17.4: 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 (Stutts, 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 al., 2016).

17.4.1. Physical Health

The high rates of co-morbid physical health conditions can negatively impact engagement in physical activity (Firth et al., 2019a). Obesity, associated chronic pain and musculoskeletal problems, can make physical activity difficult and less enjoyable, thus impacting exercise participation (Firth et al., 2016). Low cardiorespiratory fitness, seen in people living with severe mental illness, can also impact a person’s 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 al., 2016).

17.4.2. Mental Health

Common barriers from a mental health perspective include depressive symptoms, stress, low motivation, and acute psychotic symptoms (hallucinations, delusions and paranoia, avolition, anhedonia). Additional reported barriers include feeling unsafe when exercising or concerns about being injured, and low interest in exercise (Firth et al., 2016). Long-term engagement in physical activity is impacted by a person’s autonomous motivation, that is, an internal desire to participation (Vancampfort et al., 2015e). 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 (e.g., health coaching and motivational interviewing) is paramount when aiming to increase engagement (Farholm & Sørenson, 2016).

17.4.3. 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 (Daumit et al., 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 al., 2016; Firth et al., 2016; Stanton et al., 2015).

Learning Exercise Four

What are the key barriers for people with severe mental illness engaging in physical activity?

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17.4.4. Contraindications 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 low-to-moderate intensity (Stubbs et al., 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 contraindications 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 (PARQ) is a series of short questions that identifies any absolute contraindications to exercise (Thomas et al., 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 contraindications to exercise (such as hypertension or a recent cardiac event). See Table 17.1 for a list of precautions that should be considered specific to this population (Firth et al., 2016).

Table 17.1. Precautions to Consider for People with Severe Mental Illness

Potential Issues	Precautions and Considerations
Fatigue	Prolonged tiredness and poor concentration are common for people and are influenced by factors including side effects of medication, sleep troubles, and symptomology. An individualized approach to an exercise plan tailored to times when a client may be more energetic is ideal.
Social anxieties	Public places and larger groups of people can act as a deterrent to engaging in physical activity. Setting small goals around exercise and establishing a routine is important initially, and gradually progressing may help with familiarity for clients
Side-effects of medications	In addition to extreme tiredness, other side effects of taking anti-psychotic 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’s changing needs will assist with increasing their confidence.
Psychotic symptoms	While symptoms such as auditory and visual hallucinations may present 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 body-weight 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.

Learning Exercise Five

What are the key safety concerns for people with mental illness engaging in structured physical activity?