Dr Dominic Horne discusses the importance of physical activity in people with mental health problems and the role of primary care in monitoring their physical health 

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Read this article to learn more about:

  • physical health problems that affect people with serious mental illness
  • physical activity and the health and wellbeing of people with mental illness
  • the role of primary care in improving physical healthcare for people with serious mental illness.

Key points

GP commissioning messages

Mental health problems make up a significant part of a GP’s work; around 1 in 3 GP consultations have a mental health component1 and 91% of mental health problems are dealt with in primary care.2 Mental illness accounts for nearly one-half of all ill health among people under 65 years of age,3 and people with long-term physical health conditions are two to three times more likely than the general population to experience mental health problems.1

Promoting physical activity is an important way in which GPs can help to support both the physical health and mental wellbeing of individuals with mental health problems ranging from anxiety and depression through to serious mental illness (SMI), including schizophrenia and bipolar disorder. Standard advice on physical activity for adults aged 19–64 years is to aim to achieve one of the following each week:4

  • 150 minutes of moderate aerobic activity and strength exercises on 2 or more days that work all of the major muscles 
  • 75 minutes of moderate and vigorous aerobic activity and strength exercises on 2 or more days that work all of the major muscles 
  • a mixture of moderate and vigorous aerobic activity every week and strength exercises on 2 or more days that work all of the major muscles. 

… 91% of mental health problems are dealt with in primary care

Background 

Since 2013, NHS England has been promoting parity of esteem between physical and mental health.5 The Five year forward view, published in 2014, highlighted the need to break down the barriers between physical and mental health in care provision,6 while a February 2016 report from the independent Mental Health Taskforce to the NHS in England called for the development of integrated care spanning people’s physical, mental, and social needs.7 This was looked at in more detail by a recent report from The King’s Fund, entitled Bringing together physical and mental health: a new frontier for integrated care, which states that: ‘Primary care is a crucial component of efforts to build a closer connection between mental and physical health.’8

The UK Government Office for Science’s 2008 Foresight report on Mental capital and wellbeing: making the most of ourselves in the 21st century describes five ways to mental wellbeing. The second of these is: ‘Be Active… Go for a walk or run. Step outside. Cycle. Play a game. Garden. Dance. Exercising makes you feel good. Most importantly, discover a physical activity you enjoy and that suits your level of mobility and fitness.’9

The potential for exercise as a therapy for clinical or subclinical depression or anxiety has been demonstrated in numerous trials and reviews.10 There is also much evidence to support the role of exercise and physical activity in:10

  • enhancing self-esteem 
  • improving mood states 
  • reducing state and trait anxiety 
  • increasing resilience to stress 
  • improving sleep. 

Research suggests that for adults with depression, exercise can be as effective as psychological and pharmacological therapies,11 and carries neither the side-effect profile of medications nor the stigma that can be associated with psychotherapy or medication.12 One study in adults found that taking up exercise led to a reduction in odds of depression by 19% over 5 years.13 Exercising regularly has also been shown to reduce the development of anxiety12 and to reduce anxiety scores in adults with chronic illness.14 Despite these benefits of physical activity, evidence shows that people with depressive symptoms and those with schizophrenia engage in less vigorous exercise than controls.14,15

Physical health and serious mental illness 

It is a well-established fact that people with SMI die at a significantly younger age than the rest of the population (20 years and 15 years younger for men and women, respectively).16 Around 80% of this excess risk is accounted for by physical health problems, predominantly increased rates of cardiovascular disease.17 Young people with psychosis are at two to three times greater risk of developing cardiovascular disease, metabolic syndrome, and type 2 diabetes compared with their peers,18 and psychiatric patients may be up to twice as likely as the general population to be obese.19 Young people experiencing a first episode of psychosis are particularly susceptible to rapid and pronounced weight gain.20 In addition to underlying genetic and lifestyle factors, including lack of exercise, antipsychotic medication may bring about adverse changes to weight, blood glucose, and blood lipids.21

… people with serious mental illness die at a significantly younger age than the rest of the population

These concerns about the physical health of people with SMI form the basis of the Lester UK adaptation— positive cardiometabolic health resource.22 The resource provides practitioners with a simple framework not only to regularly monitor cardiovascular risk factors in people who experience psychoses and schizophrenia, but also to act to modify these risk factors, hence the mantra: ‘don’t just screen—intervene’.22

The Lester resource is aligned with NICE Quality Standard 80 (QS80) on Psychosis and schizophrenia in adults, which includes statements on assessing physical health and promoting healthy eating, physical activity, and smoking cessation. NICE QS80 advises healthcare and social care practitioners to: ‘ensure that they are aware of local healthy eating and physical activity programmes and offer these to adults with psychosis or schizophrenia.’23

Improving physical healthcare for people with mental illness 

The Commissioning for Quality and Innovation (CQUIN) scheme for 2017–2019 includes an indicator for improving physical healthcare for people with SMI, which aims to reduce premature mortality by providing cardiometabolic assessment and treatment for patients with psychoses.24 It is not solely the responsibility of secondary care to look after the physical health of people with SMI, and it is vital to ensure continuity of care through good communication and integration of services across organisational boundaries.23

In Gloucestershire, the 2gether NHS Foundation Trust has employed a health facilitator and a physical health day is run to help raise awareness among staff and service users of physical health issues affecting people with SMI. Clinical letters sent from psychiatrists to GPs have also been standardised to improve communication and ensure continuity of care.25

Worcestershire Health and Care NHS Trust and the University of Worcester have set up a programme called SHAPE (Supporting Health And Promoting Exercise),26 which offers extensive lifestyle support to young people diagnosed with psychosis. The programme includes interactive sessions with a nutritionist and a 12-week exercise programme at the university gym, with input from exercise physiologists, sports therapists, and health trainers. Numerous physical and physiological parameters are monitored with the primary aim of preventing the early weight gain that is associated with antipsychotic medication.27 In the first four cohorts (a total of 26 young people) there was no statistically significant change in body mass index (BMI) or waist circumference after 12 weeks and this was maintained at 12 months.28

The role of primary care 

Until March 2014, GPs in England were incentivised through the Quality and Outcomes Framework (QOF) to monitor the physical health of individuals on the mental health register. This included annual measurement of cholesterol (high-density lipoprotein ratio), blood glucose, and body mass index. Since these three indicators have been retired the achievement in these areas has declined significantly, as shown in Table 1, below.

Table 1: Percentage of English practices achieving QOF indicators for monitoring the physical health of people with mental illness
QOF Indicator English practices (%) achieving the indicator 
  2013–14  2014–15  2015–16 
MH004 (lipids)  81.2  43.6  44.9 
MH005 (glucose)  86.3  57.1  59.0 
MH006 (BMI)  88.9  56.5  57.4 
Calculated using data available at: www.content.digital.nhs.uk 

It is important to ensure that these physical health parameters for people with SMI are monitored in either primary or secondary care and to ensure that there is good communication between services. As previously stated, it is not sufficient to merely document abnormal results; these must be acted on in order to reduce overall cardiovascular risk.22 This does of course include supporting individuals to increase their physical activity levels. 

In her remarkable and highly recommended lecture, Bothering about Billy, the late Helen Lester pointed out that although people with SMI are at a far higher risk of developing a range of physical illnesses, evidence shows that they receive poorer primary care healthcare compared with the general population.29

Helen went on to remind us that weight management, smoking cessation, and the management of long-term conditions are core activities for the highly skilled nurses that work in primary care.29 How then does this accord with a 2014 survey of practice nurses, which found that 82% felt that they had responsibilities for aspects of mental health and wellbeing for which they had no training, and 42% had had no training in mental health and wellbeing at all?30

Many GPs and practice nurses lack confidence in dealing with individuals with SMI, feeling that they do not have the necessary specialist knowledge.31 This is not, however, a viewpoint that is shared by their patients, who value the continuity and ease of access to care that is offered by primary care.31 It is important, therefore, to ensure that our primary care workforce has not only the knowledge, but also the confidence and the capacity, to deal with individuals who are affected by mental health problems.1

There is also a role here for CCGs. The charity Mind recommends that CCGs should ensure GPs and other practice staff receive regular mental health training during protected training time.1 Furthermore, a report from the Working Group for Improving the Physical Health of People with SMI advises commissioners to set clear expectations for the provision of physical health services in mental healthcare settings, so that people with SMI are not disadvantaged in their ability to access physical health services compared with the general population. This includes taking a ‘co-production’ approach, that is, involving patients and carers in the development of services.32

Guidance exists for mental health nurses on promoting exercise, and there is no reason why this cannot be implemented equally well by practice nurses. The guidance advises that: ‘Interventions to increase physical activity should focus on activities that fit easily into people’s everyday life (such as walking), and minimising sedentary behaviour such as watching TV and playing video games.32

… brief interventions in primary care that promote physical activity are both clinically effective and cost effective

There is evidence that brief interventions in primary care that promote physical activity (exercise on prescription schemes) are both clinically effective and cost effective.33–37 Primary care practitioners are, however, advised by NICE that they should not refer people who are sedentary or inactive, but otherwise apparently healthy, to exercise referral schemes.36

Various resources are available to support the efforts of primary care professionals to promote physical activity. The Royal College of General Practitioners’ Mental health toolkit38 is a useful resource, and Mind has produced a booklet on How to improve your wellbeing through physical activity and sport, which gives advice on a wide range of ways to increase activity levels, ranging from chair-based activities, through to walking and gardening, and running and team sports.39 A similar booklet, How to look after your mental health using exercise, is available from the Mental Health Foundation,40 while, a leaflet produced by the Royal College of Psychiatrists on Physical activity and mental health provides a comprehensive overview of the subject and links to further helpful resources.41

Get set to go 

Mind has set up a programme called Get set to go, which, with support from Sport England and the National Lottery, is now operating in eight areas across England. The programme offers individuals support from volunteer peer navigators to assist them with increasing their physical activity levels, and provides training for local sport and leisure providers to make services more accessible for people with mental health problems (see Box 1, below).42,43

Box 1: Personal stories from Get set to go participants43

Mental health

  • The support and encouragement you have provided to help me back into exercise has been invaluable. I feel so much more hopeful and much better in myself! And I’m really enjoying my new exercise routine! I never thought I’d be able to do this again, and wouldn’t have done so without Get Set to Go support—so, THANK YOU!

Physical health

  • I’m starting to feel more flexible, which has helped my arthritis. Now I have more stamina to exercise longer and my high blood pressure is also starting to lower. I love boxing so much I have signed up to a Crisis boxing session.

Individual development

  • I’ve always loved football but never had the confidence to join a team. I went along to the training session full of anxiety but it was fantastic. They made me welcome and encouraged me, even though I was extremely unfit and not much cop. I’ve lost weight and got fitter and even scored my first ever goal, 25 years after getting left out of the school team. My proudest possessions are now my football boots and the medals I’ve won. I can’t begin to explain how this has helped my confidence and self-esteem.

Economic development

  • As a direct result of his involvement with the football sessions, one of our volunteers has secured part-time employment with MFC Foundation. They saw first-hand how he conducted himself in sessions and his skills engaging participants. This coupled with his previous work experience has resulted in his employment, working on an initiative called ‘The Boot Room’.

MFC=Middlesbrough Football Club

An evaluation of the Get set to go programme in Dudley, carried out by the University of Northampton’s Institute of Health and Wellbeing, found that, following the programme, there was a significant increase in the number of days per week on which participants engaged in moderate activity (from 1.32 days at baseline to 1.80 days at 3 months, and 2.29 days at 6 months). (unpublished data, personal communication from Mind).

For those who do not live in one of the eight areas where Get set to go currently operates there is an online community known as Elefriends where individuals can share advice and tips on keeping active. There are also plans to expand the Get set to go programme to 32 areas and a national event is due to be held in October 2017.

Summary 

Exercise is important for all of us; Cicero stated: ‘It is exercise alone that supports the spirits, and keeps the mind in vigour.’ This applies to an even greater extent for anyone experiencing mental health problems, from low mood right through to psychotic illness. It is especially important to monitor the cardiometabolic health of patients with SMI, and to intervene early, as these individuals are known to have much higher risks of cardiovascular morbidity and mortality. Encouraging physical activity is a vital element of this intervention, and has the potential to bring about improvements in both physical and mental health. 

At a time when psychological therapies can be hard to access and pressure exists on prescribing budgets, it makes absolute sense for GPs and their teams to be promoting physical activity as a means to achieving optimal mental health and wellbeing.

Key points

  • Mental health problems are common in primary care: 1 in 3 GP consultations has a mental health element 
  • Patients value the accessibility and continuity of care offered in primary care 
  • NHS England is promoting parity of esteem between physical and mental health 
  • Numerous trials and reviews show that exercise can be as effective as psychological therapies and drugs for treating anxiety and depression 
  • Increasing physical activity levels is also important for maintaining good mental health 
  • It is especially important to promote physical activity in individuals with serious mental illness as they are at higher risk of weight gain and cardiometabolic morbidity and mortality 
  • Since the requirements to monitor blood lipids, blood glucose, and BMI have been removed from QOF in England, achievement in these areas has declined markedly 
  • Remember: ‘don’t just screen—intervene’; promoting exercise is an important element of reducing cardiovascular risk factors 
  • Practice nurses have an important role to play in the delivery of physical activity advice and support 
  • Resources are available for primary care teams from the RCGP, Mind, the Mental Health Foundation, and RCPsych.

GP commissioning take home messages for England 

written by Dr David Jenner, GP, Cullompton, Devon 

  • Commissioners should: 
    • l ook to ensure that all patients with SMI have access to programmes to improve their levels of physical activity; these programmes could be included in local health and wellbeing strategies, with some provided by local authorities (e.g. exercise on prescription schemes through sports centres) 
    • ensure that provider trusts commit to engaging with the CQUIN for cardiometabolic assessment and treatment for people with psychosis and recognise that exercise is an evidence-based ‘treatment’ 
  • GP practices should reflect on how best to encourage patients with SMI to improve their exercise levels; a multi-disciplinary approach, involving practice nurses, HCAs, and health facilitators (where available), could be considered 
  • Commissioners could explore the possibility of contracts with third-sector providers (e.g. mental health charities) to promote exercise among mental health peer groups, such as walking groups or joint sports sessions. 

SMI=serious mental illness; CQUIN=Commissioning for Quality and Innovation