How does exercise affect people who experience extreme states of mind and what impact might this have on mental health nursing practice?
People whose experiences are classified by the medical model as schizophrenia, bipolar affective disorder or psychosis, die 16-25 years sooner on average than people with no mental health diagnosis (Department of Health (DH) 2011b). It is three times more probable they will suffer premature death (DH 2011c), with increased risk of several physical illnesses, such as heart disease, diabetes, respiratory disease and infections, and obesity (DH 2006; DH 2011b,c; Rethink 2013 a, b, c; DH 2014a; NICE 2014b).
The prescribing of anti-psychotic medication may lead to weight gain, sometimes up to 5-6 kg in the first 2 months (Foley and Morley 2011; Rethink 2013a). This may be due to several factors, including a more sedentary lifestyle and a related lack of exercise. The World Health Organisation (WHO 2015) and The Department of Health (2014b) in their policy ‘everybody active every day’ stipulate that adults should be aiming to be active on a daily basis. However 27 million adults in England are not active enough to benefit their health (DH 2012), and the Secretary of State is calling for the NHS to make the promotion of active lifestyles central to all healthcare professionals work (DH 2012).
This literature review topic was chosen because in practice as a student nurse I have thought there is inadequate emphasis placed on exercise and believe that service users would benefit from its inclusion in mental health services.
The phrase ‘extreme states of mind’ (May 2014), is used to describe people in receipt of biomedical diagnoses, such as schizophrenia, bipolar affective disorder, schizoaffective disorder and psychosis. The choice of a non-medical phrase may help in the shift from a medical to a more holistic view of the experiences of people, within which mental health difficulties are described in more compassionate, less stigmatizing ways (Carless and Douglas 2008a; Moncrieff 2009; Johnstone 2014).
In order to first identify the research question, substantial reading was necessary in the field of interest, namely exercise and mental health. A Boolean search was utilised in order to search most efficiently across a range of databases. From this, a few key interests emerged. These were women’s mental health in relation to exercise, the role of the service user voice in exercise, and exercise and serious mental health issues. As there exist a significant number of papers around depression, anxiety and exercise but little on serious mental health issues, my search was made more specific by setting the inclusion and exclusion criteria to only include papers concerning serious mental health issues.
A total of 15 papers emerged as significant. These were predominantly qualitative, with four quantitative and one descriptive study. A simplified thematic analysis was performed on the papers selected (Noblit and Hare 1988; Paterson et al 2001; Rice 2008; Aveyard 2014). Three themes emerged from the papers reviewed, which go some way towards answering the research question: the social, the psychological and the physiological effects of exercise.
The literature signified the importance of the social effects of exercise for people who experience extreme states of mind. The peer support and friendships gained from participation in exercise (Carless and Douglas 2008a, 2008b, 2012; Hodgson et al 2011; Klam et al 2006) appear as a substantial specificeffect, as does the routine and structure it brings to people’s lives (Klam et al 2006; Crone and Guy 2008; Carless and Douglas 2008b; Hodgson et al 2011; Ronngren et al 2014; Cullen and McCann 2015). Participants also identified that exercise positively affects their social roles and highlight the value of shared experience (Crone and Guy 2008; Carless and Douglas 2012; Hodgson et al 2011; Cullen and McCann 2015).
Peer Support and Friendship
Narrative inquiry seeks to find the meaning that people make of their experiences and what it means to be human. It is a creative process that can often bring about change for the participants through the process of re telling the story, narrative re-storying (Carless and Douglas 2008a). The theme of potential benefits through the development of peer support and friendship when exercising was present in several studies. The narrative inquiry work of Carless and Douglas (2008a, 2008b and 2012) hasstrong peer support and friendship themes, and a clear service user voice is heard throughout. These three studies aimed to look at how men experiencing extreme states of mind utilise narrative re-storying through exercise and sport (2008a), how they might receive social support through exercise (2008b) and the narratives of people using physical activity programmes within mental health services (2012). For some people who experience extreme states of mind, the social role that exercise provides is helpful. One participant from Carless and Douglas’s 2012 study typically described his life before engaging in sport as lacking in friends and this meant also he experienced feelings of isolation. This study has a strong service user voice, which makes the pertinence of the statements more compelling. The work of Hodgson et al (2011), supported by Crone and Guy (2008) and Cullen and McCann (2015) also illustrate the role of exercise in alleviating some of the isolation felt by service users through meeting new people in the community.
From a psychological perspective, the literature generally revealed how exercise may assist people who experience extreme states of mind to be more motivated, be more proud, confident, have greater self esteem, have fun and alleviate symptoms.
For some, participating in exercise or physical activity led to an increase in motivation to continue exercising (Fogarty and Happell 2005) and in others, exercise increased their desire to make healthy lifestyle changes, such as reducing the intake of fast foods (Klam et al 2006). Motivation can be difficult for people experiencing extreme states of mind, and whether this is because of the impact of medication on motivation or the lack of structure in their lives is unclear (Crone and Guy 2008). In a Norwegian study, Tetlie et al (2009) discussed a mandatory exercise programme in a forensic setting. Mental health professionals participated alongside patients and found this unique approach helped decrease power imbalances on the ward, promoting ‘likeness’. The effects that exercise has on increasing motivation for this population are diverse, although some people are enabled to exercise more (Fogarty and Happell 2005; Warren et al 2011). Nurses exercising with clients may also challenge stigma (Tetlie et al 2009), and this will be explored in more depth in the discussion chapter.
For some, exercise can also be fun and pleasurable, (Klam et al 2006; Crone and Guy 2008; Tetlie et al 2009; Cullen and McCann 2015). Humour in mental health is creatively prioritized by Klam et al (2006), with the incorporation of humour workshops into their ‘personal empowerment program’. In the weeks following this intervention clients were heard sharing jokes and they described how this helped them take life a little less seriously. The fun element was something that was shared between staff and patients in the study by Tetlie et al (2009), further breaking down the barriers between them.
Having fun and experiencing pleasure in life through exercise could also be a way of distracting oneself from the negative experiences of extreme states of mind. It may, according to Cullen and McCann (2015), be a useful tool for voice hearers, as the time spent concentrating on exercise is time spent not concentrating on voices. One participant defined this as ‘it takes you out of living in your mind’ (Cullen and McCann 2015, 61).
Exercise may also counteract boredom, which is often an aspect of inpatient mental health services, and in the community is exacerbated through social isolation (Crone and Guy 2008; Hodgson et al 2011).
Confidence, Pride, Self Esteem, and Sense of Purpose
The effect of exercise on confidence, pride, self esteem and sense of purpose is reported in numerous studies (Crone and Guy 2008; Hodgson et al 2011; Cullen and McCann 2015). Confidence is crucial for participating in social activities (van Deurzen 2012), and self esteem is often interconnected with this (Crone and Guy 2008). In related terms, people who experience extreme states of mind have often lost their confidence (Carless and Douglas 2008a) and sense of purpose (Hodgson et al 2011), and exercise might be something that can help restore this.By extrapolation, the psychological effects of exercise might therefore influence how well an individual participates in society (Tetlie et al 2009) and vice versa (van Deurzen 2012). Peer support, routine and social role positively impact on people’s motivation to exercise, increasing their confidence, pride, self esteem and their ability to have fun.
The majority of literature included in the review discusses the importance of maintaining good physical health for this population, especially given the negative impact medication and lifestyle can have on diabetes, weight, and the heart (DH 2006, 2011b).
Weight has been identified as a major issue in mental health difficulties (DH 2006; DH 2011c; Mental Health Foundation 2009; NICE 2011; Rethink 2013a, b; NHS 2014b; NICE 2015a). Disappointingly there was only one paper that measured weight loss as a result of exercise (Klam et al 2006). The study by Warren et al (2011) attempted to study weight loss in the USA but was flawed through a lack of accurate data recording, weight gain precipitated by meal vouchers and bias as a result of the involvement of pharmaceutical companies. Other studies have approached the issue but also failed to gain significant results as a consequence of not including diet and nutritional advice in conjunction with exercise (Schwee et al 2013).
Several qualitative studies found that people exercised in order to manage and control their weight. Interestingly, only one study directly found related weight gain and associated issues to the medication prescribed for extreme states of mind – namely second generation antipsychotics (Hodgson et al 2011). Again there are a majority of papers in this review who assert weight gain due to antipsychotic medication in their abstracts, yet only Hodgson et al (2011) reported empirical information on this.
Blood Pressure, Fasting Sugar Levels and Smoking
Klam et al (2006) described positive physical changes to blood pressure, fasting blood sugar levels, smoking and fitness among people with extreme states of mind in Canada. However, this is a descriptive paper and not generalizable. Whilst training for a 5K race, study participants increased their mean steps by 1445.33 over a 10 week period, which is an indicator of increased fitness (Warren et al 2011). Cullen and McCann (2015) highlight that exercise can make someone feel stronger and this motivates them to eat healthier when they can see their physical health improving. It is interesting that physical rather than psychological benefits of exercise were found to be most important to the participants in study by Bassilios et al (2014). This interview-based study of 45 people who use community mental health service around Melbourne, also highlight the importance of education surrounding the benefits of exercise. However, there remains a lack of quantitative evidence in this area. All of this highlights the urgent need to address the physical health of this population. Some studies have approached this issue but have failed to find significant results through poor planning, lack of validity and poor recording (Warren et al 2011; Usher et al 2012; Scheewe et al 2013).
The majority of the studies reviewed recommend that exercise is incorporated into daily mental health practice, which will require support from mental health staff. An important aspect of personal recovery highlighted, is personalised, individualised care. The significance of peer support was a key finding, as was staff exercising with service users.
The literature reflects the importance of exercise staff being highly skilled, especially in mental health. Although personal recovery frameworks advocate increased independence from mental health services, several studies recommended that mental health specific exercise support should be available for those that need it.
It is acknowledged that there are lower participation rates in exercise for women, and also recognised that the stories that women may tell about exercise may be markedly different from men’s accounts. From the literature reviewed, exercise culture can generally be viewed as a male-dominated and thus exercise provision may not be tailored to the needs and requirements of women. Much of exercise provision is based on performance, whereas women might be more interested in the relational outcomes that exercise might bring. This hints at women perhaps gaining more from the benefits of peer support in exercise, but adquate evidence to support this is not currently available.
The positive effects of exercise have been recognised in this review as similar to cohere with the four ontological realms of existentialism, notably the physical, social, spiritual and personal worlds of the individual. The importance of personal meaning and significance is a crucial goal of recovery, and mental health nurses and researchers need to explore this realm with their service users in the context of engagement with exercise.
The findings of the literature reviewed also highlight this, and also point to the benefits of peer support which may also impact on motivation and vice versa. Someone experiencing extreme states of mind might have fun when exercising, which might them lead them to feel more motivated, which in turn may inspire them to do more exercise, thus improving their health, weight and fitness. The literature thus emphasises findings emphasise the interconnected nature of human experiences and how exercise can potentially have an impact on all areas of life.
This review has highlighted the importance of the role of exercise in the process of recovery. This is a subjective process and has a different meaning for each individual, and so, in practice, the personal meaning of recovery emerges as important. Personal recovery models have outcomes differing significantly from clinical recovery, which refers to the reduction and absence of psychiatric symptoms. Personal recovery refers more to regaining social roles, building and consolidating relationships that bring meaning and value to life, and developing hope.
The literature and policy recommend that exercise should be included in mental health services, and specifically to be included in individual care plans. The DH (2012) ‘lets get moving’ pathway has brief interventions already designed, but these need tailoring to this population, which would require more research for it to be evidence based. Clearly, the inclusion of effective exercise in care plans it needs to be supported by mental health professionals.
The DH (2012) state that promotion of active lifestyles is a key role of all healthcare professionals, therefore mental health nurses need to support the promotion of exercise and its sustainment. Nurses also need to be equipped to educate their service users about exercise, know how to refer to other services and instigate practice development where necessary. Crone and Guy (2008) highlight the role of the mental health nurse as practice developers and one emerging suggestion is that they take a role in organising discounts with local sports facilities. For this to be implemented would require nurse education in exercise and a knowledge-base of how to drive practice developments themselves.
If exercise is promoted by mental health professionals and included in care plans it needs to be tailored to individual preferences. Mental health policy and guidelines promote the idea of individual care, especially in personal recovery frameworks. For exercise to be as effective as possible, service users need to be offered a choice of activities and programmes to suit their individual needs. This is especially pertinent for this population, every person’s experiences are unique and require tailored support both generally and specifically in exercise interventions.
The benefits of peer support in exercise, is a potentially interesting finding for future practice development and current guidance is to promote it in mental health services more generally. Peer support in this context is the mutual and reciprocal support provided by another person who has experienced extreme states of mind (Mental Health Foundation 2012). It appears to play a key role as one of the positive effects of exercise. NICE (2014) suggests the use of trained peer supporters in psychosis and schizophrenia and Rethink (2013c) also recommend the use of peers to aid personal recovery.
In practice as a student nurse, I have only met two peer support workers. As a future mental health practitioner I would like to be able to encourage service users to assume this role. It seems clear that they can help contribute directly in the recovery of others and themselves. However, Slade et al (2014) state that this needs to not be tokenistic, ensuring that suitable training and support for this role is in place. For the role of peer support workers to be prioritised in exercise provision, clearly more research is needed.
The review highlighted that in fact exercising with service users was something that increased motivation, reduced stigma and strengthened the therapeutic relationship. Nurses who have undertaken exercise alongside service users have been very positive about its impact, for the services users, themselves and in the case of inpatient services or recovery houses, on the unit as a whole (Happell et al 2012). If this initiative was more widely adopted, nursing staff would be exercising also, therefore taking care of their own physical health needs. However, exercise provision in mental health does demand skilled professionals who are also sensitive to the needs of people experiencing extreme states of mind.
The value of the research into the effects of exercise for people who experience extreme states of mind does not seem sufficient to influence evidence-based practice. Future research is needed in several areas, to include gender sensitivity; how exercise increases meaning in life; peer support, motivation; and service user-led research (Rose et al 2011). Importantly, there is a dearth of significant research included in this review concerning weight loss, which is a key to reducing the health risks that anti-psychotic medication poses. Medication is a contributing health risk of this population, and pharmaceutical companies have an ethical duty to produce medication with less damaging side effects (Bental 2004; Moncreiff 2009).
This review set out to look at the effects of exercise for people who experience extreme states of mind, and how these findings might impact on mental health nursing practice. There is a lack of research in this area, particularly for women, leading to deficiencies in related evidence-based nursing practice. However, the evidence available points to the positive social, psychological and physical effects of exercise.
The literature review recognises that exercise could be used to aid personal recovery, and that this might lead to a less stigmatised view of the individual and their relationship to wider society. The importance of service users being able to re-story their lives through social acceptable activities is highly significant and mental health nursing practice needs to embrace the importance of narrative in all areas of practice. Peer support is already recognised as a vital element of practice and this review recommends that it be explored further in relation to exercise and extreme states of mind. Nurses require education to assist their practice development in these contexts.
Amy Barlow, former Mental Health Nursing BSc(Hons) student
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