MAR DEL PLATA, Argentina — Many athletes experience “nervousness” — a feeling of anxiety — just before competition. For elite athletes, whether participating in an individual event or as part of a team, whether on a track, court, rink or field, this feeling can affect performance. It is a well-known phenomenon, and not unexpected, which accompanies the territory. Nevertheless, specialists should be on the lookout for signs of more serious mental disorders – those that may show up in other areas of the person’s life. These disorders may require targeted psychotherapeutic treatment or the prescription of psychotropic drugs. These are the guidelines proposed by the panelists of the session of the XXXV Argentine Congress of Psychiatry of the Argentine Psychiatric Association (APSA 2022), which was held in the seaside resort of Mar del Plata from April 27 to 30.
Ivanna Meloni Cafarelli, MD, a psychiatrist at Pirovano Hospital in Buenos Aires and a member of APSA’s Anxiety Disorders Section, often works with athletes. “It’s generally said that elite athletes aren’t particularly prone to depression because all that exercise releases endorphins and neurotransmitters, like serotonin, that inhibit feelings of sadness,” she said. “But we also know that physical activity has positive effects on patients with anxiety disorders. And everyone is entitled to have a moment, a crisis. We have seen it even in Olympic athletes who beat records.”
Meloni Cafarelli told Medscape Spanish Edition that some mental health professionals who don’t work with athletes end up saying, “How could Messi and other top athletes be depressed? They’ve got all these endorphins, they’re rich, they’re famous.”
His answer ? “It’s just not that simple. It’s not that simple. When someone is in the throes of anxiety or depression, there are more factors at play than just chemical imbalances. And we should never rule out family history or genetics A psychiatric condition that has a significant genetic component – e.g., schizophrenia, bipolar disorder, obsessive-compulsive disorder, addictive disorder – this should always be considered when we see athletes with symptoms that make us suspect something more is going on flags that need to be looked at and assessed – not so we can stick a label or a diagnosis, but so we can be more monitor the development of symptoms.
Prepare mind and body
Meloni Cafarelli mentioned that since the early 2000s, advances in neuroscience and sports psychology have reinforced the idea that when it comes to athletes, their minds and bodies must be prepared to improve their performance.
For example, there are different interventions that can help the athlete manage their pre-competitive anxiety and improve their results, noted another speaker, Lorena Casse, a specialist in sports psychology at a mental health center in Buenos Aires. In addition to progressive muscle relaxation, a method developed by Edmund Jacobson, MD, PhD, there are cognitive restructuring, visualization and certain techniques aimed at getting the athlete to focus on the process and not on the result of the competition. Casse pointed out that there are also strategies for maintaining confidence and focus on the playing field. These range from diaphragmatic breathing and the use of humor to the use of mental imagery or trigger words and taking control of distracting thoughts.
“Mental training follows the same steps as physical training, starting with pre-season conditioning and working your way up to the point of peak performance,” Casse said. However, athletes are not machines. They must be the best. Add to that the pressure of being in a situation where sport has become their livelihood, supporting not only themselves but also their families. Or maybe they’re the captain and feel more responsible for the performance of the team.
Athletes often feel compelled to hide anything that could be considered a flaw or weakness. “They want to show that they are capable, that they have what it takes, no matter how much the odds are against them,” Meloni Cafarelli said.
Leanna MW Lui, HBSc, works in the Mood Disorders Psychopharmacology Unit at Toronto Western Hospital in Canada. She said Medscape Spanish Edition“Athletes also often fall prey to a strict dichotomy: trying to stay flawless on the field or in the arena while trying to maintain their vulnerability as human beings for the rest of their lives.”
Beyond the fact that the mental health of elite athletes has been a recent topic of conversation – given the cases and firsthand descriptions of gymnast Simone Biles, swimmer Michael Phelps and tennis player Naomi Osaka – “Stigma continues to be a very pervasive barrier, and even more so in the world of elite sport. There is this feeling that seeking treatment for mental health issues is incompatible with to be a tough, competitive athlete,” said Claudia Reardon, MD, professor of psychiatry at the University of Wisconsin School of Medicine and Public Health in Madison, Wisconsin. She did not participate in the conference sessions.
“Because the proportion of athletes with mental health issues is virtually the same as that found in the general population, screenings need to be done and things caught early. That way symptoms can be quickly identified and interventions can be put in place to prevent mental illness from getting worse,” José J. Mendoza Velázquez, MD, MPA, research coordinator in the Department of Psychiatry and Mental Health at the National Autonomous University of Mexico, explained to Mexico.
When can one feel justified in proposing a psychotherapeutic treatment or appropriate psychotropic drugs? Meloni Cafarelli suggested paying attention to symptoms that persist for about 6 months. These symptoms include “difficulty falling asleep, irritability, lack of motivation, negative or even catastrophic thoughts, feelings of sadness with aggression or urge to cry, despair or inability to feel pleasure”.
For athletes with anxiety or concentration issues, she suggested also checking for any personal or family history of attention deficit/hyperactivity disorder.
Primary care providers who have patients who are athletes should ask those patients about mental health issues, even if the appointment has nothing to do with mental health per se. “Every member of the athlete’s medical team needs to keep mental health on their radar and ask specific and direct questions about these issues,” Reardon said. Medscape Spanish Edition. “It could be questions like, ‘How has your stress level been lately?’ or ‘Lately, have you felt sadder or more worried than you would like?’ “
Psychotherapy is generally considered the first-line treatment for people with mild to moderate symptoms of mental illness. Medication may be needed for those with more severe psychopathology. This presents some additional challenges. “Athletes are more reluctant when it comes to medication. They may be afraid of violating anti-doping policies. it comes from being an elite athlete,” explained Meloni Cafarelli.
Regarding doping, the psychiatrist specifies that the World Anti-Doping Agency grants exemptions; athletes are permitted to use banned psychotropic drugs when necessary to treat an acute or chronic medical condition, when the drug is highly unlikely to enhance performance, and when there is no reasonable alternative .
In a consensus statement on mental health from the International Olympic Committee, published in BMJ In 2019, Reardon and his team of 26 associates from 14 countries listed the following four key considerations when prescribing psychiatric drugs to elite athletes:
Potential negative impact on sports performance
Potential therapeutic performance enhancing effects (i.e. based on improving the condition the drug is designed to treat)
Potential non-therapeutic performance enhancing effects (i.e. ergogenic effects)
Potential Safety Risks
“Safety risks are paramount with certain psychiatric medications, as elite athletes typically exercise at much higher intensity than the general population,” the authors write. “For example, drugs whose blood levels must be tightly regulated, such as lithium, may be difficult to manage in elite athletes whose levels may be influenced by hydration status.”
But, according to Reardon, this does not mean that the threshold for starting psychopharmacological treatments in high-level athletes should be higher than that used for the rest of the population.
“Athletes shouldn’t have to put up with more suffering than anyone else. However,” she clarified, “that doesn’t mean that the drug choices we make when treating athletes can sometimes not differ from those we do for our non-athletic patients.”
Meloni, Reardon and Casse did not disclose any relevant financial relationship.
Follow Matías A. Loewy of Medscape Spanish Edition on Twitter: @MLoewy.
This article was translated from the Spanish edition of Medscape.