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BJSM Online First, published on December 18, 2014 as 10.1136/bjsports-2014-094314 Editorial
Physical activity interventions: an essential component in recovery from mental illness Simon Rosenbaum,1,2,3 Anne Tiedemann,3 Philip B Ward,1,4 Jackie Curtis,1,2 Catherine Sherrington3 Mental illness is a common and costly public health problem. One-quarter of the population experience one or more of the broad range of mental health disorders throughout their lifetime. Mental illness costs an estimated £22.5 billion per year in the UK alone.1 People with serious mental illness face a ‘scandal of premature mortality’.2 Life expectancy is up to 15 years less for people with serious mental illness than for the rest of the population. This important and widening mortality gap is more due to cardiovascular disease than suicide, which is often incorrectly assumed to be the only driver of increased mortality in the mentally ill. People with mental illness have high rates of obesity and lifestyle-related diseases3 and smoking rates three times that of the general population. The common conceptualisation of physical activity interventions as diversional, social or subtherapeutic strategies for people living with mental illness must be therefore reconsidered. Universal inclusion of exercise and dietary interventions within the standard multidisciplinary treatment of mental illness is likely to have important short-term benefits for mental and physical health as well as preventing the development of chronic lifestyle-related diseases. Sports physicians, physiotherapists, exercise physiologists and dietitians are ideally equipped to bridge the gap between physical and mental healthcare,4 ensuring that we ‘keep the body in mind’ in the holistic
1
School of Psychiatry, University of New South Wales, Sydney, New South Wales, Australia; 2Early Psychosis Programme, South Eastern Sydney Local Health District, Sydney, New South Wales, Australia; 3Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia; 4Schizophrenia Research Unit, South Western Sydney Local Health District, Sydney, New South Wales, Australia Correspondence to Dr Simon Rosenbaum, Early Psychosis Programme, The Bondi Centre, South Eastern Sydney Local Health District, 26 Llandaff St Bondi Junction, Sydney, NSW 2022, Australia; [email protected]
treatment of those experiencing mental illness. The evidence base supporting the importance of physical activity for people with mental illness is growing. We recently identified 39 randomised controlled trials investigating the impact of physical activity on mental illness.5 Meta-analysis revealed a large effect size (0.8) for our primary outcome of depressive symptoms. In order to provide clinicians with broad snapshot of the evidence to date, we included trials undertaken with patients diagnosed with major depression, postnatal depression, schizophrenia, generalised anxiety disorder and bipolar disorder and a range of exercise interventions from ‘laboratory-based’ settings to pragmatic approaches aimed at increasing physical activity. Secondary analyses revealed a large effect on symptoms of schizophrenia, a small effect on body composition (anthropometry) and a moderate effect on quality of life and functional exercise capacity from the smaller number of studies assessing these outcomes. These results provide compelling evidence of the dual impact of physical activity on physical and mental health outcomes and support the routine delivery of physical activity interventions to people with mental illness. The review also revealed some areas for attention in future studies. A number of interventions identified failed to follow established principles of physical activity and exercise prescription, suggesting design and implementation by those who lacked expertise in exercise prescription. This issue can be addressed by greater involvement of exercise professionals in mental health programme development. Another issue was poor reporting of the components of interventions. Improving the reporting of trial interventions with tools such as the Exercise Reporting Grid6 will significantly enhance the ability of future studies to identify the ‘best buys’ among physical activity interventions targeting mental health. Much work needs to be done to translate these positive research results into real-world programmes to ensure the
routine delivery of quality physical activity interventions for people with mental health problems. Multidisciplinary approaches are most likely to facilitate effective translation, while ensuring buy-in from mental health clinicians. The recognition of the International Organisation of Physical Therapists in Mental Health as a subgroup of the World Confederation of Physiotherapy7 shows the increasing recognition of the importance of this task. More needs to be done to see the transition of physical activity programmes from diversional to targeted and effective interventions, including a focus on education of mental health and sports/exercise clinicians. Referral to exercise professionals by general practitioners for people living with mental illness needs to become standard practice, with sufficient funding to ensure such referrals are likely to lead to implementation of effective, individualised interventions. Medical students must learn about the benefits of augmenting usual care with facilitated physical activity, while physiotherapists, exercise physiologists and other exercise professionals must understand the pivotal role they can play in improving the life expectancy, and expectations of life, of people with mental illness. As eloquently stated in a 2014 Lancet Psychiatry editorial, it is time to ‘activate and integrate’8 to overcome therapeutic nihilism regarding the physical health of those experiencing mental illness. The principles enshrined in the international Healthy Active Lives (HeAL) Declaration outline how these aspirations can be transformed into targets, and the actions needed to see these goals achieved (http://www.iphys.org.au/). Contributors SR drafted the manuscript with input from all authors. All authors reviewed and provided comments on the manuscript. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed. To cite Rosenbaum S, Tiedemann A, Ward PB, et al. Br J Sports Med Published Online First: [ please include Day Month Year] doi:10.1136/bjsports-2014-094314 Accepted 7 December 2014 Br J Sports Med 2014;0:1–2. doi:10.1136/bjsports-2014-094314
REFERENCES 1
2
McCrone P, Dhanasiri S, Patel A, et al. Paying the price: the cost of mental health care in England to 2026. London: King’s Fund, 2008. http://www. kingsfund.org.uk/publications/thekingsfund publications/paying the price.html Thornicroft G. Physical health disparities and mental illness: the scandal of premature mortality. Br J Psychiatry 2011;199:441–2.
Rosenbaum S, et al. Br J Sports Med Month 2014 Vol 0 No 0
Copyright Article author (or their employer) 2014. Produced by BMJ Publishing Group Ltd under licence.
1
Downloaded from http://bjsm.bmj.com/ on October 10, 2015 - Published by group.bmj.com
Editorial 3
4
2
Newcomer J, Hennekens C. Severe mental illness and risk of cardiovascular disease. JAMA 2007;298: 1794–6. Stubbs B, Probst M, Soundy A, et al. Physiotherapists can help implement physical activity programmes in clinical practice. Br J Psychiatry 2014;204:164.
5
6
Rosenbaum S, Tiedemann A, Sherrington C, et al. Physical activity interventions for people with mental illness: a systematic review and meta-analysis. J Clin Psychiatry 2014;75:964–74. Slade SC, Keating JL. Exercise prescription: a case for standardised reporting. Br J Sports Med 2012;46:1110–13.
7
8
Probst M. The International Organization of Physical Therapists working in Mental Health (IOPTMH). Ment Health Phys Activ 2012;5:20–1. Physical and mental health: activate and integrate. Lancet Psychiatry 2014;1:163.
Rosenbaum S, et al. Br J Sports Med Month 2014 Vol 0 No 0
Downloaded from http://bjsm.bmj.com/ on October 10, 2015 - Published by group.bmj.com
Physical activity interventions: an essential component in recovery from mental illness Simon Rosenbaum, Anne Tiedemann, Philip B Ward, Jackie Curtis and Catherine Sherrington Br J Sports Med published online December 18, 2014
Updated information and services can be found at: http://bjsm.bmj.com/content/early/2014/12/18/bjsports-2014-094314
These include:
References Email alerting service
This article cites 7 articles, 3 of which you can access for free at: http://bjsm.bmj.com/content/early/2014/12/18/bjsports-2014-094314 #BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
BJSM Online First, published on December 18, 2014 as 10.1136/bjsports-2014-094314 Editorial
Physical activity interventions: an essential component in recovery from mental illness Simon Rosenbaum,1,2,3 Anne Tiedemann,3 Philip B Ward,1,4 Jackie Curtis,1,2 Catherine Sherrington3 Mental illness is a common and costly public health problem. One-quarter of the population experience one or more of the broad range of mental health disorders throughout their lifetime. Mental illness costs an estimated £22.5 billion per year in the UK alone.1 People with serious mental illness face a ‘scandal of premature mortality’.2 Life expectancy is up to 15 years less for people with serious mental illness than for the rest of the population. This important and widening mortality gap is more due to cardiovascular disease than suicide, which is often incorrectly assumed to be the only driver of increased mortality in the mentally ill. People with mental illness have high rates of obesity and lifestyle-related diseases3 and smoking rates three times that of the general population. The common conceptualisation of physical activity interventions as diversional, social or subtherapeutic strategies for people living with mental illness must be therefore reconsidered. Universal inclusion of exercise and dietary interventions within the standard multidisciplinary treatment of mental illness is likely to have important short-term benefits for mental and physical health as well as preventing the development of chronic lifestyle-related diseases. Sports physicians, physiotherapists, exercise physiologists and dietitians are ideally equipped to bridge the gap between physical and mental healthcare,4 ensuring that we ‘keep the body in mind’ in the holistic
1
School of Psychiatry, University of New South Wales, Sydney, New South Wales, Australia; 2Early Psychosis Programme, South Eastern Sydney Local Health District, Sydney, New South Wales, Australia; 3Musculoskeletal Division, The George Institute for Global Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia; 4Schizophrenia Research Unit, South Western Sydney Local Health District, Sydney, New South Wales, Australia Correspondence to Dr Simon Rosenbaum, Early Psychosis Programme, The Bondi Centre, South Eastern Sydney Local Health District, 26 Llandaff St Bondi Junction, Sydney, NSW 2022, Australia; [email protected]
treatment of those experiencing mental illness. The evidence base supporting the importance of physical activity for people with mental illness is growing. We recently identified 39 randomised controlled trials investigating the impact of physical activity on mental illness.5 Meta-analysis revealed a large effect size (0.8) for our primary outcome of depressive symptoms. In order to provide clinicians with broad snapshot of the evidence to date, we included trials undertaken with patients diagnosed with major depression, postnatal depression, schizophrenia, generalised anxiety disorder and bipolar disorder and a range of exercise interventions from ‘laboratory-based’ settings to pragmatic approaches aimed at increasing physical activity. Secondary analyses revealed a large effect on symptoms of schizophrenia, a small effect on body composition (anthropometry) and a moderate effect on quality of life and functional exercise capacity from the smaller number of studies assessing these outcomes. These results provide compelling evidence of the dual impact of physical activity on physical and mental health outcomes and support the routine delivery of physical activity interventions to people with mental illness. The review also revealed some areas for attention in future studies. A number of interventions identified failed to follow established principles of physical activity and exercise prescription, suggesting design and implementation by those who lacked expertise in exercise prescription. This issue can be addressed by greater involvement of exercise professionals in mental health programme development. Another issue was poor reporting of the components of interventions. Improving the reporting of trial interventions with tools such as the Exercise Reporting Grid6 will significantly enhance the ability of future studies to identify the ‘best buys’ among physical activity interventions targeting mental health. Much work needs to be done to translate these positive research results into real-world programmes to ensure the
routine delivery of quality physical activity interventions for people with mental health problems. Multidisciplinary approaches are most likely to facilitate effective translation, while ensuring buy-in from mental health clinicians. The recognition of the International Organisation of Physical Therapists in Mental Health as a subgroup of the World Confederation of Physiotherapy7 shows the increasing recognition of the importance of this task. More needs to be done to see the transition of physical activity programmes from diversional to targeted and effective interventions, including a focus on education of mental health and sports/exercise clinicians. Referral to exercise professionals by general practitioners for people living with mental illness needs to become standard practice, with sufficient funding to ensure such referrals are likely to lead to implementation of effective, individualised interventions. Medical students must learn about the benefits of augmenting usual care with facilitated physical activity, while physiotherapists, exercise physiologists and other exercise professionals must understand the pivotal role they can play in improving the life expectancy, and expectations of life, of people with mental illness. As eloquently stated in a 2014 Lancet Psychiatry editorial, it is time to ‘activate and integrate’8 to overcome therapeutic nihilism regarding the physical health of those experiencing mental illness. The principles enshrined in the international Healthy Active Lives (HeAL) Declaration outline how these aspirations can be transformed into targets, and the actions needed to see these goals achieved (http://www.iphys.org.au/). Contributors SR drafted the manuscript with input from all authors. All authors reviewed and provided comments on the manuscript. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed. To cite Rosenbaum S, Tiedemann A, Ward PB, et al. Br J Sports Med Published Online First: [ please include Day Month Year] doi:10.1136/bjsports-2014-094314 Accepted 7 December 2014 Br J Sports Med 2014;0:1–2. doi:10.1136/bjsports-2014-094314
REFERENCES 1
2
McCrone P, Dhanasiri S, Patel A, et al. Paying the price: the cost of mental health care in England to 2026. London: King’s Fund, 2008. http://www. kingsfund.org.uk/publications/thekingsfund publications/paying the price.html Thornicroft G. Physical health disparities and mental illness: the scandal of premature mortality. Br J Psychiatry 2011;199:441–2.
Rosenbaum S, et al. Br J Sports Med Month 2014 Vol 0 No 0
Copyright Article author (or their employer) 2014. Produced by BMJ Publishing Group Ltd under licence.
1
Downloaded from http://bjsm.bmj.com/ on October 10, 2015 - Published by group.bmj.com
Editorial 3
4
2
Newcomer J, Hennekens C. Severe mental illness and risk of cardiovascular disease. JAMA 2007;298: 1794–6. Stubbs B, Probst M, Soundy A, et al. Physiotherapists can help implement physical activity programmes in clinical practice. Br J Psychiatry 2014;204:164.
5
6
Rosenbaum S, Tiedemann A, Sherrington C, et al. Physical activity interventions for people with mental illness: a systematic review and meta-analysis. J Clin Psychiatry 2014;75:964–74. Slade SC, Keating JL. Exercise prescription: a case for standardised reporting. Br J Sports Med 2012;46:1110–13.
7
8
Probst M. The International Organization of Physical Therapists working in Mental Health (IOPTMH). Ment Health Phys Activ 2012;5:20–1. Physical and mental health: activate and integrate. Lancet Psychiatry 2014;1:163.
Rosenbaum S, et al. Br J Sports Med Month 2014 Vol 0 No 0
Downloaded from http://bjsm.bmj.com/ on October 10, 2015 - Published by group.bmj.com
Physical activity interventions: an essential component in recovery from mental illness Simon Rosenbaum, Anne Tiedemann, Philip B Ward, Jackie Curtis and Catherine Sherrington Br J Sports Med published online December 18, 2014
Updated information and services can be found at: http://bjsm.bmj.com/content/early/2014/12/18/bjsports-2014-094314
These include:
References Email alerting service
This article cites 7 articles, 3 of which you can access for free at: http://bjsm.bmj.com/content/early/2014/12/18/bjsports-2014-094314 #BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
