Like sport psychology (SP), the field of sport psychiatry may involve utilization of psychological approaches to enhance athletic performance. However, a primary focus of sport psychiatry is diagnosis and treatment of mental illness in athletes. Sport psychiatry is a relatively new field, and as such, the research base is still developing. This entry reviews the diagnostic epidemiology of, and treatment options for, mental illness in athletes.
Epidemiology of Mental Illness in Athletes
Little systematic research has been conducted of the relative frequency of psychiatric disorders in athletes as compared with the general population. However, a recent review by Claudia L. Reardon and Robert M. Factor showed eating disorders and substance use disorders among athletes might be relatively more common than other psychiatric disorders in this population. Up to 60% of female athletes in certain sport-specific populations suffer from eating disorders, and the rates among male athletes are increasing. Additionally, mental health providers must consider “anorexia athletica” in athletes, in which athletes’ muscle mass masks their low body fat, but they exhibit many of the other signs of an eating disorder.
Substance use disorders, especially anabolic steroid and stimulant abuse, also appear to be diagnoses of relative concern in athletes. Athletes use steroids and stimulants to enhance performance, but these substances can also adversely impact performance. Specifically, steroids can cause mood changes, aggression, psychosis, and cognitive impairment. Stimulants can cause weight loss, tremors, and insomnia. As in the general population, athletes abuse alcohol more than any other substance.
Beyond eating disorders and substance use disorders, any psychiatric disorder could strike an athlete. However, others particularly important to consider include major depressive disorder (MDD). Some evidence suggests that MDD might be no more common in athletes than the general population, but it can be precipitated by the unique factors of overtraining, injury, poor performance, retirement from sport, and concussion.
Clinicians should also consider compulsive disorders, including muscle dysmorphia, in which muscular athletes feel they are too small, and exercise addiction, in which athletes experience “withdrawal” anxiety and depression when unable to exercise, and thus continue to exercise despite injury or dysfunction. Importantly, clinicians should not mistake superstitious rituals, common in sport, for obsessive–compulsive disorder.
Treatment of Psychiatric Illness in Athletes
Medications and psychotherapy are the two primary modalities of treatment of psychiatric illness in any population, including athletes. When prescribing medications, clinicians should consider three factors: effects on performance, anti-doping guidelines, and safety. No large, randomized, controlled trials of psychiatric medications in athletes have been published to date. However, small studies of their use in athletes have been reported and can guide medication choices. In considering antidoping guidelines, prescribers should know the guidelines of the relevant sport federation prior to prescribing any medication for a high-level athlete. Regarding safety concerns, clinicians should especially consider whether medications might become toxic in athletes who are excessively sweating and if the medications can have adverse cardiac effects in athletes pushing themselves to extremes.
There have been small studies of some antidepressants, specifically selective serotonin reuptake inhibitors (SSRIs) and bupropion. Preliminary data show that the SSRI fluoxetine may not impact athletic performance. One study shows the SSRI paroxetine to limit performance, while another shows no such impact. Early data show that bupropion might be performance-enhancing in hot temperatures and especially when used acutely as compared to over longer time periods (the latter representing how athletes generally take the medication if used for psychiatric reasons). Other antidepressants have not been systematically studied in athletes. A survey of sport psychiatrists has revealed that fluoxetine would be their antidepressant of choice for use in athletes needing medication treatment for depression.
Sedative–hypnotics and anxiolytics are another important category of medications to consider, as athletes may suffer from insomnia and performance anxiety. Melatonin is the most widely studied sedative–hypnotic used for insomnia in athletes, and it appears to have no impact on performance. Some studies show that benzodiazepines, when used for insomnia, may have a negative hangover effect on performance. This is particularly true of longer-acting benzodiazepines. Non-benzodiazepine agonists such as zolpidem and zopiclone appear to have less of a hangover effect on next-day performance. Other medications that may be used for anxiety include betablockers, which may be performance-enhancing in some sports such as archery, and thus are banned by that sport’s international federation. In contrast, they are probably performance-inhibiting in endurance sports. Likewise, the anxiolytic buspirone has been shown in one small study to be performance-inhibiting.
Medications to treat ADHD include stimulants and atomoxetine. The former have been shown in several studies to be performance-enhancing, and thus have been banned for use by athletes at high levels of competition unless the athlete has a Therapeutic Use Exemption (TUE). Atomoxetine is a selective norepinephrine reuptake inhibitor and has not been studied for impact on performance.
Mood stabilizers have been minimally studied in athletes and antipsychotics not at all. The mood stabilizer lithium may be of concern when used by athletes because of the risk of toxicity while sweating. However, even that apparently well-known risk has been called into question, as some evidence suggests that lithium levels can actually be reduced during intense exercise.
Psychotherapy alone may be used for mild cases of depression, anxiety, or sports-related adjustment issues. It may also be used as an adjunct to medications. As with prescription of medications for athletes, psychotherapy with this population presents unique challenges. Denial of psychological problems is common among successful athletes. Additionally, athletes may be used to being the “VIP” and in charge, which can interfere with therapy. Among the different types of psychotherapy, cognitive behavioral therapy may be a particularly reasonable choice for athletes given their comfort with structure, practice, and goal setting.
Clinicians, coaches, and other staff who work with athletes should be aware that mental illness can strike this population, despite athletes’ typical presentation as strong and physically and mentally sound. Once a mental illness is diagnosed, treatment may consist of medication and/ or psychotherapy.