Does The Sport Mental Health Assessment Tool-1 Accurately Triage Olympic And Paralympic Athletes?

PURPOSE: To assess previous sample representation limitations and provide classification performance metrics to evaluate the accuracy of the Athlete Psychological Strain Questionnaire (APSQ) in triaging athletes to Step 2 of the Sport Mental Health Assessment Tool (SMHAT-1). METHODS: Prior to the Paris 2024 Olympic and Paralympic Games, Team USA athletes (n = 911, age: 27.3 ± 6.1 years, 52.1% female, 26.1% Paralympic) completed the SMHAT-1 as part of a mandatory pre-Games health screening. Athletes completed both the APSQ (Step 1) and all Step 2 questionnaires, regardless of their APSQ score. Step 2 questionnaires included the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Athlete Sleep Screening Questionnaire (ASSQ), CAGE-AID for drug use, Alcohol Use Disorders Identification Test-Concise (AUDIT-C), Brief Eating Disorder in Athletes Questionnaire (BEDA-Q), and Post-Traumatic Stress Disorder (PTSD). All questionnaires were scored and marked as “flag” or “no flag” according to established thresholds. Classification performance metrics were calculated and compared to previous literature. An exploratory factor analysis was conducted to investigate covariance between Step 2 questionnaires and explain observed false negative rates (FNRs). RESULTS: The prevalence of a flagged APSQ was 24.7%. FNRs were calculated as PHQ9 = 0% GAD7 = 7.7%, ASSQ = 52.9%, AUDIT-C = 61.2%, CAGE-AID = 37.5%, BEDA-Q = 63.16%, PTSD = 11.1%, congruent with previous findings. Exploratory factor analysis showed that GAD-7 and PHQ-9 were grouped under the first factor, while CAGE-AID was grouped under the second factor. The other questionnaires did not fit distinctly into either factor, suggesting the SMAHT is assessing a broad spectrum of mental health factors, which would be difficult for a single generic screening tool to triage adequately. CONCLUSIONS: While the SMHAT-1 remains an essential tool for athlete mental health screening, the high FNRs indicate limitations in using the APSQ as an initial triage instrument. The APSQ may be better suited as a Step 2 assessment. A bespoke Step 1 screening tool that captures the diverse spectrum of mental health concerns in athletes should be considered to enhance the tool’s effectiveness and potentially increase its adoption across all levels of sport. Supported by: This work was funded in part by a grant from the International Olympic Committee.