Psychiatr Serv 56:324-331, March 2005
© 2005 American Psychiatric Association

Integrating Physical Activity Into Mental Health Services for Persons With
Serious Mental Illness
Caroline R. Richardson, M.D., Guy Faulkner, Ph.D., Judith McDevitt, Ph.D.,
F.N.P., Gary S. Skrinar, Ph.D., Dori S. Hutchinson, Sc.D. and John D.
Piette, Ph.D.

Abstract

This article reviews evidence supporting the need for interventions to
promote physical activity among persons with serious mental illness.
Principles of designing effective physical activity interventions are
discussed along with ways to adapt such interventions for this population.
Individuals with serious mental illness are at high risk of chronic diseases
associated with sedentary behavior, including diabetes and cardiovascular
disease. The effects of lifestyle modification on chronic disease outcomes
are large and consistent across multiple studies. Evidence for the
psychological benefits for clinical populations comes from two meta-analyses
of outcomes of depressed patients that showed that effects of exercise were
similar to those of psychotherapeutic interventions. Exercise can also
alleviate secondary symptoms such as low self-esteem and social withdrawal.
Although structured group programs can be effective for persons with serious
mental illness, especially walking programs, lifestyle changes that focus
on accumulation of moderate-intensity activity throughout the day may be
most appropriate. Research suggests that exercise is well accepted by people
with serious mental illness and is often considered one of the most valued
components of treatment. Adherence to physical activity interventions
appears comparable to that in the general population. Mental health service
providers can provide effective, evidence-based physical activity
interventions for individuals with serious mental illness.


Introduction

Even though the psychological benefits from regular exercise are well known,
researchers have only recently begun to examine the impact of physical
activity on the mental and physical health of individuals with serious
mental illness. The use of physical activity to promote both mental and
physical health among individuals with serious mental illness has a sound
rationale. In the general population, a strong relationship has been found
between physical activity and mental health (1,2) as well as between
physical activity and physical health (3). People who have serious mental
illness, including major depression, schizophrenia, and bipolar disorder,
often have poor physical health and experience significant psychiatric,
social, and cognitive disability (4,5). Physical activity has the potential
to improve the quality of life of people with serious mental illness through
two routes‹by improving physical health and by alleviating psychiatric and
social disability.

In this article, we first review the evidence for the benefits of physical
activity in the general population and more specifically among individuals
with serious mental illness. We then summarize what is currently known about
the epidemiology of physical activity in the population of persons with
serious mental illness. We also present an overview of the principles of
designing effective physical activity interventions. Finally, we argue that
such interventions should become a routine component of comprehensive
psychiatric care for individuals with serious mental illness.


Physical health benefits of physical activity

Physical inactivity (sedentary behavior) is a major cause of morbidity and
mortality (3). Compared with those who are physically active, sedentary
people have a substantially increased risk of developing diabetes (6,7,8),
heart disease (9,10,11,12), high blood pressure (13,14,15,16,17), and a
number of other prevalent and disabling chronic conditions (3). The effects
of lifestyle modification, including diet and exercise, on chronic disease
outcomes are large and consistent across multiple studies. For example, the
Diabetes Prevention Program study (6), a large multicenter randomized
controlled trial with more than 3,000 participants, compared an intensive
diet-and-exercise intervention with two other treatment arms, a usual-care
control group and a medical management group that received metformin. The
incidence of diabetes among participants who were randomly assigned to the
intensive lifestyle intervention was 14 percent, compared with 29 percent in
the control group. This outcome represents an almost 60 percent reduction
in risk, and the effect was twice as large as the effect of the medication.
The effect of the diet-and-exercise intervention was so impressive that a
data-monitoring board stopped the trial early.

The results for cardiovascular disease prevention are similarly impressive,
and benefits are seen even among people who already have documented disease.
In one randomized controlled trial of people with a history of congestive
heart failure, risks of heart attacks, hospitalizations, and death among
those randomly assigned to an exercise intervention were all reduced by
approximately 60 percent compared with the usual-care group (18). Physical
activity also plays a critical role in weight loss and in reducing the risk
of weight gain in the general population (19,20,21,22,23,24). Even in the
absence of weight loss, physical activity can result in substantial health
benefits, and individuals who are obese but active are on average healthier
than those who are sedentary but not obese (25).

People with serious mental illness are at higher risk of premature mortality
than the general population (26,27,28). On average, people with severe
mental illness die ten to 15 years earlier than the general population.
Although some of the excess mortality is due to suicide and accidental
death, ischemic heart disease is a common cause of excess mortality in this
population (29). In a study of all users of psychiatric services in
Australia between 1980 and 1998, age-adjusted ischemic heart disease
mortality ratios were 1.9 (95 percent confidence interval, 1.8 to 2) for
those who used psychiatric services compared with the general population
(29). Rates of comorbid illnesses, such as hypertension, diabetes,
respiratory disease, and cardiovascular disease, are as high as 60 percent
among people with serious mental illness (30,31,32). In a study of more than
38,000 persons who received care in the Department of Veterans Affairs
health system, of those with schizophrenia, 19 per cent, or almost one in
five, also had a diagnosis of diabetes (33). This finding may be due partly
to the association between atypical narcoleptics and diabetes (33,34).
However, individuals with schizophrenia are not the only persons with
serious mental illness who are at increased risk of diabetes. Depression is
roughly twice as common among patients with diabetes as in the general
population, with a prevalence of between 15 and 30 percent depending on
whether estimates are based on DSM criteria or elevated levels of depressive
symptoms measured with standardized scales (35,36,37).


Mental health benefits of physical activity


Although the physical health benefits of physical activity for people with
serious mental illness are dramatic, exercise may also confer other
important benefits in this population. The most convincing evidence for the
psychological benefits of exercise for clinical populations comes from
research examining clinical depression. Two recent meta-analyses reported
average effect sizes of .72 (38) and 1.1 (39) for exercise compared with no
treatment for depression, and both meta-analyses showed effects for exercise
that were similar to those found from other psychotherapeutic interventions.
Craft and Landers (38) reported a greater effect on moderately to severely
depressed individuals than on those who were initially classified as mildly
to moderately depressed. More modest but positive effects of physical
activity have been noted for generalized anxiety disorder, phobias, panic
attacks, and stress disorders (40).

Regular physical activity can improve mental health among people with
serious mental illness. Improvements in quality of life and emotional
well-being due to physical activity have been reported even in the absence
of objective diagnostic improvement (41,42,43). A 1999 review of exercise
interventions for people with schizophrenia identified eight
preexperimental, three quasi-experimental, and only one experimental study
(41). The authors concluded that exercise could alleviate secondary symptoms
of schizophrenia, such as depression, low self-esteem, and social
withdrawal. For some people, exercise also can be a useful coping strategy
for the positive symptoms of schizophrenia, such as auditory hallucinations
(41). Physical activity may also play a role in reducing social isolation
for people with serious mental illness. This aspect of physical activity
remains an underresearched area, although case studies suggest that
participation in physical activity can engage individual s in mental health
services, promote a sense of normalization, and offer safe opportunities for
social interaction (44,45). In addition, mental health service users have a
right to participate in recreational and leisure pursuits, such as physical
activity, which are enjoyed by the community at large.


Epidemiology of physical activity and serious mental illness

Individuals with serious mental illness are significantly less active than
the general population (46,47,48). In one study of 140 individuals with
schizophrenia, none of the respondents reported any vigorous exercise during
the previous week, and only 19 percent of men and 15 percent of women
reported participating in at least one session of moderate-intensity
physical activity (46). These physical activity levels are lower than levels
reported in the general population. In a cohort of 234 people with serious
mental illness, 12 percent reported vigorous exercise during the previous
two weeks, compared with 35 percent in the general population, and
participation in light exercise was significantly decreased as well (47). In
a cohort of 89 people with bipolar disorder, only 39 percent reported
engaging in physical activity of any intensity at least a few times a week
during the previous four weeks, compared with 70 percent of age- and
sex-matched controls (48).

Because of the combination of a sedentary lifestyle, poor diet (46,48), and
medication-induced weight gain (34,49,50,51,52), one would expect
individuals with serious mental illness to be significantly more likely to
be obese than those in the general population. However, studies examining
the prevalence of obesity in this population report mixed results, with some
studies showing significantly increased incidence of obesity (47) and others
showing no significant difference (46,53). Despite these conflicting
results, it is clear that the high prevalence of obesity is at least as
alarming for individuals with serious mental illness as it is for the
general population, and individuals who take antipsychotic medication may be
at particularly high risk of obesity-related morbidity (34,49,54). In
addition, concerns about obesity may contribute to noncompliance with
antipsychotic medication, which jeopardizes the potential for recovery and
reintegration (55).

A national consensus panel found strong evidence that second-generation
antipsychotic medications increase weight gain and the risk of diabetes
(56). The panel recommended physical activity and nutritional counseling for
all overweight and obese patients taking antipsychotic medication. Although
no randomized controlled trials have been reported, preliminary results
suggest that such lifestyle interventions can reduce weight gain in this
population (57,58).



Designing effective physical activity programs

Recommended levels of physical activity
The American College of Sports Medicine (ACSM), a national organization
interested in promoting the health of all Americans, has published a
position statement that recommends appropriate amounts of exercise needed to
attain minimal levels of physical fitness (59). Although not specific to
various disabilities, these guidelines describe the frequency, duration, and
intensity of exercise needed to develop and maintain cardiovascular fitness
and reduce body fat. According to ACSM guidelines, a minimal exercise
program should consist of at least three 20- to 60-minute exercise sessions
each week.

An alternative to this structured exercise approach is lifestyle
recommendations that focus on the accumulation of moderate-intensity
physical activity throughout the day. A Surgeon General's report (3)
recommended that "people of all ages accumulate a minimum of 30 minutes of
physical activity of moderate intensity (such as brisk walking) on most, if
not all, days of the week."

Structured versus lifestyle activity
Both structured, supervised, facility-based exercise programs and lifestyle
physical activity interventions that encourage participants to incorporate
physical activity in their daily lives may be effective for people with
serious mental illness. Structured exercise programs are appealing because
it is easier to ensure safe and appropriate levels of physical activity in a
supervised setting and because adherence can be more easily verified than
with a lifestyle intervention. However, there are some disadvantages,
including potentially costly space, equipment, and staffing. Lifestyle
interventions improve cardiorespiratory fitness and have a positive effect
on risk factors for cardiovascular disease, and they may be more effective
than structured exercise interventions in increasing levels of physical
activity (17,60,61,62,63,64,65). Their flexibility, lower cost, and easy
integration into daily schedules might be particularly appealing to
individuals with serious mental illne ss. Also, some individuals may prefer
a home-based program rather than traveling to an exercise facility three or
more times a week, particularly if transportation to and from the facility
is inconvenient.

Walking, either in the form of supervised group walks or unsupervised
home-based walking, is one of the easiest, safest, and most inexpensive
types of exercise to promote, and it is also one of the most popular forms
of exercise among those with and without chronic illness. For example, a
majority of people with type 2 diabetes who are active choose walking as
their primary form of exercise (66). Walking is an activity that almost
everyone can do almost anywhere. However, even low-cost walking programs
require planning, supervision, and evaluation and entail administrative
time. Other forms of physical activity that may be low cost and popular
include low-impact exercise videos and group aerobics classes.

Individually tailored interventions
Physical activity interventions are complex in that there are many design
components that may contribute to their effectiveness. Interventions that
target specific groups or that are tailored to the individual, taking into
account the participant's age, gender, socioeconomic status, cultural
background, health status, barriers to activity, and fitness level, are more
effective in increasing levels of physical activity than more generic
interventions (67,68,69,70). Similarly, programs that deliver exercise
prescriptions or motivational messages in printed form or by computer are
more effective than face-to-face counseling alone (71,72,73). Interventions
that focus on vigorous physical activity, such as running, soccer, or
aerobics classes, tend to be less successful than interventions that focus
on more moderate-intensity activities, such as walking (71). Although more
vigorous activities do improve cardiorespiratory fitness and speed weight
loss, the dropout rate from such pr ograms may be higher than with less
intensive interventions. Programs that employ principles of behavior
modification, including goal setting, self-monitoring, social support, and
shaping (that is, changing behavior in small steps) rather than simple
educational programs are more effective. Programs that encourage physical
activity during leisure time or unsupervised home-based activities have
better long-term adherence rates (71).

Self-monitoring
Participants need to set goals and self-monitor achievement in order to
successfully change their behavior (74,75). Unfortunately, self-monitoring
of physical activity, particularly lifestyle physical activity, is
difficult. For example, most people are unable to accurately report how much
walking they have done (76,77). Participation in a structured exercise
program, such as a regularly scheduled group class, may be easier to recall
but is still subject to recall bias. Fortunately, there are several
inexpensive and effective ways to help participants self-monitor their
physical activity. These methods include daily paper logs, Web-based logging
systems, and objective monitoring devices, including pedometers and heart
rate monitors.

Pedometers are inexpensive, reliable, and easy-to-use devices that can be
worn throughout the day (78). They count each step taken by the wearer and
report accumulated step-count on a small built-in display (79,80). Heart
rate monitors are also relatively inexpensive, reliable, and easy to use
(81,82). They consist of an elastic band worn on the chest and a watch that
displays the wearer's current heart rate. Heart rate monitors provide the
wearer with feedback about exercise intensity during an exercise session.
For more structured programs, session attendance can be tracked.
Interventions that incorporate objective physical activity assessment are
more effective than interventions that rely on participants' self-report
alone (71).

Feedback is a critical component of self-monitoring and self-regulation in
behavior change to increase physical activity (74,75). Unlike highly trained
athletes who are able to accurately assess and regulate their level of
exertion, sedentary and deconditioned individuals frequently overexert
themselves, which leads to discouragement and dropout. Feedback that is fine
grained enough to clearly document gradual incremental improvement can be a
powerful motivator. Pedometers and heart rate monitors are not too complex
for everyday use by most individuals with serious mental illness.

Group versus one-on-one sessions
Group interventions are generally less expensive than one-on-one
interventions. However, individualized attention and tailored goal setting
play an important role in behavior change among people with serious mental
illness. Providing individualized attention for participants is a challenge
in a group intervention. Even if feedback devices such as pedometers are
used, participants still need personal acknowledgment of their efforts and
oversight of their progress. Brief periodic individual conferences, log
reviews, and group leaders' participation in the exercise sessions can build
in opportunities for individualized attention. Providing certificates of
participation and holding social sessions to mark milestones can help to
recognize participants' efforts.

Self-efficacy
Lack of knowledge and experience, lack of confidence, tenuous motivation,
and unrealistic expectations can all hinder successful participation in
physical activity. Successful achievement of and recognition for small
incremental increases in physical activity gradually build self-efficacy,
and self-efficacy is one of the most important predictors of adherence in a
physical activity program (83). The "no-pain, no-gain" philosophy is of no
benefit in encouraging continued participation in an active lifestyle for
people with severe mental illness. Enthusiastic, knowledgeable, and
supportive exercise leaders are as important as the actual exercise
prescription itself. Because of a number of psychological issues, including
hypersensitivity about their bodies, which may be due to weight gain and
life experiences with trauma, it is very important to have skilled exercise
leaders who are willing to provide support to help participants overcome a
number of self-esteem barrie rs. Instilling confidence in participants'
ability to recover their wellness and develop greater resiliency is also an
essential task for any exercise leader of groups of persons with psychiatric
disability.

Participants' safety
Concerns about safety, particularly with respect to adverse cardiovascular
events, can be a barrier to the implementation of physical activity programs
in high-risk populations. Moderate-intensity activities, including walking,
are relatively safe, but some preexisting conditions may be exacerbated by
moderate exercise, even walking. The Physical Activity Readiness
Questionnaire (PAR-Q) (84) is a simple tool that is commonly used in
preparticipation screening for moderate-intensity physical activity programs
(85,86,87). Individuals who have risk factors identified by the PAR-Q should
get medical clearance before they participate in a physical activity
program.

Exercise is associated with other potential risks besides cardiovascular
risk, the most common being musculoskeletal injury. Risk of musculoskeletal
injury can be minimized by gradually increasing the intensity and duration
of activity, adding warm-up and cool-down periods to a session, and wearing
proper footwear (88). Good shoes are particularly important for individuals
with diabetes because of the risk of foot ulcers from peripheral neuropathy.
Although the side effects of various psychiatric medications do bother some
individuals, people using these medications can still continue to exercise.
There are no known serious complications to the combination of physical
exercise and psychotropic medication (89). Given that many individuals in
the population have low initial fitness levels and that drowsiness and
fatigue may be side effects of some medications, a very gradual approach to
increasing physical activity may be necessary (90).

Physical activity resources for mental health service providers

Books

Marcus BH, Forsyth LH: Motivating People to be Physically Active. Champaign,
Ill, Human Kinetics, 2003

American College of Sports Medicine: ASCM's Exercise Management for Persons
With Chronic Diseases and Disabilities, 2nd ed. Champaign, Ill, Human
Kinetics, 2003

US Department of Health and Human Services: Physical Activity and Health: A
Report of the Surgeon General. Atlanta, Center for Disease Control and
Prevention, National Center for Chronic Disease Prevention and Health
Promotion, 1996

National organizations

American College of Sports Medicine, PO Box 1440, Indianapolis, Indiana
46206-1440; telephone, 317-637-9200; Web site, www.acsm.org/index.asp

Division of Nutrition and Physical Activity, National Center for Chronic
Disease Prevention and Health Promotion, Centers for Disease Control and
Prevention, 4770 Buford Highway, NE, MS/K-24, Atlanta, Georgia 30341-3717;
telephone, 770-488-5820; Web site www.cdc.gov/nccdphp/dnpa/index.htm

Local resources

Hospital-linked fitness centers

YMCA

University kinesiology, movement sciences, or physical education departments

Web sites

Information about pedometers, www.new-lifestyles.com

National Center on Physical Activity and Disability, University of Illinois
at Chicago, www.ncpad.org/about

Resources for promoting health through physical activity, Arnold School of
Public Health, University of South Carolina,
http://prevention.sph.sc.edu/index.htm

Center for Psychiatric Rehabilitation, National Research and Training Center
in Psychiatric Rehabilitation and Recovery, www.bu.edu/cpr/rc (provides
program consultation, training, and evaluation nationally and
internationally)



Adherence
In the general population, adherence to physical activity programs drops off
sharply after six months, with less than half the participants able to stick
with the program (71). It is unrealistic to expect adherence rates to be any
better for individuals with serious mental illness. In fact, individuals
with serious mental illness often face substantial illness-related barriers
to physical activity that healthier individuals do not face. However, our
experience and existing research suggest that exercise is well accepted by
people with serious mental illness (91) and is often considered one of the
most valued components of treatment (92). If programs are made available as
part of psychiatric services, individuals will choose to enroll, and
adherence appears comparable to that in the general population (93).
Longitudinal program designs that require participants to attend sessions
regularly in order to keep up may pose a problem for individuals who
frequently but intermittently face exacerbations in their illness,
transportation problems, and other barriers that prevent regular attendance.
Such individuals, if encouraged to attend a regularly scheduled session
whenever possible, may benefit even from the intermittent program.
Evaluations that account for frequent "drop out" and "drop in" of
participants may more accurately capture the impact of such programs.

The Frontline Reports column in this issue of Psychiatric Services describes
four innovative physical activity programs implemented in mental health
treatment settings (94). Dropout rates in these programs are similar to
dropout rates for interventions in the general population. Perceived and
real barriers to participation and adherence may differ for individuals with
serious mental illness, but the desire to increase or maintain activity
levels probably does not (95). For more information on intervention design
and guidelines, see the box on this page.




Integrating activity interventions into psychiatric services

One of the most challenging aspects of assisting people with serious mental
illness to manage their care is ensuring effective coordination across their
many service providers. We believe that physical activity programs for
individuals with serious mental illness should be integrated into mental
health services. An alternative but less desirable approach would be to
refer these individuals to a primary care physician or other health care
provider for management of cardiovascular disease risk factors, including
promotion of physical activity.

There are three important reasons for integrating the promotion of physical
activity into mental health services. First, individuals with serious mental
illness have frequent contact with their mental health service providers.
Changing health behaviors can be difficult, and frequent reinforcement can
play a critical role in successful long-term adoption of regular physical
activity. Second, barriers specific to mental illness can be more
appropriately addressed by individuals who have been trained to be sensitive
and supportive around these issues. Finally, physical activity may play a
role in successful mental health recovery.

The physical activity programs that are available through medical health
providers are often fragmented and inadequate (96). Such low-intensity,
unsupportive, and fragmented physical activity programs are even less likely
to be successful in this high-risk population than in the general
population. However, primary care physicians can play an important role in
collaboratively identifying behavioral goals, reinforcing efforts to reach
behavioral targets, and addressing barriers to physical activity.
Particularly when people with serious mental illness have comorbid physical
health problems, the involvement of medical staff can ensure that the
promotion of physical activity reinforces other efforts to improve an
individual's overall health and well-being (35). The support of medical care
providers can legitimize the inclusion of exercise within an individual's
care plan and can also enhance adherence to physical activity programs.


Limitations of current research and future directions

Research on the effects of physical activity on the physical and mental
health of individuals with serious mental illness is limited. Intervention
research in this population is even scarcer. In the studies that have been
published, small samples, lack of control groups, or inadequate selection of
control groups are recurring problems. Neither randomized controlled trials
of physical activity interventions nor cost-effectiveness studies have been
conducted to evaluate such interventions for people with serious mental
illness. Further research of both a quantitative and qualitative nature is
urgently needed to examine how we can help individuals with severe mental
illness become more active. Interventions should be guided by an
evidence-based model that incorporates a process of evaluation and review.
Mental health professionals who are interested in creating physical activity
programs could collaborate with organizations such as academic institutions
to gain access not only t o expertise and resources in exercise programming
but also to research and evaluation skills. There is clearly a need to
examine how to best deliver physical activity as an adjunctive treatment for
individuals with serious mental illness (97).




Conclusions

Strategies to change physical activity behavior that have been successful in
healthier populations can be adopted for those with serious mental illness.
These interventions are feasible and popular and can result in clinically
significant behavior change in a mental health services setting. Physical
activity has an important role to play in the lives of individuals with
serious mental illness. By integrating physical activity programs into
psychiatric services, we can substantially improve the physical health
outcomes of people with serious mental illness, and we may also see
improvements in psychological and social outcomes. Thus physical activity
interventions are a critical component of a biopsychosocial approach in
recovery-oriented mental health services (98).


Acknowledgment

Dr. Piette's contribution to this work was funded by a Department of
Veterans Affairs Health Services Research and Development Career Scientist
Award.

Footnotes

Dr. Richardson is affiliated with the department of family medicine at the
University of Michigan, 1018 Fuller Street, Ann Arbor, Michigan (e-mail,
caroli@...). She is also with the Health Services Research and
Development Center for Excellence at the Department of Veterans Affairs
Medical Center in Ann Arbor, with which Dr. Piette is affiliated. Dr.
Faulkner is affiliated with the faculty of physical education and health at
the University of Toronto in Ontario. Dr. McDevitt is with the department of
public health, mental health, and administrative nursing in the College of
Nursing at the University of Illinois at Chicago. Dr. Skrinar is affiliated
with the department of health sciences at Sargent College of Health and
Rehabilitation Sciences at Boston University. Dr. Hutchinson is affiliated
with Boston University's Center for Psychiatric Rehabilitation. Dr. Piette
is also with the department of internal medicine at the University of
Michigan. The focus and scope of th is paper developed out of several
discussions that occurred at the 2003 Scientific Meeting on Physical
Activity and Mental Health at the Cooper Institute of Aerobic Research in
Dallas.


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