Background: The International Olympic Committee's Sport Mental Health Assessment Tool 1 (SMHAT-1) represents a landmark initiative for the early identification of mental health symptoms in elite athletes. Since its introduction, the tool has been widely adopted by International Federations and National Olympic Committees, with large-scale implementation at recent Olympic and Paralympic Games. While it aims to facilitate timely access to care, a comprehensive evaluation of its real-world implementation fidelity, diagnostic accuracy, and the effectiveness of its associated support pathways is crucial to inform future practice and tool refinement.
Objectives: To systematically review the published literature on the implementation and efficacy of the SMHAT-1 in elite Olympic and Paralympic sport settings. The primary objectives were to: (1) describe the landscape of SMHAT-1 implementation and identify variations in its application; (2) synthesize the evidence on the tool's psychometric properties, including validity and reliability across diverse athlete populations; (3) evaluate the clinical and performance outcomes following positive screens and subsequent support interventions; and (4) identify evidence gaps to propose recommendations for future iterations of the tool and its implementation framework.
Study Design: A systematic review was designed and conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement. A comprehensive search of PubMed, Scopus, Web of Science, and SPORTDiscus databases was performed for studies published between January 2021 and February 2026. Search terms included 'Sport Mental Health Assessment Tool', 'SMHAT-1', 'elite athletes', 'Olympics', and 'Paralympics'. Inclusion criteria specified original research studies evaluating the implementation, validation, or outcomes of SMHAT-1 in professional, Olympic, or Paralympic athletes. Data were extracted using a standardized form, and methodological quality of included studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist. A narrative synthesis was performed to integrate the findings.
Results: The search yielded 1,124 records, of which 22 studies met the full inclusion criteria. Implementation of SMHAT-1 is widespread but heterogeneous, with significant variability in practitioner training, administration protocols, and referral pathway structures. Validation studies (n=9) confirm good-to-excellent internal consistency (Cronbach's α = 0.85–0.92) but report moderate diagnostic accuracy, with false negative rates for anxiety and depression symptoms ranging from 15% to 25%, particularly in male athletes. Outcome studies (n=5) indicate that a positive screen followed by a structured intervention pathway is associated with a significant reduction in symptom severity (Hedges' g = 0.65, p < 0.01) and improved sport-specific functioning. However, less than 40% of athletes with a positive screen completed the full referral and intervention process, citing stigma and time constraints as primary barriers.
Conclusions: The SMHAT-1 is a valuable, psychometrically sound tool for initiating mental health conversations in elite sport, but its effectiveness depends on a robust implementation framework. The evidence highlights a critical 'implementation gap' between screening and support. Future efforts must focus on standardising practitioner training, developing culturally sensitive protocols, and integrating low-barrier, athlete-centred support systems to improve uptake and translate screening into tangible wellbeing outcomes. Tool refinement should address the identified false negative rates.
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