Sports Medicine and Sports Psychiatry

In sports, athletes are usually assumed to have, so to speak, a „basic heroic endowment." This goes back early in history, when the demigod Achilles, whose mother Thetis was a goddess and whose father Peleus was a man, had to choose between a short and glorious life or a long and peaceful but insignificant one. Here he decided for the glory and was provided by the intervention of the mother with extreme fighting power, which is why he was considered by his opponents as almost invulnerable and difficult to defeat.

In accordance with the model from Greek mythology, this strength and invulnerability - both from a physical and psychological point of view - are today attributed to competitive athletes. Mistakenly, mental strength is then also often equated with mental health (9). Whereby athletes can be mentally strong and at the same time mentally or physically unhealthy. This is unfortunately shown in a large number of cases in competitive sports, where the pressure to perform is one of the reasons for some fatal outcomes. A well-known example of this is Robert Enke, whose legacy lives on in the Robert Enke Foundation named after him, which addresses the issue of depression-related illnesses. There are a multitude of competitive athletes with a similar fate. Due to the beginning destigmatization of the topic of mental health in sports, there has been a slight removal of taboos in recent years, and also due to the cases that have become public, there has already been a certain professionalization in dealing with mental health and illnesses in competitive sports. This development was also accompanied by a specialization in the field of psychiatry, sports psychiatry in competitive sports, which started in the USA at the end of the 1980s and has undergone a remarkable development in recent years.

Sports medicine places the expectations of evidence-based medicine on itself, the various medical disciplines within its field, and other disciplines, thus also on sports psychiatry.

A particular challenge in competitive sports is the early detection of athletes with physical and psychological stress and illness, which requires valid, i.e. sensitive and specific, screening and diagnostics. Requirements for this diagnostics should be that it goes along without generating too much false positive and negative findings. In particular, this would be associated with the risk of stigmatization of the athletes concerned in the case of false positive findings with regard to mental disorders and illnesses, and is all the more relevant in competitive sports because abnormalities in psychiatric screening would probably often be falsely equated with the attributes of being psychologically or mentally weak. Therefore, a correspondingly solid scientific basis is needed here. Of course, this also applies to sports medicine and here, for example, to the field of sports cardiology, where, as is well known, the various professional societies have long been discussing the usefulness of a resting ECG as part of a regular fitness examination (1, 13). The evidence for the diagnostic method of the resting ECG in sports medicine is still significantly better than that of sports psychiatry diagnostics, which has yet to provide the corresponding evidence (8). This is highly relevant, because it is only on the basis of evidence-based diagnostics that consecutive treatments can be carried out and established, as is well known.

Sports psychiatry should not regard the expectations of sports medicine and the still missing evidence in many areas of competitive sports as criticism, but above all as an incentive. The description and highlighting of the importance of mental health and the prevalence of psychiatric disorders in various aspects of competitive sports that has been done by the majority so far - for example, recently in a remarkable initiative of the International Olympic Committee (14) - as well as pointing out the absence of psychiatrists in the care structures in competitive sports is and was undoubtedly important and is also considerable in its scope. However, sports psychiatry should now claim to demonstrate, based on scientific evidence, what value it can bring to competitive sports beyond a general psychiatric knowledge. Orthopedists and trauma surgeons or internists have taken this step and have been able to demonstrate the value of additional sports medicine expertise. To this end, sports psychiatry should from the outset cooperation with the established disciplines, such as sports medicine.

Although this issue talks about physical and mental health, sports medicine and sports psychiatry, it should not be forgotten that physical and mental health are inextricably linked. In addition, there needs to be an understanding that sports psychiatry, with its knowledge of sports psychiatry and medicine, should always be involved in sports medicine as a cross-cutting subject. Further reference is made to the article on sports psychiatry as a specialist discipline and its fields of activity in this thematic issue (2).

The contributions on competitive sports, in which psychiatrists and sports physicians jointly discuss proposals for supplementing existing care structures and promoting mental health, or highlight the possible addition of a psychiatric baseline assessment (PBA) to the pre-participation examination (PPE), should also be understood in this sense (3, 8). A German language version of both papers is available online on the DZSM homepage. The other contributions on competitive sports address overtraining and Mild Traumatic Brain Injury (mTBI) from a sports psychiatric and sports medicine perspective and aim to exemplify the value of additional, psychiatric expertise in these non-classical psychiatric disorders and diseases (7, 16).

Sport and exercise are known to play a relevant role in the prevention and treatment of a wide range of diseases and, in the spirit of „Exercise is Medicine," can also be described as an effective therapeutic agent - with already very good evidence - for several mental illnesses (4, 5, 12).

Thus, in addition to competitive sport, sport and exercise in mental illness and as another field of activity for sport psychiatrists will receive equal attention in this thematic issue. The reviews on geriatric psychiatric syndromes, schizophrenia and depression show the importance of physical activity across the lifespan and in the breadth of the psychiatric field in then here more classical psychiatric illnesses (10, 11, 15).

It cannot be pointed out often enough that severe mental illnesses are associated with a significantly reduced life expectancy, which can hardly be co-explained by the mental illness as such, but also and especially by the physical comorbidities (17). In the article on cardiovascular disease and excess mortality in people with depression, physical activity is also discussed as a possible „game changer" in this issue (6). The importance of sport and exercise in psychiatry therefore always includes both the positive effects on body and psyche or physical and mental health.