Mental health matters: a cross-sectional survey on depression and anxiety symptoms and the Female and Male Athlete Triad

Emily M. Olson, Emily Miro, Megan Roche, Shayna Mehta, Kristin Sainani, Emily Kraus

Clinical Journal of Sport Medicine. 2023; 33(4): 368-375.

Background: While eating disorders and disordered eating (ED/DE) are known to occur concurrently with anxiety and depression, the association between anxiety or depression and Triad Cumulative Risk Assessment (CRA) score, which includes ED/DE and clinical outcomes of low EA, have not been reported.

Purpose: This study evaluated associations between the Female and Male Athlete Triad-related outcomes and depression/anxiety in high school, collegiate and post-collegiate athletes.

Methods: A total of 1,034 (n= 254 men; n= 780 women) males and females participating in at least 7 hours of sport per week, completed a web-based survey evaluating Female and Male Athlete Triad components, disordered eating/eating disorders, injury, anxiety and depression. Participants were recreational, competitive and professional athletes ranging in age from 14 to 71 years (mean ages of 33.1 and 28.8 years for male and female participants). Items from the Female Athlete Triad Screening Questionnaire (FAST), the Eating Disorder Examination Questionnaire (EDEQ) and the Patient-Reported Outcomes Measurement Information System (PROMIS) were used for the study assessments. Primary outcomes the included Female Athlete Triad cumulative risk score (low, moderate, or high risk), age at menarche, menstrual function in the past year (i.e. eumenorrhea, oligomenorrhea, or amenorrhea), BMI (normal or low BMI according to CDC criteria), energy availability as evaluated by the EDE-Q dietary restrain subscale, pathological behaviors or self-reported eating disorder history, and bone stress injury history. The Male CRA score excluded items referencing menstrual function or age at menarche. The statistical analyses involved evaluating associations between the Triad Cumulative Risk and self-reported anxiety or depression. Multinomial logistic regression analyses evaluated associations between the Triad CRA score and outcomes of mild, moderate, or severe depression or anxiety. Separate models were conducted for male and female athletes; each model was adjusted for age.

Results: Among the 1,034 participants, a majority identified their primary sport-type as endurance (83.1% of females and 56.1% of males). More female compared to male athletes reported mild, moderate, or severe anxiety (66.7% vs. 41.3%) and depression (54.2% vs. 38.7%). In females, the prevalence of moderate and severe depression and anxiety symptoms significantly increased with Triad CRA score. Additionally, female athletes meeting criteria for severe depression or severe anxiety exhibited significantly higher Triad CRA scores as compared to the reference group (severe vs. no depression Triad CRA score= 3.9 ± 2.3 vs. 2.0 ± 1.9, p<0.001; severe vs. no anxiety Triad CRA score= 3.6 ± 2.3 vs. 2.1 ± 1.9, p< 0.001). In male participants, no associations were observed between Triad CRA score and anxiety and depression. Low EA, menarche, and oligomenorrhea risk scores per week were significantly higher in female participants with severe depression and severe anxiety scores (vs. those categorized with no anxiety or depression).

Conclusions: This is the first study to demonstrate a higher prevalence of depression and anxiety symptoms in female athletes with elevated Triad risk. These findings support the importance of considering mental health treatment and related support resources for in athletes with or at risk for the Triad.

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