Sport and exercise medicine (SEM) has gained recognition as a clinical specialty in South Africa, laying the foundation for the emergence of sport and exercise psychiatry (SEP) as a vital complementary discipline supporting the biopsychosocial approach to medical care for athletic populations. The mental health of athletes has been identified internationally as an area for prioritisation, supported by new clinical tools and resources.1 In addition, exercise is increasingly recognised as a form of mental health medicine for athletes and non-athletes.2 3 This editorial outlines the approach to developing SEP in South Africa and its applicability to similar settings globally.

An overview of sport and exercise psychiatry

Mental health conditions are common in competitive sports, carrying important considerations for overall athlete health and performance.4 SEP focuses on preventing, diagnosing and treating these conditions in both elite and recreational athletes.5 Another priority for SEP is the use of exercise as an intervention for mental health conditions in general.5

The preventative role of exercise for physical health is well known; however, a meta-analysis of Cochrane systematic reviews by Posadzki et al has, in fact, found larger effect sizes for exercise on mental health outcomes.6 Despite this, exercise is often overlooked as a potential preventative and therapeutic tool for mental health conditions.7 In South Africa, mental health conditions are a leading cause of disability.8 In low-resource healthcare settings, the accessibility and affordability of exercise make it a pertinent intervention. Collaboration and thoughtful discussion with patients should address barriers to exercising, such as crime, infrastructure, gender roles, social physique anxiety and motivation, which may require purposeful attention in those impacted by mental health conditions.

SEP may be particularly important in low- and middle-income countries (LMICs), where athletes may face additional unique challenges stemming from social determinants of mental health. These include financial insecurity, violence, adverse childhood experiences and substance use. Limited resources and geographical dispersion also present obstacles to training and competition with limited access to mental health services.

Development of the South African model

While SEP is not a registered subspecialty in South Africa, it is a growing field locally that has evolved to address both the spectrum of athlete mental health and the use of exercise as an intervention.9 Recognising both the need and the opportunity for synergy with SEM, a cohort of psychiatrists and sports physicians has started to develop SEP in South Africa using a Plan-Do-Study-Act cycle, an iterative approach to quality improvement.10 We are applying this to each of five strategic focus areas: advocacy, creating partnerships, training and education, building capacity and sustainability (figure 1). Having this clear strategic framework to guide our larger vision has allowed our small team to take advantage of all opportunities which have presented themselves without losing focus, that is, addressing the ‘low-hanging fruit’ while maintaining a clear direction.

Figure 1

The key strategies for the growth of sport and exercise psychiatry in the South African model.

Advocacy through a systemic approach

Given limited resources, we recognised that although individual and systemic approaches are needed to improve the management of athlete mental health,4 focusing on systemic change through involvement in policy and planning may be the most effective early strategy. In South Africa, this meant gaining representation in relevant committees of our National Olympic Committee and approaching specific sporting codes such as boxing and rugby to strengthen already established relationships. Being ‘in the room’ involves us in critical discussions regarding athlete mental health policy.11 Local athletes, clinicians and researchers must be consulted to adapt tools and policies to be socially and culturally appropriate: nothing about us without us.

Stakeholder engagement highlighted the need for mental health support systems for athletes with improved individual and organisational access to SEP services. This was addressed by forming a Sport and Exercise Psychiatry Special Interest Group (SEPSIG) affiliated with the South African Society of Psychiatrists, which drew from collective experience and developed referral networks. Referral networks are being progressively scaled up in the public and private health sectors in order to cater to high-performance and general practice settings. Affiliated psychiatrists and trainees also have taken certain opportunities to volunteer at recreational sports clubs in an advisory role, further building partnerships and grassroots capacity.

Creating partnerships

This inclusive South African model fosters relationships with local stakeholders in the SEM domain, such as sports physicians and sports psychologists and through group affiliation with the South African Sports Medicine Association. International mentorship is further contributing to capacity building. These include colleagues in the International Society for Sports Psychiatry (ISSP) and the SEPSIG of the Royal College of Psychiatrists.

Training and education

We used technology to establish an online discussion group for psychiatrists, trainees and interested physicians to improve access to locally relevant expertise, share research and provide a platform for complex case discussions. We have also focused on further capacity building through seminars, webinars, and conference workshops. For now, colleagues interested in formal training have been encouraged to access established programmes run by the ISSP and the International Olympic Committee.

Building capacity: creativity is key

South Africa only has 1.53 psychiatrists per 100 000 of the population, compared with some European countries with upwards of 30 per 100 000.12 This shortage is coupled with an inequitable distribution of mental healthcare availability, as 80% of psychiatrists work in private practice while public services are concentrated in urban centres.12 Creative approaches such as strategic partnerships, telehealth and the use of technology help bypass funding and human resource limitations. Telepsychiatry can help deliver scarce specialist SEP services more equitably but with some limitations for deep-rural communities with poor signal. The mental health treatment gap in LMICs can also be addressed through task-sharing initiatives,13 such as with upskilled sports physicians. As the new South African College of Sport and Exercise Medicine develops its training programmes, support from SEP for the inclusion of mental health in their curricula will help expand the expertise of specialists in SEM to deliver general mental health services.

Helping patients increase their physical activity and reduce their sedentary behaviour is considered a foundational competency for all healthcare practitioners.14 Moderate to vigorous physical activity may help mitigate some of the health risks of sedentary behaviour.15 Furthermore, these health behaviours have been shown to have disproportionately larger effects on mortality and health in individuals with low socioeconomic status.16 In resource-constrained LMICs in particular, psychiatrists should be competent in the practicalities of movement behaviour change and behavioural activation. Additional partnerships have been formed with various group exercise therapeutic initiatives provided by non-profit organisations and non-health partners, for example, surf therapy, dance groups and other more established sports. With research and the publication of local evidence of the feasibility and health economics of these interventions, we could benefit from growing investment and public-private partnerships in SEP.

Sustainability

Sustainability is critical to successful development, allowing for a purposeful focus on the future. We have dedicated committee space for early career psychiatrists and trainees to foster generational leadership and recognise the importance of diverse representation.

Adapting this model to similar LMICs

Practitioners in LMICs are likely to experience similar challenges to South Africa when establishing SEP services, including human resources, capacity and inequitable funding availability. However, taking a systemic approach with a focus on our identified five areas may provide a model to reduce some of the barriers to implementation. Collaboration between psychiatrists and physicians across LMICs could help facilitate the establishment of similar initiatives globally. A multipronged approach is needed for improving mental health services, including addressing enablers and barriers to mental health-seeking behaviour at both individual and systemic levels. Sport and exercise psychiatrists should avoid the temptation of exclusive focus on high-performance environments but also focus on capacity building, local networking, outreach and task-sharing initiatives, allowing their expertise to penetrate to the grassroots level.

Conclusion

Sport and exercise psychiatry, particularly in LMICs, can play a pivotal role in improving athlete’s mental health and promoting the population’s mental well-being through physical activity. As a pioneering model, the South African network helps provide a roadmap for strategic development, emphasising collaboration, capacity building and sustainability. Psychiatrists in LMICs might draw upon this model to advance SEP in their respective contexts, thereby championing mental health for athletes and those who seek to be active.

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