Evidence-Based Reviews

Playing through the pain: Psychiatric risks among athletes

Current Psychiatry. 2012 July;11(7):16-20

References

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Table

Differential diagnosis of conditions associated with athletic injury

Acute stress disorder
Adjustment disorder
Anxiety disorder NOS
Depressive disorder NOS
Major depressive disorder
Overtraining syndrome
Postconcussion syndrome
Posttraumatic stress disorder
NOS: Not otherwise specified

Substance use: Common and risky

Anecdotal and clinical evidence suggests that athletes in different sports engage in different substance abuse patterns. Studies show that college athletes use alcohol at higher rates than non-athletes.^22,23 In 2000, the American College of Sports Medicine reported that athletes’ abuse of recreational drugs far surpasses their abuse of performance-enhancing drugs.²⁴ Some athletes may use prescription pain medications recreationally or to self-medicate emotional pain as a result of injury. Athletes may not understand the risks of recreational use of prescription medications or illicit substances—such as cocaine’s deleterious cardiovascular effects—and may hesitate to discuss their self-medicating with physicians.

Some athletes abuse performance-enhancing drugs, such as anabolic steroids, androstenedione, stimulants, diuretics, and creatine.²⁵ Side effects of these substances include liver disease, brain hemorrhage, weight loss, and depression.²⁵

Our recommendations

Clinical Point

Understanding the meaning of an injury to the athlete is crucial to achieving recovery

Working with athletes—particularly injured athletes who have internalized sports culture—requires informed clinical effort, whether your patient is a student athlete, elite athlete, leisure athlete, or former athlete. Successful diagnosis and treatment requires understanding the meaning of athletics in your patient’s life and the extent to which he or she has “back-up” stress relievers and support systems, and assessing for cognitive dysfunction that may contribute to mood or anxiety symptoms. During evaluation, take a careful history to distinguish major depression or adjustment disorders from OTS, and assess for PTSD symptoms. When treating an injured athlete, help the patient determine whether he or she can find another outlet—preferably more than one—to replace athletics.

Clinical Point

Depressed athletes may be more likely to follow through with psychotherapy than pharmacotherapy

For an athlete who has depressive symptoms, we recommend determining whether the patient’s symptoms remit after a brief period of rest before initiating pharmacotherapy. For patients who exhibit minimal neurovegetative features, we recommend psychotherapy as a first-line treatment. Many athletes are reluctant to take medication and would be more likely to follow through with cognitive-behavioral and biofeedback interventions.

If a patient requires pharmacotherapy, ask about his or her feelings toward medications that may impact adherence. For example, is a gymnast worried about weight gain? Is a sprinter concerned with lethargy? When prescribing, be aware of the prevalence of drug and alcohol problems among athletes, understand how habits and temptations differ among sports cultures, and provide patients with psychoeducation about substance abuse when appropriate.

Related Resources

International Society for Sports Psychiatry. http://sportspsychiatry.org.
Sabo D, Miller KE, Melnick MJ, et al. High school athletic participation and adolescent suicide: a nationwide U.S. study. Int Rev Sociol Sport. 2005;40(1):5-23. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2563797. Accessed June 7, 2012.

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.