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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.