Alcohol-related aggression: New therapies may result from Ohio State study
Joshua Norman, DO, has a unique position. He’s one of the few psychiatrists in the United States embedded in a university sports medicine program dedicated to the mental health of every athlete on campus at Ohio State.
“To my knowledge, we are quite unique nationally to have a sports psychiatrist on staff full-time within a sports medicine setting. Several psychiatrists throughout the country practice Sports Psychiatry with college and professional teams, but they work part-time as consultants” Dr. Norman says.
The vision of the Sports Medicine program at The Ohio State University Wexner Medical Center is to provide a multidisciplinary medical team to each patient, and Dr. Norman is an integral part of that vision. Dr. Norman has fellowship training in consultation-liaison psychiatry, which gives him additional expertise in medically complex behavioral health patients, allowing him to successfully interface with family medicine and sports medicine physicians, orthopedic surgeons, behavioral health providers, physical therapists, athletic trainers and other health care professionals. As a result, each student-athlete receives comprehensive treatment that addresses their physical and mental health.
Ohio State is leading the national conversation on mental health
Sports psychiatry is a relatively new subspecialty but is expected to increase in demand as more high-profile athletes like Simone Biles and Michael Phelps speak out about their own experiences with mental health. Dr. Norman supports this movement.
“I think it’s really good to see athletes speaking out and encouraging an open and honest discussion. People sometimes forget that student-athletes are people; they can experience anxiety, and they have tremendous pressure on them at such a young age. I tell athletes that mental health treatment is similar to training for their sport. You train for it and work through strategies to improve your overall well-being and athletic performance. Having people like Kevin Love put a face to the topic helps young athletes feel okay about discussing their own experiences,” he says.
While the rates of depression and anxiety among athletes are similar to the general population based on the current evidence, Dr. Norman says that certain mental health conditions like eating disorders may have a higher incidence in sports like gymnastics and figure skating given the leanness requirements of these sports. He also says that many athletes are drawn to sports as physical activity can be helpful for managing certain symptoms including hyperactivity often associated with attention deficit hyperactivity disorder.
Athletes’ unique risk factors
Athletes have unique risk factors for mental health conditions because their identities may be heavily rooted in their sport. They often face pressure to excel in their sport, which may lead to increased risk for anxiety and/or depression symptoms. They are also often under significant scrutiny through social media. Additionally, injuries can present unique challenges when athletes are sidelined from their sport and removed from the daily routine of training and competition.
Dr. Norman says that individual athletes may have an elevated risk for mental health conditions compared to those in team sports. He says the camaraderie amongst team sport athletes may be protective against the development of mental health conditions, while individual sport athletes are at an increased risk for feeling isolated.
“Perfectionism is a challenge for many athletes,” he says. “We work with them to appreciate the progress and journey in their sport, not necessarily perfection.”
According to Dr. Norman, there are two main factors leading athletes to seek mental health treatment. The first is when their quality of life is reduced due to symptoms of anxiety or depression. This can be from reduced ability to complete schoolwork or find activities enjoyable. The second is decreased performance in their sport due to mental health symptoms creating difficulties with sleep, training or concentration during competition. Most athletes are referred to Dr. Norman through an athletic trainer, who’s often the first to notice the symptoms. Dr. Norman says that most of the athletes he treats are experiencing anxiety or depression.
He also treats athletes with adjustment disorders related to physical injury, ADHD and some substance use, although this is less common amongst college athletes.
Dr. Norman offers this story as a typical case: “I recently treated a college athlete from another state. He was a baseball pitcher suffering from obsessive-compulsive disorder and anxiety symptoms. Baseball is a team sport, but it can be isolating at times. There is a lot of time to think when you are on the mound. His symptoms were so significant that he could no longer throw a baseball. So, we developed a treatment plan that included medication and cognitive behavioral therapy. After much hard work, he’s back on the mound pitching again.”
Treating athletes holistically
Student-athletes’ needs for treatment are unique. Because they’re trained to overcome challenges and always perform at a high level, they may not want to admit they need assistance with a mental health condition. In addition, student-athletes often maintain a 60- to 80-hour-per-week schedule between school, training and competition, so they may not want to take the time to seek treatment. Also, even with the increased acceptance of mental health, student-athletes often worry about their privacy.
Dr. Norman opens his schedule at least one hour every day and after hours to student-athletes so they can walk in and receive treatment immediately. This contrasts with other universities, where athletes may wait six to nine months to see a psychiatrist. All athletes are screened for symptoms of depression and anxiety when they come to the sports medicine facility for any treatment.
Athletes have unique needs when prescribing medication to help with their mental health. It’s critical that the medicines not impair an athlete’s performance or training. Some medications are also banned by sports officials. For example, Wellbutrin, a popular antidepression medication, is monitored by the World Anti-Doping Agency because it may have performance-enhancing qualities at higher doses. As with any medication, Dr. Norman’s primary concern is if the medication is safe for the athlete, but he believes that antidepression medicines are usually beneficial for patients experiencing depression or anxiety symptoms.
Sports psychiatry beyond the university
Dr. Norman emphasizes that his practice is rooted in collaborating with other medical practitioners so that athletes benefit from a comprehensive medical treatment plan. For example, he works with neurologists and sleep medicine physicians to uncover and treat health issues that can be hard to manage, such as chronic fatigue. While about 20% of his time is dedicated to Ohio State student-athletes, Dr. Norman also treats patients who are former professional athletes, marathon runners, weightlifters and other active adults and high school student-athletes with anxiety and depression.
In addition, Dr. Norman works with colleagues to treat patients with dementia, Parkinson’s disease, autoimmune and other conditions that can cause mental health symptoms. His practice is unique in that his fellowship training offers additional medical expertise as a sports psychiatrist to enhance collaboration with other medical specialists to treat the whole person, body and mind.
“I credit Ohio State football head coach Ryan Day for increasing awareness of mental health conditions among our athletes,” Dr. Norman says. “These things are very common. A lot of people experience mental health symptoms, even top-performing athletes. I hope that more colleges make the commitment to prioritize their athletes’ mental health, just as much as their physical health.”
