Overview: Sports Medicine providers play a key role in the comprehensive mental healthcare of the athlete. 1 in 5 adults and 1 in 6 youths in America experience mental health illness each year (https://www.nami.org/mhstats). Participation in sports often positively impacts mental health; however, athletes are not immune to common mental health disorders seen in the general population. Athletes also contend with unique challenges – such as performance anxiety, experiencing career-limiting injuries, and body image issues specific to their sport. 

• AMSSM position statement on mental health 
• International Olympic Committee (IOC) consensus statement on mental health
• National Alliance of Mental Illness (NAMI): source of information on prevalence and incidence of mental health illness as well as resources for patients and providers

1.) Anxiety and Stress: Athletes are frequently subject to physical and psychological stressors by virtue of their athletic participation. It is important for sports medicine providers to recognize the clinical signs and symptoms of anxiety in order to facilitate appropriate treatment. 

• Rice SM, Gwyther K, Santesteban-Echarri O, Baron D, Gorczynski P, Gouttebarge V, Reardon CL, Hitchcock ME, Hainline B, Purcell R. Determinants of anxiety in elite athletes: a systematic review and meta-analysis. Br J Sports Med. 2019 Jun;53(11):722-730. doi: 10.1136/bjsports-2019-100620. PMID: 31097452; PMCID: PMC6579501. 
• Vu V, Conant-Norville D. Anxiety: Recognition and Treatment Options. Psychiatr Clin North Am. 2021 Sep;44(3):373-380. doi: 10.1016/j.psc.2021.04.005. Epub 2021 Jun 16. PMID: 34372994. 

2.) Attention-Deficit/Hyperactivity Disorder (ADHD): ADHD is a neurodevelopmental disorder characterized by difficulty maintaining concentration during tasks and/or impulsivity/hyperactivity. Accurate diagnosis can be difficult in athletes and requires a thorough history, physical exam, and diagnostic testing. While stimulant medications are effective in treating the symptoms of ADHD, their use is banned by many major sporting bodies. Providers need to be aware of specific regulations for their athlete populations.

• Ciocca M. Attention Deficit Hyperactivity Disorder in Athletes. Clin Sports Med. 2019 Oct;38(4):545-554. doi: 10.1016/j.csm.2019.05.004. Epub 2019 Jul 29. PMID: 31472765. 
• Pujalte GGA, Maynard JR, Thurston MJ, Taylor WC 3rd, Chauhan M. Considerations in the Care of Athletes With Attention Deficit Hyperactivity Disorder. Clin J Sport Med. 2019 May;29(3):245-256. doi: 10.1097/JSM.0000000000000508. PMID: 29189334. 
• Stewman CG, Liebman C, Fink L, Sandella B. Attention Deficit Hyperactivity Disorder: Unique Considerations in Athletes. Sports Health. 2018 Jan/Feb;10(1):40-46. doi: 10.1177/1941738117742906. Epub 2017 Nov 16. PMID: 29144831; PMCID: PMC5753970. 

3.) Burnout: Sports burnout has been seen in response to the chronic stress after demands of playing a sport or doing sport related activities without adequate recovery periods. This response to chronic stress causes an athlete to no longer enjoy a previously enjoyable activity. Causes a state of sport devaluation, physical and emotional exhaustion, and reduced accomplishment. Although this can happen at any age, it has been shown to be more common among younger athletes. Factors that lead to burnout include but are not limited to frequent competition, early single sport specialization, and emphasis of collegiate scholarships and/or elite-level success, and injury. Burnout can result in loss of sleep and appetite, decreased satisfaction in sport, injury, lower performance, and even withdrawal from sport. 

Treatment considerations: evaluating for prior hx of injury due to overuse during pre-participation exams, addressing any menstrual irregularities in adolescent female athletes that may predispose to bone stress injuries, monitoring of frequency of training during adolescent growth spurt. Consider education for parents and coaches regarding the concept of sports readiness. Can utilize Athlete Burnout Questionnaire to evaluate for athlete burnout. 

• DiFiori JP, Benjamin HJ, Brenner JS, Gregory A, Jayanthi N, Landry GL, Luke A. Overuse injuries and burnout in youth sports: a position statement from the American Medical Society for Sports Medicine. Br J Sports Med. 2014 Feb;48(4):287-8. doi: 10.1136/bjsports-2013-093299. PMID: 24463910. 
• Gustafsson H, Sagar SS, Stenling A. Fear of failure, psychological stress, and burnout among adolescent athletes competing in high level sport. Scand J Med Sci Sports. 2017 Dec;27(12):2091-2102. doi: 10.1111/sms.12797. Epub 2016 Nov 23. PMID: 27882607. 
• Li C, Zhu Y, Zhang M, Gustafsson H, Chen T. Mindfulness and Athlete Burnout: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. 2019 Feb 3;16(3):449. doi: 10.3390/ijerph16030449. PMID: 30717450; PMCID: PMC6388258. 
• Groenewal PH, Putrino D, Norman MR. Burnout and Motivation in Sport. Psychiatr Clin North Am. 2021 Sep;44(3):359-372. doi: 10.1016/j.psc.2021.04.008. Epub 2021 Jul 6. PMID: 34372993. 

4.) Coping with Injury and Illness: There are several factors that impact an athlete’s ability to cope with and recover from injury/illness, including psychological/mental responses to the incident as well as social support systems. Recovery from injury/illness is not simply a physical process but a psychological one as well. 

• Ardern CL, Taylor NF, Feller JA, Webster KE. A systematic review of the psychological factors associated with returning to sport following injury. Br J Sports Med. 2013;47(17):1120-1126. doi:10.1136/bjsports-2012-091203 
• Podlog L, Heil J, Schulte S. Psychosocial factors in sports injury rehabilitation and return to play. Phys Med Rehabil Clin N Am. 2014;25(4):915-930. doi:10.1016/j.pmr.2014.06.011 
• Putukian M. The psychological response to injury in student athletes: a narrative review with a focus on mental health. British Journal of Sports Medicine 2016;50:145-148. 
• Jaworski CA, Rygiel V. Acute Illness in the Athlete. Clin Sports Med. 2019;38(4):577-595. doi:10.1016/j.csm.2019.05.001 

5.) Disordered Eating: Disordered eating and eating disorders are a frequent occurrence in athletes. Several sport- and gender-specific risk factors have been identified. Prevention, early identification and the use of a multidisciplinary treatment approach have shown measurable benefit for athletes. Research and literature has largely focused on female athletes up to this point; more research is needed on the impact of eating disorders and disordered eating in male athletes. 

• Joy E, Kussman A, Nattiv A. 2016 update on eating disorders in athletes: A comprehensive narrative review with a focus on clinical assessment and management. Br J Sports Med. 2016 Feb;50(3):154-62. doi: 10.1136/bjsports-2015-095735. PMID: 26782763. 
• Neglia A. Nutrition, Eating Disorders, and Behavior in Athletes. Psychiatr Clin North Am. 2021 Sep;44(3):431-441. doi: 10.1016/j.psc.2021.04.009. PMID: 34372999. 
• Karrer Y, Halioua R, Mötteli S, Iff S, Seifritz E, Jäger M, Claussen MC. Disordered eating and eating disorders in male elite athletes: a scoping review. BMJ Open Sport Exerc Med. 2020 Oct 23;6(1):e000801. doi: 10.1136/bmjsem-2020-000801. PMID: 33178441; PMCID: PMC7642204. 

6.) Depression and Suicide: Depression among atheltes seems to occur at the same rate as the general public. There are many risk factors that participating in sports confers on athletes. Treatment of depression includes psychotherapy as well as pharmacotherapy, with fluoxetine, venlafaxine, and bupropion being common. Suicide in athletes is not well studied.

• Wolanin, Andrew PsyD; Gross, Michael MA; Hong, Eugene MD. Depression in Athletes: Prevalence and Risk Factors. Current Sports Medicine Reports: January 2015 – Volume 14 – Issue 1 – p 56-60 doi: 10.1249/JSR.0000000000000123 
• Edwards CD. Depression Assessment: Challenges and Treatment Strategies in the Athlete. Psychiatr Clin North Am. 2021;44(3):381-392. doi:10.1016/j.psc.2021.04.011 
• Baum AL. Suicide in athletes: a review and commentary. Clin Sports Med. 2005;24(4):853-ix. doi:10.1016/j.csm.2005.06.006 

7.) Hazing and Bullying: Sports creates one of the only spaces outside of wartime that violence and aggression are not only tolerated but celebrated by the general public. At times these learned behaviors are practiced by athletes on the field when the perceived benefit to the individual (a win, social clout, or perceived toughness) outweighs the costs (risk of injury, ejection from game), and are subsequently reinforced when the perpetrator is rewarded or protected for their action. When these behaviors are directed at peers rather than an adversary, the perceived benefits are grossly overestimated while the cost can include lifelong trauma. The International Olympic Committee defines hazing and bullying (H&B) as forms of non-accidental violence that are expressed through power differentials between a victim and their oppressor. Bullying is defined as a physical or psychological act including exclusion, isolation, ridicule, and/or threat that is enjoyed by the perpetrator and results in a sense of oppression within the victim. Hazing is described as a toxic, normative requirement to acceptance to a group that can include illegal or sexually explicit acts, extreme feats of endurance or deprivation, and/or substance misuse. Underpinning the prevalence of H&B is a culture of silence that perpetuates these learned behaviors and contributes to the dearth of research on the topic. Athletes at highest risk include: elite or near-elite, disabled, and LGBT athletes. 

As critical members of an athlete’s entourage, all Sports Medicine Physicians must be equipped to manage H&B by: 1. Enacting educational interventions aimed at raising awareness of H&B among athletes, coaches, and other members of the athlete entourage, 2. Implementing prevention mechanisms that treat the sociocultural underpinnings of B&H at local and national levels, 3. Creating and maintaining a Mental Health Emergency Action Plan or similar protocol that facilitates safe reporting of H&B, and protects victims from further abuse or retaliation. 4. Ensure all health providers can: recognize H&B, appropriately respond to H&B disclosures, consult and retain a multidisciplinary support team PRIOR to treating survivors, and know where and how to refer disclosures and suspicions of H&B. 

• IOC consensus statement: harassment and abuse (non-accidental violence) in sport. https://bjsm.bmj.com/content/50/17/1019
• Tenenbaum G, Stewart E, Singer RN, Duda J. Aggression and violence in sport: an ISSP position stand. J Sports Med Phys Fitness. 1997 Jun;37(2):146-50. PMID: 9239993. 
• Koontz JS, Mountjoy M, Abbott KE. Sexual violence in sport: American Medical Society for Sports Medicine Position Statement. British Journal of Sports Medicine 2021;55:132-134. 
• Jeckell AS, Copenhaver EA, Diamond AB. The Spectrum of Hazing and Peer Sexual Abuse in Sports: A Current Perspective. Sports Health. 2018 Nov/Dec;10(6):558-564. doi: 10.1177/1941738118797322. Epub 2018 Sep 7. PMID: 30192709; PMCID: PMC6204631. 

8.) Performance Anxiety: Performance anxiety is frequently cited as a factor that can impact the outcome of a sports competition. While some athletes perform well under the temporary duress that a competition can enlist, others find that anxiety negatively affects their athletic performance. 

• Palazzolo J. Anxiety and performance. Encephale. 2020 Apr;46(2):158-161. doi: 10.1016/j.encep.2019.07.008. Epub 2019 Sep 18. PMID: 31542211. 
• Partridge JA, Wiggins MS. Coping styles for trait shame and anxiety intensity and direction in competitive athletes. Psychol Rep. 2008 Dec;103(3):703-12. doi: 10.2466/pr0.103.3.703-712. PMID: 19320203. 
• Rowland DL, van Lankveld JJDM. Anxiety and Performance in Sex, Sport, and Stage: Identifying Common Ground. Front Psychol. 2019 Jul 16;10:1615. doi: 10.3389/fpsyg.2019.01615. PMID: 31379665; PMCID: PMC6646850. 

9.) Performance Enhancement (Psychology): The cornerstone paradigm within Sports Psychology as it relates to optimizing performance is the Integrative Model of Athletic Performance (IMAP). This was described in 2006 by Gardner and Moore, and establishes 3 distinct phases: pre-performance, performance, and post-performance. Each phase is informed by an athlete’s personal collection of schemas or psychological frameworks and how those are affected by other internal as well as external cues. Barriers to optimizing performance and to seeking help when mental health becomes deleterious to performance and health, include factors from psychological, cultural, gender, and religious domains, as well as general misinformation about mental health. Conversely, mindfulness practice has been shown to increase performance and bestow protective effects on an athlete’s mental health. Research on the effect size of psychological interventions as well as the length of effect are actively being studied. In order to help optimize performance and minimize the impact of mental health disorders in athletes, Sports Medicine Physicians should: 1) promote interventions to increase mental health literacy, 2) work to improve relationships and trust between athletes and health providers, and 3) act to dispel the stigma surrounding mental health. 

• Chang C, Putukian M, Aerni G, Diamond A, Hong G, Ingram Y, Reardon CL, Wolanin A. Mental health issues and psychological factors in athletes: detection, management, effect on performance and prevention: American Medical Society for Sports Medicine Position Statement-Executive Summary. Br J Sports Med. 2020 Feb;54(4):216-220. doi: 10.1136/bjsports-2019-101583. Epub 2019 Dec 6. PMID: 31810972. 
• Robert J. Schinke, Natalia B. Stambulova, Gangyan Si & Zella Moore (2018) International society of sport psychology position stand: Athletes’ mental health, performance, and development, International Journal of Sport and Exercise Psychology, 16:6, 622-639, DOI: 10.1080/1612197X.2017.1295557 
• Brown, D.J., Fletcher, D. Effects of Psychological and Psychosocial Interventions on Sport Performance: A Meta-Analysis. Sports Med 47, 77–99 (2017). 

10.) Sexual Identity and Gender Issues: Sex refers to a person’s DNA genotype and generally refers to biological differences betweens males and females. Gender is a more fluid concept of self-perception and heavily influenced by societal and cultural factors. 

• Bassett AJ, Ahlmen A, Rosendorf JM, Romeo AA, Erickson BJ, Bishop ME. The Biology of Sex and Sport. JBJS Rev. 2020 Mar;8(3):e0140. doi: 10.2106/JBJS.RVW.19.00140. PMID: 32224635. 
• Jones BA, Arcelus J, Bouman WP, Haycraft E. Sport and Transgender People: A Systematic Review of the Literature Relating to Sport Participation and Competitive Sport Policies. Sports Med. 2017 Apr;47(4):701-716. doi: 10.1007/s40279-016-0621-y. PMID: 27699698; PMCID: PMC5357259. 

11.) Sleep Disorders: Sleep is crucial to supporting mental health and optimizing athletic performance. Research has shown that changes in sleep timing, quality and quantity can affect performance and health in the short and long term. Encouraging adequate sleep hygiene and recovery can enhance athletic achievement. 

• Creado SA, Advani S. Sleep Disorders in the Athlete. Psychiatr Clin North Am. 2021 Sep;44(3):393-403. doi: 10.1016/j.psc.2021.04.010. Epub 2021 Jun 16. PMID: 34372996.
• Malhotra RK. Sleep, Recovery, and Performance in Sports. Neurol Clin. 2017 Aug;35(3):547-557. doi: 10.1016/j.ncl.2017.03.002. Epub 2017 May 30. PMID: 28673415. 
• Vitale KC, Owens R, Hopkins SR, Malhotra A. Sleep Hygiene for Optimizing Recovery in Athletes: Review and Recommendations. Int J Sports Med. 2019 Aug;40(8):535-543. doi: 10.1055/a-0905-3103. Epub 2019 Jul 9. PMID: 31288293; PMCID: PMC6988893. 

12.) Transition from Sport: Sports participation represents an important part of an athlete’s life; thus, transitions associated with athletics can represent significant life changes. Providing support for athletes’ mental and physical health, fitness, future career plans, and social relationships can ease this transition. 

• Coleman N, Roberts WO. Mental Health Aspects of Voluntary and Involuntary Sport Retirement. Curr Sports Med Rep. 2021 Dec 1;20(12):651-654. doi: 10.1249/JSR.0000000000000920. PMID: 34882122. 
• Esopenko C, Coury JR, Pieroth EM, Noble JM, Trofa DP, Bottiglieri TS. The Psychological Burden of Retirement from Sport. Curr Sports Med Rep. 2020 Oct;19(10):430-437. doi: 10.1249/JSR.0000000000000761. PMID: 33031209. 
• Giannone ZA, Haney CJ, Kealy D, Ogrodniczuk JS. Athletic identity and psychiatric symptoms following retirement from varsity sports. Int J Soc Psychiatry. 2017 Nov;63(7):598-601. doi: 10.1177/0020764017724184. Epub 2017 Aug 10. PMID: 28795636. 
• Moore HS, Walton SR, Eckenrod MR, Kossman MK. Biopsychosocial Experiences of Elite Athletes Retiring From Sport for Career-Ending Injuries: A Critically Appraised Topic. J Sport Rehabil. 2022 Aug 8:1-5. doi: 10.1123/jsr.2021-0434. Epub ahead of print. PMID: 35940582.