COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
Inquiry into the Prevention of Suicide and Self-harm: Sport NI
13 March 2008
Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mr John McCallister
Ms Sue Ramsey
Professor Eamon McCartan ) Sport NI
Dr John Kremer ) Queen’s University Belfast
The Chairperson (Mrs I Robinson):
The next two evidence sessions are part of the Committee’s inquiry into the prevention of suicide and self-harm. A paper related to these sessions has been provided to members. The first evidence session is with Sport NI, formerly known as the Sports Council. A copy of its presentation has also been provided to members. I am pleased to welcome Professor Eamon McCartan, chief executive of Sport NI, and Dr John Kremer from Queen’s University, Belfast. I invite you to speak for five or ten minutes, and there will be an opportunity after your presentation for members to ask questions. I will allow about an hour for the ensuing debate.
Professor Eamon McCartan (Sport NI):
As chief executive of Sport NI, I would like to introduce my colleague Dr John Kremer from Queen’s University, Belfast, who has written extensively on sport, physical activity and health. I would like to thank the Chairperson for the opportunity to present evidence relating to the Committee’s inquiry into the prevention of suicide and self-harm. Members have been provided with a copy of our presentation. We do not propose to talk through it in detail; instead, we will focus on the key messages. We are very happy to take questions.
Sport NI is aware of the Northern Ireland suicide prevention strategy, the aim of which is to reduce the Northern Ireland suicide rate, particularly among young people and others in high-risk groups, and to highlight the issues facing Northern Ireland in relation to suicide and self-harm. We know, personally and professionally, that suicide and self-harm are more prevalent among young males than young females, and young adults aged 15 to 34 years of age. It is more prevalent in urban areas than in rural areas, and it occurs more frequently in deprived areas than in non-deprived areas.
I will try to give the Committee a brief introduction to the role of Sport NI. In doing so, I will explain our definition of sport. We hope that through our presentation, members will have a greater awareness and appreciation of the evidence that highlights the contribution that physical recreation, physical exercise and sport can play in preventing suicide and self-harm. Article 21A of the European Sports Charter’s definition of sport will help the Committee to understand sport. It defines sport as:
“all forms of physical activity which, through casual or organised participation, aim at expressing or improving physical fitness and mental well-being, forming social relationships or obtaining results in competition at all levels.”
It is in that context that we define sport — not in the traditional context of the playing fields, but in the context of expressing or improving physical fitness and mental well-being.
Sport NI has a vision, which is, through sport, to contribute to an inclusive, creative, competent, informed and physically active community. In practice, that means that Sport NI creates and develops programmes and partnerships that will contribute to our strategic objectives. The most important of those is increased participation in sport and physical activity. We believe in the value that sport can add to the promotion of social inclusion, creating active citizens and enhancing the image of Northern Ireland at home and abroad.
Equally, we must not lose sight of the contribution that physical recreation, physical exercise and sport can make to broader Government policies such as better health, better education, a better economy and better communities. A significant part of the work that Sport NI undertakes is to create policies, programmes and partnerships to increase levels of physical activity and to increase capacity and social well-being, particularly among young people and under-represented groups.
That is done through a series of programmes, one of which is the community sport programme, the aim of which is to improve health and well-being, to build capacity in individuals and to increase sustained participation in physical activity and exercise.
Dr John Kremer (Queen’s University, Belfast):
There has been a long-standing recognition that the physical and the psychological go hand in hand. Mens sana in corpore sano: healthy mind, healthy body. Therefore, it is very welcome to have an opportunity to talk about how the psychological may have an impact on such a significant social issue as self-harm and suicide. Exercise psychology in particular is well positioned to talk about such matters. I would like to take you through some of the key findings about the relationship between the psychological and the physical.
Concerning the healthy body part of that equation, the evidence is unequivocal, namely that there are so many somatic health benefits attached to doing physical exercise. Turning to the psychological, one finds a far more complex picture. However, the general statement that can be made with a degree of certainty is that physical exercise correlates positively with psychological health except where the motives for exercise might be more questionable. There are examples in which excessive use of exercise in relation to body image might cause problems. Generally speaking, however, the picture is positive.
Critically, in relation to self-harm and suicide, there is an emerging research literature that suggests that those who exercise are less prone to suicide attempts. Of the three studies mentioned on the presentation slide before the Committee, the most important is probably that by Simon et al (2004) which states that:
“suicide attempters were far less likely than controls to report involvement in physical activity in the past month.”
Almost half as likely. When demographic factors including age, race, education and morality are removed, that affect is still found. There is a strong correlation between maintaining an exercise regime and a host of psychological variables.
There is a positive correlation between exercise, self-esteem, self-efficacy, well-being in general and cognitive functioning; and a negative correlation with anxiety, stress and depression. At the same time, there is recognition that gender-effects play their part. In competitive sports, for example, there is a phenomenon known as FAT — the female athlete triad, which is a combination of amenorrhoea, osteoporosis and disordered eating which can accompany excessive exercise. However, such conditions tend to be exceptions rather than rules. In the United States it has long been recognised by physicians that exercise is a routine form of treatment that would be prescribed. In the UK, there is increasing evidence that GPs are turning to exercise as a treatment for forms of psychological malaise. However, where and at what point still tends to be patchy. There is no consistent theme, especially in a culture best described as a “pill culture” in which people expect to be prescribed a pill for whatever illness they present.
Particular effects are associated with exercise. Mood state, for example, responds well to certain types of exercise. For some strange reason, it seems to be repetitive, boring, aerobic exercise that has the most positive effect on mood state. Most literature on the subject concerns depression and it is now well established that an effective treatment for depression — and most especially for clinical depression — is regular exercise. Aerobic exercise seems to be the most effective. Such exercise is, typically, carried out several times a week, and the longer the regime, the more likely there are to be positive effects. Maintaining a regime can sometimes be difficult for those who are not inclined to exercise because they are depressed, so there is a degree of circularity. Anxiety has also been shown to respond well to exercise, especially programmes that last longer than 20 minutes, after which time aerobic exercise then kicks in. In relation to anxiety, however, the type of exercise seems to be unimportant.
Those who maintain a reasonable level of physical fitness and engage in physical activity also seem to be well buffered against ordinary life stresses, including illness. There is a positive relationship between exercise and self-esteem, but it tends to operate only in relation to specified domains and, as one might expect, in particular in relation to domains related to physical competence.
A gender effect cannot be ignored in relation to exercise, however, and there is increasing evidence that young men are not exercising to lose weight but, to use a modern phrase, to “bulk up”. They have concerns about the initial states of their bodies and a desire to increase muscle bulk, whereas women traditionally exercise to lose weight.
Nobody is absolutely sure yet why beneficial effects occur, but there are at least four hypotheses to which people work. The first is that, by engaging in exercise, one is breaking some sort of cycle. There is a psychosocial hypothesis which says that by exercising or engaging in activity one breaks free from everyday anxieties and worries. Another hypothesis is based simply on body temperature, in that by exercising one increases one’s body temperature, which has a positive effect on mood and, more generally, on psychological well-being. Pleasure peptides, the runner’s “high” and similar explanations are abroad, but they are probably not as popular as they once were. As to which hypothesis works, it is almost certainly a combination of all of the above effects that explains why engagement in exercise can help to address psychological morbidity.
In conclusion, there is no question that physical exercise helps people to deal with a range of psychological conditions, and, in relation to self-harm and suicide, there is increasing evidence to suggest that it can play a preventive role. However, it would be over-egging the case to say that exercise provides an answer to all the problems. It is more likely that exercise can act in combination with other interventions to help to stop people who are already heading down a suicide route.
If one reviews the various intervention packages that exist, it is interesting to note how few of them mention exercise; yet many of them have time-out interventions of various sorts. Perhaps now is the time to examine more structured interventions to see where exercise can play a positive role alongside other forms of support in helping people to move further away from that route.
Unquestionably, there is a paradox in all of this. The people who are most likely to benefit from exercise are also likely to be those who are least inclined to take exercise, and that remains a significant challenge for people who work in that area. Thank you.
In conclusion, we would say that the sporting sector and Sport Northern Ireland seek to provide structured interventions that provide the opportunity for exercise or physical activity to men, to young adults, to people who live in urban areas and, most importantly, to people who live in deprived areas. Thank you.
Thank you very much, Eamon and John. During a visit to Scotland, the Committee heard how major sporting occasions, such as premier-league football matches, and major sports personalities are being used to encourage people — particularly young men — to talk about their feelings and to overcome the stigma attached to admitting to suffering from depression. As part of the programme of reaching out, they distributed little cards at all the major stadia, which gave a helpline number and said that it is good to talk. Has your group looked at that approach? Would you contemplate doing that, and if not, why not?
I am happy to answer that question.
A programme is being run in stadia across Scotland, and another programme uses icons of sport to encourage people to talk about the issue. In fact, Neil Lennon, formerly of Glasgow Celtic, came out and outlined the problems that he had experienced in his personal life. That was a mechanism for increasing awareness and for encouraging people to talk about the issue. We have not been directly involved in a programme for rugby, soccer or gaelic in Northern Ireland. The Scottish Parliament allocated sportscotland around £13 million from the health budget to help in the development and promotion of such programmes. We would seriously consider developing such a programme and promoting it at major international football matches in Windsor Park, at major rugby and gaelic matches and at the North West 200. They are probably our four biggest crowd-pullers.
Thank you for coming along and giving us an insight into the issues. Your contribution will help us with our inquiry. You said that those who would benefit most would be least likely to participate in the programmes. You also talked about people from disadvantaged communities. Are there any programmes that could target those groups specifically? Has the Department sought your views? Were you consulted on the suicide strategy? Finally, are you involved in the implementation body?
No. To the best of my knowledge, we were not consulted on the strategy, but we are aware of it. John outlined empirically that sport in the European definition has an important role to play with regard to physical exercise and activity. When we received your invitation to give evidence, we thought that it would be worthwhile to present evidence and to illustrate how sport can help people.
Someone once famously remarked, “no action without research; no research without action”. Many of the intervention programmes do not focus too much on the research. A range of activities may have been mentioned, but no one has actually decided which programmes are likely to be the most effective. If you read the literature, you would be disappointed by the small number of programmes that consider exercise as a form of therapy, even though it gives a sense of purpose and identity to those who suffer from hopelessness. The programme in Scotland targets people attending events. That is useful, but only in so far as it identifies people who may be at risk. However, we must target those people and encourage them to engage in lifestyles involving physical exercise which is sustainable in the longer term. It would be good if that sort of work could be mainstreamed into the many and varied interventions.
I would like to begin with health promotion, Investing for Health and encouraging people to participate in sport at an early age.
Sport Northern Ireland runs a successful community sport programme, which aims to promote individuals’ health and well-being. The programme is targeted at areas of social need, and it is designed to build capacity, self-worth and self-esteem. It is aimed at increasing the participation and the regulatory of participation in sport. Participation in sport, particularly in aerobic activity, a couple of times a week for 30 or 40 weeks a year was found to be the most beneficial for treating certain types of depression and anxiety.
You talked about an over-reliance on pills, and you are right in saying that there is a pill culture here. However, we are finding that other interventions can play a vital role. I hope that that is something that will come out of our inquiry.
What we have often been told that exercise is good for people mentally and physically, so it is good to have that confirmed. Exercise is part of the prevention and part of the cure for people with mental-health issues.
Do you think that GPs should automatically refer patients with mental-health problems to undertake some form of exercise programme, rather than simply prescribe pills or make a further referral? For example, establishing a connection between GPs and sports clubs or leisure centres to form part of the treatment might be useful. Similarly, would an exercise regime for patients admitted to hospital with mental-health problems be beneficial?
The most effective regimes operate in total-treatment institutions, where people are required to exercise. That can have quite a dramatic effect on clinical depression, and over several months a radical decline in those symptoms is visible. A major culture shift is needed to recognise that GPs using exercise as a form of treatment is not a second-class option or a poor cousin. In a well-maintained and well-managed environment, that can be a long-term solution to many of those problems. However, there is still resistance to such concepts. The recent debate questioning the effectiveness of drugs like Prozac is an interesting one; those antidepressants may simply be placebos. Exercise provides a cheaper and potentially more effective remedy.
Castlereagh Borough Council operates a referral scheme, helps promote a healthy lifestyle and outlook and permits its premises to be used to promote well-being.
I congratulate Castlereagh Borough Council and Belfast City Council on their efforts to combine health and leisure services. Sport NI seeks to increase rates of participation in sport and physical activity in Northern Ireland. Clear empirical evidence shows that people who participate in sport and physical activity are less likely to self-harm or commit suicide. Therefore, if more people engage in physical activity, the pool of individuals who are vulnerable to self-harm and suicide should, theoretically, reduce. Those are the preventative measures.
Moreover, there is clear empirical evidence — and thank God that it is the case — that GPs are prescribing exercise and physical activity as a remedy to deal with depression, anxiety and the continuum that leads to self-harm and suicide, rather than simply prescribing pills.
As a GP of over 20 years, I have no doubt that a person who is emotionally and mentally well will improve physically, and vice-versa. Sporting activity fills a vital role. The Committee is gradually recognising that all the different parts of the jigsaw must combine to tackle the awful scourge of suicide. Drugs have a part to play. All GPs prescribe them, and, as I have stated previously, sometimes there is no alternative. Talking therapy is also important.
However, people who are good at sports at school are more likely to continue participating when they leave school, whereas those who are not so good tend to feel a sense of failure and are more likely to give up. To a certain extent Alex has touched upon this question, but how do we encourage those non-sporting people to continue to engage in physical activity after leaving school? John mentioned pleasure peptides — is that what used to be known as endorphins? I have not exercised for about nine months, and I do not feel as good. I am going to start soon because physical exercise undoubtedly makes people feel better.
A pilot study was carried out — although I do not know the results — but we, as rural doctors in Tyrone, felt a little bit cheated. We were not allowed to prescribe exercise in the local leisure centre in Omagh for our patients, but the GPs in the town were. I thought that that was wrong. As Alex said, I have no doubt that most GPs would be very keen to prescribe exercise, rather than write prescriptions for Flouxetine — or Prozac, as it is better known. It costs £4 for a session in the training zone in the leisure centre, and that is cheaper than most drugs. GPs should be prescribing exercise. What are your views on that?
The big challenge for GPs and anyone else dealing with people who are depressed, feel worthless and have low self-esteem, is to get them motivated and interested. They lose interest and motivation and they even lack energy. We must get those people into the gyms, on to the equipment and exercising.
Part of the solution is getting the first line of contact — people working with our youth — involved in exercise. I go along with what Alex said about preventative measures, and what Eamon said about remedial measures and getting people involved in exercise. If we can get more people involved, there is no doubt that it will lessen the pool of the people who are liable to develop feelings of hopelessness and, ultimately, suicide.
One of my more interesting PhD students was a life prisoner in Maghaberry, and he did his thesis on exercise and psychological well-being among life prisoners. There was a whole array of factors about taking people to the gym, but one of the most significant factors was peers. If you are involved with a group of people who are also exercising, they were chivvying you up to go along and it was difficult to escape — [Laughter.] They tended to be the ones who kept exercising. The others were more sporadic.
However, there is a whole host of other factors at work as well. The critical one that was mentioned was the transition from organised sport at school through to voluntary sport when young people leave school. That has been a thorny issue. How do we bridge that gap? The people who are already good and talented are naturally carried forward on a tide past school into sports clubs. The rest of the young people have to find their own way. There is a void that is very difficult to cross over, unless there is a strong family connection with sport. Much work still needs to be done on that transition. It can be seen in Queen’s, where there are a lot of interesting programmes to try to encourage people back into sport.
Major cultural issues still have to be overcome, going back to the pill culture —
Can you explain what those issues are? Are they cultural issues with GPs, or is it a community attitude?
As Eamon pointed out, the definition of sport is very broad. We still carry a layperson’s definition in our heads, which is around competitive sport and the group of people that becomes the chosen ones whom we then go and watch. That is quite different from encouraging a much broader body of people to engage in exercise more for its own sake. Sometime the emphasis on competition in school sports, in terms of the body of a school, can get in the way of long-term commitment to a sport.
Some people have to rediscover running, after having taken part in cross-country at school, which hurt and which they did because they were made to. One has to rediscover the enjoyment of just going out and jogging.
May I just add to that? As I look round the room, we are all of an age that has a traditional view of sport, which is associated with school teams, performance and competition. What we, and what many in education are trying to do, is to look at sport in terms of the European definition, which should include physical exercise and physical activity, and put that in the context of healthy living, and life-long healthy living. We are trying to take exercise away from the traditional view of sport and to look at it as physical exercise and physical activity.
The traditional view has a place, and I am not saying that that should be done away with. However, we must broaden sports participation to people who may not be particularly well adapted for sports but who — like the rest of us — require physical activity not only when they are young but for the rest of their lives, and, in order to maximise physical and mental well-being from such activity — whether it is walking, jogging, cycling, disco dancing, or whatever — it must become, as Dr John Kremer said, an integral part of their healthy-living programme.
We all remember the plump kid in school who, from a class of 30 pupils, was never picked to play football because he or she was not particularly good at it. Guess what? People do not do that which they are not good at, and if they are told that they are not good at something, they tend to shy away from it. Therefore, given that some people are not particularly good at team games, alternative activities must be added to the physical-education curriculum in order to provide an opportunity for such people to access the benefits of physical exercise, which might then become embedded in their lifestyles.
If clinical grounds exist — whether for mental-health, self-esteem or even physical benefits — should GPs be allowed to prescribe physical exercise on the NHS?
Without question; the evidence has been so well established over decades that there is now no question about the benefits of physical exercise. One caveat to that is motivation. Some people use exercise dysfunctionally. Nevertheless, if screening mechanisms are in place, the general answer to your question is yes.
Down through the years, I have learned about another difficulty. If a person is suffering with depression or anxiety, he or she can hardly get out of bed in the morning, never mind getting involved in walking or running — the motivation simply is not there. The dilemma is that if such a person has cut themselves off, is isolated and does not want to see people, that message is difficult to put across.
It is, and the management of such experiences is so difficult. The challenge in this area is that, subsequent to prescription, implementation can be so difficult.
The buddy system is one technique that can be used in such circumstances. As you rightly said, people cut themselves off, they are isolated and they find it difficult to move or get out of bed. Consequently, the early initiation of a buddy system gives such people the encouragement and support they need.
Last week, I attended a conference at which Dr Maureen Murphy, on behalf of one of the health boards, presented a report — the title of which my colleagues are likely to know — about her study of the prescription of exercise. Her findings were quite exciting and, with the Committee’s permission, I will forward those findings for it to consider.
That will be helpful to us in finalising our proposals for the Minister.
Ms S Ramsey:
Like other members, I thank you for your presentation. I have a couple of comments to make, followed by a few questions.
I am interested in what you said about the Scottish Executive giving additional money to sports in order to address suicide and self harm. When discussing participation in sport, which tackles social inclusion — an issue that affects my constituency and others — it strikes me that we are losing a lot of money because of the Olympics. That might be a good thing; however, when communities attempt to gel and encourage people to become involved in all sports, they reach the last hurdle only to discover that the money has been whipped away. You must be well aware of that. On the one hand, we appear to take a step forward on the issue of suicide and self harm, but, on the other, we take two steps back on the issue of social inclusion between communities.
Michelle O’Neill said that sport has a role to play not only in relation to this issue but in Investing for Health, and we have witnessed the benefits of that.
I cannot avoid coming back to Dr Deeny’s point. Some people in the medical profession have the mindset that there is a pill for every ill. That is another component part that needs consideration.
The Chairperson made a valid point — that Scotland has taken the lead in relation to sporting icons or heroes. That is something that should be utilised here, as there are good, prominent role models in the sporting sphere. If another Government is utilising that, it could be implemented here without our having to reinvent the wheel.
Looking at some of the sporting organisations that cover the island of Ireland — particularly the GAA and rugby — do you plan to address the issues with your counterparts on an all-island basis? Strategies could be developed to tackle the issues of obesity and depression, for example, rather than only addressing the issues of suicide and self harm. As many people as possible — irrespective of gender and age — should be encouraged to get involved in sport.
I am very concerned about the issues of suicide and self harm, and an inquiry has been established to address those issues. It is encouraging to hear what is happening in relation to that. On the other hand, we are losing millions of pounds in funding due to the 2012 Olympics. Where does that leave communities that have been severely affected by suicides? People in those communities are trying to get off their knees, but every hurdle they face is higher than the last.
To put the record straight; the £13 million in funding given to the Scottish Sports Council by the Scottish Parliament was not for dealing with the issue of suicide alone; it was for health generally. A series of programmes was set up to address issues like obesity and poor cardiac health.
It is true to say that we have had a reduced budget because of the 2012 Olympics. That has impacted on all of our programmes, including community sport. In defence of the Culture, Arts and Leisure Minister, Mr Poots, he is fighting hard for additional funding for that particular deficit, and we will be discussing that issue with the CAL Committee next week.
Ms S Ramsey:
I am not being critical. What I am saying is that we are talking about having a joined-up approach to this. We are in an Executive, and need to have a joined-up approach from all Departments. If the Health Department or the Education Department tries to tackle the issues of suicide and self harm, sport has a role to play in that. That is how the jigsaw fits together.
I agree entirely with that view.
We are aware that various studies have taken place into suicide and self harm. A 2004 study identifies suicide as a major issue in the Republic of Ireland, just as it is in Wales — as we have seen recently in south Wales. It has also been a major issue in Scotland, as it is in the constituency of West Belfast; where there is a prolific cluster — that is statistically incorrect, but it is evident that there is a rise in the rate of suicide there. We liaise very closely with the Irish Sports Council. We are meeting them on 3 April, and suicide will be an item on the agenda.
There is a conundrum here, because the traditional channels that one would work through, in relation to accessing people involved in sport, do not work when it comes to social issues such as suicide, because the people who are most at risk are the least likely to be involved in organised sport.
Fresh thinking is needed to consider how to engage with those hard-to-reach, marginalised people. They need to be encouraged to engage in activities that they may well have been put off at an early age. They may have developed a lifestyle that is quite removed, and that which most people who are involved in sport would not be used to. A fresh approach is needed in order to establish who those people are, and there is a need for a culture shift.
If any of you walk in the Mournes, it is quite interesting — and has been confirmed in a recent participation report produced by Sport NI — that you will meet more people walking there who are not from Northern Ireland than people who are. You will hear more southern, eastern European, or English accents than Northern Irish accents. That is a real wake-up call, because it is a stark reminder of the cultural obstacles that still need to be overcome.
I think that, to a degree, the legacy of the Troubles and of coming out of conflict has added to those cultural obstacles. Both communities in this society have been marginalised, and in the past people did not walk or go past their own boundaries. In my own part of Strangford we now have the Comber Greenway, which consists of many miles of straight paths for cyclists and walkers. When one does go out it is quite amazing to see that it is mostly local people using it, who can not believe that they have this facility on their doorstep, stretching from Comber right through into east Belfast. It is many miles long, and the number of people who are now using it is quite amazing; the only problem is that the “hoodies” are out on their motorbikes, and that dissuades a lot of people from using it. However, I totally concur that healthy lifestyles produce healthy minds.
Everyone who had wanted to speak has now been given that chance, so I would like to thank John and Eamon for coming along. Thank you very much indeed for your attendance.