Article Text
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Abstract
Objective To identify, quantify and analyse determinants of depression, anxiety and stress symptoms among female student-athletes.
Design Systematic review and meta-analysis.
Data sources Five online databases (PubMed, CINAHL, PsychInfo, SportDiscus and Web of Science) searched from inception through 14 September 2023. Hand-searches and contacting authors for eligible studies.
Eligibility criteria for selecting studies Articles were included if they were published in English, included female student-athletes competing at National Collegiate Athletic Association institutions, and measured symptom-level depression, anxiety and/or stress.
Results and summary We screened 2415 articles; 52 studies (N=13 849) were included in the systematic review with 13 studies qualifying for meta-analysis. Seventeen determinants were identified including injury (eg, concussions), health (eg, sleep hygiene) and social factors (eg, social support). As data specific to female student-athletes was delineated from studies that included other populations, we observed 16 studies (30.7%) reported that identifying as female was a meaningful determinant of depression, anxiety and stress in athletes. Results of the meta-analysis (k=13, N=5004) suggested a small but significant association (r=0.15, 95% CI 0.05 to 0.24, p=0.004) between other determinants and depression, anxiety, and stress among female student-athletes.
Conclusion Coaches, trainers and clinicians are key contributors in supporting female student-athlete mental health, with responsibilities for integrating mental skill training, sleep hygiene education and regular assessments. Comprehensive mental health and tailored education programmes considering determinants such as injury, health and social factors specific to female student-athletes are needed to enhance mental health equity in sport.
PROSPERO registration number CRD42022362163.
- Athletes
- Female
- Anxiety
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Participation in women’s collegiate sports at the National Collegiate Athletic Association level in the USA has significantly risen since the enactment of Title IX, and though research in this area began to increase in the late 1980s, there has yet to be a comprehensive review examining prevalent mental health outcomes, such as depression, anxiety and stress, among female student-athletes.
WHAT THIS STUDY ADDS
The systematic review (N=13 849) identified 76 determinants (ie, influencing factors and variables) of depression, anxiety and stress among female-student athletes into 17 novel themes led by biological sex (eg, being a female student-athlete), health (eg, sleep, diet/eating patterns, alcohol use) and support (eg, social connection, social support, social interactions).
The meta-analysis (k=13, N=5004) revealed a significant relationship between determinants such as injury/concussion, lack of sleep, COVID-19 and lack of social support with higher levels of depression, anxiety and stress among female student-athletes, elucidating the need for proactive assessments (ie, Sport Mental Health Assessment Tool 1 and Sport Mental Health Recognition Tool 1) and timely referrals for athletes at risk for or already experiencing mental health symptoms and disorders.
This comprehensive review of 52 studies provides synthesised data for informed collaborations and decision-making among female student-athletes, coaches, clinicians and trainers in establishing a supportive environment that promotes mental health through the implementation of thorough mental health initiatives, such as educating on mental skills and sleep hygiene, encouraging open communication, conducting regular mental health assessments, providing specialised care and eliminating the stigma surrounding mental health.
Introduction
The enactment of Title IX in 1972 marked a pivotal moment for women’s involvement in collegiate sports at the National Collegiate Athletic Association (NCAA) level in the USA. Title IX was groundbreaking legislation that mandated gender equality in educational programmes, including sports.1 Title IX has fundamentally reshaped the landscape of collegiate athletics by necessitating that women had equal opportunities to participate in sports programmes, thus extending opportunities traditionally afforded to men’s teams. Over the past five decades since the passing of Title IX, there has been a notable sixfold increase in the number of women participating in collegiate sports in the USA, resulting in an estimated quarter million female student-athletes participating in the NCAA annually.2
Though interest and involvement in women’s sport has increased significantly, research focused on understanding the specific and unique factors associated with female student-athletes mental health has been limited. This gap in knowledge is particularly concerning in light of recent findings that underscore a persistent gender disparity in sport and exercise science research. A study published in 2021 illuminated a stark inequality: only 6% of studies in the field included female-only participants, while 31% of studies focused exclusively on male participants.3 This disparity in research representation raises critical questions about the understanding of female student-athletes’ experiences and needs, particularly in the realms of mental health and well-being.
There is growing concern in the field of sport and exercise science regarding the increased prevalence of depression, anxiety and stress among athletes with fundamental reviews and meta-analyses focused primarily on high-performance4 5 and elite athletes.6–9 Additionally, while there is emerging interest in including and studying female athlete mental health, to our knowledge, there has only been one prior review published.10 This scoping review emphasised the current state of the literature focuses on eating disorders and disordered eating prevalence rates among elite female athletes and did not delve into prevalent mental health outcomes, including depression, anxiety and stress. Though there is a consensus regarding the importance of mental health for athletes,4–9 evidence indicating female athletes report higher instances of anxiety and depression,6 8 9 and evidence to support female student-athletes reporting higher symptom of depression, anxiety and stress,11–26 there is an under-representation of research specific to female athletes and lack of synthesised data for informed decision-making for this important athlete population.
Research on depression, anxiety and stress among female student-athletes is crucial not only due to the impact on their overall mental health and well-being27 but also the influence on their athletic performance and participation.22 28 According to the Diagnostic and Statical Manual of Mental Disorders, Fifth Edition (DSM-5),29 the classification and codification system for mental health disorders widely used by mental health professionals in the USA, anxiety is characterised by excessive worry, fear and distress that significantly interferes with a person’s daily life. Depression is characterised by persistent and severe symptoms of low mood, sadness and loss of interest or pleasure in most activities. While there is not a specific diagnosis for stress in the DSM-5, the WHO defines stress as a natural human response that can be characterised by a state of worry or mental tension in response to a difficult situation.30 As these mental health outcomes have direct implications for how female student-athletes influence and are influenced by their teams, coaches and institutions, a comprehensive understanding of what determines depression, anxiety and stress among female student-athletes is critical foundation for evidence-informed clinical practices (ie, targeted interventions) that foster healthier athletes and more successful sports programmes.
This study aims to provide a comprehensive systematic review and meta-analysis of the determinants (ie, the influencing factors and variables) of prevalent mental health outcomes, including depression, anxiety and stress, among female-student athletes. Our primary objective is to identify, quantify and analyse these determinants of depression, anxiety and stress symptoms among female student-athletes within NCAA institutions. We hope insights from this research will directly inform evidence-based decisions, benefiting sports programmes, coaches, trainers and clinicians in their treatment and care approaches, which ultimately benefit female student-athlete mental health and well-being.
Methods
This study adhered to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines,31 ensuring transparency and comprehensive reporting. Two reviewers (authors LB and MJ) independently conducted all aspects of study selection, appraisal and review (κ=0.53, indicating moderate inter-rater agreement).32 Discrepancies were reviewed and determined at each step independently by author PH. This study was registered with PROSPERO on 10 March 2022.
Ethical approval was not required due to the nature of our study, which involved synthesising and analysing existing data without direct involvement with human subjects, interventions or sensitive information. Our institutional policies exempt such studies from formal approval when they analyse data from previously published studies without new data collection. This exemption is based on the understanding that primary ethical considerations, like obtaining informed consent and ensuring participant welfare, were addressed by the original studies included in our review.
Search strategy
A systematic search strategy was established between the lead researcher and a team of experienced academic librarians specialising in health science systematic reviews and meta-analyses. Five online databases (PubMed, CINAHL, PsychInfo, SportDiscus and Web of Science) were selected to maximise sensitivity and precision. Databases were searched from inception through 14 September 2023 to identify eligible citations. The search strategy including MeSH terms is provided in online supplemental table 1. Hand searching of citations from included studies from the database searches was completed from study inception through 20 September 2023.
Supplemental material
Study inclusion
Studies were included in the systematic review if they (a) published data on female student-athletes; (b) included a symptomatic or diagnostic anxiety or depression outcome measure based on the DSM-529; (c) included stress as an outcome measure based on reliable and validated measures among student-athletes; (d) were based in the US at an NCAA institution; (e) were published in English; (f) had a mean age greater than 18 years old. Quantitative data on female student-athletes either published or requested on study selection were required for inclusion in the meta-analysis.
Study exclusion
Studies were excluded if they were (a) non-peer-reviewed journal articles (including conference abstracts, theses and dissertations); (b) review/secondary data analysis articles; (c) case study or case reports; (d) focused solely on non-clinical anxiety symptoms or diagnoses (ie, competitive sport anxiety); (e) not published in English or (f) not student-athletes based in NCAA institutions within the US.
Study selection
The database search yielded 2936 citations along with 104 citations identified through Google Scholar and citation searching, totaling 3040 citations. Citations were imported to Covidence,33 an online software programme for managing systematic reviews. After the removal of duplicates, 2415 articles were screened with 239 assessed for eligibility. Fifty-two studies were selected for the systematic review and 13 studies contained the requisite information for inclusion in the meta-analysis. See figure 1 and online supplemental table 1—see Methods section for full details.
PRISMA 2020 flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses.
Assessment of study quality
Study quality was assessed with the Joanna Briggs Institute’s (JBI) critical appraisal tools for systematic reviews.34–36 JBI assessments were chosen based on their aim to provide a comprehensive and unbiased synthesis of relevant studies through rigorous and transparent methods.37 JBI assessments include validated appraisal checklists for different study designs with questions pertaining to design quality, analysis and reporting. Each question can be answered with yes, no, unclear, not reported or not applicable response. Only ‘yes’ responses contribute to the summed score, which is divided by the number of total questions to provide a proportion. Higher proportions (above 70%) on all checklists are equated with higher quality studies and low risk of bias.34–36 No studies were excluded from the systematic review or meta-analysis based on these findings.
Data extraction
Data were extracted from Covidence into a standard Excel template designed by the research team. The template included authors; title; journal; DOI; year; purpose; study design; NCAA division (I, II, III); measure of depression, anxiety and/or stress; age; percent freshman; number of female participants; percent female; percent white; number of teams/sports included; determinants; outcome of depression, anxiety, and/or stress; main depression, anxiety, and stress findings. LB independently completed the data extraction and created determinant themes. PH independently reviewed all articles for consistency.
Data analysis (meta-analysis)
Pearson’s r was used as a measure of effect size to reflect the correlation between various predictors of mental health (eg, social support, COVID-19) and mental health outcomes in female student-athletes. The extensive heterogeneity and non-overlapping nature of the antecedents precluded a single uniform predictor in the meta-analysis. To address this issue, all study predictors were grouped and recoded to reflect a single variable for the meta-analysis (ie, negative predictors). Predictors like injury/concussion, lack of sleep and COVID-19 were initially identified as potentially negative antecedents while predictors like social support, HS-Omega and being ‘in-season’ were identified as potentially positive antecedents. Positive predictors were reverse coded such that correlation coefficients indicated the relation between negative predictors and higher levels of depression, anxiety and/or stress.
Correlation coefficients were Fisher’s z transformed to un-bias effect sizes and 95% CIs were calculated. Due to the heterogeneity in the nature and design of the studies included in the meta-analysis, a random-effects model was employed. All analyses were conducted in JAMOVI.38
Interpretation of forest plots
Forest plots are visual summarisations of data from multiple papers with the effect size for each study depicted by squares and the overall estimated effect size represented by a diamond.39
Heterogeneity and publication bias/risk of bias
Heterogeneity of effect sizes was tested using the Q statistic distribution with k-1 df. Publication bias was examined using the Fail-Safe N, funnel plot and Egger’s regression.40
Equity, diversity and inclusion statement
Our authorship team is committed to promoting equity, diversity and inclusion within our research. We prioritised gender balance and achieved representation with two men and two women. One of our authors also identifies as a woman of colour with a disability, bringing valuable perspectives to our study. Our team comprises individuals from different stages of their academic careers, including an undergraduate student, a graduate student and two mid-career researchers in psychology, education and health sciences. While our study focuses on NCAA institutions in the USA, our goal is to illuminate the experiences of female student-athletes from diverse backgrounds. Our findings hope to contribute to the development of inclusive support systems that address their unique needs and promote their overall mental health and well-being.
Results
Description of included studies
Out of the 2415 articles that we screened, only two were published prior to 1973, the enactment of Title IX. One of these articles concentrated on personality without delving into depression, anxiety or stress.41 The second article, a thesis comparing achievement motive and anxiety, was excluded because it did not address determinants of anxiety.42 The 52 articles included for analysis were published between 1989 and 2023. There was a sharp increase in publications over the past two decades with 50 studies (96.2%) published between 2002 and 2023, 39 studies (75%) published between 2012 and 2023 and 27 studies (51.9%) published between 2018 and 2023. There has been a marked increase in research on female student-athletes since Title IX . Majority of the studies sampled Division I student-athletes (44 studies) with 11 studies including Division II student-athletes and 15 studies including Division III student-athletes. Eleven studies included multiple divisions in analysis with only one study excluding Division I student-athletes.43 The sample was primarily female (N=13 849; 56.3%), White/Caucasian (72.6%) and between 18 and 27 years old (Mage=20.3). See online supplemental tables 2 and 3 for a full summary of included study characteristics and findings.
Narrative results
Of the 52 studies, 18 explored depression only, 18 explored depression and anxiety, six explored anxiety only, four explored all three (depression, anxiety and stress), three explored stress only and three explored depression and stress. Overall, the outcome of interest was primarily depression (43 studies) followed by anxiety (28 studies) and stress (10 studies).
The primary measures of depression were the Center for Epidemiological Studies Depression Scale (13 studies), Beck Depression Inventory (eight studies) and Depression Anxiety Stress Scale-21 (three studies). The primary measures of anxiety were the State-Trait Anxiety Inventory (13 studies), Beck Anxiety Inventory (five studies) and Generalized Anxiety Disorder (GAD-7) Scale (five studies). The primary stress scales were the Perceived Stress Scale (six studies), Depression, Anxiety Stress Scale 21 (3 studies) and Stress Response Scale for Athletes (one study). Regarding study design, most studies were cross-sectional (27 studies), followed by cohort (20 studies), quasi-experimental (three studies), case–control (one study) and randomised control trial (one study).
Seventy-six determinants were identified and categorised into 17 determinant themes: biological sex (16 studies); health (12 studies); support (11 studies); injury (10 studies); sport (five studies); season (four studies); intervention (four studies); training volume (four studies); academic year (four studies); COVID-19 (three studies); religion (two studies); NCAA division (two studies); race (two studies); athlete identity (one study); anxiety (one study); self-esteem (one study); self-compassion (one study); resilience (one study); being an athlete (one study). The 13 determinant themes with two or more studies included are described in detail.
Systematic review
Biological sex
While this review aimed to understand determinants specific to female student-athletes, it is important to note that identifying as female, specifically a female student-athlete, was one of the leading reported determinants for increased depression, anxiety and stress in 16 articles.11–26 Identifying as female was associated with increased depression in 14 articles,11–23 25 increased anxiety in seven articles14 17 18 20 23 24 26 and increased stress in four articles.14 16 18 25 Moreover, female student-athletes reported a greater number of depression and anxiety diagnoses than their male counterparts.14 One study reported female student-athletes compared with male student-athletes had a 1.32 greater odds of experiencing symptoms of depression.22 Another study reported female athletes presented 1.84 times the risk of male athletes for endorsing clinically relevant depression symptoms.21 Regarding anxiety, one study reported female student-athletes were almost three times more likely than their male counterparts to endorse some level of anxiety.24
Health
Twelve articles addressed a range of health characteristics as determinants of depression, anxiety and stress.11–13 44–52 Subthemes for health included sleep,11 12 51 diet/eating patterns13 44 45 and alcohol use45 48 as well as myriad of unique health-related determinants.
Increased quality of sleep including increased days per week of rested sleep and decreased sleep dysfunction was related to decreased depression.11 12 Furthermore, in one study, female athletes reported poorer sleep quality which was linked to significantly higher levels of reported depression.12 Lack of sleep was also linked with increased stress.51
When exploring the impact of diet/eating patterns, there was a range of results. Two studies indicated problematic eating patterns were linked to increased depression among female student-athletes.13 45 However, another study indicated that higher diet quality was associated with higher levels of stress among female student-athletes.44
Among the two studies that explored alcohol as a determinant, the ranges differed. One study noted alcohol abuse and increased alcohol use was associated with increased depression and anxiety,48 while the other noted that less frequent alcohol use was associated with higher anxiety and depression among female student-athletes.45
Furthermore, increased depression among female student-athletes was linked with a range of health-related determinants including higher reports of coeliac disease and symptoms,11 lower serum vitamin D and ferritin50 and salivary cortisol during overtraining.49 Increased anxiety was linked with a range of health-related determinants including lower blood levels of HS-Omega-3 index,52 lower dietary intakes of eicosapentaenoic and docosahexaenoic acid,52 growth of oral bacteria on blood agar and mitis salivarius agar during in-season46 and growth of blood agar during off-season.46 Increased stress among female student-athletes was linked to coeliac disease.11
Support
Eleven articles studied the relationship between various types of support and depression, anxiety and stress.11 19 43 51 53–59 Depression symptoms decreased with diverse reports of support including increased social connection,11 satisfaction with social support received55 including one study focused on satisfaction of social support received by athletic trainers,57 social support from family and friends,59 positive teammate social interactions and greater perceived support,43 stronger coach-athlete relationships54 and perceived tangible support from personal and athletic sources.56 One study differentiated receiving and providing social support reporting both were associated with decreased depression among female student-athletes.53 Another study differentiated between social support from family or friends, finding in both cases inverse relationships between receiving social support and depression and perceived stress.59 Increased satisfaction with social support55 including social support received by an athletic trainer57 and increased perceived social support58 were associated with decreased anxiety symptoms. One study also noted that conflict with a romantic partner’s family was associated with increased stress.51 Finally, one study reported that the level of support varied by sex and athletic status with female student-athletes reporting less support than male athletes and female non-athletes, which was associated with increased reports of social anxiety and depressive symptoms.19
Injury
Ten articles addressed injuries including concussion, musculoskeletal and orthopaedic as determinants of depression, anxiety and stress,15 17 58 60–66 with a majority (six studies) focused on concussions.17 61–63 65 66 In general, studies reported depression decreased with time since injury15 60 61 66 though one study did not notice a difference in depression based on time.64
Among the studies that reported time as a determinant for depression, there were nuances to the timeline among concussed student-athletes with studies reporting acute increases in depression symptoms reported within 48 hours,62 66 persistent increases in depression symptoms reported 1 week15 61 through 6-month postconcussion,15 and, contrarily, decreases in depression from 1 week to 1-month postconcussion63 as well as 6 months later.66 Study-reported determinants associated with injury and depression included missed practices and competitions,15 baseline depression and postconcussion symptoms,61 63 65 estimated premorbid intelligence,65 age of first participation in organised sport,65 and prior concussion history.66
Findings were less clear with respect to anxiety. Two studies reported a relationship between time since injury and decreased anxiety.61 66 However, another study reported no relationship between time and anxiety.64 In addition, one study related there was not a relationship between anxiety and injury type.58 While another study elucidated a sex-by-concussion history interaction, thereby females with a concussion history reported significantly higher anxiety than men.17
Sport type
Five studies explored the relationship between sport type and depression, anxiety and stress.16 20 21 24 26 One study among Division I student-athletes found the highest depression prevalence in track and field student-athletes (35.4%) and the lowest in lacrosse student-athletes (13.5%), with notable differences when factoring sex.21 Female track and field athletes expressed the highest depression symptoms.21 One study among female Division III student-athletes reported those on an individual sport team were three times more likely than those on a team sport to report mild to severe anxiety.24 The same study noted that female team sport student-athletes were 2.449 times more likely to report anxiety than male individual sport student-athletes. Alternatively, no differences in depression, anxiety and stress due to sport type were found in three different studies including two studies among Division I and II student-athletes16 26 and a study among Division III student-athletes.20
Season of play
Three articles examined the relationship between seasons (ie, on- or off-, pre- or post-) and depression and anxiety15 46 50 and one study explored the positive relationship between depression and seasonal affect disorder.58 Among the studies exploring on- vs off-seasons for training/competition, being in the off-season was related to decreased depression15 but increased anxiety.46 Authors suggested these findings may be associated with health-related factors (ie, microbiota distinctions)46 in seasons. Furthermore, postseason distinct from off-season was also associated with increased depression with links to varying levels of preseason and postseason vitamin D and ferritin.50
Interventions
Four studies explored the relationship between interventions and anxiety or stress.67–70 Interventions that improved anxiety included teaching student-athletes how to use mental skills during performance and in other domains of life,68 mindfulness-acceptance-commitment69 and specific exercise types including ergometry.70 Additionally, perceived stress decreased as a result of a mindfulness intervention.67
Training volume
Four studies explored the impact of training volume on depression, anxiety and stress.49 71–73 One study found the relationship between training volume and depression was not significant.72 While another study noted from peak training to taper (a decrease in training volume), there was a decrease in depression scores moderated by trait anxiety levels.73 Additionally, overtraining among swimmers was associated with increased depression, which was able to return to baseline following a taper phase.49 Finally, with respect to continuing to train during the COVID-19 pandemic, in one study, Division III female student-athletes reported increased stress compared with their male counterparts during stay-at-home mandates.71
Academic year
Four studies explored academic class by depression and anxiety.15 22 26 58 Three of those studies identified associations between a student-athlete’s academic class and depression,15 22 58 while one study did not find a significant difference in depression risk and academic status.26 In the studies that found an association, increased depression was associated with being a freshman student-athlete.15 22 58 One study reported freshman had 3.27 greater odds of reporting symptoms of depression than their more senior counterparts.22 Contrarily, in the study that did not find an association, they noted sophomores and juniors reported the highest depression risk.26 Furthermore, that study was also the only one to explore academic status with anxiety and did not find a significant association.26
COVID-19
While a number of studies discussed the COVID-19 pandemic, only three studies explored COVID-19 in relation to depression and anxiety.18 23 74 One study among Division III student-athletes illuminated the lack of resources and absence of available facilities to train for sport was associated with increased anxiety, with female student-athletes more likely to express worry for the future during the COVID-19 pandemic.74 In contrast, in another study Division I student-athletes reported lower anxiety scores after the fall sport postponement due to the COVID-19 pandemic compared with prior.18 Additionally, one study reported female student-athletes who had previously tested COVID-19 positive reported the worst anxiety measures compared with female student-athletes who did not have a COVID-19 history and male student-athletes with or without a COVID-19 history.23
Religion
Two articles from the same lab in the early 2000s explored the relationship of religion on depression and anxiety.75 76 While religious faith was not associated with depression or trait anxiety,75 76 when controlling for gender, intrinsic religiosity was associated with depression symptoms.76
NCAA Division (I, II, III)
While most of studies exclusively sampled Division I student-athletes (34 studies; 65.4%), two studies did report differences in depression, anxiety and stress related to NCAA division status.14 71 One study found Division I student-athletes endorsed greater depression and anxiety symptoms compared with Division III student-athletes while division II student-athletes did not differ from Division I or III student-athletes.14 Another study found Division III student-athletes reported higher levels of stress compared with Division I student-athletes in response to the COVID-19 pandemic stay at home orders.71
Race
Two studies reported the associations between race and depression, anxiety and stress.14 77 One study specifically explored Asian-identified student-athletes with Asian-identified non-student athletes and found athlete status moderated the association of discrimination and depression and anxiety.77 Among Asian-identified student-athletes, above-average hours of exercise buffered the relationship between increased discrimination and increased depression.77 Moreover, while there was a positive correlation between discrimination and anxiety regardless of exercise amount, the relationship was steeper for below-average exercisers.77 Additionally, another study found that while there was no difference in anxiety or depression diagnoses, student-athletes of colour endorsed higher stress than white student-athlete counterparts.14
Meta-analysis
Of the 52 articles included in the systematic review, 13 (N=5004) studies were included for the meta-analysis based on responses from leading authors and inclusion of necessary data (see online supplemental table 1 —Methods). The random-effects model using the Fisher r to Z transformed correlation coefficient revealed a small (r=0.15, 95% CI 0.05 to 0.24) but significant (Z=2.86, p=0.004) association between determinants and mental health outcomes among female student-athletes. See figure 2.
Forest plot of effect sizes included in the meta-analysis. RE, random effects.
The random-effects model also suggested significant variability in effect sizes, Q 12=38.84, p<0.001, τ²=0.02, I²=77%) and a 95% prediction interval ranging from −0.16 to 0.45. According to the Cook’s distances, only one study44 could be considered an outlier, but neither the rank correlation (p=0.590) nor Egger’s regression test (p=0.839) indicated significant funnel plot asymmetry.
Due to the significant heterogeneity in effect sizes, we conducted a series of random-effects moderator analyses based on the systematic review determinant theme categories (eg, NCAA division (I, II, III), sport, determinant (eg, health, injury, COVID-19, intervention), valence of determinant (eg, positive, negative), and outcome measure (eg, depression, anxiety, stress)).
NCAA division, sport, determinant and valence of determinant were not significant moderators of the effect sizes of the relation between determinants and mental health outcomes (ps >0.05). See online supplemental figures 1–3. Only outcome measure (p=0.019) was a significant moderator. Studies that measured anxiety (r=0.23, p<0.01) and depression (r=0.22, p=0.003) had a significant moderate association while those that measured stress/combined outcomes had small, null effects (r=0.004, p=0.954). See figure 3.
Supplemental material
Significant moderation by outcome measure.
Publication bias
To obtain an indicator of possible publication bias, a Fail-Safe N was calculated. Results suggested that to fail to reject the null hypothesis of a null effect, an additional 302 studies with null results would be needed. Rosenthal78 suggests comparing this number with a tolerance level of 5k+10 where k indicates the number of studies included.78 In this case, the ad-hoc tolerance level was 385. Since the Fail-Safe N was less than 385, bias may be an issue. Conversely, the funnel plot showed greater sample sizes falling near the middle (and in fact, near the average overall effect size) of the distribution. While funnel plots cannot rule out publication bias, the funnel shape, paired with Egger’s regression, suggest systematic bias is unlikely. See figure 4.79
SE funnel plot.
Quality appraisal (risk of bias)
For the full quality appraisal, see online supplemental tables 4–9. The appraisal score measured as a proportion for all studies was 0.86, thus the overall risk of bias based on JBI assessment was low. Twenty-six articles were high quality with a score of 0.8 or above and 26 articles were of moderate quality with a score of 0.5–0.79. No articles were of poor quality, and no articles were excluded from the systematic review or meta-analysis based on these findings.
Discussion
This study illuminated the sharp increase in mental health and well-being research among female student-athletes with over 37 included studies (71.2%) published in the past decade. Included studies ranged from 1989 to 2023, underscoring an increase in research on depression, anxiety and stress among female student-athletes following the enactment of Title IX. The systematic review identified 76 determinants categorised into 17 novel themes led by biological sex (eg, being a female student-athlete), health (eg, sleep, diet/eating patterns and alcohol use) and support determinants (eg, social connection, social support and social interactions). As depression emerged as the most extensively studied mental health outcome (43 studies; 82.7%), our findings illuminated the need for research focused on anxiety and stress among female student-athletes. While our study aimed to identify determinants specific to female student-athletes, our findings aligned with the current state of the literature highlighting that identifying as female is a significant predictor of depression, anxiety and stress.6 8 9 12 14 15 18 19 21–26 This underscores the importance of researching female student-athletes given their predisposition for adverse mental health outcomes.
Moreover, this study provides critical synthesis that can inform evidence-based treatment and care provided by sports programmes, coaches, trainers and clinicians who work with female student-athletes. Beyond the rich and detailed analysis within the results section aimed to catalyse future research, several practical applications emerged from the data that merit highlighting for enhanced treatment and care. These applications are subdivided by various roles in efforts to provide clear and specific guidance. The calls to action, though specific to roles, do not cover all of the study’s findings and should be integrated into a collaborative care model designed to enhance the mental health and well-being of female student-athletes.
Given the overwhelming reports of higher prevalence and rates of depression, anxiety and stress among female student-athletes,12 14 15 18 19 21–26 sports programmes could counteract and proactively care for this significant burden with the development of comprehensive mental health programmes within sports organisations that ensure mental health and well-being is a priority. Sports programmes could utilise data insights from this study, such as the biological sex and health-related determinants, to create tailored education programmes to support athlete mental health and well-being. Additionally, administrators and staff within a sport organisation could establish continuous data collection and monitoring to better understand the causality between various determinants and female student-athletes reports of depression, anxiety and stress. Through data-driven approaches, sports programmes would be better able to discern the needs of their programmes and understand the overlapping factors such as NCAA division, athlete race and academic year among their female student-athletes.
As NCAA coaches are allotted a maximum of 20 structured hours per week for athletic activities for their student-athletes,80 they have a vital role in the prioritisation of mental health and well-being in their teams. Coaches that acknowledge and attend to the increased vulnerability of female student-athletes to depression, anxiety and stress could incorporate activities such as mental skills training and sleep hygiene psychoeducation into their athletic programing to provide valuable resources for their athletes.11 12 68 Furthermore, coaches are foundational in supporting their athlete’s mental health27 and can enhance their athlete’s mental health by prioritising collaborations and facilitating time and space for their athletes to work with athletic trainers and sports psychologist through direct hour allotments. Furthermore, their creation of environments and support systems that destigmatise mental health outcomes could be impactful in reducing concerns among all their athletes,81 with particular focus on the most vulnerable including freshman and those that are injured.15 22 58
Trainers and clinicians also play a pivotal role in the mental health and well-being of female student-athletes given their specialised skill sets as well as the tendency for athletes to rely more on them for support after injury, including social support.82 Moreover, given the impact of injuries, such as concussions, trainers and clinicians would benefit from increasing their regular mental health and well-being assessments for proactive monitoring and sustainable female student-athlete mental health and well-being. For instance, to assist with earlier assessments and timely referrals among athletes at risk for or already experiencing mental health symptoms and disorders, qualified trainers and clinicians could administer the International Olympic Committee Sport Mental Health Assessment Tool 1 and Sport Mental Health Recognition Tool 1.83
Furthermore, the meta-analysis highlighted both the shortage of available information on mental health outcomes among female student-athletes and the importance of considering predictors like injury, health and social factors (ie, social support). The small, positive effect of these determinants, broadly conceptualised, on higher levels of depression, anxiety and stress suggest that understanding the nature and magnitude of these predictors should be considered when improving equity in sport. Perhaps most importantly, efforts to appreciate patterns in these associations should be a top priority for exercise and sport psychologists.
Limitations and future directions
There are several important limitations of the present study. First and foremost, we were interested in the determinants of depression, anxiety and stress among female student-athletes; however, 27 studies (51.9%) included for analysis were cross-sectional, thus we acknowledge the association not causation between variables of interest. Furthermore, only one included study was a randomised control trial69 underscoring the critical need for rigorous and intentional intervention-based randomised control trails along with longitudinal studies among female student-athletes to determine causation and temporal sequencing of determinants on depression, anxiety, and stress.
Second, there is research to suggest self-report bias and underreporting of mental health outcomes.84 This is an issue as the majority of included studies assessed depression, anxiety and stress through self-report. This highlights the need for mental health and well-being researchers to collaborate with mental health and healthcare practitioners in efforts to better estimate the prevalence of common mental health outcomes. In addition, this is of particular importance among the athlete population as mental health disclosures and help-seeking behaviours have been suppressed by both social and athletic culture stigma.85
Third, only six out of 52 included studies exclusively studied female student-athletes.44 46 49 52 59 69 Thus, while we delineated specific determinants for female student-athletes, these determinants could also apply to male student-athletes as well as male and female non-athletes. It is important to note that though we list this as a limitation, all of our reported determinants and presented data are specific to female student-athletes. Furthermore, while all authors included in the systematic review were contacted for female student-athlete specific data, only 13 studies were included in the meta-analysis based on response rates and usable data. This elucidates the need for research specific to female student-athletes to clearly identify specific and unique determinants. Likewise, there was a lack of focus on female-specific needs including biological (ie, hormonal changes),86 psychological (ie, comorbidity of depression and anxiety),87 and social (ie, intersectionality) needs.88
Fourth, there were a multitude of variables for consideration including 19 different measures of depression, anxiety and stress. Similarly, determinants ranged in level of detail of with more research needed to discern unique differences. For instance, under sport, only one study went into the specific differences between sport types and identified female track and field student-athletes at greatest risk for depression.21 Future studies should intentionally examine any of the 17 listed determinant for richer details and clarity including ascertaining the differences in team versus individual, fall versus spring sport and sport type on depression, anxiety, and stress.
Fifth and finally, we acknowledge our decision to use the term female student-athlete throughout this paper to capture most closely what is reported in the literature to date. Among the included studies, 23 (44.2%) did not mention gender (ie, women)12 14–16 19–21 43 45 47 48 50–53 57 62 64 66 70–72 74 while the remaining 29 studies did mention female and/or women’s sport student-athletes, only four studies distinguished between biological sex (ie, female) and gender (ie, women).11 26 58 73 Thus, while the terminology female student-athlete fits many athletes that compete in women’s sport, it is not as inclusive as we hope for future research. Research to date has historically misused sex and gender terminology, specifically with emphasis on binary constructs, which can contribute to inaccurate research findings and erase the health experiences of gender non-conforming athletes.89 Thus, we encourage future researchers to explore intentional terminology, such as women’s sport student-athletes as well as purposefully acknowledge individuals’ preferences in identity in research and practice to best understand their specific needs. This will increase representation in research and our understanding of understudied populations.
While we acknowledge the above limitations in our study, we also note these are all calls to action among sport and exercise science researchers at the intersection of mental health and well-being. Future studies would benefit from (a) a longitudinal design, (b) addressing self-report and underreporting biases in mental health outcomes, (c) being specific to female student-athletes, (d) utilising valid and reliable measures among female student-athletes, and (e) intentionally exploring unique and specific determinants among an inclusive group of female and women’s sport student-athletes.
Conclusions
This comprehensive systematic review and meta-analysis highlights the unique challenges faced by female student-athletes and the pressing need to address their mental health and well-being. The delineation of determinants, including biological sex, health factors, and injuries provides a roadmap for sports programmes, coaches, trainers and clinicians to develop evidence-based strategies and practice evidence-based treatment and care. Stakeholders in partnership with the athletes should collaborate to create a supportive environment that encourages mental health and well-being by implementing comprehensive mental health initiatives, educating on mental skills and sleep hygiene, fostering open dialogue, offering regular mental health assessments and specialised care, and destigmatising mental health. Furthermore, the meta-analysis highlights the need for research to elucidate the causal relationships between determinants and mental health outcomes. Longitudinal studies and randomised controlled trials are imperative to establish causation and temporal sequencing. In conclusion, this study calls for a collaborative care model, involving all stakeholders, including the female student-athletes themselves, in shaping the future of mental health in sports.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Acknowledgments
The authors thank the academic librarians Angela Bardeen, Rebecca Carlson and Barbara Renner for collaborating on the development of the search strategy. The authors would also like to thank our wonderful team of undergraduate researchers Alena Bradley, Elizabeth Hancock, Thalia Hernandez, Caroline Hoyle, Jillian Janssen, Gabriella Moore, and Emily Grace Thomas and our collaborator Dr. Rachael Flatt for her help with the protocol.
References
Supplementary materials
Supplementary Data
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Footnotes
Twitter @ling_beisecker
Contributors All authors conceived the study. LB conducted the search. LB, MJ and PH screened the articles. LB and PH abstracted the data and performed the statistical analysis. LB and PH reviewed the data for consistency. LB, PH and JDD drafted the manuscript. All authors critically reviewed the manuscript and approved the final version. LB is the guarantor of this manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer-reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.