First of all, I would like to appreciate the very fact that I have so many people in the audience at eight in the morning. Either you are very early risers or really enthusiastic about this. Either way, I applaud you for coming in. I also want to thank the APA Scientific Committee for giving us the platform and the opportunity to present what we wanted to present. And before we start, I know the topic is right up there and you are here for that topic. I want to ask you a question. Who do you consider as one of the top people in chess who had really, really lots of issues and ultimately could not live in his country and had to go somewhere else? Oh my God, who is the mind reader there? I was still going to go further with the description. Okay. How many of you watch Netflix regularly? Which show comes to mind when you think of Bobby Fischer? Not his documentary, a fictional one, a book version, a female version. There you go. Did she have issues? Is it just chess or is it all sports? Anybody can have issues, right? I was just singling out a particular sport and that was an indoor one. I didn't mean to push away the outdoors one. There are many outdoor sports, more than indoor sports, which also could be looked into. Dr. Navarro, you missed my joke, or rather my mind reading effort. That's all right. Join us. The joke didn't fly very well, but the answers were pertinent. Two people could answer right on the dot. All right, so I'm Bhagwan Bharu, and without further ado, I hate that term. Yeah, Shakespeare and his much ado about nothing. I need to farm another word to that ado thing. So here we are, enough to say that all opinions in this presentation are of our own and nobody else's. I'm not going to read that whole thing, and I'm also going to tell you all four of us have no relevant financial relationships to disclose. What are we here for? Quite a fancy title we have, Athletes Achilles Hill. We were discussing about Achilles, but that discussion is for another day. I'm going to discuss if there are comorbidities, which of course, athletes are human beings, and as such, they might have similar comorbidities to the rest of the non-athletes. What are the risk factors in athletes? That's a big issue. Then we are also going to see what treatments should be available and what are the barriers keeping them from those treatments. And finally, there's always a finally, and that is to find preventive measures. There are four of us today, and we'll start with me. I'm Bhagwan Bharu, and interesting question. Boxing and Parkinson's, who comes to mind when you think of boxing? All in one voice, there you go, it was one voice, unison. All right, so, and what condition is attributed to him nowadays? Don't read the screen, please, oh, my screen changed, sorry, Parkinson's, right? Recently, we have found out that while boxing is a risk factor for Parkinson's, it is also being recommended for patients with Parkinson's, go figure. First it may have caused it, and now it's going to relieve it, some of the symptoms. So this is the connection that we often miss between things. This was just to pique your interest, and we'll go further with this. The history of sports, as you know, goes back into antiquity. We've just put 3,000 years, it may be more, it may be less, but bottom line, somewhere in that region, what we know as a fact is sports started two things. As a hunter, you needed to be sharp and trained well to run and to catch your prey if you want to survive, or you need to prepare for war, another survival method. Somebody comes to take away your land and your house, you need to beat them up. So what we can say is sports, history is power, politics, and progress. And today, of course, the sports that we see around and the most popular ones did not even exist for a long time. They're all recent ones, except maybe the marathon, right? Oh, I was too early in my talk. Here it is. About 120 years ago is what we can trace most of the stuff. Today they are in popular culture. You guys could immediately point out the names that I asked you of. So what are we here for, actually? What are we talking about? We're talking about the way sports has progressed to a point where if I'm not at the top of the game, I'm nothing. Yes? And that is healthy or unhealthy? You could argue both ways, one way or the other. The point is reached where now they have become our heroes. So what has that got to do with us? We are at the APA, American Psychiatric Association, and we're talking about sports because sportsmen also need help, and we should be there to see their unique situation and be able to provide the right kind of help. How does sports influence mental health? Good question, and the thing is that when a person is sportsman or sportswoman, what happens to their serotonin, their norepinephrine, their dopamine, their cortisol, their sleep? Nothing gets better, right? Only up to a certain stage. Remember, there are some syndromes that occur if you are going beyond what your scope is, what your range is. Stress becomes less, and more importantly, the cognitive development is much nicer. If you are a true sportsman, most have been seen to be more creative, have cognitive development, and self-regulation. I forget the name, but recently somebody was in the news who also had on the side a lot of artistic involvements. The name beat me right now. The other thing is what sports, team sports, now we're talking of team sports, what do they do? They create a lot of resilience, empathy, confidence, empowerment, social responsibility, all good things in the line of progress, and more importantly, if you involve the teens, what happens? Substance abuse goes down. Other reckless behaviors take a back seat, and those who spend time in sports do less time where? On the media. Not against social media, I'm all for it. In fact, I get lost if I don't get a message every now and then. However, we need to put it in its perspective and not be addicted to it. These two slides, the next two slides are pertaining to a healthy mind and a healthy body. What is the role of mental health in injury after sports participation? And I'm not going to give you a lot of details because otherwise my colleagues will be left with nothing to talk about. Repetition can be boring, right? So here are two points, and here are two other points. And by the way, all these are on your phone. You can download the slides and watch them at your leisure. Some of my slides can be a little more text dense, and I apologize for that, but I wanted you to get everything that I had read up so that I don't deprive you of anything I felt was important. Paralympians, that's another category of people who go through lots more challenges. These are the ones who have never been given due attention as far as mental health is concerned. Coming to what specific things happen, one of them is called overtraining syndrome. Somebody sitting for their exam, let's say law exam or medical school exam, do they ever have this overtraining syndrome? I don't think so. You can study all night, be an all-nighter, take all the Adderall you want, and still there won't be overtraining syndrome. However, this is unique in sports. What happens? And I didn't mean to suggest people should take Adderall, okay? They do, even without my saying so. It's terrifying. All right, so what is an overtraining syndrome? And I'm not going to talk about anxiety, MDD, you all know that quite well, eating disorders, body dysmorphic disorders. Each sport has its unique challenges. By the way, which particular sport has the most amount of eating disorders? And I think, again, you can all say in unison. There you go. See? You guys know everything about everything. Why are you here? Overtraining syndrome. Now, that's something that we discussed about because it can affect multiple body organs. Substance use disorders is another category that is found to be uniquely distinct amongst athletes. Body dysmorphia. This forms into two parts, actually. The eating disorder, people claim it as their own, and there's a whole new section coming up. People say it has nothing to do with eating disorders. It's a whole new category. DSM-6 may be able to decide that. Right now, the term that is being thrown out is bigorexia. People who look normal, act normal, are the ones, and they're not easily detectable unless you ask of them. So it's a subtype of body dysmorphic disorder, not easily seen unless you keep asking more and more questions. TBI. I still remember to this day, I was sitting at my breakfast table in the morning, having my breakfast, and on the TV, on ABC News, they showed two footballers coming together and one of them just turning sideways and falling. He never recovered from that fall. I'm forgetting that whole event. It was in the 90s. And that sort of created an impact in me. A young college man playing football, aspiring to do great things, became quadriplegic. That's not just TBI. That's much, much more intense. What we're talking about today is the injuries that happen. And who is there to take care of the mental aspect of that injury? Concussion and TBI sometimes are used interchangeably. There is a difference. While TBI, a person may be alert, you may not even realize that the person has had TBI. And the implications can come much later. On the other hand, concussion is pretty easy. We have those tabulated timings, 0 to 5 minutes, 5 to 15 minutes, and more, or 30 minutes. And then we decide whether it's mild, moderate, or severe. Coming to another aspect, which my colleagues will discuss more in detail, is about medications. Remember, the medications we give have all side effects. They may be mild, may be tolerable, but when it comes to sportsmanship and activity, they can form a major barrier. Dry mouth, for example, is still workable. How about somebody who has blood pressure going down, postural hypotension? Do you think that athlete would ever take that medication? Same goes for all the classes of medications that we offer. And with that, I think I have already overstepped my time. So I'm going to hand over to my colleague, Marissa Ann Manning, who's going to talk to you about prevalence of psychiatric comorbidities. Please welcome her. Thank you. Good morning, everyone. Thank you for being here bright and early to listen to our session. I'm going to start off my portion of the discussion today by talking about the prevalence of psychiatric comorbidities in athletes. And then I'm going to discuss some of their unique stressors and risk factors that really set them apart from the general population. So I wanted to start off this portion of the session with kind of a little bit of a story to set the scene. I know Dr. Brewer had mentioned earlier, it seems like we have a lot of Netflix lovers in the room. Has anyone seen the documentary The Last Dance? All right, some. Anyone ever heard of Michael Jordan? Faith has been restored. OK, so essentially Netflix published this documentary, The Last Dance, back in 2020. And it was an extremely popular documentary. It actually went on to win an Emmy for Outstanding Documentary. And the central storyline of this film is kind of centered around Michael Jordan and his rise to fame while he's playing basketball for the Chicago Bulls back in the 90s. And the documentary gained quite a following because it really documented a truly iconic time in professional sports and professional basketball as well. And while I was watching this documentary, I was particularly struck by Dennis Rodman and his role and his story in the documentary. And so the central conflict with Dennis Rodman is that he took this infamous 48-hour vacation to Las Vegas midseason. And the story for the documentary is quite sensationalized for the sake of TV. And what Rodman was up to in Vegas for two days is not really within the scope of our discussion today. But for most people, taking a two-day vacation or a two-day break from their jobs is not really headline-making news. But for a professional athlete to do something like this, it really is unprecedented. And it made me wonder, you know, what might have been some of the reasons why he felt he needed to take this break and take this time away from his program. And, you know, what we now know in 2023 is that Rodman has struggled with his mental health pretty publicly both before, during, and after his playing days. And he's spoken publicly about his struggles with things like depression, anxiety, substance abuse, and even suicidal ideation. And all of this was occurring back in the 90s when mental health and mental wellness didn't really have the visibility that it does today. And so often we think of athletes as being invincible or being larger than life. And in many ways, they are larger than life. But so much so to the point that an athlete taking a two-day break, which might just be a regular weekend for the most of us, is headline-breaking news. And so the truth is that Dennis Rodman's story is just one example of many. We find that in the past 10 years there have been more and more instances of elite athletes coming forward to speak publicly about their struggles with mental health. And oftentimes we see this pattern of them coming forward to speak up after the fact, after there's been an incident of some kind. And only more recently are we starting to see more of an aim towards prevention and recognition. So I have some examples listed here. First and foremost is Michael Phelps. I'm sure many of you have heard of him, an Olympic swimmer, still to this day the most decorated Olympian of all time. And he was famously quoted for saying that, for a long time I saw myself as the athlete that I was, but not a human being. He really embodied this idea that the public has of athletes being larger than life. And even with all his success and all his fame and all his Olympic medals, he still kind of fought this internal battle against himself and struggled with depression and SI and substance abuse. And now he's actually an ambassador for companies like Talkspace and works to provide and improve access to mental health care. There's also the story of Kevin Love, another NBA player who struggled with anxiety and panic disorder, and kind of talked publicly about how you can't achieve yourself out of a depression. So perhaps the most headline-breaking story or headline-grabbing story that I'm sure all of you have heard of is that of Simone Biles when she withdrew from the Summer Olympics in Tokyo due to mental health concerns and concerns that she wasn't in the right headspace to perform her very demanding stunts that she does as a gymnast. And she was met with both backlash and as well as praise for withdrawing from the Games. And she kind of really started this conversation that mental health and physical health are kind of one in the same. And then lastly there's also the story of Lane Johnson. He was an offensive tackle for the Philadelphia Eagles, a team that is near and dear to my heart. He actually missed three NFL games due to severe anxiety and talked to the press about how he worked closely with a psychiatrist to kind of figure out his medication regimen and get back to playing strength. And so what we learn from these very public examples is that mental health affects athletes across many different sports and across all levels. And while these are very high-profile examples, they are representative of the kinds of mental health struggles that athletes have and are struggling with. And as I had mentioned, I believe that one of the steps towards prevention is recognition. So what are we as clinicians looking for in our patients that might be athletes at any level? And so I wanted to start talking a little bit about prevalence. And so when we compare the prevalence of mental health conditions and athletes to the general population, we find that it's pretty equivalent to their age-matched peers. So for example, what you would expect to see in a population of 18 to 35 year old men and women is what you would expect to see in those population of athletes. So it's not really the diagnosis itself that's different, but rather their unique stressors and risk factors. So common things are common. Depression, anxiety, substance abuse, eating disorders. So no real changes. It's really just their stressors that impact or might impact the development of a disorder. And so when we start to actually parse out these athletes into individual groups based upon their sport, we do start to see some of those unique patterns develop. And this can kind of give us a clue to what we as clinicians should be looking for when we're treating this population. So for example, eating disorders are much more common in sports that focus on the individual rather than the team. Think sports like gymnastics, diving, bodybuilding, wrestling. Sports where weight carries a specific significance and even is a prerequisite for participation, like wrestling, making a weight class. A rather concerning statistic was that over a third of female NCAA Division I athletes reported attitudes and symptoms that would put them at risk for developing anorexia. And when it comes to substance abuse, we do start to see some differences in the substance used depending upon the sport that they play. With the exception really being alcohol, it seems that for athletes that use alcohol, they use it in the same way that their other age-matched peers would, you know, mainly for social reasons. But when it comes to substances like tobacco, it's actually more common in baseball players and football players. Whereas stimulants and steroids are actually more common in men participating in power sports like weightlifting or bodybuilding. So when it comes to depression and anxiety amongst athletes, we kind of start to see this similar pattern. It seems that these conditions are more prevalent in athletes that play individual sports or sports where judges determine an outcome. So if you think of a sport like tennis, it's one person versus one person, and they are competing for the outcome. Whereas a sport like gymnastics or figure skating, it might also be one versus one, but there's a panel of judges kind of determining the score. And so that seems to pose a unique risk for conditions like anxiety. And we can kind of think of this in contrast to a classical team sport such as basketball, where there might be five players on the court to share that responsibility and that outcome of the game, rather than just the one person kind of places that burden and anxiety on them to perform to the level. There are also some instances that are associated with anxiety, and athletes that seem to identify as playing a sport for goal-oriented purposes, rather than, you know, for fun or for love of the game. So things like obtaining a scholarship or trying to stay in shape might be associated with development of anxiety. It seems that the why behind, you know, why athletes choose to participate in a sport also matters. So as I've mentioned, what really makes these athletes unique is their unique stressors. And we've seen as we kind of parse out amongst sports that there are some patterns that develop with one higher prevalence of one diagnosis or another. But you know, as I've mentioned, against the general population it's pretty much the same. And so I wanted to talk about really what makes this population different and stand out. And so I have a list of some of the common stressors here that an athlete might be dealing with. First and foremost would be critical media exposure. This is more of a more of a concern nowadays, especially with the advent of social media. You now can have thousands of people watch, you know, a 10-second clip of the, you know, dumbest mistake you made on the court, and they'll give you all their critical feedback. And so how might that weigh on their mind? There's also an increase on travel and training demands on athletes starting even as young as high school. We used to think classically of sports as being more of a seasonal participation, such as you'd play a fall sport or winter sport or a spring sport. But now these sports are actually year-round. So it's preseason, it's postseason, it's summer travel programs. So it's a year-long kind of non-stop really intense training schedule. There's also concerns about earning potential, you know, competition for scholarships, competition for NIL deals, name, image, and likeness deals, as well as professional aspirations. And of course always injury can be a concern in this population, as well as the transfer portal, which I'm going to touch on a bit in this next slide. So I wanted to touch on these two landmark changes that I had mentioned, both the transfer portal and the NIL deals. So transfer portal was established to help kind of unify and regulate how athletes could transfer at the collegiate level from one school to another, and they can do so without penalty. As well as the advent of name, image, and likeness deals that allows young athletes to profit off their name, image, and likeness, and kind of sparks this competition for pretty lucrative brand deals, kind of encouraging that goal-based participation. It might be interesting to see how these new landmark changes in sports might affect the mental health of these athletes. For example, will these new changes maybe exacerbate mental health conditions by encouraging athletes to focus more on goal-based participation, rather than for the love of the game, which we have seen has been associated with development of things like depression and anxiety. Or, you know, might these new changes allow athletes more autonomy and sense of purpose in pursuit of their goals, and allow them to seek out better and healthier opportunities, especially when it comes to maybe transferring to a new school and finding a more supportive environment, or being allow them to make money, and profit, and support themselves. In addition to the the prevalence of mental health disorders like I've talked about, it's also important to kind of talk about what are some of their unique risk factors. So it seems like the type of sport, the coach, and the outcome are all things to consider when if you're doing a risk assessment of an athlete. So things that are associated with maybe being more of an increased risk would be, you know, as I had mentioned, individuals that play individual sports rather than team-based sports. Contact sports also pose a unique risk, and that's kind of thought to do to the increased risk of injury in contact sports. Also, the coach is actually a really important factor. If you have a coach that focuses solely on success and performance of their program versus the well-being of their athletes, that can be an increased risk for these people. And it's actually been shown that a younger athlete that identifies as a coach of having a supportive relationship with them is actually protective for their mental health. And then also, as I mentioned, outcome, being judged for a win versus defeating an opponent, that being judged is more of a risk factor for these athletes. And so some other risk factors that I want to talk about are obviously sports-related injury and concussion, performance failure, and overtraining. Both injury and performance failure can kind of exacerbate this identity crisis that a lot of athletes may struggle with when their playing days are suddenly or unexpectedly ended or even cut short. And then, as I had mentioned, overtraining, really rigorous year-long training schedules, and the role of extended travel because of this. And then the last thing that I wanted to talk about was transition periods. They always pose a unique risk in any of our patient populations. Think about a transition from someone, say, from an inpatient unit to outpatient care, transition points always pose a risk. And with athletes, it's really no different. But how I think about their transitional periods is more longitudinal across their career. So going from a junior athlete to a more elite athlete, to end of career versus retirement. I think about end of career as maybe a collegiate athlete that graduates school and is then done playing organized sports versus retirement of a professional athlete many years later. And we often find that the further along these athletes get in this longitudinal career, the harder it can be to separate themselves from their identity as an athlete. And so what might that be like for them to suddenly, you know, lose that part of themselves? And it can be hard for them to kind of parse out, you know, where they start and where they end and where the athlete starts and where the athlete ends. They've been so deeply embedded for so many years in their sports, and how might that pose a unique risk to this population? These are my references. And it is my pleasure to introduce our next speaker, Dr. Katrina Wachter. Thank you, Dr. Manning, for that wonderful discussion. And thank you everyone for being here. I just wanted to take a quick poll of the audience before I got started. How many people in the audience did play a sport in high school or college? A lot of people. Okay, perfect. So the next half of this talk will be including collegiate athletes in part of our discussion, so hopefully this will feel relevant to a lot of you. So I wanted to start off giving us a framework to work through with the second half of this presentation, and to be able to gain a better understanding of how we can treat and even prevent mental illness in athletes. So public health and social policy has told us for a long time that the framework for mental health care can't just be treatment. You may have heard that phrase, health is not simply the absence of disease, before, and this is especially true in mental health. So this figure up on the screen describes the spectrum of care, of prevention and treatment, all the way to recovery and continuing care, which includes things such as self-management, relapse treatment, and rehabilitation. This section of the presentation will focus on the green and yellow sections that prevention and treatment section, which also does encompass early intervention, which I will talk about as well. So the need for a framework for mental health and athletes is not a new concept. However, over the last 10 years there's been an absolute explosion of research conducted looking at the needs of this unique population. This was highlighted in an event that happened in 2018, when the International Olympic Committee, or IOC, they convened in Switzerland for a three-day meeting that focused on the creation of a consensus statement on clinical practice and individual and systemic interventions to improve mental health among elite athletes. So planning for this consensus started way back in 2017. It included collaboration by 13 different countries, 20 topic areas were discussed, including prevalence, diagnosis, systemic and systematic prevention, as well as individual prevention. And then they talked about recommendations for both pharmacological and non-pharmacological treatment of athletes. They defined elite athletes as those competing at professional, Olympic, or collegiate levels, although I would argue that a lot of this can be applied to any sort of athlete. And this consensus statement was published in 2019 in the British Journal of Sports Medicine. So I'm going to take a little bit of time to pull apart the consensus statement and give you some of the high-yield recommendations that they made within that statement. So the IOC consensus statement, when viewed from a high level, recommends that the management of mental health symptoms and disorders in elite athletes should take a comprehensive, integrative, athlete-centered, holistic approach that looks at the full range of the emotional, mental, physical, social, spiritual needs of these athletes. It should also take into consideration the elite athletes' particular needs and circumstances, used evidence-based treatment wherever available, and then also recognize the difference between cultures and countries that you may have to consider when you're treating athletes, because elite athletes exist throughout the entire world. And then the IOC further breaks down the treatment into two categories, or puzzle pieces, as I like to call them. You have psychotherapy and pharmacological treatment. And we'll dig into both of those shortly. One thing that I did want to note that the IOC talked about in their statement is that much of the research that they looked at came from high-income nations, so in nations like the United States. And most of these high-income nations do have more health services than the middle and low-income nations. So it's just something to take into consideration and put into context when we're talking about this information. So we're going to start with psychotherapy first. Research has shown, as most of you probably know, that with or without pharmacologic treatment, psychotherapy is a really effective treatment for a variety of mental disorders. But it is under prescribed a lot of times. There is a paucity of studies looking at specific psychotherapies in elite athletes. However, the IOC statement did lay out some shoulds and should nots for this unique population. So thinking about what clinicians should consider or should try to do when treating an elite athlete, the first and foremost thing that they mentioned was be flexible. Athletes have really busy schedules. They're traveling. They're training. So being flexible when you're able to meet with these athletes is really important. Although taking into consideration, don't keep allowing persistent canceling or molding your schedule around that person, which could lead to boundary violations. Clinicians should also utilize couples or family therapy when they're thinking about the holistic view of the elite athlete. So if there's something that's impacting functioning that's happening in the home or in the family life, that is something that the clinician should encourage. Clinicians should also recommend psychotherapy plus pharmacological therapy when indicated, so moderate to severe disease. Obtaining collateral information from coaches, colleagues, parents, anyone who the athlete consents to you talking to, can also be very helpful when thinking about how to treat this athlete holistically. And then also, you know, as Dr. Manning mentioned, substance use is a risk in elite athletes. And insisting that the athlete undergo substance use treatment if necessary, if there is something that's presenting itself from the substance use area. On the opposite end of shoulds are the should nots. So a clinician should not agree to see a surrogate for psychotherapy sessions. So that would be someone like a coach or trainer. They should not be taking care of an athlete and their coach at the same time. They should not be gaining information in a therapy session from a coach or trainer, and that is separate from gaining collateral information. Clinicians should also not provide or recommend experimental treatments, if at all possible, because this gives athletes a false sense of hope that may not actually help their current situation. And then clinicians, as I mentioned, should not allow persistent cancelling of sessions in order to still maintain those boundaries that we use as clinicians. The one thing I did want to note about psychotherapy, if you think about elite athletes, they have this very unique skill and personality characteristics that they bring to the table, like discipline, compliance with recommended regimens that actually makes them really good candidates for psychotherapeutic interventions if you're able to get them in for sessions. So now that we've discussed the treatment of elite athletes from a psychotherapy perspective, I wanted to switch gears a little bit to the other piece of the puzzle in treatment, which is pharmacotherapy. So rather than boring you with the details for every single condition that they listed in the Consensus Statement, which was a lot, and I recommend you read it, it's free access online. I instead wanted to just focus on the four key considerations that the IOC gave when thinking about prescribing medication for mental illness treatment. So first it's important to consider the potential negative impact on athletic performance. As Dr. Beru alluded to, we give medications that have lots of side effects sometimes. When we think about the different side effects, weight loss, weight gain, dizziness, insomnia, cardiac effects, sedation, these are all things that can significantly impact an elite athlete's performance in their given sport. So it shows that psychoeducation when prescribing medication is absolutely key. The second consideration is the potential therapeutic performance enhancing effects from a medication. So that would be based on the improvement of the condition in the medication that the medication is designed to treat. So that would be our good effects that don't really give a competitive edge outside the improvement in their mental health. So a good example is SSRIs. We use this to treat anxiety and depression. And SSRIs have a performance enhancing effect by treating the athlete's anxiety or depression. But there's really no ergogenic benefit to an SSRI and thereby it's usually not prohibited in professional sports. This leads us to consideration three however, which is the potential for non-therapeutic performance enhancement effects. Most notably, usually stimulants is the one that most people think of. So this would have an effect on athlete performance that's outside of the therapeutic effect of treating ADHD, for example, which is why it's banned. And there needs to be a longer conversation if you are trying to treat something with stimulants and if there are alternatives that the athlete could be taking. And then finally, and we should be doing this with all of our patients, but they did mention this especially, is the potential safety risks that come when prescribing medications to athletes. So medications such as lithium, which the hydration level of the athlete can vary the level of lithium in the body, probably not the best medication for an athlete who's working out constantly, sweating, maybe not hydrating as well as they should, or hydrating inconsistently. So taking those considerations is also very important when prescribing medications. So I wanted to take a little bit of time before we transition over to prevention to touch on the ecological systems model for elite athlete mental health in the sporting environment and how it plays a role in treatment. So like I mentioned, treatment will frequently involve other people like family, couples, etc. and without acknowledging this wide-reaching ecological factors that contribute to mental health in athletes, we would be missing the mark basically. So thinking about an ecological systems model in athletes, the smallest circle would obviously be the athlete, how they have different coping skills and the attitudes that they bring to the table, both within their sport and within their mental health. Thinking one ring out, you have your micro system, which would be the people closest to the athlete, like coaches, parents, sports medicine staff, so trainers and things like that. Further out would be the individual sport as a whole, so how mental health is viewed in the particular sport the athlete is playing. And then the largest ring within this systems model would be your macro system. So that would be your sporting environment in general, public, social media, ESPN, things like that. So it's very far-reaching and very broad in terms of the impact that it could have. So now that we've discussed treatment recommendations, largely from that IOC 2019 consensus statement, but also looking at it from an ecological model, I wanted to shift gears a little bit into some prevention. So prevention aims to reduce the risk of mental health symptoms developing or to minimize their potential impact or severity. And there are three big facets that come to light when thinking about the population of elite athletes, acknowledging barriers to care, individual strategies for prevention, and then organizational strategies for prevention. So I would think probably none of us in this room are strangers to the fact that there's a stigma associated with mental health care, big surprise. People are afraid of the unknown, and until recent years, mental health just wasn't talked about in the mainstream. Unfortunately, this, as Dr. Manning referenced, is seen in an even higher degree in elite athletes. So they really do have a heavy load to bear when it comes to performance and personal image. The stigma is changing by more athletes speaking out, but barriers to care definitely do still exist and it's important to acknowledge those. So when you think about individual stigma, athletes a lot of times will have a fear of judgment from peers or coaches for seeking behavioral health, for saying that they aren't able to fix the problem or fix themselves on their own, to train themselves out of the anxiety or the depression. There may also be a lack of psychological safety or the ability to feel safe to speak up in their environment about their mental health struggles. There may be a fear of loss or a fear of the scholarship being revoked if they seek mental health treatment, especially in your collegiate athletes. And then there's always this potential, and I think this gets higher the more mainstream the sport is, the potential for lack of confidentiality, so leaks, people finding out about treatment when you wanted to keep it a little bit closer to the vest. All of those are fears or barriers that may influence an elite athlete's willingness to receive care. And then thinking about the cultural stigma, so the other side, so thinking about criticism for fans. I am sure most of you did see all of the backlash for Simone Biles, for example, you saw both sides of that. People were angry that she was doing this and choosing to prioritize herself over her country, as they put it. So the criticism from the fans and other people worldwide can be a huge factor that stops elite athletes from seeking care. There's also a history of discrimination for minorities seeking care, that there is a specific stereotype that exists that someone may not want to perpetuate by seeking care. From a familial cultural standpoint, the feeling of bringing shame or dishonor onto their family if they seek care. And then in culture in general, just differences in what symptoms mean, so anxiety may be pathologized in one culture, but it's a normal occurrence that doesn't require treatment or any sort of intervention in another. So these are all barriers that could exist that stops an elite athlete from getting help. So keeping in mind that stigma, there are several individual level strategies that can be utilized as preventative measures for developing mental illness. So one of the most robust strategies that research has shown involves mental health literacy that's tailored to the unique individual's background and where the athlete is in the center of this literacy. So these programs can be facilitated by anybody, although it's recommended that they're facilitated by mental health professionals, because those are the people that can answer all of the questions that they may have. The extensive knowledge into the field is very helpful when creating and implementing mental literacy classes. And there are usually four basic tenets that are recommended to cover in mental health literacy. So that would be your risk factors, your signs and symptoms of mental illness, how you would seek help, and then the self-management of transient mood states. So anxiety is normal. How do you deal with the anxiety in the moment and not let it become debilitating? And noticing if it is debilitating, how do you get help, for example? In addition, there is another individual level strategy that is frequently utilized. These are the individually focused development programs, and these are even more specialized to the athlete. So they can help athletes identify personal and career goals, and it helps the athlete develop what they call a parallel non-athlete identity, which has been shown to reduce the instance of mental illness presenting during the period of transition from athlete to retired athlete or athlete to no longer athlete. In contrast to the mental health literacy programs, the individually focused development programs probably shouldn't actually be facilitated by a mental health professional, but it should be facilitated ideally by what they call a peer workforce, which is essentially other individuals, coaches, previous athletes who have experienced mental illness and have training to share their knowledge and support others. And then the third one, and I think we're all very familiar with this, is mental health screening, which we will talk about a little bit more in depth. So I'm just going to very quickly go over this section because my colleague, Dr. Nguyen, will go into screening tools a little bit more in depth. But this is the final piece of screening and prevention. So research has actually developed a good amount of screening tools that are tailored specifically to athletes. They vary in scope and size. You can see the APSQ, for example, it's 10 questions that looks at three domains of mental health strain, like self-regulation, performance, and external coping. In addition, there are depression screeners that have been developed for athletes. The profile of mood states, which isn't specifically for athletes but has been used frequently in a variety of athletic realms that looks at six dimensions of mood swings over a period of time. And then the recovery stress questionnaire, the REST-Q SPORT, which is, again, specific to sports and that looks at the elite athlete's responses to training load and measuring that recovery stress state of the athletes. So the IOC did a lot of things in that 2018 meeting that they had as well as their consensus statement. So they also recommended two screenings that they developed for the assessment of elite athletes. So the first one is the SPORT Mental Health Assessment Tool 1, or the SMAT-1 if you will. This was developed for sports medicine physicians and other licensed and registered health professionals like psychiatrists, psychologists, to assess elite athletes. And it consists of three parts. The first is a triage using the APSQ that I mentioned in the previous slide. The second part is disorder-specific screening tools, so like a GAD-7, a PHQ-9, et cetera. And then the third is an actual clinical assessment by a sports medicine physician or a psychiatrist or psychologist. The IOC recommends that this tool be used within the pre-competition period, at the end of a competition period, and whenever there's large changes in events, so like injury, big competitions coming up, things like that. So it can be used throughout the whole sport year, if you will. For non-sports medicine physicians and other health professionals, the IOC also developed the SPORT Mental Health Recognition Tool, or the SMHRT-1, which was developed for athletes and their entourage, like friends, fellow athletes, families, and coaches. And this is more to be able to use it as an early intervention tool that presents a list of athlete experiences that could be indicative of mental health problems or higher risk for mental health problems. And then it helps them get plugged in with the appropriate treatment through a mental health professional or a trainer, et cetera. So then, while individual-level strategies definitely have their role in prevention, organizational-level strategies also play a large part in the prevention of disease and promotion of mental wellness. So this list is by no means exhaustive, but I did want to highlight a few strategies that you could utilize from an organizational standpoint. So first and foremost, organizations have to make mental health a priority. We're seeing strides being made in professional sports already, such as the NBA and the NFL. Like in May of 2018, the National Basketball Players Association actually announced its own mental health and wellness program that connects players with mental health professionals in every single city that there is an NBA team. These providers are completely separate from the NBA or the Players Association, so there is that high level of confidentiality. And the NBA also adopted new rules starting in 2019 that require teams to have at least one full-time licensed mental health professional, be it a psychologist or behavioral therapist. And they have to be on the full-time staff, so they travel with the team. They're always available for the team, and every single NBA team needs one of those. The 2019 change also said that NBA teams need to have a psychiatrist that's essentially on retainer for anything that might arise. So having someone in mind, having a plan available if a mental health concern or crisis does evolve, the NBA has put the groundwork to be able to attack that before it gets too bad. The NFL has also followed suit with actually a lot of these guidelines. I have a feeling we'll be seeing this in the other major professional sports, probably in the years to come, if I had to guess. And then so second, you know, after making mental health a priority, mental health versus mental illness and the distinction and education on those differences is key. Seeking help with your mental health is not the same as treatment for mental illness. And being able to have a top-down approach when you're thinking about an organization to promote mental wellness, not treat mental illness, will help in a lot of the prevention strategies that I've been talking about. And then finally, as I mentioned, having those mental health providers on the team, so a psychiatrist, psychologist, therapist, teams and organizations have actually started having a chief wellness officer. That's something that we're starting to see in the field, that these people's jobs is truly just to make sure that these athletes are remaining well in their high-stress jobs. So keeping those things in mind from an organizational level, it's going to be really helpful in the future. And then finally, I'd be remiss if I didn't include some resources that I found along the way that talk about mental health promotion and treatment. So similar to the IOC guidelines, the IOC, as I said, was very busy. Also created this 100-page toolkit called the IOC Mental Health in Elite Athletes Toolkit. Completely free, available online if you Google that. It details diagnoses in elite athletes, the role different stakeholders can play in treatment, and then as well as resources. In addition to the toolkit, two prominent websites I found exist. Again, these are not the only two websites, but they seemed like pretty great resources. The first being Athletes for Hope and we'realllittlecrazy.org, which has recently been rebranded as samehereglobal.org. So we're all little crazy is a mental health movement that was started by sports professionals that basically tries to reduce the stigma of being sick versus not sick and think about the spectrum of mental wellness and illness, as I mentioned previously. And a lot of professional athletes have teamed up to tackle the stigma and provide programs that provide education on the spectrum of mental health. And then Athletes for Hope was a nonprofit created in 2016 that promotes philanthropy and commitment to helping others. They have a lot of different initiatives that they work on and they even teach middle schoolers about wellness and mental health, which I think is a really beautiful model of universal prevention. It's tying it back to the first slide about that prevention strategies. So these are my references. And then I will turn it over to Dr. Nguyen to discuss screening tools and the proposed new risk stratification. All right. Good morning, everyone. You know, I didn't put it together until this morning that there was a Eagles fan, or a spy, in our panel today. That was the scariest Vikings game I've ever been to. I'll probably never do it again in Phillies. And if you do, bring a different jersey. I don't know why it's progressing, but I'm gonna go back to the beginning. So, again, my name is Lieutenant Winn, as my supervisors would call me. Dr. Winn, as my patients would call me, and Mr. Nguyen, as my child and adolescent patients would call me. First year fellow, Walter Reed. Glad you guys are here today. And I'm the last thing standing between you guys, a good conversation, as well as, well, this new risk stratification system. So, just to go back to the idea about what it means to kind of address mental health in athletes. I think a lot of the things that we like to highlight, at least in this talk, is that you can't take it out of the context of what you're trying to find. So, in this, more than anything else, we try to highlight, very specifically, what is it about an athlete and their risk factors that are quite unique just to them? So, on here, more than anything else, I think Dr. Manning did a good job of kind of highlighting how, before, Michael Phelps kind of mentioned that he had a brand with him, where he saw himself as a swimmer before he saw himself as a person with fallibilities. So, that's probably the first thing out of all of this, as well. How much are they akin to their identity, and more than anything else, potentially, their team? The second is their pressure to perform, right? For us, more than anything else, we don't have to be probably as on for them as usual. So, they have the training, and then they have the game day, as well. Yes, and a two-day break might mean that that makes some news for some situations, but more than anything else, you have to consider what it means to be on. Physical injuries is kind of the, I think, worst nightmare for most athletes out there. I remember in soccer, if you were to get an injury, more than anything else, getting to varsity the following year was gonna be very, very low, right? So, usually, that is a good prognosis for the following year, if not your performance for the rest of the team, and I think for most athletes on team, they want to contribute more than anything else. Transition points, we've talked about before, and then I don't think I need to hammer home anything more about stigma. So, I get to introduce to you guys a psychometric that we came up with, right? In case you guys are wondering, it's probably not that easy to measure behaviors more than anything else. So, we have to hammer down some semantics here. The metaphor that I love using for this is actually a compass, right? So, you're all compass makers, right? Dreams come true. So, if reliability and internal consistency, when we're talking about a specific psychometric, right, are we actually gonna make something that will give us the same result each time? So, for that compass, if you were to turn it upside down and put it face up, is it gonna actually point in the same direction each time? Or, and then if it's not, how much is it going to vary by? How much it's actually going to vary by is more than anything else the Cronbach alpha, and that's what you would use to measure the internal reliability in regards to how much the variation is gonna be each time. So, you know, you turn it over, it's gonna tell you a certain direction, hopefully each time, and whether or not it's gonna be true is gonna be based on the validity. And in this, it's gonna be the validity about whether it's actually facing true north, or if you're by a very big light pole, or a very big magnetic field, it's not gonna give you that actual direction each time. And then oblique factor analysis, that's quite technical, but more than anything else, it's the balancing of the compass in itself. So, of all the psychometrics, are there other questions in there that might confound, or, well, are not necessary for the actual measuring of the behavior that you're looking for? Sorry, it's getting a little bit abstract, but that's kind of the bunny hole I have to go down to make sure that what I'm doing is not just something I just put together. So, how did we get to our scale? So, yes, I wanted to base a lot of the things on evidence, so I went through quite a bit of literature. There are a ton, a ton of questionnaires out there, some with a lot of evidence, some with no evidence, and some that are just very weird, as to why you'd wanna use that as a measuring tool. We scrutinized each and every single one in regards to sensitivity, reliability, and then we tried to put it in the same context as well. And then, last but not least, we pulled each and every single one of the questions that we thought were pertinent to identify and target a lot of the factors that we talked about earlier before. So, here is the giant list of psychometrics that I have found to be used for kind of measuring this idea about wellness of athletes. Hopefully, you guys are able to, you know, recognize a few of them on there. Luckily for you, I went through each and every single one and I highlighted the ones that had a very high internal reliability. This is starting to become a mental exercise here. And I picked out the ones with the highest sensitivity, specificity, and more than anything else, reliability, when it comes to the questions that they were measuring. The ones that I picked were the brief symptom inventory, the sports anxiety scale, general health questionnaire, as well as the athletic coping skills inventory. Let's dive into those. So, again, validity, reliability. Each and every single one is very good at measuring anxiety as well as some of the depressive symptoms as well. And then, the one that I didn't want to miss was ensuring that we had a good measure of resilience in there. I think in most psychometrics, we're just looking for the things that put them at risk but probably not so much the protective factors. And I think the protective factors should definitely be taken into account every single time we're measuring the whole person. And then, lastly, the brief symptom inventory. Interestingly enough, it also measures this hostility, phobic anxieties, as well as other psychotic features. Usually at that point, I don't know if you need a good screener for some of that, but if that's what the coach is for. Throughout all this, I ensured that each and every single one had a good alpha, a Cronbach alpha of at least 0.75. And so, if we were thinking about the compass again, it's gonna hopefully point to true north, 0.75. So, again, just to reiterate, because I am a fan of redundancy, maybe you guys are as well, these are the things that we're looking for. And this is the questionnaire that I came up with. This is a little bit more in production than it is in actual publication, so bear with me here. Acronym aptly put together is AFLEX. It's Athletes' Foundational Layer Examination, right? The emojis translate out very well, and I think that hopefully will connect with all the athletes quite well. Of all of this, every single question did come from one of the four questionnaires. The thing that they're measuring is on the right, or the thing that we're hoping to capture. And then there are 11 questions, because I like prime numbers, and I like to give people anxiety. And the one that is not on here, and it's from myself, is number six, and that is the one question I was hoping for to find out of most of these questionnaires as a protective factor, but unfortunately I didn't find it. The other item on here is that there are three protective factors. Someone's doing this. There are three protective factors on here. One, I generally feel happy and rarely sad. I maintain emotional control regardless of how things are going for me, and I have someone I can turn to for support. I don't know why eight turned out the way that it did. I'm gonna blame my colleague for that. But hopefully it'll show up on the other slide. This is the disclaimer that I would put on every single scale. Obviously, this is more of a screener to hopefully give us the signal more than anything else about what is potentially going on with the athlete. The person that would be administering this psychometric more than anything else would be the coaches as well as the staff thereof. I wouldn't say this is something that you can just hand to another athlete to do to another athlete. More than anything else, I draw that line because I think of the best third party to observe the behaviors of an athlete's performance as well as mindset. I tend to defer then to the coach, if not some of the ancillary staff. And that's what the scale I'm going to say is gonna be intended for. And that's probably why more than anything else this disclaimer is here. I wanna also say that it is a little bit more binary as well whether or not we're gonna say has symptoms, does not have symptoms. And then a little bit later on, there's a gradient about how much worry or how much urgency should be there. This is what the questionnaire would look like. These are the answers in regards to the psychometrics. One of the more fascinating things that I've found about very good gold standards out there is that in regards to the numbers that they have, the frequency or the point system or the system, binary zeros and ones actually have worked out much better than not, especially when it comes to a screening tool. So in this, yes, the frequency can give you a little bit of information as well. But if you're looking for a yes, no answer when it comes to a certain signal of, well, in this case, wellness and behavior, the 0011 system works well. You'll see this in the Vanderbilt. You'll see this in the gold standards for autism spectrum disorder of screening of ADOS-2. And the max points you can get on this is 11. With the asterisks that you see on here, it is actually reversed. So those are the protective factors. And if they answer never or rarely, those would actually be positive points when it comes to the final scale. Based on the points that come about from this, this is the urgency or kind of the action point that we would kind of recommend at the end of all of this. We are military, and so there are probably three if not four colors that we know, green, amber, and red, right? I threw in a little bit more on there, and there's orange, orange and yellow. But for this, it's kind of telling us a little bit about where the spectrum or where the range is going to be about whether or not these signals should call for urgency. Is this validated right now? No, I just showed you guys where all the evidence came from and how we decided to just put this together. When you guys see this in nature in five years, you guys can remember this moment. But, or you know, nature for very bad reasons, hopefully not. You guys can all take out your phones, and you guys could scan this QR code. I put the questionnaires into a Google Form that you guys can all save, take home with you. And then hopefully, maybe give you guys a potential guide as to what it means to, well, screen, if not assess the wellness of a athlete. You can submit the form on there, and it'll tell you the points. I mean, I'll see your response anonymously, so I don't think it really matters. But more than anything else, hopefully this is something you guys can take home from this talk here. I've already talked a little bit about how this is more of a binary system, like the Vanderbilt and the ADOS. I've already kind of talked about how the population that will be administering this is more so the coaches and the ancillary staff. And what we hope to do after this is hopefully validate, as well as conduct the pilot tests. And I think I emailed Michael Phelps the other day for expert review, he hasn't responded. But more than anything else, based on these numbers, I am hoping that the validity, based on the evidence, will give, or if not empower, some of the ancillary staff, if not the coach on the teams of elite athletes to, well, give themselves a little bit more, I guess, nuance in how they approach the mental health of their athletes. These are my references. And I'm gonna turn it over to Dr. Bharu for questions and discussion. Before we go to questions, and I'm sure there are a few, I have some announcements to make. And the first one I would like to is invite all the Walter Reed people to join me for a group photograph after we are done here. Please don't leave in the middle. And secondly, I would like to take a poll. I am not asking you to make a 100% yes or no, but just out of curiosity, out of the people in the audience, how many of you are going to come to the New York meeting next year? How many of people who are coming would like this presentation to take, go forward with it? And talk a little more. Okay, good. Our presenters were debating between this topic and a specific, a more specific topic of extreme sports. This time we have been more general. Would you think it would be worth your while to stay for a 90 minute presentation, 75 minute presentation on extreme sports? And what are the implications? Because that was a hot topic for a while. Would you think it'd be worthwhile to present on just extreme sports? I get a thumbs up, a few thumbs up, good. Extreme sports are those sports where people have much more fun, thrill. In fact, United States Postal Service came up with a stamp a few years ago on this topic, extreme sports. You can Google it, it's quite nice, fantastic stamp collection. It would be things like mountain biking, hang gliding, those types of things. There are certain definitions online which tell you what extreme sports are. As Katrina mentioned. And on a different note, on a more personal note, I am happy to make an announcement that Dr. Wachter, Katrina, and An when are engaged to be married soon. Don't remind her. And I feel honored to make that announcement. Thank you, Dr. Varun. It didn't happen today, it's been in the works for a while. So we are hopeful we will see you again in New York and present this topic further. There is a lot of room. Today what we've given you is just a bird's eye view. I'm going to open up the questionnaires if there are any. One of us would be happy to answer them. And please stay back. Why are you marrying this guy? So question. I forgot whether it was Katrina's slide or yours, but there were sort of different domains talking about identity, things like stigma, among other things. It actually, you know, in my practice I see a lot of physicians. It made me think of those. Are you able to bring that up again? Thank you. There's a list, a slide with a list of different, yeah, I mean I could relate to physician identity, I relate to the quantitative, qualitative stress and the pressure to perform, I mean we got this whole maintenance of certification, you got to worry about your boards, peer review, documentation deadlines, bean counters, and then not sure about physical injuries but in medicine, I mean with the pandemic, we're all worried about getting infected by this unknown entity, initially when we didn't know a whole lot. Physicians are fairly common. Physicians tend to move around a lot. And then for GME, a resident may go from one rotation to another. They might go from a faculty who's a dove to a faculty who's a hawk. And one might say do it this way, the other one might say do it that way. And the stigma, you know, what does it mean for my board? So I was wondering if you guys had any comments on how there might be wider implications for knowing sports psychiatry or approach to athletes, because I could think of, you know, us and how we interact with the behavioral health system. Thanks. It's an excellent point that Dr. Amin brings up and while we were talking about sports, this slide translates to beyond just sportsmanship. Executive functioning, people in the top rung are always looking to see who is going to take up their spot by becoming or excelling them. No difference in physicians' lives and especially in the residents' lives. So I think this is more and more generic. Thank you for bringing that up. I will add too, I think when you're thinking about any field that is highly specialized in any sort of realm or career, you're going to see a lot of these types of things. So two years ago, Dr. Amin and I actually presented on physician burnout and a lot of the preventative strategies that I talked about today had very close parallels to that topic from two years ago as well. So when you are focusing years and years and years on training, medicine, sports, when you have something that looks like it may take that away or may endanger that, that's when you'll see a lot of the stressors come out. »» I also saw a lot of overlap with military populations as you were speaking and you're also military. But that was a side comment. My question for you is related to, so you mentioned that a lot of these teams have like a psychologist or other behavioral health professional that travel with them. I also am aware and have heard that they have performance coaches who help them visualize and work through some of the anxiety related to performance. I was wondering if you could comment a little bit on prevention as, you know, that performance-related anxiety is probably tied to later on mental health issues that might be more global or impairing the use of those professionals. So that was my question for you. Thanks. »» Yes. So off the top of my head, I can't remember the author of this book, but there's a book that talks about that specifically. It's called Mind Gym. It's a great read if anyone wants it. It was recommended to me as a high school athlete. But basically just as in mental health, mindfulness is huge. We're teaching all of our patients how do you ground yourself? How do you visualize something? How do you bring yourself back if you're starting to feel like you're spiraling? And it is exactly the same in sports. So you are spot on. These trainers, these visualization experts that sports are bringing in are designed specifically to help learn those skills that we're actually teaching. I think that does have a huge role in prevention. So I think that's a great point. Thank you. »» While preparing for this presentation, did you come across anything about the pressure that parents put on athletes? Because it's popular in the media. For example, Venus and Serena Williams' father put a lot of pressure on them. The Formula One driver Max Verstappen's dad put a lot of pressure on him. He abandoned Max at a gas station when he was age 12 for losing a go-kart race. Did you come across any research on that? »» Yes. So and it's interesting because some of the things that I've read on there, and it goes back to the idea of identity, where the athlete themselves are not actually identifying to the sport, but rather to their parent's expectation, which is, well, which is not the best. And then later on, there's usually a transitioning point. And I find it apt because I recently picked up the cello to Annoy Katrina. But one of the things that they said throughout all of this is that it's not playing 100% on the beat that matters, and it's rigidity that matters. It is how you want to express yourself in that moment. So more than anything else, in the sport itself, if you find it to become a form of expression more than anything else, that's when that transition happens actually for a lot of the athletes, which I found was fascinating. So yes, when they begin to do it for themselves rather than their parents, I think that's kind of when they take off a little bit. I think Serena Williams might have mentioned that. But yes. Hello. I'm an addiction psychiatrist from Sydney, Australia. And I wanted to take the opportunity to just sort of pick your brain briefly. We still have in Australia a ban on zolpidem, Stilnox, Ambien, you call it, in our Australian Olympic Committee. One of the things that comes up for people in sport, professional sport, is insomnia in the context of anxiety, and even just in the context of the event. So what do you guys do? Obviously prioritizing psychological interventions and working on mindfulness is important. When you have to prescribe in the context of elite sport, I just thought I'd take the opportunity to ask you guys that question. So let me begin, and then somebody else can add to it. I am also an addiction psychiatrist, besides being a forensic psychiatrist as well. Your question is very important, and that was one of the first few slides which I just put it up on the screen, but because I was told that as a chairperson I cannot be a presenter, I only have limited time. This is a major, major factor, especially for sportsmen, and you're right. If I go through the whole gamut of all the medications for sleep, we can start from the simplest like Benadryl, Diphenhydramine, or Atarax, Hydroxyzine, and then we go on to Penzos, which I avoid for various reasons. As you mentioned Ambien, there is also Sonata, and there is Lunesta, Seroquel, Mirtazapine, Remeron, it's endless, and now we have this whole Orexin systems. Some of them are being touted downstairs. It's a very difficult concept what to do. So besides this, I also have other fields of interest, and this might come as quite naive, or I might even call it stupid. Remember our grandmas, what they used to say at night when we were kids, drink your milk and you will sleep better? As a nutritional psychiatrist, that's my other approach. Also as a yoga instructor, I can tell you there are certain techniques which are wonderful to give you a good sleep. However, those are on the side, they're called CAM, Complementary Medicine. I would still look at what I'm looking at, which kind of sports, whether sedation is going to be a problem, whether weight gain is going to be a problem, and then act accordingly and give that medication. That's as much as I can give you. Somebody can add more. Just from a military perspective, there's a lot of research that's currently going on in sleep medicine within the military because we work very high-tempo jobs, and you may have people doing missions at different times and not sleeping for several days in a row. I think, we didn't bring this up, but the idea of sleep banking and educating athletes on the idea of sleep banking, so if they have a particular competition that's coming up that's going to be higher stress, getting them some sleep in the bank, if you will, can also be a non-pharmacological technique, and then also maximizing the off-season or as much as an off-season as there is for these athletes. If you can get their sleep hygiene and their sleep habits through pharmacological methods or more therapeutic methods in the off-season, then they're able to actually apply that, so utilizing the time that you have. Here's a fun little fact. The Z-drugs came from Walter Reed Research Institute, and it's because commanders wanted soldiers to basically have this on-off switch for sleep in regards to enhancing their performance. Maybe that's saying something to that. I forgot to add one more medication in a different class, melatonin drugs. Thank you. Thank you so much for the excellent talk. As a resident, I was curious if you had any advice on how to find or create opportunities to get exposure to sports psychiatry or just treating high-level athletes. Bottom line, this field is not yet fully explored. There's a lot more that can be achieved. My advice is always keep an open mind. Find out what the requirements are. Each sports has a unique requirement, very different from the other sports. So find what the patient is about, what their needs are, what their requirements are, and then move forwards with that. That's all I can think of at this moment, if you can add. Also, if this is a field that you're interested in, there is an International Society for Sports Psychiatry. You can look them up online. They have monthly mentorship programs where they can kind of talk about how you can get involved in treating athletes and some projects that they have going on, if you're interested. There are a few people who take the title of sports psychiatry. There's an excellent book on sports psychiatry written by Dr. David McDuff. You might want to look into that and see. Extremely helpful book. Good morning. Thank each of you for your presentation. It was a wealth of information. As a child and adolescent psychiatrist, I probably function more with the junior athlete who some of them may be going into elite athleticism, even very, very young. So my first question is, is the assessment tools that you all have, is that specifically for the elite athlete? Is there anything that has been looked at as far as for like younger athletes? Could these still be used or utilized for them? And then my second question is, is for the parents who are out there, is there any recommendations as to how we can interact with them in order to kind of help with providing more protective and supportive factors for these kids, rather than critique and pushing them in a way that is creating more stress and more anxiety and potentially more depression? Yeah. Yeah. For your first question, what I found with the signals, with the psychometrics, just like all of child and adolescent, unfortunately, we have neglected the toddlers, the teens, as well as the children in regards to those psychometrics. So for this, unfortunately, no, I don't think that this would apply evidence-based-wise onto the younger population. As every child and adolescent attending has told me, you titrate to the developmental level and you start there. So unfortunately, I don't think so. For the second part, what I've found is that it's usually insight is like half the battle when it comes to the parents, as well as their motivation and drive for their child's performance. Beyond that, I can't speak more to that. Thank you. I just wanted to say thank you for putting the time into this subject and talk. It's deeply personal to me, to me as a former collegiate and professional football player with lived experience. Have you guys thought about reaching out to the NFLPA or other organizations? Because I know there's a gap, a big gap between the sports world and psychiatry that can be glaring at times, but I hope you guys realize it's an absolute goldmine if you can bridge that gap. I'd love to connect with you guys after the fact. Thank you. That seems like a really great idea. Excellent suggestion, I might add. Hopefully one day we'll all be savvy enough to be able to get all the help we need in the world. Up until now, as you can see, there's still a lot of stigma that happens all around in the sports world included. Anybody here watch Ted Lasso? I think more than half of the appeal for Ted Lasso is that it speaks to usually the culture of the sport and the team rather than the sport itself and its mechanics. I think that's what we're trying to fill that gap here and more than anything else. Last thing I'll say is that there's also an intersectional overlap with the military and athletes like you guys spoke to. The NFLPA sets up a group called Merging Vets and Players. It's a non-profit that combat military veterans and former professional athletes get together and you have like a 60 minute workout and then 30 minutes you sit on the mat, talk about a mental health emphasis and losing your sense of identity. I think that, again, if nothing else, wanted to hopefully lead you in the right direction of if we can connect these worlds, there's a lot there. Thank you. I would echo it a little bit different. I went to a tennis academy as a child. If you've watched Breaking Point with Marty Fish, he was a year older than me, so the tennis academy featured and that is where I trained. A little bit of PTSD watching that, to be very honest. Interestingly enough, tennis, you don't have that. You don't have the network, you're individuals. People have brought up children. I'm curious, right, from a young age I was trained, and if you've watched the series you'll know this, but I was trained to show no emotion, to be stoic. If you had a feeling, keep it to yourself. I wondered if you looked into any of this. I don't think tennis is unique in this, but I do think compared to other sports you have to maintain that level of composure maybe a little bit more. If you looked into how do you then get those people, if you're not looking at them young, but you're looking at them as adults, as you've trained yourself all the way into adulthood to not talk about your anxiety or depression and to kind of really combat that, how do you then get them to accurately answer these screenings? Because it's quite difficult if you've trained yourself your whole life to not show it. Then on top of that, parents, I think definitely people follow what their parents have taught them, but I think the issue you face is you do see Verstappen, you see Serena Williams, and unfortunately those people have been very successful. There is something to say about having these parents that do push you potentially to the breaking point, but you do see success in a lot of these people. Anyway, I'd push you to look a little bit at the younger age, because as we get older it's harder to change that transition. In the individual sports, we don't have that network unless you build it yourself. But thank you very much. Thank you for bringing that up. That brings up an important point. Parents are an important factor in the life of all children, and most parents aspire to kind of vicariously achieve in their kids what they could not. So there's always that push. The push has to be there. However, the push can be up to a certain point and then let go, or the push can go on beyond that point. That is very crucial to think about, because if you can continue pushing a kid in the right direction. I'm sorry. Sorry about that. So the push can be in the positive direction, but it can also be in the negative direction. can overpush and can push you in the negative way. So thank you for bringing that up. And thanks for joining us today. I think that's all the time we've had, but we'll be up here to answer and field any more questions. She has one more question. Go ahead. Yeah, go for it. What are they gonna do? Hi, thank you so much for your talk. I was a part of a college running team and there's kind of a subculture in distance running with disordered eating. When it's part of that culture, I was wondering, as an individual athlete, when you're surrounded by that, how would you advise a patient who's in that culture to cope with those demands when that's what they're surrounded by? That's a really difficult question to answer. And like Dr. Brew had mentioned, the culture of the team is a really important factor in how these athletes are able to navigate those stressors. And like I had mentioned, that concerning statistic, like a third of female athletes at the Division I level do report these attitudes and symptoms that could be concerning for an eating disorder. And it definitely is a challenging thing to address, especially depending upon the age group, the social influences, those social connections can be really important. And it's definitely something that we need to consider. I think too, just thinking about it from that holistic standpoint that I mentioned, I think this would be a really good opportunity to get that collateral and do that kind of larger ecological systems education. So the coach, for example, right? If that's an influence that is pushing these athletes one way or another, trying to make that change or at least start that process in those moments, I think could be helpful as well. Thank you all for coming. Thank you.

mental health

elite athletes

stressors

risk factors

pressure to perform

physical injuries

identity tied to sport

transition points

stigma

comprehensive care

integrative approaches

AFLEX

psychometric tool

AFLEX scale

psychometric scale

athletic coping skills

anxiety

depression

resilience

binary scoring system

urgency level

coaches and staff

mental health promotion

athletes

culture

mental well-being

resources

coaches

staff

awareness

screening programs

interventions

treatment plans

peer networks

resilience-building