A qualitative evaluation of an exercise practitioner in an outpatient child and adolescent mental health service

O’Donoghue B.

AbstractPeople affected by severe mental health disorders have a greatly reduced life expectancy compared to their non-affected peers. Cardiovascular disease is the main contributor to this early mortality, caused by higher rates of smoking, physical inactivity, unhealthy diet, sleep disturbance, excessive alcohol use or substance abuse and medication side effects. Therefore, we need to take a preventative approach and translate effective interventions for physical health into routine clinical practice. These interventions should be delivered across all stages of mental health disorders and could also have the added benefit of leading to improvements in mental health. Furthermore, we need to advocate to ensure that people affected by severe mental health disorders receive the appropriate medical assessments and treatments when indicated. This themed issue highlights that physical health is now an urgent priority for funding and development in mental health services. The widespread implementation of evidence-based interventions into routine clinical practice is an essential need for consideration by clinicians and policymakers.

Lederman O., Furzer B., Wright K., McKeon G., Rosenbaum S., Stanton R.

ABSTRACT In Australia, exercise practitioners (i.e., clinical professionals specializing in exercise assessment and delivery) are increasingly recognized as core mental health team members. In response to the COVID-19 pandemic, exercise practitioners, like other mental health professions, have had to adapt methods of clinical service delivery to ensure social distancing and reduce risk of community transmission. As such, telehealth interventions have rapidly replaced most face-to-face services. To date, evidence surrounding the application of telehealth exercise interventions for people living with mental illness is scarce, and currently there is no consensus or recommendations on how exercise practitioners can provide telehealth services for this population. As such, the aim of this article is to draw on existing research and expert opinion to provide practical and service-based guidance for exercise practitioners delivering telehealth services to people with mental illnesses. Specifically, we explore the potential benefits of telehealth exercise interventions, the various challenges and considerations of telehealth exercise among those with mental illness, and some practical solutions to guide exercise practitioners in delivering telehealth services.

Hemmings L., Soundy A.

AbstractBackground Service users with severe mental illness (SMI) are at increased risk of physical health co-morbidity such as musculoskeletal pain, neurological impairment, obesity and COPD; many of which require input from physiotherapists. Physiotherapists play a pivotal role in treatment of those with SMI but are reported to lack skills and confidence with this patient group. Furthermore, disparities in accessing healthcare are evidenced for those with SMI. Purpose This study explored experiences of physiotherapeutic care for those with co-morbid physical and mental health complaints to identify barriers and facilitators to care. Methods A qualitative study using Interpretive Phenomenological Analysis was undertaken. Semi-structured interviews were completed with service users (n=8) with longstanding physiotherapeutic and psychiatric complaints. Focus groups were completed with physiotherapists working in mental health. Verbatim transcripts of interviews were analysed using Interpretive Phenomenological Analysis to obtain in depth insight into participant experiences. Study quality was enhanced through use of methodological and investigator triangulation, negative case analysis, reflexivity and secondary coding. Analysis Data was analysed systematically following the structure: individual case analysis, emergence of themes, cross case analysis, validation of themes and ideas. Results This analysis produced five master themes: Communication [1], holistic care [2], benefit of physiotherapy [3], healthcare politics and service interaction [4], patient activation [5]. Results identified current service provision did not always meet the complexities of service user needs. Conclusion and Implications Improved physiotherapist awareness of mental health and how to communicate and treat this population was identified. The importance of better integration between services was also highlighted. A positive experience of physiotherapy is vital for patient activation and engagement with physiotherapy.

Pascoe M., Bailey A.P., Craike M., Carter T., Patten R., Stepto N., Parker A.

Background/AimThis scoping review examined the breadth and outcomes of controlled trials testing the effect of physical activity and exercise interventions across all mental health outcomes for mental health promotion and indicated prevention studies in young people.MethodsThe literature search was conducted using ‘Evidence Finder’.ResultsThirty publications were included. Available evidence suggested that interventions of varying intensity may lead to a reduction in depression symptoms and that moderate-to-vigorous-intensity and light-intensity interventions may reduce anxiety symptoms. Effects of physical activity/exercise interventions on additional mental health outcomes were also shown; however, the number of studies was small, indicating a limited evidence base. Robust research regarding the effects of physical activity/exercise on mental health promotion and as an indicated prevention strategy in young people is lacking.ConclusionThe available evidence suggests that physical activity/exercise is a promising mental health promotion and early intervention strategy and warrants further investigation.

Fibbins H., Ward P.B., Stanton R., Czsonek L., Cudmore J., Michael S., Steel Z., Rosenbaum S.

Background Integrating exercise professionals into mental health settings is a key strategy in addressing the physical health inequalities of people living with mental illness. Workforce culture surrounding physical health may impact the utilisation of exercise professionals across inpatient settings. Aims To evaluate clinician perspectives regarding the implementation of an exercise professional at the mental health service in a large, urban hospital in Sydney, Australia. Methods A qualitative study using semi-structured interviews with a purposive sample of mental health staff was conducted. Data were analysed using thematic analysis. Results Fourteen mental health clinicians (approximately 35% of all eligible staff) participated in interviews. Three themes emerged regarding the role of the exercise professional; i) drivers and facilitators; ii) support from leadership; and iii) directions for future practice. Conclusions An exercise professional within a mental health service was identified as an effective strategy in improving consumer health outcomes while increasing the knowledge and confidence of mental health clinicians regarding the provision of physical health care. Exercise professionals should be recognised as important members of the standard multidisciplinary mental health team for in patients being treated for mental illness.

Lederman O., Ward P.B., Rosenbaum S., Maloney C., Watkins A., Teasdale S., Morell R., Curtis J.

Introduction Youth with at-risk mental states (ARMS) have low levels of physical activity (PA), reduced fitness levels and experience poor sleep quality. These lifestyle factors exacerbate mental health symptoms and increase cardiometabolic disease risk. PA interventions can help prevent this decline in physical health whilst reducing mental health symptom severity. Whether PA interventions are feasible and acceptable amongst youth with ARMS is unclear. Methods This study evaluated the feasibility and acceptability of headspace Active, a pragmatic PA program offered to 14 to 25 year olds with ARMS. The 12-week exercise physiologist-led intervention was conducted in adjunct to usual care. Feasibility was determined by number of referrals, attendance, engagement in exercise sessions and dropout from the intervention. Acceptability was assessed by a 10-item questionnaire. Secondary outcomes included anthropometry, cardiorespiratory fitness and strength. Subjective PA levels, symptoms of depression and anxiety, sleep, motivation and quality of life were also assessed. Results Within 12 months, 77% of referrals completed the 12-week intervention (n = 20), with six dropouts. Of the 20 completers, 95% attended at least five sessions over the 12-week intervention. Participants found the program highly acceptable (mean = 41.2/50 on the 10-item acceptability questionnaire) and experienced significant improvements in PA, strength, motivation, depressive symptoms and sleep quality post-intervention. No changes in anthropometry were observed. Conclusion Results suggest headspace Active was feasible and acceptable and was associated with improvements in physical and mental health outcomes among ARMS youth. Given the potential scalability of this real-world PA program to other youth mental health settings, these data have implications for best practice implementation of PA interventions for individuals with emerging mental illness.

Firth J., Siddiqi N., Koyanagi A., Siskind D., Rosenbaum S., Galletly C., Allan S., Caneo C., Carney R., Carvalho A.F., Chatterton M.L., Correll C.U., Curtis J., Gaughran F., Heald A., et. al.

The poor physical health of people with mental illness is a multifaceted, transdiagnostic, and global problem. People with mental illness have an increased risk of physical disease, as well as reduced access to adequate health care. As a result, physical health disparities are observed across the entire spectrum of mental illnesses in low-income, middle-income, and high-income countries. The high rate of physical comorbidity, which often has poor clinical management, drastically reduces life expectancy for people with mental illness, and also increases the personal, social, and economic burden of mental illness across the lifespan. This Commission summarises advances in understanding on the topic of physical health in people with mental illness, and presents clear directions for health promotion, clinical care, and future research. The wide range and multifactorial nature of physical health disparities across the range of mental health diagnoses generate a vast number of potential considerations. Therefore, rather than attempting to discuss all possible combinations of physical and mental comorbidities individually, the aims of this Commission are to: (1) establish highly pertinent aspects of physical health-related morbidity and mortality that have transdiagnostic applications; (2) highlight the common modifiable factors that drive disparities in physical health; (3) present actions and initiatives for health policy and clinical services to address these issues; and (4) identify promising areas for future research that could identify novel solutions. These aims are addressed across the five parts of the Commission: in Parts 1 and 2 we describe the scope, priorities, and key targets for physical health improvement across multiple mental illnesses; in Parts 3, 4, and 5, we highlight emerging strategies and present recommendations for improving physical health outcomes in people with mental illness.

Brooke L.E., Gucciardi D.F., Ntoumanis N., Lin A.

Aims The aim and objective of the study was building on a previous call for the development of sport-based life skills interventions for young people with first episode of psychosis (FEP) (Brooke, Lin, Ntoumanis, & Gucciardi, 2018), to explore the barriers and enablers to sport participation for young people with FEP. Method We used a semi-structured interview format to conduct one-to-one interviews with young people (aged 16-25; n = 10) with FEP, and one-to-one interviews and focus groups with their clinicians (n = 33). Questions focused on barriers and facilitators (intrapersonal, interpersonal, psychological, environment, health/safety, logistical) to sport participation young people with FEP. Thematic analysis was used to analyse the data. Results Four themes (and 11 sub-themes) emerged from the analysis: (a) the need for sport in FEP recovery (perceived benefits; resource gap); (b) barriers (logistical; psychological); (c) enablers (positive environmental expectations and experiences) and (d) programme design (sport programme/type; life skills training; application to barriers/enablers). Conclusion The participants responded favourably to the idea of using sport to promote recovery post-FEP, and provided an insight into why sport is currently underutilized within FEP recovery efforts. The barriers, enablers, and specific suggestions for how to limit the barriers and strengthen the enablers are valuable for sport-based intervention design, and may be applicable to non-sport-based interventions for people with FEP.

Matthews E., Cowman M., Denieffe S.

People with severe mental illnesses have dramatically reduced life expectancy compared with the general population, which is largely attributed to physical comorbidity. Physical activity and sedentary behaviour interventions offer a safe and viable therapeutic resource for multi-disciplinary mental health care teams. The accumulating evidence supporting the role of these interventions has changed the focus of mental health strategy in some countries, with new developing roles for certain mental health professionals in this field. However, in Ireland the absence of specialised exercise practitioners places a leadership role for mental health nurses in this regard. National mental health strategy in Ireland should prioritise physical activity and sedentary behaviour interventions, make recommendations for the integration of specialised exercise practitioners in all mental health multidisciplinary teams, and recommend the provision of training and awareness for mental health nurses and other multidisciplinary professionals who are already well placed to address this issue.

Stubbs B., Vancampfort D., Hallgren M., Firth J., Veronese N., Solmi M., Brand S., Cordes J., Malchow B., Gerber M., Schmitt A., Correll C.U., De Hert M., Gaughran F., Schneider F., et. al.

AbstractPhysical activity (PA) may be therapeutic for people with severe mental illness (SMI) who generally have low PA and experience numerous life style-related medical complications. We conducted a meta-review of PA interventions and their impact on health outcomes for people with SMI, including schizophrenia-spectrum disorders, major depressive disorder (MDD) and bipolar disorder. We searched major electronic databases until January 2018 for systematic reviews with/without meta-analysis that investigated PA for any SMI. We rated the quality of studies with the AMSTAR tool, grading the quality of evidence, and identifying gaps, future research needs and clinical practice recommendations. For MDD, consistent evidence indicated that PA can improve depressive symptoms versus control conditions, with effects comparable to those of antidepressants and psychotherapy. PA can also improve cardiorespiratory fitness and quality of life in people with MDD, although the impact on physical health outcomes was limited. There were no differences in adverse events versus control conditions. For MDD, larger effect sizes were seen when PA was delivered at moderate-vigorous intensity and supervised by an exercise specialist. For schizophrenia-spectrum disorders, evidence indicates that aerobic PA can reduce psychiatric symptoms, improves cognition and various subdomains, cardiorespiratory fitness, whilst evidence for the impact on anthropometric measures was inconsistent. There was a paucity of studies investigating PA in bipolar disorder, precluding any definitive recommendations. No cost effectiveness analyses in any SMI condition were identified. We make multiple recommendations to fill existing research gaps and increase the use of PA in routine clinical care aimed at improving psychiatric and medical outcomes.

Holtrop J.S., Rabin B.A., Glasgow R.E.

There have been over 430 publications using the RE-AIM model for planning and evaluation of health programs and policies, as well as numerous applications of the model in grant proposals and national programs. Full use of the model includes use of qualitative methods to understand why and how results were obtained on different RE-AIM dimensions, however, recent reviews have revealed that qualitative methods have been used infrequently. Having quantitative and qualitative methods and results iteratively inform each other should enhance understanding and lessons learned. Because there have been few published examples of qualitative approaches and methods using RE-AIM for planning or assessment and no guidance on how qualitative approaches can inform these processes, we provide guidance on qualitative methods to address the RE-AIM model and its various dimensions. The intended audience is researchers interested in applying RE-AIM or similar implementation models, but the methods discussed should also be relevant to those in community or clinical settings. We present directions for, examples of, and guidance on how qualitative methods can be used to address each of the five RE-AIM dimensions. Formative qualitative methods can be helpful in planning interventions and designing for dissemination. Summative qualitative methods are useful when used in an iterative, mixed methods approach for understanding how and why different patterns of results occur. In summary, qualitative and mixed methods approaches to RE-AIM help understand complex situations and results, why and how outcomes were obtained, and contextual factors not easily assessed using quantitative measures.

Bailey A.P., Hetrick S.E., Rosenbaum S., Purcell R., Parker A.G.

AbstractWe aimed to establish the treatment effect of physical activity for depression in young people through meta-analysis. Four databases were searched to September 2016 for randomised controlled trials of physical activity interventions for adolescents and young adults, 12–25 years, experiencing a diagnosis or threshold symptoms of depression. Random-effects meta-analysis was used to estimate the standardised mean difference (SMD) between physical activity and control conditions. Subgroup analysis and meta-regression investigated potential treatment effect modifiers. Acceptability was estimated using dropout. Trials were assessed against risk of bias domains and overall quality of evidence was assessed using GRADE criteria. Seventeen trials were eligible and 16 provided data from 771 participants showing a large effect of physical activity on depression symptoms compared to controls (SMD = −0.82, 95% CI = −1.02 to −0.61, p < 0.05, I2 = 38%). The effect remained robust in trials with clinical samples (k = 5, SMD = −0.72, 95% CI = −1.15 to −0.30), and in trials using attention/activity placebo controls (k = 7, SMD = −0.82, 95% CI = −1.05 to −0.59). Dropout was 11% across physical activity arms and equivalent in controls (k = 12, RD = −0.01, 95% CI = −0.04 to 0.03, p = 0.70). However, the quality of RCT-level evidence contributing to the primary analysis was downgraded two levels to LOW (trial-level risk of bias, suspected publication bias), suggesting uncertainty in the size of effect and caution in its interpretation. While physical activity appears to be a promising and acceptable intervention for adolescents and young adults experiencing depression, robust clinical effectiveness trials that minimise risk of bias are required to increase confidence in the current finding. The specific intervention characteristics required to improve depression remain unclear, however best candidates given current evidence may include, but are not limited to, supervised, aerobic-based activity of moderate-to-vigorous intensity, engaged in multiple times per week over eight or more weeks. Further research is needed. (Registration: PROSPERO-CRD 42015024388).

Stanton R., Rosenbaum S., Lederman O., Happell B.

Clarke V., Braun V.

Lederman O., Grainger K., Stanton R., Douglas A., Gould K., Perram A., Baldeo R., Fokas T., Nauman F., Semaan A., Hewavasam J., Pontin L., Rosenbaum S.

Objective: The aim is to identify the role and scope of Accredited Exercise Physiologist (AEP) services in the mental health sector and to provide insight as to how AEPs can contribute to the multidisciplinary mental health team. Methods: A modified Delphi approach was utilised. Thirteen AEPs with experience in mental health contributed to the iterative development of a national consensus statement. Six mental health professionals with expertise in psychiatry, mental health nursing, general practice and mental health research participated in the review process. Reviewers were provided with a template to systematically provide feedback on the language, content, structure and relevance to their professional group. Results: This consensus statement outlines how AEPs can contribute to the multidisciplinary mental health team, the aims and scope of AEP-led interventions in mental health services and examples of such interventions, the range of physical and mental health outcomes possible through AEP-led interventions and common referral pathways to community AEP services. Outcome: AEPs can play a key role in the treatment of individuals experiencing mental illness. The diversity of AEP interventions allows for a holistic approach to care, enhancing both physical and mental health outcomes.