Inside Sports Psychiatry with Dr. David McDuff

Mark Mullen: [00:00:00] Back to Psychiatry Boot Camp. Today we're talking about sports psychiatry. I'm super excited for this one. Sports psychiatry has been on my list for a long time, and I found the perfect guest for us, the grandfather of sports psychiatry. We talk about the approach to sports psychiatry, how sports psychiatry is a bit more pastoral with a different therapeutic frame than the traditional doctor-patient relationship.

We go into some common problems that sports psychiatrists will encounter, as well as how sports psychiatrists balance the role between medications and psychotherapy approaches. And we'll talk about some common clinical scenarios for Dr. McDuff. Welcome to Psychiatry Boot Camp, Dr. David McDuff, and I will ask you to introduce yourself to our audience.

Dr. David McDuff: Okay. I'm, David McDuff. I'm a sports and performance psychiatrist from Baltimore, Maryland. I actually live a little bit to the west of [00:01:00] the city in Howard County, Maryland, in an old city called Ellicott City, Maryland. I've lived here for 40 years. I ended up here after, I moved back to the United States after living in Germany for five years while I was on active duty in the Army And I've been practicing sports psychiatry for 30 years.

Mark Mullen: So you're the author of Sports Psychiatry: Strategies for Life Balance and Peak Performance. That's from American Psychiatric Publishing back in 2012. You are-- Are you still currently the team psychiatrist for the Baltimore Orioles? 

Dr. David McDuff: Actually finished up 30 years with them at the end of 2025. I'm still doing a little consulting with them for policy questions or difficult cases.

I'm still quite connected with the, three psychiatrists, but I spent the last year and a half training my replacement, [00:02:00] a woman who's now doing more and more sports psychiatry, and that transition was very smooth, so I'm happy about that 'cause I don't wanna see us lose that legacy of being the, longest-tenured psychiatrist working with a professional sports team.

It's not nearly as common for a psychiatrist to be the primary provider as it would be for, say, a licensed psychologist. 

Mark Mullen: And could you tell us a little about your relationship with the Baltimore Ravens as well? 

Dr. David McDuff: in 1996, the Cleveland Browns were relocating to Baltimore, Maryland, and the owner, Art Modell, and his staff put out a request for proposal for a sports medicine group, and there were four sports medicine groups in Baltimore at the time.

And there was a little, you know, unexpected addendum at the bottom that said, "And any sports medicine [00:03:00] group must have an addiction psychiatrist on their staff." Well, nobody could figure out why that was in there, but while they were scrambling around to find one, three of the four, you know, asked me to be their addiction psychiatrist because prior to starting in sport, I was an academic addiction psychiatrist and going back to my military career, I did a lot of practice in addiction psychiatry.

The backstory turned out to be very interesting. Art Modell was always considered to be an owner who cared deeply about his players, and he figured out early on in his tenure with the Browns that there were a lot of talented players who left the league Because they had substance problems, and that was at a time when the league had no substance program.

So being in Cleveland, he waltzed over to the Cleveland Clinic and started chatting with a psychiatrist [00:04:00] and a psychologist who had done a little bit of work in sport, and he asked them, "Would you create a treatment program in my facility for players?" And they said, "Sure." And he started signing players to a contract with a contingency that they must attend weekly group psychotherapy, if you can believe that.

Mark Mullen: Even if they had no associated diagnosis? 

Dr. David McDuff: No, They had a documented history of a substance use disorder that was the reason they left the league, and so he brought them back into the league and required that they go to this weekly group psychotherapy. It was called the Inner Circle. That ran for 10 years, and that was why he felt so strongly that there needed to be player support in case substance problems.

And then he ended up being the owner who spearheaded the development of the league's substance prevention program. So [00:05:00] he was just a tremendous owner who attended every practice, and the players loved him, and that's not true of every owner. 

Mark Mullen: Sure. I can only imagine. 

Dr. David McDuff: And a huge supporter of onsite mental health services once they were established.

Mark Mullen: So I wanna come clean to you about how I discovered your existence. So I've had an episode on sports psychiatry on my list for a long time, and my producer, Matt, texted me a few months ago and said, "Turns out the grandfather of sports psychiatry went to Spring Hill College," which of course is my alma mater.

You and I pre-met and discussed our mutual affinity for Spring Hill College, so we'll give them a shout-out here. and I'm not 100% sure where my producer Matt Got this line that you're the grandfather of sports psychiatry, but I just wanna give you a chance to go on the record about this. Do you accept or reject the title?

Dr. David McDuff: either godfather or grandfather, but I'm certainly the longest-tenured psychiatrist working in [00:06:00] sport probably anywhere in the world, not just in the United States. And, I do consider myself to be a, you know, a groundbreaking person as it relates to mental health services being offered on site, either in a training facility for a professional team, a training room in the collegiate setting.

And I've worked at every competitive level and then some, and then lately, for the past, eight years, I've worked for the International Olympic Committee as a member of their IOC consensus panel for mental health and elite athletes, and then a smaller subgroup called the Mental Health Working Group, which was the first time they had ever done that.

But it was because they waited so long to make mental health a priority within the International Olympic Committee that the players eventually rose up [00:07:00] and said, "You must do this now." And so the IOC president at the time, President Bach, created a consensus panel and then derived from that eight people from around the world.

Two are psychiatrists of these eight, three are primary care sports medicine docs, and two are sports scientists. And we've been meeting twice a year since twenty eighteen. 

Mark Mullen: Okay, so then you're the right person for this next question. Where do you trace the roots of sports psychiatry to? Tell me how the field initially developed.

Dr. David McDuff: I think it developed more out of clinical and sports psychology. So if you examine the field of psychology and psychology's involvement in sport- You could either work as a clinician, you know, a licensed provider at the master's or the doctoral level. but for 30 years, there have been individuals who [00:08:00] trained, you know, usually in a master's or a doctoral program in performance psychology, and they've had a role in sport almost continuously.

The origins were in two individual sports, which might make sense to the, the listeners of the podcast, tennis and golf. You know, so most people appreciate those two sports as being particularly mental because you're there by yourself unless you're playing doubles, of course, in tennis. But you own every shot, you own every ground stroke, every serve, and you have to have a mental game.

So there were some early books written 30 years ago. Mental Game of Tennis is a very famous one. Psychologists also had an early role in baseball. There was a, very well-known baseball psychologist, Harvey Dorfman, who wrote an iconic book called The [00:09:00] Mental Game of Baseball, and he actually was a mental coach.

He wore a uniform, was in a dugout, went to every game, including traveling with the team on the team plane, and that was 30 years ago But my second year in baseball, I was working closely with a clinical social worker, and she and I got interested in neurobiofeedback. And then we kinda looked at each other one day and we said, "We need to learn something about performance psychology."

So we called Harvey Dorfman up and said, "We don't know much about performance psychology, but we'd like to learn about it. Would you mentor us?" This was before the internet. This was before modern-day communication that most young people think about. So he agreed without any charge to do voice supervision with us once a month for an entire [00:10:00] year.

And we just presented cases to him, and he was like a guru. He just-- He had seen every situation dozens of times over and was just such an invaluable resource to us, and I think it's very unusual for a psychiatrist to have ever had that sort of experience. And, you know, from my own point of view, my roots in the way I practice in sport comes from the military because the military learned after World War I that you can't stay in the rear.

if you wait for a soldier to break down from a stress reaction and they're in the front lines and you send them back, you know, even ten kilometers, they don't go back to their unit If instead you push the mental health assets [00:11:00] forward and they're right next to frontline soldiers or second-line soldiers, then you say, "We're here together.

We're all subjected to the same stressors." And so in military training, I trained in the Army, you go to field exercises. You go out to where the troops are training. If you happen to be on a post like I was that had basic training and tech training, training for your job. I was at the, home of the Army Signal Corps.

And then I actually ended up being a psychiatrist in combat in the first Gulf War. I was a commander of a psychiatric detachment that was about 50 people. And we broke our unit up into six teams, and each of those went forward, you know, into combat zones. I personally went with the Second Armored [00:12:00] Cavalry Regiment, which was the lead unit of Seventh Corps that went directly to the Republican Guard.

So I became comfortable practicing what we call in the military psychiatry by walking around. And so you just walk around and you introduce yourself and you just start chatting with someone. You need to have an outgoing personality style in your work. You need to be able to make people feel comfortable chatting with you pretty quickly, and then you learn something about them, and they may surprise you that they start opening up about some, you know, concern or struggle or stress.

And so When the opportunity came to work for two pro teams in '96 because the Orioles had a request for proposal for somebody to run their employee assistance program. And that [00:13:00] wasn't just for the players. That was for the players, the coaches, the other team staff, the front office. And another man and I had created an employee assistance program for our university medical center at the School of Medicine.

And so I was familiar with how to do that, how they operated. And so when we went, you know, into the sporting organizations from day one, we started going to the training facility with the Ravens and into s- to spring training as well as into the clubhouse with the Orioles. And so I started at the pro level, which is kind of ironic, and then I graduated to college.

then a few years later, I graduated to high school. So it was kind of an inverted way to practice at the highest professional level. 

Mark Mullen: So if I'm understanding the roots of the field correctly, you're saying it's closely tied to the [00:14:00] development of performance psychology, which maybe predates the field of sports psychiatry a bit.

But in sports, especially professional sports, there was a recognized need for medical treatment, especially for certain cases like addiction, which was, you know, leagues were losing players due to addiction. And of course, that is the realm of an addiction psychiatrist. So it was a, natural need for a psychiatrist for that level of care for these teams.

And then through incorporating principles of performance psychology and working alongside our non-physician colleagues, the field has sort of grown from there. 

Dr. David McDuff: Yeah. Baseball has required that each of its teams have an employee assistance program for 35 years. They were very forward-thinking. The NFL and the NBA, it was in 2019 that they both mandated every team to have on-site mental health [00:15:00] presence.

So that was really when I felt vindicated when I had been in the training facility on Monday, Tuesday, Wednesday, and sometimes on Friday every week during training camp and the season. And I saw the value in being present because we tracked what we called utilization rates. Like, if nobody comes to see you, what's the value of being there?

Any employee assistance program would be happy if 5% of the workforce came to see them annually. Well, the very first year, we had 10% of the players come see us, and then it quickly rose to 15% and then 20%. By the end of the fifth year, it was 25% every year, after year. And then it leveled off at about 25 to 35%, both in football and baseball.

And then when we started seeing every injured player, [00:16:00] because when you're around injured players, you very quickly see that if you follow them from injury to surgery to rehab to reconditioning to return to activity, return to sport or not, that there's a lot of psychology in there. In fact, now there's a lot of evidence, say, in something like, anterior cruciate ligament tear with reconstruction, that about 65% of the time, the reason they don't return to play is a psychological factor, not some problem with the knee, you know, not a subsequent meniscal tear or persistent swelling or persistent pain or graft failure.

And that, I think, surprised the orthopedic surgeons maybe more than anybody else. So we now routinely assign either a mental performance person or a mental health professional to follow a seriously injured [00:17:00] athlete from the time of injury until they return to play, and through that, to make sure that they adjust and adapt back to that return.

Or if they depart from the sport, you don't wanna withdraw the support then either, because they may go back to their home of record. And even though we were never obligated to follow athletes beyond their employment with the team, we just did that. We had this saying, "Once an Oriole is always an Oriole.

Once a Raven, always a Raven." And, it just seemed to us to be the right thing to do. 

Mark Mullen: It surprises me that the rates of utilization of the employee assistant program, you're saying, are significantly, like signif- like five times as high for athletes as for non-athlete employees who participate in these sorts of programs.

I, on one hand, I feel like, you know, athletes have to take their health very seriously because it's such a core function of how they make a living and what [00:18:00] they do. So I, can see where they would, you know, maybe take engagement with treatment more seriously, and they're just more disciplined than other people, I think, in general.

But I would also think that especially for football, there's a sort of machismo, we play through pain. You know, p- pain is a normal part of the process. Having to do difficult things like wake up at six AM and lift and, watch what I eat constantly, and, you know, you're doing a lot of things you don't want to do, and you're sort of just getting used to this mental pain and having to do this as an athlete.

So I would think that just, like, forcing your way through it would be a significant part of the culture. And therefore, I'm kind of surprised that it's 500% utilization rates for EAPs for athletes versus non 

Dr. David McDuff: I think what made the difference was being on site, having a physical presence. And I would be in the training room, that was my base of operation in football, but I would go to practice on Wednesday, which was the first install day for, you know, the game [00:19:00] plan for the following weekend, e- even Thursday.

Then it would start on Tuesday instead of Wednesday, Thursday. And after about two years, the players just got used to me being around the training room. And the head athletic trainer who had actually come to Baltimore from Cleveland, his name was Bill Tessendorf. He had been in the league already 30 years, and he confided in me about the beginning of the second year.

He said, "I just want you to know something." He said, "I am so happy you're here." He said, "I've been the team psychiatrist for 30 years, and I wasn't trained for it, and I wasn't good at it." He said, "But you're good at it." And he used to meet me at the door, and he would just grab me by the shirt sleeve and walk me over to a training table and say, "You two need to talk."

No background, no nothing, and he [00:20:00] just knew from watching my operating style. I think sometimes most of the players had no idea I was a psychiatrist. I was just another physician with a different skill set I think the fact that I had done a lot of pain management broadened my skill set. I think the fact that I practiced addiction psychiatry broadened my skill set, and the fact that I trained in a department of psychiatry and neurology, so I really understood, you know, anatomy, physiology, biomechanics, and just, you know, got back to quickly relearning that and then learning it, you know, at a much higher level, of understanding.

I was always in the training room, you know, the exam room when the head team physician or the orthopedic surgeon explained to a player the nature of their injury and whether [00:21:00] surgery was warranted. And that was an interesting activity because I would listen to the explanation. The player was shaking their head, "Yes, I understand.

Yes, I understand." I would circle back to them later that afternoon or the next day, and I said, "Just... I'm curious, tell me what you came to understand about your injury." And they got about ten percent of that conversation. And then what about the surgery? They got about five percent of that conversation. So I would go to the athletic trainer and I said, "You know, can you just circle back with him?

He needs, you know, some additional rounds of education so that he'll truly understand wh- what- what's coming i- in the next few days or weeks." And, I almost at times considered myself to be like a bee. I was just buzzing around connecting people and [00:22:00] connecting information and services with players. So I think truly for me, it was integrative medicine thirty years ago.

and I think I was an integrating force, which is particularly gratifying to,

to be in a role like that. And I think psychiatrists are uniquely suited to be a bridge with sports medicine, primary care sports medicine, sports ortho, sports nutrition, strength and conditioning. Like no one else really does that except for the athletic trainer. every Monday in football was injury day.

So you get injured on Sunday, you get worked up on Monday. By Monday evening, all the information is in, and then there would be a large meeting, and all the stakeholders gather in the same room. And from the very beginning, a psychologist and I were in [00:23:00] this same room adding in the psychosocial perspective.

And we felt very highly valued, and I think we broke down stigma. there was a really funny moment in those first few years. There was an, offensive lineman who was only six-eight and three-forty, and he was a very colorful fellow. And the training room door to the Ravens facility had these swinging doors.

And after every practice, especially once the rookies had come in, he would burst into the training room and say, "Where's my effing psychiatrist? I need to see my psychiatrist." And all these rookie players would go, "Oh my God, what have I gotten myself into? Why did I sign with this team?" But he was just kidding, and he was a major [00:24:00] force in referring other players to see us.

Sometimes I had three-way conversations. You know, the athletic trainer would take me over to a training table. There would be a player on either side of that player. I started to, you know, ask them a little bit about themselves, anything they were concerned about in the last week or so. They would just start chatting, and then the other two players would chime in, "Well, that, that bugs me, too."

And it would be a three or a four-way conversation. 

Mark Mullen: It's so fluid. I mean, I think about, like, you know, when in... I'm trying to think about these formal models that we learn in psychiatry residency training and are tested on for our board exams and how they apply to this sort of walking around psychiatry that you're talking about.

And the big one that keeps popping up in my brain is the therapeutic frame, right? Knowing where our relationship begins and ends and how our relationship is defined. And in the typical doctor-patient relationship in a typical clinic, that's pretty [00:25:00] straightforward. We don't even talk about it much because it's so societally reinforced.

But you're talking about something that I've never encountered before, which is a very... I mean, to me it feels like a very permeable membrane around the frame. I mean, you're talking about going from basically an individual therapy session in public that starts at a moment's notice to now we're doing sort of group therapy in a way at a moment's notice.

And then surely there's also a time when you say, "Hey, this is a pretty big conversation. Why don't we go back to my office and finish this?" How do you think about your therapeutic frame? 

Dr. David McDuff: When you're on site, you are very likely to identify problems in a very early stage before they consolidate into a symptom cluster, before those, that symptom cluster persist over weeks or months, before it rises up to a crisis level.

If you were offsite and you waited for someone to be referred to you, [00:26:00] you can almost guarantee that they would be far along that continuum. It would not be early on. So a 50-second interaction is a therapeutic interaction. It has an impact. And if you string a number of those together, and then if you do it in the presence of other teammates, that where you're really using team cohesion as a therapeutic force, it's just one of the things that's so unique about doing this.

But the same thing happens in the military. You may not have an office to go to. You just may be standing by a person in a cluster of other soldiers, and the same thing happens. Is-- And so you're changing the culture of the organization. In baseball, you have thirty-five percent Latino players, and they have [00:27:00] machismo at an extremely high level.

They have no tradition of mental health treatment in their culture. But yet we broke down those barriers because from the very beginning, we had a Puerto Rican-born, Dominican-raised, Spanish-speaking psychiatrist, and he taught us everything about, you know, Latin culture, and they gravitated toward him. And then we kind of borrowed from his credibility, and therefore they gravitated toward us.

So we always gave thought to the composition of our group. We always had diversity because we noticed if we would go to spring training, for example, that One person could give this introduction, you know, could talk on a topic, but we always brought five. And we brought men and women, we brought short people and tall people, [00:28:00] we brought, you know, addiction counselors, we brought, you know, clinical social workers, we brought psychiatrists.

And at the end of our, you know, introduction, and you usually had a topic talk or two, we just watched over the next five days the process of which player sought out which of our group. And there was just no predicting who would be attracted to what person. And I think we accelerated the utilization rates by having diversity, which these days and times is kind of getting you know, put down as a valid strategy in a workplace, but this is just something I've seen, you know, work in real life, and it makes a difference.

You want to replicate the composition of the group that you're serving. 

Mark Mullen: Appreciate that, and I appreciate how with this sort of flexible [00:29:00] therapeutic frame, it's especially important to make sure that you have a lot of different viewpoints and cultures well-represented so that different people can feel safe.

When I'm thinking about this frame that you're describing, and I think it's a fairly fluid frame. I appreciate that it's not unprecedented, something like the military. You know, I think you kind of have... You have a relationship not only to the individual patient, but also to the team, which is super unique about sports psychiatry.

I mean, if you're running an IOP program, maybe you're switching between individual and group psychotherapy and medication management and psychotherapy sessions, but your duty is not to a team as well. So I'm thinking about conflict of interest and boundary issues, and I would think that there are some very complicated dynamics between players and players, maybe players who are vying for the same position.

Players and coaches I know have sort of traditionally can have a lot of conflict in their relationships. I know you and I both went to Spring Hill College, and I-- a lot of my friends ran cross-country there, and there was a coach there that just made their life a living hell, and so I couldn't imagine that if my responsibility was to that coach, that I wouldn't feel a conflict of [00:30:00] interest.

And as my last example, I was a year behind future NBA All-Star Bradley Beal when I was in high school, and, he was a guard, I was a guard, and he was never able to score on me. You know, I-- nobody else could shut him down, but for some reason, when Mark Mullen guarded him, he could, never score, right?

So I imagine that he was probably very frustrated, and he was all-- he would've complained about me to his therapist. I'm kind of joking about that last one. I am joking about that last one. But do you run into these sorts of problems, these conflict of interest scenarios where you might have a duty to not just one player, but to another player?

There's a conflict, the coach, et cetera. 

Dr. David McDuff: Yeah. The ethical term is called dual agency. When you're hired by the team, but you work for the players in support of the players. But we always had a broader group than that. It was players and their family members. It was team staff and their family members, coaches and their family members, front office and their family members.

So you do get into situations, and it is [00:31:00] common that a player would say, "I think my position coach doesn't respect me. I know I have more than he seems to think I bring, you know, to my position. I don't know why I'm third in the depth chart. I think I should be second or first." And I said, "Well, it might make sense, for you and I to go have a chat with your coach, or if you're comfortable, I'll go chat with your coach."

And here's what I would say. I would say, you know, "I, I just met with, you know, Jason. what would you-- can you give me some feedback about Jason as a player and as a person?" And I would always start with, "What would you see his strengths are as a football player? What would you see as his strengths as a person?

And then what are his areas for improvement?" And as soon as I would say something like to a player, they would say, "Go talk to him. Go talk to him." [00:32:00] So as long as you script what you're gonna say on the other side of an obvious boundary. Now, psychologists are very particular about these boundaries. Because I'm a physician, I never really executed an additional release of information.

I simply operated under the umbrella that doctors who work for the same team can talk with one another just like they would in a hospital. but I didn't take advantage of that. I always asked permission to go talk with the strength and conditioning coach or gonna go talk with the sports nutritionist, and rarely, if ever, did I have anyone say, "No, I wouldn't be comfortable with that."

If they did, I'd say, "Okay, well then you and I will try to work out a solution, between the two of us," and then I might propose a follow-up meeting. 

Mark Mullen: It is a lot different than I think traditional outpatient. You know, you might [00:33:00] think about another character in someone's life as an outpatient psychiatrist and think, gosh, I wish I could just navigate this situation directly.

But of course, you would never do that. I mean, it's almost akin to the Apple TV show Shrinking, which is kind of all about shrinks trying to solve their patients' problems. But a lot of what you're talking about is not foreign to consultation-liaison psychiatry where I work. I mean, you already-- you discussed how sometimes you would hear a physician, a surgeon explain something to a patient, and you would realize that the patient didn't really explain any of this.

So then you're in more of a translational role. You're in more of an advocate role. So I do think that there are mirrors of this behavior in the field. We're gonna take a quick break. When we come back, we're gonna drill down on some nuts and bolts about the types of problems that you see. And then I also wanna hear about logistically how these sports psychiatry programs are designed in case any athletic directors or aspirational administrators would like to think about doing something like this in their own institution.

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Welcome back to Psychiatry Boot Camp. Dr. McDuff, as a sports psychiatrist, what are the most common diagnoses or problems that you see and treat? 

Dr. David McDuff: So not necessarily at the level of a diagnosis, but you see anxiety, depression, insomnia, probably number one, especially if it's a sport that involves a fair amount of international travel and crossing time zones.

You see attention deficit disorder, sometimes not diagnosed in childhood, but clearly evident, you know, either at the collegiate level or the [00:36:00] professional level. You see adjustment disorders when somebody has an injury and they have a strong emotional response to that. Those would be the major ones that you see.

Mark Mullen: When I'm thinking about-- When I was prepping for this episode, thinking about sports psychiatry in general, one thing that was kind of glaring to me is that elite athletes are not really included in our studies of how medications work for certain problems. And the physiology of elite athletes is different than the general population who is included in these studies.

So our psychiatric meds, by definition, work on the central nervous system. So they might have-- Well, they will have effects on cognitive domains, focus, cognition, et cetera, but also autonomic variables, blood pressure, heart rate, et cetera. I also think about fluid balance with athletes. So all of our lithium patients, we know how important it is to stay hydrated when you're on lithium.

But if you're an elite athlete, that gets about a thousand times harder, I would say. How do you think about the [00:37:00] balance or the role between psychotherapy versus psychopharmacology when you're treating elite athletes? 

Dr. David McDuff: I always think about to solve a problem, whether it's simple or complicated, there are really three elements to solving a problem.

One is the use of technology, and I would place medication in that bucket. The other is to take advantage of a natural or preexisting or created support network. So when you're a team, if you just look around, you can find individuals. So I always ask, "Who would you say would support you in your desire to make these changes or to better manage your anxiety?"

And we list them out. And then I'll say, "Then part of our strategy needs to be how you're going to go to them and activate their support in a formal way." [00:38:00] And then the third bucket would be behavioral change. So I generally start with that, you know, bringing about some behavioral change to see if that results in a reduction.

Say, if you have insomnia and anxiety and inattention and distractibility, you know, one good way to help resolve what is the diagnosis is to improve the sleep. So you could just take a history and see, are they staying up these days until 1:00 or 2:00 AM, and are they spending a lot of time, you know, on a digital device?

Are they eating and drinking right up until bedtime? So you can make some quick behavioral adjustments. Their sleep may well improve substantially with those. I mean, cognitive behavioral therapy for insomnia, for example, is the number one rated approach to insomnia [00:39:00] in athletics. And so we start with that.

But the approach I use with psychiatric medicine is to think about the athlete's brain as a sensitive brain And so I always start at half the lowest dosage. And so if you take, primary care practitioners, they tend to start at double the lowest dosage. They tend to accelerate the dosage very quickly up to what they think is going to be the therapeutic dosage.

So I always start with escitalopram generic for Lexapro at five milligrams. I always go two weeks instead of increasing it. Even if I feel a sense of urgency and I think I'll likely get the dosage up. But when I'm combining social support with psychotherapy, with the [00:40:00] initiation of a medicine, with an intent to generate a very strong placebo effect.

When I prescribe a medicine, I believe in it, and I transmit the strength of that belief to that person, and I don't want them to start it if they have doubts. I'll delay starting it until we address any and all concerns. And these days, they're gonna go straight to Reddit or straight to the internet, and they're gonna be scared out of their wits when they, you know, see all these side effects loaded in without stratification for which ones are mild, which ones are uncommon, and they say, "My God, why would I take a medicine that has fifty side effects?"

I don't generally approach psychiatric medicines with monotherapy either. So for example, if I started somebody who I thought had a generalized anxiety disorder on fluoxetine [00:41:00] My max dosage is probably gonna be 40 milligrams. There are plenty of psychiatrists in the community who would go to 60 or even 80.

I just don't do that. I want to get to a dosage that I think could be therapeutic, but which is not likely to start activating side effects, so then I'm much more likely to add in a second medicine. S- so I do combination strategy. So what would be something you could add in to an SSRI that might further reduce someone's anxiety?

So, you know, my go-to second choice would then be adding in buspirone. Now, I've never had that work by itself, but at 10 milligrams, starting just once a day, going again for 10 to 14 days, making sure, are you comfortable on this medicine? You know, any concern about it? Well, then I think it's okay for [00:42:00] us to raise the dosage to twice a day.

And then the addition of that second medicine brings about an additional therapeutic benefit. And I've managed to have really high adherence rates to medications, and it gets a little tricky sometimes when you have BID dosing, so you have to just try to anchor that to awakening and retiring, you know, some other routine that they have in their life.

But I'm comfortable going to a third medicine. Let's say you have what's common in sport, overlapping anxiety and depressive symptoms or just low motivation. Then I may add in buspirone, and then I may add in bupropion Now, I've practiced long enough that I've used bupropion sustained release. Most psychiatrists have never used that.

That's a BID [00:43:00] dosing schedule. So if I'm worried about activation, one good way to probe that is to just put them on 100 of the SR just during the day, and you will know within four or five days if they're gonna get activated on bupropion. And then I might, you know, test it out further by adding in a second dosage, and then if it is helpful, then I'll flip them over to the extended release because it's once a day.

So these are just some of the ways that I'm training our residents to practice the way I practice, not because I think I've discovered the magic formula, but I've just had so much success with high adherence rates, and that for me is where it's at. If you can get 70, 80, 90% adherence rates instead of what's typical, 50%, then you're more likely to [00:44:00] solve your problem.

But I'm still working on support network. What can the support network bring to this? There's an interesting approach in addiction treatment called network therapy, and that's where you bring the support network of the person who expresses an interest in discontinuing substances. You bring them all into your office at the same time.

It could be a family member, it could be an employer, it could be a best friend, it might be a sponsor from NA. And you enlist the support of those persons, and you magnify the intensity of the effect. You know, when a group surrounds a person in support, good things happen. You know, I just talked to a lacrosse player, three days ago who had 10 people in his support network And he went the entire semester going downhill academically and athletically [00:45:00] and didn't reach out to any of them.

Mark Mullen: I feel like there's so many broader psychiatric principles that I'm thinking about as you're going through all of this. The biggest one, Jerome Frank, Persuasion and Healing, when he talks about the sick role and engaging with your support system and, how there are important-- You know, when you're sick, you actually do have some duties.

You know, you are alleviated from a lot of societal responsibilities, including, you know, the traditional sort of provider role maybe to take some time off of whatever it is you're doing to provide. But then your responsibility is to try to get better, and a part of that is activating that support network.

I'm thinking about what you said about placebo. I like that you're talking about harnessing the power of placebo and not ignoring it or being ashamed of the placebo effect. You know, that's day one's-- lecture one on my psychiatric clerkship is placebo is not placebo. As physicians in general, as people who practice medicine, we have control, some control over our placebo effect.

So what can we do to harness that and help people get better? I'm also-- And then lastly, I'm thinking [00:46:00] about your substrate, I'll call it, the class of patients that you're treating. You're talking about problems with anxiety and depression. And we know that one of our predictors of do patients get better is what is their premorbid functioning?

And in these cases, the premorbid functioning is generally relatively high if they're well-functioning athletes. And so if they can marshal their forces and get appropriate treatment, and like you said, you're there sort of courtside, so you're not waiting for it to spir-spiral and unravel downhill to the point where they can't get better.

I think you're harnessing a lot of these sort of common therapeutic principles, and I'm so grateful that you went granular there with me and named specific medications and specific doses, because I think that's what-- that certainly was what I really wanna know is like, what does it actually look like in the trenches?

So thank you for that. 

Dr. David McDuff: we had a case of a baseball player who just suddenly developed severe anxiety and insomnia, and he went five days in a row with two hours of sleep [00:47:00] or less. And It was not really clear what had activated this. so we just tried to restore sleep. And we ended up starting him after we discovered, in part, there were some family stressors.

There was a death in the family, and he was in a contract year. So there were multiple-- There were baseball factors and off-the-field factors that were coming into play. And when we sent in a request for him to go on the mental health IL, the mental health-- It's kind of oxymoronic, mental health injury list, but that's what it's called.

You have to send in a document saying, you know, what's the diagnosis? You know, what's the treatment? What's the prognosis? Their reply to us, "Well, why does he need to go on the IL? He responded to only five milligrams of Lexapro." I said, "That's what happens when you harness the [00:48:00] power of a s-support network and you en-engage the person in a process of behavioral change.

You get responses at lower dosages." If you allow the person to think that medicine or technology can solve, you know, one hundred percent of a problem, you have misled them 

Mark Mullen: One more drill down question on a diagnosis. You did mention ADHD and cognitive issues. Similar approach there? Instead of starting with 30 milligrams of Vyvanse, maybe you're starting with 10, getting a lot of buy-in, going slow, or any additional considerations in athletes when we're talking about stimulants?

Dr. David McDuff: D- don't even really start with the amphetamine group. Start with the methylphenidate group. It's not as strong a stimulant, and you just can't really predict. Everyone wants to go to Adderall because they know more about, you know, the amphetamine group. So we usually start with an extended [00:49:00] release, you know, 18 or 20 milligrams of methylphenidate group.

I go for a month, you know, I'm not in a hurry to get to a higher dosage. I wouldn't do two weeks and then bump it from 20 to 30. I just wanna see what changes over four weeks, because you wanna treat them long enough at one dosage to see if other people notice. Does their coach notice a change? Does a family member notice a change?

Gather all that feedback, make an informed decision about going to the next level. Usually, once you get to about 30 milligrams of extended release, then you'll kind of know if that medicine, you know, is gonna be a match for them. The other thing that's unique to sport is the length of their day. So some days are 14-hour days, and so [00:50:00] I don't know of any extended release formulation that lasts 14 hours.

So what we do there is we'll either start the day with an immediate release, follow it by an extended release, or start with an extended release, follow it by an immediate release. So a college student would be a good example. You know, what are they gonna do after dinner, after practice, after dinner? Well, hopefully they're going to be learning, yeah, and maybe studying in order to learn.

And so we would target that important period with the medicine. During their classroom time, that tends to work better if it's an extended release formulation So we do a trial of methylphenidate. There was a period of time where there was a belief that in order to get a [00:51:00] therapeutic use exemption to be able to prescribe a stimulant, which is on the prohibited list in the NCAA and all professional sports and in WADA, all international sports, you had to start on a non-stimulant.

But if you start on something like atomoxetine, it takes you 12 weeks before you can conclude it's gonna be helpful or not, and it has a prominent gastrointestinal side effect. 

Mark Mullen: And it's just not the guidelines. That's just not the guidelines for treatment of ADHD. You don't start with a non-stimulant.

Dr. David McDuff: Yeah. The guidelines don't say that. You just have to justify why you would want to move to a stimulant. And typically, there's a sense of urgency. The person's performance is well below their potential. Yeah, and that could be for a collegiate athlete academically and athletically, but especially academically.

You don't want them to lose their [00:52:00] eligibility. It's not just your GPA, it's you have to pass two courses in your major every semester in order to be eligible. You have to be advancing in your degree requirement. There's some subtleties to eligibility. 

Mark Mullen: Well, and stimulants are the first-line treatment for ADHD, and so I would feel like robbing athletes of that opportunity to get better would be discriminating against athletes in some way.

So I'm glad to hear you clearing this up and saying that you can-- the f- as a psychiatrist, you can write about why you're choosing this first, which I think is just that this is just the way good medicine is practiced. 

Dr. David McDuff: generally speaking, the stimulants are about 70% effective, which is, you know, like top quartile for medicines in medicine.

And then the non-stimulants, they're about 50% effective if you can dance around the gastrointestinal side effects you get when you take, [00:53:00] atomoxetine in the morning. But the main reason they have severe gastrointestinal side effects is that they don't eat breakfast. It's just shocking what a high percentage of athletes have very irregular eating patterns.

So disordered eating and even eating disorders is really common, in athletics and well, but it varies a lot depending on the sport. Very common in aesthetic sports like gymnastics and swimming and diving, and then also in endurance sports, you know, distance running, especially when you get into collegiate level where their distances start to increase and their number of miles a week may go from 25 in high school to 55 for a woman and 75 to 80 for a man.

it's pretty easy to drop weight when you're doing your distance run on a Sunday before NCAA [00:54:00] cross-country finals and that's your 18-mile day. 

Mark Mullen: Not to mention you're encountering all sorts of other social stressors now that you're in college that you haven't had to cope with previously. 

Dr. David McDuff: Exactly. 

Mark Mullen: Okay, so I'm gonna try to wrap some of these questions that I had about the logistical side of building a sports psychiatry program into one question.

So let's say I'm the athletic director at a mid-major school like St. Louis University, and I think to myself, "I don't think that I'm doing a good enough job by my student athletes in terms of addressing their mental health." Dr. McDuff, what do you want me as the AD to know when I'm thinking about building sports psychiatry into a part of our athletic department?

Dr. David McDuff: I mean, first of all, I would talk about what we know about the prevalence of mental health symptoms or disorders, that continuum Mental health symptoms can interfere with functioning. Mental health disorders, by definition, interfere with functioning. So I would say to the AD, in a 12-month period, about [00:55:00] 20 to 30% of your athletes will develop mental health symptoms at a level which start to interfere with their academic functioning, with their athletic functioning, and with their social functioning.

And you don't want that to happen because even if it's social, it bleeds over into academics. If it's social and academics, it bleeds over into sport. You have to think using systems theory. Everything is both a cause and an effect. So when you have overlapping interacting domains in life, a change in one area brings about a change in all areas until a new equilibrium is established.

And the value of having on-site providers is that you identify these emerging symptoms because you may pick up they're entering a high-stress period. [00:56:00] That is, they got injured, it's not serious, but they're gonna miss two weeks. Now, any professional athlete who's gonna miss two weeks is worried about the next man up.

What might the next man up do? That person may play so well The coach is not gonna go back to you, so you have a fear that you're gonna be displaced. And so you strategically go interact with that person and make sure that their apprehensions don't interfere with their performance, so that when they do return, they confidently progress through their rehab and reconditioning.

And then when they return, they feel psychologically ready to return, and they're go. They get out there and they're performing with intensity and execution consistency. And then I say, "Furthermore, so we [00:57:00] keep them on the field, we keep them in practice, we keep them in games, and we keep them out of the newspaper."

And that usually appeals to an athletic director. 

Mark Mullen: It sounds like a big part of your pitch here is it's not enough to just offer the same resources that are available to, like, any employee, any student, where it's like, "Hey, if you have mental health problems, go see a therapist." It seems like the on-site thing is super important to you.

Dr. David McDuff: Because many student athletes on a college campus are very recognizable. Now, clearly the big guys from football, the basketball players, men and women, the volleyball players tend to have a certain body habitus that makes them recognizable. They don't feel comfortable going to student counseling and sitting in a general waiting room.

And so they're much more likely to agree to see somebody if there's an office [00:58:00] next to the training room that you can go to. The last time I worked at University of Maryland College Park was during the pandemic. They actually asked me to come work there because the rates of mental health symptoms and disorders was just, you know, took an uptick in twenty-twenty, twenty-twentyone.

And so my office was the radiology suite and where the orthopedist had an exam table and the chiropractor had a manipulation table. It looked like tech center. But I actually liked that. You know, they were accustomed to going in there, and I would sit opposite them like, on an exam table. They'd be on a rolling stool, I'd be on a rolling stool, and we would just communicate.

They were comfortable because they'd been in that room and they'd seen primary care sports medicine, and it just made me seem like another doc with a [00:59:00] different focus and a different skill set. We always tried to get 12-month contracts for a fee paid for our time because mental health billing is much more complex than med-surg billing.

The orthopedist can bill no matter where they see the individuals. When you have health plans from 20 different states with a lot of variability in mental health coverage, you can't easily set up a structure which allows you to bill and collect. So we've never gone there. We've always just said, "If you pay for our time, you will see that the reward for that, the impact for that will justify the cost."

We get injured players back, you know, more consistently, not necessarily quicker, but we do prevent delays in return to play of key players. And then [01:00:00] we evolve hopefully to multi-year contracts, so you don't worry every year, "I've gotta prove myself." But in 30 years in baseball, I think we had 13 general managers and about 13 managers.

Whenever you have a turnover in general manager and managers, you almost have to prove yourself all over again. So the fact that we survived 13 regime changes, we're all particularly proud of that 'cause we very quickly, you know, helped them realize. And the power that comes from an endorsement from a manager or a head coach, if they stand up in front of a group of players.

And we had one manager who was one of our most supportive. He said, "Guys, I wanna introduce to you our team assistance program." He said, "I've known, these men and women for three [01:01:00] years. I go see them. Everyone in this building goes to see them. I encourage you to go see them. They're present, they're available, they're easy to access.

Just reach out to-- Go have a talk to them. They could be sitting on a bench outside on a practice field." And once somebody says that, they're really putting a voice to the culture and the reduced barriers that can be achieved. 

Mark Mullen: I got just a couple more questions that I have to squeeze in before we wrap it up.

One, what would you say are the most essential personal characteristics or qualities for a sports psychiatrist to have? 

Dr. David McDuff: I think that you're comfortable going around and talking to people, initiating a conversation and engaging them in a conversation so that you put them at ease, and you just do that to establish a base of connectedness.

Now, we also do [01:02:00] regular mental health screening. And so I always like to do that with players in a group. We tried doing it individually, but what we discovered is if you're a station, you know, at the time of the pre-participation physical, and they're sitting around a table and you give them a mental health screen, they'll start looking over "Well, how'd you answer number six?"

You know, that's a depression question. well, I guess I'll answer it that way too. And that surprised us that it made them feel more comfortable. Now, you could digitally send it to them, and that's what a lot of people have moved to thinking that privacy's important. But I think we discovered that doing it out in the open and doing it in a group, you know, when we ask an individual to come into a room one-on-one, they got uptight [01:03:00] instantly and, you know, suspicion, like, "What are we gonna do in here?

You gonna ask me some questions?" No, we're gonna ask you to fill out, you know, 20 questions. Yeah, anxiety, depression, anger control, you know, sleep difficulties, you know, eating problems, performance concerns, family concerns. But we figured out a way to best balance openness and honesty with those, and then following up really gives you a chance.

It's easier to follow up on a screen positive if you've already met that person. Like, they know you a little bit, and you know them. So the whole idea of self-revelation, revealing things about yourself, like how long have you been doing this, what's your sport background, what you like about your work, things like that you might not ordinarily.

Tho- those build bridges with athletes that create that, you know, floor upon which you then [01:04:00] have, you know, more complicated interactions as time moves on. 

Mark Mullen: Guess I'd have to tell them that I was a collegiate basketball referee, which probably would shred my therapeutic alliance right up front, so I guess I'll never- 

Dr. David McDuff: Actually, I don't think it would

Mark Mullen: be a sports-- Okay, tell me about that. 

Dr. David McDuff: They, would appreciate any involvement in sport, no matter what the role. Like, I might tell them I have four kids. They all played travel soccer. I knew this much about soccer when they started playing, so I needed to learn about it, so I volunteered to be their coach when they were five and six and seven, and I learned the game.

I knew much more about basketball, but I coached a lot of youth basketball. When they know you've had connections with sports. In football, I would say I grew up going to the University of Alabama football games from the time I was six until the time I graduated from college, 'cause my uncle [01:05:00] had two children who were in the marching band, and he could get tickets.

So my dad, my brother, and I, and my uncle went to every home and away game. And, you know, since the SEC dominates to some extent, you know, f- football, you're always gonna be running into SEC players. So the fact that there's an SEC connection, you letting them know that, "I grew up in Alabama. I grew up as, you know, an Alabama football fan, but I can work with somebody from Auburn."

Like, it's kind of-- That's the way you break the ice. Office practice is enjoyable, too. It's very different. You know, I see nine-year-olds, 10, 11, 12-year-olds, you know, all the way up to, you know, adults who wanna get better in their sport, who either have a, mental disorder as a barrier to getting better or need some mental performance work And the two most common things in preteens [01:06:00] would be performance anxiety.

You know, what are you gonna do if you have a swimmer who vomited on the pool deck just before their race? You think they swam in that race? Not a chance. They bolt. They go home, they get in their car, and they tell their parents, "I'm not going to practice anymore." So you have this anxious arousal with the somatic manifestation.

Yeah, I have a whole system for addressing competitive performance anxiety and decompressing, you know, those somatic symptoms, which, you know, are the ones that really interfere with performance. And that's very gratifying to work with parents or work with a coach. so I'll involve the coach. I involve the parents heavily.

The younger the kid, the more likely the parents are to stay in the entire session and then come back session after session. Once they get to fifteen, [01:07:00] sixteen, then they want their own time and space, and so you respect that. 

Mark Mullen: Dr. Macduff, just because we're out of time, my final question for you, if we have a listener who's a medical student resident or maybe they're a therapist working somewhere and they wanna get more involved in sports psychiatry, learn more about it, where should they start?

Dr. David McDuff: medical students should join the International Society of Sports Psychiatry. It truly is an international organization. It was founded in nineteen ninety-four. They have what's called a certificate program. It's a certificate of additional training in sports psychiatry. It's twenty-seven reading modules.

It's an open book test. You have to have some mentoring. You have a scholarly project, and they've certified about a hundred and sixty medical students and psychiatric residents. Now, within psychiatry, if you have somebody that just finished their residency training, there is the American Board of Sport and [01:08:00] Performance Psychiatry that has three pathways.

Pathway A is for experienced sports psychiatrist. So you send in an application, you document through letters of recommendation your experience in sport, and then you take an exam and you become board-certified. There's a pathway B for persons who are interested but don't have the experience. They have ten mentoring sessions.

They have to accumulate four hundred hours of time in sports psychiatry, at least a hundred of which needs to be clinical. And then we've just created pathway C, which is for residents or fellows who get sports psychiatry practice time in their residency and or fellowship, and they need four hundred hours.

So this is an independent board, but it's evolving in the direction of what's typical for board [01:09:00] certification. So but it's gonna-- we only have one post-residency fellowship, but there are at least twenty programs now that have very formal fourth year electives in sports psychiatry. Huge interest across the United States now.

Mark Mullen: Beautiful. Well, thank you for coming on Psychiatry Boot Camp. I really appreciate your time. 

Dr. David McDuff: Thanks for inviting me

Mark Mullen: Thanks for listening to this episode of Psychiatry Boot Camp. If you're enjoying the show, we would love to know what you think. You can connect with us on TikTok or Instagram @psychbootcamp, or you can email me mark@psychiatrybootcamp.com. We would love any Apple reviews or Spotify ratings that you would be generous enough to provide if you enjoyed the show, and pretty soon we'll be reading some of those reviews right here on the show.

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