Claudia L. Reardon

Sport psychiatry: a systematic review of diagnosis and medical treatment of mental illness in athletes.

Sport psychiatry focuses on diagnosis and treatment of psychiatric illness in athletes in addition to utilization of psychological approaches to enhance performance. As this field and its research base are relatively new, clinicians often deliver psychiatric care to athletes without a full understanding of the diagnostic and therapeutic issues unique to this population. In this systematic review, we discuss published findings relating to psychiatric diagnosis and medical treatment of mental illness in athletes.There have been several studies looking at the prevalence of some psychiatric disorders in various athlete populations. Eating disorders and substance abuse are the most studied of these disorders and appear to be common problems in athletes. However, to provide informed understanding and treatment, we especially need more research on overtraining syndrome, bipolar disorder, suicidality, anxiety disorders, attention-deficit hyperactivity disorder (ADHD) and psychosis in athletes. Research is needed in the areas of prevalence, risk factors, prognosis and the unique experiences facing athletes with any of these disorders.Additionally, there have not been any large, systematic studies on the use of psychotropic medications in athletes. Small studies suggest that some medications may either be performance enhancing or detrimental to performance, but we need larger studies with rigorous methodology. Higher level athletes suffering from psychiatric symptoms often have reservations about taking medications with unknown performance and safety effects, and methodological issues with the current literature database preclude any definitive conclusions on performance effects of psychiatric medications. We need many more, higher quality studies on the use by athletes of antidepressants, mood stabilizers, anxiolytics, stimulants and other ADHD medications, sedative-hypnotics and antipsychotics. Such studies should utilize sensitive performance measures and involve longer term use of psychotropic medications. Furthermore, study subjects should include athletes who actually have the psychiatric disorder for which the medication is proposed, and should include more women.

Drug abuse in athletes

Drug abuse occurs in all sports and at most levels of competition. Athletic life may lead to drug abuse for a number of reasons, including for performance enhancement, to self-treat otherwise untreated mental illness, and to deal with stressors, such as pressure to perform, injuries, physical pain, and retirement from sport. This review examines the history of doping in athletes, the effects of different classes of substances used for doping, side effects of doping, the role of anti-doping organizations, and treatment of affected athletes. Doping goes back to ancient times, prior to the development of organized sports. Performance-enhancing drugs have continued to evolve, with “advances” in doping strategies driven by improved drug testing detection methods and advances in scientific research that can lead to the discovery and use of substances that may later be banned. Many sports organizations have come to ban the use of performance-enhancing drugs and have very strict consequences for people caught using them. There is variable evidence for the performance-enhancing effects and side effects of the various substances that are used for doping. Drug abuse in athletes should be addressed with preventive measures, education, motivational interviewing, and, when indicated, pharmacologic interventions.

A Didactic and Experiential Quality Improvement Curriculum for Psychiatry Residents

BACKGROUND Quality improvement (QI) education in residency training is important and necessary for accreditation. Although the literature on this topic has been growing, some specialties, in particular psychiatry, have been underrepresented. METHODS We developed a didactic and experiential QI curriculum within a US psychiatry residency program that included a seminar series and development of QI projects. Evaluation included resident knowledge using the Quality Improvement Knowledge Application Tool, implementation of resident QI projects, and qualitative and quantitative satisfaction with the curriculum. RESULTS Our curriculum significantly improved QI knowledge in 2 cohorts of residents (N  =  16) as measured by the Quality Improvement Knowledge Application Tool. All resident QI projects (100%) in the first cohort were implemented. Residents and faculty reported satisfaction with the curriculum. CONCLUSIONS Our curriculum incorporated QI education through didactic and experiential learning in a moderately sized US psychiatry residency program. Important factors included a longitudinal experience with protected time for residents to develop QI projects and a process for developing faculty competence in QI. Further studies should use a control group of residents and examine interprofessional QI curricula.

Neurology Didactic Curricula for Psychiatry Residents: A Review of the Literature and a Survey of Program Directors

ObjectiveMinimal literature exists on neurology didactic instruction offered to psychiatry residents, and there is no model neurology didactic curriculum offered for psychiatry residency programs. The authors sought to describe the current state of neurology didactic training in psychiatry residencies.MethodsThe authors electronically surveyed 172 directors of U.S. psychiatric residency training programs to examine the types and extent of neurology didactic instruction offered to their residents.ResultsFifty-seven program directors (33%) responded. The majority of these psychiatry residency programs offer neurology didactic instruction to their residents, as provided by both neurology and psychiatry faculty, in a number of different settings and covering many topics. However, room for improvement likely remains.ConclusionsThe authors hope this report will guide psychiatry residencies in optimizing their neurology didactic curricula. Further research should explore tools for assessing resident knowledge in neurology and measure the effectiveness of neurology curricula in increasing knowledge and improving clinical outcomes.

Considerations in the Use of Stimulants in Sport.

Medication treatment of adult athletes with attention-deficit/hyperactivity disorder (ADHD) is controversial. Some articles and guidelines support the use of stimulant medications in this population, while others advise against it. We believe that the important issues regarding the use of stimulant medications in athletes include the likelihood of performance enhancement, poor inter-rater reliability of ADHD diagnosis in relation to therapeutic use, policies of sport-governing bodies, psychiatric treatment of mental illness, and dangerous consequences of use. We review the literature on these five issues and conclude by discussing the ethical principle of fairness, and suggest some proposals regarding the use of stimulants by athletes that balance these five issues and fairness. Our ultimate recommendation is that stimulants should not be used by high-level adult athletes.

Psychiatric medication preferences of sports psychiatrists.

ABSTRACT Objectives: When prescribing psychiatric medications to athletes, it is important to consider issues that are especially important for this population, including side effects, safety concerns, and anti-doping policies. Only one report, from 2000, describes the prescribing preferences of psychiatrists who work with athletes. This manuscript aims to update the findings from that report, so as to help inform prescribing practices of primary care physicians, psychiatrists, and other clinicians who work with athletes. Methods: Physician members of the International Society for Sports Psychiatry (ISSP) were sent an email invitation in 2016 to complete an anonymous web-based survey on psychiatric medication prescribing preferences in working with athletes with a variety of mental health conditions. Results: Forty of 100 (40%) members of the ISSP who identified as physicians and who were emailed the survey ultimately completed it. Top choices of psychiatric medications for athletes across categories assessed included: bupropion for depression without anxiety and without bipolar spectrum disorder; escitalopram for generalized anxiety disorder; melatonin for insomnia; atomoxetine for attention-deficit/hyperactivity disorder; lamotrigine for bipolar spectrum disorders; and aripiprazole for psychotic disorders. Conclusion: Prescribers of psychiatric medications for athletes tended to favor medications that are relatively more energizing and less likely to cause sedation, weight gain, cardiac side effects, and tremor. Additionally, prescribing preferences for athletes diverged from many of the prescribing trends seen for patients within the general population, in keeping with the assumption that different factors are considered when prescribing for athletes versus for the general population.

The sports psychiatrist and performance-enhancing drugs

Abstract Drug abuse occurs in all sports and at most levels of competition. Athletic life may lead to drug abuse for a number of reasons, including for performance enhancement, to self-treat otherwise untreated mental illness, and to deal with stressors, such as pressure to perform, injuries, physical pain, and retirement from sport. This review examines the effects of different classes of substances used for doping, side-effects of doping, and treatment of affected athletes. There is variable evidence for the performance-enhancing effects and side-effects of the various substances that are used for doping. Drug abuse in athletes should be addressed with preventive measures, education, motivational interviewing, and, when indicated, pharmacologic interventions.

Psychiatric Comorbidities in Sports

Athletes are not immune to mental illness, despite outward appearances of strength and wellness. Depression and anxiety disorders may occur in athletes at least as commonly as in the general population. Eating disorders, attention-deficit/hyperactivity disorder, and substance use disorders may occur even more frequently in athletes than in the general population. Thus, it is imperative that medical professionals across all specialties are aware of these psychiatric comorbidities, and how to initiate evaluation for and treatment of them.

The sports psychiatrist and psychiatric medication

Abstract There are several critical factors to consider in prescribing psychiatric medications to athletes. In addition to the usual considerations when prescribing any psychotropic agent to any patient, the prescriber in this case should pay careful attention to: (1) potential negative impact of the medication on athletic performance, (2) potential performance-enhancing effects, and (3) potential safety risks. This paper describes an updated review of relevant research findings and considerations in the above areas within various categories of psychiatric medications. Many methodological concerns exist with the studies that have examined psychotropic medication use by athletes. These include: small sample sizes; use of the medication in dosing strategies (e.g. single dose) that do not replicate how they are usually taken in the real world; use of primarily male subjects only; use of performance measures (e.g. subtraction, multitask) in some studies that may not align with physical demands experienced by athletes in their natural athletic environments; and not using athletes who actually have the psychiatric disorder or symptom the medication was designed to treat. Despite these concerns, data currently available provide at least some guidance for clinicians wishing to make informed decisions about psychotropic prescribing for their athlete-patients.

Community psychiatry tracks for residents: a review of four programs.

Many psychiatry residency graduates end up practicing at least in part in community settings. However, declining funding and other issues prevent many residency programs from offering robust community psychiatry training to all of their residents. Accordingly, some residency programs have developed Community Psychiatry Tracks, with the goal of developing future leaders in public sector psychiatry. We cataloged US psychiatry residency programs offering Community Psychiatry Tracks by reviewing the literature and surveying training directors and members of the American Association of Community Psychiatrists. Authors from each of the four programs found to be actively offering such tracks describe their track curricula, from which we elucidated common and variable elements as well as strengths and weaknesses and then make recommendations for other programs wishing to start a track. A Community Psychiatry Track preliminarily appears to be a well-received way to offer enhanced Community Psychiatry training to interested residents, to recruit medical students to residency programs, to offer opportunities for collaboration between residents and faculty members, and to expand opportunities for scholarly work by residents.