What is SMHAT-2? The IOC’s Updated Sport Mental Health Assessment Tool
Everything sports medicine physicians and mental health professionals need to know about the IOC Sport Mental Health Assessment Tool 2: who it is for, the three steps, the thresholds that decide what happens next and what changed from the first edition. For the first edition, see What is SMHAT-1?
What is SMHAT-2?
The International Olympic Committee Sport Mental Health Assessment Tool 2 (IOC SMHAT2, often written SMHAT-2) is a standardised assessment tool that identifies elite athletes who may be experiencing mental health symptoms or disorders, so that those in need of support or treatment are referred in time. It was developed by the IOC Mental Health Working Group and published in the British Journal of Sports Medicine in July 2026, as the second edition of the SMHAT-1 released in 2021.
Why a Second Edition?
Five years of use raised concerns about SMHAT-1: its APSQ triage step missed many athletes later found above threshold, some questionnaire cut-offs needed more validation, and the tool existed only on paper. The working group reviewed the evidence, interviewed experienced users, re-analysed SMHAT-1 data and rebuilt the first two steps.
Screening, Not Diagnosis
A score at or above threshold in SMHAT-2 is not a diagnosis. It is a prompt for clinical evaluation. Diagnosis, guidance and treatment stay with a sports medicine physician or a licensed mental health professional, who uses the clinical assessment in Step 3.
Who Should Use SMHAT-2, and When?
SMHAT-2 is for elite athletes, defined as professional, Olympic, Paralympic or collegiate level and aged 16 and over, and for the clinicians who look after them.
Who Uses It?
Sports medicine physicians and other licensed or registered health professionals. Physical therapists and athletic trainers can use it alongside a sports medicine physician. Others should use the IOC Sport Mental Health Recognition Tool 2 instead.
When Is It Used?
Ideally in pre-season, a few weeks after training starts and before competition. Also mid- and end-season, and after a significant event: injury, illness, surgery, a performance concern, a major competition, suspected harassment or abuse, deselection or leaving sport.
How Should Results Be Handled?
With strict confidentiality: results are not shared without the athlete's consent and not used for selection. The IOC also asks that every athlete gets feedback after completing it, whether or not concerns were raised.
What Are the Three Steps of SMHAT-2?
Two athlete forms and a medical form, with an optional third athlete form for extra information at Step 3.
Step 1: Universal Screening (Athlete Form 1)
Every athlete answers 45 questions in about 10 minutes, covering seven key symptom clusters: anxiety (GAD-7, last 2 weeks), depression including suicidal ideation (PHQ-9, last 2 weeks), sleep disturbance (ASSQ, recent past), disordered eating (EDE-QS, past 7 days), alcohol misuse (AUDIT, past year), and single yes or no questions on cannabis and on tobacco or nicotine use in the last 6 months.
Step 2: Conditional Screening (Athlete Form 2)
About 5 minutes, and only when Step 1 calls for it. Anxiety or depression at or above threshold triggers the PC-PTSD-5, a screen for post-traumatic stress in the past month, because the three often occur together. Cannabis or nicotine use triggers the CAGE-AID, a screen for substance misuse in the last 3 months. Whatever the Step 2 scores, the athlete goes on to Step 3.
Step 3: Clinical Assessment (Medical Form)
A comprehensive clinical assessment, 30-45 minutes, by a sports medicine physician or licensed mental health professional. It gathers mental health history and context, including any harassment or abuse inside or outside sport, and for each problem rates severity, complexity, diagnostic uncertainty and previous non-response to treatment.
Optional: Athlete Form 3
When the diagnosis is uncertain, the clinician can ask the athlete to complete further screening for attention-deficit/hyperactivity disorder, bipolar disorder, problem gambling, prolonged grief, obsessive-compulsive disorder or psychosis before deciding.
Which SMHAT-2 Scores Lead to Step 2 or Step 3?
Each Step 1 score is checked against an IOC threshold. If every score is under threshold, no action is needed.
Step 2, Then Step 3
Anxiety: GAD-7 of 10 or more
Depression: PHQ-9 of 10 or more
Cannabis use in the last 6 months
Tobacco or nicotine use in the last 6 months
Straight to Step 3
Sleep disturbance: ASSQ of 8 or more
Disordered eating: EDE-QS of 15 or more
Alcohol misuse: AUDIT of 8 or more
A score of 1 or more on item 9 of the PHQ-9, the question on thoughts of self-harm, means taking immediate action according to the mental health emergency plan, as in SMHAT-1.
Severity bands: anxiety 5-9 mild, 10-14 moderate, 15 or more severe. Depression 5-9 mild, 10-14 moderate, 15-19 moderate to severe, 20 or more severe. Sleep 5-7 mild, 8-10 moderate, 11 or more severe. Alcohol 8-14 hazardous or harmful drinking, 15 or more moderate to severe alcohol use disorder.
How Is SMHAT-2 Different From SMHAT-1?
Both keep the same three-step shape and screen the same kinds of symptoms. What changed is how athletes are screened, which questionnaires are used and where each score leads.
SMHAT-1 (2021)
APSQ triage first; only scores of 17 or more go on
Disordered eating: BEDA-Q
Alcohol: 3-item AUDIT-C
Drug use: CAGE-AID at Step 2
PTSD screen optional, after the clinical assessment
Available in nine languages
SMHAT-2 (2026)
No triage: every athlete completes the universal screen
Disordered eating: 12-item EDE-QS
Alcohol: full 10-item AUDIT
Cannabis and nicotine questions; CAGE-AID only if either is yes
PC-PTSD-5 at Step 2 after raised anxiety or depression
English only for now
What Happens at the SMHAT-2 Clinical Assessment?
Using everything gathered, the sports medicine physician or licensed mental health professional chooses one of three actions.
Treat and Support
When a case is not severe, complex, diagnostically uncertain or previously unresponsive to treatment, a sports medicine or primary care physician can provide treatment and support, guided by the IOC consensus statement on mental health in elite athletes (2026).
Screen Further
When the diagnosis is uncertain or more information would help, the clinician considers the Athlete Form 3 screenings before making a definitive diagnosis and a treatment plan.
Refer
When a case is severe, complex, still diagnostically uncertain or not responding to treatment, the athlete is referred to a licensed mental health professional, such as a clinical psychologist or psychiatrist, or the most qualified provider available.
How Was SMHAT-2 Developed?
The IOC Mental Health Working Group worked through seven stages during 2025 and finalised the tool in December 2025, guided by COSMIN methodology for health measurement instruments.
Evidence and Experience
Two scoping reviews of SMHAT-1 research, interviews with experienced SMHAT-1 users, and a misclassification analysis of SMHAT-1 data from 1,035 elite athletes (mean age 24; 55% men, 45% women).
Expert Design
A two-day expert meeting at Olympic House, Lausanne, in June 2025 designed the initial tool, drawing on psychiatry, sports medicine, sports neurology, addiction medicine, measurement science and elite sport.
Clinician Validation
58 health professionals from Europe, North America, Asia and Africa rated every component. Each met the target of at least 70% rating it relevant and appropriate. Automated administration and scoring was among their suggestions to make it more feasible.
Where Can You Access SMHAT-2?
The IOC publishes SMHAT-2 free with its development paper in the British Journal of Sports Medicine, as a paper form with an Excel calculator for Steps 1 and 2. It may be copied freely in its current form but not re-branded or sold. ScreenIT offers a free digital SMHAT-2 that scores and routes each step in the athlete's record.
Paper SMHAT-2 (IOC)
The medical form and three athlete forms, printed single-sided, with an Excel calculator whose scoring and medical sheets are hidden until unhidden. Nothing to sign up for. Scores are entered and routing worked out by hand.
Digital SMHAT-2 (ScreenIT)
Free on every plan. Athlete Forms 1 to 3 and the clinical assessment in one record, scores set against the IOC thresholds automatically, the item 9 alert on the clinician's screen, a PDF report, and SMHAT-1, SCAT6 and SCOAT6 in the same patient record.
Frequently Asked Questions About SMHAT-2
What does SMHAT-2 stand for?
SMHAT-2 is the IOC Sport Mental Health Assessment Tool 2, also written IOC SMHAT2. It is the second edition of the IOC’s mental health screening tool for elite athletes, published in the British Journal of Sports Medicine in July 2026.
Which questionnaires does SMHAT-2 use?
Step 1 uses the GAD-7 (anxiety), PHQ-9 (depression), ASSQ (sleep), EDE-QS (disordered eating) and AUDIT (alcohol), plus single questions on cannabis and on tobacco or nicotine use. Step 2 uses the PC-PTSD-5 (post-traumatic stress) and the CAGE-AID (substance misuse) when Step 1 triggers them.
Why did SMHAT-2 drop the APSQ triage?
The scientific literature, experienced users and the working group’s own analysis of SMHAT-1 data all found that the APSQ missed too many athletes, up to around a third of those above threshold for alcohol misuse or disordered eating. SMHAT-2 screens every athlete across all seven symptom clusters instead.
Is SMHAT-2 a diagnostic tool?
No. A score at or above threshold is a prompt for clinical evaluation, not a diagnosis. Diagnosis and treatment decisions are made at the Step 3 clinical assessment by a sports medicine physician or a licensed mental health professional.
Can SMHAT-2 be used with athletes under 16?
SMHAT-2 is designed and validated for elite athletes aged 16 and over, at professional, Olympic, Paralympic or collegiate level.
Is SMHAT-2 available in other languages?
At publication SMHAT-2 is available in English only. The IOC Mental Health Working Group encourages translation in collaboration with it, and any translation should be reported to the working group.
Evidence & References
Primary Sources
SMHAT-2 Development: Gouttebarge V, et al. (2026), International Olympic Committee Sport Mental Health Assessment Tool 2 (IOC SMHAT2): development, content validity and feasibility. BJSM 60:1131-1142, doi:10.1136/bjsports-2025-111408
The Instrument: IOC SMHAT2, online supplemental material 4 to Gouttebarge et al. (2026)
IOC Consensus Statement: IOC consensus statement on mental health in elite athletes (2026)
SMHAT-1 Development: Gouttebarge et al. (2021), BJSM 55(1):30-37
Last Reviewed
Content last reviewed: October 2026. Based on the IOC SMHAT2 as published in July 2026.
Try ScreenIT's Free Digital SMHAT-2
Universal screening, conditional screening and the clinical assessment in one record, scored against the IOC thresholds, beside SMHAT-1, SCAT6 and SCOAT6. Free on every plan.
Start Mental Health Screening
Free Online SMHAT-2
The IOC’s 2026 athlete mental health assessment, scored and routed for you.
Free
The IOC SMHAT2 is developed by the IOC Mental Health Working Group. Not a diagnostic tool.