this effect. Further research is warranted to determine whether greater degrees of travel to college are associated with depression and anxiety among incoming collegiate athletes.
We feel we cannot ignore the fact that the study period overlapped with the COVID-19 pandemic. Previous research in adolescent athletes during the COVID-19 pandemic showed an increase in depression and a decrease in quality of life compared with the years before the pandemic. 10 Unfortunately, when sport participation was halted in the spring of 2020, most athletes lost access to the facilities, equipment, and coaching staff provided through their sport participation for continued training. In particular, graduating high school athletes experienced an abrupt end to their high school athletic careers, and may have had even greater levels of uncertainty around their future as an athlete. The uncertainty associated with the ambiguity of the timing of return to sport participation, and the impact on ability to participate at the collegiate level, could have had a negative effect on mental health for incoming collegiate athletes. Nonetheless, little is known about whether, or how, mental health among incoming collegiate athletes changed during COVID-19. although it was hypothesized anxiety and depression levels would increase among incoming student athletes each year, one might predict a disproportionate increase at the onset of the COVID-19 pandemic. This was not the case however. There were no statistically significant differences in anxiety or depression categories between years. Some have found that sport participation during COVID-19 was associated with significant psychosocial and mental health benefits among adolescents.10,17 Similarly, sport participation has been positively associated with better general mental health in the collegiate population.15,18 This may have temporarily decreased the prevalence of anxiety and depression, particularly in 2020 and 2021 as this could have been the athlete’s first time emerging from COVID-19 lockdowns. The anticipation of potential normalcy because of a hopeful return to sport and structure possibly influenced these results. The class entering college during the pandemic had no reference of how their college experience may be influenced by changes brought on by the pandemic.
This study has several limitations. As above, our categorization of distance from home may not have fully captured differences in the underlying influences on mental health that may vary between students traveling different distances to school, such as access to emotional support, familial resources, or social relationships. Factors influencing anxiety and depression that differed between groups or over time but were not included in our analysis, such as race, socioeconomic status, or scholarship status, may have influenced our results. In addition, our data collection did not allow us to determine whether athletes knew of their competition status for the upcoming season during the COVID-19 pandemic. Many collegiate sports seasons or competitions were canceled due to the COVID-19 pandemic during the study duration, and athlete awareness of cancellations may have impacted the results differently for different groups of athletes and we are unable to account for this. Finally, this study included incoming NCAA Division I collegiate athletes only and therefore may not be generalizable to other age groups or athletes participating at different competition levels.
Conclusion
Anxiety and depression among incoming NCAA Division I collegiate athletes remained stable from 2017 to 2021, despite increases among the general population before and during the COVID-19 pandemic. Female athletes reported higher levels of anxiety and depression than male athletes. Individual sport athletes reported higher levels of depression than team sport athletes. Geographic distance from home did not appear to influence anxiety or depression scores in this population. Understanding the risk factors for anxiety and depression can help identify persons at risk to facilitate early intervention to improve mental health among collegiate athletes.
Acknowledgments
The authors would like to acknowledge Stephanie Kliethermes, PhD, for statistical consultation and the Sports Medicine staff at the University of Wisconsin-Madison Division of Intercollegiate Athletics for their commitment to the welfare of the student-athletes and contributions to the Badger Athletic Performance program.
Footnotes
The authors report no potential conflicts of interest in the development and publication of this article.
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