Female Athlete Triad: Sport Gone Bad

By Claudia L. Reardon, M.D.

Psychiatrists encourage nearly everyone to participate in sports and exercise. Sports not only improve physical health but also can greatly improve mental well-being. However, if girls and women take involvement in sports too far, they can suffer a well-described triad of symptoms. The so-called female athlete triad consists of the following three inter-linked health problems:

1. Insufficient caloric intake/disordered eating


2. Menstrual problems


3. Weak bones

Girls and women who participate in “leanness sports” that emphasize thinness (running, ballet, gymnastics, figure skating, and others) are particularly at risk. If they receive the message that being thinner could result in greater athletic success, they may try to cut down on their caloric intake to levels too low to support their levels of physical activity. This can result in full-blown eating disorders, irregular menstrual cycles, and weak bones (including osteoporosis at young ages).

Some common myths about the female athlete triad include the following:

• If an athlete’s performance has not started suffering, then she must not have a problem. FACT:  Even if an athlete’s performance has not started suffering, it eventually will.  Not taking in enough calories to match activity level is not sustainable in the long-run.


• It is normal for female athletes to stop menstruating. FACT:  It is never normal for a female athlete to stop menstruating. There are serious health risks, especially bone loss, to not menstruating. Studies show that after three years of not menstruating, bone loss is likely to be permanent. Loss of future reproductive function could also occur.


• If an athlete is not eating enough to match activity level, she is aware of what she's doing. FACT: Denial is powerful. Athletes will very often feel that they are being as healthy as possible, and that meticulous attention to diet is a sign of dedication to sport. Coaches, parents, and professionals will need to help the athlete see the problems with the behaviors.


• An athlete who eats “healthy," is a top performer on the team, and excels in class is unlikely to have an eating disorder. FACT: Traits that are desirable in an athlete can make them more at risk of developing an eating disorder. Mental toughness, pursuit of excellence, performance despite pain, commitment to training, and being a team player are very similar to excessive exercise, perfectionism, denial of discomfort, and being self-less.

What can you do if someone you know might be suffering from the female athlete triad?

1. Share your concerns with the athlete.


2. Talk with the coach, athletic trainer, or school counselor.


3. Encourage the athlete to see a physician and dietitian. Not all health care professionals are familiar with the details of the female athlete triad; to help them out, you can send along this brochure with the athlete to the appointment.

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Seeing Stars is a Serious Deal - Sports-Related Concussions

By Claudia L. Reardon, M.D.

Concussions in athletes have received increased media attention recently.  More and more evidence shows that there can be serious short- and long-term consequences of concussions if athletes return to physical activity too soon.  A concussion is a brain injury and must be treated very seriously. 

How do you know if someone has sustained a concussion?  Signs and symptoms of a concussion after an athlete hits his/her head include:

• Headache


• Nausea/vomiting


• Dizziness


• Vision changes


• Sensitivity to light and sound


• Feeling confused or groggy


• Concentration difficulties


• Inability to remember events before or after the hit


• Mood, behavior, or personality changes

Importantly, most athletes with concussions won’t experience all of these signs and symptoms.  Some of them might not appear for hours or even days.  If you, a coach, a game official, or medical provider suspect a concussion, take the following steps:

• Remove the athlete from the game/practice immediately.


• Seek medical attention.


• Do not return to physical activity until cleared by a physician.  Returning to activity too soon can cause long-term physical and psychiatric problems and even death.


• When returning to play, do so gradually, under the guidance of your health care provider.

Sports participation has many positive physical and mental health benefits for children and adults alike.  In the spirit of competition, athletes and coaches often want to do everything they can to win.  However, if a concussion is suspected, it is not worth it to risk long-term brain damage to stay in the game to help the team.   

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Why Women Must Exercise for Mental Health

By Claudia Reardon, M.D.





Exercise has mental health benefits for men and women of all ages.  However, there are unique factors to consider in thinking about the mental health benefits of exercise for women in particular.  Compared to men, women have a two-fold increased prevalence of major depression throughout their reproductive life cycle.  Exercise can be a very useful treatment for depression in women at any of a number of different times in their lives:   

• During pregnancy and breastfeeding:  Depression is highly prevalent in women of childbearing age.  Medications are often necessary to treat moderate to severe depression.  However, many women wish to avoid treatment with medications during pregnancy and while breastfeeding.  At least one study has shown that women who exercised regularly reported less depression in the first and second trimesters compared with women who did not exercise.  The American College of Obstetricians and Gynecologists has recommended 30 minutes of moderate exercise on most days.

• During the postpartum period:  Exercise can also help to treat and prevent postpartum depression.  One study has shown that postpartum women who exercised three times per week had less depression than postpartum women who did not exercise. 

• During the premenstrual period:  Exercise can be useful to treat physical and emotional premenstrual symptoms.  It is less clear if exercise by itself can treat the most severe of premenstrual syndromes (called “premenstrual dysphoric disorder”), but it is still a first-line treatment strategy that most physicians would recommend. 

• During menopause:  Several studies have shown that aerobic exercise can improve both depression and insomnia occurring during menopause.  Additionally, lower intensity exercise such as yoga has been shown to improve psychological well-being in menopausal women.

Importantly, women may experience barriers to exercise.  Here are some examples of these barriers, and strategies to help address them:

• Childcare issues:  Women are often responsible for childcare, which makes it difficult for them to find opportunities to exercise.  Gyms that offer childcare services can be helpful.  Also, partners can share the workload. 

• Intimidation:  Some women may feel uncomfortable working out in the coed environment of a gym.  Consider taking women-only exercise classes, or walking or doing other exercise with women exercise buddies.

• Self-consciousness about appearance:  If a woman is already uncomfortable about her appearance, then she might worry that she’s drawing even more attention to her body by exercising, especially if wearing skimpy sports clothes.  One strategy is to try walking, which can be done almost anywhere and in almost any type of clothing.

• Guilt:  Women, especially those who are family caretakers, sometimes describe feeling guilty about taking time for themselves to exercise.  Remember, it is not a selfish thing to exercise.  You are taking time to improve your physical and emotional health, which will allow you to more effectively be there for others.  Besides, you deserve to experience the benefits of exercise!   

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Talking To Kids About Disappointment In Sports

By Claudia Reardon, M.D.



Participating in sports is generally thought of as a physically and emotionally healthy activity for children and teenagers. However, it is inevitable that children who play sports will at some point deal with disappointment. Not every play or game will go their way. While dealing with this disappointment can be difficult for children, it's also a great opportunity for growth. The excitement of the Super Bowl and other winter sporting events provide a chance to talk with your children about disappointment.

Here are some tips to keep in mind if you parent or coach a child or teenager who is dealing with disappointment in sports:



1. Acknowledge your child’s feelings about what happened. For example, you can say, “I understand that you are feeling really upset that you didn’t win the race.” Of course, this does not mean that you should agree with catastrophic statements that they might make, such as that they are the worst player that ever played or that their life is ruined because of a bad game.



2. It’s okay if kids don’t want to talk about a disappointing game or event immediately. You might simply acknowledge their feelings and tell them that you’re there for them to talk whenever they want to.



3. Help your children shift focus to what they did RIGHT on the playing field. This is especially important if your child is a perfectionist, in which case he or she is likely to focus on the one mistake rather than seeing the “big picture” of everything he or she has done right.



4. It’s certainly okay if your children’s disappointment leads them to want to improve their sports skills. Help them figure out exactly what skill they would like to improve, and then brainstorm ways to improve in that area. They might even ask for suggestions from the coach. Help your children set realistic goals and then give them praise as they work toward those goals.



5. Ask your children if they think their favorite athletes ever make mistakes in their sport. If these athletes said that they were terrible players and wanted to quit after one bad play or bad game, would your children agree with that? Of course not!



6. Disappointment is a great opportunity to reinforce resilience and determination. Remind your child that he or she is “the kind of person who doesn’t give up easily.”



7. If a child is disappointed in his or her sporting performance, that is not an excuse for poor sportsmanship. It is not okay for them to express their disappointment as anger toward the winner.



8. Remind your children that failing to make a good play or to win a game does not mean that they’re a failure overall. There still are lots of great things about them, and everyone fails sometimes. Remind them of all the things they have done well recently.

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Six Tips for Talking to your Doctor about Medication

By Claudia L. Reardon, M.D.



In my last blog, I addressed the factors psychiatrists consider in choosing a given psychiatric medication for a patient. I emphasized the importance of medication selection being a collaborative process between the physician and the patient. In the midst of an appointment with a psychiatrist, though, it can be difficult for a patient to know what to ask, and when and how to ask it. This article includes tips for patients to help them work with their physicians in finding the best medications.

1. Ask the psychiatrist, “How did you pick that medicine?” Even if you can think of nothing else to ask during an appointment, this single question will probably lead to a wealth of useful information. For example, it might lead to a discussion of the target symptoms, how the medication affects other medications or medical conditions, and side effects.


2. Make a list of medication questions to ask your psychiatrist at your next appointment. I find it extremely useful when my patients come in with a list of questions they have made since I last saw them in my office. This way, patients are sure not to forget to ask anything important to them.


3. Take notes during your appointments. It can be difficult to remember everything your psychiatrist says during your appointment, and so bringing a note pad and pen along to take notes can be useful so that later you can remember what was discussed.


4. Read books. There are a number of excellent books available for patients on psychiatric medications. In my experience, patients find especially useful the book Instant Psychopharmacology by Ronald Diamond, M.D.


5. Visit websites. Patients should be careful about which websites they visit, as not all are reliable sources of medication information. However, in addition to www.HealthyMinds.org, another reputable site is the NAMI medication website. Go to the NAMI webpage (www.nami.org) and click on the “Medications” tab on the top toolbar.


6. Try not to be embarrassed. Many patients are embarrassed to talk about concerns they have about medications, especially side effects that they find difficult to discuss. However, remember that physicians hear about all kinds of different side effects, and it is pretty hard to embarrass a physician when it comes to talk about the human body!

In addition to these strategies, you might have found others that work for you in keeping you engaged in your medication treatment. It is imperative to keep the lines of communication open with your psychiatrist and to remember that your physician is there to answer any questions you have.

Which Medicines and When: Collaborative Process of Finding the Right Medicines

By Claudia L. Reardon, M.D.

Many patients have long and trying journeys on the way to finding medication regimens that work for their psychiatric symptoms. It isn’t always obvious why psychiatrists choose certain medications and avoid others for given patients. In this blog post, I will review the process by which a physician chooses a psychiatric medication. The more the patient knows about how the psychiatrist is thinking through the medication decision-making, the more active a role that patient can play in the process. 

Psychiatrists consider the following issues when prescribing a medication:

1. Target symptoms. A patient might have many different symptoms, for example, depressed mood, anxiety, trouble with concentration, and severe insomnia. It is important to decide which symptoms should be addressed first, since it is likely that one single medicine will not help all of the symptoms. Doctors often prefer not to start multiple medications at the same time, as it otherwise can be difficult to figure out which medicine is helping or which is causing side effects. Thus, in a patient with the above symptoms, the physician might first choose to address the patient’s depressed mood with an antidepressant. Since trouble with concentration and severe insomnia could be caused by depression, it is possible that treatment with an antidepressant will help those symptoms as well. It is important to address the symptoms in the order that makes the most sense.


2. Psychiatric diagnosis. The physician cannot simply treat a target symptom with a medication without knowing the overall psychiatric diagnosis. For example, depressed mood could be due to many different diagnoses, including major depressive disorder, bipolar disorder, schizoaffective disorder, drug or alcohol abuse, or medical problems such as low thyroid. All of these would have different treatments. Major depressive disorder would be treated with antidepressants, while antidepressants can actually sometimes worsen bipolar disorder. Likewise, if a patient’s depression is caused by a medical problem, it is essential that the medical problem be addressed rather than simply “band-aiding” the symptom of depression with an antidepressant.


3. Medical conditions and other medications. It is critical that the physician be aware of all the patients’ medical issues and other medications they are taking. Certain psychiatric medications would be dangerous if prescribed to patients with certain medical problems. For example, some medications can worsen seizure disorders, cause abnormal heart rhythms, or worsen diabetes. Additionally, some psychiatric medications can have dangerous interactions with other medications.


4. Side effects. Psychiatrists must consider how a given medication’s side effects will impact a given patient. For example, a patient who drives heavy machinery for a living should probably not take a medication that causes drowsiness. On the other hand, sometimes physicians can “take advantage” of side effects. For example, if a patient is sleeping and eating poorly, the doctor might prescribe a medication with sleepiness and increased appetite as side effects.


5. History of response. If a patient or his or her family member has had a good response to a medication in the past, that might be a good reason to choose that medicine now.


6. Patient preferences. Finally, and most importantly, the physician must make sure that the patient is willing and able to take the medication being prescribed. If the patient feels that the side effects are intolerable, or simply cannot afford it, it doesn’t matter how reasonable the choice of medication might be since the patient will not take it. The physician should check with patient to ensure they are comfortable with the medication being prescribed. Likewise, patients should not hesitate to speak up if they have concerns about a medication being prescribed for them.

In summary, physicians consider a multitude of factors in choosing a psychiatric medication for a patient. Ultimately, the decision about a medication should be a collaborative one between the psychiatrist and the patient.

Concussion: Getting Back in the Game?

American Psychiatric Association Healthy Minds blogger and sports psychiatriy expert Claudia Reardon, M.D., discusses concussions in young athletes in this video blog:

Athletes Suffer from Depression Too

By Claudia L. Reardon, M.D.

Athletes don’t get depressed, right? After all, they are so physically fit and healthy that they must be equally emotionally healthy. Unfortunately, this is not true. Just like the rest of us, athletes can be at risk for depression. This is the case all the way from the school-aged child playing on a recreational team, up to the professional athlete who makes a living playing his or her sport.



Whenever we see a news story about a famous athlete with depression or an athlete who has committed suicide, it tends to come as a big surprise since athletes tend to be glamorized and admired in our society. However, here are some things we know about the reality of depression in athletes:



1. Athletes seem to be at least as likely as the general population to suffer from depression.

2. Athletes who suffer multiple concussions are up to four times as likely as other athletes to suffer depression. Athletes in some sports, including football, hockey, and soccer, are especially likely to suffer concussions.



3. Overtraining syndrome can occur in athletes who are seriously training for an event and do so beyond the body’s ability to recover. Overtraining can look very similar to depression and can actually lead to full-blown depression. Like depression, overtraining can include fatigue, insomnia, appetite change, weight loss, difficulties with motivation, and poor concentration. Overtrained athletes usually notice that their sports performance worsens. They may develop more injuries; experience muscle and joint pain, and lose enthusiasm for their sport. If an athlete is overtrained, the treatment is usually to cut back on physical activity or do cross training at a lower intensity until the symptoms start to improve. If overtraining leads to full-blown depression, medication and/or talk therapy may also be helpful.



4. Besides concussions and overtraining, other common factors that can lead to depression in athletes include injuries, competitive failure, aging, retirement from sport, and the same daily stressors that can lead to depression in the general population.



5. In recent years, athletes across several sports have started to open up about their struggles with depression. Hopefully this will help athletes with depression to feel better about seeking help for this disorder.

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