Psychology Textbook Chapter 17 Physical Activity and Severe Mental Illness

Chapter 17 Physical Activity and Severe Mental Illness Hamish , Oscar , and Simon the Body in Mind Program , South Eastern Sydney Local Health District , Australia of Medical Sciences , University of New South Wales , Australia of Psychiatry , University of New South Wales , Australia Please cite as , 2021 ) Physical activity and severe mental illness . In Jones ( Essentials and sport psychology An open access textbook ( Society for Transparency , Openness , and Replication in Kinesiology . Attribution 40 International This content is open access and part of Essentials of Exercise and Sport Psychology An Open Access Textbook . All other content can be accessed at Chapter Overview Severe mental illness refers to a group of disorders that significantly impair a psychosocial functioning . Psychosocial functioning is a person ability to engage in activities of daily life ( work , socializing , and play ) in a way that is meaningful . Although many other mental disorders can be severe , the term severe mental illness includes diagnoses of schizophrenia , bipolar disorder , and major depressive disorder . People living with severe mental illness can experience due to societal stigma in addition to poor physical health and reduced life expectancy . The impact of these disorders on a person physical health will be explored throughout this chapter , along with the beneficial role that physical activity can play in their prevention and management . The concept of lifestyle psychiatry will be explored , outlining the importance of addressing modifiable risk factors for people living with severe mental illness . In addition to physical activity , this chapter will also examine the vital role of sleep on a person physical and mental health , the role of exercise professionals within mental health systems , and the process of integrating physical activity interventions as part of routine mental health treatment in settings . For correspondence

Chapter 17 Physical Activity and Severe Mental Illness What is Severe Mental Illness ?

Many mental health conditions can be considered as severe for the people who experience them , as well as their support networks . However , the phrase severe mental illness refers to a specific group of mental health disorders including schizophrenia , bipolar disorder , and major depressive disorder , that significantly impact a person functioning in daily life and in some cases , may be associated with a distorted sense of reality . Severe mental illness can also be defined by the length of duration and the subsequent disability it has on a person life . Here we outline some severe mental illness diagnoses as well as common symptoms , to provide a brief context for how physical health can be subsequently impacted and the role that physical activity can provide as part of a treatment plan . Examples of severe mental illnesses are schizophrenia , bipolar disorder , and major depressive disorder . Schizophrenia This complex disorder can impact a person mental health , physical health , and cognitive function . Lifetime prevalence for developing schizophrenia affects approximately of the population ( Kessler et , 2005 ) It can produce intense periods of psychosis and negatively impact functioning . Symptoms of schizophrenia are generally divided into three broad categories positive symptoms , such as hallucinations or delusions , which are added to someone experience negative symptoms , describing loss of experience , which can include social withdrawal , decreased enjoyment in activities , and reduced motivation and finally , cognitive impairment , which is associated with changes in memory , attention , cognition , and executive function . Bipolar Disorder Bipolar disorder significantly impacts a person mood or affect and is characterized by periods of elevated moods or mania where people can present with increased energy , impulsivity , and reduced sleep . This can be followed with significant depressive episodes . The lifetime prevalence for developing this disorder is approximately ( et , 2010 ) Bipolar disorder can also include experiences of psychosis . Major Depressive Disorder Major depressive disorder is a prevailing and debilitating mental health condition and is one of the leading contributors to the global burden of disease . Major depressive disorder has approximately a 16 lifetime prevalence ( Kessler et , 2005 ) and accounts for of the global years lived with disability in 2010 ( Ferrari et , 2013 ) Symptoms that are commonly experienced with major depressive disorder include persistent low mood and reduced interest in activities or hobbies , in addition to poor sleep , changes in appetite , and in some cases suicidal ideation . People living with major depressive disorder may also experience declined social functioning , such as difficulties with maintaining relationships and employment . Psychosis Psychosis describes a group of symptoms which are experienced by people with a psychotic disorder ( schizophrenia ) Symptoms of psychosis impact an thoughts and perceptions and are defined by a distortion in a person perception of reality . This can include senses including smell , thoughts , visions , tactile sensations , and beliefs . Most people that develop a psychotic disorder will experience symptoms prior to 25 years of age ( Morgan et , 2012 ) It is important to recognize that psychosis is a symptom ofa mental disorder , rather than an illness itself . While we do not fully 386

, understand how psychosis develops , various factors can contribute to a psychotic episode including family history , mental or physical illness , extreme stress , trauma , and substance use . Psychosis , which is not to be confused with , typically develops in youth or adolescence and is typically accompanied by marked decline in functioning , changes in behaviour including difficulties concentrating , sleep disturbances , withdrawing from social supports , disorganized speech , depression , and anxiety . The first episode of psychosis or is when someone experiences psychosis for the first time . Symptoms of psychosis can include hallucinations , delusions , and disordered thinking and cognition . Hallucinations Hallucinations occur when someone experiences sensations inconsistent with reality . Hallucinations are most commonly auditory ( hearing voices ) but may also be visual ( seeing shapes or figures ) in tactile form ( experiencing sensations or feelings ) olfactory ( smelling odors that are not present ) or gustatory ( impacting taste ) Delusions Delusions refer to beliefs that are not based on reality and may impact individual actions or functioning . Delusions can vary depending on the individual and the illness . Delusions may , for example , be paranoid , grandiose , somatic , persecutory , or romantic in nature . Disordered Thinking and Cognition Speech and thought patterns may become confused and . People may experience problems with memory and other cognitive process ( concentration ) This can result in people behaving or communicating differently . Early Psychosis and Risk Those with or risk refers to a group of individuals who are at high risk of developing psychosis this is often referred to as the prodromal period ( et , 2016 ) To meet criteria for risk , individuals may exhibit a number of factors including genetics or family history , the presence of some brief limited intermittent psychotic symptoms ( BLIPS ) or attenuated ( threshold ) symptoms of psychosis ( Yung et , 2005 ) Youth in these categories will be diagnosed by an experienced mental health clinician using a validated assessment tool ( Nelson , 2014 ) Early intervention is a critical period , for both physical and mental health outcomes , to improve the future for youth experiencing psychosis for the first time ( et , 2014 ) Health Risks for People with Severe Mental Illness People living with severe mental illnesses face high rates of premature mortality compared to members ofthe general population ( Baxter et , 2016 ) The major contributor to this early mortality is poor physical health , often linked to diseases . In particular , people with severe mental illness have a increased risk of developing diseases compared to people without mental illness ( Firth et , 2019 ) This accounts for approximately of the premature mortality ( John et , 2018 ) This is associated with higher rates , obesity , metabolic syndrome , and respiratory complications . Additionally , people living with severe mental illness face high levels of disability , with schizophrenia being the 12 largest cause of years lived with a disability worldwide ( Vos et , 2017 ) 387

Chapter 17 Physical Activity and Severe Mental Illness Impact of Modifiable People living with severe mental illness are at high risk of disease impacted , in part , by multifactorial lifestyle risk factors including cigarette smoking , physical inactivity , consuming poor diets , and experiencing poor sleep ( Firth et , 2020 ) Cigarette Smoking People with severe mental illness are more likely to smoke cigarettes , with approximately in people a smoker compared to approximately in 10 people in the general population ( et , 2015 ) People with severe mental illness are more dependent on nicotine and have increased difficulty engaging in smoking cessation programs compared to those in the general population ( Ashton et , 2013 et , 2009 ) Physical Inactivity People with severe mental illness are less likely to be physically active than the general population and struggle to meet recommended physical activity guidelines of a minimum of 150 minutes of physical activity per week ( Firth , et , 2017 ) There are differences in physical activity engagement between differing severe mental illness diagnoses people with bipolar disorder engage in more physical activity than people with schizophrenia or major depressive disorder . and medication can affect engagement ( this will be explored in greater detail later in this chapter ) People with severe mental illness are more sedentary than the general population and on average are sedentary between hours of the day ( Firth , et , 2017 ) High levels of sedentariness may be further complicated by factors associated with the mental health disorders such as social isolation and obesity ( Firth , et , 2017 ) Poor Diet Compared with the general population , people with severe mental illness tend to have diets that are low in nutritional quality and have a higher caloric intake . Medication side effects can increase a person desire to eat desire for , foods is particularly increased ( et , 2017 ) Sleep and Mental Illness As in the general population , sleep is a significant component of maintaining good physical and mental health and represents a growing facet of mental health research ( Firth et , 2020 ) When sleep is impaired , it can lead to weight gain , increasing a person risk of the development of obesity and metabolic abnormalities . For people with severe mental illness , sleep disturbances are a highlighted risk factor that can lead to the development of psychiatric symptoms in addition to the exacerbation of known symptoms . For people with a mental disorder , up to 90 report abnormal sleep behaviour , which can include difficulty initiating sleep or insomnia ( et , 2005 ) Symptoms of severe mental illness such as paranoia can impact sleep quality ( et , 2014 ) and medications can impact sleep duration and as such decrease sleep quality ( et , 2011 ) Given the prevalence of poor sleep within this population group , providing interventions that promote good sleep practices is paramount . regular physical activity is associated with improvements in sleep quality in people with mental illness ( et , 2018 ) Social of Health High rates of early death and risk are prevalent in people with severe mental illness even once lifestyle risk factors are accounted for ( et , 2008 ) This suggests that physical health is influenced by external factors including the provision and availability of health care , 388

, socioeconomic status , and geographical location . People with severe mental illness are less likely to have access to and engage in quality health care services compared to the general population . Social of health , which includes employment and financial insecurity , homelessness , poor education , and poverty , increase a person risk of developing mental and physical illnesses ( Marmot , 2005 ) Learning Exercise One Describe some common symptoms of the main diagnoses of severe mental illness and include how these symptoms may affects a person daily functioning . Current Treatments for Severe Mental Illness Clinical approaches to managing symptoms of severe mental illnesses vary according to symptom presentation , and medical history , demographic factors , and severity of symptoms . People with severe mental illness may experience a combination of treatments including medications ( typically antidepressants and antipsychotic medications ) therapies ( such as cognitive behavioural therapy ) and occupational and social recovery therapies . Physical activity is becoming increasingly recognized as an adjunct treatment for severe mental illness , which will be explored throughout this chapter . Impact of Medications The high rates of conditions in people with severe mental illness are in part due to the of antipsychotic medications that are prescribed to treat people with severe mental illness . These medications , whilst effective in reducing symptoms of severe mental illness and reducing risks of to hospital , have significant negative effects on physical health including the , endocrine , and neuromotor systems . Weight gain is a commonly reported side effect from many antipsychotic medications , and increases a person risk of developing metabolic syndrome , diabetes , and cardiovascular complications ( et , 2008 ) Almost 80 of people who commence antipsychotic medication will experience clinically significant weight gain ( more than of their initial weight ) within their first year of beginning the medication ( et , 2009 ) Endocrine Abnormally high level of prolactin , or , is a side effect of antipsychotic medications ( et , 2014 ) This may cause unwanted such as sexual dysfunction and menstruation issues in people taking this medication ( et , 2003 ) Neuromotor Side effects are more common of the older , first generation typical antipsychotics and may include muscle spasms , restlessness , and involuntary movements which can be socially for people it affects and can be associated with a reduced quality of life ( et , 1999 Briggs et , 2008 ) 389

Chapter 17 Physical Activity and Severe Mental Illness Learning Exercise Two Outline how a person physical health may be impacted if they are receiving treatment for schizophrenia . Benefits of Physical Activity for Severe Mental Illnesses A robust body of evidence exists documenting the bidirectional relationship between physical activity and mental health ( Firth et , 2019 ) In addition , physical activity is increasingly recommended as a routine component of treatment for people with severe mental illness , to protect and promote physical and mental health . Physical activity is effective in improving health through various mechanisms including reduced blood pressure , improved glucose metabolism , and increased cardiorespiratory fitness ( et , 2013 ) Cardiorespiratory fitness is a key risk factor contributing to the premature mortality in people with severe mental illness ( et , 2015 ) Cardiorespiratory fitness is the ability of the heart , circulatory system , and lungs to supply oxygen to the skeletal muscles during physical activity . In the general population , improvements in cardiorespiratory fitness can reduce mortality by up to 13 and impact risk reduction by 15 ( et , 2009 ) For people with severe mental illness , reduction in risk following participation in an exercise program can occur in as little as weeks of structured exercise ( Firth et , 2015 , et , 2017 , Ward , et , 2015 ) Additionally , it has been demonstrated that lifestyle interventions incorporating both physical activity and dietary components are effective in preventing the weight gain associated with medication ( et , 2008 Curtis et , 2016 et , 2014 ) Severe mental mental health benefits of physical activity are outlined below . Schizophrenia Physical activity , particularly performed at a intensity , can lead to improvements in both positive and negative symptoms for people with schizophrenia ( et , 2018 ) Additionally , global cognition ( which refers to a person functioning and working memory ) improves following physical activity engagement . These cognitive improvements can occur with as little as 90 minutes of physical activity weekly that is of intensity ( Firth et , 2017 ) Structured exercise that elicits increased fitness is correlated with increased brain volume , which may impact neurogenesis ( the process by which new neurons are formed ) through plasticity in the volume of the hippocampal brain region ( et , 2010 et , 2013 ) Major Depressive Disorder Physical activity is effective in improving mood and in people with depression following a single session of exercise , particularly those that are of moderate or higher intensity ( et , 2016 ) Additionally , regular participation in physical activity in healthy people is beneficial for reducing future risk of developing depression ( Firth et , 2018 ) Studies indicate that physical activity is effective in treating depression with effects similar to traditional treatments including antidepressant medication and with fewer negative ( and many adjunct positive effects , et , 2016 ) For people with major depressive disorder , physical activity and exercise is recommended as adjunct to standard care by the World Health Organisation ( World Health Organization , 2018 ) While the mechanisms for how physical activity improves depressive 390

, symptoms are not fully clear , research indicates that physical activity can improve abnormal associated with major depressive disorder this can include cortisol reduction and decreases in chronic inflammation ( et , 2019 ) For more on the relationship between exercise and depression , see Chapter 15 ( Brush , Bipolar Disorder Early evidence related to the role of physical activity for people with bipolar disorder suggests that physical activity is protective for cardiovascular disease however , more evidence is needed regarding the impact on mood ( et , 2018 ) Research suggests that physical activity may be beneficial for mood fluctuations for people with bipolar disorder due to potential links to improvements to the brain functional connectivity ( et , 2014 ) Cardiorespiratory fitness is associated with quality of life in people with bipolar disorder for both physical and mental health domains ( et , 2017 ) Fitness Fatness People with severe mental illness are more likely to be overweight and obese , which can also impact participation in physical activity , due to not only reduced fitness , but also perceived pain and poor ( et , 2019 et , 2011 ) Achieving significant weight loss is difficult for the general population with only one in 210 males and one in 124 females achieving a healthy ( under 25 ) without surgery ( et , 2015 ) Exercise professionals and mental health should encourage people living with mental illness to engage in physical activity regardless of their body weight and perceived body image . It is important to note that without specialized dietary input , exercise is likely to be ineffective in achieving weight loss for people with severe mental illness ( Firth et , 2015 ) While this may seem disheartening for people , particularly when trying to engage in physical activity , research tells us that improving fitness can reduce risk and improve mental health , sleep quality , functional capacity , and cognition , regardless of change in weight . This can be a useful educational and motivational strategy for to assist clients in increasing physical activity levels . Learning Exercise Three Discuss ( a ) the benefits of physical activity in people with schizophrenia and ( the mechanisms of how physical activity affects depressive symptoms . Barriers to Engagement in Physical Activity Low engagement in physical activity is prevalent in the general population and this may be influenced by many factors , including socioeconomic status , low confidence and knowledge about exercise , and lack of enjoyment ( 2002 ) Further , people living with severe mental illness experience additional barriers to being physically active that can be categorized into physical health , mental health , and social factors ( Firth et , 2016 ) Physical Health The high rates of physical health conditions can negatively impact engagement in physical activity ( Firth et , Obesity , associated chronic pain and problems , can make physical activity difficult and less enjoyable , thus impacting exercise participation ( Firth et , 2016 ) Low cardiorespiratory fitness , seen in people living with severe mental illness , can also impact a 391

Chapter 17 Physical Activity and Severe Mental Illness person ability to engage in long periods of physical activity , particularly if aerobic in nature . Other issues including low energy and lethargy as a result of antipsychotic medication can be impactful ( Firth et , 2016 ) Mental Health Common barriers from a mental health perspective include depressive symptoms , stress , low motivation , and acute psychotic symptoms ( hallucinations , delusions and paranoia , anhedonia ) Additional reported barriers include feeling unsafe when exercising or concerns about being injured , and low interest in exercise ( Firth et , 2016 ) engagement in physical activity is impacted by a person autonomous motivation , that is , an internal desire to participation ( et , Given the unique barriers that people with severe mental illness face regarding physical activity participation , developing individual strategies specific to members this population group that target improvements in intrinsic motivation ( health coaching and motivational interviewing ) is paramount when aiming to increase engagement ( 2016 ) Social Factors Strong social support networks assist in the uptake and regularity of physical activity , and individuals with severe mental illness are more likely to experience social isolation which can affect engagement ( et , 2005 ) Additionally , the financial costs , lack of resources , and time pressures associated with exercising are common reasons why people with severe mental illness may not engage in physical activity ( Chapman et , 2016 Firth et , 2016 Stanton et , 2015 ) Learning Exercise Four What are the key barriers for people with severe mental illness engaging in physical activity ?

Photo by Cycling Clothing 392 , to Exercise Unless a person with mental illness has been diagnosed with severe physical issues , physical activity and exercise is generally safe and effective to prescribe , particularly if of intensity ( et , 2018 ) The unique barriers to engaging in physical activity should be taken into consideration when promoting activities and an individualized approach ( including referral to an exercise professional ) should be encouraged . Prior to beginning structured exercise programs , particularly if they are of high intensity , a person with mental illness should be screened for absolute and relative to engaging in physical activity , as per guidelines recommended by the American College of Sports Medicine ( American College of Sports Medicine , 2017 ) The Physical Activity Readiness Questionnaire ( is a series of short questions that identifies any absolute to exercise ( Thomas et , 1992 ) Additionally , people experiencing higher levels of mental distress or poor mental health symptoms may need additional support to engage in appropriate and safe exercise . Like the general population , people with mental illness should be screened for typical to exercise ( such as hypertension or a recent cardiac event ) See Table for a list of precautions that should be considered specific to this population ( Firth et , 2016 ) Table Precautions to Consider for People with Severe Mental Illness Potential Precautions and Considerations Issues Fatigue Prolonged tiredness and poor concentration are common for people and are influenced by factors including side effects of medication , sleep troubles , and . An individualized approach to an exercise plan tailored to times when a client may be more energetic is ideal . Social Public places and larger groups of people can act as a deterrent to engaging in anxieties physical activity . Setting small goals around exercise and establishing a routine is important initially , and gradually progressing may help with familiarity for clients of In addition to extreme tiredness , other side effects of taking medications medication can include visual problems , increased sweating and salivation , and issues with balance . Close monitoring of the client is important throughout the exercise session and adapting to the client changing needs will assist with increasing their confidence . Psychotic While symptoms such as auditory and visual hallucinations may present symptoms complications to engaging in physical activity , they do not preclude a person from participating . Instead , choosing activities that are lower intensity in nature should be considered . Exercises and activities such as resistance training , walking , and light stretching may be helpful . If people are presenting as manic or with extreme elevated moods , limiting distractions including music or television is encouraged . Exercising in a quiet space without people around can also be helpful . 393

Chapter 17 Physical Activity and Severe Mental Illness Learning Exercise Five What are the key safety concerns for people with mental illness engaging in structured physical activity ?

Motivation and Physical Activity Physical inactivity is not just an issue for people with mental illness as many people in the Australian general population also do not meet the recommended guidelines for physical activity ( 150 minutes of moderate or 75 minutes of vigorous physical activity weekly Australian Bureau of Statistics , 2015 ) In Australia , a little more than half of adults meet the guidelines for physical activity ( Australian Institute of Health and Welfare , 2018 ) Less than half the population in the United States meet the recommended levels of physical activity ( et , 2015 ) and rates of inactivity are higher in Europe , where almost 60 of adults do not engage in appropriate levels of activity ( et , 2010 ) Given the robust evidence demonstrating the benefits of physical activity in improving the physical and mental health of people living with severe mental illness , it is important to examine the ways in which people can be supported to engage in exercise throughout the life course . Examining people internal perceptions and motivation to exercise is a vital component of physical activity prescription ( Chapman et , 2016 Firth et , 2016 , De et , 2015 et , 2016 ) Negative symptoms that are associated with schizophrenia can be associated with lower levels of motivation towards physical activity ( et , 2015 ) These low levels of motivation may be related to a person own priorities towards exercise and their physical health , past experiences with engagement , or beliefs about structured physical activity . Competing interests and priorities including work , study , and family can also be factors that affect motivation , in addition to socioeconomic factors such as lack of access to resources ( et , 2007 ) Education about how to engage effectively and safely in structured exercise and fostering motivation through building and a sense of competency can improve participation . People may have had previous negative experiences with exercise , which may affect future performance ( et , 2018 ) The influences that may dissuade people with mental illness from engaging in physical activity should be discussed by their health care providers to formulate an exercise plan that is based on the person interests and preferences . Theory Examining the research into what motivates people to exercise is important for understanding how to support those with severe mental illness with healthy behaviours ( for more discussion on physical activity and exercise behavior , see Chapter Rebar et , 2021 , Chapter Brand , 2021 , and Chapter , 2021 ) Utilising the theory ( et , 2008 ) can be an effective way of facilitating long term enjoyment in physical activity ( see Chapter et , 2021 ) This theory is regularly used by many health professionals , including exercise specialists , to ascertain factors that guide someone motivation to engage in a particular behaviour ( exercise ) It is applicable in the and recovery of people with severe mental illness and can be used in the identification of external and internal forms of motivation . This theory examines specific basic psychological needs including autonomy , relatedness , and competence , and when applied to exercise can help people understand the reasons why they may or may not exercise . The theory states that intrinsic motivation is more conducive with exercise participation . has been identified as important in people with schizophrenia for engaging in exercise participation ( et , 2015 ) So how does this work in practice ?

Motivational 394 , interviewing can be used with clients that have a mental illness to assist in promoting positive attitudes towards exercise and to help in discovering what motivates them to engage ( 2016 ) Model of Health Behaviour Change The model ( Table ) suggests that making changes to health behaviours are typically achieved through five stages of change ( et , 1997 ) These stages of change can assist in guiding conversation , education topics , and eventually exercise prescription ( et , 1994 ) Table Stages of Change Based on the Model Stage Stage Description During this period , people are not generally considering the practical steps to beginning exercise , so it is a good time to provide basic education . Identifying what is most important to them is of importance and gradually relating these goals back to the benefits of physical activity may be appropriate . As a clinician , you may then be able to get a level of understanding as to the thoughts towards physical activity . Contemplation As a clinician you can use this time to provide more detailed education and challenge beliefs that the person may have about what participating in physical activity might look like . Motivational interviewing should continue . Preparation During this stage , the client should engage in goal setting around future planned physical activity , planning next steps , and exploring barriers and strategies to overcome challenges . Action The client should begin regular physical activity and ideally in an activity that is enjoyable to them . Work with your client to identify ways in which they might adhere to their schedule . These may include the use of activity trackers or finding a friend or partner to exercise with . Reflecting on past experiences can be helpful to manage mood and psychological states . Providing positive reinforcement should be a focus of the clinician . Working towards maintaining current physical activity levels should be a goal ofthis period . This includes increasing goal setting to periods in addition to reviewing goals to overcoming obstacles to participation . Maintenance At this stage , the client should be able to maintain their current physical activity levels independently and identify what are the internal motivating factors to their participation . New activities can be introduced and a plan to return if lapses occur can be developed . Throughout these stages , it is important to openly discuss and listen to the client needs and goals so that a approach to exercise prescription can occur ( Slade , 2010 ) Understanding that symptoms of a person mental illness may mean that the process may not be linear , and flexibility may be necessary . It can often take multiple attempts before someone succeeds in adopting lifestyle changes for the long term and as such , these stages can often be cyclical in nature . These components should be key in the education provided to clients to manage expectations and assist the client in adherence to the physical activity program . 395

Chapter 17 Physical Activity and Severe Mental Illness A typical approach of health professionals when educating people in lifestyle behavior change is to initially educate and then persuade them to adopt new behavior through prescriptive directions . However , this approach is not typically effective as the simple act of providing information does not result in behavior change . Health coaching is a method of utilizing the motivational theories previously discussed ( such as the theory and the model ) and practically applying them in a context ( Table ) Table Consider the Ways in Which People with Mental Illness Might from a Motivational Health Coaching Approach to Physical Activity Education Compared to a Traditional Model Traditional Interviewing Style Health Coaching Clinician is the expert in health Client is the expert in their own life experience and is respected topic to make autonomous decisions Clinician give advice and prescribes Client identifies areas of health they would like to work on , and solutions to solve problems clinician works through options available providing information as requested Clinician decides that client is at Client leads change and clinician uses strategies to increase the stage to make health changes client confidence and Clinician focuses on why things are Clinician provides positive encouragement at whatever stage not being achieved and solutions client is in to this Learning Exercise Six Imagine a person with schizophrenia has been referred to you for lifestyle intervention . Utilising the concepts of the theory , outline the key concepts of your interview and physical activity prescription , given the person is in the preparation phase of the model of health behaviour change . Exercise Professionals in Mental Health Services There is overwhelming evidence supporting the benefits of physical activity for people living with severe mental illness , yet there are simultaneously significant barriers to participation . As such , embedding exercise professionals within mental health services to promote the integration of exercise interventions has been of growing interest to expand upon the treatment options available to people with severe mental illness . Exercise professionals are experts in physical activity prescription , particularly for people living with chronic disease ( including mental illness ) and provide assessment , prescription , and delivery of exercise and physical activity interventions ( et , 2016 Stanton et , 2018 et , 2018 ) Throughout Europe , have performed these roles and in the United States there are a growing number of clinician exercise working in mental health settings ( et , 2019 , et , 2014 , 2018 ) Australia has an increasing number of exercise professionals working in private and public health systems , particularly in mental health services . Accredited Exercise ( are qualified health professionals that lead physical activity interventions for people living with mental 396

, illness . There are robust referral schemes that people can access for exercise counselling and prescription through care . have growing representation in many mental health care settings including community health centers and inpatient wards . They work to provide specialized services to mental health clients delivering individualized interventions in addition to the mental health workforce to be more knowledgeable regarding the benefits of lifestyle interventions . In response to this rapidly growing industry , exercise professionals specializing in mental health are represented internationally by peak bodies and organizations . Ajoint consensus statement by peak professional organizations throughout Australia , the , the , and New Zealand determined that integrating physical activity interventions lead by exercise specialists was key to improving the physical health of people living with mental illness ( et , 2018 ) The International Organization of Physical Therapists in Mental Health ( supports exercise professionals and upholds them as experts in lifestyle management and integral members of the health team ( et , Exercise and Sports Science Australia ( ESSA ) is the peak organization that represents and provides accreditation to within Australia and promotes their services to mental health bodies and the wider community . Promotion through these organizations is critical to promoting the services of exercise professionals and as such there have been emerging recommendations for exercise to be included as part of standard mental health care treatment . This is represented in documents published by the American Medical Society for Sports Medicine , Canadian Network for and Anxiety Treatments ( the National Institute for Health and Care Excellence ( NICE ) and the Mental Health Commission of ( Chang et , 2020 Mental Health Commission of New South Wales , 2016 Stanton et , 2014 ) The Importance of Culture and Organizational Leadership Despite the overwhelming evidence demonstrating the need for integrated physical activity interventions in mental health settings , there are significant challenges to their practical implementation . Traditionally , physical health in mental health settings has not been prioritized despite key principles , processes and standards to do so enshrined in international policies and guidelines ( et , 2014 ) Clinician and workplace culture has been identified as a novel and targeted way of bridging the traditional structure between physical and mental health . There is evidence suggesting that health workers that partake in healthy lifestyle behavior are more likely to promote such behaviors to their patients and refer them to exercise professionals ( et , 2018 Stanton et , 2015 ) As such , designing workplace lifestyle interventions , incorporating exercise and diet , and providing them to mental health staff may be a key strategy to improve outcomes for patients . Such interventions in mental health settings are feasible and acceptable ( et , 2018 ) and do not negatively impact productivity . Additionally , improvements to workplace satisfaction , morale , and workforce capacity can be improved through such interventions ( et , 2008 et , 2016 Tucker et , 2016 ) A Lifestyle Intervention for Youth with Mental Illness The Keeping the Body in Mind ( program ( Curtis et , 2016 ) is a lifestyle intervention implemented as part of routine clinical care in a public mental health service in Sydney , Australia . The service includes weekly individualized consultations with a physical health team including a nurse , exercise physiologist , dietitian , and peer support worker . There is a free onsite gym that is serviced by student exercise , in addition to cooking and sports groups . Initially evaluated as a pilot research project , youth with psychosis were offered this innovative program over a period and results were compared to another mental health service offering standard care ( medication and psychotherapy ) 397

Chapter 17 Physical Activity and Severe Mental Illness The program successfully prevented antipsychotic related weight gain following the intervention while participants in the control group gained almost in weight and in waist circumference over the same time . Additional improvements were also evident , including improved cardiorespiratory fitness and significant improvements in discretionary food intake and increases in diet quality . As a result , the pilot program was implemented as part of standard care and now delivers interventions by multiple teams employed on a basis across a large mental health district . Conclusion Physical activity interventions should be a key component of the standard treatment for people living with severe mental illness . These interventions can be safe , are highly acceptable , and result in improvements in both physical and mental health outcomes . Exercise professionals should be included within mental health treatment teams and be referred to by primary care physicians and mental health team members . The uptake of such services is vital to improving health outcomes for people living with severe mental illness . Further Reading , 2018 ) interventions for mental illness Physical activity as part of clinical treatment . Academic Press . International Physical Health in Youth Stream . 2021 ) Keeping the Body in Mind . 2021 ) References , 2005 ) Sleep and psychiatry . Dialogues in Clinical Neuroscience , 291 . I . 2014 ) Treatment adherence and quality of sleep in schizophrenia outpatients . in Clinical Practice , 18 ( 2008 ) weight gain in chronic and psychotic disorders A systematic critical reappraisal . Drugs , 22 ( American College of Sports Medicine . 2017 ) exercise testing and prescription . Williams Wilkins . 1999 ) Quality of it means to me Results of a survey among schizophrenic patients . Praxis , 26 ( 56 . Ashton , 2013 ) What do 1000 smokers with mental illness say about their tobacco use ?

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