The prevalence of common mental disorders and its relationship with mental toughness in professional South African rugby players

Abstract

This study explores the relationship between common mental disorders and mental toughness in professional South African rugby players. A cross-sectional survey design was used by administering a questionnaire and preliminary and bivariate analyses were conducted. The inclusion criteria were professional rugby players who are able to communicate in English. The results indicated that, in general, these players (N = 215) portray significant mental toughness (M = 5.69) on a 7-point scale. Anxiety/depression and distress measured the lowest (M = 1.65) of all the common mental disorders measured in this study. Furthermore, the results indicated a positive relationship between mental toughness and sound sleep (r = .262). Negative relationships were found between mental toughness and all other common mental disorders with the highest relationship being with anxiety/depression positive² (r = –.423). Other significant relationships were found with anxiety/depression (r = –.401), distress (r = –.259), and common mental disorders problems in general (r = –.220). The results indicated that the management of teams and clinicians need to look at specific aspects, such as alcohol consumption among players, the implications of alcohol use on performance, but also mental wellbeing in general.

Keywords

Common mental disorders mental toughness professional athletes rugby players

Common mental disorders (CMDs) refer to depressive and anxiety disorders (Patel & Kleinman, 2003). These disorders are classified in the International Statistical Classification of Diseases and Related Health Problems (ICD)-10 as ‘neurotic, stress-related and somatoform disorders’ and ‘mood disorders’. For the purpose of this article, the specific description of CMDs by Gouttebarge, Kerkhoffs and Lambert (2016) is used. They describe it as ‘symptoms of distress, anxiety, depression or substance abuse/dependence’ (p. 595). These authors go further by referring to the research done by Bültmann et al. (2002) and Verhaak et al. (2005), who indicated a high prevalence of CMDs in general and specific occupational populations. In a study carried out by Gouttebarge et al. (2015) with professional football players across five European countries, it was found that in three of the countries, both life events and career dissatisfaction were associated with CMDs. These authors suggested a multidisciplinary approach to address the need for self-awareness in professional football. Another study concluded that the number of severe musculoskeletal injuries and surgeries among European professional football players can be positively correlated with symptoms of CDMs (Gouttebarge, Aoki, et al., 2016). Gouttebarge et al. (2015) also found a high prevalence of CMDs among international professional football players.

In South Africa, no study has yet been conducted on the prevalence of CMDs among professional or non-professional rugby players. This article forms part of an initial study, which has been identified for South Africa, involving professional rugby players who are the focus of this article. A further focus of this study was to discuss the relationship between CMDs and the mental toughness (MT) of rugby players.

According to a review done on MT by Connaughton et al. (2008), various understandings exist of what MT exactly is, varying from a personal trait to a defence mechanism. According to Jones et al. (2002), MT is:

. . . having the natural or developed psychological edge that enables you to: generally, cope better than your opponents with the many demands (competition, training, lifestyle) that sport places on a performer; specifically, be more consistent and better than your opponents in remaining determined, focused, confident, and in control under pressure. (p. 209)

Gucciardi et al. (2015) define MT as a unidimensional concept, which plays an important role in performance, thriving, and goal progress – irrespective of the presence of stress. Irrespective of its definition, it is internationally well known that MT contributes to sport performance (Connaughton et al., 2010; Crust & Clough, 2011; Gucciardi et al., 2008) and has been found to be a prerequisite in competitive sports (Gucciardi, 2017) as well as a key ingredient of success (Owusu-Sekyere & Gervis, 2016). A study done by Cowden (2016) on competitive tennis players refers to a positive association between self-awareness, specifically self-insight, and MT. Self-awareness or self-insight alone is, however, not enough. Athletes should be guided to build on their awareness to take action with regard to dealing with CMDs. In this context, ‘action’ refers to working towards obtaining MT. Once an athlete is mentally tough, it would be easier to address CMDs, as MT appears to predict psychological wellbeing (Stamp et al., 2015) and psychological wellbeing counters CMDs (Risal, 2011). Therefore, if athletes work towards self-awareness and MT, it could support them in dealing more effectively with CMDs. One needs to be self-aware to take action (Polk, 2013), and action is needed to address CMDs. The current article highlights this relationship between MT and CMDs. Once this prevalence and relationship are known, the goal is to develop a mental health (MH) support programme for the players, which would hopefully address challenges and assist players with improved performance.

In keeping with the aforementioned, the present study set out to answer the following research questions:

What is the prevalence of CMDs among professional South African rugby players?

What is the relationship between CMDs and MT?

Method

Participants

The population for the study included professional South African rugby players. At the time of the study, there were 940 registered elite professional players. The inclusion criteria focused on being professional rugby players and being able to communicate in English. From the 940 registered players, a purposive sample of 215 professional South African rugby players responded and gave consent for their data to be used. This amounted to 22.87% of the total population. Although the response rate seemed poor at first glance, it was viewed as a typical response to questionnaires and was expected of a group of professional people with already full schedules.

Instruments

A cross-sectional survey design, which is viewed as an appropriate design to obtain data regarding typical behaviour (Welman et al., 2005), was used in the form of a questionnaire. The questionnaire was adapted from already existing instruments that were used in a set combination (questionnaire) in a study with retired international professional rugby union players by Gouttebarge, Kerkhoffs and Lambert (2016). Permission to use the questionnaire in the aforementioned study was granted by the authors. The adapted questionnaire for this study was constructed on Google Docs available to each participant by means of the link provided on the consent form. Responses were received anonymously. The participants had to respond to specific questions and/or statements on CMDs and MT. The various subscales below have been grouped together from different questionnaires.

Distress

Distress during the 4 weeks prior to answering the questionnaire was measured, using the Distress Screener, based on the Four-dimensional Symptom Questionnaire (4DSQ). This questionnaire has been validated in different languages, including English (test–retest coefficients ⩾0.89; criterion-related validity: area under receiver operating characteristic [ROC] curve ⩾0.79) (Braam et al., 2009; Terluin et al., 2006). Scores between 1 (no), 2, or 3 (regular or very often) can be obtained on each of the three items with scores of 2 or 3 indicating the presence of distress. The alpha coefficient for the subscale was .74 (see Table 1) and was, therefore, accepted as reliable. An acceptable alpha coefficient, according to Tavakol and Dennick (2011), is between .70 and .95, although ideally it should not be higher than .90.

Table 1.

Prevalence of CMDs.

Item	Reliability	Minimum	Maximum	M	SD
Sound sleep	.81	1.2	5.00	3.54	0.93
Anxiety/depression	.84	1.00	4.00	1.65	0.60
Anxiety/depression positive	.88	1.00	4.00	1.88	0.67
Distress	.74	1.00	3.00	1.65	0.54
Mental Toughness Index	.93	1.13	7.00	5.69	1.04

Anxiety/depression

Anxiety/depression during the 4 weeks prior to completing the questionnaire was measured. The 12-item General Health Questionnaire (GHQ-12) was used and has been validated in English (criterion-related validity: sensitivity ⩾0.70, specificity ⩾0.75, area under ROC curve ⩾0.83) (Goldberg et al., 1997). A total of 12 items were presented: the first 6 questions were formulated with scales from 1 (not at all) to 4 (much more than usual). The alpha coefficient for the items was .84 (see Table 1). The last six questions were formulated in a positive manner with scales from 1 (better as usual) to 4 (much less than usual). The alpha coefficient for the items was .88 (see Table 1).

Sleep disturbances

Sleep disturbances during the 4 weeks prior to answering the questionnaire were measured. Four questions were asked from the Patient Reported Outcomes Measurement Information System (PROMIS) (Yu et al., 2011), based on a 5-point scale varying from 1 (not at all) to 5 (very much). A score of 2 and more indicates the presence of a sleep disturbance. The questionnaire has been validated in English (construct validity: product-moment correlations ⩾0.96. The alpha coefficient for the items was .81 (see Table 1).

Adverse alcohol behaviour

The 3-item Alcohol Use Disorders Identification Test (AUDIT-C) was used to measure current levels of alcohol consumption. This test has been validated in English (criterion-related validity: area under ROC curve 0.70–0.97) (Dawson et al., 2005; De Meneses-Gaya et al., 2009). Cronbach’s alpha was not applicable, as these items were discussed separately.

Smoking

A single question was asked where the participants had to answer either yes or no.

MT

The Mental Toughness Index (Gucciardi et al., 2015) was used. The 8-item scale is rated on a 7-point scale from 1 (always false) to 7 (always true). The initial validation study (i.e., Gucciardi et al., 2015) and subsequent studies (e.g., Gucciardi et al., 2016) have found construct validity support for the instrument, along with evidence of convergent and incremental validity. Appropriate internal consistency (α = .79), composite reliability (ρ = .86 to .89), and omega coefficients (ω = .82 to .89) have been demonstrated for the measurements taken during several athlete studies (Gucciardi et al., 2015, 2016; Mahoney et al., 2014). The alpha coefficient for the items was .93 (see Table 1).

Procedure

The link to the informed consent form and questionnaire was sent to the rugby players by means of an email by a MyPlayers mediator. MyPlayers is the representative body for all professional rugby players in South Africa. Interested players needed to read the informed consent form and then by clicking on the submit button on the questionnaire, they gave consent for their data to be used. The questionnaire was made available in English. The participants were asked to complete the questionnaire within a week. However, this process took substantially longer due to the full schedules of the players. The completed questionnaires were automatically saved on a secure electronic server that only the researchers have access to.

Ethical considerations

Permission was obtained from the MyPlayers management (including the players’ representatives). Furthermore, ethical clearance was obtained from the Health Research and Ethics Committee of the North-West University.

Data analysis

The data analysis for the quantitative research was based on the SPSS Version 24 statistical programme. Statistical Services at the university assisted with the quantitative data management. To determine the suitability of the quantitative data, preliminary analyses (internal consistency, normality, homogeneity of variance) were performed to determine whether the measures and data were appropriate for parametric analyses. Bivariate analyses were also completed between each of the stressors and the MH variables (Spearman’s rank correlations).

Results

Data from Table 3 indicated the prevalence of CMDs among the 215 participants who completed the questionnaire.

Table 1 indicates that in general, the players portray significant MT (M = 5.69), where 1 represents the lowest obtainable score and 7 the highest. On average, most of the players experience sound sleep (M = 3.54) where 1 represents the lowest obtainable score and 5 the highest. Anxiety/depression and distress measured the lowest (M = 1.65) of all the CMDs. The anxiety/depression positive items (last six items) measured higher (M = 1.88) than the first six anxiety/depression items (M = 1.65). With regard to alcohol consumption, 57% of the players indicated that they have less than four alcoholic drinks a day and 74% of the players indicated that they consume two or less drinks per day. Most of the players (83.9%) indicated that they have more than six alcoholic drinks on one occasion, once a month or less frequently. Although the average scores of all the CMDs seems to be favourable, one must rather focus on the percentage of players who do experience problems with symptoms of CMDs.

To determine when symptoms of CMDs could become a problem to players, the following classification was used (see Table 2).

Table 2.

Symptoms of CMDs converted into problems.

Distress	A score of 1 to 2 received 0; a score of 2 to 3 (regular or often) received 1
Sound sleep	A score of 1 to 2 (not at all or a little) received 1; all other scores received 0
Anxiety/depression	A score of 3 to 4 (more than usual) received 1; all other scores received 0
Mental Toughness Index	A score of 1 to 3 (false) received 1; all other scores received 0
How often do you have a drink?	More than 4 times a month received a 1; all other scores received 0
How many drinks (standard glass)?	More than 4 drinks a day received 1; all other scores received 0
How often do you have six or more?	4 times a month or more received 1; all other scores received 0
Smoking	Smoking received 1; non-smoking received 0

Table 3 shows that the most pressing problem that the players are experiencing, is a problem with alcohol (47.9%), where a player has experienced at least one of the three alcohol problems. Other problems that feature are distress (16.3%), sleep disturbances (7%), together with anxiety and depression (4.2%). Smoking is indicated as a problem, with for 4.7% of the players indicating that they smoke.

Table 3.

Prevalence of problems.

Problem	Frequency	Percentage
Distress	35	16.3
Sleep	15	7
Anxiety-depression	9	4.2
Smoke	10	4.7
Alcohol	103	47.9

From these problems stated, the total number of problems that the sample of rugby players experienced was calculated (see Table 4).

Table 4.

Total number of problems rugby players experienced.

Number of problems	Number of players	Percentage
0	0	40.9
1	789	41.4
2	24	11.2
3	14	6.5

Table 4 indicates that 40.9% of the players did not experience any CMD-related problems; 89 players (41.4%) had elevated scores in one problem area; 24 players (11.2%) had elevated scores in two problem areas; and 14 players (6.5%) experienced problems in three of the identified categories. None of the players experienced elevated scores in more than three of the identified problem areas.

To illustrate the potential relationships between the above-mentioned problems and MT, Table 5 highlights a positive relationship between MT and sound sleep (r = .262). This positive relationship is supported by a study done by Haghighi and Gerber (2018) that indicated that MT could be associated with fewer mental complaints, including insomnia. The current study indicates a negative relationship between MT and CMDs (higher MT coincided with lower levels of CMD-related problems), although this relationship must be interpreted very carefully, as it does not necessarily indicate causality. The highest negative relationship was found between anxiety/depression (r = −.401), followed by distress (r = −.259) and the number of CMD-related problems experienced (r = −.220).

Table 5.

Spearman’s rank correlation of prevalence of problems with mental toughness.

Item	Mental toughness
How often do you have a drink containing alcohol?	−0.060
How many drinks (standard glass) containing alcohol do you have on a typical day?	0.023
How often do you have six or more drinks (standard glass) containing alcohol on one occasion?	−0.087
Sound sleep	0.262*
Anxiety/depression	−0.401*
Anxiety/depression positive	−0.423*
Distress	−0.259*
Smoke problem	−0.103
Number of problems	−0.220*

p < .05.

Discussion

The results indicated a presence of CMDs in 4.7% of this sample of South African professional rugby players, as most of the players displayed significant MT. To put the findings of the current study into perspective, the prevalence of CMDs in this group was found to be lower than the findings in similar recent studies. A study by Williams et al. (2016) indicated that up to 16.5% of South Africans struggle with a CMD during any given year. According to Stein et al. (2008) close to a third of the population have experienced a CMD at least once during their lifetime. This number seems to be even higher in some Western world countries where more accurate and comprehensive statistics are being recorded (Australian Institute of Health and Welfare, 2018; Stansfeld et al., 2014).

The 4.7% of CMDs found in this study appears to be lower than what has been found in recent studies, but the results, nevertheless, appear to be in line with other research on the general population from organisations such as the World Health Organization (WHO). In a 2017 publication, the WHO (2017) indicated a 4.4% prevalence of CMDs for the global population and 9% for the African region. Similarly, a 3.6% prevalence was measured for anxiety disorders, with 10% for the African region. If compared to a study done by Patel and Kleinman (2003) on the prevalence of CMDs in general, the results from the current study, however, seemed significantly lower than their results, indicating a prevalence of 20%–30% among participants in 11 studies from countries in Africa, Asia, and Latin America.

Despite the fact that approximately half of the players in the present study did not indicate any presence of CMDs, they still expressed problems with aspects often related to CMDs, such as being distressed, depressed/anxious symptoms, experiencing sleeping disturbances, and/or problems with alcohol use. Consequently, such problems still need to be addressed as it can have a debilitating effect on the performance of players and the outcome of matches (Rice et al., 2016). This is because, according to Umilatul and Niken (2020), anxiety can arise due to competitive pressures. Similarly, depression that is often associated with burnout among athletes, could lead to performance impairment (Mummery, 2005).

Although there could be several potential explanations for the relatively low level of CMDs in this cohort, it would probably partially be explained by the higher levels of MT. It is, however, important to interpret the study results very carefully, as it does not necessarily indicate causal relationships. It is, nonetheless, indicating interesting correlations which should be investigated further in future studies.

Several international studies have indicated that anxiety, depression, and distress are common among athletes (Keaney et al., 2018; Kilic et al., 2017; Walker et al., 2007; Walsh et al., 2011). In a recent study with elite athletes in the United Kingdom, 47.8% of the sample of the athletes showed signs of anxiety/depression (Foskett & Longstaff, 2018). Although the prevalence of CMDs in the current study is lower than other sports-related studies, and in line with the WHO (2017) findings on the general population, the more concerning factors are the CMD-related symptoms and behaviours of the players, including the use of alcohol, distress, sleep disturbance, and smoking, as these are all factors which can affect mental wellbeing, as well as performance.

The percentages provided in Table 3 clearly indicate that the biggest problem that rugby players in this sample must overcome is the use of alcohol. Almost half (47.9%) of the players indicated some sort of excessive alcohol use. This elevated level of alcoholic consumption in almost half of the players is also higher than one would expect in a professional sports environment, especially due to the potential negative impact this can have on performance. According to a study conducted by Prentice et al. (2015) with club rugby union players, heavy episodic alcohol consumption, associated with reduced sleep, contributes to lower body power output the morning after a drinking session. Unfortunately, measures were not indicated on anaerobic performance. A study by Lecoultre and Schutz (2009) with trained cyclists also indicated a detrimental performance influence after low to moderate alcohol use. Furthermore, according to Vella and Cameron-Smith (2010), excessive alcohol consumption can have a significant impact on the human body, including neural functioning, metabolism, cardiovascular physiology, thermoregulation, and skeletal muscle myopathy. It could, therefore, be assumed that professional rugby players would not tend to indulge in alcohol use. This tendency of high alcoholic consumption, however, is not uncommon, as was evident from the results in a study done by Martens et al. (2006), where it was revealed that higher levels of alcohol consumption are associated with higher sport performance levels. This is alarming, especially when considering a study conducted by Karnincic et al. (2018), who found that none of the participants (handball players) who were tested for alcohol consumption by making use of the Alcohol Use Disorders Identification Test (AUDIT), measured on the low-risk scale. The participants either measured as hazardous drinkers (33.77%), harmful drinkers (34.44%), or probable dependence (31.79%). In a study by Du Preez et al. (2017), it was found that elite rugby league players in Australia showed hazardous levels of alcohol use during pre-season (68.6%) and in-season (62.8%).

In the current study, more players indicated excessive alcohol use during a specific occasion (more than six drinks) than having three or more drinks per day. The findings by Turrisi et al. (2007) indicated that student athletes engage in more episodic drinking than their non-athlete peers. A South African study (Surujlal et al., 2012) highlighted the tendency of male athletes to consume high quantities of alcohol during specific occasions. Similar to the study by Gouttebarge, Kerkhoffs and Lambert (2016), it was not specified whether these drinking habits occurred during team socials or during other social occasions. In a study by Taylor et al. (2017), it was found that male student athletes are at risk of problematic alcohol consumption. It is, therefore, difficult to assess whether the alcohol consumption of the current cohort in this study is due to the culture in elite rugby environments, or if the behaviour is CMD related. On the contrary, excessive use of alcohol over a prolonged period can also contribute to possible CMD symptoms.

In addition to the findings related to alcohol consumption, only a small percentage of the players indicated that they were smokers. This small percentage of smokers among professional athletes correlates with research on smoking habits where it was found that smoking among athletes measures lower in comparison with the general population (Alaranta et al., 2006). This may be due to the awareness of athletes that smoking influences physical health and therefore potentially performance as well (Karnincic et al., 2018).

Another important finding of the present study refers to MT. Although only 3.3% of the players indicated that they do not view themselves as being MT, this should be earmarked as a concern, especially in light of its negative relationship with CMDs. According to Gucciardi et al. (2017), MT may represent a positive indicator of MH. It is, therefore, important to pay attention to the MT of players, as it plays an important role in success (Zeiger & Zeiger, 2018). Cowden (2016) conducted a study on MT and tennis, and found that MT may contribute to successful tennis performance and in a study with adolescent volleyball players, the research of Raudsepp and Vink (2018) indicated a positive association between MT and sport-specific practice. It is globally recognised that MT contributes to success in all sport (Connaughton et al., 2008) and serves as a catalyst in maintaining emotional, behavioural, and cognitive control (Jones et al., 2007). In view of the literature emphasising the importance of MT in a sport environment, the MT of professional South African rugby players must receive continual attention and be highlighted as a top priority.

This study succeeded in making specific role-players aware of the experiences of South African rugby players in this sample about CMDs and MT. However, it is possible that the participants who chose to participate in this study were the ones who felt confident enough, organised, psychologically minded, and interested in this topic, which could influence the representation of MT and CMDs. Others, who might have been struggling with CMD symptoms, might not have the drive and energy to participate in the study or would fear potential stigmatisation as a result of disclosing their mental state. Since this cannot be regarded as a random sample from the population, the results cannot be generalised to the larger population. Especially in light of the discrepancies between the prevalence of CMDs in this study and other similar research, further investigation is needed to determine the true state of CMDs in a South African professional rugby environment. Also, as this is not an interventional study, associations cannot be regarded as causal and must be interpreted with care. Despite its limitations, 22.87% of the total population provided an indication of the current prevalence of CMDs among professional South African rugby players.

Conclusion

The results showed that professional South African rugby players in this sample experience CMDs which are in line with the global statistics, but lower than similar studies in other sports environments. More concerning were the findings related to certain behaviours and other symptoms, such as increased alcohol use and the high levels of distress. CMDs are, nonetheless, still a very important area that must be addressed to enhance the wellbeing and performance of rugby players. The negative relationship between CMDs and MT in this sample also indicates that MT is an area of importance that needs to be maintained or improved, as it appears to be protecting players from CMDs.

In light of the already existing literature, this study did not reveal unexpected results in terms of the global findings. However, it is an important study, as it is the first of its kind with South African professional rugby players to give an initial indication of the prevalence of CMDs and its relationship with MT within this population. Such information can contribute towards the development of a specific MH support programme to address the unique challenges that these players experience. Apart from monitoring CMDs, the results indicated that team management and clinicians also need to look carefully at CMD-related symptoms and behaviours, such as alcohol consumption among players and its impact on performance and mental wellbeing in general. Although there is not a causal relationship between the alcohol use and CMDs in this study, excessive prolonged alcohol use can eventually affect the MH of players. Although the percentages for anxiety/depression seem relatively low in relation to general populations, it is important to address these aspects, and the presence of distress among the players.

In general, this study made a valuable theoretical contribution towards a better understanding of the prevalence of CMDs in South African rugby players and the correlation it has with MT. It also made a practical contribution by highlighting aspects that team management and physicians can closely monitor among their players to enhance their MT and limit the prevalence of CMDs, such as excessive alcohol consumption.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Herman Grobler

Kobus du Plooy

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