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The majority of mental health disorders have their onset during adolescence and early adulthood, with roughly half of these disorders emerging in mid-adolescence. While sport offers a range of critically important benefits, competitive demands on young athletes may increase susceptibility to mental health symptoms and disorders during an already challenging developmental period, especially in the context of elite sport, which is characterized by increasing professionalization and specialization. This clinical review examines key literature regarding risk factors for mental health symptoms and disorders in youth athletes, as well as providing informed practical guidance for clinicians working with this cohort.

Elite athletes suffer many mental health symptoms and disorders at rates equivalent to or exceeding those of the general population. COVID-19 has created new strains on elite athletes, thus potentially increasing their vulnerability to mental health symptoms. This manuscript serves as a narrative review of the impact of the pandemic on management of those symptoms in elite athletes and ensuing recommendations to guide that management. It specifically addresses psychotherapy, pharmacotherapy and higher levels of care. Within the realm of psychotherapy, crisis counselling might be indicated. Individual, couple/family and group psychotherapy modalities all may be helpful during the pandemic, with novel content and means of delivery. Regarding pharmacotherapy for mental health symptoms and disorders, some important aspects of management have changed during the pandemic, particularly for certain classes of medication including stimulants, medications for bipolar and psychotic disorders, antidepressants and medications for substance use disorders. Providers must consider when in-person management (eg, for physical examination, laboratory testing) or higher levels of care (eg, for crisis stabilisation) is necessary, despite potential risk of viral exposure during the pandemic. Management ultimately should continue to follow general principles of quality health care with some flexibility. Finally, the current pandemic provides an important opportunity for research on new methods of providing mental health care for athletes, and consideration for whether these new methods should extend beyond the pandemic. [Abstract copyright: © Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.]

Athletes commonly experience mental health symptoms. However, prevalence estimates require refinement so that symptoms are interpreted in context and diagnostic labels are accurately applied. Further prevalence studies are also needed in subgroups within sport, in particular female athletes, athletes with disabilities, and coaches. Existing consensus-based and evidence-based therapies must be adapted not only to the individual athlete but also to the ecology of sports. Filling the gaps in our knowledge on what treatment modifications may be required for the individual athlete and how services should be designed to deliver treatment most effectively will require well-designed studies that use standardized terminology and defined outcome measures.

Mental health symptoms and disorders are common among elite athletes, may have sport related manifestations within this population and impair performance. Mental health cannot be separated from physical health, as evidenced by mental health symptoms and disorders increasing the risk of physical injury and delaying subsequent recovery. There are no evidence or consensus based guidelines for diagnosis and management of mental health symptoms and disorders in elite athletes. Diagnosis must differentiate character traits particular to elite athletes from psychosocial maladaptations.Management strategies should address all contributors to mental health symptoms and consider biopsychosocial factors relevant to athletes to maximise benefit and minimise harm. Management must involve both treatment of affected individual athletes and optimising environments in which all elite athletes train and compete. To advance a more standardised, evidence based approach to mental health symptoms and disorders in elite athletes, an International Olympic Committee Consensus Work Group critically evaluated the current state of science and provided recommendations.

Bipolar and psychotic disorders are relatively common and likely to have a significant impact on quality of life and functioning which, in the context of elite sport, includes a potential negative impact on sporting performance. For this narrative review article, the literature on bipolar and psychotic disorders in elite athletes was comprehensively searched, and little empirical research was found. A diagnosis of bipolar or psychotic disorders may be challenging in elite athletes because of complicating factors related to the modifying role of exercise and potential precipitating impact of substance use. Medications used to treat bipolar and psychotic disorders may have side effects particularly problematic for elite athletes. Future research should be tailored to the specific characteristics and needs of elite athletes and to the sporting context in which the disorders may arise. Specifically, further research is needed on the prevalence and incidence of these conditions in elite athletes and the impact of both the disorders and their treatments on sporting performance.

The impact of mental health symptoms and disorders in elite athletes is increasingly recognised. This led the International Olympic Committee (IOC) to produce a consensus statement1 and establish a Mental Health Working Group. Members of this group have extensive experience in research and practice in the field of athlete mental health and have collectively ascertained gaps in current knowledge and practices. This editorial reflects the authors’ opinions and aims to provide researchers and practitioners with future directions relating to mental health symptoms and disorders in elite sport, focusing on prevalence/incidence, prevention, screening, assessment and treatment. The prevalence studies that are currently available have significant limitations,2 including the lack of data distinguishing mental health symptoms from disorders . The latter require a clinical assessment accounting for the intense and unique demands athletes face, which influence how symptoms and disorders may manifest. An example is the presence of mental health symptoms in overtrained athletes, how these are understood from perspectives such as low energy availability or impaired immune function and where existing classification systems may be inadequate. Studies are limited by the influence of stigma related to mental health symptoms and disorders both in and out of sporting contexts, which likely impact athletes’ responses and do not take account of additional barriers to reporting, specifically cultural barriers including sex, religion, …

ObjectivesTo develop an assessment and recognition tool to identify elite athletes at risk for mental health symptoms and disorders.MethodsWe conducted narrative and systematic reviews about mental health symptoms and disorders in active and former elite athletes. The views of active and former elite athletes (N=360) on mental health symptoms in elite sports were retrieved through an electronic questionnaire. Our group identified the objective(s), target group(s) and approach of the mental health tools. For the assessment tool, we undertook a modified Delphi consensus process and used existing validated screening instruments. Both tools were compiled during two 2-day meeting. We also explored the appropriateness and preliminary reliability and validity of the assessment tool.Sport Mental Health Assessment Tool 1 and Sport Mental Health Recognition Tool 1The International Olympic Committee Sport Mental Health Assessment Tool 1 (SMHAT-1) was developed for sports medicine physicians and other licensed/registered health professionals to assess elite athletes (defined as professional, Olympic, Paralympic or collegiate level; aged 16 years and older) potentially at risk for or already experiencing mental health symptoms and disorders. The SMHAT-1 consists of: (i) triage with an athlete-specific screening tool, (ii) six subsequent disorder-specific screening tools and (iii) a clinical assessment (and related management) by a sports medicine physician or licensed/registered mental health professional (eg, psychiatrist and psychologist). The International Olympic Committee Sport Mental Health Recognition Tool 1 (SMHRT-1) was developed for athletes and their entourage (eg, friends, fellow athletes, family and coaches).ConclusionThe SMHAT-1 and SMHRT-1 enable that mental health symptoms and disorders in elite athletes are recognised earlier than they otherwise would. These tools should facilitate the timely referral of those athletes in need for appropriate support and treatment.

Mental health symptoms and disorders amongst elite athletes have attracted a great deal of discussion recently. Current epidemiological evidence illustrates that mental health symptoms and disorders in elite athletes are prevalent and a concern for athletes, coaches, and sport organizations. Recently, seven consensus, expert, or position statements have been written on the topic of mental health in elite sport. A strategy suggested by each of the seven statements–aimed at preventing and treating mental health symptoms and disorders in elite athletes, both individually and systemically–is to employ education interventions, specifically those based on increasing mental health literacy. Mental health literacy has come to include concepts related to knowledge of effective self-management strategies, challenging mental disorder stigma, awareness and use of mental health first-aid to assist others, and the facilitation of help seeking behaviors. In elite sport, questions remain about how mental health literacy can address the unique needs of the individual athlete, but also factor in their culture and their environment to identify how to prevent and treat mental health symptoms and disorders. The purpose of this commentary is twofold: 1) to explore the evolving concept of mental health literacy within elite sport which addresses individuals, their culture, and their environment, and 2) to propose strategies for best practice and research in mental health literacy within elite sport relying on collaboration between sports psychiatry, sport psychology, and clinical psychology. Lay summary: Expert statements on mental health in elite sport have suggested the use of educational strategies to address poor mental health in elite athletes. This commentary explores the concept of mental health literacy within elite sport which addresses individuals, their culture, and their environment, and proposes strategies for best practice.Implications for Practice Mental health literacy interventions should be based on detailed knowledge of developmental, cultural, and social issues related to sport participation and systemic issues within sport settings and organizations. Mental health literacy interventions should be designed in a manner which takes due account of cultural issues and contexts, where sport organizational goals are considered while helping organizations recognize and address mental health symptoms and disorders and also create sport environments where individuals can thrive. Mental health literacy interventions should have measurable impact on both organizations and individuals.

[Figure][1] 1. 1. 2. Reardon CL , 3. Hainline B , 4. Aron CM , et al . Mental health in elite athletes: international Olympic Committee consensus statement (2019). Br J Sports Med 2019;53:667–99.[doi:10.1136/bjsports-2019-100715][2] [OpenUrl][3][

Athletes experience a range of mental health problems with at least an equivalent prevalence to the general population. This chapter explores the psychiatrist's role in sport, along a pathway of mental healthcare from 'upstream' prevention, screening, and early detection of mental stress to 'downstream' assessment, treatment, rehabilitation, and recovery from mental illness. At each stage on this pathway the psychiatrist has a broad spectrum of bio-psycho-social strategies to employ in clinical practice. Upstream, the importance of psychological resilience is described along with the concept of mental 'pre-habilitation' (a term usually associated with the prevention of physical injury). Alongside these preventative measures, early detection is improved by education, increased awareness, and by the use of effective mental health screening measures. Further downstream ready access to psychiatric expertise and good collaboration between the psychiatrist and the world of sport improve access to treatment, delivery of that treatment, rehabilitation, and return to sport during recovery.

Background The UK General Osteopathic Council (GOsC) has statutory duties of ‘promoting high standards of education and training in osteopathy and keeping the provision of that training under review'. Students graduating from osteopathic educational institutions (OEIs) must meet the GOsC Osteopathic Practice Standards . 1 Objectives One domain within the Osteopathic Practice Standards is ‘professionalism'. Supporting guidance requires explicit teaching and learning opportunities about ‘professionalism' in osteopathy. Our objectives are to establish the feasibility of adapting e-learning resources used widely in medical education to meet these requirements. Methods A consensus group of two senior faculty representatives nominated by their Deans or Principals from each of the 11 UK OEIs and senior officers from the GOsC, with expertise in standards, reviewed and adapted the items of the two Dundee Polyprofessionalism resources used to explore professionalism in medical education. Four additional items were added. The agreed inventory was tested on two groups of 4 and 12 osteopathy students. Results The adaptation and feasibility of 34 items for Professionalism in Osteopathy 1 (Academic) and the 45 items for Professionalism in Osteopathy 2 (Clinical) were agreed to explore professionalism in osteopathy. Conclusions The Professionalism in Osteopathy e-learning resources will be field tested to explore their potential to guide learning and to track and help to benchmark the learning curve in pre-registration osteopathic professionalism.

PurposeBeing excluded blights the lives of the mentally ill. Exclusion is both cause and consequence of mental ill‐health and extends beyond material deprivation to exclusion from the activities which give meaning to life. Promoting inclusion is central to the work of all mental health practitioners and the purpose of this paper is to advance the practices which support this.Design/methodology/approachThe literature on what supports social inclusion and the related concept of recovery is reviewed. The working practices and prevailing theoretical models in psychiatry are also considered in the context of understanding how these practices and models can support socially inclusive and recovery‐orientated ways of working.FindingsSocial inclusion and recovery interact dynamically. Central to being “in recovery” is the experience of being included. Social inclusion is also a platform on which to participate in life's activities and to learn to “live well” again. The practices which support these approaches are consistent with medical models of care, with the bio‐psychosocial model that prevails in psychiatric practice and with existing guidelines on the nature and purpose of the therapeutic relationship.Originality/valueObstacles are described that impede adopting new practices and these include creating additional work, increased risk in a risk averse environment, and incompatibility with current models of medical practice. This paper seeks to describe the cost of exclusion, the value of inclusion, the practices which support recovery and social inclusion and to refute the arguments for not adopting these ways of working.

Aims and methods This study aims to explore perceptions of eating disorder service strengths and to develop a clearer picture of improvements clinicians would like to see occur in the services they lead. A survey designed by the Royal College of Psychiatrists' Section of Eating Disorders was completed by 83 lead clinicians in both public and private sector services in the UK and Eire. Content analysis was performed, and common themes were identified. Results Five main strengths of a service were identified as follows: quality of treatment (n = 36), staff skills (n = 21), continuity of care (n = 15), family involvement (n = 12) and accessibility and availability (n = 11). These themes also arose when clinicians evaluated areas they wished to develop and improve. Conclusions Service providers' views were congruent with each other, NICE guidelines and quality standards as proposed by the Royal College. Although clinicians feel that their service fulfils many practice guidelines, there remains areas in which adherence is felt to be lacking. Copyright © 2011 John Wiley & Sons, Ltd and Eating Disorders Association.

Aims and methodWe surveyed 180 experienced psychiatrists on their training and practice in diagnosing and managing tardive dyskinesia in the current atypical antipsychotic era.ResultsAbout two-thirds of psychiatrists (n = 124, 69%) responded to the survey. A significant minority had no training in tardive dyskinesia, yet almost everyone recognised the need for formal training in this area. We noted a discrepancy between what respondents believed should be their ideal practice and their reported actual clinical practice. As many as 58% considered that tardive dyskinesia could be a reason for patients to pursue litigation. Many had concerns about prescribing antipsychotics for unlicensed indications, especially for incapacitous patients.Clinical implicationsIt is important to recognise current practice and gaps in training, not only to enhance training and patient care but also to mitigate against the risk of litigation.

SummaryRemission is a new research outcome indicating long-term wellness. Remission not only sets a standard for minimal severity of symptoms and signs (resolution); it also sets a standard for how long symptoms and signs need to remain at this minimal level (6 months). Individuals who achieve remission from schizophrenia have better subjective well-being and better functional outcomes than those who do not. Research suggests that remission can be achieved in 20–60% of people with schizophrenia. There is some evidence of the usefulness of remission as an outcome indicator for clinicians, service users and their carers. This article reviews the literature on remission in schizophrenia and asks whether it could be a useful clinical standard of well-being and a foundation for functional improvement and recovery.

Purpose – Eating disorders are common in sporting populations. They have an adverse effect on athletic performance and can represent a serious health problem. Many practitioners who work with athletes require guidance on how best to respond to these problems. The purpose of this paper is to present an overview of what can be done to address the problem of eating disorders in a high performance sports environment.Design/methodology/approach – Three clinicians (a psychiatrist, dietitian and psychologist) with many years experience of working in a sports environment were tasked with drafting guidelines relevant to elite sport in consultation with a senior sports physician. The group met on three occasions and corresponded by e‐mail over a 15‐month period. Existing guidelines and literature were reviewed and adapted to the UK high performance sports environment. The guideline was targeted at all practitioners, including coaches, who work in this setting and comments were invited from national sports institute...

Athletes with eating disorders risk compromising not only their performance but also their health and general well-being. These serious issues make recognizing and treating eating disorders extremely important. Unfortunately, the prevalence of eating disorders in certain sports is high, and identifying problems can be difficult. Accessing and engaging such athletes in effective treatment is also no easy task. By fostering understanding and cooperation between clinicians and others who work in the sport environment, athletes will have the best opportunity to access high quality treatment at the right time and have the greatest chance to repair both their health and sport performance. This paper takes a psychiatric perspective on eating disorders among athletes and discusses prevalence, diagnostic issues, and treatment options.

Objectives To compare UK and Kenyan athletes and to examine the influence of nationality and involvement in elite distance running on the presence of eating disorders, eating disorder psychopathology and menstrual dysfunction, in young women. Design Independent groups, with nationality and running status as independent variables. Methods Elite female distance runners were identified based on their performances in track, road and cross-country events. Questionnaire packs were sent to UK athletes and Kenyan athletes were approached at race meetings or a training camp. In all, 82 UK and 75 Kenyan athletes participated (70% and 90% of those invited) along with 97 and 101 non-athlete, age-matched controls from the two countries. All participants completed the Eating Disorder Examination Questionnaire (EDE-Q) and assessments of dieting, mental health, self-esteem and menstrual function. Results UK women had significantly higher levels of eating disorder psychopathology and more probable present and past eating disorders than enyan women. Overall, 19.5% of the UK runners had a probable present or past eating disorder, confirming the results of our earlier study (Hulley & Hill, 2001). Kenyan runners had the lowest proportion of probable cases compared with all other groups and the least eating disorder psychopathology. Athletic participation was associated with less regular menstrual periods, regardless of nationality. Conclusion These findings confirm that participation in distance running at an elite level does not in itself predispose to an eating disorder. Eating disorder risk is better represented as a combination of cultural values, elite sporting environment and person variables.

SummaryThe host country's legacy after the Olympic Games is multifaceted. Alongside such diverse elements as tourism, commerce and transport sit the health benefits of increased participation in sports and provision of the highest quality medical support for the nation's elite sporting performers. Mental health, however, merits no specific mention. This could be a missed opportunity to create a legacy that promotes the mental health benefits of exercise as well as ensuring that the mental health needs of elite sportsmen and women are recognised and met in the same manner as their physical health needs.

There is strong and consistent evidence that eating disorders are prevalent in sport and especially in weight sensitive sports such as endurance, weight category and aesthetic sports as well as jumping events. These illnesses are not only common but lead to significant physical and psychological morbidity and impaired performances. Sports organizations, and by extension the professionals whose job it is to help and support athletes, have important roles in dealing with these conditions. Preventative practices can be adopted if there is an understanding of how the sports environment contributes to the development of eating disorders. Some disorders can be difficult to detect especially in a sports environment and simple screening instruments are available. Athletes may also need help to access appropriate treatment whilst they are recovering. In many sports prevention, screening and support programs have been developed for a variety of medical conditions or sportsrelated injuries. Similar programs should be developed for eating disorders.

The shared management of patients with schizophrenia in primary care can only succeed if underpinned by valid, easily administered and clinically relevant outcome measures. While conditions such as depression and anxiety lend themselves to this approach through the development, over a number of years, of patient- and observer-rated scales, schizophrenia still lacks the capacity for meaningful outcome measures. Recently, two international working groups have developed the concept of remission in schizophrenia and recommended a simple, brief and clinically valid measure based upon improvement in key symptoms over a specified time period. The authors consider this concept and its application to primary care both as a commissioning tool and to facilitate shared care of this chronic medical condition.

Objectives: To examine the operation of a deliberate self-harm service at a large general hospital with reference to standards outlined by the Royal College of Psychiatrists. To examine the characteristics of referrals and to make recommendations for improvements to the service.Method: Data on referral and assessment characteristics were collected for 96 consecutive referrals over a three month period.Results: The services achieved the college standards in relation to the time period for assessments. Most referrals were made routinely at a predictable time but assessments were conducted on an ad hoc basis. Only a minority of those referred had a mental illness or complex problems. A significant number of patients were discharged from the A&E department without a psychiatric assessment. Assessors underemphasised the role of previous deliberate self-harm and/or the presence of mental illness in forming a judgment on the risk of suicide. After-care arrangements were predominantly medical (general practitioners or psychiatrists) with little multidisciplinary input.Conclusions: The deliberate self-harm service at the hospital could be improved by the establishment of a self-harm services planning group to oversee the delivery of the service throughout the hospital and address the deficits identified. Given the number of referrals seen within the service and the fact that deliberate self-harm is only one element of a comprehensive liaison service, consideration should be given to the establishment of a separate multi-disciplinary liaison team. Once again importance is drawn to the need for all assessors to be aware of the risk factors in relation to the future risk of suicide rather than placing undue emphasis on whether the most recent attempt was planned or impulsive in nature.

Risperidone long acting injection (RLAI) is the only long acting atypical antipsychotic available in the UK. Its impact on NHS resource use has not been widely studied. This review of medical records was conducted to quantify the impact of RLAI on NHS psychiatric secondary care resource use, primarily in terms of episodes of inpatient hospital care 12 months before and 12 months after RLAI initiation. Data on number of hospitalizations and hospital bed days were collected retrospectively, from patient notes and hospital databases in four acute psychiatric units in the UK for all individuals with a diagnosis of schizophrenia or schizoaffective disorder who were prescribed RLAI more than 12 months previously. Data were collected on 100 individuals (58 male) with a mean age 40.8 years (range 19—70). The median duration of illness before RLAI initiation was 12 years (range six months to 43 years). There were 62 admissions in the 12 months pre-RLAI, falling to 22 admissions in the 12 months post-RLAI. Number of admissions, we argue, offer a more reliable indicator of the impact of treatment than total hospital bed days in this type of study. In this study there were 40 fewer admissions in the 12 months after RLAI was initiated compared with the previous 12 months. This is important as readmission is a good proxy measure of relapse, and adherence to medication is known to be a key factor in relapse prevention.

Sports Psychiatry: Strategies for Life Balance and Peak Performance By David R. McDuff. American Psychiatric Publishing. 2012. £39.00 (pb). 310 pp. ISBN: 9781119953548 The first National Lottery draw on 19 November 1994 began a revolution in British sport that has seen Team GB climb steadily from

There has been one case reported in the literature (Medline search December 1994) of a serotonin selective re-uptake inhibitor (SSRI), fluoxetine, being associated with the development of classic migrainous symptoms (Larson, 1993). We now report a case of severe exacerbation of migraine with another SSRI, paroxetine.

EDITOR,—Christopher Dowrick and Iain Buchan suggest that neither diagnosis nor disclosure of depression in general practice has an appreciable impact on outcome and that detection should be seen simply as a marker of severity.1 It is well recognised that there is appreciable unidentified psychiatric morbidity in primary care,2 and Dowrick and Buchan's paper reinforces this point. Two other …