Psychiatric Treatment with Elite Athletes: A Stepwise Approach to Mitigate Risk
Main Article Content
Abstract
Research has suggested that elite athletes display a proneness to psychopathology, as well as increased likelihoods of engaging in risky behaviors, compared to the general population. This review addresses a gap in the literature pertaining to the pharmacotherapeutic and psychotherapeutic modalities in sports settings, resulting in either monotherapy or combination therapy. We advocate for a risk-benefit assessment to guide this process, with an aim to implement the least invasive, pragmatic option for intervention. This assessment is informed by weighing potential barriers to psychotherapy with elite athletes, (e.g. stigma, time constraints, altered expectations of outcomes, and personality factors) against the benefits and barriers of pharmacotherapy (e.g., side effects that may impact performance). We recommend evidence-based practices that align with a balance of both the athlete’s and the organization’s goals; ultimately, preserving the well-being and rights of the athlete. Finally, treatment must be tailored to address variables that are relevant to elite athletes (e.g., side effects impacting performance, altered expectations, doping regulations). We suggest the notion of “flexibility within fidelity” in our stepwise guide, in that there can be fluidity and movement across the assessment stages to adjust recommendations as needed for the sake of optimizing the athlete’s care and goals.
Article Details
How to Cite
MANOCCHIO, Andrew M; AKPOBIYERI, Abigail O.; STILLMAN, Mark A.
Psychiatric Treatment with Elite Athletes: A Stepwise Approach to Mitigate Risk.
Medical Research Archives, [S.l.], v. 12, n. 4, apr. 2024.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/5275>. Date accessed: 27 july 2024.
doi: https://doi.org/10.18103/mra.v12i4.5275.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
References
1. Glick ID, Stillman MA, McDuff D. Update on integrative treatment of psychiatric symptoms and disorders in athletes. Phys Sportsmed. 2020;48(4):385–91. Doi: 10.1080/ 00913847.2020.1757370
2. Stillman MA, Manocchio AM, Glick ID. Combining pharmacotherapy with psychotherapeutic management for the treatment of psychiatric disorders among athletes. Sports Psychiatry. 2023; Doi: 10.1024/2674-0052/a000056
3. Ford JA. Alcohol use among college students: A comparison of athletes and nonathletes. Subst Use Misuse. 2007;42(9): 1367–77. Doi: 10.1080/10826080701212402
4. Lindqvist A, Moberg T, Ehrnborg C, Eriksson BO, Fahlke C, Rosén T. Increased mortality rate and suicide in Swedish former elite male athletes in power sports. Scand J Med Sci Sports. 2014;24(6):1000–5. Doi: 10.1111/sms.12122
5. McDuff DR, Baron D. Substance use in athletics: A sports psychiatry perspective. Clin Sports Med. 2005;24(4):885–97. Doi: 10.1016/j.csm.2005.06.004
6. Glick ID, Stillman MA, Reardon CL, Ritvo EC. Managing psychiatric issues in elite athletes. J Clin Psychiatry. 2012;73(5): 640–4. Doi: 10.4088/JCP.11r07381
7. Leddy MH, Lambert MJ, Ogles BM. Psychological consequences of athletic injury among high-level competitors. Res Q Exerc Sport. 1994;65(4):347–54. Doi: 10.1080/ 02701367.1994.10607639
8. Blackburn IM, Bishop S, Glen AI, Whalley LJ, Christie JE. The efficacy of cognitive therapy in depression: A treatment trial using cognitive therapy and pharmacotherapy, each alone and in combination. Br J Psychiatry. 1981;139:181–9. Doi: 10.1192/bjp.139.3.181
9. Hellstedt J. Invisible players: a family systems model. Clin Sports Med. 2005;24:899–928. Doi: 10.1016/j.csm. 2005.06.001
10. Reardon CL, Factor RM. Sport psychiatry: A systematic review of diagnosis and medical treatment of mental illness in athletes. J Sports Med. 2010;40(11):961–80. Doi: 10.2165/11536580-000000000-00000
11. Stillman MA, Brown T, Ritvo EC, Glick ID. Sport psychiatry and psychotherapeutic intervention, circa 2016. Int Rev Psychiatry. 2016;28(6):614–22. Doi: 10.1080/09540261.2016. 1202812
12. Beutler LE. Making science matter in clinical practice: redefining psychotherapy. Clin Psychol (New York). 2009;16:301–17. Doi: 10.1111/j.1468-2850.2009.01168.x
13. Chiles JA, Lambert MJ, Hatch AL. The impact of psychological interventions on medical cost offset: A meta-analytic review. Clin Psychol (New York). 1999;6(2):204. Doi: 10.1093/clipsy.6.2.204
14. Heird EB, Steinfeldt JA. An interpersonal psychotherapy approach to counseling student athletes: clinical implications of athletic identity. J Coll Couns. 2013;16:143–57. 10.1002/j.2161-1882.2013.00033.x
15. 1Pierce RA. Athletes in psychotherapy: how many, how come? J Am Coll Health. 1969;17:244–9.
16. Glick ID. Adding psychotherapy to pharmacotherapy: Data, benefits, and guidelines for integration. Am J Psychother. 2004;58(2):186–208. Doi: 10.1176/appi. psychotherapy.2004.58.2.186
17. Gorman JM. Combining psychodynamic psychotherapy and pharmacotherapy. Psychodyn Psychiatry. 2016;44(2):183– 209. Doi: 10.1521/pdps.2016.44.2.183
18. Stillman MA, Ritvo EC, Glick ID. Psychotherapeutic treatment of athletes and their significant others. In: Baron D, Reardon CL, Baron SH, editors. Clinical Sports Psychiatry. John Wiley & Sons; 2013:115–23. Doi: 10.1002/9781118404904. ch11
19. Stillman MA, Glick ID, McDuff D, Reardon CL, Hitchcock ME, Fitch VM, et al. Psychotherapy for mental health symptoms and disorders in elite athletes: A narrative review. Br J Sports Med. 2019;53(12):767–71. Doi: 10.1136/bjsports2019-100654
20. Gitlin MJ. Antidepressants in bipolar depression: an enduring controversy. Intrl J Bipolar Dsrds. 2018;6(1). Doi: 10.1186/s40345-018-0133-9
21. Tohen M, Frank E, Bowden CL, Colom F, Ghaemi NS, Yatham LN. The International Society of Bipolar Disorders (ISBD) task force on the nomenclature of course and outcome in bipolar disorders. J Affective Dsrds. 2010;122:S15. Doi: 10.1016/j.jad.2010.01.030
22. Parise G, Bosman MJ, Boecker DR, Barry MJ, Tarnopolsky MA. Selective serotonin reuptake inhibitors: their effect on high intensity exercise performance. Arch Phys Med Rehabil. 2001;82(7):867–71. Doi: 10.1053/apmr.2001.23275
23. Strachan AT, Leiper JB, Maughan RJ. Paroxetine administration to influence human exercise capacity, perceived effort or hormone responses during prolonged exercise in a warm environment. Exp Physiol. 2004;89(6):657–64. Doi: 10.1113/expphysiol.2004.027839
24. Watson P, Hasegawa H, Roelands B, Piacentini MF, Looverie R, Meeusen R. Acute dopamine/noradrenaline reuptake inhibition enhances human exercise performance in warm, but not temperate conditions. J Physiol. 2005;565(3):873–83. Doi: 10.1113/jphysiol.2004.079202
25. Piacentini MF, Meeusen R, Buyse L, De Schutter G, Kempenaers F, Van Nijvel J, et al. No effect of a noradrenergic reuptake inhibitor on performance in trained cyclists. Med Sci Sports Exerc. 2002;34(7):1189–93. Doi: 10.1097/ 00005768-200207000-00021
26. Baum AL. Psychopharmacology in athletes. In: Begel D, Burton RW, editors. Sport psychiatry. New York: WW Norton & Company, 2000; 249–59.
27. Macleod AD. Sport psychiatry. Aust N Z J Psychiatry. 1998;32 (6):860–6. Doi: 10.3109/00048679809073876
28. Wilmore JH. Exercise testing, training, and beta-adrenergic blockade. Phys Sportsmed. 1988;16(12):46–51. Doi: 10.1080/00913847.1988.11709662
29. Atkinson G, Drust B, Reilly T, Waterhouse J. The relevance of melatonin to sports medicine and science. Sports Med. 2003;33:809–31. Doi: 10.2165/00007256-200333110- 00003
30. Chandler JV, Blair SN. The effect of amphetamines on selected physiological components related to athletic success. Med SciSports Exerc. 1980;12(1):65–9. Doi: 10.1249/ 00005768-198021000-00013
31. Smith GM, Beecher HK. Amphetamine sulfate and athletic performance: I. Objective effects. JAMA. 1959;170(5): 542–57.
32. Taylor MJ, Freemantle N, Geddes JR, Bhagwagar Z. Early Onset of Selective Serotonin Reuptake Inhibitor Antidepressant Action. Arch Gnrl Psych. 2006;63(11):1217. Doi: 10.1001/archpsyc.63.11.1217
33. Ethical Principles of Psychologists and Code Of Conduct (2002, amended effective June 1, 2010, and January 1, 2017). PsycEXTRA Dataset. American Psychological Association; 2002. Doi: 10.1037/e305322003-001
34. Bär KJ, Markser VZ. Sport specificity of mental disorders: The issue of sport psychiatry. Eur Arch Psychiatry Clin Neurosci. 2013;263(S2):205–10. Doi: 10.1007/s00406-013- 0458-4
35. Broch TB, Kristiansen E. “The margin for error”: Ritual coping with cultural pressures. Scand J Med Sci Sports. 2014;24(5): 837–45. Doi: 10.1111/sms.12077
36. Report of the 2005 Presidential Task Force on Evidence-Based Practice. PsycEXTRA Dataset. American Psychological Association; 2006. Doi: 10.1037/e582372010-001
37. Zaré A, Stull T. Integrating sports psychiatry in the interdisciplinary care of elite sports teams. Sports Psychiatry. 2023;2(4):157–62. Doi: 10.1024/2674-0052/a000055
38. Bleacher AA, Olin SS, Nadeem E, Pollock M, Ringle V, Bickman L, et al. Implementing a Measurement Feedback System in Community Mental Health Clinics: A Case Study of Multilevel Barriers and Facilitators. Admin Plcy Mntl Hlth Mntl Hlth Srvcs Rsrch. 2015;43(3):426–40. Doi: 10.1007/s10488-015-0642-0
39. Jensen-Doss A, Haimes EMB, Smith AM, Lyon AR, Lewis CC, Stanick CF, et al. Monitoring Treatment Progress and Providing Feedback is Viewed Favorably but Rarely Used in Practice. Admin Plcy Mntl Hlth Mntl Hlth Srvcs Rsrch. 2016;45(1):48–61. Doi: 10.1007/s10488-016-0763-0
40. Kendall PC, Gosch E, Furr JM, Sood E. Flexibility Within Fidelity. Journal of the Am Acdm Child Adol Psych. 2008;47(9):987–93. Doi: 10.1097/chi.0b013e31817eed2f
41. Kendall PC, Frank HE. Implementing evidence‐based treatment protocols: Flexibility within fidelity. Cncl Psych: Scnce and Prct. 2018;25(4). Doi: 10.1111/cpsp.12271
42. Rice SM, Purcell R, De Silva S, Mawren D, McGorry PD, Parker AG. The mental health of elite athletes: A narrative systematic review. Sports Med. 2016;46:1333–53. Doi: 10.1007/s40279-016-0492-2
2. Stillman MA, Manocchio AM, Glick ID. Combining pharmacotherapy with psychotherapeutic management for the treatment of psychiatric disorders among athletes. Sports Psychiatry. 2023; Doi: 10.1024/2674-0052/a000056
3. Ford JA. Alcohol use among college students: A comparison of athletes and nonathletes. Subst Use Misuse. 2007;42(9): 1367–77. Doi: 10.1080/10826080701212402
4. Lindqvist A, Moberg T, Ehrnborg C, Eriksson BO, Fahlke C, Rosén T. Increased mortality rate and suicide in Swedish former elite male athletes in power sports. Scand J Med Sci Sports. 2014;24(6):1000–5. Doi: 10.1111/sms.12122
5. McDuff DR, Baron D. Substance use in athletics: A sports psychiatry perspective. Clin Sports Med. 2005;24(4):885–97. Doi: 10.1016/j.csm.2005.06.004
6. Glick ID, Stillman MA, Reardon CL, Ritvo EC. Managing psychiatric issues in elite athletes. J Clin Psychiatry. 2012;73(5): 640–4. Doi: 10.4088/JCP.11r07381
7. Leddy MH, Lambert MJ, Ogles BM. Psychological consequences of athletic injury among high-level competitors. Res Q Exerc Sport. 1994;65(4):347–54. Doi: 10.1080/ 02701367.1994.10607639
8. Blackburn IM, Bishop S, Glen AI, Whalley LJ, Christie JE. The efficacy of cognitive therapy in depression: A treatment trial using cognitive therapy and pharmacotherapy, each alone and in combination. Br J Psychiatry. 1981;139:181–9. Doi: 10.1192/bjp.139.3.181
9. Hellstedt J. Invisible players: a family systems model. Clin Sports Med. 2005;24:899–928. Doi: 10.1016/j.csm. 2005.06.001
10. Reardon CL, Factor RM. Sport psychiatry: A systematic review of diagnosis and medical treatment of mental illness in athletes. J Sports Med. 2010;40(11):961–80. Doi: 10.2165/11536580-000000000-00000
11. Stillman MA, Brown T, Ritvo EC, Glick ID. Sport psychiatry and psychotherapeutic intervention, circa 2016. Int Rev Psychiatry. 2016;28(6):614–22. Doi: 10.1080/09540261.2016. 1202812
12. Beutler LE. Making science matter in clinical practice: redefining psychotherapy. Clin Psychol (New York). 2009;16:301–17. Doi: 10.1111/j.1468-2850.2009.01168.x
13. Chiles JA, Lambert MJ, Hatch AL. The impact of psychological interventions on medical cost offset: A meta-analytic review. Clin Psychol (New York). 1999;6(2):204. Doi: 10.1093/clipsy.6.2.204
14. Heird EB, Steinfeldt JA. An interpersonal psychotherapy approach to counseling student athletes: clinical implications of athletic identity. J Coll Couns. 2013;16:143–57. 10.1002/j.2161-1882.2013.00033.x
15. 1Pierce RA. Athletes in psychotherapy: how many, how come? J Am Coll Health. 1969;17:244–9.
16. Glick ID. Adding psychotherapy to pharmacotherapy: Data, benefits, and guidelines for integration. Am J Psychother. 2004;58(2):186–208. Doi: 10.1176/appi. psychotherapy.2004.58.2.186
17. Gorman JM. Combining psychodynamic psychotherapy and pharmacotherapy. Psychodyn Psychiatry. 2016;44(2):183– 209. Doi: 10.1521/pdps.2016.44.2.183
18. Stillman MA, Ritvo EC, Glick ID. Psychotherapeutic treatment of athletes and their significant others. In: Baron D, Reardon CL, Baron SH, editors. Clinical Sports Psychiatry. John Wiley & Sons; 2013:115–23. Doi: 10.1002/9781118404904. ch11
19. Stillman MA, Glick ID, McDuff D, Reardon CL, Hitchcock ME, Fitch VM, et al. Psychotherapy for mental health symptoms and disorders in elite athletes: A narrative review. Br J Sports Med. 2019;53(12):767–71. Doi: 10.1136/bjsports2019-100654
20. Gitlin MJ. Antidepressants in bipolar depression: an enduring controversy. Intrl J Bipolar Dsrds. 2018;6(1). Doi: 10.1186/s40345-018-0133-9
21. Tohen M, Frank E, Bowden CL, Colom F, Ghaemi NS, Yatham LN. The International Society of Bipolar Disorders (ISBD) task force on the nomenclature of course and outcome in bipolar disorders. J Affective Dsrds. 2010;122:S15. Doi: 10.1016/j.jad.2010.01.030
22. Parise G, Bosman MJ, Boecker DR, Barry MJ, Tarnopolsky MA. Selective serotonin reuptake inhibitors: their effect on high intensity exercise performance. Arch Phys Med Rehabil. 2001;82(7):867–71. Doi: 10.1053/apmr.2001.23275
23. Strachan AT, Leiper JB, Maughan RJ. Paroxetine administration to influence human exercise capacity, perceived effort or hormone responses during prolonged exercise in a warm environment. Exp Physiol. 2004;89(6):657–64. Doi: 10.1113/expphysiol.2004.027839
24. Watson P, Hasegawa H, Roelands B, Piacentini MF, Looverie R, Meeusen R. Acute dopamine/noradrenaline reuptake inhibition enhances human exercise performance in warm, but not temperate conditions. J Physiol. 2005;565(3):873–83. Doi: 10.1113/jphysiol.2004.079202
25. Piacentini MF, Meeusen R, Buyse L, De Schutter G, Kempenaers F, Van Nijvel J, et al. No effect of a noradrenergic reuptake inhibitor on performance in trained cyclists. Med Sci Sports Exerc. 2002;34(7):1189–93. Doi: 10.1097/ 00005768-200207000-00021
26. Baum AL. Psychopharmacology in athletes. In: Begel D, Burton RW, editors. Sport psychiatry. New York: WW Norton & Company, 2000; 249–59.
27. Macleod AD. Sport psychiatry. Aust N Z J Psychiatry. 1998;32 (6):860–6. Doi: 10.3109/00048679809073876
28. Wilmore JH. Exercise testing, training, and beta-adrenergic blockade. Phys Sportsmed. 1988;16(12):46–51. Doi: 10.1080/00913847.1988.11709662
29. Atkinson G, Drust B, Reilly T, Waterhouse J. The relevance of melatonin to sports medicine and science. Sports Med. 2003;33:809–31. Doi: 10.2165/00007256-200333110- 00003
30. Chandler JV, Blair SN. The effect of amphetamines on selected physiological components related to athletic success. Med SciSports Exerc. 1980;12(1):65–9. Doi: 10.1249/ 00005768-198021000-00013
31. Smith GM, Beecher HK. Amphetamine sulfate and athletic performance: I. Objective effects. JAMA. 1959;170(5): 542–57.
32. Taylor MJ, Freemantle N, Geddes JR, Bhagwagar Z. Early Onset of Selective Serotonin Reuptake Inhibitor Antidepressant Action. Arch Gnrl Psych. 2006;63(11):1217. Doi: 10.1001/archpsyc.63.11.1217
33. Ethical Principles of Psychologists and Code Of Conduct (2002, amended effective June 1, 2010, and January 1, 2017). PsycEXTRA Dataset. American Psychological Association; 2002. Doi: 10.1037/e305322003-001
34. Bär KJ, Markser VZ. Sport specificity of mental disorders: The issue of sport psychiatry. Eur Arch Psychiatry Clin Neurosci. 2013;263(S2):205–10. Doi: 10.1007/s00406-013- 0458-4
35. Broch TB, Kristiansen E. “The margin for error”: Ritual coping with cultural pressures. Scand J Med Sci Sports. 2014;24(5): 837–45. Doi: 10.1111/sms.12077
36. Report of the 2005 Presidential Task Force on Evidence-Based Practice. PsycEXTRA Dataset. American Psychological Association; 2006. Doi: 10.1037/e582372010-001
37. Zaré A, Stull T. Integrating sports psychiatry in the interdisciplinary care of elite sports teams. Sports Psychiatry. 2023;2(4):157–62. Doi: 10.1024/2674-0052/a000055
38. Bleacher AA, Olin SS, Nadeem E, Pollock M, Ringle V, Bickman L, et al. Implementing a Measurement Feedback System in Community Mental Health Clinics: A Case Study of Multilevel Barriers and Facilitators. Admin Plcy Mntl Hlth Mntl Hlth Srvcs Rsrch. 2015;43(3):426–40. Doi: 10.1007/s10488-015-0642-0
39. Jensen-Doss A, Haimes EMB, Smith AM, Lyon AR, Lewis CC, Stanick CF, et al. Monitoring Treatment Progress and Providing Feedback is Viewed Favorably but Rarely Used in Practice. Admin Plcy Mntl Hlth Mntl Hlth Srvcs Rsrch. 2016;45(1):48–61. Doi: 10.1007/s10488-016-0763-0
40. Kendall PC, Gosch E, Furr JM, Sood E. Flexibility Within Fidelity. Journal of the Am Acdm Child Adol Psych. 2008;47(9):987–93. Doi: 10.1097/chi.0b013e31817eed2f
41. Kendall PC, Frank HE. Implementing evidence‐based treatment protocols: Flexibility within fidelity. Cncl Psych: Scnce and Prct. 2018;25(4). Doi: 10.1111/cpsp.12271
42. Rice SM, Purcell R, De Silva S, Mawren D, McGorry PD, Parker AG. The mental health of elite athletes: A narrative systematic review. Sports Med. 2016;46:1333–53. Doi: 10.1007/s40279-016-0492-2