Exercise as a health intervention

The mental health benefits of participation in physical activity may seem self-evident, although they are disappointingly hard to prove. In young people small but non-significant improvements have been noted in mental health, ^{Reference Biddle and Asare3} specifically in anxiety and depression ^{Reference Larun, Nordheim, Ekeland, Hagen and Heian4} and self-esteem, ^{Reference Ekeland, Heian, Hagen, Abbott and Nordheim5} and there is a consistent association between sedentary time spent using screen-based media and poorer mental health. ^{Reference Biddle and Asare3} A modest and not statistically significant clinical improvement is seen when adult patient populations are studied, including in conditions such as depression ^{Reference Mead, Morley, Campbell, Greig, McMurdo and Lawlor6} and schizophrenia. ^{Reference Gorczynski and Faulkner7} Most studies describe a heterogeneous mix of exercise interventions and although this reflects real life, where opportunities for sports participation thankfully come in great variety, it does reduce the likelihood of a robustly positive finding. However, in contrast to other interventions including psychotherapies, there is a paucity of any demonstrable negative effects of exercise participation.

Health is not the only reason for engaging in physical activity and many participants cite the opportunities created for social interaction as an important factor. ^{Reference Foster, Hillsdon, Cavill, Allender and Cowburn8} This may be especially important for those who are regularly and frequently excluded from a participative life by reason of their illness or condition. Those with enduring mental illnesses are frequently multiply disadvantaged in this way and find themselves excluded from opportunities in education, employment and housing as well as leisure activities. ^{Reference Boardman, Boardman, Currie, Killaspy and Mezey9} Participation in leisure activities among people with schizophrenia is especially low. ^{Reference Shimitras, Fossey and Harvey10} Might sport be a vehicle where the journey to participation, inclusion and recovery begins? There are already many, although often isolated, examples of sport and exercise being used to promote social inclusion for psychiatric patients with the greatest disability and disadvantage (www.pmasports.com). There will be potential advantages for mental health services in delivering socially inclusive outcomes and in promoting recovery if they are able to form and sustain links with sports organisations. The psychiatrists who embrace this will be those who build an Olympic legacy for mental health.

Exercise as an intervention to enhance the mental well-being of the population falls clearly within the remit of a pledge to improve health via participation in sport, whereas using sport as a driver of social inclusion has a direct parallel with the Paralympics pledge to enhance the lives of those who live with disability and disadvantage. It is disappointing that their inclusion in the Olympic legacy statement is not more explicit.

Mental illness and athletes

Sport and exercise medicine is a multidisciplinary field that focuses on two areas. First, the use of exercise as an intervention to improve outcomes across a range of health-related conditions including obesity and cardiac disease, and second, the provision of specialist treatment for medical problems related to sport. The latter is closely related to another facet of the Olympic legacy of ensuring the best available sports medicine support for the country's leading performers. If there is to be an Olympic legacy for mental health, this could and should include provision of psychiatric services to athletes.

The prevalence of psychiatric morbidity in elite sport is not insignificant. Perhaps the most frequently studied is the high prevalence of eating disorders especially, but not exclusively, in sports such as gymnastics, endurance running and weight category sports, for example judo, boxing and wrestling. ^{Reference Sundgot-Borgen and Torstveit11} Alongside this is an increasing awareness of the sports-specific factors that contribute to an increased risk of developing a psychiatric disorder. ^{Reference Thompson, Sherman, Thompson and Sherman12} Depressive disorders are at least as common as in non-sporting populations ^{Reference Yang, Peek-Asa, Corlette, Cheng, Foster and Albright13} and again there has been interest in how the sports environment contributes to this. ^{Reference Burton, Begel and Burton14,Reference Mummery15} Public interest in such cases in elite sport may be helpful in raising concerns and has been a stimulus to increased awareness and further research in, for example, Germany ^{Reference Markser16} and the USA. ^{Reference Guskiewicz, Marshall, Bailes, McCrea, Harding and Matthews17}

To address conspicuous psychiatric morbidity in the sports arena there has to be acknowledgement within sport that a problem needs addressing and expertise from psychiatry that is willing and able to assist. It is perhaps no coincidence that eating disorders, the sports-related psychiatric condition about which there is greatest awareness, is the one area where the UK has both a national sports-specific guideline ¹⁸ and a national treatment and research centre (opened in Loughborough in 2011). However, whereas most sports teams would expect to know, for example, how to access orthopaedic care and even to have a close and ongoing working relationship with an orthopaedic specialist, could they say the same about their relationship with mental health services and psychiatrists? Such relationships exist (baseball in the USA is a worthy exception) but they are not the norm. ^{Reference Torre19} Contrast the rapid, multidisciplinary response of a team of experts to a physically injured sportsman with the typical response when mental health problems are (often all too reluctantly) disclosed. As advocates for our patients it is our duty to speak out where discrimination and stigma exist and to appeal for equality of access to treatments for physical and mental health problems. Better medical care for elite sports performers, an Olympic legacy pledge, has to include ready access to psychiatric expertise. It would be a major contribution to the de-stigmatisation of mental illness if the psychiatric care of Team GB were accorded parity with other healthcare needs and with it recognition that even for the nation's elite sportsmen and women there is no health without mental health. That really would be an Olympian legacy.

Are psychiatrists prepared?

Do psychiatrists need any special skills to treat sportsmen and women? As clinicians we must understand not only a syndrome or illness but also the context in which this has occurred – in this case, sport. This means exploring the hopes, aspirations and fears of the individual, what they value most and what they might lose, the key individuals and relationships is their life, the external stressors and supports to which they are exposed and much else besides. We do this for all our patients and a willingness to understand and work with the context in which a disorder has arisen is one of our key competencies. ²⁰ We may not know it but we already have the skills to assess and treat special people (sportsmen and women) in the unusual environment of elite sport.

The necessary knowledge need not extend to a detailed understanding of a particular sport and its rules. Indeed, a psychiatrist who is too close to a sport and its leading performers may experience a difficult countertransference that impedes his or her ability to provide the highest quality treatment. ^{Reference Begel21} The essential competencies are those of any good psychiatrist. Although interviewing a sportsperson may require flexibility and a willingness to consider diverse and ‘athlete-centred’ venues for the consultation, this is no different to the approach of any modern community psychiatrist. Athletes may be a hard-to-reach group but they are deserving of our attention and we have the skills to assist them. Making our expertise available is our contribution to the Olympic legacy.