Stepping up early treatment for help‐seeking youth with at‐risk mental states: Feasibility and acceptability of a real‐world exercise program

Lederman O., Ward P.B., Firth J., Maloney C., Carney R., Vancampfort D., Stubbs B., Kalucy M., Rosenbaum S.

People living with mental illness often experience poor sleep quality compared to the general population. Poor sleep quality exacerbates symptoms of mental illness and contributes to increased physical comorbidities. Exercise has been shown to be an effective non-pharmacological treatment for managing poor sleep in the general population. Little is known regarding the efficacy of targeted exercise interventions for improving sleep quality amongst individuals with a mental illness. We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) examining the impact of exercise on sleep quality in people with mental illness. Major electronic databases were searched from inception until June 2018 for exercise-based RCTs that included either subjective and/or objective measures of sleep quality in people with severe mental illness (SMI). Eight RCT's were included in the meta-analysis, involving use of a range of exercise modalities in people with SMI diagnoses. Overall, exercise had a large statistically significant effect on sleep quality (hedges g = 0.73, 95% CI; (0.18, 1.28), p-value = 0.01; N = 8, n = 1,329, I2 = 91.15%). The beneficial effect of exercise on sleep quality outlined in this study highlights the important role exercise has in improving health outcomes for people living with mental illness. Further research is required to determine the efficacy of exercise on sleep in people experiencing a psychiatric illness and to explore the effects of exercise intervention elements such as modality, frequency, intensity and delivery settings.

Newberry R.E., Dean D.J., Sayyah M.D., Mittal V.A.

Exercise has increasingly been proposed as a healthful intervention prior to and after the onset of psychosis. There is some evidence to suggest that youth at clinical high risk (CHR) for psychosis are less physically active and report more barriers to engaging in exercise; however, there has been relatively limited empirical work documenting this phenomenon, and to date, relationships between physical activity, barriers, and clinical phenomenology have been unclear.CHR (N = 51) and healthy control (N = 37) participants completed a structured clinical interview assessing attenuated psychotic symptoms and substance use, and an exercise survey that assessed current exercise practices, perceived physical fitness, and barriers related to engaging in exercise.CHR youth engaged in less physical activity, exhibited lower perception of fitness, and endorsed more barriers related to motivation for exercise. The CHR group showed significant negative correlations where lower perceptions of fitness were associated with increased negative, disorganized, and general symptoms. Decreased frequency of activity was related to more barriers of motivation. Interestingly, greater symptomatology in the CHR group was associated with more barriers of self-perception and motivation for engaging in exercise. However, findings suggested a nuanced relationship in this area; for example, increased physical activity was associated with increased substance use.The results of the current study support the notion that sedentary behavior is common in CHR youth, and more broadly, provide an impetus to target motivation through supervised exercise and fitness tracking to promote the health and well-being of CHR individuals.

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.

Hallgren M., Skott M., Ekblom Ö., Firth J., Schembri A., Forsell Y.

AbstractBackgroundExercise has mood-enhancing effects and can improve cognitive functioning, but the effects in first-episode psychosis (FEP) remain understudied. We examined the feasibility and cognitive effects of exercise in FEP.MethodMulti-center, open-label intervention study. Ninety-one outpatients with FEP (mean age = 30 years, 65% male) received usual care plus a 12-week supervised circuit-training program, consisting of high-volume resistance exercises, aerobic training, and stretching. Primary study outcome was cognitive functioning assessed by Cogstate Brief Battery (processing speed, attention, visual learning, working memory) and Trailmaking A and B tasks (visual attention and task shifting). Within-group changes in cognition were assessed using paired sample t tests with effect sizes (Hedges’ g) reported for significant values. Relationships between exercise frequency and cognitive improvement were assessed using analysis of covariance. Moderating effects of gender were explored with stratified analyses.ResultsParticipants exercised on average 13.5 (s.d. = 11.7) times. Forty-eight percent completed 12 or more sessions. Significant post-intervention improvements were seen for processing speed, visual learning, and visual attention; all with moderate effect sizes (g = 0.47–0.49, p < 0.05). Exercise participation was also associated with a positive non-significant trend for working memory (p < 0.07). Stratified analyses indicated a moderating effect of gender. Positive changes were seen among females only for processing speed, visual learning, working memory, and visual attention (g = 0.43–0.69). A significant bivariate correlation was found between total training frequency and improvements in visual attention among males (r = 0.40, p < 0.05).ConclusionSupported physical exercise is a feasible and safe adjunct treatment for FEP with potential cognitive benefits, especially among females.

Dean D.J., Bryan A.D., Newberry R., Gupta T., Carol E., Mittal V.A.

Lederman O., Rosenbaum S., Maloney C., Curtis J., Ward P.B.

Young people experiencing psychotic illness engage in low amounts of physical activity have poor fitness levels and poor sleep quality. This study aimed to determine the prevalence of these modifiable cardiometabolic risk factors among individuals with at-risk mental states (ARMS), who are at increased risk of developing psychosis. A cross-sectional study was conducted in a community-based youth mental health service. Thirty participants (23%♀, 21.3 ± 1.7 years old) were recruited, 10 with ARMS, 10 with first-episode psychosis (FEP) and 10 healthy volunteers. Physical activity levels were assessed using self-report and objective measures. Aerobic capacity, upper body strength, hamstring flexibility, forearm grip strength and core endurance were assessed. Sleep quality, depression and anxiety were measured by self-report questionnaire. The ARMS group did not differ significantly on anthropometric measures from FEP or healthy volunteers. They engaged in significantly less physical activity (p < 0.05) and had poorer sleep quality (p < 0.05) than healthy volunteers. Our results are consistent with other studies that found that youth with ARMS are at greater cardiometabolic risk. Interventions aimed at improving these modifiable risk factors may assist with preventing the decline in physical health associated with the development of psychiatric illness.

Chapman J.J., Coombes J.S., Brown W.J., Khan A., Chamoli S., Pachana N.A., Burton N.W.

Introduction Adults with mental illness have increased risk of cardiovascular disease. High-intensity interval training (HIIT) is more efficacious than moderate-intensity continuous training (MICT) for improving cardiorespiratory fitness (CRF); however, the utility of HIIT for this group is unclear. The aim of this study was to compare the feasibility and acceptability of HIIT and MICT in adults with mental illness. A secondary aim was to compare the efficacy of HIIT and MICT on mental health and fitness. Method Inactive adults with self-reported mental illness participated in aerobic exercise three times/week over 12 weeks. Participants were randomised to HIIT (3x4-min bouts at 85–95% peak heart rate [HRpeak] interspersed with 3-min recovery bouts) or MICT (1 × 30-min at 65–75% HRpeak). Feasibility was assessed using attendance and withdrawal rates. Acceptability and mental health was assessed using self-administered questionnaires. Fitness was measured using indirect calorimetry during a graded fitness test to exhaustion. Results 24 participants consented and 16 participants began the intervention (HIIT, n = 8; MICT, n = 8). Completion rates (HIIT, n = 4; MICT, n = 5) and median attendances were similar (HIIT = 81%, MICT = 86%). Most participants were satisfied with their allocation (88% MICT; 100% HIIT), and found the exercise enjoyable (63% MICT; 100% HIIT). Equal numbers reported that they would like to continue the exercise (63%), and that they would feel confident doing so without supervision (75%). No significant differences were found between groups on mental health and fitness. Conclusion This preliminary evidence suggests that HIIT was as acceptable and feasible as MICT for adults with mental illness.

Lederman O., Suetani S., Stanton R., Chapman J., Korman N., Rosenbaum S., Ward P.B., Siskind D.

Objectives: Evaluation of physical activity (PA) programs among populations with severe mental illness (SMI) has predominately focused on efficacy and therapeutic benefits. There is now strong evidence to support the benefits of PA in people with SMI. What remains is a gap in the implementation of pragmatic and sustainable PA interventions in mental-health settings. The current paper provides examples of interventions that have been successfully implemented in Australian settings, identifies key components of successful PA interventions and outlines practical strategies that can assist with widespread implementation of PA interventions in mental-health settings. Conclusions: There is an emergence of PA interventions being imbedded within a variety of mental-health settings. These interventions vary in terms of mode and intensity of service delivery. Yet, all aim to increase PA and reduce sedentary behaviour. Adopting the identified strategies may help facilitate successful implementation and increase access to PA interventions for mental-health service users.

Hjorthøj C., Stürup A.E., McGrath J.J., Nordentoft M.

Several studies and meta-analyses have shown that mortality in people with schizophrenia is higher than that in the general population but have used relative measures, such as standardised mortality ratios. We did a systematic review and meta-analysis to estimate years of potential life lost and life expectancy in schizophrenia, which are more direct, absolute measures of increased mortality.We searched MEDLINE, PsycINFO, Embase, Cinahl, and Web of Science for published studies on years of potential life lost and life expectancy in schizophrenia. Data from individual studies were combined in meta-analyses as weighted averages. We did subgroup analyses for sex, geographical region, timing of publication, and risk of bias (estimated with the Newcastle-Ottawa Scale).We identified 11 studies in 13 publications covering all inhabited continents except South America (Africa n=1, Asia n=1, Australia n=1, Europe n=7, and North America n=3) that involved up to 247 603 patients. Schizophrenia was associated with a weighted average of 14·5 years of potential life lost (95% CI 11·2-17·8), and was higher for men than women (15·9, 13·8-18·0 vs 13·6, 11·4-15·8). Loss was least in the Asian study and greatest in Africa. The overall weighted average life expectancy was 64·7 years (95% CI 61·1-71·3), and was lower for men than women (59·9 years, 95% CI 55·5-64·3 vs 67·6 years, 63·1-72·1). Life expectancy was lowest in Asia and Africa. Timing of publication and risk of bias had little effect on results.The effects of schizophrenia on years potential life lost and life expectancy seem to be substantial and not to have lessened over time. Development and implementation of interventions and initiatives to reduce this mortality gap are urgently needed.None.

Poe S., Brucato G., Bruno N., Arndt L.Y., Ben-David S., Gill K.E., Colibazzi T., Kantrowitz J.T., Corcoran C.M., Girgis R.R.

There has been recent interest in understanding the role that sleep disturbance plays in patients at Clinical High Risk for psychosis (CHR). We assessed sleep disturbance in 194 CHR patients and 66 healthy control subjects and their relationship to symptoms (positive, negative and general functioning). Patients experienced significantly more sleep disturbance than healthy control subjects and their sleep disturbance was related to greater positive and negative symptoms and worse overall functioning. Targeting sleep disturbance in CHR individuals may provide alternative means of treating the CHR syndrome.

Falkai P., Malchow B., Schmitt A.

Schizophrenia is a severe neuropsychiatric disorder with incomplete remission because of negative and cognitive symptoms in a large proportion of patients. Antipsychotic medication is successful in modulating positive symptoms, but only to a lower extent negative symptoms including cognitive dysfunction. Therefore, development of innovative add-on treatment is highly needed. In this review, recent evidence from clinical studies reveals effects of aerobic exercise on cognitive deficits in schizophrenia patients.First studies and meta-analyses on aerobic exercise in schizophrenia patients have shown effects on positive, negative, and global symptoms and cognitive domains such as global cognition, working memory, and attention. Underlying neurobiological mechanisms such as neuroplasticity-related synaptogenesis and neurogenesis have been identified in animal studies and possibly mediate effects of aerobic exercise on brain structure and function.Different aspects of methods (e.g., endurance training versus yoga and Tai Chi), length and dose of the intervention, supervision of patients by sports therapists as well as maintenance of cognitive improvement after cessation of training have been raised by previous studies. However, minimal and most effective dosage of the intervention and mechanisms underlying changes in neuroplasticity need to be answered in future basic and large-scale randomized clinical trials.

Sormunen E., Saarinen M.M., Salokangas R.K., Telama R., Hutri-Kähönen N., Tammelin T., Viikari J., Raitakari O., Hietala J.

Schizophrenia spectrum disorders are associated with high morbidity and mortality in somatic diseases. The risk factors of this excess mortality include, e.g., obesity, dietary factors, and physical inactivity, especially after the onset of psychosis, but there are limited early developmental data on these factors in individuals who later develop psychosis. A population-based cohort study “Cardiovascular Risk of Young Finns” started in 1980 with 3596 children and adolescents from six different age groups (3, 6, 9, 12, 15, and 18 years). Cardiovascular health parameters, including questionnaire of physical activity before first hospitalization (≤18 years), were studied in 1980, 1983, and 1986. All psychiatric diagnoses of the participants were derived from the Finnish Hospital Discharge Register up to the year 2012. We identified diagnostic groups of non-affective psychosis (n = 68, including a schizophrenia subgroup, n = 41), personality disorders (n = 43), affective disorders (n = 111), and substance-related disorders (n = 49), based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Groups were compared with controls with no psychiatric diagnoses (n = 3325). Sex, age, body mass index, birth weight, non-preterm birth, and mother’s mental disorders were included in the statistical model. Low physical activity in childhood and adolescence (9–18 years) independently predicted later development of non-affective psychosis. Lower physical activity index (relative risk 1.26 [1.1–1.5]), lower level of common activity during leisure time (relative risk 1.71 [1.2–2.5]), and non-participation in sports competitions (relative risk 2.58 [1.3–5.3]) were associated with a higher risk for later non-affective psychosis (expressed as increase in relative risk per physical activity unit). The findings were even stronger for schizophrenia, but no such link was observed for other diagnoses. The cause of low physical activity in premorbid/prodromal phase is likely to be multifactorial, including deviant motor and cognitive development. The results provide a rationale for including exercise and physical activity interventions as a part of psychosis prevention programs. Researchers in Finland show that low physical activity in childhood and early adolescence increases the risk of developing schizophrenia. Jarmo Hietala at the University of Turku and colleagues assessed data collected between 1980 and 1986 from an ongoing population study of the physical activity of 3596 participants before and after puberty. By linking these data to hospital records they found that physical activity was lower among those who later developed non-affective psychosis, particularly schizophrenia. Further, when adjusting for other known psychosis risk factors, the effect of physical inactivity remains significant. There are likely to be multiple causes for this physical inactivity, including delayed motor development before the onset of psychosis. Although the mechanism through which exercise can lower the risk of disease is unclear, there is evidence that physical activity can trigger structural and functional brain changes. These findings support including exercise and physical activity in psychosis prevention and early intervention programs.

Schuch F.B., Vancampfort D., Sui X., Rosenbaum S., Firth J., Richards J., Ward P.B., Stubbs B.

Physical activity (PA) is protective from future depression, however, the potential impact of cardiorespiratory fitness (CRF) on the development of depression is less clear. We aimed to investigate if lower levels of CRF are associated with a higher risk for depression onset. Major electronic databases were searched, from inception to January 2016 for prospective cohort studies evaluating the association between CRF and incident depression. Pooled hazard ratio (HR) with 95% confidence intervals (CIs) were calculated. Methodological quality was evaluated using the Newcastle-Ottawa scale (NOS). Three prospective studies were identified and data from two studies were pooled. Our data provide preliminary evidence found that people with low CRF and medium CRF were at increased risk of developing depression (n=1,128,290, HR=1.76, 95% CI 1.61-1.91, p

Bauman A., Ainsworth B.E., Bull F., Craig C.L., Hagströmer M., Sallis J.F., Pratt M., Sjöström M.

Before the development of the International Physical Activity Questionnaire (IPAQ), population measures of physical activity were country-specific, noncomparable, and mostly developed to assess leisure-time activity. Given the global increases in noncommunicable disease1 the need for internationally comparable physical activity surveillance measures was identified. An initial meeting at World Health Organization Headquarters in 1998 convened a group of physical activity scientists to plan the development and testing of such a measure, resulting in IPAQ. The purpose of this commentary is to reflect upon the first decade of experience with IPAQ, compare its intended to its actual use, and comment on its strengths and weaknesses as an addition to the armamentarium of self-report physical activity measures. IPAQ development was premised on the need to develop international population measurement to assess ‘total physical activity’ across the domains of work, domestic tasks, active transport, and leisure time, because patterns of activity across domains were expected to vary widely by country.2 IPAQ was developed because of the desire for cross-country comparison and international physical activity surveillance. To enhance use across countries, the measures were

Markland D., Tobin V.

Drawing on self-determination theory, Mullan, Markland, and Ingledew (1997) developed the Behavioural Regulation in Exercise Questionnaire (BREQ) to measure the continuum of behavioral regulation in exercise contexts. The BREQ assesses external, identified, introjected, and intrinsic regulations. Mullan et al. initially included a set of amotivation items but dropped these due to high levels of skewness and a restricted response range in their development sample. It would clearly be useful to assess amotivation for exercise. This study aimed to test the factorial validity of a modified BREQ with amotivation items reinstated in a sample likely to exhibit a wider range of amotivation responses. A total of 194 former exercise referral scheme participants completed the revised instrument (BREQ-2). Although the amotivation items were still skewed, confirmatory factor analysis using the Satorra-Bentler (1994) scaling correction to χ2 indicated an excellent model ft. The BREQ-2 could prove useful to researchers wishing to assess amotivation in order to develop a more complete understanding of motivation for exercise.

Chong Y.Y., Chien W.T., Mou H., Ip C.K., Bressington D.

Álvaro L., Camilo L., Jesús B., Diego M., Javier B.

This chapter addresses the issue of healthcare disparities among individuals with severe mental disorders (SMD) by focusing on the integration of physical activity therapies as an adjunctive treatment facilitated by physical health professionals within the current mental health paradigm. Emphasis is placed on the compelling need for a holistic and multidisciplinary approach, considering that prevailing mental health services often overlook physical exercise as a pivotal element in both the prevention and treatment of this escalating concern. To achieve this goal, an enhanced understanding of how such interventions can be meticulously designed and effectively implemented in “real-world” conditions is imperative to optimize patient adherence. This chapter reviews selected case studies that have successfully implemented physical activity programs within mental health services, thereby enhancing the overall health and quality of life of people with SMD. Moreover, the chapter explores the existing barriers impeding the effective implementation of this innovative approach in mental health, offering insightful strategies to overcome these obstacles. Taking this evidence together and undertaking a review of the updated literature, this chapter provides a robust foundational framework for comprehending the significance and feasibility of integrating physical activity therapies into the comprehensive treatment paradigm for SMD.

De Micheli A., Provenzani U., Krakowski K., Oliver D., Damiani S., Brondino N., McGuire P., Fusar-Poli P.

Background: The clinical high risk for psychosis (CHR-P) construct represents an opportunity for prevention and early intervention in young adults, but the relationship between risk for psychosis and physical health in these patients remains unclear. Methods: We conducted a RECORD-compliant clinical register-based cohort study, selecting the long-term cumulative risk of developing a persistent psychotic disorder as the primary outcome. We investigated associations between primary outcome and physical health data with Electronic Health Records at the South London and Maudsley (SLaM) NHS Trust, UK (January 2013–October 2020). We performed survival analyses using Kaplan-Meier curves, log-rank tests, and Cox proportional hazard models. Results: The database included 137 CHR-P subjects; 21 CHR-P developed psychosis during follow-up, and the cumulative incidence of psychosis risk was 4.9% at 1 year and 56.3% at 7 years. Log-rank tests suggested that psychosis risk might change between different levels of nicotine and alcohol dependence. Kaplan-Meier curve analyses indicated that non-hazardous drinkers may have a lower psychosis risk than non-drinkers. In the Cox proportional hazard model, nicotine dependence presented a hazard ratio of 1.34 (95% CI: 1.1–1.64) (p = 0.01), indicating a 34% increase in psychosis risk for every additional point on the Fagerström Test for Nicotine Dependence. Conclusions: Our findings suggest that a comprehensive assessment of tobacco and alcohol use, diet, and physical activity in CHR-P subjects is key to understanding how physical health contributes to psychosis risk.

Asad-Cabrera I., Borrueco-Sánchez J., López-Sánchez C., Lopez-Moral A., Munguía-izquierdo D., Bueno-Antequera J.

People with severe mental disorders (SMD) coexist with other diseases derived from a lack of physical activity and sedentary lifestyles. Although physical exercise programs can be interesting when it comes to solving this problem, adherence to them is low and the dropout rate is notable, so that these people do not manage to benefit from the positive effects of physical activity. In this sense, encouraging autonomous motivation seems to be the key to achieving greater attendance at training sessions and achieving a stage of change of action or maintenance. To this end, directing attention toward the support and satisfaction of three basic psychological needs (autonomy, competence, and relationships) seems essential. In this endeavor, different behavior change techniques (BCTs) have been successfully used to promote more self-determined motivations and increase physical activity.

Hui T.T., Garvey L., Olasoji M.

AbstractThe aim of this study is to explore the views and understanding of youth mental health clinicians with regard to the physical health of young people with early psychosis and their perspectives on lifestyle interventions improving the health and well‐being of young people with early psychosis. Physical health disparities leading to premature mortality among people with mental illness are well evident in the literature. Mental health and physical health are directly correlated. The risk of poor physical health often begins before the onset of mental ill health. Young people with early psychosis are highly susceptible to poor physical health. A co‐designed integrated approach focusing on early prevention and intervention in overall well‐being and health is imminent for this targeted population to prevent poor physical health trajectory across the lifespan. Ten clinicians were recruited and participated in this study through semi‐structured interviews. Five themes were identified: (i) Impact of early psychosis, (ii) Focus of care, (iii) Conversations around physical health, (iv) Co‐location of specialist roles and (v) Health literacy. The findings of this study confirm the dimensional impact of early psychosis on the well‐being and health of young people through the vicious cycle of early psychosis. Promotion of health literacy along with social connectedness and elements of self‐determination, as well as having a prime focus on the individuals' experience in the journey of health promotion through participation in lifestyle interventions, has been identified as critically prominent.

Klemmer B., Kinnafick F.E., Spray C., Chater A.M.

Jeftic I., Furzer B.J., Dimmock J.A., Wright K., Boyd C., Budden T., Rosenberg M., Kramer B., Buist B., Fitzpatrick I., Sabiston C., de Jonge M., Jackson B.

The incidence of mental illness is greatest among young adults, and those enrolled in higher education may be particularly vulnerable compared to the general young adult population. Many higher education institutions employ student support staff tasked with implementing strategies to improve student wellbeing and mental illness. However, these strategies tend to be focused on clinical therapies and pharmacological interventions with limited lifestyle approaches. Exercise is an effective method for addressing mental illness and promoting wellbeing, yet widespread provision of structured exercise services to support treatment options for students with mental health challenges has not been fully realized. In an effort to guide exercise strategies for student mental health, we synthesize considerations for developing and delivering exercise programs in higher education settings. We draw directly from the evidence base on existing exercise programs in higher education; and the broader behavior change, exercise adherence, health psychology, implementation science, and exercise prescription literatures. Our broad considerations cover issues regarding program engagement and behavior change, exercise ‘dose’ and prescription, integration with other on-campus services, and robust research and evaluation. These considerations may provide impetus for widespread program development and implementation, as well as informing research focused on protecting and improving student mental health.

Matthews E., Cowman M., Mulhare B., Banville E., Kissane S., Lederman O., Lowney P., Ronan F., Denieffe S.

Abstract Background: Physical activity interventions can confer a range of physical and mental health benefits among young people with mental disorders. In some contexts, such as Ireland, integrated physical activity is not easily available within child and adolescent mental health services. Therefore, an interagency pilot intervention was established in a child and adolescent mental health service in Ireland with the integration of a novel exercise practitioner into the multidisciplinary mental health team. Objective: A qualitative evaluation was conducted to understand the impact of the pilot intervention and to understand issues of implementation that arose throughout. Methods: In-depth qualitative interviews with service users’ parents/guardians (N = 3) and a single focus group with existing service providers (N = 3), framed by the RE-AIM framework were conducted to evaluate the pilot intervention. Data were analysed using thematic analysis to explore themes. Results: Three overarching themes were identified. These were as follows: (i) Making changes toward healthier physical activity behaviours; (ii) An intervention of therapeutic holism; and (iii) The integrated service delivery. Conclusions: This research provides insight on the value of a novel integrated exercise practitioner in outpatient young persons’ mental health services in Ireland, indicating an enhanced and complimentary therapeutic service. These findings will be helpful for integrating Exercise Practitioners in this setting going forward.

Czosnek L., Rosenbaum S., Rankin N.M., Zopf E.M., Cormie P., Herbert B., Richards J.

Physical activity interventions are recommended for community-based youth mental health services to prevent physical health disparities. Implementation is challenging, and studies focusing on the methods to achieve change are needed. This study aims to identify the context, implementation strategies, and implementation outcomes that illustrate how physical activity interventions were implemented within an early intervention service in Australia.A theoretically informed case study was undertaken. Data from a community-based youth mental health service that delivers an early psychosis programme were collected between July and November 2020. Three data sources were accessed (1) interviews with service managers, mental health clinicians and exercise physiologists; (2) document review of organizational policies and procedures; and (3) survey using the Program Sustainability Assessment Tool. The implementation outcomes investigated were acceptability, fidelity, penetration, and sustainability. Framework analysis was used, and a logic model developed guided by an established template, to interpret findings.Forty-three contextual factors and 43 implementation strategies were identified. The data suggests that creating a new clinical team and auditing and feedback are critical for implementation. High levels of acceptability and sustainability were described, while fidelity of implementation was difficult to establish, and penetration was low.The relationship between constructs suggests several mechanisms underpinned implementation. These include changing professional beliefs, establishing new organizational norms, augmenting existing work processes, and aligning physical activity with priorities of the mental healthcare system and existing work tasks. This case study provides direction for future health service planning of physical activity interventions in community-based youth mental health service.

Mawer T., Kent K., Williams A.D., McGowan C.J., Murray S., Bird M., Hardcastle S., Bridgman H.

Mental illnesses are the leading cause of disability in young people, and lifestyle interventions in young people at risk of mental illness remain a priority. Opportunities to improve nutrition and physical activity among young people through youth mental health services remain unclear. This study aimed to determine the knowledge and behaviors towards nutrition and physical activity, the barriers and enablers to improving behaviors, and the preferred providers and sources of information for nutrition and physical activity among a sample of young people attending a youth mental health service. A mixed-method study was conducted in regional Tasmania, Australia in a sample of young people (15–25 years) attending a youth mental health service (headspace). A quantitative survey (n = 48) determined young people’s nutrition and physical activity knowledge, behaviors, barriers and enablers to achieving recommendations, and their preferred providers and sources of information. Structured interviews and a focus group further explored these concepts (n = 8), including the role of the mental health service as a provider of this support. The majority of participants did not meet national recommendations for nutrition and physical activity, despite possessing a high level of knowledge regarding their importance for mental health. Improving mental health was a common enabling factor for participants choosing to alter diet and physical activity habits, but also the leading barrier for participating in physical activity. Young people wanted to receive information from reputable health providers, ideally through social media sources. headspace was seen as an important potential provider of this information. Our results indicate that there is a clear need to improve diet and physical activity habits to enhance mental and physical health outcomes in this at-risk group, and youth mental health services could provide further interventions to support their clients. Specialized staff (e.g. dietitians and exercise physiologists) may provide additional benefits alongside existing mental health care support.

Ren D., Wang Y., Han M., Zhang Y., Cai C., Liu K., Li R., Liu H., Ou J., Wang Y., Han J., Chen R.

Compared to its cis-heterosexual counterpart, the sexual and gender minority (SGM) population is disproportionately susceptible to mental health problems, including depression, anxiety, and minority stress. They are also facing unique help-seeking barriers when in need of support. Past research has shown promising results in using interventions to promote help-seeking intentions and attitudes of the cis-heterosexual population. However, there were no known help-seeking interventions targeting the SGM population. This protocol illustrates a study design to test the efficacy of a newly-developed internet-based program aimed to promote help-seeking for mental health in LGBTQ+ young adults.This study is a randomized controlled trial that aims to promote and improve the SGM young adults' help-seeking by integrating animated psychoeducational videos, group discussion, and the SGM youth help-seeking brochure. Primary outcomes, including help-seeking intentions and attitudes, will be measured at baseline, post-intervention, one-month post-intervention, and three-month post-intervention. The secondary outcomes, including help-seeking stigma, help-seeking literacy, mental health literacy, and help-seeking behaviors, will be measured at the same time points.This is an internet-based, multi-dimensional, and integrative intervention tailored to the needs of the SGM population. It addresses an important gap in the current landscape of mental health promotion for the SGM population. The findings from this trial will provide new knowledge on promoting help-seeking among the SGM population, paving the road for future research that focuses on addressing mental health issues faced by the SGM population.Chictr.org.cn: ChiCTR2100053248.

Fibbins H., Edwards L., Morell R., Lederman O., Ward P., Curtis J.

Background: Physical activity significantly improves mental illness symptoms and physical health for people living with mental illness. Mental health services do not routinely provide their consumers with access to exercise professionals for physical activity engagement. Barriers exist to integrating physical activity as part of standard care including staff culture, finance, and resources. This study examines the feasibility of newly established exercise physiology clinic within a mental health service in Sydney, Australia.Methods: A single site, open trial was conducted in a community centre within a large mental health district. A meeting room was converted into a part-time exercise physiology clinic where individualised physical activity interventions were delivered by an accredited exercise physiologist. Outcome measures including BMI, cardiovascular fitness, and self-reported physical activity were collected.Results: A total of 84 mental health consumers (17% of eligible consumers within the mental health service) participated in the clinic on average for one exercise session weekly. Moderate-to-vigorous physical activity significantly increased and sedentary time significantly decreased (p &lt; 0.001).Conclusions: Exercise physiology clinics are feasible within mental health services and should be incorporated as part of standard care.

Gossip K., John J., Comben C., Page I., Erskine H.E., Scott J.G., Diminic S.

Aim To identify and describe key service components that should be incorporated into age-appropriate integrated mental health care for young adults aged 18–24 years. Methods Key service components were identified through a mixed-methods approach including targeted examinations of the literature and structured discussions with experts in youth mental health. Results Seven key components were identified as important for providing age-appropriate mental health care to young adults. Two were classified as clinical service components (structured psychological therapies; care coordination and liaison), three were classified as non-clinical service components (vocational support; youth development; peer support) and two as integrated non-clinical and clinical service components (lifestyle interventions and family and network support). Example service models for each of these key service components were identified and described. Conclusions This is the first study to identify and describe key service components for age-appropriate mental health care for young adults. The findings provide mental health service planners with a framework of services that should be considered when planning and resourcing services for this age range.

Xie Y., Wu Z., Sun L., Zhou L., Wang G., Xiao L., Wang H.

Background: It is necessary to seek alternative therapies for depression, because side effects of medications lead to poor adherence and some patients do not achieve a clinical treatment effect. Recently the role of exercise as a low-cost and easy-to-use treatment for depression has gained attention with a number of studies showing that exercise is effective at reducing depressive symptoms and improving body functions such as cardiorespiratory system and cognitive function. Because of the heterogeneity of exercise therapy programs, there is no standardized and unified program. Few studies have summarized the specific properties of exercise programs (type, intensity, duration, and frequency) and clinical prescriptions for exercise are not mentioned in most articles.Aims: This study aimed to investigate the feasibility and efficacy of exercise therapy for patients with depression, in order to appraise the evidence and outline accepted guidelines to direct individualized treatment plans for patients with depression based on their individual situations.Methods: A systematic review of English language literature including papers published from 2010 to present in PubMed was performed. Given the feasibility of prescribing exercise therapy for patients with depression, nearly 3 years of clinical studies on the treatments of depressive symptoms with exercise were first reviewed, comparing the exercise programs utilized.Conclusions: Exercise has therapeutic effects on depression in all age groups (mostly 18–65 years old), as a single therapy, an adjuvant therapy, or a combination therapy, and the benefits of exercise therapy are comparable to traditional treatments for depression. Moderate intensity exercise is enough to reduce depressive symptoms, but higher-dose exercise is better for overall functioning. Exercise therapy has become more widely used because of its benefits to the cardiovascular system, emotional state, and systemic functions.Recommendations: Aerobic exercise/mind-body exercise (3–5 sessions per week with moderate intensity lasting for 4–16 weeks) is recommended. Individualized protocols in the form of group exercise with supervision are effective at increasing adherence to treatment.

Hui T.T., Garvey L., Olasoji M.

People with mental illness experience a shorter life expectancy compared to the general population. Poor physical health trajectory emerges following the onset of psychosis and is further compounded by the initiation of antipsychotic treatment. Young people are particularly at risk as the onset of mental illness mostly occurs between the age of 12 and 25 years. This represents a crucial period for early intervention to prevent a physical ill health trajectory. Furthermore, those who are at ultra-high risk for psychosis should also be targeted for early intervention. Lifestyle interventions have been identified as the first-line physical health promotion practice for improving the physical health of people with severe mental illness. The aim of this study was to conduct a scoping review following the JBI methodological guidance on scoping reviews to explore the current literature on lifestyle intervention trialled for early psychosis, including first-episode psychosis and those who are at ultra-high risk for psychosis. This review also explores the extent of literature examining physical health literacy in this specific population. The literature search was conducted on Medline, Embase, PsycINFO and Scopus. Twenty-two studies were included for the purpose of this scoping review, 21 of which examined the effects of lifestyle interventions and one of which reported on physical health literacy. This scoping review indicates the need for co-designed lifestyle interventions with the involvement of service users, families and carers and a focus on promoting physical health literacy, social support, and an incorporation of a health behaviour change model focus on promoting autonomous motivation. The findings of this study can inform future development of a novel co-designed lifestyle intervention for the targeted population.