Combining pharmacotherapy with psychotherapeutic management for the treatment of psychiatric disorders among athletes
Abstract
Abstract:Introduction: Previous literature has highlighted athletes as a population that is particularly vulnerable to a range of psychiatric symptoms and disorders. Although psychotherapy and pharmacological interventions have been demonstrated as clinically effective for athletes in isolation, the potential for a combination of such approaches (integrative treatment) as superior to either modality is of increasing interest and importance. Specifically, the athlete population may benefit from an integrative approach since it faces unique factors and implications for treatment, including but not limited to doping regulations, performance modulation secondary to psychiatric medication, and particular barriers to adherence (e.g., personality factors, athlete-specific schedules, stigma). Methods: To retrieve relevant articles for our review, we searched five electronic databases (PubMed (MEDLINE), SportDiscus via EBSCO, PSycINFO viaProQuest, Scopus and Cochrane). Athletes were defined as those competing at professional, Olympic, or collegiate/university levels. Results: We seek to highlight clinically relevant factors, conceptual models, rationales and examples of an integrative approach so as to set the stage for future literature aiming to investigate such a topic on both theoretical and experimental levels. Conclusion: Ultimately, our review seeks to provide a rationale for systematically assessing factors for and against combination therapy for each athlete, a risk benefit analysis aimed at providing a clinically effective and parsimonious intervention strategy, which may include the use of one or multiple intervention modalities. Such a strategy will ideally facilitate positive outcomes for athletes’ personal functioning which may consequently maintain or augment their athletic performance, initiating a positive feedback loop of optimal functioning.
Introduction
There is rising evidence that high-performance athletes are among groups who are at a heightened vulnerability for the experience of subclinical mental health symptoms as well as psychiatric disorders compared to the general population. Gulliver et al. identified at least one symptom consistent with psychological distress, panic disorder, general anxiety, social anxiety, or an eating disorder in their athlete sample [1]. The work by Glick et al. [3] identified a 60% prevalence rate of eating disorders in female athletes required to maintain specialized physiques for the sake of athletic performance. Heightened risk for a range of pathology persists, including increased likelihood for 1) death by suicide in the retired elite male athlete population compared to the general male population, problematic gambling behaviors, and binge-drinking in college athlete populations compared to the non-athlete college population [2, 3, 4, 5]. The aforementioned correlates are arguably augmented in the cases of injured, recovering athletes who have been discovered to experience higher rates of anxiety, depression, and low self-esteem compared to their healthy counterparts [6]. We believe these findings to be particularly concerning for elite athletes as the consequences of clinical symptomatology can include reduced athletic performances that then further exacerbate the clinical syndrome(s) they experience. Essentially, the experience of any one clinical mental health symptom or psychiatric disorder can initiate a positive feedback loop or bidirectional relationship between poor athletic performance and psychiatric symptomatology in such individuals.
This paper will focus on combining medication with psychotherapeutic intervention for the management of these problems and disorders.
With the heightened risk for impacted mental health established, best-practice intervention strategies become relevant, the menu of options include psychotherapy, pharmacological intervention, or both (combined therapy). Although the efficacy of psychotherapeutic interventions (individual, family/couples, group) are well-documented [7, 8], the generalizability of these findings to our niche population of interest demands caution. There is little and mostly anecdotal literature that provides a stable evidence base for guiding psychotherapeutic intervention for elite athletes [9, 10], but there is some work that postulates the population responds quite well to cognitive-behavioral strategies [11]. Separately, with regard to athletes, pharmacological treatments can be effective, at times, but require due diligence regarding their side effects, among other issues [12, 13]. In light of the aforementioned literature, there appear to be implications for treatment that are unique to the athlete population. Further, the implications for using psychotherapy or pharmacotherapy alone could reasonably be addressed by combining these modalities (e.g., stabilizing psychotic symptoms via medication in order to increase effectiveness of a psychotherapeutic intervention) and we find that conducting a review of literature that may set the stage for future theoretical or experimental clinical research may be considered useful. Ultimately, in light of the existing literature pertaining to psychological vulnerability, intervention, and well-being of elite athletes, we aim to provide a review of the literature to establish that although psychotherapy and pharmacological intervention methods can be effective in isolation, there is much benefit to being attune to the circumstances and potential for positive treatment outcomes that are possible via integrative treatment approach, combination therapy.
Methods
For this review, we searched five electronic databases (PubMed (MEDLINE), SportDiscus via EBSCO, PSycINFO viaProQuest, Scopus and Cochrane) from inception to July 2023. Search terms relating to mental health disorders, sports participation, pharmacotherapy, psychotherapy, and combination therapy were combined. To retrieve relevant articles, inclusion criteria were: (1) the study population consists exclusively of current or former athletes and (2) the article is written in English. To avoid missing any relevant publications, references of the included studies were screened. Other literature was also reviewed, including that related to combination pharmacotherapy – psychotherapy with general populations or with non-athletes, where there were gaps in athlete-specific literature. Athletes were defined as those competing at professional, Olympic, or collegiate/university levels.
Treatment: Medication
Generally speaking, medication as a sole mode of intervention for a psychiatric condition can be effective in the reduction of some symptomatology but is largely considered inferior to combined approaches due to documented treatment outcomes that are otherwise superior [12]. Nonetheless, a moderate amount of literature regarding the use of medication in athlete populations exist, although the quality and applicability of findings vary [14]. A comprehensive review of potential impacts on athletic performance secondary to psychiatric medication conducted by Reardon and Factor highlights the variability of side effects of such drugs, as well as those side effects that are particularly unfavorable to a population that is incentivized to maintain peak performance. For example, antidepressants like paroxetine and fluoxetine have been demonstrated to have no impact on athletic performance (positive or negative) but bupropion has been shown to potentially extend one’s performance in heat due to impacts on the athlete’s perception of their effort, although such findings are not consistent across such studies [15, 16, 17]. Further, in cases which medication seems to have impacted performance, the mechanisms by which performance may be enhanced by certain antidepressants have varied but are largely attributed to the dopaminergic effects of such drugs [17, 18]. Relevant literature has also investigated the interaction between mood stabilizers, like lithium and valproic acid, and athletic performance. Findings include recommendations to avoid discontinuing lithium dosing prior to physical exertion (when it is consistently used) as well as concerns pertaining to weight gain, tremors, and dehydration [19, 20]. In light of this information, we aim to emphasize that in the athlete population there is a) preferential use of particular psychiatric medications favoring those that are least likely to affect athletic performance and b) avoidance of certain classes of drugs in order to avoid violation of doping standards in high-level sports. Literature demonstrating such includes a reported 63% preference for the antidepressant fluoxetine compared to other such drugs by sports psychiatrists due to lack of weight gain as a side effect [19]; 58% of sports psychiatrists preferring valproic acid for mood stabilization due to lack of weight gain, tremors, sedation, and dehydration as potential side effects; discovery of reduced muscle strength following beta-blockers used as anxiolytics [21]; avoidance of sedative hypnotics despite their efficacy in the treatment of sleep and anxiety disorders due to their potential impact on physiological output [22].
While the negative side effects of pharmacological interventions are of concern, the potential performance-enhancing properties of other such drugs can put athletes in a position to violate anti-doping policies. Beta-blockers contain properties that can enhance fine motor control and elevate one’s aim in certain activities, which led to a ban of the drug class in Olympic sports [19]. Stimulants are generally used with caution, especially with regard to athletes treated for ADHD since such drugs are consistently shown to augment strength, extend capacity for exhaustion, and permit higher heart rates [23, 24]. We would like to affirm that although pharmacological approaches to psychiatric intervention are generally effective alone, their secondary effects that can modulate athletic performance are of particular concern to the elite athlete population.
Treatment: Psychotherapy
Although some athletes and clinicians defer to pharmacological approaches in isolation, there is consistent evidence that such an approach may be insufficient to reduce problematic psychiatric symptoms and disorders to normative levels [12]. Worthy of note, athlete preference for non-psychotherapeutic intervention can, at times, be attributed to stigma associated with mental health treatment. Thus, we recommend two core strategies when proposing psychotherapy as a treatment modality to such populations: 1) display a readiness to address athlete-specific issues and normalize this modality as standard and effective treatment to relevant parties (i.e., family, friends, coaches, teammates) and 2) reframe psychotherapy as “performance help” aimed at the reduction of performance-inhibiting symptomatology [25]. The rationale for use of psychotherapy as a mode of intervention is not simply the inconsistency and issues that may arise from pharmacological interventions, rather, implementation of such ensures best, evidence-based practices as well as a mechanism for facilitating adherence to medication regimens that would be otherwise impacted by psychiatric symptoms that interfere with such regimens (e.g., low motivation, depressive symptoms) [26, 27]. When psychotherapeutic strategies are selected, three modes are available to the clinician: individual, family/couples, and group psychotherapy. Since we are more interested in the complicating factors that may arise during the course of psychotherapy, we will not provide an overview for each mode here but refer those interested to Glick et al. [31] for more detailed overview.
Complicating factors to psychotherapy
Although the nuances of the therapeutic process are beyond the focus of this paper, we believe it is still valuable to briefly discuss complicating factors that may arise during the psychotherapeutic course that are unique to elite athletes. Such challenges may include diagnostic ambiguity, barriers to help-seeking behaviors, altered expectations about services, and personality factors.
Diagnostic ambiguity may arise due to a less-than-optimal heterogeneity between psychiatric conditions and normative athlete behavior. More clearly, internalizing or externalizing symptoms that would be considered otherwise pathological can, in fact, be at least somewhat normal in elite athletes. For example, over-training syndrome (OT) and depression share diagnostic criteria (i.e., fatigue, decreased cognitive efficiency, significant weight change, decreased appetite, low motivation) [28]. Ritualistic behaviors performed by athletes can also be considered to be differentiated from the repetitive behaviors involved in obsessive-compulsive disorder due their restrictions to particular settings (e.g., the locker room, playing field) and lack of impact on life functioning [14, 29]. Transdiagnostic clinical interventions that apply the same underlying treatment principles across mental disorders, without tailoring the protocol to specific diagnoses may better address the heterogeneity and comorbidity that is often found among this population [30].
Clinical work involving the treatment of high-performance athletes must acknowledge barriers to their help-seeking behaviors. Stigma associated with seeking mental health treatment for this population can include narratives of weakness, untrustworthiness, or being crazy [3, 31]. Unsurprisingly, behaviors that enhance athletic performance are highly problematic as they may reduce the likelihood that the athlete both recognizes the faulty behavior as well as their investment in the remediation of such behavior thereafter (e.g., anorexia nervosa or bulimia nervosa facilitating weight loss, use of anabolic steroids facilitating muscle growth and augmented performance) [4, 28].
Elite athletes are often accustomed to “special treatment” that can carry over to the therapeutic relationship. Concerns stemming from their altered expectations may include navigating communications between athlete’s assistants regarding treatment, demands of flexibility regarding meeting times and location, and payment of services [3, 30, 32]. Finally, personality factors of narcissism and aggression are demonstrated to be rather consistent traits of elite athletes [25]. Such traits may result in a reduced acknowledgement for the need to receive mental health services or even alter expectations regarding course of treatment – timeline of results, for example [3]. These expectations can negatively impact their investment in psychotherapy and, in some cases, result in the development of grandiosity, reduced empathy, and a more easily engaged anger response [13, 25].
Combination therapy
Thus far, we have reviewed the literature discussing the clinical picture for the implementation of pharmacological and psychotherapeutic interventions for high-performance athletes. We also provided variables crucial to understanding the nuances of these modalities in reference to the general population, but also those unique to our population of interest. To this point we have approached pharmacological and psychotherapeutic intervention as nearly dichotomous modalities, but we now seek to elucidate combination therapy, which, often times, is demonstrated or is least suggested as best practice, even among elite athletes.
Despite the treatment efficacy of combination therapy, a myriad of factors may limit the degree to which it is implemented into regular practice for the athlete population some of which include concerns of stigma, not being allowed to play, negative past experiences with mental health services, time restrictions due to practice, games, and travel, as well as hypermasculinity [33, 34, 35, 36]. Conversely, caution for utilizing pharmacological approaches in unison with psychotherapy is vital due to concerns of violating antidoping regulations and medication side effects that inhibit aspects of athletic performance [13].
Despite the aforementioned limiting factors for the dogmatic use of combination therapy, we align with Glick et al.’s [31] recommendation for integrative treatment that prescribes whatever pharmacological and psychotherapeutic interventions are necessary and making adjustments as needed via risk-benefit assessment [30]. Such an integrative approach will include systematic, coordinated care between a team of physicians, trainers, mental health providers, and other relevant team members who represent competency in the range of domains associated with the athlete’s mental health, physical health, and athletic performance.
Combination therapy: The rationale
Overall, the rationale for advocating for combination therapy as a premier intervention strategy includes literature demonstrating combined approaches as more often than not superior to any one treatment modality when used alone as well as the potential for medication or psychotherapy alone being not only insufficient but even counterproductive to treatment goals [12, 26, 27, 30]. Combined approaches acknowledge the utility of psychotherapy for improving adherence to medication regimens, the etiology for disrupted mental health characterized by life or performance-related stressors, and the utility of pharmacological interventions in the management of psychiatric symptoms that would otherwise impede the effectiveness of psychotherapy (e.g., psychotic symptoms). Although randomized control trials for combined therapy in elite athletes have yet to be conducted, Nathan and Gorman (2015) thoroughly examined evidence to conclude that combination therapy is not only recommended but dictates evidence-based practice for the treatment of at least schizophrenia, bipolar disorder, bulimia, depression, ADHD, sleep disorders, and very likely PTSD [37, 38].
Combination therapy: Conceptual models
Conceptually speaking, three outcomes exist when combined therapy is implemented: positive effects, negative effects, and no effect. When no effect is yielded after implementation, it does not necessarily mean that the monotherapies are entirely ineffective in isolation, rather, there was no benefit gained from combined treatment. Conversely, negative effects encapsulate the unfavorable outcome in which treatment results in an increase in symptom severity or relapse. Ideally, a positive outcome is produced via combined therapy which can be achieved via one of three mechanisms: additive, facilitative, or synergistic. When the positive effect is additive, the individual contributions of pharmacotherapy and psychotherapy are summed, highlighting the effectiveness of each modality individually. Facilitative effects include one modality as more effective than the other, but the inclusion of the less effective modality enhances the effectiveness of the dominant one, yielding a net positive outcome. Essentially, one modality “elicits” more positive potential from the other. For example, earlier, we mentioned the utility of medication in controlling more severe psychiatric symptoms which would render psychotherapy to be more effective, clinically speaking, than it would be otherwise (e.g., psychotic disorders) [37]. Finally, synergistic positive outcomes occur when the combined efficacy of psychotherapy and pharmacotherapy is beyond what could have been yielded from their additive capacities. That is, combination therapy results in a positive outcome that surpasses the summed gains of each modality. Synergistic models underscore that mental health conditions are not only psychological but also require consideration of pathophysiology [39].
Combination therapy: Application
With reference to the elite athlete population, these conceptual models for combined therapy serve as a guide for recommendations that are already made in preceding literature. Such emphasizes that determining cases in which combination therapy would be appropriate is not formulaic, but, instead, a deliberate and thorough assessment by the mental health professional and/or integrative team must be made to identify what is most effective for the patient with an aim to maximize parsimony of intervention. To reiterate, if one modality yields desired results then the implementation of an additional modality is not warranted [37].
Consensus on what constitutes successful and effective treatment includes the clinician’s conceptualization of the disorder, assessment of the utility of each component of employed intervention(s), as well as the patient’s conceptualization of the source of their psychiatric symptoms – as echoed by Glick at al.’s (2020) aforementioned guideline for integrative treatment: a risk-benefit analysis, especially in psychiatric treatment of elite athletes [37, 40].
In light of the information presented in our review thus far, we refer to examples in which an integrative approach to psychiatric intervention may be relevant when working with high-performance athletes. Such illustrations may involve 1) psychological symptoms secondary to injury, surgery, and/or rehabilitation; 2) persistent concussive symptoms that may endure physiologically longer than expected; 3) mental health screenings in both the preseason and early season; 4) symptoms consistent with eating disorder or relative energy deficiency in sport (RED-S); 5) psychiatric emergencies and severe injuries [41, 42, 43, 44, 45]. Please see Glick et al. [31] for expanded detail and application regarding these situations benefitting from an integrative approach.
Conclusion
Elite athletes are not immune to mental health issues, in fact, some literature would lead us to consider them a vulnerable population [2, 3, 4, 5]. Such individuals are exposed to particularly unique circumstances that may exacerbate existing psychiatric symptomatology or even initiate onset of symptoms or disorder. We reviewed the utility of pharmacological and nonpharmacological therapies as well as instances in which their effectiveness may be limited. In the athlete population, special considerations of these therapy modalities arise: medication side effects impacting athletic performance, violation of antidoping regulations, diagnostic ambiguity, barriers to help-seeking behaviors, altered expectations about services, and personality factors. Combination therapy may function via a range of mechanisms when positive outcomes are attained (i.e., additive, facilitative, synergistic). We advise against utilizing combined modalities ubiquitously but do emphasize that such an intervention strategy has been shown as not only efficacious but also uniquely aids athletes (among other populations) to 1) improve adherence to medication regimens, 2) acknowledge etiology for disrupted mental health secondary to life or performance-related stressors, and 3) utilize pharmacological interventions to augment opportunity for favorable outcomes via psychotherapy. We recommended the use of a risk-benefit analysis when assessing the viability of a combined approach in the treatment of the athlete population [30]. When benefit is assessed to be yielded by the use of combination therapy, we advocate for the use of the Quality Treatment Equation that is achieved by a four-headed intervention strategy (Figure 1): medication, family intervention, individual intervention, and consumer group support [37].
The literature pertaining to the best, evidence-based practices for psychiatric intervention in the elite athlete population is growing but, admittedly, scarce with regard to evidence of controlled clinical trials that dictate treatment intervention [46]. We hope that the collection of such future literature may guide the development of models and/or guidelines for psychiatric interventions across symptoms patterns and diagnoses in order to ascertain the mental health of elite athletes that are inextricably linked to not only their athletic performance but also personal functioning.
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