First international consensus statement on sports psychiatry.

Sports psychiatry is a young field of medicine and psychiatry that focuses on mental health among athletes, and sports and exercise within psychiatry and mental disorders. However, the development of sports psychiatry and its fields of activity vary from region to region and are not uniform yet. Sports psychiatry and the role of sports psychiatrists have also already been discussed in the field of sports and exercise medicine, and within medical teams in competitive and elite sports. A uniform definition on sports psychiatry, its fields of activity, sports psychiatrist, and the essential knowledge, skills, and abilities (plus attitudes, eKSA+A) of the sports psychiatrist were developed as part of an International Society for Sports Psychiatry (ISSP) Summit, as well as First International Consensus Statement on Sports Psychiatry. Three fields of activity can be distinguished within sports psychiatry: (i) mental health and disorders in competitive and elite sports, (ii) sports and exercise in prevention of and treatment for mental disorders, and (iii) mental health and sport-specific mental disorders in recreational sports. Each of these fields have its own eKSA+A. The definitions on sports psychiatry and sports psychiatrists, as well as the framework of eKSA+A in the different fields of activity of sports psychiatrists will help to unify and standardize the future development of sports psychiatry, establish a standard of service within sports psychiatry and together with the neighboring disciplines, and should be included into current, and future sports psychiatry education and training.

A Retrospective Observational Study of Psychosocial Determinants and Psychiatric Diagnoses of Mass Shooters in the United States.

Our aim was to better understand the underlying psychiatric, psychosocial, and psychodynamic aspects of mass shootings in the United States (US). The Mother Jones database of 115 mass shootings from 1982-2019 was used to study retrospectively 55 shooters in the US. After developing a psychiatric-assessment questionnaire, psychiatric researchers gathered multiple psychosocial factors and determined diagnoses and treatment by evaluating the clinical evidence obtained by interviewing forensic psychiatrists, who had assessed the assailant, and/or by reviewing psychiatric evaluations conducted during the judicial proceedings. All 35 surviving-assailant cases were selected. Additionally, 20 cases where the assailant died at the time of the shootings were randomly selected from the remaining 80 cases. The majority of assailants (87.5%) had misdiagnosed and incorrectly treated or undiagnosed and untreated psychiatric illness. Most of the assailants also experienced profound estrangement not only from families, friends, and classmates but most importantly from themselves. Being marginalized and interpersonally shunned rendered them more vulnerable to their untreated psychiatric illness and to radicalization online, which fostered their violence. While there are complex reasons that a person is misdiagnosed or not diagnosed, there remains a vital need to decrease the stigma of mental illness to enable those with severe psychiatric illness to be more respected, less marginalized, and encouraged to receive effective psychotherapeutic and pharmacologic treatments.

A Retrospective Observational Study of Psychosocial Determinants and Psychiatric Diagnoses of Mass Shooters in the United States.

Our aim was to better understand the underlying psychiatric, psychosocial, and psychodynamic aspects of mass shootings in the United States (US). The Mother Jones database of 115 mass shootings from 1982-20119 was used to study retrospectively 55 shooters in the US. After developing a psychiatric-assessment questionnaire, psychiatric researchers gathered multiple psychosocial factors and determined diagnoses and treatment by evaluating the clinical evidence obtained by interviewing forensic psychiatrists, who had assessed the assailant, and/or by reviewing psychiatric evaluations conducted during the judicial proceedings. All 35 surviving-assailant cases were selected. Additionally, 20 cases where the assailant died at the time of the shootings were randomly selected from the remaining 80 cases. The majority of assailants (87.5%) had misdiagnosed and incorrectly treated or undiagnosed and untreated psychiatric illness. Most of the assailants also experienced profound estrangement not only from families, friends, and classmates but most importantly from themselves. Being marginalized and interpersonally shunned rendered them more vulnerable to their untreated psychiatric illness and to radicalization online, which fostered their violence. While there are complex reasons that a person is misdiagnosed or not diagnosed, there remains a vital need to decrease the stigma of mental illness to enable those with severe psychiatric illness to be more respected, less marginalized, and encouraged to receive effective psychotherapeutic and pharmacologic treatments.

A Retrospective Observational Study of Psychosocial Determinants and Psychiatric Diagnoses of Mass Shooters in the United States.

Our aim was to better understand the underlying psychiatric, psychosocial, and psychodynamic aspects of mass shootings in the United States (US). The Mother Jones database of 115 mass shootings from 1982-2019 was used to study retrospectively 55 shooters in the US. After developing a psychiatric-assessment questionnaire, psychiatric researchers gathered multiple psychosocial factors and determined diagnoses and treatment by evaluating the clinical evidence obtained by interviewing forensic psychiatrists, who had assessed the assailant, and/or by reviewing psychiatric evaluations conducted during the judicial proceedings. All 35 surviving-assailant cases were selected. Additionally, 20 cases where the assailant died at the time of the shootings were randomly selected from the remaining 80 cases. The majority of assailants (87.5%) had misdiagnosed and incorrectly treated or undiagnosed and untreated psychiatric illness. Most of the assailants also experienced profound estrangement not only from families, friends, and classmates but most importantly from themselves. Being marginalized and interpersonally shunned rendered them more vulnerable to their untreated psychiatric illness and to radicalization online, which fostered their violence. While there are complex reasons that a person is misdiagnosed or not diagnosed, there remains a vital need to decrease the stigma of mental illness to enable those with severe psychiatric illness to be more respected, less marginalized, and encouraged to receive effective psychotherapeutic and pharmacologic treatments.

Combining Asian and American pedagogy to improve clinical psychopharmacology practice.

As the world becomes increasingly interconnected, psychiatrists across geographical regions and from various international organizations need to collaborate to promote global health and wellness. A necessary step is for nations of the world to develop combined teaching initiatives and curricula to ensure best practices are shared globally. In no field of medicine is this more pressing than in psychiatry - especially psychopharmacology given the recent advances in the field. This paper highlights the need to work collaboratively in developing teaching curricula in psychopharmacology in order to incorporate pedagogy and content from international partners-here from Asia and America.

The Role of a Sport Psychiatrist on the Sports Medicine Team, Circa 2021.

The field of sports psychiatry is in early stages of development and the role of the sport psychiatrist continues to evolve as the psychiatric needs of athletes become more apparent. Today's sports psychiatrist has increasing roles, including treatment of athletes, coaches, and their support personnel as well as providing an in depth and broad understanding of the medical and psychiatric demands in sport. The ongoing development of the field will help determine the eventual growth and expansion in the field.

Domestic Mass Shooters: The Association With Unmedicated and Untreated Psychiatric Illness.

BACKGROUND: Given the relative lack of psychiatric information and data on the perpetrators of US mass shootings, the aim of our study was to understand who these "mass shooters" were and whether they had a psychiatric illness. If so, were they competently diagnosed, and if so, were they treated with appropriate medication for their diagnoses before the violence? METHODS: Because a prospective study of diagnosis and treatment could not, for obvious reasons, be carried out, we designed a retrospective, observational study of mass shooters, defined as those who killed 4 or more people with firearms between 1982 and 2012 or who killed 3 or more people with firearms between 2013 and 2019 in the United States. We used the Mother Jones database-a database of 115 persons identified as committing a mass shooting in the United States between January 1982 and September 2019. In the vast majority of the incidents identified in the database, the perpetrator died either during or shortly after the crime, leaving little reliable information about their history-especially psychiatric history. We focused on the 35 mass shooters who survived and for which legal proceedings were instituted because these cases presented the most reliable psychiatric information. For each of these 35 mass shootings, we interviewed forensic psychiatrists and forensic psychologists who examined the perpetrator after the crime and/or collected the testimony and reports by psychiatrist(s) at trial or in the postconviction proceedings contained in the court record. In addition, we reviewed available information from the court proceedings, public records, a videotaped interview of assailant by law enforcement, social media postings of the assailant, and writings of the assailant. After collecting the clinical information from multiple sources on each case to make a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnosis, we also completed a Sheehan Diagnostic Scale. After this, 20 additional cases where the assailant died at the crime were randomly selected form the remaining 80, to determine whether there were differences in psychiatric diagnoses and treatment between such assailants and those who survived. RESULTS: Twenty-eight of 35 cases in which the assailant survived had a psychiatric diagnosis-18 with schizophrenia, 3 with bipolar I disorders, 2 with delusional disorders, persecutory type, 2 with personality disorders (1 paranoid and 1 borderline), 2 with substance-related disorders without other psychiatric diagnoses, and 1 with posttraumatic stress disorder. Four had no psychiatric diagnosis, and in 3, we did not have enough information to make a diagnosis.Of 15 of 20 cases in which the assailant died, 8 had schizophrenia. None of those diagnosed with psychiatric illnesses were treated with medication. CONCLUSIONS: A significant proportion of mass shooters experienced unmedicated and untreated psychiatric disorder.

Persistent Barriers to the Use of Long-Acting Injectable Antipsychotics for the Treatment of Schizophrenia.

PURPOSE/BACKGROUND: One of the major challenges in the treatment of schizophrenia is nonadherence, defined as the failure to take medications as prescribed. Nonadherence is a strong predictor of symptom relapse, hospital readmission, and poorer long-term outcome. Although long-acting injectable antipsychotics (LAIs) have been found to be superior to their oral analogs at reducing relapse in large-scale meta-analyses, their prevalence seldom exceeds 30% even in populations with a history of nonadherence. We review multiple barriers to the use of LAI utilization and suggest strategies to address them. METHODS/PROCEDURES: We searched for the following terms: long-acting injectable/depot antipsychotics, schizophrenia, barriers, and attitude/perception in both the PubMed search index and Google scholar from 1995 to 2018. A total of 329 studies were selected, of which data from 13 were reviewed for this article. Only peer-reviewed studies, randomized controlled trials, systematic reviews, and meta-analyses that describe barriers to using LAIs were included. FINDINGS/RESULTS: Several barriers to using LAIs were identified. These are organized into 3 overarching categories: those related to the clinician; those related to the patient; and systems barriers. Clinician factors include the perception of LAIs as coercive, fears of not being able to control the dose, as well as current practice patterns and guidelines. Patient factors include perception of the injection as painful or intrusive, general lack of knowledge, and a sense of coerciveness. For each identified barrier, we propose potential solutions. IMPLICATIONS/CONCLUSIONS: We identified multiple barriers to using LAIs in patients with schizophrenia. Specific strategies are suggested for overcoming each of these barriers.

The problem of medical-psychiatric illness in the homeless and its occurrence in the midst of a viral pandemic: A commentary.

This article has the purpose of examining the problem of getting help for the medical-psychiatric-substance use group of "homeless" people on the streets of our cities, who refuse treatment. The problem has gradually worsened since closure of state hospitals and subsequent lack of community resources. It has been stalemated, in part, by advocates, who argue for personal autonomy and freedom rather than involuntary diagnosis and treatment over the life of these people. It has reached a crisis situation secondary to such potential patients being imprisoned and/or sick with COVID-19 being potential health and legal threats. We review A) the nature of the problem, B) the current social-legal availability of treatment and long-term management (or lack of one) in the context of societal rejection of these potential patients, and C) suggest what might be done, locally and nationally. Mandating scientifically-based medical orders to citizens regardless of personal freedom - are now being implemented to manage the COVID-19 pandemic. We argue for creating a similar med-psych short- and long-term system as a new approach to help this group. They are now mostly being ignored "to die on the streets."

Update on integrative treatment of psychiatric symptoms and disorders in athletes.

Primary objective: In this review, we detail the issues and disorders athletes present with, guidelines for making diagnostic formulations and treatment goals, and strategies for delivering integrated treatment attuned to the athlete and their team and/or sport. In addition, we highlight special issues associated with athletes and their families. Reasoning: Data suggests athletes experience comprable incidence and prevalence rates to the general population of psychiatric disorders. The mental and physical demands placed on athletes are unique and may increase their susceptibility to certain mental health problems. The current literature regarding integrative interventions in athletes is sparse and largely anecdotal. We provide a summary of the scientific evidence from a literature review conducted by the IOC Consensus Committee on Mental Health in Elite Athletes, reviews and expert clinical strategies recommended by the authors of four books on sports psychiatry written since 2012, and our own review of the literature related to psychotherapy with elite and non-elite- athletes. Main outcomes and results: At the moment there are no randomized controlled trials assessing the use of psychotherapy or medication for mental illness in athletes to guide treatment. Controlled studies examining psychological interventions in collegiate athletes have demonstrated improvements in mental health symptomology. Although these studies were limited to collegiate athletes they assist in providing a foundation for elite athletes as well. For the assessment and management of the mental health needs of athletes' to be on a par with their physical needs, more high-quality scientific epidemiological and treatment intervention studies are needed. Conclusions: Development of specific models of psychiatric intervention for athletes with significant psychopathology and impairment appears to be warranted. These interventions should include individual, family/marital, and group psychotherapy with or without medication using evidence-based treatments.

Are Patients With Schizophrenia Better Off With Lifetime Antipsychotic Medication?: Replication of a Naturalistic, Long-Term, Follow-Up Study of Antipsychotic Treatment.

PURPOSE/BACKGROUND: The question of whether people with schizophrenia should be treated with antipsychotics for life has been debated for decades. We recently reported results of 2 retrospective long-term naturalistic studies examining the association of medication adherence and global outcomes in different demographic samples. In both, we found that patients with a history of better adherence to antipsychotic medication had better quality of life outcomes. Using similar methodology, here we present such associations for a very different sample-patients with chronic schizophrenia with a long past history of antipsychotic treatment that had been treated for 19 to 53 years in a Veterans Affairs clinic. METHODS: This is a retrospective, naturalistic, longitudinal 19- to 53-year (mean average, 33.5 years) lifetime follow-up of a consecutive series of patients with schizophrenia, who had at least 8 years of antipsychotic treatment. Lifetime data were collected on (1) their medication adherence, (2) long-term global outcome, and (3) life satisfaction. Outcomes were rated by 2 different clinicians, one with information on medication adherence (nonblind rater) and one without (blind rater). Linear regression models, adjusted for age, family support, substance use disorder, race, marital status, and number of years in treatment were used to estimate the association between adherence and each outcome. RESULTS: A total of 20 patients were assessed. Medication adherence was positively associated with the blind clinician's rating of global outcome (P = 0.049) and the Global Assessment of Functioning (P = 0.021). In the nonblinded clinician's rating, medication adherence was positively related to global outcome (P = 0.001) and to the patient's report of life satisfaction (P = 0.028). IMPLICATIONS/CONCLUSIONS: This replication study, together with our previous 2 studies, is consistent with the recommendation for continuous, long-term treatment for chronic schizophrenia over many years of a patient's lifetime unless medically contraindicated.

Healthy Eating, Physical Activity, and Sleep Hygiene (HEPAS) as the Winning Triad for Sustaining Physical and Mental Health in Patients at Risk for or with Neuropsychiatric Disorders: Considerations for Clinical Practice.

Neuropsychiatric disorders stem from gene-environment interaction and their development can be, at least in some cases, prevented by the adoption of healthy and protective lifestyles. Once full blown, neuropsychiatric disorders are prevalent conditions that patients live with a great burden of disability. Indeed, the determinants that increase the affliction of neuropsychiatric disorders are various, with unhealthy lifestyles providing a significant contribution in the interplay between genetic, epigenetic, and environmental factors that ultimately represent the pathophysiological basis of these impairing conditions. On one hand, the adoption of Healthy Eating education, Physical Activity programs, and Sleep hygiene promotion (HEPAS) has the potential to become one of the most suitable interventions to reduce the risk to develop neuropsychiatric disorders, while, on the other hand, its integration with pharmacological and psychological therapies seems to be essential in the overall management of neuropsychiatric disorders in order to reduce the disability and improve the quality of life of affected patients. We present an overview of the current evidence in relation to HEPAS components in the prevention and management of neuropsychiatric disorders and provide suggestions for clinical practice.

The Crisis in Psychiatric Hospital Care: Changing the Model to Continuous, Integrative Behavioral Health Care.

Inpatient psychiatric hospital services, as they currently exist, have little to no evidence base. Deficits in the current system represent a critical missed opportunity to improve the trajectory of patients' lives and long-term outcomes. The authors posit that a fresh approach to hospitalization is needed, one that incorporates distinct, measurable goals tied to a comprehensive, individualized treatment plan tailored to address a patient's lifetime course of illness. A structured approach can ultimately improve care quality and continuity by allowing for rigorous testing of each aspect of the assessment and care provision process, improving patient outcomes and care engagement while shortening average lengths of hospital stays, and accelerating the movement of care to cost-effective, need-specific settings. In an effort to move the field toward establishing a systematic, evidence-based protocol for hospital-based psychiatric care, the authors describe a new model, called the S.E.T.U.P. approach.