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BeiseckerL, etal. Br J Sports Med 2024;0:1–10. doi:10.1136/bjsports-2023-107328
Depression, anxiety and stress among female
student- athletes: a systematic review andmeta-
analysis
Ling Beisecker ,1,2,3 Patrick Harrison ,4 Marzia Josephson,5 J D DeFreese 2,3
Systematic review
To cite: BeiseckerL,
HarrisonP,
JosephsonM, etal.
Br J Sports Med Epub ahead
of print: [please include Day
Month Year]. doi:10.1136/
bjsports-2023-107328
►Additional supplemental
material is published online
only. To view, please visit the
journal online (http:// dx. doi.
org/ 10. 1136/ bjsports- 2023-
107328).
1Department of Health Sciences,
The University of North Carolina
at Chapel Hill, Chapel Hill, North
Carolina, USA
2Human Movement Science
Curriculum, The University of
North Carolina at Chapel Hill,
Chapel Hill, North Carolina, USA
3Exercise and Sport Science,
University of North Carolina at
Chapel Hill, Chapel Hill, North
Carolina, USA
4Department of Psychology and
Neuroscience, The University of
North Carolina at Chapel Hill,
Chapel Hill, North Carolina, USA
5College of Education, University
of Kentucky, Lexington,
Kentucky, USA
Correspondence to
Ling Beisecker, Department of
Health Sciences, The University
of North Carolina at Chapel Hill,
Chapel Hill, NC 25799, USA;
lbeisecker@ unc. edu
Accepted 3 January 2024
© Author(s) (or their
employer(s)) 2024. No
commercial re- use. See rights
and permissions. Published
by BMJ.
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.
INTRODUCTION
The enactment of Title IX in 1972 marked a pivotal
moment for women’s involvement in collegiate
sports at the National Collegiate Athletic Associa-
tion (NCAA) level in the USA. Title IX was ground-
breaking 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 tradi-
tionally 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
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.
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2BeiseckerL, etal. Br J Sports Med 2024;0:1–10. doi:10.1136/bjsports-2023-107328
Systematic review
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 knowl-
edge 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 exer-
cise 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 litera-
ture focuses on eating disorders and disordered eating preva-
lence 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 impor-
tance 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 profes-
sionals 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 symp-
toms 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, indi-
cating 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 special-
ising 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.
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. Quan-
titative 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 cita-
tions identified through Google Scholar and citation searching,
totaling 3040 citations. Citations were imported to Covidence,33
an online software programme for managing systematic reviews.
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BeiseckerL, etal. Br J Sports Med 2024;0:1–10. doi:10.1136/bjsports-2023-107328
Systematic review
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 infor-
mation for inclusion in the meta- analysis. See figure 1 and online
supplemental table 1—see Methods section for full details.
Assessment of study quality
Study quality was assessed with the Joanna Briggs Institute’s (JBI)
critical appraisal tools for systematic reviews.34–36 JBI assess-
ments were chosen based on their aim to provide a comprehen-
sive 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 ques-
tion 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; deter-
minants; 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 identi-
fied as potentially positive antecedents. Positive predictors were
reverse coded such that correlation coefficients indicated the
relation between negative predictors and higher levels of depres-
sion, anxiety and/or stress.
Correlation coefficients were Fisher’s z transformed to un- bias
effect sizes and 95% CIs were calculated. Due to the hetero-
geneity in the nature and design of the studies included in the
meta- analysis, a random- effects model was employed. All anal-
yses 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.
Figure 1 PRISMA 2020 flow diagram. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta- Analyses.
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Systematic review
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 depres-
sion, 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 deter-
minants 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 determi-
nant, 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 relation-
ships54 and perceived tangible support from personal and athletic
sources.56 One study differentiated receiving and providing social
support reporting both were associated with decreased depres-
sion among female student- athletes.53 Another study differenti-
ated between social support from family or friends, finding in
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BeiseckerL, etal. Br J Sports Med 2024;0:1–10. doi:10.1136/bjsports-2023-107328
Systematic review
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 asso-
ciated 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, musculo-
skeletal 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 depres-
sion 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 base-
line 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 Divi-
sion 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 Divi-
sion 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 depres-
sion, 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, over-
training among swimmers was associated with increased depres-
sion, 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 depres-
sion 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 facili-
ties 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
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Systematic review
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 Divi-
sion 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 depres-
sion, 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 asso-
ciation of discrimination and depression and anxiety.77 Among
Asian- identified student- athletes, above- average hours of exer-
cise buffered the relationship between increased discrimination
and increased depression.77 Moreover, while there was a posi-
tive 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.
The random- effects model also suggested significant variability
in effect sizes, Q12=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 determi-
nant 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.
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 regres-
sion, suggest systematic bias is unlikely. See figure 4.79
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 exten-
sively 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
Figure 2 Forest plot of effect sizes included in the meta- analysis. RE,
random effects.
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BeiseckerL, etal. Br J Sports Med 2024;0:1–10. doi:10.1136/bjsports-2023-107328
Systematic review
findings aligned with the current state of the literature high-
lighting that identifying as female is a significant predictor of
depression, anxiety and stress.6 8 9 12 14 15 18 19 21–26 This under-
scores 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 develop-
ment 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 facil-
itating 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 experi-
encing 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 consid-
ering 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 depres-
sion, 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 under-
reporting of mental health outcomes.84 This is an issue as the
majority of included studies assessed depression, anxiety and
Figure 3 Significant moderation by outcome measure.
Figure 4 SE funnel plot.
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Systematic review
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 determi-
nants 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. Further-
more, 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 consider-
ation 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 deter-
minant 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 biolog-
ical 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 find-
ings 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 exer-
cise 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 high-
lights 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 strat-
egies and practice evidence- based treatment and care. Stake-
holders 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.
Twitter Ling Beisecker @ling_beisecker
Acknowledgements 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.
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.
Patient consent for publication Not applicable.
Ethics approval Not applicable.
Provenance and peer review Not commissioned; externally peer- reviewed.
Data availability statement All data relevant to the study are included in the
article or uploaded as supplementary information.
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.
ORCID iDs
LingBeisecker http://orcid.org/0000-0001-5336-9264
PatrickHarrison http://orcid.org/0000-0003-3476-1812
J DDeFreese http://orcid.org/0000-0003-3233-0699
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