Integration of physical activity programs within multi-disciplinary psychiatric care: evidence to practice and the Australian experience

Abstract

Objectives: Physical activity (PA) and exercise is increasingly being recognised as an efficacious component of treat- ment for various mental disorders. The association between PA and cardiometabolic disease is well established, as is the strong link between mental illness, sedentary behaviour and poor cardiometabolic health. Examples of suc- cessful integration of clinical PA programs within mental health treatment facilities are increasing. The aim of this review was to summarise the evidence regarding PA and mental illness, and to present examples of clinical exercise programs within Australian mental health facilities.
Methods: A narrative synthesis of systematic reviews and clinical trials was conducted.
Results: Evidence supporting the inclusion of PA programs as an adjunct to treatment for various conditions was presented; including depression, schizophrenia, anxiety disorders, post-traumatic stress disorder and substance abuse. In light of the available evidence, the inclusion of clinical PA programs within mental health treatment, facilitated by dedicated clinicians (exercise physiologists / physiotherapists) was justified.
Conclusions: PA is a feasible, effective and acceptable adjunct to usual care for a variety of mental disorders. There is a clear need for greater investment in initiatives aiming to increase PA among people experiencing mental illness, given the benefits to both mental and physical health outcomes.

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DOI: 10.1177/1039856215590252
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AustrAlAsiAn
Psychiatry
The association between physical activity (PA) and
both reduced all-cause and cardiovascular mortal-
ity is well established.1 Exercise, a structured sub-
set of PA, has since been cited in clinical guidelines and
position statements for diabetes,2 cardiovascular disease3
and cancer.4 Despite the well-established health benefits
of physically-active lifestyles, people experiencing men-
tal illness are less likely to engage in PA, compared to
the general population.5,6 Coupled with high rates of
smoking7 and poor dietary habits,8 physical inactivity is
a key modifiable risk factor that contributes to the pre-
mature mortality observed within this population.9 An
evidence-based approach to increasing PA, in addition
to usual care among people experiencing mental illness
Implementing evidence-based
physical activity interventions
for people with mental illness: an
Australian perspective
Simon Rosenbaum School of Psychiatry, University of New South Wales, Sydney, NSW, and; Early Psychosis Programme,
The Bondi Centre, South Eastern Sydney Local Health District, Sydney, NSW, and; Musculoskeletal Division, George Institute for
Global Health and Sydney Medical School, University of Sydney, Sydney, NSW, Australia
Anne Tiedemann Musculoskeletal Division, George Institute for Global Health and Sydney Medical School, University of
Sydney, Sydney, NSW, Australia
Robert Stanton School of Medical and Applied Sciences Central Queensland University, Rockhampton, QLD, Australia
Alexandra Parker Orygen, the National Centre of Excellence in Youth Mental Health, University of Melbourne, VIC, and;
Headspace National Youth Mental Health Foundation Ltd, Melbourne, VIC, Australia
Anna Waterreus School of Psychiatry and Clinical Neurosciences, University of Western Australia, Crawley, WA, Australia
Jackie Curtis School of Psychiatry, University of New South Wales, Sydney, NSW, and; Early Psychosis Programme, The Bondi
Centre, South Eastern Sydney Local Health District, Sydney, NSW, Australia
Philip B Ward School of Psychiatry, University of New South Wales, Sydney, NSW, and; Schizophrenia Research Unit, Ingham
Institute for Applied Medical Research, South Western Sydney Local Health District, Liverpool, NSW, Australia
Abstract
Objectives: Physical activity (PA) and exercise is increasingly being recognised as an efficacious component of treat-
ment for various mental disorders. The association between PA and cardiometabolic disease is well established, as
is the strong link between mental illness, sedentary behaviour and poor cardiometabolic health. Examples of suc-
cessful integration of clinical PA programs within mental health treatment facilities are increasing. The aim of this
review was to summarise the evidence regarding PA and mental illness, and to present examples of clinical exercise
programs within Australian mental health facilities.
Methods: A narrative synthesis of systematic reviews and clinical trials was conducted.
Results: Evidence supporting the inclusion of PA programs as an adjunct to treatment for various conditions was
presented; including depression, schizophrenia, anxiety disorders, post-traumatic stress disorder and substance
abuse. In light of the available evidence, the inclusion of clinical PA programs within mental health treatment,
facilitated by dedicated clinicians (exercise physiologists / physiotherapists) was justified.
Conclusions: PA is a feasible, effective and acceptable adjunct to usual care for a variety of mental disorders. There
is a clear need for greater investment in initiatives aiming to increase PA among people experiencing mental illness,
given the benefits to both mental and physical health outcomes.
Keywords: depression, exercise, mental illness, physical activity, schizophrenia
Corresponding author:
Simon Rosenbaum, The Bondi Centre, South Eastern Sydney
Local Health District, 26 Llandaff Street, Bondi Junction,
NSW 2022, Australia.
Email: s.rosenbaum@unsw.edu.au
590252APY0010.1177/1039856215590252Australasian PsychiatryS Rosenbaum et al.
research-article2015
Invited Article
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Australasian Psychiatry
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and that is in line with the Australian Physical Activity
Guidelines,10 is clearly justified and should be prioritised
(Table 1).11
Although the somatic benefits of PA are established,
the impact on mental health outcomes is less clear,
with non-standardised approaches to PA intervention
design and implementation impacting robust evalua-
tion. Nonetheless, multiple systematic reviews and
meta-analyses have identified the positive effects of
exercise and PA across a broad range of mental disor-
ders,12 including depression,13 anxiety,14 schizophre-
nia15–17 and bipolar disorders;18 with significant effect
sizes (SMD) ranging from SMD = 0.46–1.0 (Table 2 and
Table 3).
Depression
1. Epidemiological data show an inverse relation-
ship between PA participation and the develop-
ment of depressive symptoms.19,20
2. A 2013 Cochrane Collaboration review of exercise
interventions identified 39 trials, with 35 (n = 1356)
of these comparing exercise with no treatment or a
control condition, finding a SMD = 0.62 (95% CI:
−0.81 to −0.42), indicating a moderate effect.13
 Interventions designed to increase PA more
broadly, e.g. exercise advice or PA counselling,
were excluded.13
 When only trials of higher methodological
quality (allocation concealment, blinded out-
come assessment and intention-to-treat analy-
sis) were included, the effect size of the six
trials (n = 464) was a non-significant SMD =
0.18 (95% CI: –0.47 to 0.11).13
3. The methodological limitations of the literature
were further highlighted in a 2014 meta-analy-
sis of 20 trials investigating the impact of PA
and exercise interventions on depressive symp-
toms amongst people experiencing mental dis-
orders.12
Table 1. Australia’s physical activity and sedentary behaviour guidelines10
Physical activity Sedentary behaviour
Be active on most, preferably all days every week Minimise amount of time spent in prolonged sitting
150–300 minutes of moderate intensity physical activity or
75–150 mins vigorous activity or Combination of both
Break up long period of sitting as often as possible
Muscle strengthening activities on at least 2 days per week
Table 2. Summary of selected meta-analyses published between 2013–2014
Author Year Population Intervention Studies
included (N)
Outcome Effect size (SMD)
Pearsall etal. 2014 Serious mental
illness
Exercise 2 Negative
symptoms
− 0.54; p = 0.4; no effect
2 Positive symptoms − 1.66; p = 0.1; no effect
3 Anxiety /
depression
− 0.26; p = 0.43; no effect
Daley etal. 2014 Antenatal
depression
Exercise 6 Depression − 0.46; p = 0.03; medium
Rosenbaum etal. 2014 Varied mental
illness
Physical activity 20 Depressive
symptoms
− 0.8; p < 0.001; large
8 Schizophrenia
symptoms
− 1.0; p < 0.01; large
Cooney etal. 2013 Depression Exercise 35 Depression − 0.62; p < 0.001; medium
Josefsson etal. 2013 Depression Exercise 12 Depression − 0.77; p < 0.001; medium
SMD: standardised mean difference
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A range of interventions (aerobic exercise,
resistance exercise, multimodal group-based
exercise, walking, aquatic exercise, exercise
counselling, tai chi, dance therapy and yoga)
designed to increase PA were effective at reduc-
ing depression symptoms, regardless of psychi-
atric diagnoses.12
4. A 2014 review of the exercise program characteris-
tics associated with the effective treatment of
depression revealed that the dose and modality of
exercise considered efficacious for the treatment
of depression is similar to that included in guide-
lines for the general population, and for the treat-
ment of health conditions such as Type II
diabetes.21
Schizophrenia
1. PA,12 yoga15 and physical therapy17 are shown to
be effective in schizophrenia.
2. A 2014 meta-analysis of exercise interventions
found that whilst exercise therapies increase lev-
els of PA participation, there is no improvement
in symptoms or body mass index (BMI);22 how-
ever, only two eligible trials were identified (n =
84) and pooled for meta-analysis, highlighting
the dearth of research in this area.
3. A subsequent 2014 meta-analysis of eight trials
found a significant effect of PA interventions on
symptoms of schizophrenia (SMD = 1.0 (95% CI:
0.47–1.13); however, this large pooled effect was
primarily driven by trials of poor methodological
quality, not published in English.12
4. Given people with schizophrenia are at increased
risk of metabolic changes, including weight gain,
insulin resistance and dyslipidaemia;23 the rou-
tine inclusion of PA interventions as an adjunc-
tive treatment was justified24 and supported by
the 2014 ‘UK NICE Guidance’ on the manage-
ment of psychosis and schizophrenia.25
5. Aerobic exercise capacity is also a correlate of psy-
chosocial functioning in both established schizo-
phrenia26 and first-episode psychosis,27 highlighting
the importance of interventions targeting exercise
capacity.
6. Exercise-induced increases in brain-derived neu-
rotropic factor (BDNF) and insulin-like growth
factor (IGF-1), which are associated with neuro-
genesis, angiogenesis and neuroplasticity,28 have
also been identified as a potential treatment strat-
egy for people experiencing schizophrenia.29,30
E.g. hippocampal plasticity has been previ-
ously demonstrated following a moderate-
intensity (blood lactate concentration of about
1.5 – 2 mmol/L) aerobic exercise intervention,
over 12 weeks.31
Hippocampal volume significantly increases
in exercising patients with chronic schizo-
phrenia, compared with no change in a com-
parable, non-exercising group.31 Furthermore,
the changes in hippocampal volume are sig-
nificantly correlated with changes in maximal
oxygen uptake (VO2max) in the exercise group.
In contrast, a pilot study of young people
experiencing a first episode of schizophrenia-
spectrum psychosis, found no significant
change in hippocampal volume, despite a 25%
increase in maximal oxygen capacity,32 high-
lighting the need for further translational stud-
ies to clarify the brain correlates of exercise in
schizophrenia.
Anxiety and post-traumatic stress disorder
(PTSD)
1. PA interventions were shown to be beneficial as
an adjunctive treatment for anxiety disorders.14
Both aerobic and other forms of exercise (e.g.
resistance training) were effective as an adjunct
to routine treatment, although less so than
medication.14
Table 3. Summary of selected systematic reviews published from 2012–2014
Author Year Population Intervention Studies included (n)
Posadzki, etal. 2014 Addiction Yoga 8
Soundy, etal. 2014 Schizophrenia Walking 10
Stanton, etal. 2014 Inpatients Exercise 8
Jayakody, etal. 2013 Anxiety disorders Exercise 8
Vancampfort, etal. 2012a Schizophrenia Physical therapy 10
Vancampfort, etal. 2012b Schizophrenia Yoga 3
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The findings were based on eight randomised
controlled trials (RCTs), highlighting the
dearth of evidence in this area.
2. A subsequent review found that exercise appeared
to improve anxiety symptoms for healthy adults,
those with a chronic illness, and among people
experiencing specific anxiety disorders including
generalised anxiety disorder (GAD) and panic dis-
order.33
3. The feasibility and acceptability of both aerobic
and resistance-based exercise was also previously
demonstrated among people with GAD.34
4. A recent study found a clinically-significant effect
of adding individualised, structured exercise,
combining a walking and a resistance-based pro-
gram, for inpatients with PTSD.35
The exercise intervention significantly reduced
psychiatric symptoms, including self-reported
PTSD symptoms, depression, anxiety and
stress.35 Positive effects for key physical health
outcomes (body weight and waist circumfer-
ence), with significant between-group differ-
ences and reductions found in the intervention
group.35
5. A brief aerobic exercise program (2 weeks long)
also is shown to reduce PTSD symptoms,36 whilst
two recent trials of yoga for PTSD also report sig-
nificant effects.37,38
Bipolar affective disorder
1. Intervention studies relating to bipolar disorder
are lacking, yet it has been shown that people
with bipolar disorder are less physically active,
with lower self-efficacy, comorbid health condi-
tions, social isolation and lower education levels,
associated with the lower PA levels in this popula-
tion.39–42
2. A retrospective cohort study of a voluntary walk-
ing group embedded within an inpatient psychi-
atric facility provides preliminary support for the
positive effect of exercise, but more rigorous RCTs
are lacking in the available literature.18,43
Substance abuse / dependence
Exercise has increasingly gained attention as a potential
adjunct to treatment for alcohol and substance use dis-
orders.44 Moderate intensity, group-based aerobic exer-
cise,45 yoga46 and acute exercise sessions47 are shown to
be efficacious in the treatment of alcohol disorders;
whilst high-intensity interval training48 and combined
aerobic and resistance-based interventions49 are shown
to be feasible, acceptable and effective in the treatment
of methamphetamine and substance use disorders.
Examples of existing clinical exercise
services
Allied health clinicians with expertise in exercise pre-
scription (exercise physiologists50 and physiothera-
pists51) are best placed to deliver clinical exercise
programs to people experiencing mental illness.
Examples of clinical exercise programs within psychiat-
ric treatment facilities are increasing within Australia.
For example, the Mental Health Intensive Care Unit
(MHICU) at Prince of Wales Hospital (Randwick, NSW,
Australia) incorporated a clinical exercise program and
employed a dedicated specialist clinician (exercise
physiologist). In addition, the ‘Keeping the Body in
Mind’ programme within the Early Psychosis
Programme at the Bondi Centre (SESLHD) demon-
strated the effectiveness of including clinical exercise
programs into usual care. Antipsychotic-induced
weight gain was attenuated with individualised life-
style interventions, including exercise and dietetic
components.52
Given these promising examples of successful integra-
tion of exercise-based interventions into usual care,
three full-time, dedicated exercise physiology positions
to provide clinical exercise interventions were recently
established by the mental health service in South Eastern
Sydney. This translation of research findings into policy
is a significant step towards the integration of clinical
exercise programs as a core component of routine clini-
cal care for mental health consumers; however, there are
few exercise programs within usual care, despite evi-
dence highlighting the high attendance rates and satis-
faction of patients with exercise programs delivered via
inpatient settings.53
In addition to the public sector, private psychiatric facil-
ities are increasingly employing dedicated exercise clini-
cians to facilitate clinical exercise programs and
multidisciplinary staff training as a part of evidence-
based rehabilitation.54 Other settings with a growing
interest in the role of clinical exercise programs include:
the national youth mental health services (‘Headspace’)55,
non-government organisations (e.g. the Schizophrenia
Fellowship’s ‘New Moves’ program), and general prac-
tice, via Medicare-funded referral schemes.56 The transla-
tion of research findings on integrating PA guidance and
motivational enhancement in Headspace centres57 led
to allied health clinicians embedding this approach into
standard psychological treatment for young people with
mild-to-moderately high-prevalence disorders, such as
depression and anxiety.58
The importance of PA was also recently highlighted in
the ‘Healthy Active Lives’ declaration (HeAL) (www.
iphys.org.au). The HeAL declaration provides ambitious
5-year targets aimed at improving the health of young
people experiencing first-episode psychosis. Among the
targets is a specific PA goal that within 2 years of the
onset of psychosis, > 50% of the people should be
engaged in age-appropriate PA (e.g. 150 minutes per
week).59
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Rosenbaum et al.
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Challenges to implementation
People experiencing mental illness face considerable bar-
riers to increasing PA levels over and above those experi-
enced by the general population, including amotivation.60
Integration of exercise clinicians (exercise physiologists
and physiotherapists) with training in mental illness as
members of the multidisciplinary mental health team is
an important strategy that has gained traction, yet faces
considerable challenges. There is a need for education
modules outlining the role of exercise for the treatment
of mental illness across a range of disciplines, including:
psychiatry, psychology, mental health nursing, peer well-
ness coaches, occupational therapy and social work. This
is particularly relevant for nursing, because nurses repre-
sent the largest component of the mental health work-
force, have regular face-to-face contact and have
well-established therapeutic relationships with consum-
ers.61 Through education, the capacity for culture change
and hence, the acceptance of clinical exercise therapy
within treatment facilities is likely to improve. Up-skilling
existing health-professionals regarding basic principles
of exercise prescription and evidence-based approaches
to improving motivation62,63 is essential, as is the need
for dedicated exercise clinicians with expertise in exercise
programming, to ensure that interventions are evidence-
based and represent ‘best practice’.
To facilitate the successful integration of exercise clini-
cians into the mental health workforce, mental illness
should be included as a key component of exercise phys-
iology and physiotherapy training. Comprehensive
training will change the perception of the benefits asso-
ciated with exercise and PA from a ‘diversional activity’
to an intervention, with clinically-important physical
and mental health outcomes. Understanding that the
barriers to engaging in PA faced by individuals with
mental disorders are not dissimilar to general factors
related to engaging in and adhering to psychological or
medication interventions will also assist in developing
integrated and targeted interventions across mental
health services.64 Similar principles likely apply to the
integration of dieticians as members of the multidiscipli-
nary mental health team.65
Apart from culture change, the challenge of funding new
positions is a fundamental challenge to the widespread
adoption of exercise-based interventions as part of stand-
ard mental health care. With more examples of services
investing in clinical exercise programs, cost-benefit and
cost-effectiveness analyses of such initiatives are needed, in
order to provide the economic rationale for re-investment.
Given the impact of exercise on physical health outcomes
alone, and the unacceptable rates of preventable
cardiovascular-related mortality experienced by this popu-
lation, the cost of inaction is evident. Despite a lack of
research regarding the biological mechanisms that under-
lie PA-related improvements in psychiatric symptoms in
people with mental illness, PA appears to be a feasible,
acceptable and efficacious adjunctive treatment for a wide
range of mental disorders.
Disclosure
The authors report no conflict of interest. The authors alone are responsible for the content
and writing of the paper.
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