OCD and Medication for Athletes
by Dr. Janet Chen
OCD in Athletes
The prevalence of anxiety has been estimated to be anywhere between 30–60%. Plus, it has only increased since the COVID-19 pandemic across all age ranges. Obsessive compulsive disorder (OCD) is a kind of anxiety that is characterized by recurring thoughts and repetitive behaviors or rituals. It has a prevalence rate of about 1.2%–2.3% for adults.
OCD symptoms can be highly debilitating. For competitive athletes, there is a great deal of overlap between OCD and traits that are necessary for athletes to train and compete at high levels. These include perfectionism, rituals, calorie obsession, body focus, and superstitions. This is not surprising because the sports culture is embedded in competition and pressure to succeed. There is both internal pressure and external pressure placed on athletes. A study that was published in the American Journal of Psychiatry in 2017 found that OCD may be as common as 5.2% among college athletes. This is more than double the expected rates.
It is important to be vigilant about OCD in athletes given the level of distress it can cause. It can be challenging for an athlete to admit to having a mental illness. Some may see it as a weakness that might limit their chances of winning. Also, coaches tend to put a lot of emphasis on mental toughness. It takes courage, therefore, for an athlete to talk about a mental illness.
Treatment for OCD
There are usually three recommended treatment paths for OCD. They are: therapy, medication, and therapy and medication combined. Usually for mild levels of anxiety, treatment with therapy alone will be enough. Cognitive behavioral therapy (CBT) and exposure and response prevention (ERP) are the therapy approaches that are most often used for OCD.
If the level of anxiety is moderate or severe, combination treatment is recommended. This involves therapy and medication taken together. The combination treatment allows for quicker symptom relief compared to therapy or medication alone. In addition, starting medication treatment for OCD can often allow for more success with the therapy. This is because it becomes easier to absorb the therapy skills and then apply them. At severe symptom levels, the OCD symptoms can be so overwhelming that it becomes impossible to implement skills from therapy. Medication treatment can make it easier to practice the exposure work outside of a therapy session.
OCD Medication for Athletes
For athletes, there are special things to consider when thinking about starting a medication. They are: 1) side effects, 2) safety concerns, and 3) anti-doping policies.
It is important to consult with a doctor before starting or stopping medications. The decision to start a medication needs to be made thoughtfully and carefully because all medications come with side effects. The discussion with the physician will include talking about the risks versus benefit of being on the medication. They will also cover the severity of the psychiatric symptoms, the expected positive effects of the medication, and how much the OCD or anxiety symptoms are affecting function.
Side Effects
The medication discussion should always include a comprehensive list of potential side effects. Medication use or medication side effects should not impair athletes' physical performance. Sedation, weight gain, or imbalance are common side effects for athletes to consider. Prescribers of psychiatric medication for athletes tend to favor medications that are more energizing and cause less weight gain, sedation, tremor, and cardiac side effects.
Fortunately, there are many safe and well tolerated medications that can be used to treat OCD. Typically the first-line medication used for treatment of OCD is from the selective serotonin reuptake inhibitor (SSRI) class or the selective norepinephrine reuptake inhibitor class (SNRI). These medications are also known as antidepressant medications. However, they are also great medications for use in treatment of anxiety. When the medication is first started, there should be frequent monitoring for side effects and for dose titration.
Doping
Organizations such as the U.S. Anti-Doping Agency (USADA), National Anti-Doping Organization (NADO), or the World Anti-Doping Agency (WADA) publish guidelines about allowed and prohibited medications and also about how to collect samples. The prohibited medication lists include both over-the-counter and prescribed medications. Some medications are prohibited only in certain dosages or certain routes of administration.
For competitive athletes, it is helpful to pay attention to the rules for traveling abroad. A medicine that may be allowed in one country may not be allowed in another country. Also, if you have to purchase medication in a foreign country, make sure to check the ingredients. You should do so even if it looks similar to the medication you take at home. The WADA does not prohibit SSRI and SNRI antidepressants.
Effect on Performance
While there is a lot of debate about this topic, no evidence supports that taking an SSRI/SNRI will improve athletic performance. Taking medication for OCD can help restore energy and motivation, improve mood, or stop the process of the obsessions and compulsions. However, it is unlikely to provide benefits beyond the athlete’s normal baseline performance. In other words, SSRIs and SNRIs do not directly improve athletic performance. They can have indirect positive benefits on performance because of the intimate connection between our mental health and our physical health.
In conclusion, it is important to identify OCD in the athlete population, especially given the strong association between the high expectations of the sports culture and perfectionism. Once OCD has been diagnosed, there are successful treatments that include therapy and potentially also medication. The addition of medication treatment is often helpful in providing symptom relief to allow for an athlete to participate in his/her sport. For athletes, there are special considerations when choosing a medication to start on. Therefore, it is important to work with a knowledgeable provider.
About Dr. Janet Chen
Dr. Janet Chen is double board certified in psychiatry and child and adolescent psychiatry by the American Board of Psychiatry and Neurology. She previously served as the Chief of Child and Adolescent Ambulatory Services at New York Presbyterian Hospital/Weill Cornell Medicine in Manhattan. She was also the Medical Director of the Child Psychiatry Access Network at UT Health McGovern Medical School in Houston, Texas.
During her time on the faculty at both universities, Dr. Chen grew the collaborative care relationship between the Division of Child Psychiatry and Department of Pediatrics by providing specialized training to other physicians. She has presented at multiple national conferences and has been featured on television and podcasts discussing parenting strategies. In addition, Dr. Janet Chen was awarded a Zero Suicide Initiative grant from the Cardinal Health Foundation in August 2020 to study prevention and treatment of suicide within the NYPH system.
Dr. Chen is the founder of her own private practice, Empire Behavioral Health. EBH is a multidisciplinary practice that includes child psychiatry, adult psychiatry, and therapy providers. Dr. Chen sees patients of all ages and uses an integrated approach that incorporates psychotherapy and/or psychopharmacology. EBH is currently accepting new patients for virtual or in-person appointments at the office located in West University Place.
