Mental Health Management of Elite Athletes During COVID-19: A
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Br J Sports Med: first published as 10.1136/bjsports-2020-102884 on 23 September 2020. Downloaded from Review Mental health management of elite athletes during COVID-19: a narrative review and recommendations Claudia L Reardon ,1,2 Abhinav Bindra,3 Cheri Blauwet,4 Richard Budgett,5 Niccolo Campriani,6 Alan Currie ,7,8 Vincent Gouttebarge,9,10 David McDuff ,11,12 Margo Mountjoy ,13,14 Rosemary Purcell,15,16 Margot Putukian ,17,18 Simon Rice,16,19 Brian Hainline 20 For numbered affiliations see ABSTRACT during the pandemic span various treatment modal- end of article. Elite athletes suffer many mental health symptoms and ities, inclusive of community- based or outpatient disorders at rates equivalent to or exceeding those of psychotherapy, outpatient pharmacotherapy and Correspondence to the general population. COVID-19 has created new higher levels of care,9 all of which are addressed Dr Claudia L Reardon, Department of Psychiatry, strains on elite athletes, thus potentially increasing in this article. It is likely that these considerations University of Wisconsin School their vulnerability to mental health symptoms. This will hold relevance into the foreseeable future given of Medicine and Public Health, manuscript serves as a narrative review of the impact anticipated future waves of COVID-19. Madison, Wisconsin, USA; of the pandemic on management of those symptoms clreardon@ wisc. edu in elite athletes and ensuing recommendations to METHODS guide that management. It specifically addresses Accepted 28 August 2020 We searched key databases (PubMed, SportDiscus, psychotherapy, pharmacotherapy and higher levels PsycINFO, Scopus and Cochrane) in May 2020. of care. Within the realm of psychotherapy, crisis Search terms relating to COVID-19, elite athletes, counselling might be indicated. Individual, couple/ athletes, sports, mental health, management and family and group psychotherapy modalities all may be treatment were combined. No limits were placed helpful during the pandemic, with novel content and on the search. Databases required slightly modified means of delivery. Regarding pharmacotherapy for terminology to adhere to the databases’ controlled mental health symptoms and disorders, some important vocabulary. Papers must have been available in aspects of management have changed during the English to be included in this manuscript. Using this pandemic, particularly for certain classes of medication strategy, 39 articles were identified. After screening including stimulants, medications for bipolar and for relevance, this was reduced to 6. References in psychotic disorders, antidepressants and medications for the resulting papers were reviewed to identify addi- substance use disorders. Providers must consider when tional related publications. Other literature was also in- person management (eg, for physical examination, reviewed, including that focused on non-pandemic laboratory testing) or higher levels of care (eg, for crisis management recommendations for elite athletes stabilisation) is necessary, despite potential risk of viral and pandemic recommendations for non-athletes, exposure during the pandemic. Management ultimately http://bjsm.bmj.com/ where there were gaps in elite athlete- specific and should continue to follow general principles of quality COVID-19- specific literature. Altogether, 109 rele- health care with some flexibility. Finally, the current vant references and sources were found. pandemic provides an important opportunity for research on new methods of providing mental health care for athletes, and consideration for whether these new PSYCHOTHERAPY methods should extend beyond the pandemic. Psychotherapy is defined as the treatment of mental health symptoms or disorders or problems of living on September 23, 2020 by guest. Protected copyright. by psychological means, often based on therapeutic principles, structure and techniques.10 It is often INTRODUCTION regarded as the treatment of choice for elite athletes Elite athletes (defined as professional, Olympic/ with mild to moderate mental health symptoms and Paralympic or collegiate) suffer from many mental disorders.1 10 This would seemingly remain the case health symptoms and disorders at rates equiva- during the COVID-19 pandemic, with athletes lent to or exceeding those of non-athletes. 1 The traditionally particularly well-suited to cognitive- COVID-19 pandemic has created new mental health behavioural therapy because they are accustomed to stressors for everyone; for athletes, these have been structure, direction, practice, goal setting and self- © Author(s) (or their addressed in recent publications.2–5 However, the reliance.10 11 However, the nature and delivery of employer(s)) 2020. No pandemic’s impact on management of mental health psychotherapeutic interventions might vary because commercial re- use. See rights and permissions. Published symptoms and disorders in athletes has received of the pandemic. For example, crisis counselling 12 13 by BMJ. little scholarly attention. Management in general might be the preferred intervention for athletes for athletes has focused on the cardiac complica- whose mental health is primarily being affected To cite: Reardon CL, tions, screening for asymptomatic disease, and by direct effects of the pandemic, such as the Bindra A, Blauwet C, et al. 6–8 Br J Sports Med Epub ahead return to sport, incorporating hygiene measures. morbidity or mortality of loved ones, friends and of print: [please include Day Here, we delineate management considerations members of the athlete entourage; personal illness; Month Year]. doi:10.1136/ for mental health symptoms and disorders in elite devastating loss of one’s home or job; a lost oppor- bjsports-2020-102884 athletes. Options for management in elite athletes tunity for an important athletic event (eg, World Reardon CL, et al. Br J Sports Med 2020;0:1–10. doi:10.1136/bjsports-2020-102884 1 Br J Sports Med: first published as 10.1136/bjsports-2020-102884 on 23 September 2020. Downloaded from Review Table 1 PTSD- type symptoms triggered by the pandemic and potential treatment modalities106–109 Symptom category Manifestations Potential modalities Intrusion Intrusive memories, nightmares, flashbacks, intense distress or physiological ► Trauma- focused cognitive- behavioural therapy reactivity after exposure to reminders of the trauma ► Prolonged exposure therapy Negative moods/cognitions Inability to recall events related to the trauma, distorted beliefs about the ► Cognitive processing therapy world, distorted blame of self/others for causing the trauma, fear, horror, guilt, ► Eye movement desensitisation and reprocessing anger, decreased interest in activities, feeling alienated from others, constricted affect Altered arousal/reactivity Irritability, aggression, self- destructive behaviour, hypervigilance, exaggerated startle response, problems concentrating, sleep disturbance Avoidance Shunning pandemic- related memories or external reminders of the trauma Dissociative Numbing, detachment, decreased awareness, derealisation, depersonalisation PTSD, post- traumatic stress disorder. Championships, Olympics) or collapse of social structure. The of their entourage benefit from psychoeducation, defined as an central objectives of crisis counselling, as opposed to more tradi- intervention designed to obtain and maintain mental health by tional psychotherapy, are ensuring safety, promoting return to providing information, educational materials and/or feedback/ functioning and providing immediately available resources.12 14 advice to individuals who might have mental health symptoms or Symptoms directly related to the pandemic might resemble those disorders.10 Thus, virtual psychoeducational sessions or written of acute stress disorder (for symptoms lasting 3 days to 1 month materials might benefit groups of athletes via provision of infor- in duration) or post- traumatic stress disorder (PTSD, for symp- mation about pandemic stressors relevant to athletes, strategies toms lasting >1 month in duration). When these types of symp- for overcoming them and mechanisms for referral to psycho- toms are present, PTSD- specific psychotherapy might be helpful therapy. For those athletes referred for individual psychotherapy for athletes (table 1). as a result of group psychoeducational interventions such as this, Psychotherapy with athletes may occur at the individual, expanded psychoeducation in addition to more formal crisis couple/family or group levels.10 Couple/family psychotherapy counselling, cognitive- behavioural therapy or other psychother- might be needed by some elite athletes at this time; compared apeutic modalities if appropriate may have benefit. with athletes’ usual frequent absences for travel, spending more time together could be a source of tensions. Group psycho- PHARMACOTHERAPY therapy to replicate some team dynamics within therapy groups Medications to treat mental health symptoms and disorders might also be useful for athletes during the pandemic, since remain an important tool for management, especially for those they have lost much of their accustomed team structure.10 with moderate to severe symptoms.1 For some elite athletes and These modalities are currently being offered in virtual formats many categories of medications, these treatments will remain the (eg, telephone, video), depending on location.15 Despite some same. However, some circumstances have changed because of delays in converting to virtual formats, increasingly, providers of the pandemic;