Narrative review of mental illness in cricket with recommendations for mental health support

McCabeT, etal. BMJ Open Sp Ex Med 2021;7:e000910. doi:10.1136/bmjsem-2020-000910

Open access Review

Narrative review of mental illness in

cricket with recommendations for

mental health support

Thomas McCabe ,

1,2

Nicholas Peirce,

3,4

Paul Gorczynski,

Neil Heron

6,7

To cite: McCabeT, PeirceN,

GorczynskiP, etal. Narrative

review of mental illness in

cricket with recommendations

for mental health support. BMJ

Open Sport & Exercise Medicine

2021;7:e000910. doi:10.1136/

bmjsem-2020-000910

Accepted 29 December 2020

NHS Ayrshire and Arran,

Kilmarnock, UK

School of Medicine, Dentistry &

Nursing, University of Glasgow,

Glasgow, UK

Centre For Sports Medicine,

Nottingham University Hospitals

Trust, Nottingham, UK

National Cricket Performance

Centre, England and Wales

Cricket Board, Loughborough,

Sport and Exercise Science,

University of Portsmouth,

Portsmouth, UK

Centre of Public Health,

Queen's University, Belfast, UK

Department of Primary Care,

Keele University, Staffordhsire,

Correspondence to

Dr Thomas McCabe;

thomas. mccabe5@ ggc. scot.

nhs. uk

employer(s)) 2021. Re- use

permitted under CC BY- NC. No

commercial re- use. See rights

and permissions. Published by

BMJ.

ABSTRACT

Introduction Epidemiology reporting within the

cricketing medical literature has emerged over the past

2 years, with a focus on physical injuries. Despite mental

health in elite sport gaining increasing recognition, few

studies have addressed mental health symptoms and

disorders within cricket. Recently, cricketers have been

prominent in the mainstream media describing their lived

experiences of mental illness. As a result, some have

withdrawn from competition and suggested there is an

unmet need for mental health services within the sport.

Objectives (i) To appraise the existing evidence

on mental health symptoms and disorders amongst

cricketers. (ii) To provide guidance on shaping mental

health research and services within cricket.

Design A narrative review of the literature from inception

of available databases until 26 July 2019, with analysis

and recommendations.

Results Five studies were included in this narrative

review. Studies covered a range of mental health

symptoms and disorders, including distress, anxiety,

depression, sleep disturbance, suicide, adverse alcohol

use, illicit drug use, eating disorders and bipolar disorder.

Results indicated that cricketers are at high risk for

distress, anxiety, depression and adverse alcohol use.

When compared with the general population, cricketers

are more likely to experience anxiety and depressive

symptoms. Rates of suicide were proposed to be high for

test cricketers. Overall, studies to date have been of low

quality, demonstrating non- rigorous research methods.

Some studies have relied on non- validated questionnaires

to collect self- reported data on mental health symptoms

and disorders, while others have presented biographical

data obtained through searches of the media.

Conclusions The results of this narrative review

highlight the lack of evidence underpinning mental

health services for athletes within cricket. We suggest

the following recommendations for future research

and practice: (i) normalising mental health symptoms

and disorders; (ii) working with and helping vulnerable

demographic segments within the target population; (iii)

designing and implementing early recognition systems of

mental health symptoms and disorders; (iv) addressing the

mental health needs of cricketers on a population basis.

INTRODUCTION

Injury epidemiology reporting within the

cricket medical literature has emerged over

the past 2 years with a focus on physical

injuries.

1–4

Cricket researchers have been

proactive in standardising the description

of physical injuries in order to better define

injury cohorts and structure appropriate

preventive and responsive services.

5 6

contrast, there is a lack of research evidence

on the mental health of cricketers, despite

this being an area of interest within the wider

sporting medical literature.

7–9

Such a deficit

of evidence has been noted, particularly by

the International Olympic Committee in

their consensus statement on the mental

health of elite athletes.

9 10

Their statement

highlighted the need to collect rigorous

evidence in order to design, implement and

evaluate sport specific mental health services.

This lack of evidence limits the design, imple-

mentation and evaluation of both preventive

and responsive mental health services for

cricketers. From a behavioural epidemiolog-

ical perspective,

estimating the prevalence

of mental health symptoms and disorders

and thus understanding individual and envi-

ronmental factors associated with them, is

necessary to improve evidence- based practice.

In the mainstream media, cricketers have

been among the first sportspeople coming

forward to describe their mental health

symptoms and disorders.

12–16

Furthermore,

some have withdrawn from national team

Summary of new ndings

► For cricketers, existing preventative and respon-

sive mental health services for addressing mental

illness in cricketers are not underpinned by research

evidence.

► From the data available, prevalence levels of mental

health symptoms and disorders among cricketers

are similar to athletes in in other sports.

► The mental health of cricketers appears to be under

close media scrutiny.

► This narrative review provides guidance on design-

ing and implementing mental health prevention and

intervention services for cricketers.

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selection

17 18

and have gone ‘public’ to describe their

experiences, which is not routinely seen in other sports.

There has been a television series (Mind Games, Sky

Sports, UK) as well as a film (The Edge), focussing on

the mental strain that cricketers experience, particularly

when ‘on tour’, at the very highest level of the sport.

19 20

This anecdotal evidence indicates that there may be an

unmet need for mental health provision. It is interesting

to note; however, that most of the cricketers featured

in the media discussing mental health difficulties have

retired from the game.

OBJECTIVES

The purpose of this paper was twofold: (i) to appraise

the existing evidence on mental health symptoms and

disorders among cricketers and (ii) to provide guidance

on shaping mental health research and services within

cricket.

METHODS

A narrative review of the literature was conducted to iden-

tify relevant studies. Literature describing mental health

symptoms and disorders in cricket was identified by

searching MEDLINE, EMBASE, CINAHL, PsycINFO and

SPORTDiscus from inception until 26 July 2019. This was

carried out by a medical librarian. Key words searched

included ‘cricket’ AND ‘chronic stress’ OR ‘Depression’

OR ‘Anxiety’ OR ‘Generalised anxiety disorder’ OR

‘Recurrent depression’ OR ‘Agitated depression’ OR

‘Mixed anxiety’ OR ‘Chronic depression’ OR ‘Panic’ OR

’Insomnia’ OR ‘Drinking behaviour’ OR ‘Alcoholism’

OR ’Addiction’ OR ‘Suicide’ OR ’Suicide attempt’ OR

‘Self harm’ OR ‘Eating disorder’ OR ‘Anorexia nervosa’

OR ‘Bulimia’ OR ‘ADHD’ OR ‘Post traumatic stress

disorder’ OR ‘PTSD’. A manual search of reference lists

of relevant studies was also conducted.

Study inclusion

Two independent reviewers (GW and AP) screened titles

and abstracts for eligibility. Studies must have met the

following inclusion criteria:

1. Elite level cricketers, where elite was defined as com-

peting at the national, international or professional

level.

2. Quantitative data on mental health symptoms and dis-

orders.

3. Written in English.

Studies were excluded from the review if they met the

following criteria:

1. Papers with a primary focus on performance related

aspects of game play.

2. Book chapters.

3. Conference abstracts or

4. Full text of the article was not available.

RESULTS

In total, 24 studies were identified by the search strategy.

After reviewing the identified studies, 5 studies were

included in the narrative review.

21–25

Papers were

excluded for the following reasons: conference abstract

(n=2); book chapters (n=2) and not mental health

focused (n=15).

The five studies included were published between 2007

and 2018 and involved samples of current and retired

professional cricketers from Australia (n=3), England

(n=2), New Zealand (n=1) and South Africa (n=2).

Other nationalities may have been included within Jones

et al cohort.

Various methods were used to collect data,

including cross- sectional designs,

21 23

an observational

prospective cohort design,

a review of biographical

data

and a narrative review.

Three studies focused

exclusively on men,

22 23 25

while two studies were inclu-

sive of women.

21 24

Studies covered a range of mental

health symptoms and disorders, including: distress

symptoms

21 24

; anxiety symptoms

21–24

; depressive symp-

toms

21–24

; sleep disturbance

; suicide

22 25

; alcohol use

23 24

;

illicit drug use

; eating disorder symptoms

and bipolar

disorder.

Main ndings

Of the two studies that focused on distress,

21 24

only the

results of Schuring and colleagues provided informa-

tion that was exclusive to cricketers. The results from

Gulliver et al pertained to a group of professional Austra-

lian athletes, where results were aggregated and of which

cricketers made up the largest sport sampled. However,

it was not possible to extract data that was exclusive to

cricketers. Overall, results obtained through the use

of the Kessler 10

indicated that 15.7% (SD=6.0%) of

athletes experienced distress symptoms, with women

(16.7%, SD=5.7%) appearing more likely than men

(14.6%, SD=6.1%) to indicate such symptoms. From the

findings of Schuring and colleagues, prevalence rates of

distress symptoms were 38.4% (95% CI 28.0% to 49.8%)

among current South African cricketers and 26.3% (95%

CI 14.8% to 42.2%) for retired cricketers. Results were

obtained using the Distress Screener.

Increased distress

was significantly associated with a higher level of career

dissatisfaction (OR=0.8, 95% CI 0.7 to 0.9) and increased

number of surgeries (OR=1.8, 95% CI 1.1 to 3.1).

Regarding anxiety and depressive symptoms, four studies

provided insight.

21–24

Again, as with distress symptoms,

data obtained by Gulliver and colleagues did not pertain

exclusively to cricketers, but rather the entire sample of

professional Australian athletes. Overall, results obtained

through the use of the Generalised Anxiety Disorder 7

scale

indicated that 4.1% (SD=3.9%) of athletes experi-

enced anxiety symptoms, while results obtained through

the use of the Centre for Epidemiologic Studies Depres-

sion scale

indicated that 11.6% (SD=9.31%) of athletes

experienced depressive symptoms. For both anxiety and

depressive symptoms, higher prevalence values appeared

to be in the female than male groups (anxiety symptoms,

4.8% vs 3.3%; depressive symptoms, 12.6% vs 10.3%).

The work of Hundertmark presented information

anecdotally on a number of Australian cricketers who

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experienced anxiety and depressive symptoms and how

such symptoms impacted their personal and professional

lives.

Some cricketers experienced hardship as a result

of moving clubs, while some were later housed within

psychiatric facilities. The experiences of anxiety and

depressive symptoms were also documented to be asso-

ciated with suicide. Jones and colleagues indicated that

both current and retired English cricketers were more

likely than members of the general public to experience

anxiety and depressive symptoms.

Among the cricketers

sampled, the prevalence for anxiety symptoms was 10.3%

(95% CI 6.5% to 16.0%) and 6.7% for depressive symp-

toms (95% CI 3.7% to 11.7%). Rates of anxiety (12.4%,

95% CI 7.4% to 20.0%) and depressive (8.8%, 95% CI

4.8% to 15.8%) symptoms were higher among cricketers

over the age of 50 years than the entire sample of crick-

eters. The results of Schuring and colleagues provided

the most comprehensive data on anxiety and depressive

symptoms among cricketers from the studies included

in this review.

In their study, the General Health Ques-

tionnaire 12

was used to collect data on both anxiety

and depressive symptoms. Overall, prevalence rates of

anxiety and depressive symptoms were 37.0% (95% CI

26.8% to 49.1%) for current cricketers and 24.3% (95%

CI 13.2% to 40.3%) for retired cricketers. Adverse life

events (OR=1.3, 95% CI 1.0 to 1.8) and career dissatis-

faction (OR=0.8, 95% CI 0.7 to 0.9) were significantly

associated with anxiety and depressive symptoms among

current cricketers.

With sleep disturbance, Schuring and colleagues

used the PROMIS (short form)

and found that 38.4%

(95% CI 28.0% to 49.8%) of current cricketers while

21.1% (95% CI 10.8% to 36.6%) of retired cricketers

experienced sleep disturbance. Sleep disturbance

was significantly associated with career dissatisfaction

(OR=0.9, 95% CI 0.8 to 1.0).

Suicide was examined by two studies.

22 25

Hundertmark

focused on the effects of anxiety and depressive symp-

toms and how they were associated with various personal

and professional challenges which resulted in suicide

for a number of cases presented. Shah and colleagues

collected biographical data on 2794 test cricketers from

various media sources, including David Firth’s book,

Silence of the Heart: Cricketing Suicides.

Overall, they noted

20 test cricketers had died by suicide, a rate of 715.4 per

100 000 for the period 1877–2014. Most suicides occurred

in retirement (n=17), to those who experienced physical

health issues (n=14), other mental health symptoms and

disorders (n=14) and financial problems (n=10).

With adverse alcohol use, two studies provided

data.

22 24

Hundertmark noted the influence of alcohol

on various anxiety and depressive symptoms and the

role it played in coping with the demands of the sport.

They noted high levels of drinking among various cricket

clubs across the state of Victoria, Australia. Schuring

and colleagues collected data using the AUDIT- C

and

found that 26.0% (95% CI 17.3% to 37.2%) of current

cricketers and 22.2% (95% CI 11.5% to 38.3%) of retired

cricketers experienced symptoms of adverse alcohol use.

Neither significant injuries, surgeries, adverse life events

or career dissatisfaction were significantly associated with

adverse alcohol use. Full details on the included studies,

including results pertaining to illicit drug use,

eating

disorder symptoms

and bipolar disorder

can be found

in table 1.

DISCUSSION

The existing epidemiology research base of cricket popu-

lations gives only partial insight into the prevalence of

mental health symptoms and disorders and longer- term

outcomes of participation in the sport at an elite level.

Comparisons between mental health symptomology,

suicide and the general population have been made but

with significant methodological limitations apparent.

The studies included suggest that despite retired crick-

eters experiencing anxiety and depressive symptoms at

a higher rate than other common chronic illness, they

look back on their careers favourably.

Added to this,

rates of mental health symptomology in cricketers still

playing, suggest similar rates than other areas of elite

team sport.

34–39

The studies included in this review do

not offer information on current management strategies

for mental illness or outcomes resulting from periods of

mental ill- health. In particular, suicide rates of cricketers

with comparison to the general population should be

treated with caution, given the relatively small cohort of

cases reported over many decades, with varying attitudes

towards mental health symptoms and disorders within

this time. One must also consider how epidemiological

reporting of mortality in differing continents may have

influenced this further.

Despite the lack of definitive data around mental ill-

health in cricketers, this is a topic which should not be

ignored by the wider cricket multidisciplinary team.

One should not assume that due to a lack of established

medical data that an unmet need does not exist with

regards to mental health provision in cricket. Elite crick-

eters continue to tell of the mental health difficulties

they face, although through the media. Unfortunately,

stigma within the game and barriers to disclosure still

exist.

Given the multifactorial aspects of mental health

symptoms and disorders and the suggested unique influ-

ences that cricket places on players, it is important for

administrators to provide provision and pathways to care

alongside psycho- education programmes to reduce the

risk in later or post careers, as proposed by Hundert-

mark.

This to date, has not been standardised across

countries and the different playing levels of the game.

The cricket medical literature has been a front runner

in attempting to standardise reporting of physical injury

outcomes

5 6

but this literature now needs to address

mental health symptoms and disorders and further

develop the International Olympic Committee statement

on mental health in elite athletes.

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Recommendations and future directions for mental health

support in cricket

Given a limited evidence base found within the literature

within this review, we have extrapolated the information

available and incorporated with recommendations based

on the work of Reardon and colleagues.

Thorough mental health epidemiology studies in crick-

eters are needed in order to understand the scale of the

problem, which is not accurately known at present. The

most common mental health symptoms (with the excep-

tion of disordered eating

) are estimated to be at a similar

prevalence to or slightly higher in elite athletes when

compared with the general population.

The unique

culture and demands in cricket, proposed by Hundert-

mark

and Shah et al,

may produce differing results in

mental health presentations than that seen in wider sport

populations thus far. In particular, there has been no

studies considering only female cricketers. Replication of

results produced elsewhere about the unique demands

and pressures on female sport competitors could provide

a framework for enhanced care.

In order to facilitate the true impact of mental health,

where possible, researchers should aim to report mental

illness in keeping with the International consensus state-

ment on injury in cricket,

using ‘match time- loss’ injuries

(or illness) as a way of quantifying the issue. This may

help in providing parity for psychological issues, valuing

mental health equally with or as a comorbid factor along-

side physical health, although in a sport with increased

openness. Nevertheless, further research is needed

to understand the extent in cricket that mental health

symptoms and disorders carry an unwelcome stigma and

where barriers for help seeking behaviour exist.

Physical injury and surgical intervention have been

suggested as being risk factors for mental symptoms and

disorders in other sports.

43 44

To date, this has not been

Table 1 Summary of included studies

Study, country Study type Characteristics Mental health questionnaire Prevalence

Gulliver et al,

Australia

Cross- sectional Male (n=44)

Female (n=21)

Kessler 10 scale (K- 10),

Center for

Epidemiologic Studies

Depression Scale (CES- D),

Generalised Anxiety Disorder

scale (GAD- 7), Social Phobia

Inventory

(SPIN), Panic Disorder Severity

Scale

(PDSS- SR), SCOFF

questionnaire

(SCOFF), prior counselling

measure of the General Help-

Seeking Questionnaire

(GHSQ).

Results not specic to cricketers.

The study explored symptoms of

depressive symptoms (27.2%), eating

disordered symptoms (22.8%), general

psychological distress (16.5%), social

anxiety symptoms (14.7%), anxiety

symptoms (7.1%) and panic disorder

symptoms (4.5%). Overall results,

46.4% of athletes experienced at least

one of the mental health symptoms

explored.

Hundertmark,

Australia

Narrative review All cases male None provided. Mental health symptoms and disorders

included alcohol use, illicit drug use,

mood disorders, suicide, bipolar

disorder. Cases presented on individual

male cricketers.

Jones et al, England

Cross- sectional Age: mean

57.2 years (SD=14.2)

Male (n=165)

Assessed through self- report

questionnaire. Questionnaire

designed specically for the

study. Questionnaire based

on questions from the English

Longitudinal Study of Ageing.

Prevalence of anxiety symptoms was

10.3% and depressive symptoms was

6.7%.

Schuring et al, South

Africa

Observational

prospective cohort

study with follow- up

Current:

Age: mean 27 years

(SD=5)

Male (n=68)

Female (n=10)

Retired:

Mean 36 years

(SD=6)

Male (n=38)

Questionnaires included:

Distress Screener; the

General Health Questionnaire

(GHQ- 12)

PROMIS and the

Audit- C.

Prevalence rates- current cricketers

included distress (38.4%), sleep

disturbance (38.4%), anxiety/

depression (37%) and adverse alcohol

use (26%).

Prevalence rates- retired cricketers

included distress (26.3%), anxiety/

depression (24.3%), adverse alcohol

use (22.2%) and sleep disturbance

(21.1%).

Shah et al, Australia,

England, New Zealand,

South Africa

Review of

biographical review

Age: median age

at death 50 years

(range 28–67).

Male (n=2794).

Data on suicide extracted from

two books (Firth 1991, Firth

2001) and the obituary of the

Wisden Cricketers Almanack

(1988–2015).

A total of 20 suicides were recorded

for the total sample of test cricketers

between 1877 and 2014.

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replicated in cricket populations.

21 24

However, when

natural human reactions, such as ‘disappointment’ and

‘fear of further injury’, are most likely to progress to a

mental illness is less well understood. Alongside basic pain

control

and other psychosocial interventions, medics

should consider when the optimal time is to assess mental

state and formulate psychological wellness. Furthermore,

formalised psychological support embedded within a

return to play programme should become common-

place. Mental health symptoms and disorders should

be considered if there is any noticeable deviation in the

expected injury recovery period. Fast bowlers with stress

fractures could be a subset of cricketers to focus on for

any proposed intervention, given the relative availability

of research in this area and well documented recovery

phases.

1 46 47

Cricket is played across a wide variety of countries

and cultures. As such, the understanding, stigma and

resources to support mental healthcare provision varies

significantly. However, cricket has a unique opportunity,

in light of the cultural importance and open culture

in some countries, to provide research opportunities

that can overcome unhelpful barriers and provide

valuable insights, both within and outside sport. Thus,

while financial investment in mental health may not

be seen as a priority in some cricketing organisations,

the International Cricket Council (ICC) should ensure

minimal standards of care for mental health and work

towards parity for all elite level cricketers regardless of

geographical location but with sensitivity and respect

toward cultural beliefs, as suggested by the International

Olympic Committee consensus statement.

Head injuries, including sports- related concussion,

and its linkage with mental health is a particular area

of focus within contact sports literature at present.

Data from professional soccer cohorts who have been

exposed, in part, to repeated minor head trauma through

heading of the football, suggests poorer neurocognitive

long- term outcomes when compared with the general

population.

This has contributed to rule changes and

guidance on how children learn core skills in sport, in

order to proactively minimise the risk of adverse longer

term outcomes.

50 51

Cricket has an opportunity to docu-

ment all helmet strikes as unique events, often with video

evidence,

thus robust data on head injuries in batsmen

will emerge in the coming years. Helmets are used exten-

sively throughout cricket by batsmen, wicketkeepers,

some umpires and close in fielders, but wearing helmets

has however, not been proven to reduce rates of concus-

sion in sport.

Investigating long term mental health and

neurocognitive outcomes after a head injury in cricket,

with comparison to those unaffected, should be achiev-

able, with historical and new assessments of cognition

being available for elite level cricketers. Furthermore,

data within a non- contact sport such as cricket, will go

some way to informing debate with regards causation of

neurodegenerative diagnosis in sporting populations.

Hence, surveillance of these cricketers, with a focus

on mood or affective symptoms should be an aim for

researchers.

Touring is an important characteristic of the elite game

resulting in prolonged time away from home and conse-

quent dislocation from many individuals’ normal support

mechanisms.

22 25

Players may develop pathological defence

mechanisms when faced with stress outside of traditional

social supports and environment.

A recent narrative

review

focused on mental health emergencies in elite

athletes and suggested an ‘emergency action plan’ is essential

for sport stakeholders to implement. The review goes further

to describe the most common psychiatric ‘crisis’ presenta-

tions and suggests management strategies, with emphasis

on early intervention. Anecdotally, responsibility for overall

management, especially when on tour, would lie with the

team medic/physician and this may raise the possibility of

expansion of training needs for sport medicine physicians,

with recent changes to the sports and exercise medicine

doctor curriculum reflecting this.

High standards of care,

alongside early intervention, are important aspects in order

to minimise the risk of poorer longer- term outcomes in

mental health and perhaps ‘save’ careers. Learning resulting

from these clinical cases can be challenging and is perhaps

best placed for ‘debriefs’, which sports physicians should play

a central role in.

Administrators, management, cricketing law makers and

medical teams should consider working towards best prac-

tice to assist with addiction in cricket, be that from alcohol,

recreational drugs or betting. Anecdotally, alcohol and

cricket have had long associations. This is reflected to some

extent in research—originally by Hundertmark

and also

in a cohort of current elite cricketers, were adverse alcohol

use was estimated to be at 26%.

Gambling is a very sensitive

subject in cricket worldwide and violations carry heavy penal-

ties for individuals. A recent systematic review of gambling

addition in sport was undertaken,

providing guidance on

the topic. The ICC Anti- Corruption Code of Conduct is clear

with regards requirements of elite cricketers and assists with

upholding the integrity of the game.

The England and

Wales Cricket Board Recreational Drug Use Policy is simi-

larly unambiguous with regards expectations of cricketers

with regards drugs, such as cocaine or cannabis.

Several

countries have welfare directed recreational drug detection

and gambling detection programmes. Any form of addiction

can have catastrophic consequences on careers and life in

general and are almost impossible for players or coaches to

disclose given the consequences of ‘being caught’. There-

fore, any player ‘caught’ with banned drugs or betting

violations should be offered a comprehensive assessment

and support with bio- psycho- social formulation

with consid-

eration of safeguards for the future. This is already available

to some but not all. An alternative option is for cricketers to

be able to anonymously self- refer for assessment and treat-

ment of these issues. Reintegration for individuals troubled

with addiction issues, particularly which of gambling, is a

sensitive topic within the sport and one the wider cricketing

community has not widely accepted.

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The Athlete Psychological Strain Questionnaire (APSQ)

has emerged as an acceptable screening tool for use in

male and female elite athletes.

Cricketers experiencing

subthreshold symptoms could be responsive to early inter-

vention as a result of identification from a screening tool

designed for sporting cohorts. Timing of screening must

be carefully considered, given that risks such as those that

occur with physical injury, may fluctuate at various times

throughout an elite athlete’s career. Traditionally ‘team

medicals’ are carried out during preseason and utilisation of

a screening programme for mental illness alongside other

screening tests, such as cardiac screening, could contribute

to normalisation of mental distress. Thus, the APSQ could

be undertaken with athletes in preseason, with this score

being compared with certain high- risk periods, for example,

periods of injury or intense competition. Furthermore,

in addition to the APSQ, the IOC have proposed Sports

Mental Health Assessment (SMHAT- 1) and Recognition

Tool to follow on from wider screening.

The paper suggests

embedding The SMHAT- 1 into the precompetition period

(ie, ideally a few weeks after the start of sport training), as

well as within the mid- season, end- season period and also at

periods of high stress such as after a major competition.

Competition, travel and training have been proposed as

risk factors for disrupted sleep within sporting cohorts.

Indeed, disturbed sleep is part of the diagnostic criteria

for depressive disorder.

The National Institute of Care

and Excellence recommend sleep hygiene as a first line

intervention on those suffering with subthreshold symp-

toms

and indeed is included in the management for many

mental illnesses. Thus, environment and timings of training

and matches, especially early on during a tour, should be

arranged and optimised to improve sleep in order to mini-

mise impact on well- being and mental health as well as on

physical performance.

Consideration of delivery and effectiveness of preven-

tion strategies, such as those proposed within the literature

search,

21 22

for mental ill- health in cricket is needed. Some

sporting administrations advocate the wider topic as a

medical issue; others view the topic within the overall well-

being of their employees.

Cricketing authorities should

review, reflect and optimise services used to tackle the issue

on a population basis. Work rooted in mental health literacy,

provides individual and environmental programming

designed to help athletes better understand mental health

symptoms and disorders, address stigma and set intentions to

seek support.

Indeed, the Professional Cricketers’ Associa-

tion (PCA)

is an organisation providing support and welfare

programmes for professional cricketers within England and

Wales. Alongside the England and Wales Cricket Board, they

have been proactive in creating avenues of help for those in

need of psychiatric expertise. The PCA commissioned an

unpublished extensive independent review of their approach

to mental health provision in 2019. This allowed synthesis

of resources, cost effective use of mental health providers,

consideration of need at various levels within the profes-

sional game and demonstrated treatment models being

used and over what period of time. Overall cricketers using

the service benefitted from the expertise they received and

the ease with which they accessed care. These pathways now

need further embedding within English and Welsh cricket

as well as similar strategies employed in the other cricketing

countries.

Finally, cricketers have been proposed to be at greater risk

of death by suicide.

However, this narrative was purported

many years ago, and calculations of numbers of cricketers

taking their own life (as well as that to which they were

compared) does not appear to have clear statistical validity.

Suicide is a complex phenomenon and has multifactorial

causation. Calculating data resulting from these tragic events

are complicated by relatively small numbers and reporting

inconsistency. Added to this, learning from cases is limited by

multiple biases and largely reliant on secondhand accounts

of circumstances leading up to death. Therefore, in light of

the anecdotal nature of this books findings

and the signifi-

cant reputational impact on a sport that has been suggested

to have higher than expected rates, further evidence in this

area would be welcome. Regardless of the extent of suicide

as an issue, cricket does carry a number of risk factors and

improvements in already existing prevention practices and

strategies in cricket should continue to be expanded on.

64 66

These prevention practices and strategies could include:

► Identification and management of mental illness,

particularly in early stages.

► Creation of a psychologically aware and welcoming

environment.

► Responding to patients’ needs in a timely manner

when in crisis.

► Robust risk assessment and safety planning.

► Provision of easily accessible information and mental

health expertise.

Strengths and weaknesses

The strengths of this paper are:

1. It is the first of its type to synthesise existing mental

health literature within cricket.

2. We provide a framework for those working within

cricket to improve mental health services and respond

to the growing concern of unmet need.

3. The review focuses on mental health in cricket, at a

time when health and sport practitioners are partic-

ularly seeking guidance in this area within sports and

exercise medicine.

The potential limitations of this paper are:

1. Lack of quality studies to include in the review to form

more concrete conclusions on the mental health of

cricketers.

2. Cricket lends itself to literature from individuals with

vast experience in the game and knowledge. Much of

this insight, which was included in books and commer-

cial publications, was not considered within this paper.

CONCLUSION

This is the first review of the mental health literature in

cricket. Interest in the overall topic remains high within the

on August 27, 2024 by guest. Protected byhttp://bmjopensem.bmj.com/BMJ Open Sport Exerc Med: first published as 10.1136/bmjsem-2020-000910 on 29 January 2021. Downloaded from

McCabeT, etal. BMJ Open Sp Ex Med 2021;7:e000910. doi:10.1136/bmjsem-2020-000910

Open access

wider sporting community. The review highlights the lack of

quality evidence underpinning any identification or inter-

vention strategy already in existence for mental health issues.

Thus, we propose ways to address this within a cricket popu-

lation, including cultivation of a psychologically friendly

environment and with targeting of ‘at risk’ groups. These

interventions provide a basic framework for expansion of

already embedded knowledge and clinical expertise within

the medical provision for cricket.

Twitter Thomas McCabe @dr_t_mccabe and Neil Heron @neilSportDoc

Acknowledgements The authors wish to thank Amanda Wright, librarian with

NHS Greater Glasgow and Clyde, for her assistance with the literature search

and Ian Thomas, Director of Development and Welfare at the PCA (Professional

Cricketers Association) for guidance and background on the topic.

Contributors TM completed all the primary data analyses assisted by PG and

supported by NH, provided a rst draft of the manuscript. NH, PG and NP edited

manuscript drafts and TM collated all author comments to the nal submitted

version. All authors have approved the nal submitted version of the manuscript.

Funding The authors have not declared a specic grant for this research from any

funding agency in the public, commercial or not- for- prot sectors.

Competing interests NP is afliated with the England and Wales Cricket Board.

Patient and public involvement Patients and/or the public were not involved in

the design, or conduct, or reporting, or dissemination plans of this research.

Patient consent for publication Obtained.

Provenance and peer review Not commissioned; externally peer reviewed.

Open access This is an open access article distributed in accordance with the

Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which

permits others to distribute, remix, adapt, build upon this work non- commercially,

and license their derivative works on different terms, provided the original work is

properly cited, appropriate credit is given, any changes made indicated, and the

use is non- commercial. See:http://creativecommons.org/licenses/by-nc/4.0/.

ORCID iDs

ThomasMcCabe http://orcid.org/0000-0002-2775-8669

NeilHeron http://orcid.org/0000-0002-4123-9806

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