There is a long and thoughtful tradition of medical help for the “physical health” of athletes independent of age and level of competition. As the role of sports in society has evolved, teams have spared no expense in the development of performance teams to assist athletes. This includes strength and conditioning coaches, sports dieticians, athletic trainers, and performance psychologists all to enhance the performance of the athlete and the team.
For a variety of deeply ingrained and long-standing reasons, there has been far less focus on what has been called “mental health”—ie, psychiatric problems and disorders. It is only in recent decades when athletes, the public, and some pathologists in the sports medicine field have recognized that brain injury is positively associated with behavioral problems in football players.1 In addition, there has been increasing attention to the on- and off-field “bad” behavior of athletes, coaches, team owners, and significant others—sending the message that such behavior is related to team success.
Ironically, most teams and leagues still do not have psychiatric physicians as part of their medical staff. Two recent developments have changed the landscape. The International Olympic Committee (IOC) has, in 2018, for the first time convened a consensus meeting on “Mental Health in Elite Athletes,” bringing together experts from a variety of medical and other fields.2 Second, several former National Basketball Association (NBA) players have convinced their Players Association to set up a network of “mental health” providers (psychiatrists and psychologists) in every NBA city to be available to help current and former players with their mental health problems. Importantly, the National Football League has just announced that they are asking every team to incorporate a sports psychiatrist on their sports medicine staff.
As such, it may be time to ask, “Can a psychiatrist with ‘sports expertise'” be helpful to teams and leagues as an integral part of the medical staff?”
THE CURRENT SCENE
This article succinctly summarizes the literature around “sports psychiatry” for athletes of all ages, genders, and sports. The focus is on what a psychiatrist can add to the structure and function of a sports medicine team. We describe the roles of the sports psychiatrist, including special problems that may be encountered when working with athletes and their families and strategies to maximize sports psychiatrists' effectiveness.
DEVELOPMENT OF THE SPORTS PSYCHIATRY FIELD
In 2016, one of us edited a journal issue on “Sports Psychiatry.”4 Two overviews included therein summarized the origins of this new field in the early 1990s, defined it and its objectives, and described its evolution over the next 3 decades.4,6 In that issue, Dan Begel, MD, one of the founders of the field of sports psychiatry, stated looking back on its history:
As the role of sports psychiatry has expanded, its clinical repertoire has increasingly incorporated performance-enhancing methods. Although it is generally agreed that the central role of sports psychiatry is to provide clinical psychiatric care to the athletic community, that is, treatment of illness, the inherent interdependence of athletic performance and personal life has inevitably drawn clinicians into the realm of performance.7
Other included articles described the broader range of the field6 with articles on such topics as “cheating,”8 performance-enhancing substances (PESs),9 substance use disorders,10 and concussion/TBI.11 A central theme was the stigma associated with working with athletes seeking help, that is, psychotherapy and medication for psychiatric problems and disorders.12 As such, another article focused on changing the culture of sports.13
Stigma has gradually diminished—but not totally disappeared—and teams have begun to develop consulting relationships with psychiatrists on whom they can rely for treatment of a wide range of clinical issues. Clinicians and researchers have advocated for: (1) increased study of the mental aspects of youth sports; (2) more controlled, rather than anecdotal, research; and (3) studies of coaches and the mental aspects of and implications of coaching.8
As mentioned, in 2018, the IOC brought together experts in the field for development of a consensus statement, representing a systematic review of the literature and expert opinion on mental health in elite athletes.2 The IOC's effort aimed to improve and protect the health of the athlete. In addition to describing the incidence and prevalence of psychiatric disorders, they reviewed issues related to diagnosis and psychotherapeutic and pharmacologic treatment of common psychiatric symptoms and disorders such as, but not limited to, mood and anxiety disorders, attention-deficit/hyperactivity disorder, post-traumatic stress disorder, eating disorders, sleep disorders, and gambling and other addictions. They also discussed harassment and abuse, mental aspects of injury, barriers to mental health treatment, and psychiatric emergencies as well as suggesting ways of positively shaping the work-sports environment from a mental health standpoint.2
THE ROLE OF SPORTS PSYCHIATRISTS ON THE SPORTS MEDICINE TEAM
Two recent articles by psychiatrists who have been working with professional teams for many years describe the contributions of a sports psychiatrist.4,14 They discuss prevention and early detection of what they call “mental stress,” defined as issues associated with playing. They detail assessment, treatment, rehabilitation, and recovery—including return to sports/play— from psychiatric illness. Of special note is the article by McDuff and Govan, psychiatric physicians who describe day-to-day function as a sports psychiatrist and how to actually work with sports organizations and teams season-by-season.14 They describe challenges at different levels of competition and how sports psychiatrists can work with coaches, athletic trainers, other staff, and team owners/administrators, all of whom are crucial to team function. Finally, they are one of the few to suggest ways of evaluating the effectiveness of the psychiatric role.14
THE SPORTS MEDICINE TEAM WITH OR WITHOUT PSYCHIATRISTS
Given how sport has changed, and how the role of psychiatrists has evolved, is it necessary to have a psychiatrist on every team? Counterarguments might include the following: (1) they cost money; (2) they come with the legacy of stigma associated with psychiatric illness; (3) those who seek help may worry about privacy issues and thus not come for help; (4) coaches may believe their authority is being challenged over some of the issues that might arise; and (5) perhaps most importantly, unlike an orthopedist, whose treatments are accepted as the standards of care without attached stigma, the effectiveness of mental health treatments is not always as objectively and quickly demonstrable and measurable.
We think the time has come for teams, athletes, and their significant others to decide whether it makes sense to add to their sports medicine staff a sports psychiatrist—a physician who has expertise and experience in the pathophysiology, diagnosis, and management of psychiatric illnesses including substance use disorders, mood and anxiety disorders, eating disorders, and other serious conditions. Sports psychiatrists may provide psychotherapeutic and psychopharmacologic interventions with an understanding of the athletic environment. Sports psychiatrists are equipped to treat a range of mental health problems from mild to severe to mitigate the risk of those problems and potentially prevent career-ending illness if not properly managed. Such a role for sports psychiatry would bring the aims of optimizing the performance of and mental health and well-being of athletes, and perhaps most importantly, changing the “kill at any cost” culture of sports, while simultaneously improving healthy competition at all levels, for all genders, and most cultures.
References
1. McDuff D, Thompson D, Garvin M. Football, in the ISSP Manual of Sports Psychiatry, New York, NY: Rutledge; 2018: 149–162.
2. Reardon CL, Hainline B, Aron CM, et al. Mental health in elite athletes: International Olympic Committee consensus statement. Br J Sports Med. 2019;53:667–699.
3. Glick ID, Castaldelli-Maia JM. Sports psychiatry 2016: a developing field. Int Rev Psychiatry. 2016;28:528–649.
4. Currie A, Johnston A. Psychiatric disorders: the psychiatrist's contribution to sport. Int Rev Psychiatry. 2016;28:587–594.
5. Glick ID, Castaldelli-Maia JM. Sport psychiatry 2016: brain, mind, and medical-psychiatric care. Int Rev Psychiatry. 2016;28:545–546.
6. Begel D. Sport psychiatry twenty-four years later. Int Rev Psychiatry. 2016;28:547–550.
7. Kamis D, Newmark D, Begal D, et al. Cheating and sports: history, diagnosis and treatment. Int Rev Psychiatry. 2016;28:551–555.
8. Creado S, Reardon C. The sports psychiatrist and performance-enhancing drugs. Int Rev Psychiatry. 2016;28:564–571.
9. Gil F, Guerra A, Castaldelli-Maia JM. Discussing prevalence, impacts, and treatment of substance use disorders in athletes. Int Rev Psychiatry. 2016;28:572–578.
10. Riggio S, Jagoda A. Concussion and its neurobehavioural sequelae. Int Rev Psychiatry. 2016;28:579–586.
11. Stillman MA, Brown T, Ritvo EC, et al. Sport psychiatry and psychotherapeutic intervention, circa 2016. Int Rev Psychiatry. 2016;28:614–622.
12. Glick ID, Brodwin D. It's time to change the culture of sports. Int Rev Psychiatry. 2016;28:629–630.
13. McDuff DR, Garvin M. Working with sports organizations and teams. Int Rev Psychiatry. 2016;28:595–605.
