Profess

(1)

Rece ved / Gel ş: 10.10.2020 · Accepted / Kabul: 29.10.2020 · Publ shed / Yayın Tar h : 01.03.2021

Correspondence / Yazışma: Ömer Serkan Kara · Hacettepe Ün vers tes , Tıp Fakültes Spor Hek ml ğ Anab l m Dalı, Ankara, Turkey · omerserkankara@gma l.com

Research Art cle / Araştırma Makales

Profess onal athletes have h gher anx ety levels dur ng COVID-19 outbreak compared to recreat onal athletes and sedentary people

Profesyonel sporcular COVID-19 salgını sırasında rekreasyonel sporcular ve sedanter b reylere kıyasla daha kaygılı

Ömer Serkan Kara¹ , Gökhan Büyüklüoğlu² , N han Büyüklüoğlu³ , Selçuk Gül⁴ , Mehmet Mesut Çeleb² , Hasan Kaya³

1Department of Sports Med c ne, Faculty of Med c ne, Hacettepe Un vers ty, Ankara, Turkey 2Department of Sports Med c ne, Faculty of Med c ne, Ankara Un vers ty, Ankara, Turkey

3Psych atry Sect on, Ankara C ty Hosp tal, Ankara, Turkey 4Sports Med c ne Sect on, Erzurum State Hosp tal, Erzurum, Turkey

ABSTRACT

Object ve: Although the COVID-19 outbreak affected almost all the people globally, the number of studies investigating the effects on professional ath‐

letes are very low. Therefore, we aimed to examine anxiety levels, mental toughness and daily habits of professional and recreational athletes during the early phase of the pandemic and compare these with sedentary control objects.

Mater als and Methods: 634 participants were evaluated in April 2020 with an online survey consisted of sociodemographic data, exercise habits and outbreak-related questions, along with Turkish versions of Sports Mental Toughness Questionnaire (SMTQ) and State-Trait Anxiety Inventory (STAI).

329 of the participants were professional athletes, 135 were recreational athletes and 170 were sedentary people.

Results: Professional athletes (PROs) scored significantly higher (p<0.017) than recreatio-nal athletes (RECRs) and sedentary people (SEDs) on SMTQ and State-Anxiety Scores, but not on Trait-Anxiety Score (p˃0.05). Besides, there were no significant differences between RECRs and SEDs on any of the scores (p˃0.05). For SMTQ scores; activity level, gender and age are found to be significantly predictive. State-Anxiety scores were only signifi‐

cantly correlated with activity levels, whereas, gender and age were signiﬁcantly correlated with the Trait-Anxiety scores (p<0.05).

Conclus on: Being a high-level professional athlete is related to higher state anxiety levels during the COVID-19 outbreak. Even though professional athletes are mentally tougher, which will help them cope with high anxiety levels, they may need extra psychologic support as long as the pandemic and restrictions continue.

Keywords: professional athletes, physical activity, COVID-19, anxiety, mental toughness ÖZ

Amaç: COVID-19 salgını tüm insanları etkiledi, ancak profesyonel sporcular üzerindeki etkilerini araştıran çok az çalışma var. Bu nedenle pandeminin erken döneminde profesyonel ve rekreasyonel sporcuların anksiyete düzeylerini, mental dayanıklılıklarını ve günlük alışkanlıklarını incelemeyi ve bunları sedanter bireylerle karşılaştırmayı amaçladık.

Gereç ve Yöntemler: 634 katılımcı 2020 yılı Nisan ayında sosyodemograﬁk bilgiler, egzersiz alışkanlıkları ve salgınla ilgili soruların yanı sıra Sporda Men‐

tal Dayanıklılık Ölçeği (SMDÖ) ve Durumluk-Sürekli Kaygı Envanterinin (DSKE) türkçe versiyonlarından oluşan çevrimiçi bir anket ile değerlendirildi. Katı‐

lımcıların 329’u profesyonel sporcu, 135’i rekreasyonel sporcu ve 170’i ise sedanter bireylerdi.

Bulgular: Profesyonel sporcular (PRO'lar) Mental Dayanıklılık ve Durumluk-Kaygı puan-larında rekreasyonel sporculardan (REKR'ler) ve sedanter kişiler‐

den (SED'ler) anlamlı ölçüde daha yüksek (p<0.017) puan almasına karşın Sürekli-Kaygı puanında anlamlı bir farklılık gözlenmedi (p˃0.05). Ayrıca, REKR'ler ve SED'ler arasında puanların hiçbirinde anlamlı bir fark yoktu (p˃0.05). Toplam SMDÖ puanlarını belirleyici faktörler ﬁziksel aktivite düzeyi, cinsiyet ve yaş olarak saptandı. Durumluk Kaygı puanları sadece aktivite düzeyi, Sürekli Kaygı puanları ise cinsiyet ve yaş ile önemli ölçüde ilişkili bulun‐

du (p<0.05).

Sonuç: COVID-19 salgını sırasında, profesyonel sporcu olmak, daha yüksek durumluk kaygı düzeyi ile ilişkili bulundu. Profesyonel sporcular kaygıyla baş etmelerini kolaylaştıran yüksek mental dayanıklılığa sahip olsalar da pandemi ve sportif faaliyetlerin kısıtlamaları sürdükçe ilave psikolojik yardıma ihtiyaç duyabilirler.

Anahtar Sözcükler: profesyonel sporcular, ﬁziksel aktivite, COVID-19, anksiyete, mental dayanıklılık

INTRODUCTION

Novel coronav rus d sease (COVID-19) spread all over the world and became a pandem c. People were encouraged to

"stay at home" as much as poss ble, keep soc al d stance and wear mask (1). Governments even had to mpose curfe‑

(2)

ws, lockdowns and take s m lar measures to m t gate the spread of the outbreak. All these restr ct ons, the ncreas ng number of cases and deaths on a global scale and the news n the med a s gn f cantly ncreased anx ety and stress n soc ety (2). Moreover, people have nev tably been spend ng more t me at home and mov ng less than before (3).

Profess onal athletes d er from the normal populat on w th the r da ly l fe, expectat ons and stressors (4-6). Sus- pend ng leagues, postpon ng mega sport ng-events, restr c- t ng access to gyms, cancel ng team tra n ng and pay cuts are some of the major stressors encountered dur ng the pandem c by th s exclus ve commun ty (7). The mpact of these l m tat ons on the psychology of athletes cannot be den ed and should be explored (8). Recreat onal athletes, on the other hand, d verge from profess onal athletes n terms of the r approach to sports and the psycholog cal effects of exerc se on them (9,10). For recreat onal athletes, tra n ng s a way of cop ng w th stress (9,11). S nce these people mostly engage n phys cal act v t es n publ c spaces and gyms, they are s gn f cantly a ected by the restr ct ons.

M t gat on strateg es also d srupt the rout ne da ly phys cal act v t es of the sedentary people.

Regular phys cal act v ty s known to prevent the development of anx ety n the general populat on, reduce depress - on and mprove mental well-be ng, sleep qual ty and cogn - t ve funct ons (12). Chron c d sease-related anx ety has been shown to decrease w th exerc se (13). Bes des, nd v - duals w th a pred spos t on to anx ety spectrum d sorders do not reach the d sorder level f regular phys cal act v ty s ma nta ned (14). Moreover, stud es nvest gat ng e ects of exerc se on psych atr c symptoms dur ng the pandem c also revealed support ng results (15-17). Although exerc se s cons dered as one of the lead ng strateg es for prevent ng mental d sorders, the relat onsh p between phys cal act v ty level and psycholog cal parameters s a research subject yet to be clar f ed (18).

Anx ety can be cons dered as a s tuat on or event-related trans ent state (e.g., state anx ety), or a relat vely stable personal ty character st c (e.g., tra t anx ety) w th the for- mer be ng more l kely to ncrease n l fe-threaten ng and harsh cond t ons (19). The pandem c s a challeng ng s tuat on that ncreases anx ety n people, and t cannot be de- n ed that psycholog cal res l ence a ects th s context. Psyc- holog cal res l ence s the ab l ty to successfully overcome advers t es and adapt desp te the challeng ng cond t ons. It also has some features, such as ma nta n ng healthy development and struggl ng w th a negat ve s tuat on (20). Th s concept, wh ch s one of the ma n nterests of psychology, has found ts place n sports as "mental toughness". Whet- her mental toughness (MT) s a state-spec f c feature or a

cont nuous tra t n personal ty s st ll the subject of research (21). Nevertheless, t s known that MT of el te athletes who face more challeng ng cond t ons s h gher than recreat onal athletes (22). Even though athletes are known to be mentally res l ent to challeng ng s tuat ons, one should cons der that the pandem c has ts own features.

"Athlete's mental health" s a grow ng concern among the sports med c ne commun ty recently. Desp te th s, to the best of authors' knowledge, there are very few stud es n- vest gat ng the e ects of the pandem c on profess onal athletes n current l terature (23,24). In these extraord nary cond t ons, wh ch are the f rst t me n the modern world w th an unknown end, early research related to the exerc se hab ts and relat onsh p of those w th psycholog cal parameters may gu de the measures to be taken to protect pub- l c health, e ther phys cally or mentally. Therefore, we a med to nvest gate anx ety levels, mental toughness and da ly hab ts of profess onal and recreat onal athletes (study groups) n the current s tuat on and compare these w th sedentary control subjects.

MATERIALS and METHODS Participants and Design

A er approval of the local eth cs comm ttee (no: İ4-245-20), a total of 634 part c pants were cross-sect onally evaluated n Apr l 2020. Part c pants were cons sted of 3 groups; profess onal (el te) athletes, recreat onal athletes, and sedentary people abbrev ated as PROs, RECRs, and SEDs, respec- t vely. PROs were compet ng at e ther the top-level nat onal league or the f rst d v s on for the r sports branch, RECRs were part c pat ng n var ous types of sports for fun or general well-be ng, and SEDs were not part c pat ng n any k nd of regular phys cal act v ty.

Patient and Public Involvement

Pat ents or the publ c were not nvolved n any part of th s study.

Methods

The part c pants were evaluated anonymously w th an onl - ne survey v a Google Docs™ appl cat on. The survey con- s sted of 4 ma n sect ons; soc odemograph c data-related, COVID-19-related, exerc se-related (only for PROs and RECRs), and Turk sh vers ons of Sports Mental Toughness Quest onna re (SMTQ) and State-Tra t Anx ety Inventory (STAI) (25,26).

Soc odemograph c data cons sted of age, gender, educat on level, mar tal status, number of ch ldren, presence of chro- n c llness, smok ng, and alcohol consumpt on.

In the COVID-19-related part, nformat on about f they l ve

(3)

Table 1. Sociodemographic Characteristics of Participants

Characteristic Professional Recreational Sedentary Full sample

n % n % n % n %

Gender

Female 115 34,9 69 51,1 104 61,2 288 45,4

Male 214 65,1 66 48,9 66 38,8 346 54,6

Marital status

Single 86 26,1 11 8,1 39 22,9 136 21,4

Married/partnered 243 73,9 124 91,8 131 77,1 498 78,6

Divorced/widowed 0 0 0 0 0 0 0 0

Other 0 0 0 0 0 0 0 0

Children

Yes 62 18,8 4 2,9 0 0 66 10,4

No 267 81,2 131 97,1 170 100 568 89,6

Chronic Disease

Yes 17 5,1 16 11,9 29 17,1 62 9,8

No 312 94,9 119 88,1 141 82,9 572 90,2

Smoking Status

Smoker 70 21,3 26 19,3 46 27,1 142 22,4

Non-smoker 259 78,7 109 80,7 124 72,9 492 77,6

Alcohol Consumption

Yes 135 41,1 94 69,7 76 44,7 305 48,1

No 194 58,9 41 30,3 94 55,3 329 51,9

Measure Professional Recreational Sedentary Full sample

M SD M SD M SD M SD

Age 25,3 5,53 25,3 5,52 27,2 8,13 25,8 6,39

Education Level 14,5 2,11 16 1,48 15,8 1,95 15,2 2,06

M: Mean, SD: Standard Deviation

nosed w th COVID-19, f any relat ve of the rs was d agnosed w th COVID-19, v deo call numbers per day were obta- ned. Also, part c pants were asked to score the r sleep from 1 to 10 w th 10 represent ng the r usual, pre-pandem c sleep.

The exerc se-related part quest oned the follow ng, current weekly exerc se t me (hours/week) and exerc se ntens ty (scored from 1 to 10 w th 10 represent ng the r overall exer- c se ntens ty before pandem c), current njury status (PROs only), pre-pandem c weekly exerc se t me (RECRs only).

PROs were add t onally asked f they were nformed about the nfect on by the r team doctor, f they rece ved an exer- c se program from the team, how they th nk the r performance would be a ected by the course of the pandem c (both nd v dually and as a team w th separate quest ons).

SMTQ s a 4-po nt L kert-type quest onna re developed by Sheard, Golby, and Wersch n 2009 (27) cons st ng of 14 tems. The sum of 14 tems y elds a total raw SMTQ score, wh ch ranges from 14 to 56. The State-Tra t Anx ety Inven- tory developed by Sp elberger et al. (28) s also a 4-po nt L - kert-type quest onna re used to measure the state and tra t anx ety levels ndependently and conta ns a total of 40 quest ons, each cons st ng of 20 quest ons. The sum of tems s calculated, then pre-determ ned constants (50 for the sta-

te, 35 for the tra t) are added to y eld STAI scores. Wh le n- terpret ng both of the results, there are no cut-o values, but h gher scores show greater MT and h gher anx ety, respect vely. Val d ty and rel ab l ty of Turk sh vers on of both the SMTQ and STAI are demonstrated before by Pehl van (26) and Oner et al.(25), respect vely.

Exclusion Criteria

Part c pants younger than 18 years of age, profess onal athletes compet ng at a lower level than abovement oned and healthcare profess onals were excluded from the study.

Data Analyses

Data were f rst screened for outl ers and normal ty. Ch -squ- are tests were used n the nter-group compar son of catego- r cal var ables, and categor cal var ables were expressed as numbers and percentages. P values lower than 0.05 were cons dered as stat st cally s gn f cant. PROs were cons sted of predom nantly males (n=214, 65.0%, p< 0.01) and SEDs were cons sted of predom nantly females (n=104, 61.2%, p<0.01). Therefore, we conducted mult var ate analyses of co-var ance (MANCOVA) to establ sh whether there were n- ter-group d erences n 3 quest onna re scores w th gender as a co-var ant. In the compar son of 3 groups as for quest - onna re scores, un var ate analys s of var ance (ANOVA)

was used, and p values lower than 0.05 were cons dered as stat st cally s gn f cant. For further compar sons of poss ble b nary comb nat ons of groups, the post-hoc test was used, and p values lower than 0.017 were cons dered as stat st - cally s gn f cant us ng the Bonferron correct on. For b var -

ate correlat ons, the Pearson correlat on coe c ent was used, and p values lower than 0.05 were cons dered as sta- t st cally s gn f cant. The calculat ons were performed us ng a stat st cal package program Stat st cal Package for Soc al Sc ences (SPSS) vers on 22.0.

(4)

RESULTS

Table 2. Descriptives of COVID-19- related questions

Questions Professional Recreational Sedentary Full sample

n % n % n % n %

Compliance to “Stay Home” Recommendations

Compliant 310 94,2 119 88,1 150 88,2 579 91,3

Non-compliant 19 5,8 16 11,9 20 11,8 55 8,7

With Whom The Participant Lives

With someone 309 93,9 120 88,8 153 90 582 91,8

Alone 16 4,8 15 11,2 17 10 48 7,6

At team facility 4 1,3 0 0 0 0 4 0,6

Existence of at-risk population for COVID-19 at home

Yes 116 35,2 53 39,2 84 49,4 253 39,9

No 213 64,8 82 60,8 86 50,6 381 60,1

Diagnosis of COVID-19 in participant

Yes 0 0 0 0 2 1,2 2 0,3

No 329 100 135 100 168 98,8 632 99,7

Diagnosis of COVID-19 in participant’s relatives

Yes 20 6,1 5 3,7 11 6,5 36 5,7

No 309 93,9 130 96,3 159 93,5 598 94,3

Table 3. Descriptives of Scales and Sleep Scores

Measure Professional Recreational Sedentary

M SD M SD M SD

State Anxiety Score (STAS) 46,1 6,01 44.4 4.54 44,3 6,33

Trait Anxiety Score (TRAS) 45,8 6,31 45.9 6.59 46,7 6,57

SMTQ 41,1 6,01 37.0 6.79 36,0 6,80

Conﬁdence 15,4 2,91 14.2 2.99 14,1 3,31

Constancy 13,6 2,05 12.0 2.41 11,7 2,46

Control 12,0 2,95 10.7 2.94 10,1 3,02

Sleep Score 5,8 2,63 6.51 2.36 5,9 2,40

M: Mean, SD: Standard Deviation, SMTQ: The Sports Mental Toughness Questionnaire

Kruskal Wallis Test p values for STAS: 0.001, for TRAS: 0.198, for SMTQ and its subscales: <0.001, for Sleep Score: 0.056

Descriptive Data

The descr pt ve stat st cs for soc odemograph c data, the data collected w th the COVID-19 related sect on of our survey, and the quest onna res and sleep scores of part c pants are presented n Table-1, Table-2, and Table-3, respect vely.

The d str but on of sport branches among profess onal athletes s shown n F g.1.

COVID-19-Related Issues

Only 2 part c pants (both from SEDs) were d agnosed w th COVID-19. The presence of an at-r sk nd v dual for COVID- 19 at home, and v deo call number per day (d v ded as <1 and ≥1) d d not s gn f cantly a ect the quest onna re scores.

Exercise-Related Issues

There was a s gn f cant (p<0.01) d erence between PROs and RECRs n current weekly exerc se t me [M=8.1, SD=4.4;

M=4.5, SD=2.9, respect vely, 95% CI (24.03, 38.03) Cohen's d=1.14]. Wh le both groups' self-reported exerc se ntens ty seemed to be decreased (M=6.3, SD=1.9; M=5.9, SD=2.4, respect vely), there was no s gn f cant d erence between the

groups (p=0.15). Compar ng before and a er the pandem c, there was a s gn f cant d erence (p<0.01) n weekly exerc - se t me for RECRs [M=7.6, SD=4.3; M=4.5, SD=2.9, respect - vely, 95% CI (2.35, 3.85)]. Among PROs, 37.4% of part c - pants conf rmed that they were nformed by the r team phy- s c ans about COVID-19, 60.2% were th nk ng that the r performance would be negat vely a ected, 66.2% were th n- k ng that the r team performance would be negat vely a ected, 60.8% declared they had been sent an exerc se program for the "stay at home" per od (78.5% of these part c - pants reported str ct adherence to the r program). Part c - pants w th an exerc se program scored s gn f cantly [p<

0.05, 95% CI (0.02, 0.93), Cohen’s d=0.32] h gher on the constancy subscale of SMTQ than the ones w thout t.

Among the athletes who d d not rece ve a tra n ng program from the r team or coach, 73.6% stated that they had been exerc s ng n a ser ous manner at least for a few days a week. Injury status at the t me of the pandem c (recorded as njured or not) was not assoc ated w th state anx ety scores (p=0.21).

(5)

Figure 1. Pie chart demonstrating the distribution of sport branches among professional athletes

Questionnaire and Sleep Scores

The MANCOVA for groups w th gender as a co-var ate was s gn f cant for quest onna res (W lks' k=0.97, p<0.01). The follow-up un var ate analys s of var ance and post-hoc analyses showed that PROs scored s gn f cantly h gher than RECRs and SEDs on SMTQ [p<0.017, Cohen’s d=0.08 and 0.10, 95% CI (2.52, 5.65) and (3.65, 6.55), respect vely] and State-Anx ety Scores [p<0.017, Cohen’s d=0.03 and 0.02, 95% CI (0.28, 3.14) and (0.52, 3.16), respect vely], but not on Tra t-Anx ety Score. Bes des, there were no s gn f cant d e- rences between RECRs and SEDs on any of the scores.

Due to the d erences between three groups n the quest - onna re scores, a "groups by genders" MANOVA was conducted. Both the act v ty level and the gender have s gn f - cant ma n e ect (W lks' k=0.89, p<0.01; W lks' k=0.95, p<0.01, respect vely), yet the nteract on e ect (W lks' k=0.99, p=0.41) wasn't s gn f cant. The follow-up un var ate analys s of var ance showed that the males scored s gn f - cantly h gher (p<0.05, Cohen’s d=0.05) on SMTQ scores and s gn f cantly lower (p<0.05, Cohen’s d=0.03) on Tra t-Anx - ety scores. Bes des, there were no s gn f cant d erences between genders on State-Anx ety scores.

We conducted a l near regress on analys s to ascerta n the relat onsh p between poss ble pred ctors (act v ty level, gender, and age) and the scores. For SMTQ scores; act v ty level, gender, and age s gn f cantly pred cted total score (DR2=0.11, b=-0.30; DR2=-0.04, b=0.20; DR2=0.01, b=0.12, respect vely). For State-Anx ety scores; only act v ty level s gn f cantly pred cted the score (DR2=0.02, b=-0.14). For Tra t-Anx ety scores; gender and age s gn f cantly pred cted the score (DR2=0.03, b=0.17; DR2=0.01, b=-0.11).

For Tra t-Anx ety scores, there was a s gn f cant (r=0.42, p<0.01) pos t ve correlat on w th State-Anx ety scores, and a s gn f cant (r=-0.36, p<0.01) negat ve correlat on w th SMTQ scores.

There was no s gn f cant d erence between groups or genders n sleep scores (p=0.56 and p=0.48, respect vely), but sleep scores pos t vely correlated w th SMTQ scores (r=0.10, p<0.01).

DISCUSSION

The COVID-19 outbreak has a ected our l ves n every aspect, and ts consequences are accord ngly global, n terms of mental health. Anx ety has been one of the ant c pated results of such global nc dences (29). In our study, we a med to nvest gate anx ety levels and MT, the relat onsh p and d erences between them among profess onal athletes, recreat onal athletes and sedentary nd v duals dur ng the early phase of COVID-19 pandem c. We hypothes zed that profess onal athletes would d er from other groups n terms of anx ety and mental toughness levels, and y elded accord ngly.

State and Trait Anxiety Scores

Evaluat on of general anx ety levels before the pandem c (tra t-anx ety) and current anx ety levels dur ng the outbreak (state-anx ety) were conducted by us ng STAI. In our study, the state anx ety scores were nterpreted as one of the mental outcomes of the COVID-19 outbreak. PROs had the h ghest scores, but there was no s gn f cant d erence between RECRs and SEDs, or genders. There m ght be seve- ral reasons for PROs hav ng h gher state-anx ety. The f rst conf rmed COVID-19 case n Turkey was on 11 March 2020.

Nevertheless, ne ther profess onal leagues were suspended nor compet t ons were canceled; thus, athletes st ll part c - pated n matches unt l 19 March 2020. It means that athletes somewhat encountered the r sk of transm ss on. Altho- ugh 80% of the COVID-19 cases reported were m ld n seve- r ty(30), pneumon a s the most frequent severe presentat - on of the d sease and long-term outcomes are unknown yet.

From the sports med c ne aspect, pulmonary compl cat ons are always poss ble, but not l kely, as most of the el te athletes are young and do not have comorb d t es. However, severe pulmonary nvolvement could comprom se an athlete's performance capac ty due to pulmonary f bros s (31,32).

On the other hand, the suspens on of leagues and cancella- t on of matches also took el te athletes apart from the r regular tra n ng rout ne and soc al env ronment. The emer- gence of the pandem c n a per od when contract renewal and transfer negot at ons would take place and the champ - onsh p race would reach the f nal result, along w th the un- certa nty of when normal zat on would beg n, m ght have

(6)

caused add t onal stress (8,33). Econom c, occupat onal, health-related, and soc al concerns altogether could have ncreased anx ety n PROs dur ng the COVID-19 outbreak (8).

Regard ng tra t-anx ety, our results showed that females and younger part c pants had h gher scores overall, whereas PROs, RECRs, and SEDs have not d ered s gn f cantly.

Profess onal athletes could be expected to have lower tra t- anx ety scores wh le cons der ng the protect ve e ect of regular phys cal act v ty from anx ety. However, the pande- m c has been go ng on for two months at the t me we collected the data, and th s could, and th s could have a ected the m ndset of part c pants answer ng the quest ons blur- r ng the l nes between tra t and state anx ety tems. Also, a recent meta-analys s (34) on anx ety determ nants n athletes from d erent compet t ve levels demonstrated that athletes and non-athletes had no d erences n anx ety prof - les, and ascerta ned that females, younger athletes, and n- jured athletes had h gher anx ety levels, comparable to our f nd ngs.

Sen s k et al. conducted a s m lar study where they nvest - gated the e ects of solat on on mental health and found that athletes had lower anx ety and depress on symptoms compared to non-athletes (23). In terms of anx ety levels, the d erent results m ght be due to the t me-per od, wh ch was two months later than our study, so w th the passage of t me adaptat on m ght have come along and anx ety m ght have subs ded. Another survey on athletes' mental health dur ng the pandem c was conducted by P llay et al. (24), n wh ch they nvest gated only depress ve symptoms n el te and sem -el te athletes and found that 52% of athletes felt depressed at some t me. Comparable to our results, they also found l festyle and sleep-wake cycle d sturbances n athletes.

Mental Toughness Scores

Our research demonstrated that males, older part c pants, and profess onal athletes had h gher MT scores, whereas there was no s gn f cant d erence between RECRs and SEDs. N cholls et al. (35) concluded that males had h gher total MT scores than females, age and years of exper ence pred cted h gher scores of MT. W th regard to age and MT, many stud es showed that older age was both related and pred cted h gher MT (27,35,36). Ga n ng exper ence and b - olog cal changes m ght be respons ble for th s. MT scores may suggest some state-spec f c features of a person, as well as a personal ty tra t (21). When descr bed as a state feature, MT cons sts of react ons that nd v duals form to stay calm and stable when they encounter stress or cr s s.

When def ned as a pers stent mental state or personal ty tra t, MT s assoc ated w th be ng tough and durable, matu-

re, pract cal, self-conf dent and ach ev ng success through e ort n adverse cond t ons (37). Wh le Clough et al. (38) have suggested that MT s a tra t-l ke personal ty characte- r st c, some authors have suggested genet c l nks (39,40).

Both genet c stud es on MT concluded that MT s partly n- her ted, but also a ected by env ronmental cond t ons, so t can part ally change n t me or as a response to events. St ll, there s no def n te conclus on as to whether MT s a cont - nuous feature or a feature that var es depend ng on the s - tuat on. Cons der ng our study was cross-sect onally des g- ned, t would be nappropr ate to comment on how MT scores a ected by the pandem c. However, the compar son of both study groups w th sedentary people, to the best of our knowledge, for the f rst t me n the l terature, along w th the total number of part c pants, are some of the strengths of th s study.

Current Status and Exercise Habits

In the current state of th s pandem c, l v ng w th someone at-r sk for COVID-19 (e.g., hypertens on, COPD and older age) could be cons dered as a factor that can a ect anx ety levels, but our study d d not support that. Presumably, par- t c pants had other sources of anx ety rather than l v ng w th someone at h gher r sk, such as career ssues and econom c concerns. Moreover, n terms of soc al support, v deo calls were cons dered as a cop ng strategy w th stress and anx ety, but anx ety levels were not s gn f cantly assoc ated w th these factors, as well. Accord ngly, v deo calls m ght not be a robust anx ety-reduc ng factor alone.

One of the strengths of our study s that we have reached 329 el te athletes across the country, a cons derable amount of top t er and f rst d v s on players of all popular sports, part cularly soccer and volleyball (F g.1). We revealed that most of the el te athletes (60.8%) were sent a home exerc se program by the r sta (e.g., team, coach and athlet c tra- ner). A vast major ty of the part c pants (78.5%) to whom a program was prov ded have str ctly adhered to that program. Gett ng an exerc se program from the sta could have mplemented the dea of constant mon tor ng by the team, and thus made the athletes feel valued, supported, and per- severant. Th s could be the reason for ncreased "constancy" subscale scores of MT w th n the group part c pat ng an exerc se program. Also, 73.6% of el te athletes w thout any prov ded program stated that they are exerc s ng n a ser ous manner at least a few t mes a week. Th s comm t- ment to exerc se among PROs can be cons dered as another hallmark of qual f cat on of the study populat on. St ll, the decrease n self-reported exerc se ntens ty of PROs should be cons dered by sta , espec ally when plann ng the proper tra n ng rout ne a er the pandem c to decrease the devasta- t ng e ects of detra n ng.

(7)

Limitations

One of the l m tat ons of our study was ts cross-sect onal des gn. It could prov de more prec se results n a prospect - ve des gn. Secondly, an onl ne survey s always a constra- nt; a face-to-face study could have been more rel able be- cause some of the quest ons m ght have been answered w t- hout fully understand ng. Speak ng of rel ab l ty, apply ng scales comes w th the l m tat on of try ng to f t many d e- rent nd v duals nto the same concept. It s d cult to measure an abstract concept w th n a var ety of people. F - nally, the self-reported measures could cause the athletes to have not been ent rely honest w th the r responses due to the st gma attached to mental health. However, t s assu- med that anonym ty el m nated th s concern.

CONCLUSION

Our study was among the f rst stud es to evaluate the el te athletes dur ng the COVID-19 pandem c n regards to the psycholog cal outcomes. Th s study showed that at the be- g nn ng of the COVID-19 outbreak, be ng a h gh-level profess onal athlete was related to h gher state anx ety levels, most probably due to mult ple reasons d scussed above.

Further research s needed to assess the psycholog cal m- pacts of the pandem c on the el te athletes and to gu de the management of them. When we adapt to the current s tuat - on, the consequences of th s pandem c n terms of athletes' mental health should be assessed and supported by mental health care prov ders, preferably exper enced n sport psychology.

Acknowledgements / Teşekkür

The authors thank Dr.İsma l Kaya from Gülhane Tra n ng and Research Hosp tal, Ankara and Dr.Uğur D l çıkık from İstanbul Başakşeh r C ty Hos- p tal, İstanbul for the r ass stance dur ng the data collect on, and Yankı Çobanoğlu from Ayndo, Netherlands and Den z Özcan from D stant Tech, Ankara for the r ass stance n ed t ng the manuscr pt. No fund ng was rece ved related to th s art cle.

Conﬂict of Interest / Çıkar Çatışması

The authors declared no con cts of nterest w th respect to authorsh p and/or publ cat on of the art cle.

Financial Disclosure / Finansal Destek

The authors rece ved no f nanc al support for the research and/or publ - cat on of th s art cle.

REFERENCES

Ebrah m SH, Ahmed QA, Gozzer E, Schlagenhauf P, Mem sh ZA. Cov d-19 and commun ty m t - gat on strateg es n a pandem c. BMJ. 2020;368:m1066.

Wang T, Du Z, Zhu F, Cao Z, An Y, Gao Y, et al. Comorb d t es and mult -organ njur es n the tre- atment of COVID-19. Lancet. 2020;395(10228):e52.

Hall G, Laddu DR, Ph ll ps SA, Lav e CJ, Arena R. A tale of two pandem cs: How w ll COVID-19 and global trends n phys cal nact v ty and sedentary behav or a ect one another? Prog Car- d ovasc D s. 2020;S0033-0620(20)30077-3.

Keaney LC, K ld ng AE, Mer en F, Dulson DK. The mpact of sport related stressors on mmun ty and llness r sk n team-sport athletes. J Sc Med Sport. 2018;21(12):1192-9.

Bauman NJ. The st gma of mental health n athletes: Are mental toughness and mental health seen as contrad ctory n el te sport? Br J Sports Med. 2016;50(3):135-6.

Reardon CL, Ha nl ne B, Aron CM, Baron D, Baum AL, B ndra A, et al. Mental health n el te athletes: Internat onal Olymp c Comm ttee consensus statement (2019). Br J Sports Med.

2019;53(11):667-99.

Sch nke R, Papa oannou A, Henr ksen K, S G, Zhang L, Haberl P. Sport psychology serv ces to h gh performance athletes dur ng COVID-19. Int J Sport Exerc Psychol.

2020;18(3):269-72.

Mann RH, Cl BC, Boyko J, Bekker S. Athletes as commun ty; Athletes n commun ty: Cov d- 19, sport ng mega-events and athlete health protect on. Br J Sports Med.

2020;54(18):1071-1072.

De La Vega R, Parastat dou IS, Ruíz-BarquíN R, Szabo A. Exerc se add ct on n athletes and le- sure exerc sers: The moderat ng role of pass on. J Behav Add ct. 2016;5(2):325-31.

Bär KJ, Markser VZ. Sport spec f c ty of mental d sorders: The ssue of sport psych atry. Eur Arch Psych atry Cl n Neurosc . 2013;263(SUPPL.2):205-10.

Allegre B, Souv lle M, Therme P, Gr ths M. Def n t ons and measures of exerc se dependence.

Add ct Res Theory. 2006;14(6):631-46.

Warburton DER, N col CW, Bred n SSD. Health benef ts of phys cal act v ty: The ev dence.

Cmaj.2006;174(6):801-9.

Herr ng MP, O’Connor PJ, D shman RK. The e ect of exerc se tra n ng on anx ety symptoms among pat ents: A systemat c rev ew. Arch Intern Med. 2010;170(4):321-31.

Kandola A, Vancampfort D, Herr ng M, Rebar A, Hallgren M, F rth J, et al. Mov ng to Beat Anx - ety: Ep dem ology and Therapeut c Issues w th Phys cal Act v ty for Anx ety. Curr Psych - atry Rep. 2018;20(8):63.

Mauger G, Castrog ovann P, Battagl a G, P pp R, D’Agata V, Palma A, et al. The mpact of phys - cal act v ty on psycholog cal health dur ng Cov d-19 pandem c n Italy. Hel yon.

2020;6(6):e04315.

Jacob L, Tully MA, Barnett Y, Lopez-Sanchez GF, Butler L, Schuch F, et al. The relat onsh p between phys cal act v ty and mental health n a sample of the UK publ c: A cross-sect onal study dur ng the mplementat on of COVID-19 soc al d stanc ng measures. Ment Health Phys Act. 2020;19:100345.

Schuch FB, Bulz ng RA, Meyer J, Vancampfort D, F rth J, Stubbs B, et al. Assoc at ons of modera- te to v gorous phys cal act v ty and sedentary behav or w th depress ve and anx ety symptoms n self- solat ng people dur ng the COVID-19 pandem c: A cross-sect onal survey n Braz l.

Psych atry Res. 2020;292:113339.

Arango C, Díaz-Caneja CM, McGorry PD, Rapoport J, Sommer IE, Vorstman JA, et al. Prevent ve strateg es for mental health. The Lancet Psych atry. 2018;5(7):591-604.

Sp elberger CD, Rehe ser EC. Measur ng anx ety, anger, depress on, and cur os ty as emot onal states and personal ty tra ts w th the STAI, STAXI and STPI. Comprehens ve Handbook of Psycholog cal Assessment Vol. 2 Personal ty Assessment. Hoboken, NJ, US: John W ley & Sons Inc; 2004. p. 70-86.

Masten AS, Coatsworth JD. The Development of Competence n Favorable and Unfavorable En- v ronments: Lessons from Research on Success l Ch ldren. Am Psychol. 1998;53(2):205- 220.

Gucc ard DF, Hanton S, Gordon S, Mallett CJ, Temby P. The Concept of Mental Toughness: Tests of D mens onal ty, Nomolog cal Network, and Tra tness. J Pers. 2015;83(1):26-44.

Coll ns D, MacNamara Á. The Rocky Road to the Top. Sport Med. 2012;42(11):907-14.

Şenışık S, Denerel N, Köyağasıoğlu O, Tunç S. The e ect of solat on on athletes’ mental health dur ng the COVID-19 pandem c. Phys Sportsmed. 2020;00(00):1-7.

P llay L, Janse van Rensburg DCC, Jansen van Rensburg A, Ramagole DA, Holtzhausen L, D jkst- ra HP, et al. Nowhere to h de: The s gn f cant mpact of coronav rus d sease 2019 (COVID-19) measures on el te and sem -el te South Afr can athletes. J Sc Med Sport.

2020;23(7):670-9.

Oner N, Le Compte A. Durumluk-Surekl kayg envanter el k tab . Istanbul: Bo- ğaz ç Yay nları. Istanbul: Bogaz ç Un vers tes ; 1985.

Pehl van H. Sporda Mental Dayanıklılık Ölçeğ Uyarlama: Geçerl k ve Güven rl k Çalışması. Celal Bayar Ün vers tes ; 2014.

Sheard M, Golby J, Van Wersch A. Progress toward construct val dat on of the Sports Mental Toughness Quest onna re (SMTQ). Eur J Psychol Assess. 2009;25(3):186-93.

Te chman Y, Mal neck F. Manual for the Hebrew state-tra t anx ety nventory.

Palo Alto, CA Consult Psychol Press. 1978;

Torales J, O’H gg ns M, Castaldell -Ma a JM, Ventr gl o A. The outbreak of COVID-19 coronav rus and ts mpact on global mental health. Int J Soc Psych atry. 2020;66(4):317-20.

Wu Z, McGoogan JM. Character st cs of and Important Lessons from the Coronav rus D sease 2019 (COVID-19) Outbreak n Ch na: Summary of a Report of 72314 Cases from the Ch nese Center for D sease Control and Prevent on. J Am Med Assoc. 2020;323(13):1239-42.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

(8)

Sun P, Lu X, Xu C, Sun W, Pan B. Understand ng of COVID-19 based on current ev dence. J Med V rol.2020;92(6):548-51.

G lat R, Cole BJ. COVID-19, Med c ne, and Sports. Arthrosc Sport Med Rehab l.

2020;2(3):e175-6.

Cors n A, B sc ott GN, E rale C, Volp P. Football cannot restart soon dur ng the COVID-19 emergency! A cr t cal perspect ve from the Ital an exper ence and a call for act on. Br J Sports Med.2020;54(20):1186-1187.

R ce SM, Gwyther K, Santesteban-Echarr O, Baron D, Gorczynsk P, Gouttebarge V, et al. Deter- m nants of anx ety n el te athletes: a systemat c rev ew and meta-analys s. Br J Sports Med.2019;53(11):722-30.

N cholls AR, Polman RCJ, Levy AR, Backhouse SH. Mental toughness n sport: Ach evement level, gender, age, exper ence, and sport type d erences. Pers Ind v d D f.

2009;47(1):73-5.

Marchant DC, Polman RCJ, Clough PJ, N cholls AR, Jackson JG, Levy AR. Mental toughness: Ma- nager al and age d erences. J Manag Psychol. 2009;24(5):428-37.

Crust L. Mental toughness n sport: A rev ew. Int J Sport Exerc Psychol. 2007;5(3):270-90.

Clough PJ, Earle K, Sewell D. Mental Toughness: The Concept and Its Measurement. In I. Cocke- r ll (Ed tor). Solut ons n Sport Psychology. London: Thomson; 2002. p. 32-43.

Horsburgh VA, Schermer JA, Veselka L, Vernon PA. A behav oural genet c study of mental toughness and personal ty. Pers Ind v d D f. 2009;46(2):100-5.

Golby J, Sheard M. The relat onsh p between genotype and pos t ve psycholog cal development n nat onal-level sw mmers. Eur Psychol. 2006;11(2):143-8.

31.

32.

33.

34.

35.

36.

37.

38.

39.

40.