The Association Between the Female Athlete Triad and Mental Health in High School Athletes

BACKGROUND: The Female Athlete Triad (Triad) is the interrelationship of low energy availability, reproductive irregularities, and low bone mineral density. It is theorized that mental health illness can both contribute to and result from low energy availability. Limited data exists that describes the relationship between the Female Athlete Triad and mental health symptoms. HYPOTHESIS/PURPOSE: The purpose of this study was to investigate the relationship between the Triad and mental health illness, specifically depression and anxiety symptoms, in high school athletes. METHODS: This was a cross-sectional survey study of high school athletes distributed via social media with responses accepted from 12/30/20 – 2/15/21. Data was collected including age, sex, training history, menstrual history, history of bone stress injuries, and eating behaviors. The Female Athlete Triad Coalition Consensus Statement Cumulative Risk Assessment Tool was used to score athletes (range: 0-10 points) and to classify them as low-, moderate-, or high-risk for Female Athlete Triad. Mental health was assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) Emotional Distress Depression and Anxiety short form questionnaires. Mental health scores were scored as none, mild, moderate, or severe self-reported depressive or anxious symptoms. Ordinal logistic regressions were performed. RESULTS: There were 78 self-reported female high school participants (mean age = 16). Depression symptoms were reported in 74% of participants (19% mild, 40% moderate, 15% severe). Anxiety symptoms were reported in 64% of participants (18% mild, 26% moderate, 21% severe). Triad risk assessment responses categorized participants as 45% low risk, 41% moderate risk, and 14% high risk of developing the Triad. Depression symptoms were significantly associated with increasing Triad risk assessment score: Odds Ratio (per 1 point Triad risk score) = 1.245 (1.004 – 1.544) (p = .0462). Anxiety symptoms were also significantly associated with increasing Triad risk assessment score: Odds Ratio (per 1 point Triad risk score) = 1.264 (1.020 – 1.567) (p = .0319). CONCLUSION: Anxiety and depression symptoms were both significantly associated with increasing Triad risk scores in this preliminary cross-sectional study. Notably, this study is limited by sampling bias. Further research is needed to explore the relationship between mental health illness and the Female Athlete Triad.