Sports Psychiatry: Journal of Sports and Exercise

Psychiatry
The role of mental health care in reaching optimal performance in sports
Aaron A. Mack, David Baron, and Jean Reinert
Online First Publication, June 9, 2023. https://dx.doi.org/10.1024/2674-0052/a000050

CITATION
Mack, A. A., Baron, D., & Reinert, J. (2023, June 9). The role of mental health care in reaching optimal performance in
sports. Sports Psychiatry: Journal of Sports and Exercise Psychiatry. Advance online publication.
https://dx.doi.org/10.1024/2674-0052/a000050
Letter to the Editor
The role of mental health care in
reaching optimal performance
in sports
Aaron A. Mack1 , David Baron2, and Jean Reinert1
1Department of Psychiatry, Research, and Innovation, St Luke’s University Health Network, Bethlehem, PA, USA
2Department of Psychiatry, Western University of Health Sciences, Pomona, CA, USA
Introduction
Mental health care should be seen as an essential factor
in sports performance, and athletes should be supported
when seeking care for mental health issues. The Covid-19
pandemic has raised awareness of the importance of
mental health care in sports. Athletes are speaking up
about their experiences with mental health issues, under-
scoring the need for better care, resources, and support.
Annual physical and mental health screenings, along
with ongoing monitoring, should be implemented to ensure
the overall health of athletes. This paper proposes refram-
ing mental health care in sports as a ‘legal perfor-
mance enhancement’ to improve and maintain athletic
performance.
Mental health has historically been a marginal field
within the realm of sports performance. Even though psy-
chological and mental well-being are known to be key fac-
tors in sports performance, mental health is often
overlooked and not given the same degree of attention as
other aspects of an athlete’s performance, such as physical
conditioning and nutrition.
However, more so recently, during the Covid-19
pandemic, we have seen an undeniable shift in the public’s
awareness of the importance of mental health care, partic-
ularly among athletes. Several high-profile athletes [1] have
increasingly been speaking out about their own experience
with mental health issues and the need for better mental
health care and support. This shifts how mental health is
viewed and affects an athletes’ performance. It is now
becoming widely accepted that mental health is an essential
factor in athletic performance and that athletes need to be
proactive in seeking care for mental health issues. Thus, this
paper proposes a fundamental shift in how we view the
mental health care paradigm in sports by reframing it as a
Ó 2023 The Author(s) Distributed as a Hogrefe OpenMind article
under the license CC BY-NC-ND 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0)
‘legal performance enhancement’ that will improve and
maintain an athlete’s performance.
Objectives
The objective of this concept paper is to introduce mental
health as a core component of an athlete’s development
and performance. Intentionally addressing mental health
in sports is a proactive approach that can shift current
perceptions of remaining reactive to mental health issues.
Background
Sports psychiatry has advanced significantly over the past
few decades, leading to a greater acceptance of seeking help
for mental health issues among high performing athletes.
Evidence suggests that athletes with better mental health
are more likely to perform better than their peers, stay
motivated, and show greater resilience in the face of diffi-
cult situations on and off the playing field [2, 3, 4, 5, 6].
Moreover, early sport-specific mental health interventions
can improve an athlete’s performance [4, 5, 7]. However,
mental health is often not given the same level of attention
as other aspects of an athlete’s performance, and it is
usually overlooked or downplayed as a factor in athletic
performance.
Despite the increasing awareness of the importance of
mental health on performance, many athletes are still
often reluctant to seek help for their mental health issues.
This is in part due to the stigma that is still attached to seek-
ing help for mental health issues, preventing athletes from
admitting to feeling vulnerable and losing their competitive
edge. Many athletes feel that disclosing mental health
issues evoke feelings of shame and being seen as being
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2 A.A. Mack et al., Mental health care & sports performance
not “mentally tough” [8, 9]; further leading to a culture of
silence, continued stigma, and the undervaluing of mental
health in the sports world. For this reason, it is imperative
that athletes are supported when taking the initiative to seek
care for any mental health issues they may be experiencing,
and by fully integrating sports psychiatrists and sports
psychologists into sports medicine, we can change this cul-
tural viewpoint.
Sports medicine physicians are essential in helping to
maintain athletes’ safety and physical health, providing
comprehensive medical care from injury prevention to
diagnosis and treatment. Their primary focus is not on the
mental health aspects of athletes. However, in the proposed
framework sports medicine physicians can assist in recog-
nizing early signs of mental illness and bridging the gap
between athletes and the appropriate mental healthcare
professionals, helping them to understand both the risks
and benefits of seeking help.
While psychiatrists play a key role in treating mental
health issues, the field of sports psychiatry is still in its
infancy compared to sports psychology. Sports psychologists
have been invaluable in helping athletes manage the mental
and emotional demands of competition and training, pro-
viding support, guidance, and strategies to help athletes
stay focused and motivated while maintaining a healthy
balance between sports and life. In the proposed frame-
work, sports psychologists can further guide athletes on
safely and ethically navigating to more specialized mental
healthcare through collaboration with sports psychiatrists,
while still helping athletes develop skills and strategies
needed to cope with the unique stressors associated with
the demands of their sport.
Proposed approach
The proposed approach is to redefine mental health care as
a ‘legal performance enhancement’ for athletes, with the
aim of giving mental health the same attention and
importance as any other performance-enhancing tool. To
obtain a comprehensive understanding of the overall
health of athletes, specific early screenings and monitoring
must be implemented and conducted to gain an accurate
view of their physical and mental health, including well-
being, stressors, and adjustments [2, 3] so that timely sport
appropriate interventions are implemented. This shift in
perspective would allow mental health to be seen as a tool
to improve performance rather than just managing psy-
chopathological issues. To that end, the proposed approach
includes the implementation of two assessments: the
Psychiatric Basic Assessment (PBA) and Sports Psychiatric
Examination (SPE) [10].
Sports Psychiatry. 2023;1–3
under the license CC BY-NC-ND 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0)
The PBA should be administered annually with the
preparticipation physical evaluation (PPE) to provide a
baseline measure of an athlete’s mental health, allowing
for potential concerns to be identified early and addressed.
The SPE is a comprehensive, in-depth assessment and
provides a more complete picture of an athlete’s mental
health over time. This allows for any changes or issues to
be identified and attended to quickly with individual-
ized sport appropriate treatment plans. Treatment plans
may include a variety of mental health interventions,
such as cognitive-behavioral therapy (CBT), mindfulness,
and sport appropriate psychotropics, to help improve an
athletes’ performance and resilience in the face of
difficulty.
Implications for sports psychiatry,
athletes and sporting organizations
The implications of this shift could lead to a greater focus on
mental health interventions and the development of new
techniques to improve performance. This could include
providing education on the signs and symptoms of mental
health issues, and guidance on how to seek help for mental
health issues. This shift would also help destigmatize
mental health care and encourage greater dialogue and
support around the issue.
Additionally, sports psychiatry can also play an essential
role in creating guidelines and protocols to ensure that the
use of mental health treatments is done ethically and safely.
This could include developing guidelines on the use of
sport-appropriate psychotropics and other treatments,
and developing protocols to ensure that athletes receive
the best possible care and support.
Furthermore, it is important to understand the implica-
tions of an athlete seeking help for mental health issues.
Seeking help for mental health issues can be a difficult deci-
sion for athletes. However, it is vital to recognize the poten-
tial benefits of seeking help and the importance of mental
health treatment in sports performance. Suppose mental
health awareness is initiated early, such as before college
or becoming a professional. It can reduce the internal taboo,
shame, and stigma an athlete faces while seeking help.
In addition, sports psychiatrists can support athletes and
coaches to help them navigate the complex process of
seeking help for mental health issues and ensure that
athletes receive the best possible care.
Overall, the redefinition of early mental health screen-
ing and treatment has the potential to revolutionize
sports performance, and sports psychiatrists have an
important role to play in ensuring that this shift in attitude
is conducted ethically and safely; and this shift would
Ó 2023 The Author(s) Distributed as a Hogrefe OpenMind article
A.A. Mack et al., Mental health care & sports performance
also help to destigmatize mental health care treatment,
encouraging greater dialogue and support around mental
health issues.
Conclusion
In conclusion, this paper has explored redefining mental
health care in the context of sports as a “legal performance
enhancement”. By reframing mental health care in this
way, the role of sports psychiatrists can be expanded to
include not just treating psychopathological issues but also
developing strategies to help athletes achieve and maintain
their optimal performance. However, this cannot be done
by sports psychiatrist alone, a multidisciplinary collabora-
tive effort which includes sports medicine, sports psycholo-
gists, and sports psychiatrists is needed. They each play a
critical role in helping athletes manage the physical, men-
tal, and emotional demands of competition and training.
In the proposed framework, these professionals can help
athletes better understand and manage the physical and
psychological aspects of their sport. The pre-participation
Psychiatric Basic Assessment (PBA) and Sports Psychiatric
Examination (SPE) concepts mentioned in this paper sup-
port the potential of early mental health screenings and
interventions to improve and maintain performance. They
provide a foundation for further research into the effects
of mental health and early mental health care on athletes’
performance.
Furthermore, this shift in perspective could lead to more
comprehensive mental health awareness programs for all
sporting levels (primary, collegiate, and professional),
greater collaboration between medical professionals, and
the promotion of mental health resources and support
within sports organizations. Ultimately, redefining mental
health care in sports could lead to a new paradigm in which
mental health is given the same attention and importance as
any other aspect of an athlete’s performance.
By emphasizing mental health, sports organizations
could create a healthier and more supportive environment
for all athletes, leading to increased camaraderie and
trust between athletes, coaches, and other staff, thus allow-
ing for a better understanding of mental health needs and
more effective strategies for performance enhancement.
In addition, this shift in perspective can open the door
for more evidence-based research into the effects of men-
tal health interventions on athletes’ performance, which
could help optimize athletes’ performance in various
sports. Ultimately, by recognizing and addressing the
importance of mental health in sports, we can create a
Ó 2023 The Author(s) Distributed as a Hogrefe OpenMind article
under the license CC BY-NC-ND 4.0 (http://creativecommons.org/licenses/by-nc-nd/4.0)
3
better and healthier environment for athletes and help
them achieve their highest potential.
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History
Received April 21, 2023
Accepted May 24, 2023
Published online June 9, 2023
Conflict of interest
The authors declare no conflict of interest.
ORCID
Aaron Mack
https://orcid.org/0009-0009-0136-9305
Dr. Aaron Mack, M.D., MSc
Department of Psychiatry, Research, and Innovation
St Luke’s University Health Network
800 Ostrum Street, #107
Bethlehem, PA 18015
USA
aaron.mack@sluhn.org
Sports Psychiatry. 2023;1–3