Coping strategies for handling stress and providing mental health in elite athletes: a systematic review

Background The combination of stressors unique to the athletic context plus the sensitive developmental phase that elite athletes go through during their peak performance may increase the athletes’ vulnerability to mental health decrements. To emphasize the necessity to raise elite athletes' awareness of health risks, it seems to be essential to teach them coping skills to handle stress and to make affected athletes aware of how to recognize, evaluate, and articulate potential risks to their health. Objective This systematic review analyzes coping strategies used by elite athletes to deal with stress and the effect of these strategies on mental health to identify gaps that future research could prioritize. Methods The current review analyzes studies containing quantitative, qualitative, and mixed data and results, all of them focusing on coping strategies to deal with stress and the effect of coping strategies on elite athletes' mental health. Literature search for this systematic review took place between August and October 2023 and included the use of 3 electronic databases: PubMed, PsychINFO, SPORTdiscus. Results There were initially 5,705 hits from 3 electronic databases, hand search and from a complementary search in Google Scholar. After the screening process and quality appraisal 30 studies were included. The analyzed study results point to a broad spectrum of coping categories, elite athletes make use of to deal with stressful situations. The results of this review underpin the necessity that especially young athletes being confronted with a wide range of stressors, need to be taught mental skills to cope with these stressors. In addition, teaching coaches and teammates about social support seemed to decrease elite athletes' stress reactions, such as anxiety or depressive symptoms. Conclusion Coping in elite sporting settings is very complex and dynamic. There is evidence of coping being effective to buffer stress, but the interrelationships between stressor, appraisal of the stressor, application of a corresponding coping strategy and its effect especially in terms of mental health outcomes is still unclear because of lacking intervention-based study designs.


Introduction
For some time now, research on the impact of stress on mental health has been an increasingly important issue in elite sport (1).
The context of elite sports consists of various stressors (2), including competitive, organizational, and personal stressors, that have the potential to increase the risk of mental health related problems and mental illness in elite athletes (1).The stressors elite athletes experience during their competitive years may be of different nature.That means that interdependencies between stress and mental health related problems in elite sport, can vary from athlete to athlete (1).Previous approaches to stress or stress management clearly show that stress is one of the key health risk factors (3).
The combination of stressors unique to the athletic context plus the sensitive developmental phase (4) that elite athletes go through during their peak performance may increase the athletes' vulnerability to mental health decrements.
In this context, it seems important to understanding the ageperformance-health relationship to promote the athletes' health (5).Significant for the onset and development of mental healthrelated problems in elite athletes is the concept of psychological strain which is characterized by a combination of perceived stress and the difficulty to cope with stress.If coping resources are extended beyond an elite athlete's capacity, stress-related symptoms of psychological strain may rise (6).To emphasize the necessity to raise elite athletes' awareness of health risks, it seems to be essential to teach them coping skills to handle stress and to make affected athletes aware of how to recognize, evaluate, and articulate potential risks to their health (7).
Since elite athletes are continuously confronted with the most varied challenges, environments, and stressors (2), it is not only from a biopsychosocial perspective (8,9) to be desirable but also from the transactional stress perspective as well as from conservation of resources (COR) theory to develop flexible coping strategies against the potential negative impact of stressful life events (10,11).The "classical" cognitive psychological approach of Lazarus (12) and Lazarus and Launier (13) sees the process of coping with stress as an equilibration process of an imbalanced psychophysical state.The question of coping effectiveness, however, is different in elite sports than in the field of clinical psychology.In contrast to people in everyday life, elite athletes are inevitably confronted with critical situations in competition.
To date, scientific attention has not explicitly focused to analyze the possibly effect of coping strategies to handle stress regarding mental health within the context of elite sports (14).Nicholls and Polman (15) reviewed the literature on coping in sport spanning 16 years (1988-2004) to examine evidence for the types of coping strategies applied by elite athletes and coping effectiveness, whereas Sarkar and Fletcher (16) focused on the interplay between stressors and protective factors and their influence on psychological resilience in elite athletes.
However, it is this knowledge of factors affecting athletes' mental health that is of tremendous importance to research.This is where the current systematic review comes in to contribute to this scenario aiming to analyze coping strategies used by elite athletes to deal with stress and the effect of these strategies on the mental health of elite athletes to identify gaps that future research could prioritize.As such the purposes to this systematic review are twofold: To give an overview of the coping strategies elite athletes use to cope with stress (1) and to investigate the effectiveness of these strategies for coping with stress (2).

Methods
Methodologically, this systematic review is informed by the (PRISMA) guidelines (17,18) that serve the generation of systematic reviews and meta-analyses.The PRISMA explanation was used as a guideline, and relevant recommendations were implemented in the study analysis as much as possible in the sense of methodological strictness and quality.The current review analyzes studies containing quantitative, qualitative, and mixed data and results, i.e., it represents a systematic mixed study overview (19).

Search strategy
Literature search for this systematic review took place between August and October 2023 and initially included the use of 3 electronic databases: PubMed, PsychINFO, SPORTdiscus.The rationale for using these databases relates to their prominent usage in other review articles (1,14).Database searches included the following search strings (e.g., for PsychINFO): ([TITLE-ABS-KEY (sport*)] AND [TITLE-ABS-KEY (athlete*)] AND [TITLE-ABS-KEY (mental AND health)] AND (TITLE-ABS-KEY (coping strategies OR skills) AND (TITLE-ABS-KEY psych* AND problem OR stress).
The following process was applied to identify documents relevant to this systematic review: (1) Search in 3 electronic databases (PubMed, PsychINFO, SPORTdiscus); (2) hand search; (3) complementary search in Google Scholar to ensure that no studies were overlooked.
Table 1 shows the development of search terms.
To minimize the risk of missing relevant studies the publishing date was not restricted.

Inclusion and exclusion criteria
The author analysed all matches based on title or abstract.If the information contained therein did not suffice, the relevant full text was consulted, as well.All studies included had to meet the following criteria: • Elite athletes were defined as either members of the Olympic squad, or as participants in competitions at the international and national levels, or as being active at a professional level (e. g.NCAA) (20), • The studies examined the effect of coping strategies on mental health, • The contributions were original articles, • The studies were available in full text, • And they were published in English.

Studies were excluded from this review if
• The test persons were under the age of 12, • The test persons did not comply with the definition of an "elite athlete" as specified in the inclusion criteria, • Only the abstract was available, but not the full text, • Data was missing on the study population or main findings and outcomes • And the studies were cross-sectional because they did not allow any deductions pertaining to the effect of coping strategies preferably on mental health (lack of causality)/if the relationship between coping strategies to manage stress and outcome was not analyzed.
This systematic review followed the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) (see Figure 1 study selection flow chart).
A template was created for data extraction to specify the required information (study design, participants, test objective, gender distribution, tests/material used, main results, key effects) of the studies included.

Quality assessment
Due to the heterogeneity of the studies included and due to the lack of randomized, controlled trials, a standardized risk-of-bias evaluation was not performed.As an alternative, the quality of the studies selected was evaluated based on the assessment tool "QualSyst" (22).This assessment tool includes 14 items (see Supplementary Table S1).The scoring is based on how well a scoring was met (no = 0, partial = 1, yes = 2); "NA" represents items that do not apply to the study design and are thus excluded from the calculation of the summary score.Each study's summary score was calculated by adding the total score and dividing it by the total possible score.The scores ≤55%, 55%-75%, and ≥75% indicate low, medium, and high quality, respectively.It is recommended to exclude any low-quality study from the systematic review.

Selection of literature
There were initially 5,705 hits from 3 electronic databases (PubMed, PsychINFO, SPORTdiscus), hand search and from a complementary search in Google Scholar.All duplicates were removed, and after screening the title and abstract, the entire text was read.33 research articles were chosen for this systematic review (see Figure 1).However, 3 out of 33 research articles were deemed to be of low quality and thus were excluded from this review.Thus, this systematic review was based on 30 studies that covered the research questions.Table 2 represents the details of the 30 studies included in this systematic review.The author has used quantitative and qualitative study designs as well as a combination of both to examine coping strategies and the effectiveness of the coping strategies applied to handle stress and to influence mental health.
Interestingly, the first study included was published in 1998 (Pensgaard & Ursin), which emphasizes a constant interest in coping in an elite sporting context.In addition, most studies have focused more on coping to handle stress rather than comprising the impact of coping on elite athletes' mental health (31,40,47).
The analyzed study results point to a broad spectrum of coping categories, elite athletes make use of to deal with stressful situations.The results representation outlines a categorization of the most widely used higher-order coping dimensions based on their function and intension (12,53), such as problem-orientated and emotion-regulative coping.Problem-orientated coping strategies are intended to change the stressful situation, whereas emotion-regulative coping deals with the emotional distress associated with the situation (10).To describe the complexity and heterogeneity of coping within the context of elite sport and the effectiveness of coping strategies applied by elite athletes regarding their mental health, some higher-order coping dimensions were used to structure the study results.Avoidance coping comprises both behavioral and psychological efforts to get rid of a stressful situation (54).Approach coping strategies involve the confrontation of the source of stress and the attempt to reduce it (e.g. taking direct action or planning) (55).With the help of appraisal-focused coping the stressful situation is reevaluated to reduce its intensity and importance (e. g. restructuring) (56).The application of the aforementioned macrolevel dimensions of coping seems to be suitable to provide an overall characterization of elite athletes' stress responses.However, these higher-order dimensions conceal the heterogeneity and complexity of the various coping responses and consider insufficiently the aspect of mental health.As the extracted literature mainly focused on coping in elite sporting context the classification of coping was completed by (1) type of sports, (2) gender, (3) dimensions of coping and (4) effectiveness of coping in terms of mental health.This approach was chosen to refer best to the review's objective/research questions.

Coping and type of sports
Findings show that teammates play an important role in the experience and appraisal of stress and coping in team sports.
When others influenced the stress and coping process situations were more likely to be appraised as a challenge and more adaptive problem-and emotion-focused strategies were used, whereas when a stressor was appraised as a threat a more maladaptive coping strategy or no coping at all was reported (23,45).The results also revealed that there is a significant relationship between coping with stress and perceptions of risk in extreme athletes, practicing extreme sports (43).
Pain coping strategies including distraction from pain, praying, reinterpreting pain sensations, ignoring pain and pain catastrophizing were observed to be related to athletes' inclination to play through pain (44).
The results indicated that pain catastrophizing explained an incremental portion of the variance in the prediction of sportrelated pain behavior, over and above the intensity of pain experienced during sport activity.The more athletes catastrophized their pain, the less they were inclined to play through the pain.

Coping and differences in gender
Regarding gender the analyzed studies revealed some differences.Studies observed that female athletes showed higher levels of anxiety and used more often emotion-focused coping strategies compared with male athletes and that female athletes experienced more intense stress from their coaches than did male athletes (32,46).Also, skill level affected athletes' coping style among both female and avoidance oriented strategies Caucasians experienced higher stress intensity and tended to use only an approach-behavior style; women reported higher stress intensity for coach-related sources of acute stress and used approach-behavioral and avoidance coping styles more often than their male counterparts; Hispanics did not differ from other groups on any measure Skein et al.Behavioral and task oriiented strategies Stress levels were significantly incresed in periods of high scheduling commitments with no differences between sexes Chronic sleep deprivation experienced by elite athletes may suggest that not only their recovery is impaired but also their mental health and well-being may be negatively affected.and male athletes; according to the percentages, more elite male athletes had an approach coping style, and more non-elite male athletes had an avoidance coping style, and more elite female athletes had an avoidance coping style and more non-elite females had an approach coping style.As well, findings showed that there are significant differences between men and women in their assessment of the frequency of using given strategies for coping with stress.Women were more likely than men to use strategies of searching for emotional support and instrumental support in threat situations; men reported using the strategy of relying on a sense of humor significantly more frequently than women did.No statistically significant differences between men and women were observed in levels of satisfaction with life and in the assessment of risks associated with extreme sports.

Coping strategies applied in elite sports
Study results regarding coping strategies in elite sports to handle stress showed that athletes adopted more often a taskoriented coping style to confront stressful sport-related situations (30,36).
Investigation of coping strategies in relation to athletes' illness revealed significantly different profiles of coping in resilient and non-resilient athletes.Those athletes, who remained healthy despite an elevated level of recent life stress generally favored problem-focused coping and seeking social support, whereas in the non-resilient group avoidance strategies were more dominant (37).Results also indicated that resilience correlated positively with task-oriented coping and negatively with emotion-oriented coping.Participants with lower resilience scored higher on emotion-oriented coping and distraction-oriented coping, whilst higher scores on resilience were observed on task-oriented coping (39).The findings of Hill et al. (25) revealed that avoidant coping was related to higher levels of athlete-burnout and higher levels of problem-focused coping were related to higher levels of self-oriented perfectionism.
Studies concerning coping style and coping strategies showed that athletes often used coping strategies that were commensurate with their coping style.

Effectiveness of coping in terms of mental health and handling stress
The results of Dolenc (46) showed that problem-focused coping is associated with lower levels of anxiety and that emotion-focused coping is associated with higher levels of neuroticism.The obtained results indicated positive correlations between proactive coping, moderate physical activity, self-efficacy, and mental health.Results indicated as well that biological and psychological factors contribute in complex ways to influence the psychological well-being and mental health status of young female athletes.Regarding the use of coping styles, the balance between adaptive and maladaptive coping styles predicted an outcome variable of clinical significance (42).
Coping strategies emerged as a predictor of variance of mental health in gymnastics but not in basketball.The results of the present study revealed that the adaptive scales were positively related to well-being and negatively to distress.The observation that coping style was most closely associated with mental health in comparatively short gymnasts was novel and of particular interest.
The study of Guo et al. (24) examined differences between athletes with high and low coping self-efficacy (CSE) levels under acute psychological stress.The study showed that low-CSE athletes lacked confidence and hence were more likely to not know what to do when facing stress.By contrast, low-CSE athletes paid greater attention to negative information and the consequences of failure, not only causing them to lose confidence in their abilities but also affecting their subsequent coping behavior and possibly their mental health status.
The results showed that athletes needed to be prepared for the total competitive experience that includes both organizational and competitive stressors.Further findings revealed the importance of social support as a coping strategy and that informational and emotional support in combination with cognitive strategies were used most to cope effectively with competitive stress and to influence mental health positively.In addition, coach support was important to cope with both organizational and competitive stressors and it turned out that athletes tend to seek more likely support from people the feel close to.

Discussion
This systematic review attempts to outline the current knowledge of coping strategies for handling stress and providing mental health in elite athletes.
Overall, the findings of this review add to domain-related reviews (1,14) suggesting, that elite athletes face various stressors during their sports career, that, if not well managed, put them at an increased risk of poor mental health.Despite growing interest in this topic, the factors that influence elite athletes' mental health remain unclear and therefore warrant further research.The transactional model of stress and coping (10) proposes that effective coping is an important variable to buffer the detrimental effects of stressors on mental health, as coping resources theoretically influence an athlete's ability to effectively deal with the challenges and stresses of sport participation.
According to Lazarus (57) coping strategies can be described as behaviors that help elite athletes to handle their problems, joys, and stresses of life.In line with Hobfoll's COR theory (58) someone with resources is less likely to encounter stressful circumstances that negatively affect psychological well-being and mental health.Hence, an elite athlete with coping skills such as high coping self-efficacy, highly pronounced resilience, sense of coherence or support from coaches, teammates, family members or friends can apply these resources in terms of coping with stressful situations towards growth and development instead of using these skills defensively to offset stressors.The athlete makes use of his resources to solve problems inherent to stressful situations.The more resources are available the more likely these resources are used to fit upcoming demands in stressful contexts.However, limited attention has been given to the potential relationship of athletic coping skills with well-being and mental health and how coping and its effectiveness are associated with elite athletes' mental health, despite Smith et al.'s (59) suggesting that these variables would be related to each other.
According to the current state of research stress symptoms, stemming from physical as well as psychological factors, are especially detrimental to elite athletes, as they rely on their physical and mental health and functioning for performance success.An increasing body of evidence shows that elite athletes experience mental-health problems, that can be maladaptive if not treated at an early stage, as they can lead to compromised psychological and physiological functioning (60).Concerning the relationship between stress and resulting mental health problems, the different coping strategies elite athletes use to handle stress can be important (15,61).
Therefore, dealing effectively with stress and the actions one decides to take depend mainly on the characteristics of the stressor and largely determines the health costs of a stress transaction (62).
This systematic review aimed to address this issue by analyzing both quantitative, qualitative, and mixed-method study designs examining elite athletes and the effectiveness of their coping strategies to handle stress and to protect their mental health.The findings are also consistent with the transactional model (10,57) and show parallels to the biopsychosocial determinants (see Table 1) influencing mental health in an elite sporting context (63).Worth mentioning are determinants on the psychological level (e.g., personality, perceived stress, coping repertoires) as well as on the social level (e.g., support systems) and the biological level (e.g., sleep, gender, age) as they were all focused on in the studies analyzed in this review.

Coping and type of sports
The identification of new coping strategies at the team sports level represents an important step in the understanding of communal coping in team sports because it offers a new perspective of how teams cope dealing with communal stressors.The identified communal coping strategies concretely describe the collective actions teammates use to cope.
The findings of studies analyzed in terms of type of sport showed that in extreme sports concentrating on forming interpersonal relations through looking for instrumental and emotional support seems more natural to women (43).One possible explanation could be that women assess threats more realistically and do not feel the need to underestimate them to gain social approval.Men in contrast tried to preserve their image as brave and strong individuals.
Competing despite having health problems can cause irreversible physical damage and therefore may affect not only an athlete's professional career but also his long-term health.Studies investigating the phenomenon of playing hurt have shown that playing despite having health problems often is accompanied with disregarding medical guidelines or hiding pain from coaches and teammates (7).As social pressure is mainly generated by coaches or other team members, it can be presumed that also the way of communication in sports networks plays a decisive role regarding athletes' willingness to compete hurt or ill.In this regard the role of the coach regarding establishing athletecentered communication strategies to prevent athletes from paintrivializing or competing despite injuries or illness seems to be more than mandatory (64).
The present review emphasized the contribution of pain coping in predicting athletes' inclination to play through their pain, whereas previous studies have shown how social networks can lead athletes to accept pain as a "part of the game" and can generate pressure on athletes to continue competing despite such pain (65, 66).

Coping and differences in gender
The findings of the analyzed studies show that there may be various reasons for gender differences in coping behavior (32,46).
Findings are also consistent with previous sport psychology research showing that female athletes assess stressful situations as more negative compared to male athletes.Female athletes had stronger feelings of tension and worry with greater susceptibility to a variety of stressful events and seek for more social support.One reason that males and females cope differently could be the emergence of differences in the socialization process because of gender role stereotypes and expectations from the social environment.That could implicate that gender differences may influence an athlete's selection of coping styles and strategies and, that females are more inclined to make use of an emotion-oriented coping style, whereas men use more often active coping.Also, the significant findings between skill levels for the athletes' use of cognitive appraisal and coping style are consistent with results of former studies (67).There is to some extent empirical evidence that less-skilled male and female athletes differ on various psychological characteristics.However, differences in psychological characteristics based on gender are less common among highly skilled athletes (68).It is possible, that at a particular elite level of competition, athletes of both genders make cognitive appraisals and adopt coping styles that are similar and effective.

Coping dimensions applied in elite sports
In view of the coping dimensions applied in elite sports the findings of this review suggest that among the analyzed strategies of coping with stress, avoidance may be related to health and absenteeism by contributing to psychological distress and emotional arousal, which may in turn suppress immunity.In addition, there is evidence that avoidance could also relate to illness in terms of not taking care of oneself when one is ill (38).As illness itself could serve as a socially accepted means of avoiding stressful situations, an avoidance strategy may temporarily be adaptive to cope with uncontrollable stressors.One possible disadvantage could be that illness prevents the use of more problem-and emotion-focused strategies in terms of proactive coping.Furthermore, the willingness to use active coping strategies can be predicted on the base of meaningfulness and sports activity.It can be expected that problemfocused strategies are more likely used by athletes or people with a strong sense of meaningfulness.
According to Aspinwall and Taylor (69) proactive coping involves providing the necessary resources and skills to prepare for confronting and anticipating stressors.
As resilience is one of the resources permitting athletes to protect their health (16), resilience takes on great importance to determine whether athletes will be able to go through stressful situations they are confronted with during their sports career to cope with their stressors.According to the findings it seems that high resilient qualities associate with coping strategies that might contribute more effectively to adapt to stressors and possible failures in elite sports (39).However, more research is required to confirm that enhanced resilience might not only contribute to better sport performance but also improve elite athletes' coping skills and mental health status, as resilience is a relatively stable construct (70).

Effectiveness of coping in terms of mental health and handling stress
The accumulation of stressors during childhood was found to render participants more susceptible to stress throughout adulthood.This finding suggests that the accumulation of stressors over life course may limit the coping resources to deal with the demands of a stressful situation.When coping resources are limited, individuals will typically appraise a stressful situation more as a threat.Repeated threat appraisals have been linked to deleterious health consequences (e.g., depression).Athletes who experienced greater and more lifetime stressors demonstrated difficulty in establishing and maintaining interpersonal relationships.According to extent literature a lack of interpersonal relationship can increase the cumulative effects of stress (31).
The analysis of the reviewed papers goes in line with Lazarus' (61, 71) findings that emotions will occur when a person appraises encounters with the environment as having either a positive or negative impact for well-being in terms of the person's goals.Fear will be provoked when an individual believes that failure is a threat to the achievement of goals.
Chronic sleep deprivation experienced by elite athletes may suggest that not only their recovery is impaired but also their mental health and well-being may be negatively affected.
For athletes, poor sleep can result in impaired recovery, but also diminished athletic performance and increased injury risk are seen as health influencing factors.According to Asplund and Chang (60), a bi-directional relationship has been observed, which means that sleep problems in athletes are positively correlated with depression or anxiety, while just mentioned psychiatric conditions can lead to sleep disturbances and therefore compromise sleep quality.Coming along that due to fear of negative evaluation, lack of mental health literacy and/or limited knowledge of where and how to seek help, elite athletes still fail to report sleep and mental health problems (72).
Aside from these barriers mentioned above and differential sport demands there may undetermined athlete differences that influence the nature of coping responses.Differences in psychological maturity may explain why the tendency to employ adaptive vs. maladaptive coping strategies was more closely associated with mental health in athletes.Especially, if athletes are delayed in their psychological maturity, they may be less capable of using adaptive coping strategies to effectively deal stressors, including sport-specific demands, such as participating at competitions, training, and social life.
Again, the findings are reflected in the research of Lazarus and Folkman (10).From their point of view individual resources that help to deal successfully with the demands imposed by of a particular situational context (in our case the context of elite sports) determine the level and intensity of distress experienced.That's why resources should be directed to detect early signs of mental health problems in this age group, as around 19 years of age, just after completing high school and moving from junior to senior competitions, seems to be a particularly vulnerable age for onset of mental health problems in elite athletes.
The results of this review underpin the necessity that especially college-students being confronted with a wide range of stressors, need to be taught mental skills to cope with these stressors.In addition, teaching coaches and teammates about social support seemed to decrease college-student athletes' stress reactions, such as anxiety or depressive symptoms.This finding is also in line with the transactional model of stress and coping (10), which proposes that coping efforts and social support can decrease the effects of stressors on a person's mental health.
However, traditional sport psychology is mainly focused on optimizing performance in a presumably healthy population, although mental health problems in elite sport have received increased attention, revealing the need for a broader mental health continuum (42,73) and for more attention to the potential relationship of athletic coping skills with well-being and mental health (40).As coping self-efficacy has a positive mental health effect on athletes' ability to cope with stress, athletes can thus better cope with and eliminate interference caused by competitive stressors and eventually achieve their best performance and protect their mental health (24).

Practical implications and future directions
Understanding the mechanisms of the coping process and its complexity in the context of handling stress may assist in the development for future interventions.As mental health plays a key role in many functions that are necessary in a context of elite sporting, future studies may investigate strategies to cope effectively with the stressors elite athletes are confronted with, such as improving stress management techniques to avoid stress.To improve mental health and coping skills exploring the coping process across a broader range of sports and participants may help to reduce athletes' vulnerability to emotional abuse and any mental health impairments.
Therefore, more research is needed to determine the underlying factors and antecedents that predict an athlete's coping preferences following specific types of stressful events and then to target meaningful and effective interventions (26).With the help of longitudinal designs links between an athlete's coping style and their actual application of coping strategies following various sources of acute stress as a function of sport type (e.g., individual and team), skill level, gender, age, and culture can be examined (48).That means that future approaches in sport psychology research may move beyond the identification of stressors and prevalence rates to point more vehemently to the complexity of mental-health problems in elite sports.The research directions displayed in Table 3 could be adapted to an elite sporting context in future projects to investigate and improve understanding elite athletes' coping strategies regarding to cope with stress and mental health.

Limitations
This systematic review shows a few noteworthy limitations.First, this systematic review includes only English language studies, which may limit the representation of the results.Second, this review is not a meta-analysis which was not possible to realize due to the heterogeneity of study designs.Third, the paucity of research in the field and the lack of well-designed, intervention-based research in elite athletes' coping to handle stress and to provide mental health contributes the poor overall quality of study reporting on this topic (39, 40).Moreover, variables such as age, gender, type of sport (e.g., individual or team sport) or effectiveness of applied coping strategies have not been considered in a standardized manner (34,48).
Finally, the author's attempt to structure the dimensions of coping must be considered in a critical way.According to the cognitive-transactional stress theory, two functions can be distinguished: problem-related coping and emotional coping (57).
However, the function is seen independently of the effect.According to Weber and Laux (74) this dual function model should not be classified by functions, but rather by subjective intentions, i.e., by the very personal functionality of a behavior with respect to an individual's preferred goals.These personal intentions can be divided into four facets: the regulation of emotions, the solution of the underlying problem, the maintenance of self-worth, and the control of social interactions.Whether and when these four regulatory goals are met is then a question to be addressed independently.Content areas such as well-being, physical and mental health, or social behavior serve as one criterion for efficiency.

Conclusion
Coping in elite sporting settings is very complex and dynamic.This is the first systematic review that has analyzed coping strategies to handle stress and to provide mental health in an elite sporting context.The findings of this review lend increased support that an athlete's use of coping strategies at least partially reflects the coping style.The application of coping style and coping strategies seem to be a function of the type and the intensity of the stressors an athlete is confronted with or of the athlete's cognitive appraisal of the stressful event.
Results highlight that coping strategies play an important role in understanding the handling of sport-specific and non-sport specific stressors in an athlete's professional career.There is evidence of coping being effective to buffer stress, but the interrelationships between stressor, appraisal of the stressor, application of a corresponding coping strategy, its effect especially in terms of mental health outcomes is still unclear because of lacking intervention-based study designs.
Future research is needed that assesses these relationships primarily as previous studies revealed that elite athletes tend to

Practical implications
Future directions • Athletes competing in individual sports or sports where athletes are expected to reach their performance peak at an early age, such as gymnastics, may benefit from learning to use adaptive coping strategies [like problem-focused coping, seeking social support, or cognitive restructuring (minimizing threat)] (42) • In team sports coping effectiveness training programs combined with attention modification issues should be incorporated in the training of athletes to help them to better cope with and eliminate interference caused by competitive stressors and eventually achieve their best performance and protect their mental health (24) • Development of stress management programs to help teams to collectively solve problems, to strengthen the mental health status of the whole team and to strengthen relationships under stressful conditions (23) • Exploring the coping process across a broader range of sports and participants to reduce athletes' vulnerability to emotional abuse and any mental health impairments, • Relationships between protective or immune resources such as the sense of coherence and the effectiveness of coping strategies to deal with stress in an extreme situation such as the COVID-19 pandemic should be examined in a more detailed way in the context of developing coping interventions in the context of elite sports (38) • More research is needed to determine the underlying factors and antecedents that predict an athlete's coping preferences following specific types of stressful events and then to target meaningful and effective interventions to improve mental health and coping skills (26) • Training adolescent athletes to use task-orientated coping might help them to deal with competitive anxiety in sport.

( 33 )
Pre-post design To examine sleep characteristics, scheduling of activities, perceived stress and coping strategies between periods of high and low scheduling commitments in adolescent athletes 20 Australian adolescent athletes (males, n = 10 females, n = 10), M = 15.0,SD = 1.0 Netball, rugby league, basketball, softball, and athletics, Australia

TABLE 1
Development of search strings.

TABLE 2
Overview of publication details.

TABLE 3
Practical implications & future directions.
(48)supportive coach-athlete relationship is highly recommended especially if coaches want athletes continuing long-term competitive participation(34)• Assessing simultaneously the use and effectiveness of coping strategies to clearly disentangle the effects of the use vs. effectiveness of a wide variety of coping strategies• Examining links between an athlete's coping style and their actual application of coping strategies following various sources of acute stress as a function of sport type (e.g., individual and team), skill level, gender, age, and culture with the help of longitudinal designs(48)