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.
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.
The ability of mental health practitioners to work well with persons with serious long-term mental illness has expanded significantly over the past two decades. Learning to do this well involves acquiring a broad base of knowledge and a complex range of skills. Such knowledge and experience must be incorporated into the basic residency curriculum for general psychiatrists, though with some notable exceptions this has not occurred for a number of important reasons, including money and the new image that psychiatry is trying to assume. The key elements of such a curriculum include 1) specific learning goals, 2) working within an effective treatment system with high quality clinical rotations, 3) good role models, 4) high quality psychiatric supervision, 5) a well-grounded didactic program, and 6) high quality clinical rotations. We discuss these elements in detail, and we describe the training program in community psychiatry at the University of Wisconsin Medical School Department of Psychiatry. Our residency training program and supervising faculty are affiliated with and partially funded by the Mental Health Center of Dane County to the benefit of both. This marriage between the public-sector mental health care provider and the academic psychiatric training program has created benefits for both parents plus a fertile environment for training future generations of psychiatrists.
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