Sports Medicine

, Volume 40, Issue 11, pp 961–980 | Cite as

Sport Psychiatry

A Systematic Review of Diagnosis and Medical Treatment of Mental Illness in Athletes
  • Claudia L. ReardonEmail author
  • Robert M. Factor
Review Article


Sport psychiatry focuses on diagnosis and treatment of psychiatric illness in athletes in addition to utilization of psychological approaches to enhance performance. As this field and its research base are relatively new, clinicians often deliver psychiatric care to athletes without a full understanding of the diagnostic and therapeutic issues unique to this population. In this systematic review, we discuss published findings relating to psychiatric diagnosis and medical treatment of mental illness in athletes.

There have been several studies looking at the prevalence of some psychiatric disorders in various athlete populations. Eating disorders and substance abuse are the most studied of these disorders and appear to be common problems in athletes. However, to provide informed understanding and treatment, we especially need more research on overtraining syndrome, bipolar disorder, suicidality, anxiety disorders, attention-deficit hyperactivity disorder (ADHD) and psychosis in athletes. Research is needed in the areas of prevalence, risk factors, prognosis and the unique experiences facing athletes with any of these disorders.

Additionally, there have not been any large, systematic studies on the use of psychotropic medications in athletes. Small studies suggest that some medications may either be performance enhancing or detrimental to performance, but we need larger studies with rigorous methodology. Higher level athletes suffering from psychiatric symptoms often have reservations about taking medications with unknown performance and safety effects, and methodological issues with the current literature database preclude any definitive conclusions on performance effects of psychiatric medications. We need many more, higher quality studies on the use by athletes of antidepressants, mood stabilizers, anxiolytics, stimulants and other ADHD medications, sedative-hypnotics and antipsychotics. Such studies should utilize sensitive performance measures and involve longer term use of psychotropic medications. Furthermore, study subjects should include athletes who actually have the psychiatric disorder for which the medication is proposed, and should include more women.


Melatonin Major Depressive Disorder Eating Disorder Bupropion Bulimia Nervosa 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



The authors report no funding for the preparation of this review and no relevant conflicts of interest. Both authors made substantial contributions to this work and meet criteria for authorship. We thank the anonymous reviewers of this manuscript for their very helpful suggestions.


  1. 1.
    Begel D. Family systems-based treatment of the athlete family. In: Begel D, Burton RW, editors. Sport psychiatry. New York (NY): WW Norton & Company, Inc., 2000: 206–28Google Scholar
  2. 2.
    Glick ID, Kamm R, Morse E. The evolution of sport psychiatry, circa 2009. Sports Med 2009; 39 (8): 607–13PubMedGoogle Scholar
  3. 3.
    Hellstedt J. Invisible players: a family systems model. Clin Sports Med 2005; 24 (4): 899–928PubMedGoogle Scholar
  4. 4.
    McDuff DR, Morse ED, White RK. Professional and collegiate team assistance programs: services and utilizationpatterns. Clin Sports Med 2005; 24 (4): 943–58PubMedGoogle Scholar
  5. 5.
    Kamm RL. The sport psychiatry examination. In: Begel D, Burton RW, editors. Sport psychiatry. New York (NY): WW Norton & Company, Inc., 2000: 159–90Google Scholar
  6. 6.
    Glick ID, Horsfall JL. Diagnosis and psychiatric treatment of athletes. Clin Sports Med 2005; 24 (4): 771–81PubMedGoogle Scholar
  7. 7.
    Baum AL. Sport psychiatry: how to keep athletes in the game of life, on or off the field. Curr Psychiatry 2003; 2 (1): 51–6Google Scholar
  8. 8.
    Baum AL. Psychopharmacology in athletes. In: Begel D, Burton RW, editors. Sport psychiatry. New York (NY): WW Norton & Company, Inc., 2000: 249–59Google Scholar
  9. 9.
    Burton RW. Mental illness in athletes. In: Begel D, Burton RW, editors. Sport psychiatry. New York (NY): WWNorton & Company, Inc., 2000: 61–81Google Scholar
  10. 10.
    Oler MJ, Mainous AG, Martin CA, et al. Depression, suicidal ideation, and substance use among adolescents: areathletes at less risk? Arch Fam Med 1994; 3: 781–3PubMedGoogle Scholar
  11. 11.
    Yang J, Peek-Asa C, Corlette JD, et al. Prevalence of and risk factors associated with symptoms of depression incompetitive collegiate student athletes. Clin J Sport Med 2007; 17 (6): 481–7PubMedGoogle Scholar
  12. 12.
    Puffer JC, McShane JM. Depression and chronic fatigue in the college student-athlete. Prim Care 1991; 18 (2): 297–308PubMedGoogle Scholar
  13. 13.
    Donohue B, Covassin T, Lancer K. Examination of psychiatric symptoms in student athletes. J Gen Psychol 2004; 131: 29–36PubMedGoogle Scholar
  14. 14.
    Rosen LW, Smokler C, Carrier D, et al. Seasonal mood disturbances in collegiate hockey players. J Athl Train 1996; 31 (3): 225–8PubMedGoogle Scholar
  15. 15.
    Kasper S, Rogers SLB, Yancey A, et al. Phototherapy in individuals with and without subsyndromal seasonal affectivedisorder. Arch Gen Psychiatry 1989; 46: 837–44PubMedGoogle Scholar
  16. 16.
    Macleod AD. Sport psychiatry. Aust N Z J Psychiatry 1998; 32: 860–6PubMedGoogle Scholar
  17. 17.
    Armstrong LE, VanHeest JL. The unknown mechanism of the overtraining syndrome: clues from depression andpsychoneuroimmunology. Sports Med 2002; 32: 185–209PubMedGoogle Scholar
  18. 18.
    Morgan WP, Brown DR, Raglin JS, et al. Psychological monitoring of overtraining and staleness. Br J Sports Med 1987; 21 (3): 107–14PubMedGoogle Scholar
  19. 19.
    Schwenk TL. The stigmatization and denial of mental illness in athletes. Br J Sports Med 2000; 34 (1): 4–5PubMedGoogle Scholar
  20. 20.
    McCann S. Overtraining and burnout. In: Murphy SM, editor. Sport psychology interventions. Champaign (IL): Human Kinetics, 1995: 347–65Google Scholar
  21. 21.
    Callister R, Callister RK, Fleck SJ, et al. Physiological and performance responses to overtraining in elite judo athletes. Med Sci Sports Exerc 1989; 22: 816–24Google Scholar
  22. 22.
    Costill DL, Flynn MG, Kirwin JP, et al. Effects of repeated days of intensified training on muscle glycogen andswimming performance. Med Sci Sports Exerc 1998; 20: 249–54Google Scholar
  23. 23.
    Hackney AC, Pearman SN, Nowacki JM. Physiological profiles of overtrained and stale athletes: a review. Appl Sport Psychol 1990; 2: 21–33Google Scholar
  24. 24.
    Parham WD. The intercollegiate athlete: a 1990s profile. Couns Psychol 1993; 21: 411–29Google Scholar
  25. 25.
    Backmand H, Kaprio J, Kujala U, et al. Influence of physical activity on depression and anxiety of former eliteathletes. Int J Sports Med 2003; 24: 609–16PubMedGoogle Scholar
  26. 26.
    Schwenk TL, Gorenflo DW, Dopp RR, et al. Depression and pain in retired professional football players. Med Sci Sports Exerc 2007; 39 (4): 599–605PubMedGoogle Scholar
  27. 27.
    Baum AL. Suicide in athletes: a review and commentary. Clin Sports Med 2005; 24 (4): 853–69PubMedGoogle Scholar
  28. 28.
    Smith AM, Milliner EK. Injured athletes and the risk of suicide. J Athl Train 1987; 29: 337–41Google Scholar
  29. 29.
    Smith AM, Scott SG, Wiese DM. The psychological effects of sports injuries: coping. Sports Med 1990; 9: 353–69Google Scholar
  30. 30.
    Begel D. The psychopathology of everyday athletic life. In: Begel D, Burton RW, editors. Sport psychiatry. New York (NY): WW Norton & Company, Inc., 2000: 82–92Google Scholar
  31. 31.
    Kamm RL. Interviewing principles for the psychiatrically aware sports medicine physician. Clin Sports Med 2005; 24 (4): 745–69PubMedGoogle Scholar
  32. 32.
    Northon PJ, Burns JA, Hope DA. Generalization of social anxiety to sporting and athletic situations: gender, sportsinvolvement, and parental pressure. Depress Anxiety 2000; 12: 193–202Google Scholar
  33. 33.
    Glasser W. Positive addiction. New York (NY): Harper and Row, 1976Google Scholar
  34. 34.
    Sachs ML, Pargman D. Running addiction: a depth interview examination. J Sport Behav 1979; 2: 143–55Google Scholar
  35. 35.
    Yates A, Leehey K, Shisslak CM. Running: an analogue of anorexia? N Engl J Med 1983; 308 (5): 251–5PubMedGoogle Scholar
  36. 36.
    Pope H, Gruber A, Choi P, et al. Muscle dysmorphia: an underrecognized form of body dysmorphic disorder. Psychosomatics 1997; 38: 548–57PubMedGoogle Scholar
  37. 37.
    Calhoun JW, Ogilvie BC, Hendrickson TP, et al. The psychiatric consultant in professional team sports. Child Adolesc Psychiatr Clin N Am 1998; 7 (4): 791–802PubMedGoogle Scholar
  38. 38.
    Rosen LW, McKeag DB, Hough DO, et al. Pathogenic weight-control behavior in female athletes. Phys Sportsmed 1986; 14 (1): 79–86Google Scholar
  39. 39.
    Burckes-Miller ME, Black DR. Behaviors and attitudes associated with eating disorders: perceptions of collegeathletes about food and weight. Health Educ Res 1988; 3: 203–8Google Scholar
  40. 40.
    Byrne S, McLean N. Elite athletes: effects of the pressure to be thin. J Sci Med Sport 2002; 5: 80–94PubMedGoogle Scholar
  41. 41.
    Torstveit MK, Rosenvinge JH, Sundgot-Borgen J. Prevalence of eating disorders and the predictive power ofrisk models in female elite athletes: a controlled study. Scand J Med Sci Sports 2008; 18: 108–18PubMedGoogle Scholar
  42. 42.
    Sundgot-Borgen J, Torstveit MK. Prevalence of eating disorders in elite athletes is higher than in the generalpopulation. Clin J Sport Med 2004; 14: 25–32PubMedGoogle Scholar
  43. 43.
    Thiel A, Gottfried H, Hesse FW. Subclinical eating disorders in male athletes: a study of the low weight categoryin rowers and wrestlers. Acta Psychiat Scand 1993; 88: 259–65PubMedGoogle Scholar
  44. 44.
    Glazer JL. Eating disorders among male athletes. Curr Sports Med Rep 2008; 7 (6): 332–7PubMedGoogle Scholar
  45. 45.
    Swoop RA, Murphy SM. Eating disorders and weight management in athletes. In: Murphy SM, editor. Sport psychology interventions. Champaign (IL): Human Kinetics, 1995: 307–26Google Scholar
  46. 46.
    Johnson LD, O’Malley PM, Bachman JG, et al. Monitoring the future national survey on drug use, 1975–2003, Vol. II. College students and adults ages 19-25. NIH publication no. 04-5508. Bethesda (MD): National Instituteon Drug Abuse, 2004Google Scholar
  47. 47.
    Green GA, Uryasz FD, Petr TA, et al. NCAA study of substance abuse habits of college student-athletes. Clin JSport Med 2001; 11 (1): 51–6Google Scholar
  48. 48.
    O’Brien CP. Alcohol and sport: impact of social drinking on recreational and competitive sports performance. Sports Med 1993; 15: 71–7PubMedGoogle Scholar
  49. 49.
    Miller BE, Miller MN, Verhegge R, et al. Alcohol misuse among college athletes: self-medication for psychiatric symptoms? J Drug Education 2002; 32 (1): 41–52Google Scholar
  50. 50.
    McDuff DR, Baron D. Substance use in athletics: a sports psychiatry perspective. Clin Sports Med 2005; 24: 885–97PubMedGoogle Scholar
  51. 51.
    Su TP, Pagliaro M, Schmidt PJ, et al. Neuropsychiatric effects of anabolic steroids in male normal volunteers. JAMA 1993; 269: 2760–4PubMedGoogle Scholar
  52. 52.
    Moss HB, Panzak GL. Steroid use and aggression [letter]. Am J Psychiatry 1992; 149: 1616PubMedGoogle Scholar
  53. 53.
    Pope HG, Katz DL. Psychiatric and medical effects of anabolic-androgenic steroid use: a controlled study of 160athletes. Arch Gen Psychiatry 1994; 51: 375–82PubMedGoogle Scholar
  54. 54.
    Kerber CS. Problem and pathological gambling among college athletes. Ann Clin Psychiatry 2005; 17 (4): 243–7PubMedGoogle Scholar
  55. 55.
    Lesieur HR, Rosenthal RJ. Pathological gambling: a review of the literature (prepared for the American Psychiatric Association Task Force on DSM-IV. Committeeon Disorders of Impulse Control Not Elsewhere Classified). J Gambling Stud 1991; 7: 5–39Google Scholar
  56. 56.
    Miller TW, Adams JM, Kraus RF, et al. Gambling as an addictive disorder among athletes: clinical issues in sportsmedicine. Sports Med 2001; 31 (3): 145–52PubMedGoogle Scholar
  57. 57.
    Cantu RC. Prevention of athletic injuries: the role of the sports medicine team. In: Mueller FO, Ryan AJ, editors. Head and neck injuries. Philadelphia (PA): FA Davis, 1991: 201–13Google Scholar
  58. 58.
    Broshek DK, Barth JT. Neuropsychological assessment of the amateur athletes. In: Bailes J, Day A, editors. Neurological sports medicine: a guide for physicians andathletic trainers. Rolling Meadows (IL): The AmericanAssociation of Neurological Surgeons, 2001: 155–68Google Scholar
  59. 59.
    Freeman JR, Barth JT, Broshek DK. Sports injuries. In: Silver JM, McAllister TW, Yudofsky SC, editors. Textbookof traumatic brain injury. Washington, DC: American Psychiatric Publishing, 2001: 453–76Google Scholar
  60. 60.
    Broshek DK, Kaushik T, Freeman JR. Gender differences in outcome from sports-related concussion. J Neurosurg 2005; 102: 856–63PubMedGoogle Scholar
  61. 61.
    World Anti-Doping Agency [online]. Available from URL: [Accessed 2009 Aug 13]
  62. 62.
    Blomstrand E, Celsing F, Newsholme E. Changes in plasma levels of aromatic and branched chain amino acids duringsustained exercise in man and their possible role in fatigue. Acta Physiol Scand 1988; 133: 115–21PubMedGoogle Scholar
  63. 63.
    Blomstrand E, Hassmen P, Ekblom B, et al. Administration of branched chain amino acids during sustainedexercise-effects on performance and on plasma concentrationof some amino acids. Eur J Appl Physiol 1991; 63: 83–8Google Scholar
  64. 64.
    Blomstrand E, Hassmen P, Newsholme E. Effect of branched chain amino acid supplementation on mental performance. Acta Physiol Scand 1991; 143: 225–6PubMedGoogle Scholar
  65. 65.
    Roelands B, Hasegawa H, Watson P, et al. The effects of acute dopamine reuptake inhibition on performance. Med Sci Sports Exercise 2008; 40 (5): 879–85Google Scholar
  66. 66.
    Parise G, Bosman MJ, Boecker DR. Selective serotonin reuptake inhibitors: their effect on high-intensity exerciseperformance. Arch Phys Med Rehabil 2001; 82: 867–71PubMedGoogle Scholar
  67. 67.
    Meeusen R, Piacentini MF, van Den Eynde S, et al. Exercise performance is not influenced by a 5-HT reuptakeinhibitor. Int J Sports Med 2001; 22: 329–36PubMedGoogle Scholar
  68. 68.
    Wilson WM, Maughan RJ. Evidence for a possible role of 5-hydroxytryptamine in the genesis of fatigue in man:administration of paroxetine, a 5-HT re-uptake inhibitor,reduces the capacity to perform prolonged exercise. Exp Physiol 1992; 77: 921–4PubMedGoogle Scholar
  69. 69.
    Strachan AT, Leiper JB, Maughan RJ. Paroxetine administration fails to influence human exercise capacity, perceivedeffort or hormone responses during prolonged exercise in awarm environment. Exp Physiol 2004; 89.6: 657–64PubMedGoogle Scholar
  70. 70.
    Piacentini MF, Meeusen R, Buyse L, et al. Hormonal responses during prolonged exercise are influenced by a selectiveDA/NA reuptake inhibitor. Br J Sports Med 2004; 38: 129–33PubMedGoogle Scholar
  71. 71.
    Watson P, Hasegawa H, Roelands B, et al. Acute dopamine/ noradrenaline reuptake inhibition enhances humanexercise performance in warm, but not temperate conditions. J Physiol 2005; 565.3: 873–83PubMedGoogle Scholar
  72. 72.
    Roelands B, Hasegawa H, Watson P, et al. Performance and thermoregulatory effects of chronic bupropion administrationin the heat. Eur J Appl Physiol 2009; 105 (3): 493–8PubMedGoogle Scholar
  73. 73.
    Piacentini MF, Meeusen R, Buyse L, et al. No effect of a noradrenergic reuptake inhibitor on performance intrained cyclists. Med Sci Sports Exercise 2002; 34 (7): 1189–93Google Scholar
  74. 74.
    Roelands B, Goekint M, Heyman E, et al. Acute noradrenaline reuptake inhibition decreases performance innormal and high ambient temperature. J Appl Physiol 2008; 105 (1): 206–12PubMedGoogle Scholar
  75. 75.
    Fowler NO, McCall D, Chou T-C, et al. Electrocardiographic changes and cardiac arrhythmias in patients receivingpsychotropic drugs. AmJ Cardiol 1976; 37: 223–30Google Scholar
  76. 76.
    Waslick BD, Walsh BT, Greenhill LL, et al. Cardiovascular effects of desipramine in children and adultsduring exercise testing. J Am Acad Child Adolesc Psychiatry 1999; 38 (2): 179–86PubMedGoogle Scholar
  77. 77.
    de Zwaan M. Exercise and antidepressant serum levels. Biol Psychiatry 1992; 32: 210–11PubMedGoogle Scholar
  78. 78.
    Smith DF. The effect of exercise and pain-stress on the renal clearance of lithium, sodium, potassium, and creatininein the rat. Int Pharmacopsychiatry 1973; 8: 217–20PubMedGoogle Scholar
  79. 79.
    Miller EB, Pain RW, Skripal PJ. Sweat lithium in manicdepression. Br J Psychiatry 1978; 133: 477–8PubMedGoogle Scholar
  80. 80.
    Jefferson JW, Greist JH, Clagnaz PJ, et al. Effect of strenuous exercise on serum lithium level in man. Am J Psychiatry 1982; 139 (12): 1593–5PubMedGoogle Scholar
  81. 81.
    Tilkian AG, Schroeder JS, Kao J, et al. Effect of lithium on cardiovascular performance: report on extended ambulatorymonitoring and exercise testing before and duringlithium therapy. Am J Cardiol 1976; 38: 701–8PubMedGoogle Scholar
  82. 82.
    Cowan DA. Drug abuse. In: Harries M, Williams C, Stanish WD et al., editors. Oxford textbook of sports medicine. New York (NY): Oxford University Press, 1994: 314–29Google Scholar
  83. 83.
    Wilmore JH. Exercise testing, training, and beta-adrenergic blockade. Phys Sportsmed 1988; 16: 45–50Google Scholar
  84. 84.
    Schwenk TL. Psychoactive drugs and athletic performance. Phys Sportsmed 1997; 25 (1): 33–46Google Scholar
  85. 85.
    Marvin G, Sharma A, Aston W, et al. The effects of buspirone on perceived exertion and time to fatigue in man. Exp Physiol 1997; 82: 1057–60PubMedGoogle Scholar
  86. 86.
    Kennedy M. Drugs and Athletes: an update. Adverse Drug React Bull 1994; 169: 639–42Google Scholar
  87. 87.
    Smith GM, Beecher HK. Amphetamine sulfate and athletic performance. I: objective effects. JAMA 1959; 170: 542–57Google Scholar
  88. 88.
    Chandler JV, Blair SN. The effect of amphetamines on selected physiological components related to athletic success. Med Sci Sports Exerc 1980; 12 (1): 65–9PubMedGoogle Scholar
  89. 89.
    Shaikin B. Baseball’s 2008 drug test results released in report. Los Angeles Times, 2009 Jan 10 [online]. Available from URL: [Accessed 2010 Sep 17]Google Scholar
  90. 90.
    Hickey G, Fricker P. Attention deficit hyperactivity disorder, CNS stimulants, and sport. Sports Med 1999; 27 (1): 11–21PubMedGoogle Scholar
  91. 91.
    Conant-Norville DO, Tofler I. Attention deficit/hyperactivity disorder and psychopharmacologic treatments in theathlete. Clin Sports Med 2005; 24 (4): 829–43PubMedGoogle Scholar
  92. 92.
    Atkinson G, Drust B, Reilly T, et al. The relevance of melatonin to sports medicine and science. Sports Med 2003; 33 (11): 809–31PubMedGoogle Scholar
  93. 93.
    Gonzalez-Alonso J, Teller C, Andersen SL, et al. Influence of body temperature on the development of fatigue duringprolonged exercise in the heat. J Appl Physiol 1999; 86: 1032–9PubMedGoogle Scholar
  94. 94.
    Walters TJ, Ryan KL, Tate LM, et al. Exercise in the heat is limited by a critical internal temperature. J Appl Physiol 2000; 89: 799–806PubMedGoogle Scholar
  95. 95.
    Reilly T, Atkinson G, Budgett R. Effect of low-dose temazepam on physiological variables and performance tests following a westerly flight across five time zones. IntJ Sports Med 2001; 22: 166–74Google Scholar
  96. 96.
    Ito SU, Kanbayashi T, Takemura T, et al. Acute effects of zolpidem on daytime alertness, psychomotor and physicalperformance. Neurosci Res 2007; 59: 309–13PubMedGoogle Scholar
  97. 97.
    Holmberg G. The effects of anxiolytics on CFF. Pharmacopsychiatry 1982; 15 Suppl.: 49–53Google Scholar
  98. 98.
    Maddock RJ, Casson EJ, Lott LA, et al. Benzodiazepine effects on flicker sensitivity: role of stimulus frequencyand size. Prog Neuropsychopharmacol Biol Psychiatry 1993; 17: 955–70PubMedGoogle Scholar
  99. 99.
    Mougin F, Bourdin H, Simon-Rigaud ML, et al. Hormonal responses to exercise after partial sleep deprivationand after a hypnotic drug-induced sleep. J Sports Sci 2001; 19: 89–97PubMedGoogle Scholar
  100. 100.
    Tafti M, Besset A, Billiard M. Effects of zopiclone on subjective evaluation of sleep and daytime alertness and onpsychomotor and physical performance tests in athletes. Prog Neuropsychopharmacol Biol Psychiatry 1992; 16: 55–63PubMedGoogle Scholar
  101. 101.
    Grobler LA, Schwellnus MP, Trichard C, et al. Comparative effects of zopiclone and loprazolam on psychomotorand physical performance in active individuals. Clin JSport Med 2000; 10 (2): 123–8Google Scholar
  102. 102.
    Paul MA, Gray G, Kenny G, et al. Impact of melatonin, zaleplon, zopiclone, and temazepam on psychomotor performance. Aviat Space Environ Med 2003; 74 (12): 1263–70PubMedGoogle Scholar
  103. 103.
    Charles RB, Kirkham AJT, Guyatt AR, et al. Psychomotor, pulmonary and exercise responses to sleep medication. Br J Clin Pharmac 1987; 24: 191–7Google Scholar

Copyright information

© Adis Data Information BV 2010

Authors and Affiliations

  1. 1.Department of PsychiatryUniversity of Wisconsin Hospital and ClinicsMadisonUSA

Personalised recommendations