Mental health symptoms and disorders are common among elite athletes, may have sport related manifestations within this population and impair performance. Mental health cannot be separated from physical health, as evidenced by mental health symptoms and disorders increasing the risk of physical injury and delaying subsequent recovery. There are no evidence or consensus based guidelines for diagnosis and management of mental health symptoms and disorders in elite athletes. Diagnosis must differentiate character traits particular to elite athletes from psychosocial maladaptations.Management strategies should address all contributors to mental health symptoms and consider biopsychosocial factors relevant to athletes to maximise benefit and minimise harm. Management must involve both treatment of affected individual athletes and optimising environments in which all elite athletes train and compete. To advance a more standardised, evidence based approach to mental health symptoms and disorders in elite athletes, an International Olympic Committee Consensus Work Group critically evaluated the current state of science and provided recommendations.

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Mental health in elite athletes: International Olympic Committee consensus statement (2019).

Despite the high prevalence of performance-enhancing drug (PED) use, media attention has focused almost entirely on PED use by elite athletes to illicitly gain a competitive advantage in sports, and not on the health risks of PEDs. There is a widespread misperception that PED use is safe or that adverse effects are manageable. In reality, the vast majority of PED users are not athletes but rather nonathlete weightlifters, and the adverse health effects of PED use are greatly underappreciated. This scientific statement synthesizes available information on the medical consequences of PED use, identifies gaps in knowledge, and aims to focus the attention of the medical community and policymakers on PED use as an important public health problem. PED users frequently consume highly supraphysiologic doses of PEDs, combine them with other PEDs and/or other classical drugs of abuse, and display additional associated risk factors. PED use has been linked to an increased risk of death and a wide variety of cardiova...

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Adverse Health Consequences of Performance-Enhancing Drugs: An Endocrine Society Scientific Statement

Long-term psychiatric and medical consequences of anabolic-androgenic steroid abuse: a looming public health concern?

Aims Anabolic–androgenic steroids (AAS) are widely used illicitly to gain muscle and lose body fat. Here we review the accumulating human and animal evidence showing that AAS may cause a distinct dependence syndrome, often associated with adverse psychiatric and medical effects. Method We present an illustrative case of AAS dependence, followed by a summary of the human and animal literature on this topic, based on publications known to us or obtained by searching the PubMed database. Results About 30% of AAS users appear to develop a dependence syndrome, characterized by chronic AAS use despite adverse effects on physical, psychosocial or occupational functioning. AAS dependence shares many features with classical drug dependence. For example, hamsters will selfadminister AAS, even to the point of death, and both humans and animals exhibit a well-documented AAS withdrawal syndrome, mediated by neuroendocrine and cortical neurotransmitter systems. AAS dependence may particularly involve opioidergic mechanisms. However, AAS differ from classical drugs in that they produce little immediate reward of acute intoxication, but instead a delayed effect of muscle gains. Thus standard diagnostic criteria for substance dependence, usually crafted for acutely intoxicating drugs, must be adapted slightly for cumulatively acting drugs such as AAS. Conclusions AAS dependence is a valid diagnostic entity, and probably a growing public health problem. AAS dependence may share brain mechanisms with other forms of substance dependence, especially opioid dependence. Future studies are needed to characterize AAS dependence more clearly, identify risk factors for this syndrome and develop treatment strategies.

Anabolic–androgenic steroid dependence: an emerging disorder

Adverse health effects of anabolic-androgenic steroids.

Background
Rule violations among elite-level sports competitors and tragedies among adolescents have largely defined the issue of non-medical anabolic-androgenic steroid (NMAAS) use for the public and policy makers. However, the predominant and oft-ignored segment of the NMAAS community exists in the general population that is neither participating in competitive sports nor adolescent. A clearer profile of NMAAS users within the general population is an initial step in developing a full understanding of NMAAS use and devising appropriate policy and interventions. This survey sought to provide a more comprehensive profile of NMAAS users by accessing a large sample of user respondents from around the United States.

https://link.springer.com/content/pdf/10.1186%2F1550-2783-4-12.pdf

A league of their own: demographics, motivations and patterns of use of 1,955 male adult non-medical anabolic steroid users in the United States

Steroid madness : Has the dark side of anabolic-androgenic steroids (AAS) been over-stated?

Testosterone, identity and the body: Exploring cultural definitions of disorder.

The Food and Drug Administration’s action on androstenedione suggested a new interest in utilizing the authority provided by the Dietary Supplement Health and Education Act, and a heightened enforcement policy against what the agency deems to be adulterated new dietary ingredients. This pronouncement on androstenedione is illustrative of the lack of cooperation and communication that exists between the Food and Drug Administration and the sports nutrition industry. The industry must conduct and publish safety studies and police itself against unscrupulous marketers who make false or unsubstantiated claims. At the same time, representatives and government officials must take a close look at the inherent and institutionalized bias that exists against dietary supplements within our government and begin to find ways to undo the existing bias by promoting productive and meaningful dialogue between respective groups. The purpose of this chapter is to discuss various sensationalized media reports and anti-supplement positions by some members of Congress while illustrating the general institutionalized bias against alternative health approaches that creates an environment for less than honorable marketers and at the same time compromises the freedoms of Americans to make their own health choices under the Dietary Supplement Health and Education Act.

Special Legal Review

This study analyzed publicly available autopsy reports of male bodybuilders under the age of 50 who reportedly died from cardiovascular-related events. A general Google search with the terms “dead bodybuilders” was performed on 10 February 2022. Six reports were available for review and analysis. Bodybuilders had the following means: age (±SD) = 36 ± 7.1 years; height 1.82 ± 0.02 m; weight = 103.8 ± 5.3 kg; weight of heart = 575 ± 134.4 g; and left ventricular myocardium thickness (n = 3) = 16.3 ± 3.5 mm. The bodybuilders analyzed had a mean heart weight that is 73.7% heavier than the reference man (575 g vs. 332 g). Similarly, 100% of the autopsies reported left ventricular myocardium thickness of 16.3 ± 3.5 mm; this is 125% thicker than normative data for men. While abuse of AASs for prolonged periods of time may contribute to some of the cardiac abnormalities present in these bodybuilders, it should be noted that cardiac hypertrophy, including left ventricular hypertrophy, has also been reported in drug-free strength athletes. Each autopsy report included cardiovascular abnormalities within the cause of death. Association does not mean causation, but nonetheless bodybuilders should be aware of potential contributing cardiovascular risks with AAS abuse.

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Rick Collins

Papers

A league of their own: demographics, motivations and patterns of use of 1,955 male adult non-medical anabolic steroid users in the United States

Steroid madness : Has the dark side of anabolic-androgenic steroids (AAS) been over-stated?

Testosterone, identity and the body: Exploring cultural definitions of disorder.

Special Legal Review

Dead Bodybuilders Speaking from the Heart: An Analysis of Autopsy Reports of Bodybuilders That Died Prematurely