Evidence-Based Reviews

Sport psychiatry: How to keep athletes in the game of life, on or off the field

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Some athletes’ toughest opponents are depression, addictions, and eating disorders. Managing these patients’ mental illnesses is a new niche for psychiatry



Sport psychiatry—a relatively new subspecialty—emphasizes treating mental illness caused in athletes by a pre-existing disposition, stressors unique to sports, or use of anabolic steroids or other substances. Sport psychiatrists do not set out to enhance an athlete’s performance, although effective therapy may produce that outcome.

Athletes of all ages and levels, from Little League to the Olympics, are vulnerable to psychiatric disorders. Using real-life examples, let’s look at the practice of sport psychiatry and examine common psychopathologies in athletes.

Psychiatry in the gym

Psychiatric illness in an amateur or professional athlete may arise from coincidence, a predisposing pathology that first attracted the athlete to the arena, or a psychopathology caused by the sport itself. Some athletes succumb to suicide (Box 1),1 although insufficient data exist to establish the prevalence.

Educating athletes, their families, coaches, and trainers about mental illness is key to identifying at-risk athletes and referring them for treatment. To that end, think of sports and psychiatry in a consultation-liaison model.2 A psychiatrist working alongside an orthopedist at the gym would help remove the stigma of psychiatric illness in sports and allow for timely diagnosis and treatment.

Box 1


An article in Sports Illustrated describes a history consistent with attention-deficit/hyperactivity disorder in a young man named “Kenny,” who played high school football and ultimately took his own life. In the sportswriter’s words:

“…to be in sports, to be active—that was always what motivated him, diverted him from the less active pleasures of life. His grades were invariably better during the football season. The only time he really floundered was after he finished school, and there was no more football to point to in the fall.”1

Special stressors of athletes

Stressors unique to athletes that may cause, trigger, or worsen psychopathology include pressure to win, constant risk of injury, and the specter of sudden retirement at an early age.

Pressure to win. Parents and coaches pursuing vicarious aspirations may push a child athlete to physical and emotional extremes, a dynamic that Tofler calls “achievement by proxy.”3 These adults may send children away from home for training or remove them from school in the hope that they will excel at a sport. Intense training may preclude normal childhood friendships and pursuits and may become frankly abusive.4

Gymnast Christy Henrich competed in one World Cup gymnastics meet with a broken foot and ultimately died of complications of anorexia nervosa. During the girl’s training, her mother was quoted as saying, “A gymnast without a high pain threshold is a gymnast without a career. Their body is a machine, and they are a person. The two are separate.”5

Injuries can threaten the athlete’s career and are a major cause of stress. Olympic diver Greg Louganis was devastated by knee injuries that ended his gymnastics career at a young age, before he switched to diving.6

Retirement. Even in the absence of injuries, most athletic careers are relatively short because of their physical demands. Professional athletes may be so focused on their sports careers that they are ill-equipped to face life without athletic competition. Retirement, with its abrupt change in emotional support and finances, can be overwhelming.

Golden Gloves boxer Gerry Cooney recalls a difficult descent into retirement, complicated by alcohol. He received treatment and now runs an organization designed to help other boxers through the transition to a life without sports.

Affective disorders in athletes

Unipolar and bipolar affective disorders occur in athletes, as in any population. Sometimes athletes with depression find temporary relief in athletic involvement—in some cases for substantial periods.

Depression. U.S. Olympic diver Wendy Williams describes years of denying and coping with depression. Eventually, however, her affective symptoms required psychiatric intervention. Refusing medication, she first tried psychotherapy alone. Several years later, after a worsening of symptoms and several episodes of suicidal ideation, Williams relented to drug therapy to good effect.7

Bipolar disorder. Bipolar mania can cause the same behavioral disturbances in athletes as in anyone else. Stressors in professional athletes’ lives can trigger a manic episode, however, and the public may witness the episode’s manifestations. When this occurs, the athlete’s mental illness is generally misunderstood by the public and misrepresented in the media.

In discussing the use of psychological screens for prospective National Football League players, for example, a sportswriter explained the rationale as going for “…the right mix of on-field aggression and off-field character. No team wants to draft the next Dimitrius Underwood.”8

Underwood, who reportedly has bipolar disorder, slashed his throat under the pressure of being a first-round draft pick while a member of the Miami Dolphins. He survived and went on to play 19 NFL games before being released this season by the Dallas Cowboys.9

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