Promoting mental health through physical activity: examples from practice
Jones, Martin
ABSTRACT
The physical health benefits of exercise are well established but there is also growing research evidence of links between physical activity and mental health benefits, including mood elevation, better cognitive functioning and improved self-perception, self-esteem and self-efficacy. Physical activity has also been shown to enhance the effectiveness of psychological therapies and to have a role in improving quality of life and symptom management for people with a wide range of mental health problems. Physical activity has a double benefit, since people with mental health problems are also at increased risk of a range of physical health problems, including cardiovascular disease, endocrine disorders and obesity. However referral to a physical activity specialist is rarely available in psychiatric settings. This paper gives two examples of how provision of physical activity facilities and programmes staffed by qualified specialists can contribute towards improving mental health and quality of life for people with mental health problems.
The Department of Health (1996) emphasises that physical activity is an important health-related behaviour. Subsequently there has been a plethora of information and research indicating that exercise has health-related benefits. The case for exercise and health has largely been made on grounds that it has an impact on coronary heart disease, obesity and diabetes. However in recent years there has also been an increased interest in research into the role of exercise in both the treatment and promotion of mental health.
Physical activity appears to relieve symptoms of depression and anxiety and improve mood. Regular physical activity may also reduce the risk of developing depression. Reviews of the literature have indicated the potential benefits of exercise as a treatment for clinical or sub-clinical depression or anxiety, and of physical activity as a means of improving quality of life through enhanced self-esteem, improved mood states, reduced state and trait anxiety, resilience to stress and improved sleep (Fox, 1999). Although data on levels and type of physical activity among mental health inpatients are limited (see Brown et al, 1999), exercise may help alleviate some of the negative symptoms of schizophrenia, may be an effective coping strategy for symptoms such as hallucinations and may also help to improve quality of life for people with mental health problems (Faulkner & Biddle, 1999). Given the prevalence of mental health problems (they are expected to account for 15% of all chronic diseases by 2020: a larger proportionate increase than that for cardiovascular diseases (Murray & Lopez, 1996)), the potential of physical activity as a preventive intervention is also attracting increasing interest. Approximately 25% of the population per year needs medical help for mental health problems and the NHS and social services spend almost £4 billion a year on the treatment of mental health problems (DoH, 2001). Including physical activity in prevention and treatment regimes for both physical and mental health problems therefore has considerable potential for reducing health costs.
The research base on physical activity and mental health is relatively recent in comparison with the volume produced on the effects of activity on physical health and disease. Significantly, only a passing reference is made to physical activity in the national service framework for mental health (DoH, 1999a).
Evidence exists of links between physical activity and reduced anxiety and depression, elevated mood, better cognitive functioning, and improved physical self-perception, self-esteem and self-efficacy (Biddle et al, 2000; Skrinar, 2003). The strongest link is found in the treatment of clinical depression, in both the short and long term (Mutrie, 2000). People who exercise regularly report that they feel better following a programme of physical activity. A survey by the mental health charity Mind found that 59% of people thought exercise could help prevent mental health problems such as depression and over 60% said it helped reduce stress and anxiety (Baker, 2001). Further evidence is highlighted by Fox (1999), who found that exercise was as effective as psychotherapeutic interventions in the treatment of depression. Similarly, Faulkner and Biddle (2001) also suggest that exercise can enhance the effectiveness of behavioural modification programmes such as cognitive behavioural therapy (CBT). The evidence is sufficiently persuasive to encourage further scrutiny.
People with mental health problems are generally less active and more sedentary than the general population, especially hospital patients, where opportunities for activities may be lacking (Grant, 2000). Despite the potential health benefits, the systematic prescription of therapeutic exercise is rare in mental health settings. Martinson (2000) notes that the cost of pharmacological and psychological treatments is escalating and care systems will soon be unable to meet the need for these treatments. In comparison, exercise therapy is simple and inexpensive, and on physical health grounds alone there is a strong case for including physical activity as one of a range of treatment options. People with mental health problems are at much greater risk of cardiovascular disease, obesity, diabetes and respiratory problems than the general population (Brown et al, 1999; Phelan et al, 2001; Harris & Barraclough, 1998; Barr, 2001). A person with schizophrenia can expect to live ten years less than someone without a mental health problem and around half of this excess mortality is caused by physical health problems (Brown et al, 2000). Lack of exercise and poor diet are likely to be contributory factors (Musselman et al, 1998). Currently, routine referral to a physical activity or dietary specialist is not commonplace in psychiatric settings (such as psychiatric hospitals), although some research suggests that people with mental health problems would very much value such opportunities (Friedli & Dardis, 2002; Faulkner et al, 2003).
Unfortunately there currently exist no data on the levels, regulation or types of physical activity taking place within UK psychiatric hospitals. One factor influencing opportunities for physical activity may be that the closure of the large mental asylums and the move towards community based treatment and care resulted in the loss of on-site facilities for recreational and vocational activities, and these do not appear to have been replaced by opportunities for inpatients to access public leisure facilities in the community. Provision of physical activity also requires trained and qualified personnel and, again, there are no data on availability, skills and training of staff with competence as exercise specialists and the expertise to treat people with a multitude of mental and physical problems as well as the skills to work in psychiatric settings.
Case studies
To initiate and encourage further debate, and to demonstrate how physical activity can be used in practice, examples of two psychiatric hospitals that have developed systematic physical activity programmes for their patients are outlined below. One is based in North Staffordshire, the other in London. Although both have developed their physical activity programmes in different ways, neither have a formal process of evaluation to assess patient benefits. Moreover, there is no common audit tool or database of such information. This highlights the seemingly haphazard, unsystematic nature of developments in this area and the need for a formal programme of evaluation and research into the health and other benefits of physical activity for people with mental health problems, and in particular those using acute mental health services.
Harplands Hospital, Stoke-on-Trent
Prior to 2001, psychiatric inpatient facilities in North Staffordshire were provided from St Edwards Hospital, a Victorian asylum, and four wards in the local district general hospital, in a building that was originally a workhouse. Following five years of negotiations with local organisations, including users and carers, approval was given for the development of new mental health facilities. The Harplands Hospital was opened in September 2001 and caters for adult (18+ years) acute admissions, with a neural behavioural unit, a drug and alcohol unit and a mother and baby unit. There is also provision for access to a wide range of community resource centres with both inpatient and outpatient facilities, all supported by specialist services. The new service infrastructure cost a total of £35 million: £25 million in Public Finance Initiative monies for Harplands, and £10 million state funding for the resource centres. Such development has afforded an ideal opportunity for a review of clinical strategies to modernise care.
Programme delivery
The physical activity programme is managed by the physiotherapy department. The department comprises a superintendent, one full-time and one part-time senior 1 physiotherapist and three physiotherapy assistants, and provides a fully functioning, multi-skilled professional in/outpatient physiotherapy service for all mental health patients and staff in North Staffordshire, plus a wide variety of physical activity programmes. The Harplands Hospital has a purpose-built sports hall that caters for both inpatients and outpatients and offers a wide range of fitness activities such as circuit training and team and individual games (badminton, basketball, Volleyball, 3-a-side soccer, hockey and indoor bowls). There is also a fitness suite comprising a multi-gym, cycle ergometer, rowing machine, jogging machine and a sit-up/punch bag matted area, as well as a two-bedded clinical treatment room. An outdoor games area was also created, and is currently under review. In addition, key members of nursing staff have been trained by the physiotherapy department to supervise patient multi-gym programmes at weekends and evenings as there are currently no physiotherapy staff on duty during these times. The programme is detailed below (Table 1).
Physiotherapists, in general, assess, diagnose, treat and rehabilitate patients and staff with a multitude of problems – mobility difficulties, respiratory problems, musculo-skeletal problems (eg. back pain, neck pain, joint pain/dysfunction, soft tissue injuries, muscle pain/dysfunction etc), migraine, neurological problems (eg. stroke, Alzheimer’s disease, brain trauma, spinal problems, Parkinsons disease, Huntington’s disease, multiple sclerosis), rehabilitation pre- and post-surgery and cardiac rehabilitation. These problems may be further complicated by a patients mental health diagnosis. Likewise, a patients mental health diagnosis may complicate assessing, diagnosing and treating their physical problems. Traditionally, therapists (eg. physiotherapists and occupational therapists) in mental health have argued for a more holistic and biopsychosociological approach to assessment and interventions (Skelly, 2003) and have identified cognitive behavioural approaches as having relevance to the management of many conditions. Interestingly, many physiotherapists working outside mental health are now acknowledging this perspective (eg. as a treatment for chronic pain).
Evaluation
The increase in facilities and a positive drive to promote physical activity by the physiotherapy staff has resulted in a sharp increase in the number of patients taking up these services since the hospital opened; numbers almost doubled in the first 12 months, totalling 4800 contacts. Anecdotal evidence suggests that patients feel better after their physical activity sessions. A formal audit is needed to establish the strengths and weaknesses of the programme and to ensure a more efficient and effective use both of facilities and staff.
Future developments
Key aspirations for the future include additional funding to:
* expand the programme to include specialist cover at weekends and evenings
* allow greater access for community-based patients and resource centres
* enable staff to promote the physical activity programme more actively through increasing communication within the hospital (patients, staff and management alike
* create carer links.
Such funding would also enable the service to introduce a higher level of physiotherapy assistant grades (technical instructor III and II) and upgrade current senior physiotherapist posts to clinical specialist posts in order to facilitate recruitment and retention (Rawlings, 2003).
The department has been a keen supporter of community links and is able to make contact with local leisure resources, enabling patients to move away from the hospital setting, so encouraging socialisation and integration into society. Nursing staff are encouraged to participate with their patients, improving interaction. Through such a medium, patients and staff are also encouraged to adopt a more long-term approach to physical activity. The physiotherapy staff, in conjunction with the hospital manager, have also initiated a hospital staff fitness programme in work time. The department is attempting to establish itself as a centre of excellence, both at the Harplands Hospital and within the mental health services in North Staffordshire.
Springfield University Hospital, London
The Springfield University Hospital, which is part of the South West London & St Georges Mental Health NHS Trust, stands in its original Victorian grounds. It was purpose-built in 1884 and its elevated site was chosen so that patients could see both the sunrise and sunset. Today many of the original buildings are still in use and there are extensive grounds for the patients to use at their leisure.
The physical therapies department is the only one of its kind in the trust. In 1992 the physiotherapy department, based at the trust headquarters at Springfield University Hospital, expanded to include staff specialists in physical activity and massage therapy. all three services operate independently but are linked under a single management and funding structure. In 1997 the department was renamed ‘physical therapies’ to reflect the range of skills in the department and to emphasise its multi-disciplinary approach.
Over the past few years the trust has expanded and currently serves a population of more than one million across the London boroughs of Sutton, Merton, Richmond, Kingston and Wandsworth. Consequently, the physical therapies department extended its service to cover the whole organisation. The physical activity service currently covers four hospitals and provides 29 activity sessions for both ward-based and community patients (see Table 2).
Programme delivery
The physical activity service in Springfield Hospital includes sessions with the drug detox and recovery ward, the eating disorder unit, the alcohol detox ward, the intensive care admissions ward, the specialist behaviourist unit and the minimum secure forensic unit and national deaf services. Several sessions are also made available for staff use. In line with the national service framework (NSF) for mental health recommendations, the service has recently set up an exercise session for the carers of people with mental health problems. This has proved to be a very popular session and there are plans to expand its capacity in the future. As with the Harplands Hospital initiatives (above), the service recognises the value of a women-only session and providing facilities for staff. A full list of the activities is shown in Table 2.
The physical activity service consists of one team manager, three full-time exercise therapists at technical instructor grade I, II & III and a part-time tech II grade exercise therapist. The team members are predominately graduates of sports science or a related discipline and have a high level of vocational sport and exercise qualifications. There is a strong emphasis on continual professional development.
Evaluation
The physical activity service has contact with an average of 220 clients each week. The Springfield gym site has an open session five mornings per week and receives an average of 25-30 visits each day. It is the first point of contact with a client once a referral has been received from a community mental health team or a ward. At this point a thorough health screen and motivational interview is conducted with the client. This, together with information on their mental health and medical and exercise history, is used to determine an appropriate programme of exercise. A recent audit of client satisfaction highlighted the importance of high calibre staff in the successful running of the service. A total of 91% of respondents found the staff to be friendly or very friendly. In addition to physical activity, social interaction with the gym staff was also considered to contribute to the feeling of well-being. As with the Harplands Hospital, a formal appraisal of the effectiveness of the programme has yet to be carried out. However, working practice is in accordance with the American College of Sports Medicine and the Gayton Group GP referral scheme guideline for exercise prescription. Audit data both from service users and their referrers are currently under review.
Future developments
It is the aim of the service to progress clients from hospital-based activities to community settings supported by the service and ultimately into an exercise habit independent of the service. A current proposal is to recruit user involvement in running independent exercise sessions in the community, although it is recognised that independent exercise may not always be possible for some people (Figure 1).
Currently clients are involved in the staff recruitment process, but the recent audit of service users indicated that just under half (46%) would like to be involved in running the service. Possible training links with local colleges are also being explored.
The physical activity service has become a victim of its own success. The demand for more sessions, together with a three-month waiting list and the few staff to cover such a wide area, has led to certain compromises. Notably, research and development, essential for professional recognition of the service, has been neglected, and in the past the service has suffered from high staff turnover and lack of funding. It is felt that raising the profile of the service through professional research and development could combat this problem. In light of this, a recent service review decided to accept only referrals with clinically diagnosable conditions, such as acute depression, for a three-month period. It is hoped that in this way the service can continue to provide the best level of care.
Discussion
Both departments include the use of exercise as a therapeutic intervention in the treatment of mental health problems, using the theories and understanding outlined in the earlier part of the paper. This is achieved both in conjunction with other health care professionals/therapies and as independent practitioners. The Springfield Hospital physical activity service is essentially an exercise-based department, while the Harplands physiotherapy service has developed into providing exercise as an adjunct and support to physiotherapy remedies in a mental health setting. This is significant because, while it is important to have a detailed appreciation of mental health problems and their treatment, it is also necessary to have a comprehensive knowledge of both exercise theory and delivery. There is currently no recognised specialist preparation and qualification for exercise professionals working in mental health, or for mental health professionals wishing to attain a necessary level of competence in the exercise arena. This raises issues about legal or professional liability for anyone delivering or supervising such activities, should an accident occur or incorrect advice and/or delivery be given. The Harplands, for example, regularly has to update physiotherapy students with evidence-based exercise theory, suggesting that a physiotherapy qualification alone does not prepare them to deliver many technical elements of exercise practice. Considering the role of physical activity in treating mental health patients, those involved in teaching professions allied to medicine should examine the possibility of having a specialist professional qualification that combines the necessary medical/ psychiatric and exercise therapy knowledge, encompassing both theoretical and practical applications.
Conclusion
Physical activity is now firmly established as an approach by which a variety of mental health problems may be improved, either as a sole intervention or in conjunction with other therapeutic options. In addition, physical inactivity can be detrimental to health generally, and there is an increasing call for physical activity to become part of a patient’s rehabilitation programme (Faulkner & Biddle, 2001). Unfortunately, its role is neither fully understood nor acknowledged by many mental health nursing staff (Faulkner & Biddle, 2002). Changing this could be simply through a re-think of current training and service delivery to promote physical activity as a core activity. This approach could enhance not only patient health and well-being but also that of staff.
The physical activity and mental health research base is relatively recent compared to the body of evidence on the benefits of activity for physical health and disease. The significance of the relationship between physical activity and mental wellness may be undervalued both in its short and longer term effects. Regular participation is necessary for the accumulation of benefits. The literature supports this premise, indicating that mental health outcomes also motivate people to persist in physical activity (Biddle & Mutrie, 2001).
The impact of physical activity on mental health could be assessed by concentrating on the following:
* increasing awareness of the role of exercise in preventing mild to moderate anxiety and depression and in relieving both acute and chronic symptoms as part of wider initiatives to improve public activity levels
* increasing understanding of the relationship between mental well-being and physical health, the effects of exercise on psychiatric medications and vice versa
* opportunities for physical activity for people with mental health problems (inpatients and outpatients), including initiatives like exercise on prescription, walking the way to health etc
* assessment of the effects of exercise on subjective well-being, mood, self-esteem and self-efficacy, as well as assessing impacts on stress, sleep and cognitive performance
* assessment of impact of exercise on quality of life and social inclusion
* comprehensive evaluation of physical activity programmes and their impact on mental health.
Acknowledgements
The authors wish to acknowledge Professor Ken Fox and Jim McKenna of the Department of Exercise and Health Sciences at Bristol University for their support in preparation of this paper.
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Martin Jones
Senior physiotherapist
Harplands Hospital, North Staffordshire
Combined Healthcare NHS Trust
Carol O’Beney
Health and fitness advisor
Physical activities service, Springfield Hospital, London
Contact
martin.jones@nsch-tr.wmids.nhs.uk 101782 441623
Contact
carol.obeney@swlstg-tr.nhs.uk
Copyright Pavilion Publishing (Brighton) Ltd. Mar 2004
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