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Dr Amit Mistry – Mental Health Challenges in Elite Sport – Injury Rehab Network

The second Injury Rehab Network event of 2024 with BASRaT featured a presentation from Dr Amit Mistry, Psychiatrist from Well Athletic. The online event took place on the evening of Tuesday, 6th February, with 220 sports rehabilitation practitioners in attendance.

Dr Mistry discussed mental health challenges in elite sports. The recording is available to watch here

Amit Mistry

Dr Amit Mistry, Psychiatrist

Dr Amit D. Mistry is a Consultant Psychiatrist dual trained in General Adult & Old Age Psychiatry and chair of the Royal College of Psychiatrists Sport & Exercise Special Interest Group. He is the Consultant Sports Psychiatrist to England Women’s XI Cricket (ECB), ASICS Europe and has private admitting rights to the Nightingale Hospital, London.

Dr Mistry is part of the Eating Disorders Services teams in the NHS and supports patients in the private sector.

In 2021, he co-published “Case Studies in Sports Psychiatry” with Cambridge University Press. This was the first ever sports psychiatry book to have been co-authored by sports clinicians and elite athletes. His published research is related to athlete mental health, wellbeing within the sport, exercise addiction and disordered eating. He holds a visiting clinical lecturer position at Queen Mary’s University London (QMUL) in Sport & Exercise Medicine (SEM).

Mental Health Challenges in Elite Sport

Dr Mistry’s presentation reviewed the role of a Consultant Sports Psychiatrist working within elite sport. The talk focused on common mental health challenges seen in athletes and examples of how they can be managed as a multi-disciplinary team. The latter part of the talk included interactive case studies and examples of best practice management.

Exercise Stages

Dr Mistry considered a continuum of exercise where individuals may participate from a recreational level through to exercise addiction.

Evidence Base

Amit discussed how the evidence base for exercise for severe mental illness has grown, including participation in aerobic and resistance training. There is now strong evidence for the benefits of exercise for most psychiatric conditions, but evidence is limited for some.

Dr Mistry described how localised injuries such as a torn tendon can become systemic, with individuals developing a range of co-morbidities similar to drug addiction. Some conditions, such as Bipolar Affective Disorder, may not be suitable for exercise to form part of treatment.

A sporting career may impact positively or negatively on an athlete’s mental health and psychiatric conditions. Amit considered the pros and cons:

Pros	Cons
The athletic arena is a way of coping with the disorder.	Athletes may have a psychiatric illness precipitated or exacerbated by sport.
You can achieve high levels of success despite a co-existing primary psychiatric disorder.	Major risks with transitions, e.g., injuries, retirement, or de-selection.
Positive personality traits for individual and/or team performance/success.	Negative personality traits.
Emotional support is available to high-performing/successful athletes.	Emotional support may not be available when athletes need it most (are not able to access support as a non-competing athlete).

Amit discussed how mental health morbidity is common (especially with physical comorbidities, which are often musculoskeletal injuries). Conditions may be present where psychiatric morbidity is:

Under-recognised
Under-treated
Stigmatised

Development of Sports Psychiatry

Dr Mistry discussed how sports psychiatry has developed over the last 30 years, moving from isolated case studies to a growing evidence base, international research, collaboration, and the development of screening tools. In 2022, the Journal of Sport and Exercise Psychiatry was created, and Amit recommends this as a useful source of information for practitioners.

Role of the Sports Psychiatrist

Amit described the role of the Sports Psychiatrist (fully trained physician), including therapeutic approaches and performance support. Sports Psychiatrists are advocates for physical activity and exercise and work as part of multi-disciplinary teams.

Dr Mistry discussed the role Sports Psychiatrists play in ruling out medical causes for psychiatric symptoms and disorders.

Upset Basketball Player

Mental Health Prevalence in Elite Sport

Dr Mistry discussed the prevalence of mental health problems in athletes, with meta-analysis findings showing that 34% of athletes experienced anxious or depressive symptoms. This figure is slightly higher than the general population. In a UK survey of 143 elite athletes, 48% reported symptoms of anxiety and depression.

Amit noted that there is limited data for Olympic and Paralympic athletes, but research shows there is a higher prevalence of mental health problems amongst Paralympic athletes.

Eating Disorders

Amit discussed the issue of early specialisation in sports and recommended that young people should not specialise too early as the demands of specific sports can reinforce eating disorders.

In relation to eating disorders in sports, Dr Mistry described how the coaching approach, pressure to lose weight to improve, and the need to wear revealing sports kit can all cause issues. Athletes are often driven and determined, but this trait can also reinforce eating disorders.

Amit presented an eating disorder spectrum with categories from normal eating to disordered eating and a diagnosed eating disorder. Dr Mistry discussed research in relation to eating disorders, which shows individuals may also have exercise addiction.

For the diagnosis of eating disorders in athletes, Dr Mistry described that BEDA-Q is a validated screening tool for use by physicians.

REDS and Psychological Indicators

Dr Mistry discussed Relative Energy Deficiency in Sport (REDS) and psychological indicators linked with problematic low energy availability and REDS, including:

Eating disorders
Primary or secondary exercise addiction
Cognitive dietary restraint
Drive for thinness
Perfectionistic traits
Mood disturbances/ fluctuations
Depressive symptoms and anxiety with injury/ recovery
Reduced sleep quality

Amit considered optimum performance weight and the following factors:

Individual
Multiple MDT perspectives
Season stage
Performance metric
It may not be an ideal or sustainable long-term weight (e.g. health and performance risks)

Dr Mistry discussed resources available from IOC to assist with screening and diagnosis of REDS.

Eating Disorders and Return to Play

Amit described the importance of the MDT team approach to understanding the mental health continuum and risk stratification. Dr Mistry noted that only anorexia nervosa and bulimia nervosa have established guidelines for levels of clearance for participation in sport.

Dr Mistry discussed REDS and OTS (Over Training Syndrome), where athletes may deteriorate from training periodisation through to overreaching and rest, OTS/ REDS and in worst cases to depression and inflammatory cascade.

Neurodiversity

Dr Mistry described neurodiversity and psychiatric conditions, including ADHD and autism. Amit explained how these conditions may overlap with other psychiatric conditions.

Dr Mistry considered the pros and cons of diagnosis, with athletes benefitting from validation and an understanding of their disorder and access to evidence-based biopsychosocial treatment. Diagnosis may however create stigma amongst peers and could create occupational barriers or overshadow the many strengths of an individual. Diagnosis is also lifelong.

Medication

Psychiatric Medication

Dr Mistry discussed considerations when prescribing medication for psychiatric conditions:

Negative impact on performance
Therapeutic (mental health) performance enhancement
Safety risks
Non-therapeutic performance enhancement
Performance vs health

Case Study

Amit presented a case study and discussed how a biopsychosocial model is core to treatment. Treatment for psychiatric conditions in sports incorporates the following elements:

Psychological – DBT (Dialectical Behaviour Therapy) skills, CBT-ED (20 sessions), Food diary
Social – Return to play contract. MDT team approach
Biological (medication) – SSRI (CVS safety)/ Duloxetine (neuropathic pain)/ Quetiapine

Q&A

Dr Mistry kindly answered questions put forward by practitioners who attended the session. Please see the presentation recording for Amit’s insights to the questions.

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