Time to Move on Physical Activity as Usual Care for Mental Illness

Physical inactivity is estimated to cause 9% of premature mortality worldwide,¹ but recognition of the benefits of being physically active is increasing. In addition to the cardiometabolic benefits of regular bodily movement, physical activity has repeatedly been shown to have antidepressant and anxiolytic qualities, both as monotherapy and as adjunctive therapy.^2,3

For people experiencing mental conditions beyond depressive disorders and anxiety, little evidence on useful treatment strategies is available. However, support exists for the notion of addressing the limited participation in physical activity seen among people with serious mental illnesses like schizophrenia, because a sedentary lifestyle happens to be a key modifiable risk factor for the development of metabolic syndrome. A recent editorial⁴ in The British Journal of Psychiatry made an urgent call “for better clinical trial evidence to determine how best to increase levels of physical activity”^(p239) in people with schizophrenia, while a subsequent letter⁵ made reference to mental health physiotherapists as professionals ready to lead the charge in delivering evidence-based interventions.

Our review⁶ of 39 studies with varying participant diagnoses, including major depressive disorder and schizophrenia, aimed to determine what effect physical activity has on symptoms of depression in people with a mental illness, while also determining the impact on symptoms of schizophrenia, anthropometry, aerobic capacity, and quality of life.

The key findings were unsurprising, revealing that indeed physical activity is effective in improving both the physical health and mental health of people experiencing mental illness. However, the effect sizes of methodologically stronger trials were smaller than those of studies of a poorer quality. We also found that the intervention protocols were often poorly described, failed to utilize clinicians with expertise in exercise prescription, and often failed to meet basic principles of exercise programming.

Critics of physical activity interventions in people with mental illness often cite studies with negative findings such as those of Chalder et al,⁷ in which a predominantly telephone-based intervention had little effect on mood in a sample of participants with depression. Such interventions are unlikely to be comparable to, for example, supervised exercise programs incorporating an individualized prescription and incorporating both resistance- and aerobic-based components provided by allied health clinicians (such as exercise physiologists and physiotherapists). Unfortunately, this criticism reflects the current conceptualization (and subsequent lack of funding) of the role of physical activity as a diversion strategy rather than as a clinically meaningful intervention requiring clinicians with unique expertise.

At what point do we decide that sufficient evidence exists for a cultural change within psychiatric care, whereby exercise physiologists or physical therapists (and indeed dietitians) are considered as standard members of the multidisciplinary mental health team? Such paradigm shifts are often limited by the bottom line. Rather than looking at the cost of delivering such interventions, we need to consider the cost of failing to do so.

Financial disclosure:Mr Rosenbaum had no relevant personal financial relationships to report.

References

1. Lee I-M, Shiroma EJ, Lobelo F, et al. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet. 2012;380(9838):219–229. PubMed

2. Cooney GM, Dwan K, Greig CA, et al. Exercise for depression. Cochrane Database Syst Rev. 2013;9:CD004366. PubMed

3. Jayakody K, Gunadasa S, Hosker C. Exercise for anxiety disorders: systematic review. Br J Sports Med. 2014;48(3):187–196. PubMed

4. McNamee L, Mead G, MacGillivray S, et al. Schizophrenia, poor physical health and physical activity: evidence-based interventions are required to reduce major health inequalities. Br J Psychiatry. 2013;203(3):239–241. PubMed

5. Stubbs B, Probst M, Soundy A, et al. Physiotherapists can help implement physical activity programmes in clinical practice. Br J Psychiatry. 2014;204(2):164. PubMed

6. Rosenbaum S, Tiedemann A, Sherrington C, et al. Physical activity interventions for people with mental illness: a systematic review and meta-analysis [published online ahead of print March 31, 2014]. J Clin Psychiatry. doi: 10.4088/JCP.13r08765. Abstract

7. Chalder M, Wiles NJ, Campbell J, et al. Facilitated physical activity as a treatment for depressed adults: randomised controlled trial. BMJ. 2012;344:e2758. PubMed