Inequalities in physical health are thought to underlie the premature mortality experienced by people with severe mental illness (SMI) (Ribe et al, 2014). People with SMI have a higher risk of cardiovascular disease (Gardner-Sood et al, 2015) and one of the main modifiable risk factors in this patient group is a lack of exercise (Stubbs et al 2016a; Vancampfort et al 2016a).

The question for researchers and healthcare professionals now is how do we increase activity in patients with severe mental illness?

Meta-syntheses of qualitative literature (Mason and Holt, 2012; Soundy et al 2014) have tried to address this and the subject of my blog today attempts to go further by conducting a systematic review and meta-analysis of quantitative data from survey-based studies, which explore the motivating factors and barriers towards exercise in patients with SMI (Firth et al, 2016).

Methods

• The search included articles up to May 2016 in the following electronic databases: Ovid Medline, Allied and Complementary Medicine Database (AMED), PsycINFO, EMBASE, and the Health Management Information Consortium (HMIC) database. Google Scholar and reference lists of retrieved articles were also searched.
• Eligible studies were English language only and >80% of sample had a confirmed diagnosis of SMI (e.g. schizophrenia, schizoaffective disorder, other psychotic disorders, bipolar disorder or major depressive disorders). Studies that reported proportional data on motivating factors and/or barriers towards physical activity among people with SMI, from questionnaires, surveys or other quantitative methods were included.
• 1,163 articles were identified (1,534 prior to removal of duplicates). 1109 articles were excluded after reviewing title and abstracts and full text versions were retrieved for 54 articles, of which 9 were eligible for inclusion. A further 3 articles were identified from Google Scholar.
• Thus in total 12 studies, comprising 6,431 psychiatric patients with SMI were eligible for inclusion.

Results

Motivating factors

• The most endorsed reason for exercising was to improve physical health (91%), increasing fitness/energy was a motivating factor for 75%, improving appearance (77%) and losing weight (83%)
• Reducing stress (80%) and managing mood (81%) were popular psychological motivating factors, as was improving sleep patterns (72%). Enjoyment of exercise was only endorsed by 54% of patients
• Social aspects of exercise were seen as a motivating factor for just 27% of patients.

Barriers

• Tiredness/low energy was reported as a barrier by 45% of patients and physical illness and poor health was a barrier for 25% of patients.
• Stress/depression was a barrier to exercise for 61% and disinterest in exercise a barrier for only 32%. Data on low motivation was not suitable for meta-analysis but was stated as a common psychological barrier to exercise.
• The most frequently experienced practical barrier was a lack of support, reported by 50% of patients. Lack of time was only identified as a barrier by 19% of patients.

Conclusions

The purpose of this study was to examine the motivating factors and barriers towards exercise among people with severe mental illness in order to design and target interventions to increase exercise participation in this group. Using 12 studies, and data from 6,431 psychiatric patients, Firth et al (2016) showed that the primary incentive to participate in exercise was to improve physical health, and to achieve weight loss, comparable to the general population (Sherwood and Jeffery, 2000).

An interesting finding of this study was that perceived benefits of exercise such as reducing stress and mood enhancement were also barriers to exercise. Lack of support was a major barrier. Indeed, other studies have shown that in patients with SMI, interventions that provide professional support are more effective (Vancampfort 2015, 2016b, Stubbs et al 2016b).

While there is currently a lack of cost effectiveness research examining supervised exercise in SMI, similar programmes for Diabetes, Heart Disease and Mild Depression have shown that professionally delivered exercise training produce large economic benefits (Deloitte Access Economics, 2015).

More research is needed comparing the effectiveness (and cost-effectiveness) of different exercise programmes in patients with SMI taking into account the unique barriers these patients face.

Strengths and limitations

A major strength of this study is the large number of patients included in the analysis and that within this sample 50% of participants belonged to an ethnic minority. However, no studies made any comparison of motivations or barriers between ethnic groups, despite other studies showing that there are significant differences (Dergance et al, 2003; Belza et al 2004). In this sample 85% of respondents had a diagnosis of schizophrenia, thus it is unclear if these results can be generalised across all severe mental illnesses.

Despite the large total sample, some of the motivations and barriers assessed in the meta-analysis were examined in only 3 of the 12 included studies, and not all data was suitable for inclusion in the meta-analysis. Undertaking a full systematic review may have negated this factor to some extent but it still remains that for individual motivating factors or barriers the sample size varied greatly, undermining their impact.

One of the purposes of this study was to overcome the criticisms of previous meta syntheses of qualitative literature that are affected by interviewers’ biases and the small sample sizes (Mason and Holt, 2012; Soundy et al 2014). However, in using studies based on self-reported data from questionnaires and surveys the data here are subject to response bias as well as problems caused by lack of information or experience amongst participants.

Summary

• Data from this large systematic review and meta-analysis show that improving physical health, weight loss and fitness are the main motivating factors for patients with SMI to engage in exercise
• Reducing stress, low mood and fatigue are major psychological motivating factors to engage in exercise in patients with SMI, however patients also cite these factors as barriers to exercise presenting a unique challenge for the design of interventions
• Lack of support is the major socio-economic barrier in patients with SMI
• Further research is required to see if professional. supervised interventions are indeed cost effective in patients with SMI
• Further research is also needed to examine if these results can be generalised across ethnic minorities and other psychiatric disorders such as bipolar disorder and major depression.

Links

Primary paper

Firth J, Rosenbaum S, Stubbs B et al (2016) Motivating factors and barriers towards exercise in severe mental illness: a systematic review and meta-analysis. Psychol Med. 2016 Aug 9:1-13

Other references

Belza B, Walwick J, Shiu-Thornton S (2004) Older adult perspectives on physical activity and exercise: voices from multiple cultures. Prev Chronic Dis. 2004 Oct;1(4):A09

Dergance JM, Calmbach WL, Dhanda R (2003) Barriers to and benefits of leisure time physical activity in the elderly: differences across cultures. J Am Geriatr Soc. 2003 Jun;51(6):863-8. [PubMed Abstract]

Deloitte Access Economics (2015). Value of Accredited Exercise Physiologists in Australia, Exercise and Sports Science, Australia, October 2015 (PDF)

Gardner-Sood P, Lally J, Smith S (2015) Cardiovascular risk factors and metabolic syndrome in people with established psychotic illnesses: baseline data from the IMPaCT randomized controlled trial. Psychol Med. 2015;45(12):2619-29

Mason OJ, Holt R (2012) Mental health and physical activity interventions: a review of the qualitative literature. J Ment Health. 2012 Jun;21(3):274-84 [PubMed Abstract]

Ribe AR, Laursen TM, Sandbaek A et al (2014) Long-term mortality of persons with severe mental illness and diabetes: a population-based cohort study in Denmark. Psychol Med. 2014 Oct;44(14):3097-107 [PubMed abstract]

Sherwood NE, Jeffery RW (2000) The behavioral determinants of exercise: implications for physical activity interventions. Annu Rev Nutr. 2000;20:21-44 [PubMed Abstract]

Soundy A, Freeman P, Stubbs B (2014) The transcending benefits of physical activity for individuals with schizophrenia: a systematic review and meta-ethnography. Psychiatry Res. 2014 Dec 15;220(1-2):11-9 [PubMed Abstract]

Stubbs B, Firth J, Berry A (2016a) How much physical activity do people with schizophrenia engage in? A systematic review, comparative meta-analysis and meta-regression. Schizophr Res. 2016 May 31. [PubMed Abstract]

Stubbs B, Vancampfort D, Rosenbaum S (2016b) Dropout from exercise randomized controlled trials among people with depression: A meta-analysis and meta regression. J Affect Disord. 2016 Jan 15;190:457-66 [PubMed Abstract]

Vancampfort D, Rosenbaum S, Schuch FB (2015) Prevalence and predictors of treatment dropout from physical activity interventions in schizophrenia: a meta-analysis. Gen Hosp Psychiatry. 2016 Mar-Apr;39:15-23 [PubMed Abstract]

Vancampfort D, Firth J, Schuch F (2016a) Physical activity and sedentary behavior in people with bipolar disorder: A systematic review and meta-analysis. J Affect Disord. 2016 Sep 1;201:145-52 [PubMed abstract]

Vancampfort D, Rosenbaum S, Schuch F (2016b) Cardiorespiratory Fitness in Severe Mental Illness: A Systematic Review and Meta-analysis. Sports Med. 2016 Jun 14. [PubMed Abstract]

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Thomas Wood CC BY 2.0