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, we worked with experts from multiple areas in psychiatry to bring you thoughtful articles about a wide variety of psychiatric issues, from youth mental health in competitive sports to the implications of civil commitment for substance use disorders. Here are some highlights from the issue.

Civil Commitment for Substance Use Disorders: Coercion or Compassion?

The United States of America has entered the third year under siege from not just 1, but 2 epidemics: COVID-19 and addiction. Each scourge has multiplied the victims and magnified the death toll of the other; together, they have caused immeasurable suffering and loss.

 On November 17, 2021, the Centers for Disease Control and Prevention (CDC) made the grim announcement that annual overdoses passed the 100,000 mark. The 100,306 tragic deaths represent a nearly 30% increase from the prior year. Fatalities from synthetic and semisynthetic opioids, especially fentanyl, along with methamphetamine and cocaine were all higher in the past 12 months than in the period before.

 The vast majority of those who overdosed would meet criteria for a substance use disorder (SUD). 

An Update on the Presentation, Nosology, and Causes of Postpartum Psychosis

 (PP) is an umbrella term for the impairing and isolating psychotic-mood symptoms experienced by a small proportion of women (1 to 2 women every 1000 deliveries) shortly after childbirth. Despite being recognized for centuries, the condition has historically been understudied. However, over the past 10 to 15 years, stimulated by a growing interest in women’s health and increasing crosstalk among biomedical practitioners in diverse fields, we are finally starting to characterize PP more comprehensively and beginning to understand its associated risk factors and biological basis. 

On Thin Ice: Competitive Sports & Youth Mental Health

Your patient is 15 years old. Legally, they cannot smoke, they cannot drink, they cannot drive or make decisions for themselves. But they are pressured to take a cocktail of drugs, vitamins, and supplements, limit their diets, wear skin-tight costumes, and compete under a global microscope. There, the whole world watches them shine…or delights in their failures. What do you advise your patient and their family caregivers? 

Navigating to a Broader Population of First-Episode Patients

One of the core and troubling lessons that I learned during my psychiatric residency in the late 1980s continues to haunt me. For patients with serious mental illnesses (SMI), the greater the duration of time before a patient is diagnosed and enters treatment, the longer a symptomatic episode lasts, the more episodes the patient has, the less adherent the patient is with treatment, the more psychosocial stressors the patient is challenged by, the greater the presence of comorbid substance abuse, and the more disconnected the patient becomes from mainstream society, the worse the patient’s long-term prognosis will be. Intuitively, this is simply common sense. 

. And be sure to stay up-to-date by subscribing to the 

Do you have a comment on any of these or other articles? Have a good idea for an article and want to write? Interested in sharing your perspectives? Write to us at 

The experts weighed in on a wide variety of psychiatric issues for the June 2022 issue of Psychiatric Times.

From the Pages of Psychiatric Times: June 2022

The American Academy of Pediatrics (AAP) announced today that more than 300 pediatricians have submitted personal testimonies to the US Senate Judiciary Committee ahead of the committee’s hearing on gun violence prevention. The pediatricians’ submissions illustrated how gun violence has impacted patients, communities, and lives. According to the AAP, all stories were submitted in just over 2 days and range from heart-wrenching accounts of patients who have experienced gun violence to the long-term trauma caused by gun violence exposure.

The American Psychiatric Association (APA) also released a statement on firearm violence on June 1 in response to the recent mass shootings in Uvalde, Buffalo, Houston, and more than 200 other US locations in 2022 so far. “Firearm violence is a public health crisis, and it is preventable,” the APA said in its statement. “APA is committed to federal efforts to protect our youth and all citizens from gun violence and implores Congress to enact firearm safety legislation that will promote safe communities and reduce morbidity and mortality due to firearm-related violence.”

A bipartisan gun safety proposal, if passed, would make improvements to the background check system, support red flag laws, enhance school safety, close domestic violence loopholes, and introduce stronger penalties for straw purchasing—a criminal act in which an item, especially a firearm, is bought by an individual on behalf of another who is legally unable to make such a purchase.

“We have been elected to the US Senate to respond to American crises,” US Senate Majority whip Dick Durbin, a Democrat from Illinois, said in a statement on June 12, 2022. “Each of the elements in this bipartisan gun safety package has the potential to save lives. I continue to believe military-style assault weapons that can shred the bodies of their victims have no place in civilian use—but we cannot let the perfect Congressional response be the enemy of the good. Though this agreement falls short in this and other respects, it can and will make our nation safer.”

During the hearing, AAP president Moira Szilagyi, MD, PhD, FAAP, testified before senators to discuss the emotional and physical toll of gun violence on young people and the need for comprehensive policies to keep children safe. Additionally, she urged the Senate to complete action on the recently announced bipartisan framework on gun safety as a much-needed first step in addressing gun violence.

“These testimonies should be required reading for every senator and representative,” said Szilagyi in the AAP announcement. “Their words and perspectives vary, but their common thread is urgency. Children and adolescents are dying. We must act now. Pediatricians will continue to speak up in every way we know how until we see meaningful policy change.”

The psychiatric community will also continue to advocate for change that will help save lives, according to the APA. “We implore our elected officials to act on meaningful, common-sense measures and begin to heal the divisions that have prevented progress in this area of public health for far too long,” the APA said in its statement. “This senseless loss of life must end, and as a nation, we should expect action from federal and state legislative and executive leaders. Our children and communities deserve better.”

Here is a preview of the pediatricians’ testimonies to the US Senate Judiciary Committee:

“Children who are shot are usually rushed to the hospital—without their parents—as fast as possible by EMS or police. So I have looked into the terrified eyes of many children after they’ve been shot and tried to comfort them. I tell them that they’re in a safe place now, that we’re going to take care of them, while around them our ER staff moves quickly, cutting off clothes, placing IVs, assessing the injuries, treating pain, and doing our best to minimize the damage after the injury occurred. The feeling of their scared eyes, locked on mine, while I tell them they’re safe, is a feeling I don’t forget. There is a promise in that look we share. They desperately want an adult to take care of them. I tell them they’re safe in a safe place now, but in my heart, I don’t know if they are.”

– Halden Scott, MD, Denver, Colorado, Pediatric Emergency Medicine (page 4 of the document)

“One of the many that I have treated in the emergency department and the Level 1 trauma center was a young child who pulled his father’s gun and pretended to play war with his brother; not knowing that the gun was real and loaded he fatally shot his 6-year-old brother in the chest. The child kept crying hysterically, refusing to separate from his dead brother. The parents were agonized for the child who died and their other child who will carry the guilt of killing his brother for life.”

– Madeline Joseph, MD, Jacksonville, Florida, Pediatric Emergency Medicine (page 32)

“Gun violence can occur at any time, any place and under any circumstances. In this case of road rage, the driver from another car got angry and shot the car through the trunk, and the bullet went into the child sitting in the back seat.”

– Mustafa Kabeer, MD, Irvine, California, Pediatric Surgery (page 21)

“For example, last week, a mother brought in her 8-year-old daughter to discuss the child’s difficulties sleeping. Ever since she went through active shooter ‘run, hide, fight’ drills at her elementary school, she has experienced nightmares. She cannot sleep in her own bed. She cannot sleep with the lights off. She cries nearly every day when her mother waves goodbye to her from the bus stop because she is scared it will be the last time she ever sees her mom.”

– Dr. Nancy Heavilin, Somers Point, New Jersey, General Pediatrics (page 14)

1. More than 300 pediatricians submit personal testimonies of gun violence to Congressional record. American Academy of Pediatrics. June 15, 2022. Accessed June 15, 2022. 

https://www.aap.org/en/news-room/news-releases/aap/2022/more-than-300-pediatricians-submit-personal-testimonies-of-gun-violence-to-congressional-record/

2. Statement from the American Psychiatric Association on firearm violence. American Psychiatric Association. June 1, 2022. Accessed June 15, 2022. 

https://www.psychiatry.org/news-room/news-releases/apa-statement-on-firearm-violence

3. Durbin statement on new bipartisan gun safety framework. Committee on the Judiciary. June 12, 2022. Accessed 15, 2022. 

https://www.judiciary.senate.gov/press/dem/releases/durbin-statement-on-new-bipartisan-gun-safety-framework

A version of this article appears on the 

 website. You can access the original article 

The American Academy of Pediatrics included these testimonies in a statement submitted to the US Senate Judiciary Committee in advance of the committee’s hearing on gun violence prevention.

Pediatricians Submit 300+ Personal Gun Violence Testimonies to Congressional Record

“One-third of kids in middle school and high school in North America are struggling socially—one-third,” Elizabeth Laugeson, PsyD, told attendees of the 2022 American Psychiatric Association Annual Meeting. “Do you think they’re all getting services? Probably not. And if you think about the consequences of this, it’s pretty disturbing.”

Laugeson is the founder and director of the University of California, Los Angeles (UCLA) PEERS Clinic; training director of the Tarjan Center for Developmental Disabilities and Health Sciences; and clinical assistant professor of psychiatry and biobehavioral sciences at the Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine, at UCLA. She is also the author of 

The Science of Making Friends: Helping Socially Challenged Teens and Young Adults

The estimated 1 in 54 US children diagnosed with autism spectrum disorder (ASD) may especially experience social difficulties, according to Thomas E. Brown, PhD, of the Brown Clinic for ADHD and Related Disorders and the University of California-Riverside School of Medicine. Brown added that about 50% to 75% of individuals on the autism spectrum also have attention-deficit/hyperactivity disorder (ADHD).

Youth with ASD who exhibit symptoms of ADHD tend to have more difficulty with adaptive behaviors at home, in school, and in their community, and may fall behind in a wide variety of executive functions, including activation, focus, effort, emotion, memory, and action. They also experience several social challenges, including poor social communication, poor social awareness, poor social cognition, less constructive social engagement, and few close meaningful (reciprocal) friendships, according to Laugeson. Youth may experience any or all of these challenges even if they do not meet full DSM criteria for an ADHD diagnosis.

Teaching targeted social skills can help youth with ASD and ADHD, Laugeson added, noting the impact of common issues such as rejection and bullying on mental health, self-esteem, academic performance, and beyond even in youth who are not neurodivergent. “What we know is that peer rejection is one of the strongest predictors of mental health problems,” she said, noting a connection between rejection and depression, anxiety, loneliness, substance abuse, early withdrawal from school, and suicidal ideation and attempts.

Laugeson explained that evidence-based programs teaching targeted social skills, such as the PEERS Clinic at UCLA, can help youth with ASD and ADHD improve in common challenge areas such as social communication, awareness, engagement, and cognition. At PEERS, they work with preschoolers, adolescents, and young adults by teaching them targeted strategies for building friendship and relationship skills, managing conflict, and handling rejection through training, teleconferences, virtual boot camps, and role-play videos and exercises. 

They also help all age groups deal with both direct (verbal, physical) and indirect (cyberbullying, gossip) forms of bullying. “The reality is that every kid gets teased. Even adults get teased. What matters is how you react to it,” Laugeson said, noting that the most common advice youth receive for handling bullies is often ineffective. 

“What are most young people told to do in response to teasing? Ignore it, walk away, tell an adult. But these are not ecologically valid strategies—and yet, this is what adults tell kids to do... It’s an epidemic of bad advice.”

PEERS shows youth the effects of these strategies in comparison to more effective techniques through role-play exercises and videos.

Based on the research, the PEERS approach works. Laugeson shared a recent study on outcomes of PEERS treatment in individuals with ASD, ADHD, and with both ASD and ADHD. All groups demonstrated significant improvements in social skills (ASD: 

<.001) and decreases in features of autism (ASD: 

“Even though the groups started differently at baseline,” she said, “they all improved after this treatment at the same rate.”

Overall, teaching targeted social skills can be helpful to youth who have ASD, ADHD, or both ASD and ADHD, as well as those who are not neurodivergent. “What if conversational skills—and more broadly, social skills—were not an art, but a science? Our research in social skills training for teens and young adults with social difficulties is based on this premise,” Laugeson wrote in 

“We believe that social skills can be taught, much in the way we might teach math or science. By breaking down complex, seemingly sophisticated social skills into concrete rules and steps of social behavior, we can demystify and to some extent decode the ‘art form’ that is social skills.”

How can we help this unique patient population thrive? Experts weigh in at the 2022 APA Annual Meeting.

The Youth Mental Health Crisis: Supporting Patients With ASD and ADHD

Your patient is 15 years old. Legally, they cannot smoke, they cannot drink, they cannot drive or make decisions for themselves. But they are pressured to take a cocktail of drugs, vitamins, and supplements, limit their diets, wear skin-tight costumes, and compete under a global microscope. There, the whole world watches them shine…or delights in their failures. What do you advise your patient and their family caregivers?

Kamila Valieva is a 15-year-old Olympic figure skater who competed for the Russian Olympic Committee (ROC) in the 2022 Olympic Winter Games, held in Beijing. During the team event, Valieva became the first woman ever to land a quadruple jump on Olympic ice. Days later, reports of a failed drug test came to light.

She tested positive for trimetazidine, a banned substance according to the rules of the World Anti- Doping Agency. Trimetazidine, a drug used for treating angina, is believed to improve an athlete’s endurance. There was talk of banning Valieva from skating in the individual competition and stripping the ROC of the gold medal they won in the team event, which Valieva helped them earn.

On February 14, the Court of Arbitration for Sport determined that Valieva would be allowed to continue to skate, despite the failed drug test. Among the reasons for such: disqualifying her would cause Valieva “irreparable harm.”

 However, in allowing her to skate, perhaps the court caused just that: irreparable harm. The controversial clearing brought the youth to the center of attention—not for her ability, but out of anger at the injustice to other Olympian athletes. It also failed to address an important issue: What is the impact of the pressures being placed on these youth?

Danielle Kamis, MD, the backup sports psychiatrist for the 2022 Winter Olympics and Paralympics, urges observers to consider how substances can impact an athlete’s outlook, mood, and performance.

“Athletes train many hours, days, and years in order to perform at their peak at competition, which can last for only minutes at a time during their time to perform. There is no banned substance that is worthwhile to put all of this time, energy, and training all at risk,” Kamis told 

™. “If an athlete abuses a banned substance, the player now not only has to balance the stress of competition and training, but also the feelings of guilt and secrecy in hiding a substance that was abused.”

Valieva’s story raises many provocative questions. To start, what will society do to children in order to make them win? What should be sacrificed in the name of competition? How much pressure is too much? And how do we pick up the pieces when young athletes are pushed too far?

 with young athletes is crucial, now more than ever.

Harry Miller, a former offensive lineman on Ohio State University’s football team, recently announced his retirement after struggles with suicidal ideation.

 In a 2-page letter posted on Twitter, Miller admitted he “would rather be dead than a coward,” referring to his fear of seeking help due to the potential reaction. He credits his retirement decision to the guidance from his coach, Ohio State head coach Ryan Day, arguably among the most important people in his life as an athlete.

“We frequently observe media portrayals, social media commentary, coaches, and even parents, who view mental health difficulties as a sign of weakness,” said Wilsa M.S. Charles Malveaux, MD, MA, a sports psychiatrist in Los Angeles, California, and the CEO of WCM Sports Psych. “Changing the dialogue around mental illness and being more open about challenges can help to decrease this 

This could have helped Katie Meyer, the star goalkeeper and captain of Stanford University’s women’s soccer team, who died from suicide in March 2022. Following her death, her mother said: “There’s so much pressure I think on athletes…especially at that high level balancing academics and a high competitive environment. And there is 

 and there is stress to be perfect, to be the best, to be number 1.”

Sports have been known for their positive impact on child and adolescent mental health. Young athletes do better academically. 

 provide exercise, a way to meet friends, and a place to learn skills like perseverance, teamwork, and problem-solving.

 These positive experiences can enhance their lives in important ways.

“Successful game play can increase self-esteem and confidence and improve [a child’s] overall self-image,” Birgit Amann, MD, medical director and founder of the Behavioral Medical Center in Troy, Michigan, told 

™. “They can learn the importance of developing and using patience and learn the value of practicing their sport.”

Research supports these conclusions. For example, a study examining sports participation found that it can also help protect against 

 and suicidal ideation by boosting self-esteem and increasing social support. Results showed the odds of suffering from depression decreased by 25% and suicidal ideation decreased by 12% as sports participation increased.

Results of another study indicated that boys who play sports during their early childhood are less likely to experience emotional stress, including depression and anxiety, later in life compared with boys who did not participate in sports.

“Given the recent soaring rates of mental health challenges among children, adolescents, and their families, it is more important than ever to foster protective factors such as team sport involvement,” Hannah Simon, MD, a child and adolescent psychiatry fellow at NewYork-Presbyterian Hospital, told 

Amann also noted the potential benefits of playing multiple sports, rather than specialization in a single sport. “Playing multiple sports can broaden their experiences,” she explained. “It can improve their overall athletic development, and because they are using different muscles for different sports they play, it can potentially prevent overuse injuries, which are more common when children play a single sport. It can also prevent 

, which is more common when a child specializes in 1 sport.”

Increased pressure—particularly on high-level athletes—may contribute to the risk of depression or anxiety (

“Like a broken bone, anxiety and depression may require rest, support, and rehabilitation in the form of therapy, and in some cases, even medications in order to heal. I emphasize that improving and preserving mental health requires hard work and practice, analogous to the way we gain mastery in any sport,” Simon commented.

In a study of elite Canadian swimmers, it was found that 68% of the surveyed athletes met criteria for a major depressive episode, with 34% meeting diagnostic criteria and 26% self-reporting mild to moderate symptoms of depression post competition. The 

 prevalence doubled among the top 25% of athletes. Female athletes in particular are at risk for depression, according to a study by the National Collegiate Athletic Association (NCAA) Division I, the NCAA’s most competitive division.

 One study found “many student-athletes report higher levels of negative emotional states than non-student athlete adolescents.”

“When you are told that your body represents a value out of 10, that is a problem. If your body is the vehicle in which you can achieve physical excellence, that’s another story,” Warren Y.K. Ng, MD, MPH, president of the American Academy of Child and Adolescent Psychiatry, told 

™. “We have to think about the values, the messages, and the culture related to the sport and the messages that we are giving young people about their bodies.”

Framing and focus, stressed Ng, is crucial. If the adults—parents, coaches, supporters—frame an Olympic or elite-level competition as a once-in-a-lifetime opportunity to showcase the youth’s abilities, but also focus on how the event is not their entire life, the youth can have a positive mindset. “We need to be respective of their age and humanity,” Ng commented.

Although some degree of pressure can be healthy for kids, it is important to gauge when pressure goes too far.

“Athletic pressures can teach kids how to navigate stressful life events and build 

 in the face of defeat,” Simon explained. “[They] can improve kids’ self-esteem by providing a sense of mastery as they learn a new skillset and feel empowered to overcome their own insecurities. However, if the pressure to perform results in significant impairment in personal functioning—as evidenced by problems with sleep or appetite, significant weight loss or weight gain, decline in grades, distressing anxiety or mood symptoms—then it may be time to reconsider whether continuing the sport is healthy for this child.”

 lists tips to share with young athletes and their families to prevent and reduce anxiety.

Injuries are often a catalyst for anxiety, depression, and 

 among athletes. Many athletes may also show signs of 

 When a young athlete’s identity and sense of self-worth is closely tied up in their sport, injury can leave them feeling lost and alone.

“An injury can have a significant negative impact on children, emotionally,” said Amann. “They can become more depressed and anxious, and even feel frustrated and angry. They can become more disengaged with family and friends and become withdrawn. The longer the recovery takes, the greater the risk for these emotional issues.”

In a study of NCAA Division I football players, 33% of injured athletes reported high levels of depressive symptoms compared with 27% of noninjured athletes, measured using the Center for Epidemiological Studies Depression scale.

 Although emotional responses of sadness or loss from injury are normal, coaches and parents should be cognizant of problematic emotional responses (

 can be particularly challenging for student athletes, as there is no defined timeline for recovery and return to play.

 Further, concussion management necessitates cognitive and physical rest, which can be hard for an athlete who is used to much activity.

Performance-enhancing drugs, unproven supplements, and extreme dieting can lead to severe mental health consequences, yet these strategies—often offered by trusted adults—are a reality for many athletes.

In the case of Valieva and other Russian figure skaters, they may delay puberty by eating only “powdered nutrients” or by taking leuprorelin (Lupron), a puberty blocker known to induce 

. They are also said to restrict their eating to stay light enough for complicated jumps, and to use “smelling salts” to help them perform while injured.

Figure skating is not the only culprit. The NCAA reported the number of student athletes testing positive for stimulant medications has increased 3-fold in recent years.

, and blood doping are common ways to perform despite pain.

Performance failure is significantly associated with depression: If an athlete does not win or at least do extraordinarily well in their competition, they feel increasingly depressed.

According to research, as many as 70% of young athletes stop playing organized sports by age 13. The increased pressure to specialize in a single, high-level sport—and win—may be a driving factor in the lower participation rates of adolescents in organized sports.

,” said Mark Hyman, JD, George Solomon Endowed Chair in Sports Journalism at the University of Maryland. “They’re not having fun anymore. They’re weary of the pressure. They’re tired of being yelled at by coaches and, sometimes, by their parents. The most talented players sometimes are forced to quit because they’ve been playing competitively for so long that they’re hurt…But those for whom winning is the most important thing can unravel a child’s devotion to a team and a sport quickly.”

Simone Biles, considered the greatest gymnast of all time and winner of 4 

, recently spoke out about deeming mental health more valuable than competing, after she withdrew from the US women’s gymnastics team final in the Summer Olympic Games held in Tokyo in 2021.

“Put mental health first, because if you don’t, then you’re not going to enjoy your sport and you’re not going to succeed as much as you want to,” Biles said. “It’s OK sometimes to even sit out the big competitions to focus on yourself, because it shows how strong of a competitor you really are, rather than just battle through it.”

Rashmi Parmar, MD, a psychiatrist with Mindpath Health, applauds Biles’ strength. “She definitely paved the way for future aspiring young athletes to advocate for their emotional well-being in face of stressful situations,” Parmar shared with 

™. “In general, there is a huge taboo among younger athletes about seeking help for their mental health, followed by low awareness and denial of the ‘need to seek help.’ Many embrace the ‘perfect’ or ‘superhuman’ identity as a normal part of their lives.”

Young athletes and their mental health are in crisis. Dr Kamis offers the following advice for caring for young elite athletes: “Be grateful to have the opportunity to work with such talented and driven people. Show them the compassion that perhaps they do not take the time to show themselves.”

1. Ryan M. Kamila Valieva will continue to compete in Olympics, panel rules. Popsugar. February 13, 2022. Accessed February 18, 2022. 

https://www.popsugar.com/fitness/kamila-valieva-tests-positive-trimetazidine-2022-olympics-48712618

2. The CAS ad hoc division declines to impose a provisional suspension on the Russian figure skater Kamila Valieva. Court of Arbitration for Sport. News release. February 14, 2022. Accessed February 18, 2022. 

https://www.tas-cas.org/fileadmin/user_upload/CAS_Ad_Hoc_Media_Release_Beijing_8.pdf

3. Harry Miller: Ohio State offensive lineman says he is medically retiring from football, citing mental health struggles. 

 March 11, 2022. Accessed March 14, 2022. 

https://www.cnn.com/2022/03/11/sport/ohio-state-harry-miller-medically-retiring-spt-intl/index.html

4. Fieldstadt E. Parents of Stanford soccer captain found dead in dorm say they ‘had no red flags.’ NBC News. March 4, 2022. Accessed March 14, 2022. 

https://www.nbcnews.com/news/us-news/parents-stanford-soccer-captain-found-dead-dorm-say-no-red-flags-rcna18700

5. Benefits of sports for adolescents. University of Missouri Health Care. Accessed March 3, 2022. 

https://www.muhealth.org/conditions-treatments/pediatrics/adolescent-medicine/benefits-of-sports\

Sports participation as a protective factor against depression and suicidal ideation in adolescents as mediated by self-esteem and social support.

7. Harbec M-J, Goldfield G, Barnett TA, Pagani LS. 

Physical activity as both predictor and outcome of emotional distress trajectories in middle childhood. 

8. Depression and anxiety in sports. American Medical Society for Sports Medicine. Accessed March 3, 2022. 

https://www.sportsmedtoday.com/depression-and-anxiety-in-sports-va-245.htm

9. Yang J, Peek-Asa C, Corlette JD, et al. 

Prevalence of and risk factors associated with symptoms of depression in competitive collegiate student athletes.

10. Neal TL, Diamond AB, Goldman S, et al. 

Interassociation recommendations for developing a plan to recognize and refer student-athletes with psychological concerns at the secondary school level: a consensus statement.

11. Tucker LV. How sports psychiatry benefits athletes. Lawrence Tucker, MD. October 16, 2016. Accessed March 14, 2022. 

http://drlawrencetucker.com/how-sports-psychiatry-benefits-athletes/

12. Pok-Him Tam J, Sahni M. Mental health of elite young athletes: spot and support them before it’s too late. British Journal of Sports Medicine blog. August 14, 2017. Accessed March 14, 2022. 

https://blogs.bmj.com/bjsm/2017/08/14/mental-health-elite-young-athletes-spot-support-late/

13. Specialized care supports athletes’ unique mental health needs. The Ohio State University Wexner Medical Center. News release. February 7, 2022. Accessed March 14, 2022. 

http://osuwmc.multimedia-newsroom.com/index.php/2022/02/07/specialized-care-supports-athletes-unique-mental-health-needs/

14. Flanagan L. Why are so many teen athletes struggling with depression? 

. April 17, 2019. Accessed March 14, 2022. 

https://www.theatlantic.com/education/archive/2019/04/teen-athletes-mental-illness/586720/

15. Brewer BW, Petrie TA. A comparison between injured and uninjured football players on selected psychological variables. 

16. American College of Sports Medicine; American Academy of Family Physicians; American Academy of Orthopaedic Surgeons, et al. 

Psychological issues related to injury in athletes and the team physician: a consensus statement.

The psychological response to injury in student athletes: a narrative review with a focus on mental health.

18. Wenxin Wang R. The culture of child abuse that’s poisoning figure skating. 

. February 16, 2022. Accessed March 14, 2022. 

https://slate.com/culture/2022/02/kamila-valieva-coach-eteri-tutberidze-abuse-russia-doping.html

20. NIDA Blog Team. Crossing the line: athletes risk their health when using performance-enhancing drugs. National Institute on Drug Abuse. December 11, 2014. Accessed March 14, 2022. 

https://archives.drugabuse.gov/blog/post/athletes-risk-their-health-when-using-performance-enhancing-drugs

21. Hammond T, Gialloreto C, Kubas H, Davis HH IV. 

The prevalence of failure-based depression among elite athletes.

22. Brenner JS; Council on Sports Medicine and Fitness. 

Sports specialization and intensive training in young athletes.

. Updated October 21, 2014. Accessed March 3, 2022. 

https://www.nytimes.com/roomfordebate/2013/10/10/childrens-sportslife-balance/keep-sports-fun-3

24. Silva D. ‘We’re human, too’: Simone Biles highlights importance of mental health in Olympics withdrawal. NBC News. July 27, 2021. Accessed March 3, 2022. 

https://www.nbcnews.com/news/olympics/we-re-human-too-simone-biles-highlights-importance-mental-health-n1275224

What will society do to children in order to make them win? What should be sacrificed in the name of competition? How much pressure is too much? And how do we pick up the pieces when young athletes are pushed too far?

Even before we were forced into isolation and schools across the country shut down due to COVID-19, our society was experiencing a pediatric mental health crisis. One in 5 children were already living with a mental health disorder prior to spring 2020.

 As children and families dealt with the repercussions of the pandemic, the mental health struggles young people faced were exacerbated. In December 2021, US Surgeon General Vivek H. Murthy, MD, issued a special advisory alerting the country to this national crisis.

This impact is only starting to be calculated, but early research shows that emergency department visits for suspected suicide attempts were nearly 51% higher for adolescent girls in spring 2021 compared to the same time in 2019, before the pandemic. As many as 25% of youth around the world are experiencing clinically elevated depression symptoms—double the estimated prepandemic level; and as many as 20% of youth are experiencing clinically elevated anxiety symptoms—again, double the prepandemic level.

Unfortunately, hospitals across the country are facing staffing shortages in many specialties and disciplines. There has long been a shortage of psychiatrists and other behavioral health professionals,

 and it is abundantly clear that there are not enough child psychiatrists to meet demand, either now or in the future.

To address this crisis in the context of limited resources and improve access to mental health care for children and adolescents, hospital systems should work with partners to develop an integrated system of care across their region. These systems should offer multiple levels of care, from crisis and inpatient psychiatric services through treatment in primary care and schools—even school-based prevention interventions can be useful in reducing the need for mental health services.

This is not just a pipedream or an idealistic notion, as Nationwide Children’s Hospital and its many partners in and around Columbus, Ohio, have been developing this kind of integrated system of care. The hospital’s Big Lots Behavioral Health Pavilion was launched at the start of the pandemic in 2020. It is now the largest pediatric mental health care and research facility of its kind in the United States. It serves as a hub of treatment for young people in crisis, but also has partial hospitalization and intensive outpatient and outpatient services that can coordinate with our crisis services.

 However, our system reaches far beyond the Pavilion, with community-based services, school-based mental health programs and evidence-based prevention programs.

We also train primary care and other providers to deliver mental and behavioral health care at the community level, and this training is a crucial part of our system. To ensure success, there is ongoing education, support, and consultation to these community providers.

The hospital achieves this in part through Project ECHO, a learning collaborative

 that helps community providers become more comfortable managing behavioral and mental health conditions, as well through support programs

 that allow pediatricians and other primary care professionals to have virtual 15-minute consultations with experts for guidance on diagnosis, medications, and other issues. Project ECHO is designed to help move knowledge, not patients. This allows psychiatric experts to share their robust expertise with community practitioners and increases access to high quality psychiatric care to kids across the region.

It should be a goal of hospitals and other facilities nationwide to utilize strong partnerships so that every level of care is accounted for in our system, leveraging the resources that already exist in their areas to improve the well-being of children. This coordinated approach allows for the community-wide delivery of the appropriate level of high-quality care to each individual child, while potentially decreasing the burden on families who may otherwise need to travel out of town for treatment.

Although it is important to recognize the gravity of the pediatric mental health crisis, I am hopeful that if more providers work collaboratively with a variety of partners, we will be able to tackle this issue and improve the futures of children not only within communities but across the country.

is chief of the department of psychiatry and medical director of behavioral health at Nationwide Children’s Hospital.

1. U.S. Surgeon General issues advisory on youth mental health crisis further exposed by COVID-19 pandemic. US Department of Health & Human Services. News Release. December 7, 2021. Accessed April 25, 2022. 

https://www.hhs.gov/about/news/2021/12/07/us-surgeon-general-issues-advisory-on-youth-mental-health-crisis-further-exposed-by-covid-19-pandemic.html

2. The U.S. Surgeon General’s Advisory. Protecting youth mental health. Department of Health and Human Services Office of the Surgeon General. 2021. Accessed April 25, 2022. 

https://www.hhs.gov/sites/default/files/surgeon-general-youth-mental-health-advisory.pdf

3. Axelson D. Beyond a bigger workforce: addressing the shortage of child and adolescent psychiatrists. 

. April 10, 2020. Accessed April 25, 2022. 

https://pediatricsnationwide.org/2020/04/10/beyond-a-bigger-workforce-addressing-the-shortage-of-child-and-adolescent-psychiatrists/

4. Big Lots Behavioral Health Pavilion: transforming children’s mental health through an unprecedented community commitment. Nationwide Children’s Hospital. Accessed April 25, 2022. 

https://www.nationwidechildrens.org/specialties/behavioral-health/behavioral-health-pavilion

5. Project ECHO. Nationwide Children’s Hospital. Accessed April 25, 2022. 

https://www.nationwidechildrens.org/for-medical-professionals/education-and-training/echo

6. Behavioral health treatment insights and provider support (BH-TIPS

. Nationwide Children’s Hospital. Accessed April 25, 2022. 

https://www.nationwidechildrens.org/specialties/behavioral-health/for-providers/treatment-insights-and-provider-support

How can integrated systems of care help us provide the appropriate level of high-quality care to each individual child?

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