17.6: 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 (Lederman et al., 2016; Stanton et al., 2018; Stubbs et al., 2018). Throughout Europe, physiotherapists have performed these roles and in the United States there are a growing number of clinician exercise physiologists working in mental health settings (Fibbins et al., 2019; Stubbs, Probst, et al., 2014; Stubbs & Rosenbaum, 2018).

Australia has an increasing number of exercise professionals working in private and public health systems, particularly in mental health services. Accredited Exercise Physiologists (AEPs) are university-qualified health professionals that lead physical activity interventions for people living with mental illness. There are robust referral schemes that people can access for evidence-based exercise counselling and prescription through universal-health care. AEPs 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 upskilling 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. A joint consensus statement by peak professional organizations throughout Australia, the U.S, the U.K, 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 (Rosenbaum et al., 2018). The International Organization of Physical Therapists in Mental Health (IOPTMH) supports exercise professionals and upholds them as experts in lifestyle management and integral members of the multidisciplinary health team (Stubbs, Soundy, et al., 2014b). Exercise and Sports Science Australia (ESSA) is the peak organization that represents and provides accreditation to AEPs 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 (CANMAT), the National Institute for Health and Care Excellence (NICE), and the Mental Health Commission of NSW (Chang et al., 2020; Mental Health Commission of New South Wales, 2016; Stanton et al., 2014).

17.6.1. 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 (Shiers et al., 2014).

Clinician and workplace culture has been identified as a novel and targeted way of bridging the traditional siloed 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 (Rosenbaum et al., 2018; Stanton et al., 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 (Fibbins et al., 2018) and do not negatively impact productivity. Additionally, improvements to workplace satisfaction, morale, and workforce capacity can be improved through such interventions (Forsberg et al., 2008; Hjorth et al., 2016; Tucker et al., 2016).

17.6.2. A Real-World Lifestyle Intervention for Youth with Mental Illness

The Keeping the Body in Mind (KBIM) program (Curtis et al., 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 physiologists, in addition to cooking and sports groups.

Initially evaluated as a pilot research project, youth with psychosis were offered this innovative program over a 12-week period and results were compared to another mental health service offering standard care (medication and psychotherapy).

The KBIM program successfully prevented antipsychotic related weight gain following the intervention while participants in the control group gained almost 8kg in weight and 7.0cm 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 KBIM teams employed on a full-time basis across a large mental health district.