ADHD in athletes and anxiety medications may increase the risk of heat stroke

On a hot day in the spring of 2021, as the Columbia College Koala softball players in South Carolina left the field at the end of an inning, athletic trainer Kenya Moore noticed a disoriented player.

The player complained of dizziness, shortness of breath, and muscle tremors. Moore said she suspected heatstroke, put her in an ice bath and called 911. As the athlete recovered and Moore examined the circumstances leading up to the accident, one thing stood out: The athlete had just changed her ADHD medication.

The incident stuck with her, and Moore, now a graduate teaching and research assistant in the University of South Carolina’s athletic training program, is among a group of sports medicine experts working to raise awareness about the high risk of heatstroke that athletes face. Those taking medications for conditions including ADHD, anxiety, and depression. Experts are also calling for more research, especially as mental health awareness has led more people to seek help, which often includes medication.

Federal data show that heat illness diagnoses and heatstroke deaths have increased as global temperatures have risen. This summer, the hottest on record globally, five middle and high school football players in the United States died from heat stroke — the most since 2011, according to the National Center for Catastrophic Sports Injury Research.

“It’s almost like one of those perfect storms,” said Michael Szymanski, a research associate at the University of Connecticut. UConn is home to the Corey Stringer Institute, which studies heat-related deaths in sports.

Nearly one in three college students takes some type of psychotropic medication, according to the Healthy Minds 2023-24 study of college students’ mental health. It is not uncommon for young people to have multiple mental health conditions and take more than one medication. About 35% of elite athletes “suffer from eating disorders, burnout, depression, and/or anxiety,” according to a 2021 statement from the American College of Sports Medicine.

Nationally, doctors wrote 567 million prescriptions for mental health medications in 2022, according to data research firm Statista, second only to prescriptions for high blood pressure medications. This includes middle school students and middle-aged weekend warriors, who are less likely than college and professional athletes to be monitored by medical staff but may also be more susceptible to heat illness.

Studies show that medications to treat mental health conditions can increase the risk of heatstroke by constricting blood vessels or inhibiting sweating, preventing the body from cooling itself adequately. They can also raise blood pressure and core temperature, reduce the body’s perception of fatigue and/or place general stress on the cardiovascular system.

“Blood vessels dilate to dissipate heat during exertion,” Szymanski said. But steroids, for example, can block this mechanism because they constrict blood vessels. “You just have an intense system.”

In June, Don Emerson, a clinical assistant professor at the University of South Carolina, spoke to the National Athletic Trainers’ Association about four types of mental health medications — antipsychotics, antidepressants, anxiolytics, and stimulants — and their possible link to heat stroke. It found that medications with potential risk factors included popular brand names like Adderall, Ritalin, Xanax, and Ambien, as well as bupropion, a generic antidepressant often sold under the brand name Wellbutrin.

Emerson was a researcher on a 2021 study that showed higher body temperatures among marching band participants who took mental health medications.

Erin Pettinger, an athletic trainer at Georgetown University who attended Emerson’s presentation, said the research rang true for her. It has seen a rise in the number of athletes taking these drugs and numbers about 40 on its current rosters. Several years ago, during a particularly hot fall in Washington, D.C., about a half-dozen athletes suffered from heat illness over the course of a week.

“What all of these people had in common was that they had been diagnosed with ADHD, and they were all on medication,” she said.

Former University of Maryland football player Jordan McNair, who died of heatstroke in 2018, was taking a prescription for Vyvanse, a stimulant used to treat ADHD. The independent investigation into his death concluded that the medical team should have identified medication as a risk factor. “There is general concern among the medical community about student-athletes participating in physical activity while taking stimulant medications, although there are no general precautions listed in drug information sheets,” the report states.

When asked whether these types of medications are tested for heatstroke risk or whether they list heatstroke as a potential risk factor, an FDA spokeswoman wrote that the approval process for each drug is unique and she could not answer based on that. The four drug classes.

Last year, the US Food and Drug Administration (FDA) updated warning information on stimulants used to treat ADHD, listing Adderall, Concerta, Dexedrine, and Ritalin as examples. The updated labels ask patients to watch for increased heart rate or blood pressure but do not mention heat stroke, exercise or exertion.

ESPN found no mention of heat in a review of various FDA drug guides. It is unlikely that any manufacturer specifically tests for heat-related reactions, Emerson said.

“They discuss all the effects on the heart and kidneys and other types of effects, but not heat specifically,” she said. “The problem is that if something affects those systems, it affects thermoregulation.”

Sports medicine professionals face challenges in tracking athletes’ medications. Athletes may not want to disclose such information for fear of being stigmatized, and many athletes come to a new college or team using medications prescribed by a doctor in their hometown rather than the team or university physician. A less important factor is the perception by some athletes that certain mental health medications improve performance or act as appetite suppressants—reasons that athletes are unwilling to share with sports medicine staff.

The softball player who suffered from heat illness was prescribed medication by a doctor not affiliated with the team or school, said Moore, the former Columbia College athletic trainer.

“I know we’ve had conversations about: ‘Do we need to report this to the doctor again? You’re not feeling well. Is there a way to change the dose?'” she said.

In middle and high schools, which sometimes don’t have athletic trainers, parents should make sure the school is aware of any medications and potential risks, said Tim Neal, director of athletic training education at Concordia University Ann Arbor.

Dr. Corinne Hudson, a sports medicine physician at MedStar Health in the Washington, D.C., area, where she works as a team physician for Georgetown University athletics and the Washington Wizards and Mystics, said she hopes athletes and athletic personnel become more aware of the risks so they can continue to take their medications while finding… Other ways to deal with the heat.

“If someone has depression or anxiety, I would never want to suggest that someone not take medication for depression or anxiety,” Hudson said.

“I think it’s probably better for us to educate athletes about not increasing the risk even further. Right? Don’t have three cappuccinos and have a bunch of caffeine right before a race or before a hot soccer day.”

In most cases, Pettinger said, athletes prefer to continue taking the medication and take greater precautions through drinking water, sleeping and other preventative measures.

While much of the discussion focuses on heatstroke — from which 72 football players have died since 1996 — Neal said it’s worth monitoring potential drug effects simply because heat risks can inhibit how much athletes exercise or compete.

“Because they are tired or dehydrated, not to the point where they need care, but it reduces their performance,” he said. “And then when their performance diminishes, guess what that does? It makes them anxious or makes them depressed.”

The increased risk of heat illness extends beyond athletes participating in regular competition to people of all ages participating in races and other outdoor events, driving a heightened need for awareness, said Hudson, who volunteers for the Boston Marathon.

“When we think about marathons and mass events, we now look at people between 40 and 50 who are also on ADHD medication. So they are still on stimulants, as they are now,” she said. Taking blood pressure medications. “We just need to think about what that will do for us in terms of juvenile safety. I think awareness is number one.”