The role of the sports psychiatrist

Media coverage can be an additional mental health stressor for an athlete or team but can also raises awareness of important needs. This issue of Sports Psychiatry includes a review of media coverage of mental health issues during the recent, but delayed Tokyo Olympic Games [1]. As the authors indicate, many aspects of the media coverage were positive with athletes viewed as ‘human’ and relatable; perspectives that may allow for better consideration of their mental health needs and how these might be addressed.

This issue also contains another review highlighting the prevalence of mental health symptoms and disorders in sport (in this case football) [2] alongside a study of a population often neglected in research studies (the elite adolescent athlete) [3]. Both studies are confirmatory of previous findings of a substantial prevalence of mental health concerns. Yet there is still a risk that mental health concerns will be under-diagnosed or under-managed in a system with significant barriers to accessing expert mental health care and that fails to fully acknowledge the mental and physical connectedness of being human and of being an athlete [4].

In this context what then is the role of a sports psychiatrist? How can a psychiatrist benefit the individual athlete; support and work together with the athlete’s healthcare and performance team at an interdisciplinary and interprofessional level; and help to develop a mentally healthy culture in which athletes can thrive?

Sports psychiatry practice

Although well-being and illness are related concepts, they do not exist on a continuum [4]. Those who experience illness can also experience well-being whilst not all those who experienced a poor sense of well-being will do so because of an illness. Looking after athlete well-being is insufficient to address all mental health concerns and the distinction between well-being (or lack of) and health (or illness) is an important one to address when promoting sports psychiatry practises for those experiencing mental health symptoms and disorders. Clinical expertise in assessment and treatment of mental disorders will still be required even if there is good provision for well-being needs and early, expert treatments produce better outcomes across a range of mental health disorders [5, 6]. Moreover, prevention and aftercare are also integral parts of medical, including psychiatric practice. Both require appropriate clinical expertise and for the sports psychiatrist should be just as much a matter of course in care concepts as assessment and treatment.

The psychiatrist working in sport must be able to accurately formulate an athlete’s difficulties and address sport specific diagnostic issues such as in eating disorders and Relative Energy Deficiency in Sport (RED-S) or in relation to over-training and depression and competition anxiety and anxiety disorders. In addition, they must understand the complexities and concerns when prescribing psychotropic medication for an unusual group with unusual physiological demands and exercise/performance needs [7]. The psychiatrist working in sport is also required to adapt their practises for use in a sport setting [8]. Elements of this include the flexibility to work around the busy schedules of the elite performer without over responding to the occasional expectation of favourable treatment or even unrealistic demands. It is necessary to understand the specific situation in which an athlete finds him/herself, especially in the case of existing psychiatric complaints and illnesses. This includes specific personality traits as well as a possible sport-specific manifestation of mental illnesses. Good working relations with the athlete’s health and performance team are also key requirements. For all these reasons and more sports psychiatry emerges as a specialism and a valued resource for athletes, sports teams and sports organisations.

Mental health services for athletes

Whilst providing specialist mental health services at major events is important nonetheless evidence suggests that they are infrequently used with 8 consultations initiated by athletes and support staff during the Tokyo Olympic Games and 2 during the subsequent Paralympic Games [9]. There may be several reasons for this. There can be more immediate concerns such as musculoskeletal injury or sports performance at a major event and athletes and entourage members may be more willing to disclose their concerns to their own psychiatrist (if available) or other members of the healthcare team rather than to a stranger. Several national Olympic organisations already provide psychiatric services to their Olympic teams. Some of these were reviewed at the last symposium hosted by the International Society for Sports Psychiatry (ISSP) and are presented in this issue [10].

The characteristics of an effective mental healthcare service for athletes have been investigated and described [11]. Two central issues are the extent to which services should be sport specific and whether they are provided externally or integrated into the sports organisation or team [12]. Evidence suggests services are more likely to be utilised if they are available on-site, free and comprehensive. There are different tasks and a different focus for managing mental healthcare in the off season, mid-season and pre- and post-competition and it is preferable if services are provided year-round rather than just at a major event [11].

Describing the care pathway for an athlete with mental health symptoms is also important. Key points in the pathway begin with knowing how to access healthcare and facilitating this when necessary. Professionals should be clear about the roles and the responsibilities of all those involved in providing mental health support. Recently, the author proposed a concept for interprofessional collaboration between mental trainers and sports psychologists, as wells as sports psychiatrists and psychotherapists when mental health complaints and illnesses arise [13]. This includes understanding who is best placed to help with a performance concern and when to seek advice from a clinician, therapist or mental health expert such as a sports psychiatrist [12]. Return to play decisions during recovery from a mental health problem also need careful management and demand close collaboration between the sports psychiatrist, wider mental health team and the performance team including coaches [14]. Furthermore, appropriate return to play recommendations should be elaborated for all common mental illnesses in elite sports. In all cases the best interests of the athlete should be central to every decision and the athlete personally involved in decision-making at each stage. Considerable expertise, sound clinical judgement and an understanding of the stresses and pressures in the sports environment are all required when training and competition are reintroduced during recovery and where the skills and expertise of a sports psychiatrist may be invaluable. The aim is to create a virtuous spiral of increasing recovery and improved mental health as sports training and participation are reintroduced.

Mental health policy development

Finally, as recommended in this issue by Nahman and Tan [15], a sports psychiatrist can be at the forefront of research endeavours in the major issues facing elite sports and involved and contributing to new and better policies that safeguard the emotional welfare of sports participants.

Conclusion

Supporting mental well-being is a necessary but insufficient response to address concerns about athlete mental health. Athletes also need high quality mental health treatment and care such as provided by the sports psychiatrist with their specialist knowledge, skills and ways of working. Lastly, athletes deserve to work in an environment that is supportive of their mental health; that provides for them when they are ill and where there are no risks that their mental health will be harmed by sports participation [16]. The sports psychiatrist has a valuable contribution to make to the creation of this environment.