Football does not improve mental health: a systematic review on football and mental health disorders

Football affects billions of people in the world, that is, from the world famous, very well paid professionals down to the unpaid amateur players on a wet muddy pitch on a cold December morning. It impacts sometimes highly significantly on the lives of fans and spectators who watch avidly by attending matches or watching on TV. It is often a defining characteristic of a person’s self-identity. Early ‘getting to know you’ conversations can include questions about your job, whether you have children, your marital status and ‘which team do you support?’ Having a successful team can increase awareness of a town or city anywhere in the world and can have a huge economic impact on that town or city.

The incredible passion, loyalty and fanaticism that supporting a team can engender in some individuals has led to an interest in how the active process of supporting a club can impact on the physical and mental health of supporters and participants. Some studies suggest that football may induce a feeling solidarity and togetherness amongst players and fans (McKeown et al. 2015) or can create a sense of belonging and a catharsis of stress and tensions amongst spectators (Pringle 2004). However, not all games are won and Vallerand et al. (2008) suggest that football may induce both positive, that is, harmonious, and negative, that is, obsessive behaviours.

For players, there might be the success, the rewards of promotion and the rewards of higher income if games are won frequently by their team. On the other hand, losses of games may cause distress and disappointment and thus might negatively affect the well-being of the losing side. High-profile suicides in players and managers have recently raised the awareness of the necessity to look at mental health issues in those involved in the professional game (Pringle 2012).

Negative effects of football appear more pronounced when physical health problems from football-related injuries affect the well-being and performance of players, a notable example being the current research into heading the ball and the development of dementia (Faden and Loane 2015). Thus, the physical and mental health of players needs to be focussed on by managers, teams and football associations.

Accidents and injuries in football may affect the whole body but most frequently involve the legs, knees, arms and the head with one long-term effect of football and other sports appearing to be an increased risk of osteoarthritis (Schuring et al. 2016).

Severe and repetitive concussion in sports may lead to chronic traumatic encephalopathy (Janssen et al. 2017, Manley et al. 2017). In some cases, dementia might be the late consequence of severe brain injury (Shively et al. 2012, Faden and Loane 2015). Such damage might not, however, necessarily be permanent with recovery from concussion not being uncommon (Iverson et al. 2017). Neuropsychological impairments in soccer may also be the consequence of minor repetitive concussions during games and especially when heading the ball. However, the effects of heading on longterm outcome are less than clear. Studies that could form the basis for such conclusions including the effects of heading are of mostly limited methodological standards or of low sample size and need improved research methodology (Rutherford et al. 2003, Maher et al. 2014).

This suggests that even though brain damage can affect subjective mental health and well-being as well as being a cause for depression or dementia, there is as yet limited unequivocal evidence that neuropsychological damage to the brain causes significant increases in mental disorders in groups of active or retired professional or amateur players. However, it is not clear which mental health disorders may be caused or affected.

For those playing the game, much of the literature has focused on performance and psychological or mental health symptoms of professional players. Wiggins and Brustad (1996) found that anxiety may influence performance expectations both positively and negatively depending on the participant’s response. Different groups of football players vary in their anxiety levels and how they manage anxiety. High competitive anxiety may increase the risk of injury (Junge et al. 2000). Not just performance anxiety but anxiety connected to negative life-stress and daily hassle were predictors of injuries amongst professional soccer players (Ivarsson and Johnson. 2010, Ivarson et al. 2013). It was not just the presence of anxiety but the ineffective coping mechanisms to deal with everyday anxiety that were found by predictors of injuries in young players in Johnson and Ivarsson’s study (2011), whilst athletes who perceived their anxiety to be debilitative showed higher levels of burnout (Wiggins et al. 2005). Laux et al. (2015) suggested early signs of this process could be found by monitoring stress-related fatigue and poor sleep in professional football players.

Away from the professional game, much of the research on playing and watching football has focused on the mental health benefits that are generated primarily from being part of a supportive group that generates a feeling of warmth, purpose and social inclusion (McElroy et al. 2008, Smith and Pringle 2010, Pringle 2009). These very subjective issues are very difficult to identify, measure and compare between samples or over time. Consequently, for this systematic review, we focussed on major mental health disorders, if possible, and their differences between groups or changes over time.

The present paper, therefore, plans to assess the effects of football on the mental health of players, referees or spectators by reviewing and evaluating cross-sectional studies that assess the frequency, respectively, prevalence of major mental health disorders in groups of professional and non-professional players, referees or spectators, if possible, compare these with relevant comparison groups, and by also reviewing cohort studies that measure the changes of frequencies of mental health disorders before and after a football-related event.

To investigate the relationship between football/soccer and common mental health disorders, we performed a systematic review on using the following databases: PubMed, Medline and CINAHL (Cumulative Index to Nursing and Allied Health Literature). The relevant literature search was performed during July and August 2017. The search terms were football/soccer and mental health/mental disorder or schizophrenia/depression or anxiety/obsessive compulsive disorder. These disorders were selected as they are the most common and severe mental health disorders that, therefore, would be most easy to identify and measure in their frequencies.

The question of interest addressed the effect of participation in or watching football on the frequencies of major mental health disorders.

Consequently, we chose the following criteria for the inclusion of studies in the review:

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Study participants must include subjects exposed to football such as football players, football referees, spectators (directly and via TV).

Exclusion criteria were the following:

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Studies focussing on subjects exposed to American football and Australian Rules football were excluded as these games share the name but are different from football/soccer, they are contact sports sharing commonalities with Rugby.

The extracted data included names of authors, year of publication, study design, sample size and demographics, country of study, type of diagnostic instruments, definition of caseness, frequency respectively prevalence of mental health disorders, overall and specific study results and potential bias. Biases were assessed using Cochrane criteria (Higgins et al. 2017).

A total of 662 papers were identified from the literature search using the above-mentioned search terms in three scientific publication data bases: PubMed, Medline and CINAHL.

Titles and abstracts of these papers were screened for their relevance on the interaction between mental health disorders and football.

The following papers were excluded from this systematic review for the following reasons:

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6 papers were in other languages, but not English.

Of the remaining 213 papers on football and mental health issues,

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65 papers focussed on trauma, concussions and its neuropsychological consequences.

The full manuscripts of the remaining 35 papers were received and their contents were assessed for their relevance to the study question and for their compliance with the inclusion/exclusion criteria.

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12 papers were excluded as they did not include any quantitative estimates of mental disorders, such papers dealt with the use of football to improve mental health in different groups including spectators, soccer fans and patient groups, that is, subjects with schizophrenia or learning disability (e.g. Hudson et al. 2017). The majority of these studies were experience reports of different football-related projects without quantitative data.

Finally, we identified 17 papers that investigated the influence of soccer on the prevalence of depression and other mental health problems in different group. These were summarised in Table 1.

Table 1

Fourteen of these studies focussed on previous players or current professional players or referees or a mixture of these groups.

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12 of these 14 studies focussed on active professional players,

Only three studies looked at other non-professional samples.

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One paper looked at the mental health of adolescents involved in football training.

No paper looked specifically at the mental health of football fans.

Table 1 provides a description and a summary of results of the studies assessing the prevalence of depression and anxiety in active, retired male and female players. Mental health problems were prominent in all active and retired professional groups, that is, players and referees, even though the results were not completely consistent. There was a suggested relationship between osteoarthritis, the number of severe injuries, recent life events, career dissatisfaction, low social support, employment status and hours of work after retirement and the prevalence of anxiety and depression in active and retired football players and referees. Some studies indicated that playing position and the level of performance might also impact on the mental health.

None of the studies have used psychiatric instruments that would result in a specific psychiatric diagnosis. The used scales, that is, the Health-Related Quality of Life Scale, the 12-item General Health Questionnaire (GHQ-12) and Centre of Epidemiological Studies Depression Scale are meant to be screening instruments for mental health problems that should then trigger the use of interviews that allow making diagnoses according to international criteria such as the International Classification of Diseases . The team from FIFA (The Federation of International Football Associations, Gouttebarge, being first or senior author, see Table 1) used the GHQ-12 to diagnose anxiety/depression. They also assessed distress, sleep disturbance, adverse alcohol behaviour, adverse smoking behaviour and adverse nutrition behaviour, which are important to assess present problems in comparison with other populations. The relationships with the above-mentioned risk factors usually go in the same negative direction as the ones with anxiety/depression. However, because of the varying prevalences of the disorders and the outcomes, minor differences and the differences between significant versus non-significant correlations are impossible to interpret adequately.

Perhaps the most interesting finding of Gouttebarge’s recent work relates to the prevalence of mental health problems in professional players of the game. His 2013 survey of 253 current and former players in 6 different countries found that the 104 (26%) respondents still playing the game reported suffering from mental health symptoms including anxiety and depression (Gouttebarge et al. 2015). These estimates echo findings by Prinz et al. whose study of female football players reported 25.2% of participants suffered a mild or moderate depression at least once during their football career.

The estimates of 26% (Gouttebarge et al.) and 25.2% (Prinz et al.) resonate strongly with the often quoted one in four statistic for the prevalence of mental health problems in the general population. This may suggest that playing at a high level does not impact positively on mental health even though these studies have not included relevant control groups assessed with the same methods, which severely limits the validity of the conclusions.

There is only one study that assessed the effects of soccer training on the mental health of adolescents (see Table 1). Considering the popularity of soccer playing in the general population, that is, around 250 million players in the world, one would have expected more studies on the effect of football on the mental health and well-being in amateur players. The study by Richards et al. (2014) even found that adolescents aged between 11 and 14 years had higher depression-like symptoms than those on the waiting list and those who have not been enrolled at all. There were no positive effects in the female adolescents. Consequently, the common statement that physical activity and sport participation is always good for mental health must be challenged. As highlighted above, it may well be not the process of playing but the ability or inability to find successful coping strategies to the stress this generates that may be at the heart of the findings of this study. The study has the advantage that it assessed local concepts of mental health in post-war Uganda, but, on the other hand, it makes comparisons with future studies in other countries difficult if not impossible. As a summary, the general claim that playing soccer improves mental health and well-being in non-professionals must be challenged before relevant studies can provide the necessary positive evidence.

Studies on the mental health of spectators of football matches are rare again.

An older Scottish study carried out by Masterton and Mender (1990) at the Edinburgh Royal Infirmary was the first to look for connections between football and mental health presentations. It showed reductions in emergency psychiatric presentations to hospital occurred during and after the finals of the 1990 World Cup, an effect evident in women as well as men. This, they surmised, could arise from enhancement of national identity and from the generation of a sense of belonging and social cohesion. This increase in feelings of inclusion they suggest has an impact on the mental health of some fans. Diagnostic categories were not assessed in this study.

There are two later studies assessing the mental health effects in possible spectators before, during and after a World Cup (see Table 1). Lau et al. (2015) observed a small but significant reduction of GHQ-12 scores in subjects from the general population of Hong Kong after versus before the 2006 World Cup Finals. Hassanian-Moghaddam et al. (2017) reported an increase in hospital admissions in Teheran because of intentional overdoses during the 2014 World cup. The effect was significant in female subjects aged 12–20 years but not in males or other age groups. Both studies thus have contradicting, that is, positive and negative effects on the mental health of spectators. Both of these studies provide no clarity on the possible reasons for the observed outcomes. Consequently, the studies provide some evidence that watching soccer may have an influence on the mental health of possible spectators but is far from clear if possible effects are positive or negative, and if so, under which circumstances.

Pringle’s work with fans of Mansfield Town FC in England (Pringle 2002, 2004, 2009) drew some strong correlations between attending football matches and the developing of positive attributes such as a sense of belonging, the opportunity for catharsis, the development of family bonds (especially between fathers and sons) and a sense of hope. Whilst these are positive attributes that can help develop resilience and promote well-being, these studies did not show reduction of symptoms or any significant change for those experiencing active mental health problems.

We could not identify any study that assessed active mental health symptoms in soccer fans and identified a positive impact on these as a result of supporting a team or attending matches. Even though there are large populations of soccer fans all over the world, we do not know if supporting a football team actually improves their mental health. Such studies might be an easy and a relevant subject of future research.

This systematic review investigated the effects of soccer on mental health in groups of players and spectators. There is no consistent evidence that playing or watching soccer improves the mental health of active or retired professional players and referees or spectators.

However, if we state that there is no evidence that it improves the mental health in these groups, we cannot exclude that individual subjects, either players or fans, find their personal happiness in football and this can be a component in reducing the potential for developing some mental health problems.

We also did not look at the immediate and short term effects of playing or watching a football game on mental health. As far as we are aware, there are very few such studies available (Selmi et al. 2017).

In summary, there is no consistent evidence that playing or watching soccer makes players or spectators happy and reduces the burden of mental health problems.

Football catches large audiences globally. Such audiences are frequently used for commercial purposes by product advertisement and promotion. However, more recently, health-promoting organisations have used football as a tool to contact a greater audience and promote engagement with mental health promotional activities (Pringle 2009, Pringle and Sayers 2004, Spandler et al. 2013). Football has been used by nurses providing help for people with mental health problems as a metaphor for life (Duffin 2006, Pringle 2009), and football has been used as a vehicle to facilitate post-war disarmament, demobilisation and reintegration processes in Sierra Leone (Dyck 2011).

Australian rural football club leaders have been trained to serve as mental health advocates with an investigation of the impact of the Coach the Coach project revealing an increased capacity to recognise mental illness and an increased confidence to respond to mental health difficulties in others (Pierce et al. 2010).

Soundy et al. (2015) systematically reviewed sports interventions in patients with schizophrenia indicating that sport has the potential to improve an individual’s quality of life through providing a meaningful normalising activity that leads to achievement, success and satisfaction. McElroy et al. (2008) reported marked benefits in self-esteem and engagement for people with psychosis taking part in their football league whilst Battaglia et al. (2013) recommended soccer as an add-on to schizophrenia treatment.

In summary, although a range of studies have observed positive effects on subjective well-being in patient groups, the vast majority of these have been evaluations of interventions that have had small sample groups providing subjective anecdotal evidence. Consequently, the hard evidence for a positive effect of soccer in any population is weak at best.

Under these circumstances, it may be astonishing that football is recommended as a proven method to improve the actual mental health of participants and spectators.

All studies assessing the prevalence or 12 months incidence of mental disorders in professional players and referees have used questionnaires and different cut-off scores to define caseness. These questionnaires were not meant to diagnose psychiatric disorders. Consequently, none of the studies have used usual approved diagnostic instruments to diagnose depression and anxiety disorder. In addition, the General Health Questionnaire (GHQ-12) did not allow to distinguish between depression and anxiety disorders. It may be recommended that future studies use acknowledged diagnostic instruments that enable psychiatric diagnoses and thus the comparison with studies in the general population and other samples.

Some of the answers of the players might be influenced by their tendencies to provide socially desirable answers, as shown by Smith et al. (2002). This might also bias the numbers of cases and the calculated prevalence and incidence rates. This effect might most likely reduce the estimated prevalence rates.

Most studies on professional players (see Table 1) may have been prone to possible selection bias because of low recruitment and low retention rates in the follow-up studies. Subjects with possible mental problems and those who suffered possible triggers might have been more interested to participate in a study on mental health and risk factors than those without. This might lead to an overestimation of the relationships between triggers and poor mental health.

A possible hindsight bias, that is, depressed subjects remembering more injuries, more problems with management and/or less psychological support might also confound and most likely enhance the estimated relationship between possible triggers and mental health problems. This problem is common in cross-sectional studies assessing risk factors and outcome at the same time. Consequently, future studies on possible triggers of mental health, therefore, need to be prospective over several years.