When Does an Elite Athlete Need Mental Health Treatment?

Matías A. Loewy

May 27, 2022

MAR DEL PLATA, Argentina — Many athletes get the "jitters" — a feeling of anxiety — just prior to competing. For elite athletes, whether they're participating in an individual event or as part of a team, whether on a track, court, rink, or field, this feeling can affect performance. It is a well-known, and not unexpected, phenomenon that comes with the territory. Nevertheless, specialists should keep a lookout for signs of more severe mental disorders — ones that may show up in other areas of the person's life. These disorders may call for targeted psychotherapeutic treatment or the prescription of psychotropic drugs. This is the guidance put forth by session panelists at the Argentine Psychiatric Association's XXXV Argentine Congress of Psychiatry (APSA 2022), which was held at the seaside resort town of Mar del Plata from April 27 to 30.

Ivanna Meloni Cafarelli, MD, a psychiatrist at Pirovano Hospital in Buenos Aires and a member of APSA's anxiety disorders section, often works with athletes. "It's usually said that elite athletes are not especially prone to developing depression, because all that exercise releases endorphins and neurotransmitters, like serotonin, which inhibit feelings of sadness," she said. "But we also know that physical activity has positive effects on patients with anxiety disorders. And everyone's allowed to have a moment, a crisis. We've seen this even in record-breaking Olympic athletes."

Meloni Cafarelli told Medscape Spanish Edition that some mental health professionals who don't work with athletes end up saying, "How could Messi and other top athletes get depressed? They've got all those endorphins going, they're rich, they're famous."

Her answer? "It's just not that straightforward. It's not that simple. When someone is in the throes of anxiety or depression, there are more factors at play than just chemical imbalances. And we should never rule out family history or genetics. A psychiatric condition that has a significant genetic component — for example, schizophrenia, bipolar disorder, obsessive-compulsive disorder, an addictive disorder — this always has to be taken into account when we see athletes with symptoms that make us suspect that there's something more going on. These are red flags that have to be looked into and evaluated — not so that we can slap on a label or diagnosis but so that we can be more attentive to the symptoms' evolution."

Preparing Mind and Body

Meloni Cafarelli mentioned that since the early 2000s, advances in neuroscience and sports psychology have been reinforcing the view that, when it comes to athletes, their mind and their body need to be prepared to improve performance.

For example, there are different interventions that can help the athlete manage their precompetitive anxiety and improve their results, noted another of the conference speakers, Lorena Casse, a sport psychology specialist at a mental health center in Buenos Aires. In addition to progressive muscle relaxation, a method developed by Edmund Jacobson, MD, PhD, there's cognitive restructuring, visualization, and certain techniques aimed at getting the athlete to focus on the process and not on the outcome of the competition. Casse pointed out that there also are strategies to maintain confidence and concentration on the field of play. These range from diaphragmatic breathing and the use of humor to utilizing mental images or trigger words and taking control of distracting thoughts.

"Mental training follows the same steps as physical training, starting with preseason conditioning and going all the way through to the point of reaching peak performance," said Casse. However, athletes are not machines. They've got to be the best. Add to that the pressure of being in a situation in which the sport has become their livelihood, one that supports not only themselves but their family as well. Or maybe they're the captain and they feel a greater responsibility for how the team performs.

Athletes often feel forced to hide anything that could be viewed as being a failing or a weakness. "They want to show that they're capable, that they have what it takes, no matter how high the odds are stacked against them," said Meloni Cafarelli.

Leanna M. W. Lui, HBSc, works at the Mood Disorders Psychopharmacology Unit at Toronto Western Hospital in Canada. She told Medscape Spanish Edition, "Athletes also often fall prey to a strict dichotomy: attempting to remain flawless on the field or in the arena while trying to maintain their vulnerability as human beings in the rest of their lives."

Beyond the fact that the mental health of elite athletes has been a recent topic of conversation — given the cases and firsthand descriptions of gymnast Simone Biles, swimmer Michael Phelps, and tennis player Naomi Osaka — "the stigma continues to be a highly prevalent barrier, and even more so in the world of elite sports. There's this feeling that seeking treatment for mental health issues is incompatible with being a tough, competitive athlete," said Claudia Reardon, MD, professor of psychiatry at the University of Wisconsin School of Medicine and Public Health in Madison, Wisconsin. She did not participate in the conference sessions.

"Because the proportion of athletes with mental health problems is practically the same as that found in the general population, we need to do screenings and detect things early. This way, symptoms can be quickly identified, and early interventions can be implemented to prevent the mental illness from getting worse," explained José J. Mendoza Velázquez, MD, MPA, research coordinator in the Department of Psychiatry and Mental Health at the National Autonomous University of Mexico, in Mexico City.

At what point can we feel justified in providing psychotherapeutic treatment or appropriate psychotropic drugs? Meloni Cafarelli suggested paying attention to symptoms that persist for 6 months or so. Such symptoms include "difficulty falling asleep, irritability, lack of motivation, negative thinking or even catastrophizing, feelings of sadness with aggression or an urge to cry, hopelessness, or inability to feel pleasure."

For athletes who present with anxiety or concentration problems, she suggested also checking for any personal or family history of attention-deficit/hyperactivity disorder.

Primary care providers who have patients who are athletes should ask those patients about mental health problems, even if the appointment has nothing to do with mental health per se. "Every member of the athlete's medical team has to keep mental health on their radar and ask specific, direct questions about such issues," Reardon told Medscape Spanish Edition. "These can be questions like, 'How's your stress level been lately?' or 'Lately, have you been feeling more sad or more worried than you'd like?' "

Considerations About Medications

Psychotherapy is generally regarded as the first-line treatment for those with mild to moderate symptoms of mental illness. Medications may be needed for those with more severe psychopathology. This presents some additional challenges. "Athletes are more reluctant when it comes to medications. They might be afraid of violating doping policies. There's also a concern that they'll be looked at as someone who, without the drugs, wouldn't be able to deal with the pressure that comes with being an elite athlete," Meloni Cafarelli explained.

With regard to doping, the psychiatrist pointed out that the World Anti-Doping Agency does grant exemptions; athletes are allowed to use prohibited psychotropic medications when needed to treat an acute or chronic medical condition, when it is highly unlikely that the drug would enhance performance, and when there is no reasonable alternative.

In a mental health consensus statement from the International Olympic Committee, which was published in BMJ in 2019, Reardon and her team of 26 collaborators from 14 countries listed the following four key considerations when prescribing psychiatric medications to elite athletes:

  1. Potential negative impact on athletic performance

  2. Potential therapeutic performance-enhancing effects (ie, based on improvement in the condition the medication is designed to treat)

  3. Potential nontherapeutic performance enhancement effects (ie, ergogenic effects)

  4. Potential safety risks

"Safety risks are paramount with certain psychiatric medications, as elite athletes commonly exercise at much higher intensity than the general population," write the authors. "For example, medications with blood levels that must be tightly regulated, such as lithium, can be difficult to manage in elite athletes whose levels might be influenced by hydration status."

But, according to Reardon, this does not mean that the threshold for starting psychopharmacologic treatments in elite athletes has to be higher than that used for the rest of the population.

"Athletes shouldn't have to bear any more suffering than anybody else does. However," she clarified, "this doesn't mean that the medication choices we make when treating athletes may not sometimes differ from those we make for our nonathlete patients."

Meloni, Reardon, and Casse have disclosed no relevant financial relationships.

Follow Matías A. Loewy of Medscape Spanish Edition on Twitter: @MLoewy.

This article was translated from the Medscape Spanish edition.


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