Antidepressant Medications And Athletic Performance

Published November 9, 2020 03:48PM

Psychiatrist: “I mean, baby, lots of people are on those pills. Like, everyone.”

Psychiatrist: “Yes! That’s what I’ve been trying to tell you. You’re not alone in this.”

Those lines are from the show Crazy Ex-Girlfriend, the brilliant reflection on mental health that included the song “Antidepressants Are So Not A Big Deal.” That link is bookmarked on my computer for two reasons. One, it’s a straight banger. Two, it’s hard to talk about mental-health medication, and comedy is a good way into the discussion for some athletes.

Before getting to the performance studies, I’ll say what I have seen over the years. Antidepressants can change lives. Antidepressants can save lives. And antidepressants can help support long-term athletic breakthroughs.

An athlete I coach suffered from anxiety, the type that led to so many sleepless nights. He started sertraline (Zoloft), and he was able to get to start lines with love in his heart—and become a world-class trail runner in the process.

Another athlete is a trauma survivor. She started fluoxetine (Prozac) and the nightmares slowed down. She could run with a bit less of that fear, and she got faster than ever.

My mom suffered from depression when I was a kid. She started venlafaxine (Effexor XR), and that daily pill allowed her to be herself—a bright light in the world whose shine is a North Star for everyone that knows her.

There are so many stories like that. There are also stories of antidepressants not working. Maybe they lead to bad side effects, or an athlete feels slower, or something else entirely. Often, athletes need to experiment with medication or dose or combining medication with other strategies. Sometimes, that doesn’t work either, and other interventions are needed.

The hard part about summarizing the impacts of antidepressants is that they are nearly impossible to generalize across the athletic population. And each of those individual experiences is 100% valid, an N=1 experiment that can have variable results across individuals (or in the same individual over time). Our brains and experiences are just too unique for universal answers. Isn’t that the coolest?

Here’s all I know for sure.

If we all knew who else was on antidepressant medication, there would be ZERO stigma. Tons of pro athletes, tons of celebrities, tons of amazing scholars and comedians and parents and children and many of your friends, too. Being human is hard and brain chemistry is not something we control. Antidepressants aren’t for everyone—the list of people they haven’t worked for would be a long one as well. But for the someones they are for, a little pill each day can make all the difference.

Along with therapy and other practices (including running), antidepressants are tools in the mental-health toolbox. And for some athletes, it’s the key tool for the job of getting through life with love and joy.

Fortunately, there is no evidence that antidepressants hurt performance.

In fact, they may help performance in some instances. Let’s dig down into some of the studies.

This article deals with selective serotonin reuptake inhibitors (SSRIs), though there are many different options within the SSRI label, and in other groups too. SSRIs allow the neurotransmitter serotonin to stay in the synapse for a longer time, leading to more serotonin available to neurons (Mayo Clinic overview here).

A monumental 2018 review article in The Lancet looked at 28,552 citations consisting of 522 trials with 116,477 total participants to come to this finding: “All antidepressants were more efficacious than placebo in adults with major depressive disorder.” However, the effects (including side effects) have high individual variance, and the statistical prevalence of antidepressant use varies depending on the source and population. For example, 2011 study found lower prevalence of antidepressant use in elite athletes than the general population, but that is subject to dozens of confounding variables.

When it comes to antidepressants, there is no one size fits most recommendation or outcome. Our brains are these miraculous organs that can create entire universes within just a few inches of space, so maybe we shouldn’t expect them to be universally predictable.

That is super cool, but also super frustrating when thinking about how athletes respond to different medications, doses and timelines. Therein lies the big dilemma when thinking about how antidepressants affect athletic performance. What antidepressant? What dose? What population? And perhaps most importantly—what timeline? If many of the medications take weeks and months for adaptation to primary effects and side effects, then it’s immensely challenging to isolate cause-and-effect in a controlled study.

In addition, it’s hard to understand the underlying physiological process we’re measuring. There are a number of theories of how SSRIs could impact performance. Some studies theorize that SSRIs could decrease the perception of pain signals due to the analgesic properties of serotonin, which could theoretically improve performance. On the other end, some of the same studies note that SSRIs could increase fatigue because excess serotonin may impair central-nervous-system function. Both theories are subject to unresolved debate.

A 2019 study in the Journal of Physiology theorized that SSRI use may increase activation of unfatigued muscle but could exacerbate central fatigue during prolonged sustained contractions, which could have effects on endurance. Serotonin is interlocked with all brain function, including how we perceive and process signals while running, so the possibilities are endless if you dig down into the literature far enough (particularly for central fatigue). You could theorize impacts to adaptation based on similar mechanisms.

There could also be impacts to electrical muscle activity, structural properties and energy metabolism in skeletal muscle tissue (2018 review study), bone (2018 study) and metabolism. Maybe the best summary of the variation in responses was in this 2016 study on cardiovascular effects: “both beneficial and adverse cardiovascular events can be established following the chronic use of various types of SSRIs.” We have thousands of physiological processes interacting with the uniqueness of each brain and body to create a layer cake of conflicting results.

SSRIs and Performance

Keep those caveats in mind when thinking about these study results, since digging down into the data often shows high individual variance. Even if the study shows no change in performance, many athletes perform better while some may perform worse. Your personal experience is valid and backed by science, even if it varies from others.

A 2001 study in the Physical Medicine and Rehabilitation journal had two cohorts: acute use and chronic use of SSRIs (in this case, fluoxetine). Healthy, college-aged men took fluoxetine six hours before testing in the acute cohort, and for two weeks before testing in the chronic cohort. There was no change in cycling tests.

Another 2001 study in the International Journal of Sports Medicine had trained male cyclists take fluoxetine before cycling time trials. There were no performance changes, though there were some hormonal variations among treatment groups that could have uncertain effects longer-term. Similarly, a 2005 study in Experimental Physiology found no change in cycling performance in hot temperatures after taking paroxetine (brand name Paxil).

A fascinating 2014 study in the Journal of Sports Science and Medicine had more complex findings. That study used three different doses of paroxetine—10, 20 and 40 mg, and separated the all male participants into a low aerobic-capacity group and a high aerobic-capacity group. The high aerobic-capacity group had impaired performance at the 20 mg dose, but not 10 or 40. And even at the 20 mg dose, two of the eight high-capacity participants improved. Why the heck would higher doses and lower doses not cause any performance decrease, while the middle dose does? Goldilocks got screwed in that study design.

(For completeness, a 2008 study in the Journal of Applied Physiology found a performance decrease for athletes taking reboxetine, which is a norepinephrine reuptake inhibitor that acts on a different neurotransmitter than SSRIs.)

Put it all together, and there is no conclusive evidence. A 2016 review article in the International Review of Psychiatry summarized the problem: “antidepressants have only been studied in athletes in small studies of short duration.” That review also highlights the problem of an emphasis on male study subjects and athletes without mental-health issues. In the 2019 International Olympic Committee consensus statement on mental health in athletes published in the British Journal of Sports Medicine, SSRIs were highlighted as an appropriate treatment strategy for some athletes. That summary was backed up by the most recent 2020 review article in the Sports and Exercise Medicine journal.

One Big Question Remains

How does long-term SSRI use impact performance for athletes that suffer from mental-health issues, particularly major depressive disorder or severe anxiety? It’s impossible to say for sure. There could be positive effects for motivation and consistency, which has been backed up in some animal models. Maybe cortisol could be reduced from stress, leading to better adaptation. Or perhaps it goes the other way, with longer-term hormonal effects or changes to fatigue processes for some athletes. And this might all be different for female athletes. If I have to read one more study with zero female participants (and without plans for a follow up), I will lose my damn mind.

With the science unresolved, let’s go to the anecdotes. Many elite athletes I know personally take antidepressant medications. That includes international champions. I also know athletes who feel like they suffer on SSRIs, both in terms of performance and mood. I certainly don’t have an answer.

But I will say this.

If you are carrying a weight that you can’t shake off, you are not alone. Comedian Neal Brennan described his depression as a weight vest that he had to carry around everywhere, leading him to try numerous treatments, some of which helped and some which didn’t. If you are experiencing that feeling too, there are options. Talk to mental-health professionals like therapists and psychiatrists, finding if there is an option that works for your brain and your body.