Role of suboptimal psychiatric evaluation in the development of first episode psychosis in an athlete

Open AccessRole of suboptimal psychiatric evaluation in the development of first episode psychosis in an athleteA case reportKenneth Oforeh, Stanley Nkemjika, Olaniyi Olayinka, and Shiraz AzimKenneth OforehKenneth Oforeh, MD, Interfaith Medical Center, 1545 Atlantic Avenue, Brooklyn, NY 11213, USAkenneth.oforeh@gmail.com Department of Psychiatry, Interfaith Medical Center, Brooklyn, NY, USA Search for more papers by this author, Stanley Nkemjika Department of Psychiatry, Interfaith Medical Center, Brooklyn, NY, USA Department of Population Health Sciences, School of Public Health, Georgia State University, Atlanta, GA, USA Search for more papers by this author, Olaniyi Olayinka Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA Search for more papers by this author, and Shiraz Azim Department of Psychiatry, Interfaith Medical Center, Brooklyn, NY, USA Search for more papers by this authorPublished Online:February 09, 2022https://doi.org/10.1024/2674-0052/a000008PDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinkedInReddit SectionsMoreIntroductionIn sports, the role of a sports psychiatrist is underestimated, their functions with that of sports psychologists are essential and synergistic to the welfare of athletes. However, to date, it appears to have remained uneasy as there has been vice versa condescending tolerance and patronizing among both specialties [1]. Considering that the sports psychologist utilizes the psychosocial angle to cater to athletes [2], the sports psychiatrists are equally important as they use the biological mechanisms to cater to athletes [3, 4]. So far, most sports teams accommodate only sports psychologists [5], but not sports psychiatrists whose roles are very different within the group. Sports psychologists who are more predominant in most professional team setups, could be assumed not to be helpful in accommodating and motivating the essential role of sports psychiatrists in the healthy balance of athletes [1, 6]. Thus, they cater to the psychological and psychiatric needs of athletes, which poses the risk of suboptimal therapeutic management for psychiatric disorders. This suboptimal psychiatric treatment stems from mismanagements and misdiagnosis of athletes [7, 8], which ultimately leads to further decompensation into much acute organic mental disorder and likely loss of career among potential elite athletes [9].Based on the evidence in literature, the effectiveness of psychological treatments on psychotic disorders has been explored in controlled trials over the last 15 years, which led to the conclusion that they are an important adjunct to antipsychotic medication [10]. However, these studies had mainly been carried out on individuals with chronic treatment-resistant psychosis, where participants had already been stabilized on antipsychotic medication [11, 12]. Thus, there remains little literature on patients with first episode of psychosis. Similarly, there is a gap in sports psychiatry literature on the sequential impact of poor or suboptimal psychological evaluation and assessment based on a team’s psychologist or sole expertise of non-sports psychiatrists among professional and collegiate athletes globally. Hence, we present a case of a young male athlete whose suboptimal evaluation of initial psychiatric symptoms led to subsequent substance use disorder and comorbid first psychotic break and depressed mood.Case reportA 24-year-old African American male, single, unemployed, college graduate with unclear past psychiatric history and cannabis use disorder, was escorted by his outpatient psychiatrist to the psychiatric emergency department for evaluation. Per report, the patient presented for his monthly psychiatry outpatient appointment but was observed to be acutely psychotic as he exhibited disorganized behavior in the form of paranoid delusions and endorsed auditory hallucinations.Per collateral and patient report, his symptoms started four years ago in college where he won a scholarship after playing basketball in a community college for a year. The patient suffered a groin injury but played through the season without seeking medical attention as he was a “key” player in his team. Following chronic aggravation of the injury which sidelined him from playing basketball, he reported feeling “depressed” which he described as low mood, lack of concentration, and low motivation. Subsequently, he developed auditory hallucinations which he described as hearing voices of multiple people simultaneously. He reported seeking treatment from the school’s sports psychologist and his primary care physician, which gave partial therapeutic effect at the time, however, his continued absence from the basketball court led to a cascade of worsening of depressive symptoms, social withdrawal, compensatory cannabis use, increased severity of auditory hallucination, and suicidal ideations but without specific plans or intent to act. After the semester, he reported feeling isolated because he could not travel back home to visit his family due to lack of financial support. Consequently, he stopped eating and started using other illicit substances, one of which he thinks was “intravenous heroin”. Eventually, he was able to return home to his family. While at home, he was repeatedly psychiatrically cleared after three mental health screening consultation visits with his primary care provider within two years. However, six months after the last screen, he reported sleeplessness, increased energy, grandiose delusions evidenced by thinking he had unique and magical powers, thoughts of superiority and auditory hallucinations, which led to his first inpatient psychiatric admission that lasted twelve days. During this admission, he was prescribed valproate and olanzapine. However, valproate was discontinued due to benign neutropenia, and it was substituted for risperidone. After discharge, he was not adherent to his medications due to fainting spells which he described as allergies. Subsequently, his primary care provider referred him to an outpatient psychiatrist who instituted aripiprazole and discontinued risperidone and olanzapine. He maintained adherence to aripiprazole until his second and current inpatient hospitalization.On presentation in the psychiatric emergency unit, the patient seemed to be responding to internal stimuli as he appeared to be interacting with himself. Paranoia was also elicited as evidenced by how he gazed at people suspiciously. He repeatedly interrogated the treatment team, asking what they wanted from him and if they worked for the government or were sent by them. He refused search protocol, began pacing the unit and demanded discharge. Upon further questioning, he refused to answer any questions and grew increasingly agitated and aggressive. He was irritable, uncooperative and not compliant with the unit limit setting. He could not be verbally redirected. To ensure safety, he was given intramuscular Haloperidol 5 mg once and Diazepam 2 mg once for agitation after declining oral regimen and was then admitted. Laboratory investigations on presentation were all unremarkable and within normal limit, except for urine toxicology screen which was positive for cannabinoids. His echocardiogram, chest radiograph, computed tomography of the head and SARS-COV2-19 serology all returned negative findings.The inpatient psychiatry team continued his outpatient aripiprazole daily for psychosis, but up titrated during his admission to ensure therapeutic effect. The patient’s presenting features resolved following treatment regimen and he was discharged back to the community. He appeared motivated to continue with his mental health care as an outpatient.DiscussionSports psychiatry remains an emerging specialty both for the public and the sports audience [13]. Despite the documented evidence of the benefits of an integrated approach in the management of several health problems and mental health disorders, the role and services of a sports psychiatrist remains low in the mental health balance of athletes [14]. This was evident in our patient based on the presented case report. Following initial psychiatric decompensation, a sports psychiatrist who possesses the background knowledge of sports-specific stressors and pharmacotherapy specific for athletes could have promptly identified, evaluated, diagnosed, and treated the presenting complaint. Instead, the patient consulted a psychologist for an obvious mental health illness. Our patient had symptoms of sports injury-related mood and psychotic disorder which could have been resolved through an adequately integrated approach of care from psychosocial and biological management modalities. Additionally, not recognizing the prodromal symptoms of psychosis in our patient following consultation from non-sports specialized psychologists and psychiatrists further enhances the significance of a sports psychiatrist. An opportunity to provide psychoeducation to the patient and monitor the patient for possible progression to a psychotic disorder was missed. This supports the importance of the role of sports psychiatrists in the management of athletes. Despite this evidence, there remains a lack in the literature.Following this dearth, we reviewed the literature on the EMBASE, PSYCHINFO, SPORTDiscus, and PubMed databases regarding the integrated management approach of both the sports psychologist and psychiatrist. Additionally, we searched the database for evidence of sub-optimal clinical assessment of athletes, which resulted to further mental health decompensation. The search results suggest a gap in the literature on these topics as we found no studies. Rather, evidence from the literature shows that psychological evaluations and treatment management assists the athletes to live a balanced healthy life and depict the roles and importance of sports psychology. There remains a lack of biological treatments by sports psychiatrists for most sports-related mental health problems in the literature [15]. Our case portrays and bolsters the relevance of sports psychiatry as an essential field.ConclusionSports psychiatrists perspectives on common mental health disorders management are lacking in literature and still needs more research. For the case presented here, we achieved an insight into the importance of the professional evaluations of a sports psychiatrist. Hence, an assessment from a sports psychiatrist may have stopped the spiral decline in our patient’s mental health. Currently, the role of sports psychiatrist is suboptimal or non-existent in both amateur and professional sports. We recommend a more inclusive approach by sports outfits and establishments towards the mental health welfare of their staff by acquiring the services of sports psychiatrists. Finally, national sports bodies should consider requiring more team sports to have a designated or an on-staff sports psychiatrist who caters for the team.References1 Singh A, Singh S. Psychiatrists and clinical psychologists. 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First citation in articleGoogle ScholarFiguresReferencesRelatedDetails Volume 1Issue 2May 2022ISSN: 2674-0052eISSN: 2674-0052 ReceivedDecember 28, 2021AcceptedJanuary 29, 2022Published onlineFebruary 9, 2022 InformationSports Psychiatry (2022), 1, pp. 70-72 https://doi.org/10.1024/2674-0052/a000008.© 2022The Author(s)LicensesDistributed as a Hogrefe OpenMind article under the license CC BY 4.0 ( https://creativecommons.org/licenses/by/4.0)Conflict of Interest:All authors declare that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. All authors declare that there are no other relationships or activities that could appear to have influenced the submitted work. Authors declare no conflict of interest. All authors consent to this manuscript’s publication.PDF download