Suicide in the Context of Elite Sport: a Meta-Ethnographic Synthesis

. Suicide or its attempts are a serious problem that has drawn the attention of different areas of knowledge related to the field of sports. However, in most cases, the analyses are based on psychopathological visions or physical trauma without understanding the particularities of mental health. The article presents a meta-ethnography review of the literature on qualitative research on suicide in athletes from 2012 to 2022. The topics addressed in the studies are diverse: the importance of healthy relationships, the visibility of mental health problems, the normalization of violence by coaches


Introduction
Suicide is a serious global public health issue, ranked as the tenth leading cause of death worldwide, with over 703,000 annual deaths, according to the World Health Organization (WHO, 2021).Furthermore, it ranks as the fourth leading cause of death among young people aged 15 to 29, both for men and women.The estimated annual rate is nine deaths per 100,000 population, representing 1.3% of all deaths worldwide.In the context of sports, research on suicide has addressed this topic from various areas of knowledge, focusing on psychopathological aspects (Hussain et al., 2022), physical traumas (Azad et al., 2016;Burke, 2012;Omalu et al., 2010), and its association with the use of anabolic substances (Alibegović, 2018;Hussain et al., 2022).However, there is a lack of research that focuses on mental health care, overlooking the specificities of the phenomenon in athletes, considering biopsychosocial aspects.A recent study conducted by Pichler et al. (2023) shows that the recent calls for investigating suicidality among athletes have resulted in a considerable amount of literature.This literature provides evidence regarding lower rates of suicide among professional and high-performance athletes, as well as similar incidence and prevalence of mental conditions, known as risk factors for suicide.These lower rates raise many unanswered questions for the authors, given the difficulty in studying the actual reasons that lead to suicide.Nevertheless, the authors emphasize that athletes are not immune to suicide and that their main risk factors seem to be associated with traumatic brain injury, physical injuries, frequent abuse of performance-enhancing drugs, and anabolic-androgenic steroids, elevating the risk of suicide in this population.Nevertheless, the authors suggest that this group requires special attention, as the predisposing and precipitating factors for suicidal tendencies may be different compared to the non-athlete population.It is essential to consider the particularities of each group (elite athletes, individuals with chronic pain, children, and adolescents involved in grassroots sports, amongst others), as Wegner et al. (2014) demonstrated.
While the study on suicide poses numerous challenges in pinpointing its causes, Camilo et al. (2023) provide insights into suicidal ideation among combat athletes disseminated in digital media between 2004 and 2022.Among the 20 news articles found, the authors detected a predominance of suicidal thoughts in athletes following a defeat, even (albeit to a lesser extent) in successful athletes.
Furthermore, it is crucial to consider that athletes from various disciplines face numerous obstacles when seeking support for their mental health, possibly due to the sports culture influenced by the motto "no pain, no gain" (Dodd et al., 2021).It is also relevant to mention that the masculinities present in the sports environment are associated with bravery, honor, strength, vigor, reason, leadership, physical pain control, and the suppression of feelings and emotions (Camilo et al., 2023;Lomas, 2014), can lead to the denial of emotional problems.
Therefore, given the seriousness of the global suicide problem and the need to delve into the topic from the athletes' perspectives, the main objective of this study is to conduct a systematic review of the literature using the metaethnography methodology, focusing on suicide in athletes from various disciplines from the perspective of mental health.More specifically, the four axes that guide this overarching goal are: a) to analyze how scientific literature addresses the topic of suicide from the athletes' subjectivities; b) to delve into the roles played by the individuals who make up the support network for athletes; c) to understand the motivations of athletes for developing suicidal ideation; d) to compile the recommendations from scientific literature for preventing the issue of suicide.

Method
Meta-ethnography is distinctive in using the author's interpretations of the study as variables for knowledge construction (Soundy and Heneghan, 2022).The process of analytical synthesis involves a personalized reading of the studies and the systematic comparison of the meaning of concepts to identify new ideas and overarching theories, considering the context of each study (Britten et al., 2002).
Meta-ethnographic review identifies areas with divergent ideas amongst studies, while also highlighting areas for future research and the derivation of new issues (Atkins et al., 2008).Furthermore, its application is recommended in the study of sport and exercise psychology (Soundy and Heneghan, 2022).
This research adopts a social constructionist approach, drawing from prior studies in sport and exercise psychology (Koshoedo et al., 2015;Soundy and Heneghan, 2022;Camilo et al., 2022).The meta-ethnography follows the seven steps identified by Noblit and Hare (1988) and is organized in three main sections: systematic search (phases 1 and 2), critical evaluation (phases 3, 4, and 5), and results (phases 6 and 7).

Phase 1. Protocol and Registration
The systematic review commenced by formulating the guiding question ("How does qualitative scientific literature address the topic of suicide in athletes?") in accordance with the PICo strategy (Population/Problem, Phenomenon of Interest, and Context), with the acronym P -athletes, Isuicide, Co -various sports modalities.The review protocol was registered with PROSPERO [CRD42023389003], and the review is reported following PRISMA guidelines (Page et al., 2021).Written in a language other than English, Spanish, or Portuguese.Articles with the keywords in their abstract or title: a) English: "suicide" AND "athletes" or b) Spanish: "suicidio" AND "deportistas" or c) Portuguese: "suicídio" AND "atletas."

Phase 2. Search Strategy and Selection Criteria
Articles with keywords not specified in the inclusion criteria.
Studies conducted with athletes.
Studies were conducted with a different group of individuals, where the athlete was scarcely cited and not the primary focus of the work.Utilization of qualitative methodologies (observations, interviews, focus groups, ethnography, and case studies).
Utilization of quantitative methodologies.
Searches were conducted in the following databases: BVS, Embase, Medline/Pubmed, PsycInfo, SAGE Open, Scopus, SPORTDiscus, and Web of Science (WOS).The search was restricted to articles published between 2012 and 2022 in English, Spanish, and Portuguese.The search terms used were "suicide" and "athletes" in English, "suicidio" and "deportistas" in Spanish, and "suicidio" and "atletas" in Portuguese.Titles and abstracts of the retrieved articles were examined to identify primary qualitative studies reporting participants' subjective opinions.Two authors independently searched the included databases using the agreed search terms.The titles and abstracts of the returned articles were used to identify studies that potentially met the inclusion criteria: primary qualitative studies reporting the participants' subjective opinions.Description of the items 1) Was there a clear statement of the research objectives?
2) Is a qualitative methodology appropriate?3) Was the research design appropriate to address the research objectives?4) Was the recruitment strategy appropriate to the research objectives?5) Were the data collected in a way that addressed the research problem? 6) Has the relationship between the researcher and participants been adequately considered?7) Have ethical issues been considered?8) Was the data analysis sufficiently rigorous?9) Is there a clear statement of the results?10) How valuable is the research?

Phase 3. Reading of the Studies
The quality of the studies was assessed using the CASP (Critical Appraisal Skills Programme) tool for qualitative research, following the criteria of Malpass et al. (2009) and Moretti and Herkovits (2021).Each researcher used ten items to evaluate each article individually, and then the evaluations were compared during a team meeting.The detailed analysis is provided in Table 2.
It was included in a study (Oforeh et al., 2022) despite receiving a lower CASP score due to its potential informativeness in qualitative reviews (Bridges et al., 2010).Quality assessment was not an exclusion criterion, and no studies were excluded.Overall, the CASP-based evaluation indicated clarity in the records and sufficiency for the stated objectives.References were exported to the qualitative software Atlas.ti22.

Phase 4 and 5. Determining How the Studies Relate
Two reviewers compared and organized the studies into conceptual categories, identifying similarities and differences.After reaching an agreement, a third reviewer rephrased the descriptions of each conceptual category.

Phase 6 and 7. Synthesis of Translations and Expression of Synthesis
The final themes were organized into a conceptual model, considering the similarities and differences between the studies.Strategies were employed to maintain accuracy and reduce bias, including researchers with qualitative analysis experience and data immersion.The researchers' position and potential impact on the analysis were explored through reflection and discussion.

Results
This study includes 8 studies, all in English and conducted by researchers from four different countries (United States, Japan, Canada, and New Zealand).These countries share advanced, diverse, and highly developed economies despite significant cultural differences.As an example, according to the International Monetary Fund (IMF, 2021), three out of the four countries are among the top 20 countries with the highest GDP in the world (out of a total of 194): the United States ranks 1st, Japan 3rd, Canada 10th, and New Zealand 51st.
Another point that caught our attention was that none of the studies analyzed addressed the interrelationship between covid-19 and suicide.However, it is essential to note and warn that the pandemic has had a significant impact on the mental health of athletes worldwide (Almonacid et al., 2021;Leon Zarceño et al., 2022;Monterrosa Quintero et al., 2023).
The following table (Table 3) summarizes the objectives and methodology.What is addressed regarding suicide?Camiré (2015) has identified suicide as a significant and recurring issue.According to one of the participants, strong relationships and closeness with children/athletes can be crucial in situations of danger, such as suicide.The research noted that, despite some successful cases, there are also examples of strong relationships with student-athletes that did not have a happy outcome.
In André-Morin et al.'s (2017) study, the presence of suicidal ideation and suicidal attempts was identified in an athlete three months after suffering a concussion.The participant, after the brain injury, expressed a decision to commit suicide due to her "failure" in sports (volleyball), school, and her relationship with her partner.
McDonald and Kawai (2017), considering the reality of sports education in Japan, concluded that coaches normalize acts of violence.They contemplate this behavior as a necessary form of discipline and, in many cases, interpret it as indicative of loving and kind training.This can lead to suicide or suicide attempts.
Marsters and Tiatia-Seath's (2019) study problematizes the issue of suicide, highlighting the importance of mental health research.However, in the interviews conducted by the authors, there were no significant contributions identified on the topic.Gross et al. (2020) point to the invisibility and normalization of mental health problems and suicidal ideation, emphasizing the importance of addressing this issue in student-athletes by providing guidance and useful resources for those working with this group.
In their research with former hockey professionals, Gaetz (2021) identified numerous challenges they face after their sports careers, which can lead to various psychopathologies such as depression, anxiety, mania, and suicidal ideation.One of the interviewees even reported significant issues related to prolonged depression that culminated in a suicide attempt.Additionally, Harvey et al. (2021) depicted a swimmer's experience and the lack of emotional support from various socio-educational institutions when he sought help (family, club, university, sports federation), leading to suicide attempts.
Finally, Oforeh et al. (2022) identified suicidal ideation associated with other psychopathologies but without specific plans or intention to act.

The support network for athletes
The existence of a social support network is of great importance for athletes (Sampaio & Teques, 2019), as it helps them to cope with the stress and the competitive pressure (Altynay et al., 2024), as well as to recover from injuries and prevent psychological problems.This network can be composed of friends, family, coaches, and other sports professionals.The World Health Organization (WHO, 2014) recognizes the relevance of mental health professionals in suicide prevention and the promotion of mental health in general.The role of these professionals should be a priority, as well as that of psychiatrists, psychologists, social workers, and educators, amongst others (WHO, 2021).These experts have a privileged perspective for identifying individuals at risk of suicide through constant assessment and early detection of signs and symptoms of mental disorders such as depression, anxiety, and bipolar disorder.Suicide prevention is a task that involves society as a whole and requires the participation of the entire community, including friends, family, and community organizations (WHO, 2021).The following table (Table 4) presents the different individuals and professionals involved in the support network of the athletes who participated in the selected research, indicating a) their importance to the athlete, b) the weaknesses or difficulties they face, and c) the role they should play.Change the excessive conformity to violent taibatsu practices and create space for more democratic sports practices without threatening the positive social and physical education that occurs within bukatsudo.

Marsters y Tiatia-Seath (2019)
Family A loving and supportive family was considered central to fostering healthy emotions and mental well-being.
Pressures for the athlete's performance, as this group is likely to assume financial responsibilities for their family.
Explore possible interventions for this phenomenon in future research.

Sports psychologists and counselors
Provide specialized mental health support.
The imbalance that may exist in the priorities of sports psychologists, as they may sometimes be more concerned with athletic performance and put mental health of athletes in the background.
People working with student-athletes are recommended to complete formal suicide prevention training.

Gaetz (2021)
Coaches, teammates, family members, doctors, and sports therapists Provide information, in addition to social, emotional, and support.
Lack of understanding in the athlete's environment about concussion recovery (teammate and family members).
Investigate more in-depth the impact of having socially supportive or unsupportive coaches and athletic therapists, as well as the impact of facilitating (or hindering) recovery.

Harvey et al. (2021)
Family, training partners, coaches, psychologists, psychiatrists Proximity to the athlete, knowledge about their routine.
Invisibility about various mental health issues and excessive concern with athletic performance.
Better and deeper training for coaches, psychologists, psychiatrists, and others on various mental health issues involving athletes are recommended.

Sports psychologists and psychiatrists
Opportunity to provide psychoeducation to the patient/athlete and monitor a possible progression to a psychotic disorder.
Not mentioned.Not mentioned.
In seven of the eight analyzed studies, the importance of teachers/coaches, their perspectives, caring relationships, and support was emphasized.Similarly, the pressures for good results (Harvey et al., 2021) or exemplary behavior (McDonald and Kawai, 2017) were more relevant and evident than the mental health of the athletes.The positive role of teachers/coaches was primarily based on their proximity to the athlete and the knowledge of their routines (Camiré, 2015;Harvey et al., 2021).Marsters and Tiatia-Seath (2019) noted that the emotional support provided by coaches through daily text messages to inquire about how the athletes were feeling, how well they were resting, and whether they had symptoms, among other aspects, was positively valued by the athletes.
Athletes also appreciate the informative support they receive from doctors regarding complete cognitive and physical recovery (André-Morin et al., 2017).Oforeh et al.
(2022) also emphasize the importance of having psychiatrists specialized in the sports field and multidisciplinary teams.Despite significant evidence of the benefits of an integrated approach in managing various health problems and mental disorders, the role and services of a sports psychiatrist remain limited (Oforeh et al., 2022).The role of psychologists was also identified as necessary in various research, both in a clinical context and in relation to sports performance (André-Morin et al., 2017;Gross et al., 2020;Harvey et al., 2021;Marsters and Tiatia-Seath, 2019;McDonald and Kawai, 2017).Gross et al. (2020) highlights the existing confusion among sports psychologists concerned with sports performance and the limitations of their professional training in this context, which should be evaluated in specific studies.
The closeness and support provided by the family were positively evaluated regarding the mental health of athletes (Marsters and Tiatia-Seath, 2019), but paradoxically, the financial expectations can overshadow caregiving relationships (Camiré, 2015).

Issues that have affected athletes identified with suicidal ideation
Although Camiré's work (2015) does not point to any risk factors for athletes' mental health, all other studies address important issues in this area.André-Morin et al. (2017) identified risk factors as the prolonged combination of concussion symptoms and academic decline.
According to Marsters and Tiatia-Seath ( 2019), all athletes reported academic problems, such as reduced class attendance, difficulties in concentrating when studying, and consequently, poor grades.
McDonald and Kawai ( 2017) analyze violent practices in training and how these can become normalized and contribute to psychological illness.
In the autoethnographic studies by Harvey et al. ( 2021) and Gross et al. (2020), it is observed a combination of factors involved in mental illness, but they seem to coincide with the high demands to which athletes are exposed.Furthermore, their suffering is invisible and appears to be solely focused on performance and victory.
Gaetz's study (2021) considered that athletes at risk of mental health (and therefore suicide) were due to their high exposure to unique or repetitive events, such as concussions/subconcussions.
Consistent with this analysis, Oforeh et al. (2022) reported that the continuous absence of athletes in rehabilitation from training led to a cascade of worsening depressive symptoms, social isolation, compensatory cannabis use, increased severity of auditory hallucinations, and suicidal ideation.

Recommendations made in the studies to address the issue of suicide
It is important to emphasize again that the evaluated studies did not have the primary objective of analyzing suicide, so the recommendations made did not delve into specific intervention or prevention methods.
Considering this limitation, Camiré (2015) considers that teachers and coaches are the closest people to athletes and, therefore, they will be the first to notice when something is wrong and should act (through dialogue, engagement, etc.).Therefore, they play a prominent role, and it is essential that club and school administrators and directors identify ways to train coaches, both in terms of financial access (e.g., allocating funds to cover the cost of specific courses) and logistical support (e.g., considering relieving them of certain school responsibilities, such as lunch or recess supervision), and recognize their contributions to the sports program.
In the case of André-Morin et al. (2017), it is highlighted the need for social support for college athletes with concussion throughout their recovery process, to assist them during this crucial and challenging time in their lives and prevent mental illnesses and suicide risks.
McDonald and Kawai (2017) emphasize the importance of further examining punitive and aggressive coaching practices, as seen in Japan.
Significant contributions are presented, such as suggestions for ongoing training for teachers, coaches, and health professionals, as observed in Gross et al. (2020) andGaetz (2021).Athletes may have skills to conceal their emotional distress (Gross et al., 2020), emphasizing the importance of a specialized approach to their behaviors.
Therefore, Harvey et al.'s work (2021) emphasizes the need for ongoing training for coaches and health professionals from a critical and in-depth perspective on mental health and suicide, avoiding reducing it to a simple course with inflexible protocols designed to protect clubs, associations, or federations from possible legal issues.According to the author, it is essential that teachers and coaches maintain close and authentic relationships with students and athletes.
In addition to coaches, it is recommended, according to Oforeh et al. (2022), that clubs and associations have a sports psychiatrist on their teams, both in amateur and professional settings, as psychopathological cases can go unnoticed by those without specific training.The role of psychologists in the sports context to promote mental health, in addition to performance, is also highlighted, as mentioned by Gross et al. (2020).The studies also emphasized the need for additional courses on mental health for these professionals and stressed the notion that athletes are people before they are athletes (Gaetz, 2021;Oforeh et al., 2022).
Finally, Marsters and Tiatia-Seath (2019) emphasize the importance of reciprocal family support, positive social relationships, and a balance between sports performance and personal development as fundamental for the mental wellbeing of young athletes.

Discussion and Conclusions
Qualitative research is essential for understanding the experiences and perspectives of athletes.While it has the potential to uncover significant insights and provide a more holistic understanding of the issue of suicide in sports, its current scope remains somewhat limited.Therefore, delving deeper into this theme is crucial.Specifically, the metaethnographic review of qualitative studies on suicide among athletes has revealed several noteworthy findings and ideas.The various studies included in this research shed light on the intricate interplay of factors influencing athletes' mental health and the prevalence of suicidal ideation within this population.
Firstly, it is noteworthy that these studies originate from countries with advanced economies.This observation leads to several possible conclusions.On one hand, these economically developed nations likely possess more resources to fund and conduct research across various domains, including mental health in sports.Additionally, they may prioritize raising awareness about mental health issues.On the other hand, countries with advanced economies often foster a strong sports and competitive culture, which could impact the prevalence of mental health challenges among athletes.However, the absence of studies in less developed economies does not imply that mental health problems among athletes are absent there.Instead, it may reflect limitations in resources, visibility, or access to mental health care, hindering comprehensive research.Therefore, expanding research to a broader range of contexts and economies is crucial for a more comprehensive understanding of athletes' mental well-being worldwide.
Secondly, it is concluded that, despite sports practice being beneficial for mental health by helping reduce stress, anxiety, and depression, it can also have a negative impact.Some factors that can provoke it include intense pressure to achieve optimal performance, injuries that can trigger depression and feelings of worthlessness, the normalization of violence in sports education, as well as harassment, discrimination, and abuse in high-performance sports.Additionally, the analyzed studies suggest that athletes may have skills to hide their emotional pain.Although none of the analyzed studies directly addressed the interrelation between Covid-19 and suicide (some of them are pre-pandemic, but others are post-pandemic), it is crucial to recognize that the pandemic also had a significant impact on athletes' mental health worldwide, given the diverse circumstances they faced, and this impact should be further explored in more detail.All these findings underscore the multifaceted nature of the challenges faced by athletes and emphasize the need for a comprehensive approach to mental health support within the sports community.
Thirdly, it is concluded that the support network for athletes plays a crucial role in suicide prevention, with teachers, coaches, family members, and mental health professionals playing fundamental roles.The positive influence of coaches in maintaining affectionate relationships and providing emotional support was evident in several studies.Additionally, the importance of mental health professionals, including psychiatrists and psychologists, in suicide prevention was highlighted.
Finally, it is concluded that, although the studies did not primarily focus on suicide intervention or prevention methods (because suicide analysis was not their main objective), they provided valuable recommendations.It is recommended that professionals working with athletes (teachers, coaches, and health professionals) be trained from a critical and deep perspective on mental health and suicide, avoiding courses with inflexible protocols, as mental health is as important as physical health.And it is essential to focus on building close and genuine relationships with athletes: it is crucial to remember that athletes are people before athletes, and attention should be paid to everyday events that influence athletic performance and vice versa.Additionally, it is important to understand the perspectives and experiences of athletes at different levels.And, of course, it is crucial for athletes to have access to mental health services to assist them in navigating challenges that may arise in their sports environment and fostering resilience and well-being.

Figure 1 .
Figure 1.Flowchart of Study Selection Identified in the Bibliographic Search Source: Self-developed based on the PRISMA diagram.(Liberati et al., 2020).

Table 2 .
Analysis of the Document Corpus Using the Critical Appraisal Skills Program (CASP) 10 Camiré (2015) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes André-Morin et al., (2017) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes McDonald y Kawai (2017) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Marsters y Tiatia-Seath (2019) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Gross et al. (2020) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Gaetz (2021) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Harvey et al. (2021) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Oforeh et al. (2022) Yes Yes No Yes No No No No Yes No Source: Self-developed based on the Critical Appraisal Skills Program.

Table 3 .
Characteristics of the research