What is SMHAT-1? The IOC’s Sport Mental Health Screening Tool
Everything healthcare professionals need to know about the Sport Mental Health Assessment Tool 1 — the first internationally standardised, sport-specific mental health screening tool developed by the IOC Mental Health Working Group.
What is SMHAT-1?
The Sport Mental Health Assessment Tool 1 (SMHAT-1) is the first internationally standardised, sport-specific mental health screening tool. Published in the British Journal of Sports Medicine in 2021, it was developed by the IOC Mental Health Working Group — 11 international experts convened after the 2018 IOC consensus meeting on mental health in elite athletes. It is designed for use by sports medicine physicians and licensed mental health professionals with athletes aged 16 and older at professional, Olympic, Paralympic, or collegiate level.
Modelled on the SCAT Approach
The SMHAT-1/SMHRT-1 pairing was deliberately modelled on the SCAT/CRT concussion tool pairing. Just as the SCAT provides clinical assessment and the CRT enables sideline recognition, the SMHAT-1 provides clinical screening and the companion SMHRT-1 enables mental health recognition by coaches, family, and athletes themselves. This familiar framework lowers adoption barriers for sports medicine professionals already using SCAT6.
Designed for Digital Delivery
The original IOC publication explicitly states the tool is 'designed to be ideally embedded in a privacy-secured online platform.' Unlike legacy paper tools adapted for digital use, the SMHAT-1 was conceived from the outset for digital administration — recognising that athlete privacy, automated scoring, and longitudinal tracking require technology-enabled delivery.
What is the SMHAT-1 three-step screening process?
The SMHAT-1 three-step screening process is a structured pathway that progresses from sport-specific triage (Step 1: APSQ) through disorder-specific screening across six validated instruments (Step 2: anxiety, depression, sleep, alcohol, substance use, and disordered eating) to clinical assessment and management (Step 3). Each step has defined thresholds that determine whether an athlete progresses to the next level of evaluation.
Step 1 — Triage: Athlete Psychological Strain Questionnaire (APSQ)
The APSQ is a 10-item self-report instrument developed and validated specifically in elite athletes. It assesses three subscales: Self-Regulation, Performance, and External Coping. Scored on a 5-point Likert scale (1 = none of the time, 5 = all of the time), with a total range of 10–50. Severity levels: ≥15 moderate, ≥17 high, ≥20 very high psychological distress. Score ≥17 triggers progression to Step 2. Psychometrics: Cronbach's alpha 0.81 (males), 0.84 (females); AUC values 0.90–0.95.
Step 2 — Disorder-Specific Screening: Six Instruments
Athletes who triage positive complete all six instruments simultaneously. Each has published clinical thresholds:
GAD-7 (Anxiety) — 7 items, 0–21, threshold ≥10
PHQ-9 (Depression) — 9 items, 0–27, threshold ≥10
ASSQ (Sleep Disturbance) — SDS 0–17, threshold ≥8
AUDIT-C (Alcohol Misuse) — 3 items, 0–12, threshold ≥4 men / ≥3 women
CAGE-AID (Substance Use) — 4 items, 0–4, threshold ≥2
BEDA-Q (Disordered Eating) — 9 items, 0–18, threshold ≥4
Step 3 — Clinical Assessment and Management
Conducted by a sports medicine physician or licensed mental health professional. Step 3a (sub-threshold): Brief intervention — psychoeducation, mindfulness, mental skills training. Re-assess with APSQ after intervention. Step 3b (positive screen): Comprehensive clinical assessment evaluating severity (functional impairment, risk to self/others) and complexity (comorbid conditions). Non-severe, non-complex cases managed by sports medicine physician. Severe, complex, or treatment-resistant cases referred to psychiatrist or clinical psychologist.
The Team USA study (n=1,066 Olympic/Paralympic athletes across 51 sports) found that the APSQ triage step has a 67.5% false negative rate — two-thirds of athletes who screened positive on Step 2 instruments would have been missed by APSQ triage alone. The recommended approach (and the approach ScreenIT uses) is to administer Steps 1 and 2 together, using the APSQ as contextual information rather than a gatekeeper. This matches the protocol used by the US Olympic and Paralympic Committee.
What instruments does SMHAT-1 include?
SMHAT-1 includes seven validated screening instruments selected for their clinical utility in sport settings: the APSQ for triage (Step 1), plus the GAD-7 (anxiety), PHQ-9 (depression), ASSQ (sleep), AUDIT-C (alcohol), CAGE-AID (substance use), and BEDA-Q (disordered eating) for disorder-specific screening (Step 2). Each instrument has published clinical thresholds and established psychometric properties.
Step 1: Triage
APSQ (Athlete Psychological Strain Questionnaire)
The only sport-specific instrument in the SMHAT-1 battery. 10 items assessing self-regulation difficulties, performance concerns, and external coping. Score range 10–50. Threshold: ≥17 (high distress). Normative data: males 14.4 (SD 5.18), females 15.08 (SD 4.41). Validated in elite athlete populations with AUC 0.90–0.95.
Step 2: Mood and Anxiety
GAD-7 (Generalised Anxiety Disorder)
7 items scored 0–3 over the past 2 weeks. Score range 0–21. Severity: 0–4 minimal, 5–9 mild, 10–14 moderate, 15–21 severe. SMHAT-1 threshold: ≥10. General population sensitivity 89%, specificity 82% at ≥10.
PHQ-9 (Patient Health Questionnaire)
9 items scored 0–3 over the past 2 weeks. Score range 0–27. Severity: 0–4 minimal, 5–9 mild, 10–14 moderate, 15–19 moderately severe, 20–27 severe. SMHAT-1 threshold: ≥10.
Step 2: Sleep
ASSQ (Athlete Sleep Screening Questionnaire)
15–16 items. Key metric: Sleep Difficulty Score (SDS) derived from 5 items. SDS range 0–17. Severity: 0–4 none, 5–7 mild, 8–10 moderate, 11–17 severe. SMHAT-1 threshold: SDS ≥8. Sensitivity 81%, specificity 93%. Developed and validated specifically for elite athletes.
Step 2: Substance Use
AUDIT-C (Alcohol Use Disorders Identification Test — Consumption)
3 items (frequency, quantity, binge frequency) scored 0–4 each. Score range 0–12. SMHAT-1 threshold: ≥4 (men) / ≥3 (women). Sensitivity 86%, specificity 89% at ≥4 for men. Score of 0 = no alcohol use.
CAGE-AID (Adapted to Include Drugs)
4 yes/no items using the CAGE mnemonic: Cut down, Annoyed by criticism, Guilty feelings, Eye-opener. Score range 0–4. SMHAT-1 threshold: ≥2. Extends original CAGE alcohol screening to include drug use.
Step 2: Eating
BEDA-Q (Brief Eating Disorder in Athletes Questionnaire)
9 items covering body dissatisfaction, drive for thinness, dieting behaviour, and perfectionism. Score range 0–18. SMHAT-1 threshold: ≥4. Sensitivity 82.1%, specificity 84.6%. Important limitation: Originally validated only in female elite athletes.
How is SMHAT-1 scored and interpreted?
SMHAT-1 produces domain-specific scores across six instruments plus the APSQ triage. No single score diagnoses a mental health condition — scores indicate when clinical assessment is warranted.
Triage Score (APSQ)
Step 1
Total score 10–50. Score ≥17 indicates high psychological distress. The APSQ does not diagnose — it identifies athletes who warrant further screening. ScreenIT administers Steps 1 and 2 together based on evidence that the APSQ alone misses two-thirds of positive screens.
Screening Scores
Step 2
Each Step 2 instrument has its own clinical threshold. Scores above threshold indicate the need for clinical assessment (Step 3), not a diagnosis. Multiple positive screens across domains suggest greater clinical complexity.
Clinical Context
Interpretation
Interpret scores in the context of the athlete's baseline data, injury history, training load, competition phase, and life events. Research shows screening-positive rates (51–53% in Olympic cohorts) far exceed specialist-referral rates (9.5% after clinical interview), demonstrating that clinical context is essential for appropriate resource allocation.
The standard PHQ-9 and GAD-7 thresholds (≥10) were validated in general populations. Research in student-athlete populations suggests lower cutoffs (≥6 for both PHQ-9 and GAD-7) may be more appropriate, as athletes may present differently. The SMHAT-1 uses the standard ≥10 thresholds. Clinicians should be aware of this limitation and consider lower thresholds when clinical suspicion warrants.
When should athletes be screened with SMHAT-1?
Athletes should be screened with SMHAT-1 at predictable high-risk timepoints throughout the athletic lifecycle, including pre-season, during injury rehabilitation, at major competition transitions, and following concussion. Mental health screening should be periodised alongside physical assessments to normalise the process, reduce stigma, and catch emerging issues before they escalate to clinical severity.
Pre-Season Baseline
A few weeks after training resumes
Establish mental health baseline alongside physical testing. Identify pre-existing conditions before competition stress. Critical for concussion assessment — pre-existing symptoms confound diagnosis.
Mid-Season Check
Midpoint of competitive season
Monitor for accumulating stress, overtraining effects, sleep disruption, and substance use patterns.
Post-Season Review
After final competition
Assess burnout, evaluate career satisfaction, identify athletes who struggled silently through the season. Only 22.4% of athletes in need will have self-referred.
Post-Injury
After significant injury, especially concussion
Concussion increases depression risk 1.6× (single) to 2.4× (3+). Athletes with pre-existing psychiatric symptoms have 5× higher risk of persistent post-concussion symptoms.
Career Transition
Deselection, retirement, level change
18–39% of retired athletes experience anxiety/depression. Forced retirement is significantly worse than planned.
After Major Events
Post-competition, major life events
Performance outcomes, media exposure, social media abuse, and interpersonal violence are all established risk factors.
The Help-Seeking Gap
A 2023 meta-analysis found that only 22.4% of athletes who need mental health support actually seek it. Over 40% of barriers relate to stigma and fear of deselection. Routine, standardised screening removes the burden from athletes to self-identify — the same principle that transformed concussion management. Without routine screening, nearly four in five athletes in need are missed.
Why was SMHAT-1 created?
SMHAT-1 was created by the International Olympic Committee (IOC) because elite athletes lacked a standardised, sport-specific mental health screening framework. Before SMHAT-1, mental health assessment in sport relied on general population instruments applied ad hoc, with no consensus on which tools to use, when to screen, or how to interpret results in athletic contexts. The IOC convened an expert panel to develop an evidence-based pathway that addresses the unique psychological demands of competitive sport.
The Problem: A Third of Athletes Affected
A 2019 meta-analysis by Gouttebarge and colleagues found that 33.6% of current elite athletes report symptoms of anxiety or depression. A separate study found lifetime prevalence of mental health problems reaching 51.7% (58.2% female, 42.3% male). Despite these rates, no standardised, sport-specific mental health screening tool existed. Clinical practice relied on generic instruments (PHQ-9, GAD-7) that lack sport context, miss sport-specific stressors, and were validated in general populations where athletes may present differently.
The Solution: IOC Consensus to Action
In November 2018, the IOC convened 20 experts in Lausanne who reviewed 14,689 published articles to produce the 2019 IOC Consensus Statement on Mental Health in Elite Athletes — the most comprehensive expert review of athlete mental health to date, led by Claudia Reardon with 27 co-authors. The IOC then established the Mental Health Working Group (11 experts, chaired by Vincent Gouttebarge) who developed both the SMHAT-1 and its companion recognition tool (SMHRT-1) during 2019 meetings in Lausanne. The SMHAT-1 was refined through a Delphi process with 15 independent experts, achieving over 90% agreement on the tool's usefulness.
The SMHRT-1 Companion Tool
The Sport Mental Health Recognition Tool 1 is designed for athletes and their entourage (coaches, family, fellow athletes) — not health professionals. It presents a list of observable changes (thoughts, feelings, behaviours) that may indicate mental health problems, encouraging the observer to facilitate help-seeking. This parallels the CRT6/SCAT6 model where non-clinical observers recognise concerns and clinical professionals assess.
What is the evidence for SMHAT-1 in practice?
The evidence for SMHAT-1 in practice comes from implementation across multiple Olympic programmes, professional leagues, and university settings since its 2021 publication. Real-world data from the US Olympic and Paralympic Committee (n=1,066 athletes across 51 sports), Australian Institute of Sport, and NCAA programmes demonstrates both the tool's feasibility and important findings about screening accuracy and prevalence rates.
Team USA — Tokyo/Beijing
2023 Study
1,066 athletes across 51 Olympic/Paralympic sports. Administered digitally via online survey platform. APSQ positive: 29.5%. Key finding: 67.5% false negative rate for APSQ triage alone. Most prevalent positive screens: BEDA-Q (40.2%), AUDIT-C (31.6%), ASSQ (16.8%).
Anderson et al. (2023), British Journal of Sports Medicine
Team USA — Paris 2024
2025 Study
847 SMHAT-1 assessments (52% women, 26.7% Paralympic). 53.1% had a positive screen. Follow-up outcomes: 31.8% resolved with discussion only, 26.0% already connected to outside services. Protocol: 48-hour follow-up for positive screens.
Anderson et al. (2025)
Polish Olympic Athletes
2024 Study
1,121 elite athletes (545 female, 576 male). 72.4% scored above APSQ triage threshold. 51% screened positive on Step 2. After clinical intake interview: only 9.5% required specialist referral, 24.2% received psychoeducation, 66.3% required no action.
Waleriańczyk et al. (2024), BJSM 59(1):56–63
Japanese Male Rugby
2022 Study
220 professional rugby players from Japan's Top League. Japanese players scored significantly higher than Australian normative data (mean APSQ 19.16 vs 14.67, Cohen's d = 0.76). APSQ Japanese version: Cronbach's alpha 0.84.
Sports Psychiatry
Canadian University Programme
2023 Study
~550 student-athletes across 17 sports at a large Ontario university. Three repeated measurements over the academic year. Confirmed feasibility and good internal consistency in university athletes.
Clinical Journal of Sport Medicine 2023;33(1):5–12
How are mental health and concussion connected?
Mental health and concussion are bidirectionally linked — concussion increases the risk of mental health symptoms, and pre-existing mental health conditions increase both concussion risk and recovery time. This makes integrated screening with tools like SCAT6 and SCOAT6 essential alongside SMHAT-1 in any sports medicine programme.
Concussion Increases Mental Health Risk
Athletes with a prior concussion have a 46% higher risk of mental health disability (Burns et al., 2022). A dose-response relationship exists: each additional concussion further increases depression risk (Guskiewicz et al., 2007; Burns et al., 2022). Approximately 20% of concussed athletes report depression; 33% report anxiety post-injury.
Mental Health Affects Concussion Recovery
Athletes with pre-existing psychiatric symptoms are significantly more likely to develop persistent post-concussion symptoms (Amsterdam Consensus, 2023). Pre-existing depression and anxiety produce symptom profiles comparable to acute concussion — complicating diagnosis without baseline data.
Why Integrated Screening Matters
SCOAT6 includes optional GAD-7 and PHQ-2 screening — but these cover only two of six SMHAT-1 domains. Without baseline mental health data from SMHAT-1, clinicians cannot distinguish pre-existing symptoms from concussion-related symptoms. ScreenIT integrates SCAT6, SCOAT6, and SMHAT-1 in a single patient record for complete longitudinal tracking.
Where to Access SMHAT-1
The SMHAT-1 is freely available for clinical use. The IOC authors explicitly recommend digital delivery. ScreenIT digitises SMHAT-1 alongside 70+ other validated assessments.
Paper SMHAT-1 (PDF)
The official SMHAT-1 was published in the British Journal of Sports Medicine (2021, Vol 55, Issue 1) and is available via the IOC Athlete365 platform. It can be freely copied for distribution to individuals, teams, and organisations. Any revision or translation requires IOC Mental Health Working Group approval.
View on Athlete365Digital SMHAT-1 (ScreenIT)
ScreenIT has IOC authorisation for the digital SMHAT-1 — all seven instruments (APSQ, GAD-7, PHQ-9, ASSQ, AUDIT-C, CAGE-AID, BEDA-Q) with automated scoring, instant threshold flagging, and longitudinal tracking. Administers Steps 1+2 together following the evidence-based protocol used by Team USA. Free for unlimited assessments.
Get Started Free →Frequently Asked Questions About SMHAT-1
What is the SMHAT-1?
The Sport Mental Health Assessment Tool 1 (SMHAT-1) is the first internationally standardised, sport-specific mental health screening tool. Developed by the IOC Mental Health Working Group and published in the British Journal of Sports Medicine in 2021, it provides a structured three-step pathway: triage (APSQ), disorder-specific screening (GAD-7, PHQ-9, ASSQ, AUDIT-C, CAGE-AID, BEDA-Q), and clinical assessment. It is designed for athletes aged 16+ at professional, Olympic, Paralympic, or collegiate level.
Who developed the SMHAT-1?
The SMHAT-1 was developed by the IOC Mental Health Working Group — 11 international experts chaired by Vincent Gouttebarge (Amsterdam IOC Research Centre). It was built upon the 2019 IOC Consensus Statement on Mental Health in Elite Athletes, led by Claudia Reardon with 27 co-authors who reviewed 14,689 published articles. The SMHAT-1 was refined through a Delphi process with 15 independent experts, achieving over 90% agreement on the tool’s usefulness.
Who can administer the SMHAT-1?
The SMHAT-1 is designed for sports medicine physicians and licensed mental health professionals. Steps 1 and 2 are self-report questionnaires completed by the athlete. Step 3 (clinical assessment) must be conducted by a qualified clinician. For non-clinical observers (coaches, parents, fellow athletes), the companion SMHRT-1 (Sport Mental Health Recognition Tool 1) is available.
How long does the SMHAT-1 take?
Steps 1 and 2 (triage + screening) take approximately 10–15 minutes for the athlete to complete. Step 3 (clinical assessment) duration varies based on clinical complexity. Digital administration via ScreenIT reduces the time further through automated scoring and guided workflows.
What does the SMHAT-1 screen for?
Six mental health domains: anxiety (GAD-7), depression (PHQ-9), sleep disturbance (ASSQ), alcohol misuse (AUDIT-C), substance use (CAGE-AID), and disordered eating (BEDA-Q). The triage step uses the sport-specific Athlete Psychological Strain Questionnaire (APSQ) covering self-regulation, performance concerns, and external coping.
Should I use the APSQ triage as a gatekeeper?
Current evidence advises against relying on the APSQ alone to determine who proceeds to Step 2. The Team USA study (n=1,066 athletes) found that 67.5% of athletes who screened positive on Step 2 instruments scored below the APSQ triage threshold. The recommended approach is to administer Steps 1 and 2 together, using APSQ scores as contextual clinical information rather than a screening gate.
How often should athletes be screened?
The IOC recommends screening during the pre-competition period, mid-season, end of season, and following significant life events (major injury, surgery, suspected harassment or abuse, unexplained performance concern, end of competitive cycle, sport transition). Pre-season screening is especially valuable as it establishes a baseline for comparison throughout the season.
Is the SMHAT-1 appropriate for the NCAA mental health mandate?
The SMHAT-1 was designed for professional, Olympic, Paralympic, and collegiate athletes — explicitly including the NCAA population. It provides multi-domain validated screening consistent with the NCAA Mental Health Best Practices requirement for annual screening using empirically validated tools.
What is the difference between SMHAT-1 and SMHRT-1?
The SMHAT-1 is a clinical screening tool for healthcare professionals. The SMHRT-1 (Sport Mental Health Recognition Tool 1) is a recognition checklist for athletes, coaches, family, and entourage — designed to identify observable changes that may indicate mental health problems and encourage help-seeking. This mirrors the SCAT6/CRT6 model.
Is the SMHAT-1 available digitally?
Yes. The original IOC publication states the tool is designed to be ideally embedded in a privacy-secured online platform. Digital implementations include the US Olympic and Paralympic Committee (via Qualtrics for 1,066+ athletes), Japanese rugby (web-based), and ScreenIT (IOC-authorised, free, with automated scoring across all seven instruments).
What happens after a positive SMHAT-1 screen?
Positive screens progress to Step 3: clinical assessment by a sports medicine physician or licensed mental health professional. The clinician evaluates severity and complexity. Non-severe cases may be managed with brief intervention; severe, complex, or treatment-resistant cases are referred to a psychiatrist or clinical psychologist. The Polish Olympic study showed that after clinical interview, 66.3% required no further action, 24.2% received psychoeducation, and only 9.5% required specialist referral.
Evidence & References
Primary Sources
IOC Consensus Statement: Reardon CL, Hainline B, Aron CM et al. BJSM 2019;53(11):667–699
SMHAT-1 Development: Gouttebarge V, Bindra A, Blauwet C et al. BJSM 2021;55(1):30–37
APSQ Development: Rice S et al. Int J Sport Exerc Psychol 2020;18(6):759–774
APSQ Cut-Points: Rice S et al. BMJ Open Sport Exerc Med 2020;6(1):e000712
Implementation Studies
Team USA: Anderson T et al. BJSM 2023. PMC:10579191
Team USA Paris 2024: Anderson T et al. (2025)
Polish Olympic: Waleriańczyk W et al. BJSM 2024;59(1):56–63
Canadian University: Wootten E et al. CJSM 2023;33(1):5–12
Japanese Rugby: APSQ-J validation. Sports Psychiatry
Component Instruments
PHQ-9: Kroenke K et al. J Gen Intern Med 2001;16(9):606–613
GAD-7: Spitzer RL et al. Arch Intern Med 2006;166(10):1092–1097
ASSQ: Samuels CH et al. BJSM 2016;50(7):418–422
AUDIT-C: Bush K et al. Arch Intern Med 1998;158(16):1789–1795
CAGE-AID: Brown RL et al. Prev Med 1998;27(1):101–110
BEDA-Q: Martinsen M et al. Med Sci Sports Exerc 2014;46(8):1666–1675
Prevalence and Context
Meta-Analysis: Gouttebarge V et al. BJSM 2019;53(11):700–706
Lifetime Prevalence: Gulliver A et al. J Sci Med Sport 2015;18(3):255–261
Help-Seeking: Breslin G et al. Psychology of Sport and Exercise 2024
Concussion–Depression: Guskiewicz KM et al. Med Sci Sports Exerc 2007;39(6):903–909
Concussion–Mental Health Disability: Burns K et al. J Clin Transl Res 2022;8(3)
Content last reviewed: February 2026. Based on SMHAT-1 published January 2021.
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