SPORT MED Athlete Mental Health- Hot Topics and Minefields. January 26, 2019 Dr. Carla Edwards, MD, MSc, FRCP(C) Sport Psychiatrist

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1 SPORT MED 2019 Athlete Mental Health- Hot Topics and Minefields January 26, 2019 Dr. Carla Edwards, MD, MSc, FRCP(C) Sport Psychiatrist

2 OBJECTIVES: Review different types of patients that may present for sport medicine consultation or treatment, where mental health challenges are evident Learn to identify and manage complex multifactorial cases Case Reviews and Discussion (throughout!) Following Through 2

3 HOT TOPICS Cannabis use Harassment and abuse Self Harm and suicide Severe Mental Illness 3

4 22 year old Track and field athlete (shot put) presented for evaluation of neck pain and problems with performance Carded athlete, competes internationally What are the key words, and where do we start? CASE 1: 4

5 Key Words: Neck pain examine, investigate Performance struggles Screen for contributing factors Carded athlete has a support team CASE 1: 5

6 Neck: mild impingement, improved with physiotherapy Performance (and daily function) affected by significant anxiety and poor self regulation (in sport and in daily life) Despite treatment with pharmacological agents for anxiety, he requests CBD oil What are the big issues? CASE 1: 6

7 Anxiety, poor self regulation (Affecting performance and daily function) Cognitive strategies and mental performance techniques can be delivered by a Mental Performance Consultant, Sport Psychologist, or Sport Psychiatrist CBD oil Although the use of cannabis is legalized in Canada, it continues to be prohibited for use in sport- a positive test would result in a sanction CBD oil can contain trace amounts of THC CASE 1: 7

8 18 year old elite basketball player frequently presents with minor complaints- which interfere with training Teammates and coaches complain that she is distracting (attire, behavior), and sometimes rude and dismissive The athlete was asked to step away from training and the training environment for several weeks to focus on stabilization (and understand the issues) following an emotional meltdown during training What are the key words, and where do we start? CASE 2: 8

9 Frequent minor physical complaints Amplified by anxiety, easily derailed Distracting attire and behavior in the training setting, sometimes rude and dismissive Impulsivity, disinhibition, disorganization, oppositionality, argumentativeness, high risk behaviors, and difficulty managing behaviours were also issues. CASE 2: 9

10 What kinds of issues would you conceptualize? (Differential Dx) How do you approach this case? CASE 2: 10

11 Address the physical complaints, provide reassurance and what they can expect. Involve a mental health expert for support and collaboration CASE 2: 11

12 Time away from training presented an opportunity to perform full clinical evaluations (sport psychiatry), including validated screening tools. Screening tools and mood tracking forms: Fulfilled criteria for ADHD-combined presentation Did not support a diagnosis bipolar diagnosis Some indication that OCP influenced mood in the months leading up to the meltdown Clinical history and encounters also indicated the presence of histrionic personality features and the tendency to engage in attention-seeking behavior due to childhood bullying and exclusion CASE 2: 12

13 20 year old varsity soccer player brought by teammate due to concerns about mood and safety Medical issues: spondylolisthesis, bilateral labral tears (hips) requiring surgery Clear reluctance to engage Where do you start? CASE 3: 13

14 Physical: referred to ortho Mental health: referred to psychiatry Fulfilled criteria for MDD, suicidal thoughts, positive family Hx of suicide Throughout the year of having both hips repaired, she suffered severe depression and grades dropped significantly. CASE 3: 14

15 One night went out with friends- they later went back to her student house and she was sexually assaulted by a varsity football player while a number of his and her teammates were present (they prevented her from leaving). He sent them home via Uber and stayed to continue assaulting her. There was a 200lb difference between them and he kept telling her, no one says no to me. CASE 3: 15

16 She fought him off and was choked, bitten, bruised, and sustained broken nails in the process. Upon disclosing her injuries in my office, she vehemently resisted making a report. I don t want to ruin his life; and I don t want to go through that for no one to believe me. To expand her network of supports, she was encouraged to share some details of her depression with her roommate (who was also a teammate). Unfortunately, this teammate weaponized the information and used it to bully and harass her CASE 3: 16

17 And then: the complaint And then: the ex-coach Questions: What about the sexual assault? What about the psychological abuse and harassment? What about this coach s behaviour? Outcome: hips repaired, maintained meds and appointments, moved into a new apartment, GPA went from The football player has moved on to the CFL and continues to assert that he did nothing wrong CASE 3: 17

18 THE TOUGH QUESTIONS What are the ethics? What are our responsibilities as physicians? Fully managing a case in which bullying, harassment, or abuse are suspected is not like anything else you have experienced- it tugs at your morals, ethics, and medicolegal responsibility; and can affect relationships and your professional environment. 18

19 FOLLOWING THROUGH Sometimes NOT digging deeper or asking those few extra questions would be the EASIEST thing to do. You don t have to do anything about it if you don t know anything, right? Inaction perpetuates the problem, can have a greater impact on the victim, and can facilitate further victimization. Action can impact careers, result in job loss, but can also affect and potentially save lives. 19

20 FOLLOWING THROUGH Not everything will fall under mandatory reporting laws; however we can have a role in supporting the victim in different ways. Knowing (or inquiring about) pathways for reporting offenses in your organization is a good place to start. Being a support for that athlete and helping them to expand their network of support is also important. Inquiring about safe people to discuss concerns with (ie the coach, if it a case of teammate harassment). Can also be very valuable 20

21 FOLLOWING THROUGH Understanding how your organization handles complaints of bullying and harassment is important- so that accurate advice can be given to the athletes (ie will the complaint and investigation be managed discretely and with provision of protection for the athlete? Or will the athlete(s) be forced to confront their abuser in person?) This would likely influence the athlete s likelihood to report. And you can always call the CMPA for advice!! 21

22 ADDITIONAL SCENARIOS TO DISCUSS? 22

23 THANK YOU! 23