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Cricket: Mental Health Emergencies

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  • Cognacity Wellbeing
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Case Studies in Sports Psychiatry - edited by Amit D. Mistry August 2020

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The British Association for Psychopharmacology guidelines specify the scope and targets of treatment for bipolar disorder. The third version is based explicitly on the available evidence and presented, like previous Clinical Practice Guidelines, as recommendations to aid clinical decision making for practitioners: it may also serve as a source of information for patients and carers, and assist audit. The recommendations are presented together with a more detailed review of the corresponding evidence. A consensus meeting, involving experts in bipolar disorder and its treatment, reviewed key areas and considered the strength of evidence and clinical implications. The guidelines were drawn up after extensive feedback from these participants. The best evidence from randomized controlled trials and, where available, observational studies employing quasi-experimental designs was used to evaluate treatment options. The strength of recommendations has been described using the GRADE approach. The guidelines cover the diagnosis of bipolar disorder, clinical management, and strategies for the use of medicines in short-term treatment of episodes, relapse prevention and stopping treatment. The use of medication is integrated with a coherent approach to psychoeducation and behaviour change.
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Bipolar and psychotic disorders are relatively common and likely to have a significant impact on quality of life and functioning which, in the context of elite sport, includes a potential negative impact on sporting performance. For this narrative review article, the literature on bipolar and psychotic disorders in elite athletes was comprehensively searched, and little empirical research was found. A diagnosis of bipolar or psychotic disorders may be challenging in elite athletes because of complicating factors related to the modifying role of exercise and potential precipitating impact of substance use. Medications used to treat bipolar and psychotic disorders may have side effects particularly problematic for elite athletes. Future research should be tailored to the specific characteristics and needs of elite athletes and to the sporting context in which the disorders may arise. Specifically, further research is needed on the prevalence and incidence of these conditions in elite athletes and the impact of both the disorders and their treatments on sporting performance.
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This book provides an up-to-date, authoritative, and highly readable overview of psychiatry, suitable for all psychiatrists, as well as medical students, general practitioners, and other mental health professionals. Written by experienced clinicians, the new edition has been substantially rewritten and updated. The first three chapters cover the symptoms and signs of psychiatric disorders, psychiatric classification (including DSM-5), and how to conduct a psychiatric assessment. Chapters on ethics and the law (including the Mental Health Act), aetiology, and evidence-based approaches, set the scene for description of the major syndromes of adult psychiatry. In each chapter, description of the cardinal clinical features is accompanied by the latest evidence on epidemiology, aetiology, treatment, and outcome. Subsequent chapters cover child psychiatry, the psychiatry of old age, intellectual disability, forensic psychiatry, substance misuse, suicide, and self-harm, and psychiatry in medical settings. After a new chapter on global mental health, two chapters cover psychological and psychopharmacological treatments: their indications, efficacy, side effects, and mechanisms. The final chapter describes how psychiatric services are organized.
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Mental health disorders (MHD) in elite athletes is a topic that has received increased attention in recent years. The overall aim of this position statement is to enhance awareness of this important topic and to critically discuss optimal service provision for athletes who suffer from MHD. In the first part of the paper a short overview of the research on MHD in elite athletes is provided. Elite athletes seem to have comparable prevalence rates for the most common MHD when compared to non-athletic peers, but there are still many disorders that have not been investigated in athletes. Sport specific situations such as injuries, periods of overtraining and career termination may put athletes at an increased risk of developing MHD. In the second part of the paper, models of service provision for elite athletes suffering from MHD from six European countries are presented, focusing on 1) professional service providers, 2) support systems, 3) diagnostic assessment, 4) clinical treatment, 5) performance during treatment, 6) screening, and 7) education systems. It emerges that competencies, certification issues, and professional boundaries of the involved service providers, as well as the structure of the National Health Care systems differ strongly across European countries, which makes defining a golden standard difficult. In the third part of this paper, the authors provide general recommendations for athletes and coaches, clubs, federations, organizations and scholars that hopefully will inspire stakeholders to optimize their support systems.
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Athletes are not immune to mental illness, despite outward appearances of strength and wellness. Depression and anxiety disorders may occur in athletes at least as commonly as in the general population. Eating disorders, attention-deficit/hyperactivity disorder, and substance use disorders may occur even more frequently in athletes than in the general population. Thus, it is imperative that medical professionals across all specialties are aware of these psychiatric comorbidities, and how to initiate evaluation for and treatment of them.
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Athletes experience a range of mental health problems with at least an equivalent prevalence to the general population. This chapter explores the psychiatrist’s role in sport, along a pathway of mental healthcare from ‘upstream’ prevention, screening, and early detection of mental stress to ‘downstream’ assessment, treatment, rehabilitation, and recovery from mental illness. At each stage on this pathway the psychiatrist has a broad spectrum of bio-psycho-social strategies to employ in clinical practice. Upstream, the importance of psychological resilience is described along with the concept of mental ‘pre-habilitation’ (a term usually associated with the prevention of physical injury). Alongside these preventative measures, early detection is improved by education, increased awareness, and by the use of effective mental health screening measures. Further downstream ready access to psychiatric expertise and good collaboration between the psychiatrist and the world of sport improve access to treatment, delivery of that treatment, rehabilitation, and return to sport during recovery.
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There are several critical factors to consider in prescribing psychiatric medications to athletes. In addition to the usual considerations when prescribing any psychotropic agent to any patient, the prescriber in this case should pay careful attention to: (1) potential negative impact of the medication on athletic performance, (2) potential performance-enhancing effects, and (3) potential safety risks. This paper describes an updated review of relevant research findings and considerations in the above areas within various categories of psychiatric medications. Many methodological concerns exist with the studies that have examined psychotropic medication use by athletes. These include: small sample sizes; use of the medication in dosing strategies (e.g. single dose) that do not replicate how they are usually taken in the real world; use of primarily male subjects only; use of performance measures (e.g. subtraction, multitask) in some studies that may not align with physical demands experienced by athletes in their natural athletic environments; and not using athletes who actually have the psychiatric disorder or symptom the medication was designed to treat. Despite these concerns, data currently available provide at least some guidance for clinicians wishing to make informed decisions about psychotropic prescribing for their athlete-patients.
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Accelerated aging has been proposed as a mechanism explaining the increased prevalence of comorbid general medical illnesses in bipolar disorder. To test the hypothesis that lost life years due to natural causes starts in early and mid-adulthood, supporting the hypothesis of accelerated aging. Using individual data from nationwide registers of patient with a diagnosis of bipolar disorder we calculated remaining life expectancies before age 90 years for values of age 15, 25, 35…75 years among all individuals alive in year 2000. Further, we estimated the reduction in life expectancy due to natural causes (physical illnesses) and unnatural causes (suicide and accidents) in relation to age. A total of 22,635 patients with bipolar disorder were included in the study in addition to data from the entire Danish general population of 5.4 million people. At age 15 years, remaining life expectancy before age 90 years was decreased 12.7 and 8.9 life years, respectively, for men and women with bipolar disorder. For 15-year old boys with bipolar disorder, natural causes accounted for 58% of all lost life years and for 15-year old girls, natural causes accounted for 67% increasing to 74% and 80% for 45-year old men and women, respectively. Data concern patients who get contact to hospital psychiatry only. Natural causes of death is the most prevalent reason for lost life years already from adolescence and increases substantially during early and mid-adulthood, in this way supporting the hypothesis of accelerated aging. Early intervention in bipolar disorder should not only focus on improving outcome of the bipolar disorder but also on decreasing the risk of comorbid general medical illnesses. Copyright © 2015 Elsevier B.V. All rights reserved.
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Estimates of lifetime risk of suicide in mental disorders were based on selected samples with incomplete follow-up. To estimate, in a national cohort, the absolute risk of suicide within 36 years after the first psychiatric contact. Prospective study of incident cases followed up for as long as 36 years. Median follow-up was 18 years. Individual data drawn from Danish longitudinal registers. A total of 176,347 persons born from January 1, 1955, through December 31, 1991, were followed up from their first contact with secondary mental health services after 15 years of age until death, emigration, disappearance, or the end of 2006. For each participant, 5 matched control individuals were included. Absolute risk of suicide in percentage of individuals up to 36 years after the first contact. Among men, the absolute risk of suicide (95% confidence interval [CI]) was highest for bipolar disorder, (7.77%; 6.01%-10.05%), followed by unipolar affective disorder (6.67%; 5.72%-7.78%) and schizophrenia (6.55%; 5.85%-7.34%). Among women, the highest risk was found among women with schizophrenia (4.91%; 95% CI, 4.03%-5.98%), followed by bipolar disorder (4.78%; 3.48%-6.56%). In the nonpsychiatric population, the risk was 0.72% (95% CI, 0.61%-0.86%) for men and 0.26% (0.20%-0.35%) for women. Comorbid substance abuse and comorbid unipolar affective disorder significantly increased the risk. The co-occurrence of deliberate self-harm increased the risk approximately 2-fold. Men with bipolar disorder and deliberate self-harm had the highest risk (17.08%; 95% CI, 11.19%-26.07%). This is the first analysis of the absolute risk of suicide in a total national cohort of individuals followed up from the first psychiatric contact, and it represents, to our knowledge, the hitherto largest sample with the longest and most complete follow-up. Our estimates are lower than those most often cited, but they are still substantial and indicate the continuous need for prevention of suicide among people with mental disorders.
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Sport psychiatry focuses on diagnosis and treatment of psychiatric illness in athletes in addition to utilization of psychological approaches to enhance performance. As this field and its research base are relatively new, clinicians often deliver psychiatric care to athletes without a full understanding of the diagnostic and therapeutic issues unique to this population. In this systematic review, we discuss published findings relating to psychiatric diagnosis and medical treatment of mental illness in athletes. There have been several studies looking at the prevalence of some psychiatric disorders in various athlete populations. Eating disorders and substance abuse are the most studied of these disorders and appear to be common problems in athletes. However, to provide informed understanding and treatment, we especially need more research on overtraining syndrome, bipolar disorder, suicidality, anxiety disorders, attention-deficit hyperactivity disorder (ADHD) and psychosis in athletes. Research is needed in the areas of prevalence, risk factors, prognosis and the unique experiences facing athletes with any of these disorders. Additionally, there have not been any large, systematic studies on the use of psychotropic medications in athletes. Small studies suggest that some medications may either be performance enhancing or detrimental to performance, but we need larger studies with rigorous methodology. Higher level athletes suffering from psychiatric symptoms often have reservations about taking medications with unknown performance and safety effects, and methodological issues with the current literature database preclude any definitive conclusions on performance effects of psychiatric medications. We need many more, higher quality studies on the use by athletes of antidepressants, mood stabilizers, anxiolytics, stimulants and other ADHD medications, sedative-hypnotics and antipsychotics. Such studies should utilize sensitive performance measures and involve longer term use of psychotropic medications. Furthermore, study subjects should include athletes who actually have the psychiatric disorder for which the medication is proposed, and should include more women.
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Several previous studies have established that low treatment adherence is common among bipolar patients and may explain high rates of recurrence. On the other hand, some patients keep relapsing even when they strictly follow their prescribed somatic treatments. Psychological interventions such as psychoeducation may foster early recognition of prodromal symptoms and minimize the risk of relapse. To date, studies assessing the usefulness of psychoeducation in fully compliant patients are lacking. This was a single-blind, randomized, prospective clinical trial on the efficacy of group psychoeducation in remitted fully compliant DSM-IV bipolar I patients (N = 25) who were compared with a group with similar characteristics (N = 25) who did not receive psychoeducation. All patients received naturalistic pharmacologic treatment. Recruitment began in 1997 and follow-up was completed in January 2002. The follow-up phase comprised 2 years during which all patients continued receiving naturalistic treatment without psychological intervention and were assessed monthly on several outcome measures. At the end of the 2-year follow-up, 23 subjects (92%) in the control group fulfilled criteria for recurrence versus 15 patients (60%) in the psychoeducation group (p < .01). The number of total recurrences and the number of depressive episodes were significantly lower in psychoeducated patients. Although the present study has the limitation of small sample size, psychoeducation showed its efficacy in preventing relapses in bipolar I patients who were adherent to drug treatment. The action of psychoeducation seems to go beyond compliance enhancement and may support a tripod model composed by lifestyle regularity and healthy habits, early detection of prodromal signs followed by prompt drug intervention, and finally treatment compliance.
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Although high incidence rates of mania have been described in some ethnic minority populations, little is known about any ethnic differences in the early clinical presentation of bipolar disorder. All cases of operationalised DSM-IV bipolar I disorder (BPI), first manic episode, within a defined epidemiological catchment area over a 35-year period, were identified; sociodemographic data, including ethnicity, and clinical information were then extracted. The proportion of African-Caribbean (n=52), African (n=33) and white European (n=149) cases who experienced a depressive episode before onset of mania and psychotic symptoms at first mania were compared. African-Caribbean and African groups were significantly less likely to have experienced a depressive episode before onset of first mania, at 13.5% and 6.1%, respectively, compared with 28.1% in the white European group. African-Caribbean and African groups also experienced more severe psychotic symptoms at first mania, but there were no differences in mood incongruent or first rank symptoms between ethnic groups. Data pertaining to diagnosis and clinical symptoms were extracted by retrospective case note review. Ethnic differences in clinical presentation of bipolar disorder may have implications for assessment and treatment of ethnic minority patients.
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This article describes how sports medicine physicians can best approach the diagnoses of mental illness in athletes. Examples of psychiatric problems common to athletes, their incidences in the population, and diagnostic tips to ferret them out are given. Vignettes of well-known athletes who have had these problems are included. Each highlights how the lack of diagnostic awareness of mental health issues in the athletic community and the stigma of "mental illness" prevented the athlete from getting treatment sooner.
Bipolar and psychotic disorders in elite athletes: A narrative review
  • A Currie
  • P Gorczynski
  • Rice
  • Sm
  • R Purcell
  • R H Mcallister-Williams
  • Hitchcock
  • Me
Management of mental health emergencies in elite athletes: A narrative review
  • A Currie
  • D Mcduff
  • A Johnston
  • P Hopley
  • Hitchcock
  • Me
  • C L Reardon