By SHERRY BOSCHERT

Elsevier Global Medical News

EXPERT ANALYSIS FROM THE ANNUAL MEETING OF THE AMERICAN PSYCHIATRIC ASSOCIATION

HONOLULU – They’re not sports psychologists. And they’re not neurologists. Sports psychiatrists have their own position to play in the care of athletes.

A neurologist deals with memory and function after concussion, for example, but a sports psychiatrist also diagnoses and treats the short- and long-term psychiatric sequelae of traumatic brain injury (TBI) or other injuries, Dr. Ira D. Glick said at the meeting.

A sports psychiatrist in general might diagnose and treat psychopathology, symptoms, or disorders within an athlete or problems related to the athlete’s family, significant other, team, or the sport.
Just as a private-practice psychiatrist’s job is to help bring patients to their highest quality of life, “our job as sports psychiatrists is to bring athletes to optimal mental health and athletic performance,” said Dr. Glick, professor of psychiatry and behavioral sciences at Stanford (Calif.) University, who coauthored a paper with Dr. Claudia L. Reardon on the subject.

Treatment might target attention-deficit/hyperactivity disorder, anxiety disorders, depression, psychotic disorders (rarely), or substance abuse problems (frequently). Symptoms can interfere with performance, as in the athlete who develops so many obsessive-compulsive rituals before a game that he can’t get on the field in time. Aggression, cheating and gambling, and suicidal ideation and behavior all might occur less frequently in athletes than in the general population. However, there are always some who will engage in these behaviors.

In fact, Dr. Glick recently traveled to Germany to consult with psychiatrists in that country on the suicide of Robert Enke, the goalkeeper for Germany’s national team who took his life in 2009 after concealing many years of depression.

Female athletes in particular face family problems that don’t get enough attention. “It’s almost impossible to have a life if you’re a professional woman athlete. You’re always on the move; you can’t raise kids; you have to have your husband around to have a relationship,” said Dr. Glick, who is on the board of directors of the International Society for Sports Psychiatry. “These are tremendous family problems that have hardly been addressed. If somebody wants to make a career, focus on sports psychiatry now and carve out a niche” specializing in helping female athletes, he suggested.

Sports psychiatrists also look at systemic issues, such as the impact on athletes from the “posse” of people surrounding them, including agents, coaches, trainers, and others. Sports psychiatrists also might focus on problems in a particular sport, such as TBI in football, doping in cycling, or brain damage in boxing.

Once psychopathology is identified, the sports psychiatrist helps set goals. “One of the special characteristics of our field is deciding: goals for whom? The athlete? The team? Their significant others? Set the goals first, and then treat,” Dr. Glick said.
“That world is a very different world than the average patient who visits a psychiatrist’s office with depression, anxiety, or family problems. Sports psychiatry requires special skills and special treatments,” he said.

Treatment might involve individual psychotherapy for the athlete or someone close to the athlete – as in marital therapy – pharmacotherapy, or prescribing self-help groups such as Alcoholics Anonymous.
All professional sports leagues now have psychiatrists working with them specifically on substance abuse. “Steroid use is a huge issue, but that’s just the tip of the iceberg of what’s going on out there. What team physicians will tell you is that athletes will do anything and take anything to get a competitive advantage,” he said.

Substance abuse might even contribute to the long-term sequelae of TBI. “We don’t know what the confounders are,” he noted. “Steroids, for all we know, may be rotting out these brains. We know that in boxing, it’s from the hits, but we’re not that sure yet about the etiology of many of the brain-damage problems in other sports.”

Dr. Glick currently is attempting to work with professional sports leagues, unions, and the retired players’ associations around retirement issues for athletes. The average career in the National Football League lasts 4 years. In the National Basketball Association, it might be 5 years. Professional athletes may have neglected an education to compete and find themselves in retirement by age 23 with dim prospects and physical and psychiatric sequelae from their athletic years.

Athletes commonly are loathe to see a psychiatrist, in part because of the stigma and fear that they will be considered “crazy.” This gradually is changing, but some psychiatrists try to avoid stigma by speaking in terms of mental health instead of labeling these as psychiatric issues or disorders, he said.
Even when the problem is physical, such as a concussion, athletes often don’t admit it or seek help out of fear that the physician will prevent them from playing.

A wide variety of alternative-care “gurus,” as well as psychologists, counselors, and trainers, compete with psychiatrists to offer care for athletes. The efficacy of alternative interventions is unknown, as there are no outcome data.

Sports psychologists established a practice niche long before sports psychiatrists, and are much better organized, he said. Sports psychiatrists need to develop subspecialty requirements and training programs, a code of ethics, guidelines, and curricula to make the field more scientific. “We’re the new kids on the block,” he said.

Dr. Glick has been a consultant or speaker or received research grants from Bristol-Myers Squibb, AstraZeneca, Janssen, Pfizer, Shire, Solvay, GlaxoSmithKline, Merck, and Novartis. He holds stock in Johnson & Johnson