Psychiatry - July 2008 - (Page 60)

properties. The question then arises, “If an individual truly has adult ADHD, is the use of stimulants actually providing a performanceenhancement edge or simply providing a restorative function?” Furthermore, if the governing bodies deny athletes effective and standard treatment for psychiatric disorders, are they discriminating against the mentally ill? In this context it is not surprising that Major League Baseball (MLB) in 2007 gave out 103 therapeutic exemptions for the use of stimulants for ballplayers with ADHD. This figure is disconcerting when juxtaposed with the 26 therapeutic exemptions given just one year earlier in 2006. It is also no surprise that this dramatic increase temporally coincided with the Mitchell investigation. George Mitchell was a former United States senator, who was appointed by the commissioner of Major Leagues Baseball to conduct a 20-month inquiry of performance-enhancing drugs. This high-profile investigation resulted in a 409-page report11 that not only made recommendations but also identified a number of highprofile baseball players who admitted illegal drug use. The subsequent media attention has certainly made athletes more careful when using performance-enhancing drugs and seeking therapeutic exceptions. The dramatic increase in asking for a therapeutic exemption suggests that some baseball players may be looking for a loop hole to continue stimulant abuse by seeking them through fictitious therapeutic exemptions, whereas in the past they would take the drugs covertly. If so, are these violations being addressed by physicians with expertise in diagnosing ADHD and whose allegiance is to maintain baseball’s integrity? Although sport psychiatrists are now finally being consulted, it is disconcerting that they do not sit on any major sports medical advisory boards. For example, the drug policy of the MLB is administered by a pediatrician. The USADA has a 12-member board that consists of three physicians, a 60 Psychiatry 2008 [ J U L Y ] gynecologist, orthopedist, and urologist. The time has come for these agencies to develop a published, standardized policy that clearly and fairly defines which athletes meet criteria for psychiatric disorders and what drugs provide psychoactive properties that enhance performance. Another reason to involve psychiatric consultation in professional sports stems from recent reports that antidepressant drugs have been implicated as performance-enhancement agents. It is now well known that the selective serotonin reuptake inhibitors (SSRIs) are recognized as first-line treatment for anxiety disorders and their various subtypes.12 Additionally, a selective serotonin-norepinephrine re-uptake inhibitor (SNRI), such as venflaxine, also has received approval for generalized anxiety disorders. Although this situation may sound counterintuitive or even absurd, consider the hypothetical example of a professional athlete who is anxious by nature but does not meet DSM criteria for an anxiety disorder. If this athlete is regularly competing on a public stage, he is likely to experience more anxiety than if working daily at a desk job. The more patients are symptomatic, the more aggressively physicians treat them. Are these athletes being given an unfair advantage if they can biologically increase their capacity to calmly compete in high-stress competition, even if the medication used is permitted? If so, who is ethically responsible to define this subtle issue and enforce fair policy? It seems that the burden falls less on the athlete, who is likely to be naïve to these implications, and more on the clinical experts who create policy with each sport’s governing body. Another developing concern is the use of antidepressants for treating what is commonly termed overtraining syndrome. Overtraining refers to a negative response to training stress and is often due to chronically high training levels without periods of lower training loads.12 Overtraining also can lead to fatigue and depression.13 It has been hypothesized that overtraining syndrome may involve disregulation of brain serotonin and neuroendocrine function.15,16 Treatment logically dictates that SSRIs and SNRIs should be effective, and these have anecdotally been reported to help athletes with this common problem.17 Moreover, the use of SNRIs for various pain conditions makes one consider if this class of drug can benefit endurance athletes who inherently cope with tremendous pain during training and competition. The question should be asked if the use of an antidepressant in these situations is fair. CONCLUSION Physicians involved in professional sport need to fully understand the complexity of performanceenhancing drugs and where we draw the line. To do so, not only must the physiologic and psychotropic properties of each drug be considered, but also the individual characteristics of each sport and, more important, the individual biology of each athlete. A medical system for athletes that ensures a fair and accepted standard for all individuals in a given sport needs to be established. In a world of advancing neuroscience and concomitant psychotropic drug development, the psychiatrist must become an advocate for the appropriate uses of psychoactive medicines. The issues involved are complex and potentially have far reaching cultural effects in how psychotropic medicines are perceived by the public. Unfortunately, the majority of prescriptions given for psychotropic drugs are not given by psychiatrists and probably the world of sport is no exception.18,19 If the integrity of the practice of medicine and professional sport are to be maintained, all involved must be more informed and directly involved in the decision making about medication efficacy and appropriateness. To address the issue of where the line is drawn and who draws it, the world of sports is

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Psychiatry - July 2008 Editor's Message Editorial Advisory Board Contents PsychRx Letters to the Editor Reliability of Diagnoses: Do Psychiatrists Use Structured Interviews In Real Clinical Settings? Trend Watch: Use of Atypical Antipsychotics in the Elderly Review: The Struggle for Mental Healthcare in New Orleans-One Case at a Time Psychotherapy Rounds: Psychotherapeutic and Adjuntive Pharmacologic Approaches to Treating Posttraumatic Stress Disorder Original Research: Baseline Dissociation and Prospective Success in Special Forces Assessment and Selection Commentary: Performance-Enhancing Drugs: Where Should the Line Be Drawn and By Whom? Commentary: Psychiatric Diagnosis and the Pathlogist's View of Schizophrenia Journal Watch Classified Advertising Information for Authors

Psychiatry - July 2008

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