Athletes Not Invincible When It Comes to Mental Illness

Numerous studies show exercise benefits mental health, particularly mood, said Robert Burton, M.D., director of medical education at Evanston Hospital in Evanston, Ill., and coauthor of the book Sport Psychiatry (W.W. Norton, 1999).

“We should encourage depressed patients who are inclined to exercise to do it,” Burton said, “although we don’t yet know the dose/response ratio.” Exercising three times a week may yield more health benefits than exercising once a week, he said, “but at some point more exercise becomes too much.” Some people suffer overuse syndromes and injuries. Some become obsessed with exercise or develop an eating disorder or body dysmorphic disorder.

Olympic hurdler Derrick Adkins recalls feeling sad and tearful on occasion, without knowing why, starting around age 9. He joined the school track team at 13 and found running made him feel better.

At Georgia Tech, he said, coaches pushed his teammates to train harder. They urged him to relax. He majored in mechanical engineering and made the dean’s list, graduating in 1993. He moved on to professional track-and-field events. “I had reached my childhood dream,” he said, “but ironically, my depression became worse.”

Adkins didn’t tell his friends, his coach, or even his parents, with whom he’d always been close. The stigma, he felt, was too great. In the throes of depression in early 1996, he lost 17 pounds. His track performance fell, too. Pressed by insomnia and growing despair, he called Atlanta psychiatrist Cassandra Wanzo, M.D. She diagnosed his major depressive disorder and prescribed an antidepressant.

The drug lifted his mood rapidly, but also made him lethargic. With the Olympics coming up in August of that year, he threw his medication away. “I was obsessed with winning a gold medal,” he said, and he did, setting the world record in the 400-meter hurdles. About three weeks after this event, which he called “the highest moment in my life,” his mood plummeted again, triggering thoughts of suicide.

He improved after another course of antidepressants, he said, though he’s not currently taking medication. Now studying for his master’s degree in divinity, Adkins plans to be a minister. He reports that praying and reading the Bible help him cope better with his depression. He’s also running again and hopes to train for the 2004 Olympics. “Winning the Olympics was a great victory,” Adkins said, “but overcoming my depression was an even greater one.”

Adkins’s mother, Carole Adkins, said parents rarely view good grades or honors in sports as a problem for their children. “You don’t see it as obsessive studying or training,” she said at the APA symposium. “You see it as an achievement.”

One article about her son, Adkins said, charged that Wanzo ruined Derrick’s career by putting him on medication. “Nothing could be further from the truth,” said Adkins. “She saved his life. The person comes first; the job is secondary.”

A well-functioning family is a key social support system for an athlete, said Ian Toffler, M.D., a Los Angeles child psychiatrist. Producing a champion involves many people, often with different agendas. Developmentally appropriate decisions may be unpopular. Some parents abrogate to a coach their responsibility for deciding on intensity of training or playing despite injuries.

When athletic prowess becomes apparent early, families sometimes focus narrowly and intensely on a child’s performance. In 1996 gymnasts were required to be at least 16 years old in the year they participated in the Olympics, a positive step, Toffler said. Some Olympic sports still permit entrants as young as 14. Some parents, he observed, can’t handle a child’s loss. And some families have trouble dealing with success. If a child becomes the family’s main bread winner, role reversal may occur. Some families cast a blind eye to the use of performance-enhancing drugs or extreme weight-loss diets.

Boxer Gerry Cooney initially found boxing a way to escape troubles at home. His father was an alcoholic, he said, and often told him, “You’re no good—you’ll never amount to anything.” Then he started winning fights, and his picture appeared in newspapers. “That made me somebody,” Cooney said. When Cooney was 19, his father died, and Cooney took on responsibility for supporting his mother and five siblings.

By 1981 Cooney had earned more than $1.5 million as a boxer. In 1982 his photo was on the cover of Time. He then lost his fight for the world heavyweight championship to Larry Holmes. “Drinking, drugs, and sex filled the void after that,” he said. “I was a 30-year-old man who was frightened. What was I going to do next?”

Cooney had stopped drinking and using drugs by the time he sought psychiatric help a few years later. He resisted taking the fluoxetine his psychiatrist prescribed, too. “But it started to help right away,” Cooney said. “Within three weeks, I felt a lot better.”

Cooney retired in 1990, with a 28-3 record. Soon after, he married. In 1998 he and his wife, Jennifer, founded the Fighter’s Initiative for Support and Training (FIST, www.helpboxers.org), a nonprofit organization that helps boxers, who typically retire while still young, to develop other job skills.

Prescribing psychotropic medications for athletes requires knowing not only the particular person but also the demands of his or her sport, said Antonia Baum, M.D., a psychiatrist in private practice in Chevy Chase, Md., and vice president of the ISSP.

Her recent survey of ISSP members, Baum said, showed sedation was the adverse effect psychiatrists most seek to avoid when they prescribe a drug for an athlete. Other concerns include a medication’s potential for causing extrapyramidal side effects, lowering blood pressure, and causing tremor, arrhythmias, and weight gain. Sexual side effects ranked low, she said, but deserve attention in a young, vigorous population.

The antidepressants that survey respondents most often prescribed for athletes were sertraline (Zoloft), followed closely by bupropion (Wellbutrin), but the International Olympic Committee (IOC) has put bupropion on its list of prohibited substances as of September 1, 2001, terming it a stimulant.

“There is no exception for therapeutic use,” IOC spokesperson Isabelle Tornare told Psychiatric News. Psychiatrists need to start a dialogue with the IOC, Baum said, to assess potentially discriminatory practices toward athletes receiving appropriate treatment for mental illness.

While many athletes fear psychotropic medications will undermine their performance, jockey Julie Krone said sertraline stopped her anxiety attacks and restored her energy and sense of timing.

The attacks began after two horrendous falls. In 1993 another rider’s miscalculation in a race sent her flying from her horse. The pack trampled her, bruising her heart and injuring her right ankle so badly surgeons doubted she would walk again.

She recovered fully, but fell again in a 1996 race, fracturing both hands. On returning to racing, she found she couldn’t control her horses. “They picked up my fear at the starting gate and bolted,” she said. “I was known for my timing, but I lost it.” She also suffered from nightmares and daytime flashbacks.

A casual encounter with a psychiatrist who was also a race-horse owner led to her seeing him four times a week for psychotherapy. She refused to take medication then. After moving to New Jersey, she picked a new psychiatrist because his first name was the same as that of a horse she liked. That psychiatrist prescribed sertraline, and two weeks after she started taking the medication, she said, “it was like a rainbow appeared. I stopped having anxiety attacks.”

Krone retired in 1999, the all-time winningest woman jockey. Recently married, she now works as a horse-racing analyst and television commentator in California and as a spokesperson for Pfizer Inc., maker of Zoloft. ▪

Kamm's Web site can be found at mindbodyandsports.com. A link to the International Society for Sport Psychiatry can be found at www.mindbodyandsports.com/issp/index.html.