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Sunday, August 19, 2012

Olympics and Mental Health

With the London Summer Olympics under way, Medscape interviewed Dr. Ira Glick, Professor Emeritus of Psychiatry at the Stanford University School of Medicine, Stanford, California, and founder of the International Society for Sport Psychiatry, to discuss the potential mental health effects of athletics and athletic training regimens.

Medscape: Could you give an overview of what psychiatric illnesses, effects, and/or mental health issues might be of concern in young Olympic athletes? And which sports pose the biggest risks of athletes developing these kinds of problems?
Dr. Glick: In young athletes, the major problems are in the "thin" sports like gymnastics, running, and dancing, where you get eating disorders. The other big thing with Olympic athletes is the issue of overtraining and burnout. We've looked at this issue of athletes versus nonathletes, and although no one has studied this scientifically, the incidence of major psychiatric illness is either less than or equal to that of the general population. That's because most of the stuff we treat is genetic. We know NIMH [National Institute of Mental Health] studies have shown that there's a 15% incidence of mental illness in the general population. And you have to figure that that's going to be in athletes also. No one has ever systematically studied 100 gymnasts and seen what percentage have eating disorders; the best we can figure is that it's a low incidence.
Medscape: Even if there's not a big split in terms of incidence compared with the general population, what's unique about treating a high-level athlete for mental health issues?
Dr. Glick: There are 2 major issues. One is the gladiator mentality: There's narcissism; they believe nothing can go wrong; they don't need help; they can overcome it. And just for that alone, they don't want to go to therapy, either for psychotherapy or medication. The medication issue becomes a little more complicated because they're afraid that it's going to impair their performance. The other part of this is that there's a stigma to going to see psychologists or psychiatrists -- or even nonpsychiatrists, internists, or general practitioners. If they go for help, it's a sign of weakness. The stigma of mental illness becomes a very important issue.
Another issue is that when it's over, it's over. Their whole life is focused around this. And then suddenly they're left without it. Unless they've lived a balanced life and have other things going in their lives, it's very difficult for them to adjust to being a regular guy or gal.
Medscape: How might the stigma of mental illness in athletes be addressed? Does it need to start with the athletes or with the institutions that they are involved with?
Dr. Glick: The institutions that they're involved with are gradually -- but very, very slowly -- beginning to get mental health components into their programs. But the focus has been on performance enhancement. It's only been when there's a focus not only on performance enhancement, but solving problems of the sport, the stresses of a particular sport, and recognizing that athletes, like non-athletes, are subject to the same illnesses. Another thing that you can do is have athletes come out with their struggles. Actors and other famous people with mental and physical illnesses are coming out and saying that they've been treated. And that's helped. All of this has worked toward breaking down the stigma of working with athletes.

Contact vs Noncontact Sports

Medscape: We've talked mostly about noncontact sports. How do you compare the mental health ramifications of noncontact vs contact sports? Head injuries, for example, must present different issues versus excessive weight loss or overtraining.
Dr. Glick: Contact sports such as football or soccer have the additional burden of traumatic brain injuries, which cause both brain damage and subsequent psychiatric symptoms like depression, difficulty getting along, and difficulty thinking clearly. There's an association with early-onset dementia because there's real brain damage as well as personality effects. It's harder to cope with the normal stresses of life. In Olympic sports, there's obviously some contact in soccer and basketball. In addition, with these sports there are associated injuries that would show up 20-30 years later, such as traumatic arthritis and other residua of orthopedic injuries, which cause a lot of physical pain and emotional pain associated with depression and decreased function.
Medscape: Do you think that going through so many years of grueling physical activity makes athletes more prone to psychiatric side effects, such as trying to cope with long-term physical ailments that develop because of their careers?
Dr. Glick: Being less able to cope is a problem, also the fact that their orthopedic injuries are more severe. But in addition, they could also be working with a less functional brain, which is causing significant problems in socializing and in relationships. Now not everybody gets this. But it certainly increases the risk for having long-term problems.
Medscape: Can you elaborate on the mental health systems in place for young athletes? What improvements are needed to improve mental health outcomes in this population?
Dr. Glick: I think there's a lot of improvement needed. Everybody I've spoken to, the athletes and other sports psychiatrists, say that youth athletic programs are slowly bringing mental health into the picture. But it's a very slow process and it's very difficult to get psychiatrists and psychologists involved, especially psychiatrists. Psychologists seem more socially acceptable because they're there presumably not because there's something wrong with the athletes but because they're helping them to do better in their sport. And some of the pro leagues, like the NBA, have very extensive programs for helping athletes. They work with the rookies. They have people in their office that they bring in to talk to them about life, relationships, and working with coaches. But they're really the exception. So, it's slowly changing, but very slowly. And what we're advocating is much greater use of professionals in both youth and adult programs -- the same way it would be unheard of now to have a program without a trainer or an internist or a general or family physician.
Medscape: Olympic athletes can compete at as young as 15 years of age. Does the fact that such a person is still developing, yet competing at the elite Olympic level, change the management approach?
Dr. Glick: They have incredible physical attributes, but mentally they're just kids and their brains are just developing. Their personalities are developing. And again, nobody is following this. Nobody has done a long-term, follow-up study to know for sure the science of this. Obviously, the media speculates that there might be longer-term problems with them. You can argue that these are people with terrific personalities; they're able to use their personality to become good at a sport. Or you can say that there are terrific stresses here. And a lot of these kids are going to end up with long-term problems. All you read about are those who have done well. Once a year there's a story on a gymnast who's now in her twenties and is doing okay. But nobody knows the systematic follow-up of those who you don't hear about. So it's certainly a real concern.
Medscape: In high-profile settings such as the Olympics, what beneficial interventions might sports psychologists or psychiatrists offer?
Dr. Glick: It would be useful to have a psychiatrist there to at least do supportive, brief therapy as problems come up in the course of competition. In terms of the future, what's the future going to hold for these athletes? It would help them to have some counseling or psychotherapy available as part and parcel of the Olympic experience, rather than have it be seen as a sign of weakness.
Medscape: You mentioned how athletes looked at going to a psychiatrist or psychologist as a means of gaining a performance edge, as opposed to as a way to cope. How do you think we change that perception to one about learning how to deal with the internal challenges that athletes might be struggling with?
Dr. Glick: I think the media can help by pointing out that seeking mental health is an old stigma (if you went, there was something wrong with you) and that teams have adapted from that. Second, it can be emphasized that working with a psychologist might help athletic performance. But that's a relatively recent phenomenon. And again, there's very little science behind it. It's all pop psychology. There are techniques like imaging and straight psychotherapy, but it's hard to know whether they really increase performance. There's never been a controlled study of, say, taking 100 wrestlers and giving 50 of them the pop psychology intervention and 50 of them no intervention to see which group does better. That's what would be needed. There's no question that if you're sick, going to a doctor usually helps rather than harms; at the very least, it doesn't hurt you. We want to instill the same thing in athletes about mental health: Just as having a physician available to treat your cold or bronchitis or sprained knee is helpful, so, too, is having a psychiatrist available to help you deal with the stress of having to succeed.
Medscape: What are the biggest risks that athletes run in regard to long-term mental health? What are the most potentially damaging issues that athletes face once their playing days are over?
Dr. Glick: One thing is that not everybody succeeds -- almost everybody fails. I was reading this book called The Art of Fielding -- a great book. One of the concepts in it is that what separates those who are successful from those who are not is the ability to cope with failure. Almost everybody in the Olympics is going to fail, so the ability to cope is number one. Number two is having to cope with physical injuries. And number three is being out of the spotlight; you have to have developed the balance to go on to the next part of your life. That is really the biggest issue: staying balanced. Sports are a means to a happy, successful life, but they're not the end.

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