Mind Over Motion Screening Toolkit Site

Mind Over Motion — Athlete Mental Health Screening Toolkit

PHQ-9: Patient Health Questionnaire

Depression severity screening. Validated in athletic populations. Critical for pre-surgical psychiatric risk stratification.

KEY EVIDENCE Athletes with pre-existing depression have 2.8x longer rehabilitation and 40% higher rates of chronic post-surgical pain. PHQ-9 ≥ 10 before elective orthopedic surgery = psychiatric consultation required (JBJS 2022).

Scoring: 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly every day

#	Over the last 2 weeks, how often have you been bothered by:	0	1	2	3

TOTAL SCORE: — / 27

SCORE	SEVERITY	CLINICAL ACTION — ATHLETIC POPULATION
0 – 4	Minimal	No action required. Rescreen at next visit.
5 – 9	Mild	Watchful waiting. Optimize pre-op if surgical candidate. Rescreen 2 weeks.
10 – 14	Moderate	Psychiatric consult before elective surgery. Consider CBT referral. Active monitoring.
15 – 19	Mod-Severe	Defer elective surgery. Psychiatry referral. SSRI consideration. Weekly monitoring.
20 – 27	Severe	Urgent psychiatry referral. Assess for SI. No elective procedures until stabilized.

Key Threshold: PHQ-9 ≥ 10 before elective orthopedic surgery = psychiatric consultation required (JBJS 2022).

GAD-7: Generalized Anxiety Disorder Scale

Anxiety severity screening. Differentiates performance anxiety from GAD. Correlates with injury fear and re-injury anxiety.

Scoring: 0 = Not at all 1 = Several days 2 = More than half the days 3 = Nearly every day

#	Over the last 2 weeks, how often have you been bothered by:	0	1	2	3

TOTAL SCORE: — / 21

SCORE	SEVERITY	CLINICAL ACTION
0 – 4	Minimal	No action. Monitor.
5 – 9	Mild	Watchful waiting. Relaxation techniques. Rescreen 4 weeks.
10 – 14	Moderate	Consider CBT referral. Evaluate for performance anxiety vs. GAD.
15 – 21	Severe	Psychiatry referral. Pharmacotherapy evaluation. Active SI screening.

TSK-11: Tampa Scale for Kinesiophobia

Measures fear of movement and re-injury. Critical for return-to-sport readiness. TSK-11 ≥ 37 = high kinesiophobia warranting structured psychological intervention before RTP clearance.

KEY EVIDENCE Athletes returning before 9 months post-ACLR have 4x graft re-rupture rate. TSK ≥ 37 at time of clearance = re-injury risk independent of physical readiness (JOSPT 2021).

Scoring: 1 = Strongly disagree 2 = Disagree 3 = Agree 4 = Strongly agree

#	Statement	1	2	3	4

TOTAL SCORE: — / 44

SCORE RANGE	INTERPRETATION	RETURN-TO-SPORT GUIDANCE
11 – 25	Low fear	Standard RTP progression. No psychological intervention needed.
26 – 36	Moderate fear	Enhanced reassurance. Education on re-injury rates. Consider brief CBT.
37 – 44	High fear	Structured ACT or CBT required before RTP clearance. Sport psychology referral.

Pre-Surgical Psychiatric Screening Protocol

4-Step Evidence-Based Protocol for Orthopedic Surgical Candidates

KEY EVIDENCE Athletes with pre-existing depression have 2.8x longer rehabilitation and 40% higher rates of chronic post-surgical pain. PHQ-9 ≥ 10 before ACL reconstruction predicts significantly worse 2-year KOOS outcomes (JBJS 2022).

STEP 1 PRE-OP INTAKE

Administer PHQ-9 and GAD-7

Screen for prior psychiatric history

Administer Pain Catastrophizing Scale (PCS)

Document substance use history

Assess sleep quality (Pittsburgh Sleep Quality Index)

STEP 2 RISK STRATIFICATION

PHQ-9 < 5 → Proceed with surgery as planned

PHQ-9 5–9 → Optimize pre-operatively (sleep, expectations, CBT referral)

PHQ-9 ≥ 10 → Psychiatric consultation before elective surgery

CRITICAL: Active suicidal ideation → Delay elective procedure, refer emergently

STEP 3 PRE-OP OPTIMIZATION

Refer to sport psychologist for pre-surgical CBT

Optimize sleep hygiene pre-operatively

Set realistic return-to-sport timeline with the patient

Discuss opioid plan explicitly — expectations and alternatives

STEP 4 POST-OP MONITORING

PHQ-9 at weeks 2, 6, and 12 post-op

Opioid usage log — track morphine equivalents

Sleep and mood diary (patient-reported)

TSK-11 administered if kinesiophobia suspected — flag if ≥ 37

Monthly reassessment until return-to-sport clearance

Protocol adapted from: AAOS Clinical Practice Guidelines; IOC Mental Health Consensus Statement 2021; JBJS 2022; Ghayour-Minaie M et al.

REDs Clinical Red Flag Checklist

Relative Energy Deficiency in Sport (IOC 2023). Affects ALL sexes. Male athletes are significantly underdiagnosed.

0 red flags checked — 3 or more triggers comprehensive REDs workup

⚠ 3+ red flags: Comprehensive REDs workup required. Target energy availability ≥ 45 kcal/kg FFM/day. Multidisciplinary management: MD + RD + Psychologist. No RTP until EA restored.

CATEGORY	RED FLAG	☐

Return-to-Sport: 4-Domain Mental Readiness Framework

Physical clearance ≠ mental clearance. All 4 domains must be satisfied before RTP clearance is granted.

KEY EVIDENCE 63% of athletes physically cleared for RTP report significant re-injury fear at clearance (JOSPT 2021). This framework integrates psychological readiness into RTP decision-making.

RTP MENTAL CLEARANCE STATUS

Complete all items in each domain to assess clearance status.

Scope-of-Practice & Referral Quick Reference

Clinical domains, your scope by discipline, referral triggers, and appropriate referral targets.

CLINICAL DOMAIN	YOUR SCOPE (MD/PA/PT/ATC)	REFER WHEN	REFER TO
Depression	PHQ-9, brief counseling, SSRI if within scope	PHQ-9 ≥15, SI present, treatment-resistant, complex trauma	Sports psychiatrist, clinical psychologist
Anxiety	Identify performance vs. clinical anxiety; beta-blockers situational	GAD-7 ≥15, panic disorder, PTSD, social anxiety with impairment	Psychiatrist, CBT-trained psychologist
Return-to-Sport	TSK-11 admin, timeline with PT/ATC, readiness documentation	TSK ≥37 unresponsive to reassurance; PTSD pattern	Sport psychologist, ACT therapist
Eating Disorders	SCOFF/EDE-Q, vital signs, labs	Any purging, BMI <18 active athlete, bradycardia, electrolyte abnormalities	ED specialist, RD, psychiatry
Performance	Mindfulness, sleep hygiene, goal-setting conversation	Performance anxiety with somatic symptoms, burnout	CMPC, sport psychologist
Substance Use	CAGE/AUDIT screening, opioid risk assessment	Active dependence, failed self-management, withdrawal symptoms	Addiction medicine, psychiatry

KEY ABBREVIATIONS

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