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Building Healthy Communities through Multidisciplinary Community-Based Lifestyle Interventions


Abstract and Figures

The poor physical health of people with mental illness is recognised internationally as a human rights issue; national mental health plans and consensus statements promote early intervention. Lifestyle factors such as physical inactivity and poor diet contribute significantly to increased risk of preventable physical conditions in this group. Lifestyle interventions can help people make health-promoting choices; however, economic and logistic barriers hinder effective implementation of lifestyle interventions within routine care for people with mental illness. Innovative approaches to collaborative care and resource sharing across mental health sectors may increase feasibility of embedding implementation into practice. The aim of this article is to inform the development of sustainable service models for the provision of lifestyle interventions in routine mental health care. To achieve this, we describe learnings from successive implementation projects, and present preliminary data supporting feasibility.
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Justin Chapman1,2,3 *
Sarah Childs4
Gregory Pratt2
Stephen Tillston1
Geoffrey Lau3
Joe Petrucci5
Sue Patterson6
1 PCYC Queensland, Brisbane, Australia
2 QIMR Berghofer Medical Research Institute, Brisbane, Australia
3 Metro South Addictions and Mental Health Service, Brisbane, Australia
4 Richmond Fellowship Queensland, Brisbane, Australia
5 Neami National, Cairns, Australia
6 Metro North Mental Health Service, Brisbane, Australia
*Correspondence to
The poor physical health of people with mental illness is recognised internationally as a human rights
issue; national mental health plans and consensus statements promote early intervention. Lifestyle
factors such as physical inactivity and poor diet contribute significantly to increased risk of preventable
physical conditions in this group. Lifestyle interventions can help people make health-promoting
choices; however, economic and logistic barriers hinder effective implementation of lifestyle
interventions within routine care for people with mental illness. Innovative approaches to collaborative
care and resource sharing across mental health sectors may increase feasibility of embedding
implementation into practice. The aim of this article is to inform the development of sustainable service
models for the provision of lifestyle interventions in routine mental health care. To achieve this, we
describe learnings from successive implementation projects, and present preliminary data supporting
People with mental illness have a life expectancy of 10-20 years shorter than the general population1.
Excess mortality is related primarily to preventable physical conditions such as cardiovascular
disease1. People with severe mental illnesses such as schizophrenia are up to four times more likely
to have multiple physical co-morbidities2, increasing complexity of treatment, health service
expenditure, and hindering recovery from mental health conditions3,4. Aiming to redress inequity in
care and outcomes, Australia’s Fifth National Mental Health and Suicide Prevention Plan incorporates
the physical health of people with mental illness as a Priority Area for service development5, and the
National Mental Health Commission’s Consensus Statement Equally Well emphasises taking an early
intervention and prevention approach to addressing health determinants6.
Lifestyle behaviours, such as exercise and diet, can be modified to reduce risk and promote
management of physical and mental health conditions7. Being physically active can improve quality
of life and wellbeing8, prevent or delay the onset of some mental illnesses in people with early signs
of mental health issues9, and reduce symptoms of depression, anxiety and psychotic disorders10-13. A
healthy diet can also reduce depression and anxiety12,13, and is also related to symptoms of
psychosis14. Exercise physiologists and dietitians have expertise in personalised prescription and
behaviour change strategies that can be applied to improve effectiveness of exercise and nutrition
interventions15,16. Thus increasingly, mental health services are encouraged to provide or facilitate
access to lifestyle interventions and involve exercise physiologists and dietitians in the
multidisciplinary mental health team16,17.
However, various barriers operating at the individual, organisational, and systems level hinder the
implementation lifestyle interventions for people with mental illness. People with mental illnesses face
many barriers to adopting and maintaining a healthy lifestyle, which can reduce intervention
effectiveness unless programs are tailored to address these barriers18,19. Organisationally, finite
resources and competing priorities constrain investment in specialist non-mental health clinicians
such as exercise physiologists and dietitians. While mental health clinicians can help consumers
improve health-related behaviours using behaviour change approaches, they often lack confidence
and organisational support to do so20,21. Many mental health services do not have exercise facilities
onsite, and although clinicians report a desire to refer to existing community-based programs, they
also report low knowledge of available programs and low confidence that programs adequately
address the physical health of consumers20. At the systems level, fragmentation of services across
primary, secondary and tertiary care weakens referral pathways to interventions tailored to people
with mental illness and reduces accessibility4.
Innovative approaches are needed to improve access to evidence-informed lifestyle interventions for
people with mental health issues (including people at risk, and with a diagnosed mental illness).
Collaborative partnerships across public mental health, non-government support organisations, and
community sports and recreation organisations may improve referral pathways and accessibility. The
aim of this article is to inform the development of sustainable service models for the provision of
lifestyle interventions in routine mental health care. To achieve this, we describe the iterative
development of a local community lifestyle program for people with mental illness into a state-wide
service through a series of research and implementation projects. Preliminary data supporting
feasibility are also presented.
Descriptive overview
Healthy Bodies, Healthy Minds (HBHM) is a PCYC Queensland exercise and nutrition program for
people with mental illness. Developed and implemented in 2015-2017, it has evolved into state-wide
program operating from Far North to South East Queensland. Development has been supported by
a series of research and implementation projects (sites of operation shown in Figure 1). To describe
this process, five ‘phases’ of evolution are considered:
(1) Collaboration for development and implementation of program.
(2) Partnerships formalised for co-delivery under federal disability funding.
(3) Program informs design of a randomised controlled trial (RCT).
(4) RCT informs program expansion.
(5) Partnerships formalised for co-delivery under Primary Heath Network funding.
Based on learnings from these phases, a concept model to inform future implementation or service-
based quality improvement initiatives is presented. Observations about successful elements inherent
in this program evolution are discussed.
Program content
HBHM is an 8-week program with 2-hr weekly group sessions involving a 1-hr nutritional session
followed by a 1-hr exercise session. The nutrition content supports individual goal setting and finding
a healthy balance, covering topics of healthy recipes and takeaway options, Mediterranean diet, the
gut-brain connection and relationship with stress, mood, sleep, mindful eating and healthy habit
formation. The exercise component is designed to progressively improve exercise-related knowledge
and confidence, so participants develop personalised programs based on abilities and preferences
by the end of the program. Participants receive a gym membership at no cost to support continued
Eligibility criteria have been dependent on funding scope; however, all HBHM programs required
participants to be (i) over 18 years of age, and (ii) receiving treatment for a mental health condition
from a public mental health service or a non-government organisation. Programs in Far North
Queensland additionally accepted referrals from primary care or private clinics; participants of NDIS
funded programs needed specific NDIS funding arrangements. Exclusion criteria for all HBHM
programs were (i) receiving treatment for an eating disorder for which symptoms may be exacerbated
by exercise; and (ii) not receiving medical clearance for presenting medical conditions. HBHM
participants consented to use of routinely collected evaluation data by a third-party for research
purposes. Ethical approval for use of this data was obtained from the QIMR Berghofer Medical
Research Institute Human Research Ethics Committee (P2398).
Procedural and evaluation data from HBHM programs implemented from 2015 to 2019 were
combined. Of the variety of outcomes used, Kessler-6 scale of psychological distress (K6) and
physical health measures (weight, waist, blood pressure, walk test) were included in all programs.
Baseline and post-intervention data for these outcomes were compared using paired t-tests; other
outcomes are intended for future publications.
Details of program development, funding, collaborations and partnerships, and evaluation measures
are summarised in Table 1 (Appendix). For consistency of terminology, ‘collaboration’ is used to
describe collaborative efforts between organisations named on funding applications or project
proposals, and ‘formalised partnership’ is used to describe collaboration formalised under
organisational agreement.
Descriptive overview
(1) HBHM was initially developed and piloted in 2015-2017 with a consortium of non-government
organisations (NGOs), Metro North Mental Health Service (MNMHS), and PCYC Queensland, a
not-for-profit community sports and recreation organisation. The program was well received by
mental health staff, and demand for participation exceeded capacity. The program was evaluated,
with a comprehensive report provided to the funding agency and collaborators increasing
confidence in the program and implementation team. The evaluation supported a successful
application to deliver HBHM in Far North Queensland in 2017-2018. Collaborations were formed
with QIMR Berghofer Medical Research Institute, a statutory research institute, and the Cairns
Mental Health, Alcohol, Tobacco and Other Drugs Service (Cairns MH&ATODS) for the proposal.
(2) Reform of mental health care/service structure and funding in the non-government sector resulted
in the National Disability Insurance Scheme (NDIS) transitioning into operation 2017-2019.
Continued collaboration with NGOs supported adaptation of the program for administration under
NDIS, including the involvement of exercise physiologists and dietitians funded under the
scheme. Program adaptation included manualising content and automating intake and
assessment procedures to improve scalability. Richmond Fellowship Queensland (RFQ), a
community organisation which supports people with mental health challenges and social
disadvantage, formalised partnership with PCYC Queensland for co-delivery of HBHM.
(3) Program data indicated that participant attendance to the gym was low after conclusion of the
supervised group sessions, despite receiving a free gym membership. To evaluate if an
intervention to enhance motivation to exercise improved physical activity outside supervised
sessions, a randomised controlled trial was developed and received hospital-based research
funding22. Pilot data from previous HBHM rounds and pre-exiting collaborations with research
personnel at QIMR Berghofer, MNMHS and Metro South Addictions and Mental Health Service
(MSAMHS) were essential in this development.
(4) Preliminary data from the RCT combined with evidence of existing collaborations with research
partners, public mental health services and NGOs supported further development. Primary Health
Network funding supported translation of the RCT into practice in Far North Queensland, with
both the HBHM exercise program and motivational intervention from the RCT being implemented
without study-related constraints (e.g. random allocation, strict referral pathways). Referral
pathways were expanded to encompass primary care and private clinic settings. Demand for the
program exceeded capacity, and comprehensive evaluation and reporting increased confidence
in the project team.
(5) Continued Primary Health Network investment in Far North Queensland led to a to formalised
partnerships with public health services (both mental health and general health) for co-delivery
of a community-based Allied Health lifestyle service. An exercise physiologist delivers a group-
based exercise program at PCYC Queensland, and Allied Health staff from public services deliver
other lifestyle interventions as part of the program (e.g. stress management, smoking cessation
etc). Similarly, the exercise physiologist provides an in-reach service, delivering exercise
programs at the inpatient ward and rehabilitation unit.
The incremental successes over these research and implementation projects, has enabled the
program to evolve into a lifestyle intervention model which can be used to inform the development of
future service models. This model involves increasing service integration to improve program
sustainability by formalising organisational relationships for co-delivery and co-location. Co-delivery
increases staff knowledge and confidence in programs, strengthens referral pathways, and embeds
implementation into routine practice through mutual investment from partner organisations. Co-
location at community and health service sites, and flexibility to be administered under different
funding schemes increases accessibility for participants.
Program data
As of 14th of April 2019, a total of 49 HBHM programs
had been implemented since 2015 across eight
Hospital Health Service regions, with 311 participants.
At the time of data collation there were an additional
55 participants being inducted into eight programs
that were not included in analyses. Richmond
Fellowship Queensland co-delivered 25 of these
programs for 133 participants. A participant flow
diagram is provided in Figure 2, and an overview of
participant characteristics is provided in Table 2.
Of the 311 participants enrolled, 285 (92%)
commenced group sessions. Data on completion and
withdrawal rates were available for 183 participants;
these data were not available for 102 participants of
NDIS-funded programs for whom only attendance
data were available. Of these 183 participants, 145
(79%) completed, 100 (69%) of whom provided post-
intervention data.
Attendance data were available for 246 participants
(86% of the 285 participants who began program
sessions); attendances were not captured for 39
participants due to logistical issues. For these 246 participants, median attendance was 5 out of 8
(63%) supervised sessions (25th-75th percentile = 25% to 75%). When only considering the 145
participants who were known to complete the program, 117 participants had attendance data available
(data for 28 participants missing). For these 117 completers, median attendance was 6 out of 8 (75%)
supervised sessions (25th-75th percentile = 50% to 88%).
Completed program
n=145 (79% of 183 participants for
whom this data was available)
Post assessments
n=100 (69% of completers)
Began program sessions
n=285 (92%)
Figure 2: Participant flow diagram
‘Inducted’ to program
n=311 (60%)
Table 2: Health and demographic characteristics of participants at baseline (n=311)
Age in years (mean, SD) 41 (12)
Sex n %
Female 150 48%
Missing 34 11%
Psychological distress A
High distress (score >15) 86 28%
Missing 34 11%
Aboriginal or Torres Strait Islander
Aboriginal 16 5%
Torres Strait Islander 2 1%
Aboriginal and Torres Strait Islander 3 1%
Neither 187 60%
Missing 103 33%
Self-reported diagnoses
Number of diagnoses
One 110 35%
Two or more 167 54%
Missing 34 11%
Single diagnosis reported
Psychotic disorder 68 22%
Bipolar disorder 21 7%
Depression 8 3%
Anxiety disorder 8 3%
Substance use disorder 2 1%
Other 2 1%
Multiple diagnoses reported B
Depression 109 35%
Anxiety disorder 103 33%
Substance use disorder 21 7%
Eating disorder 9 3%
Bipolar disorder 33 11%
Psychotic disorder 56 18%
Borderline Personality Disorder 18 6%
Post-traumatic stress disorder 37 12%
Body Mass Index (kg/m2)
Underweight (<18.5) 3 1%
Normal weight (18.5 – 24.9) 42 14%
Overweight (25 – 29.9) 64 21%
Obese (>30) 143 46%
Missing 59 19%
Smoking status
Never/ex-smoker 128 41%
Daily/occasionally 144 46%
Missing 39 13%
Note: The 55 participants actively involved in program inductions at the time of data
collation were not included in summaries.
A Psychological distress was measured using the Kessler-6 scale; scores over 15 indicate
high distress
B Individual diagnoses reported by those who reported multiple diagnoses, hence the
proportions sum to greater than 100%.
Baseline and post-intervention data are presented in Table 3. For the 100 participants with post-
intervention data, significant improvements were found for psychological distress, t(96)=5.08,
p<0.005, and physical capacity, t(69)=4.58, p<0.005. Indicators of metabolic health (weight, blood
pressure, waist circumference) remained similar.
Table 3: Outcomes for measures used across all program implementation
phases (n=100)
Baseline Post
Mental health mean (SD) mean (SD)
Psychological distress
Total score 12.2 (4.5) 9.8 (5.4) **
Physical health
Systolic blood pressure (mmHg) 119.9 (17.1) 118.8 (13.7)
Diastolic blood pressure (mmHg) 82.0 (11.7) 82 (11.0)
Waist circumference (cm) 101.2 (19.4) 100.9 (18.4)
Weight (kg) 89.8 (24.8) 89.8 (26.7)
Physical capacity
Walk test distance (m) 478 (104) 531 (121) **
Missing 25 (25%) 25 (25%)
n (%) n (%)
Body Mass Index
Underweight (<18.5 kg/m
) 1 (1%) 1 (1%)
Normal weight (18.5-24.9 kg/m
) 15 (15%) 15 (15%)
Overweight (25-29.9 kg/m
) 30 (30%) 30 (30%)
Obese (>30 kg/m
) 37 (37%) 37 (37%)
Missing 17 (17%) 17 (17%)
a Psychological distress measured using the Kessler-6 scale.
b Physical capacity estimated using the submaximal six-minute walk test.
** Statistically improved outcomes (p<0.005) assessed using paired t-tests
Successful elements involved in program evolution have been (1) evaluation, (2) partnership, and (3)
leadership. Comprehensive qualitative and quantitative evaluation and reporting in all these projects
served to increase confidence of funding bodies, and supported subsequent applications to expand
operation. The development of a randomised controlled trial based on the program strengthened its
evidence-informed, which added further quality to implementation proposals. Partnership for co-
delivery of the program strengthened referral pathways, and increased participant engagement
through multidisciplinary involvement. Leadership is recognised as an important element of success
in implementation initiatives23, and has been a common thread throughout the success of the
program’s evolution. Leadership from collaborators was vital in formalising partnership because it
required championing the proposal to senior management, and an initial commitment of resources to
trial the relationship. Leadership from the lead author (JC), who was integrally involved in all steps of
designing and implementing each of the presented projects, was essential for continuing the
momentum of each project into subsequent projects. JC held affiliations with three different
organisations during this process which proved advantageous for driving collaborations, highlighting
the potential for jointly appointing staff in collaborative projects to increase service integration and
Over the past four years, the program has made an impact on the health and wellbeing of people with
mental health issues, and has been building influence in the mental health sector. It has been cited
in local research reviews24-26, highlighted as a successful investment in mental health reform
funding27, and received Mental Health Week Achievement Awards28. Procedural data indicating the
feasibility and scalability of the program was presented, which is important for evidencing capacity to
deliver on large-scale proposals. The program is evolving into a model for the effective and
sustainable implementation of preventative lifestyle interventions for people with mental health issues.
This model will continue to develop through successive partnerships and research and
implementation projects, with the vision of becoming a state-wide platform for interventions to improve
health and wellbeing of people with, or at risk of developing, chronic conditions. Such a service would
play an important role in translating research evidence into practice, as well as being a platform to
launch large multi-site clinical trials into the impact of different exercise or diet regimes on outcomes,
such as cognition, symptomatology, hereditary markers etc. Important next steps will be to formalise
partnerships with General Practice, trial a ‘Wellbeing Hub’ service delivery approach, combine with
workforce development models in public services to improve continuity, and evaluate the impact on
Leadership, partnership and evaluation were important elements in the success of implementation
projects that have led to a scalable model for the provision of lifestyle interventions for people with
mental illness involving co-delivery and co-location as central embedding mechanisms to improve
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Table 1: Overview of development phases
(1) 2015 - 2018: Healthy Bodies, Healthy Minds (HBHM) program developed; 8-week program with 2-hr weekly sessions involving exercise, nutrition and social
engagement. Individualised exercise programs developed with participants, then completed weekly with group supervision. Delivered by personal trainers and chefs.
Funding: Brisbane North Partners in Recovery (2015-2017); Queensland Mental Health Commission (2017-2018)
Collaborations: PCYC Queensland, Metro North Mental Health, Communify QLD, Open Minds, Headspace, Neami National, Richmond Fellowship QLD, and Aftercare.
QIMR Berghofer Medical Research Institute became formal collaborator for 2017-2018 programs.
Implementation sites: Redcliffe, Pine Rivers, Zillmere, Milton, Fortitude Valley, Logan, Cairns, Edmonton, Yarrabah
Evaluation: Kessler-6 scale of psychological distress (K6), quality of life (AQOL-8D), recovery assessment scale (RAS), depression anxiety and stress (DASS21), Patient
Health Questionnaire (PHQ-9), DSM-V Cross-cutting measure, physical health measures (weight, waist, blood pressure, walk test) including blood indicators (blood sugar,
cholesterol, triglycerides), attitudes toward substance use, and qualitative interviews.
(2) 2017 - Current: HBHM delivered by exercise physiologists and dietitians with multidisciplinary care coordination from staff at partnering organisations. Co-delivered with
non-government mental health organisations under contract arrangement.
Funding: National Disability Insurance Scheme (NDIS)
Collaborations: PCYC Queensland, Richmond Fellowship Queensland (RFQ), Neami National and Me-Well, Mind Australia
Sites: Toowoomba, Ipswich, Ashmore, Sunshine Coast, Logan, Capalaba, Zillmere, Pine Rivers, Bundaberg, Hervey Bay, Cairns, Edmonton, Mareeba
Evaluation: Physical activity motivation (BREQ-3) attitudes toward eating (IES2), and physical health (weight, waist, blood pressure, walk test).
(3) 2017 - Current: Randomised controlled trial of exercise program compared with motivational intervention.
Funding: RBWH Foundation Research Scheme and Metro South Research Scheme.
Collaborations: PCYC Queensland, Metro North Mental Health Service, Metro South Addictions and Mental Health Service, QIMR Berghofer.
Sites: Milton, Fortitude Valley, Logan, Beenleigh, Cairns, Edmonton, Mareeba
Evaluation: Objectively measured physical activity (using accelerometers worn for eight weeks), Kessler-6 scale of psychological distress (K6), physical activity motivation
(BREQ-3), sleep quality (PSQI), self-reported physical activity (SIMPAQ), physical health (weight, waist, blood pressure, walk test), and qualitative interviews.
(4) 2017 - 2019: Implementation of study interventions in Far North Queensland.
Funding: North Queensland Primary Health Network
Collaborations: PCYC Queensland, Cairns Mental Health & ATODS, QIMR Berghofer.
Sites: Milton, Fortitude Valley, Logan, Beenleigh, Cairns, Edmonton, Mareeba
Evaluation: Objectively measured physical activity (using accelerometers worn for eight weeks), Kessler-6 scale of psychological distress (K6), physical activity motivation
(BREQ-3), sleep quality (PSQI), self-reported physical activity (SIMPAQ), physical health (weight, waist, blood pressure, walk test), and qualitative interviews.
(5) 2018 - Current: Deed of Collaboration established with Cairns Hospital and Health Service (CHHHS) for co-delivery of community-based Allied Health programs.
Funding: North Queensland Primary Health Network
Collaborations: Cairns MH&ATODS and CHHHS
Sites: Cairns, Edmonton, Mareeba
Evaluation: Depression, anxiety, stress (DASS21), Kessler-6 scale of psychological distress (K6), physical activity motivation (BREQ-3), physical health (weight, waist, blood
pressure, walk test)
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Technical Report
Full-text available
Staff attitudes and opinions on addressing physical health within mental health and addiction services
Technical Report
Full-text available
A report on the role of physical therapy and exercise staff in mental health services.
Full-text available
Introduction: Schizophrenia spectrum disorders (SSD) represent a cluster of severe mental illnesses. Diet has been identified as a modifiable risk factor and opportunity for intervention in many physical illnesses and more recently in mental illnesses such as unipolar depression; however, no dietary guidelines exist for patients with SSD. Objective: This review sought to systematically scope the existing literature in order to identify nutritional interventions for the prevention or treatment of mental health symptoms in SSD as well as gaps and opportunities for further research. Methods: This review followed established methodological approaches for scoping reviews including an extensive a priori search strategy and duplicate screening. Because of the large volume of results, an online program (Abstrackr) was used for screening and tagging. Data were extracted based on the dietary constituents and analyzed. Results: Of 55,330 results identified by the search, 822 studies met the criteria for inclusion. Observational evidence shows a connection between the presence of psychotic disorders and poorer quality dietary patterns, higher intake of refined carbohydrates and total fat, and lower intake or levels of fibre, ω-3 and ω-6 fatty acids, vegetables, fruit, and certain vitamins and minerals (vitamin B12 and B6, folate, vitamin C, zinc, and selenium). Evidence illustrates a role of food allergy and sensitivity as well as microbiome composition and specific phytonutrients (such as L-theanine, sulforaphane, and resveratrol). Experimental studies have demonstrated benefit using healthy diet patterns and specific vitamins and minerals (vitamin B12 and B6, folate, and zinc) and amino acids (serine, lysine, glycine, and tryptophan). Discussion: Overall, these findings were consistent with many other bodies of knowledge about healthy dietary patterns. Many limitations exist related to the design of the individual studies and the ability to extrapolate the results of studies using dietary supplements to dietary interventions (food). Dietary recommendations are presented as well as recommendations for further research including more prospective observational studies and intervention studies that modify diet constituents or entire dietary patterns with statistical power to detect mental health outcomes.
Full-text available
Introduction Physical activity (PA) has diverse benefits for physical and mental health and can reduce symptoms of mental illness. Adults with mental illness face practical, psychosocial and socioeconomic barriers to adopting and maintaining PA, and it is unclear how to effectively promote PA in this group. Supervised exercise interventions provide high support but may not promote autonomous motivation, which is important for PA maintenance. The aim of this study is to compare the effectiveness of two interventions to promote PA in adults with mental illness. Methods and analysis This is a randomised controlled trial of two interventions to promote PA: (1) supervised exercise and gym membership and (2) motivational discussions and self-monitoring of PA using fitness trackers. The intervention duration is 16 weeks, including 8 weeks of weekly supervised group sessions, and 8 weeks of access to the gym or fitness tracker unsupervised. Participants are community-dwelling adults recruited from outpatient clinics of public mental health services. The primary outcome is PA adoption assessed using GENEActiv accelerometers worn continuously over 8 weeks. Secondary outcomes measured at baseline, postintervention (8 weeks) and follow-up (16 weeks), include exercise motivation, psychological distress and self-reported PA assessed using self-administered questionnaires and indicators of physical health measured by a researcher blinded to allocation (blood pressure, weight, waist circumference, 6 min walk test). Participant experiences will be assessed using qualitative focus groups with analysis informed by a theoretical model of behaviour (COM-B). Ethics and dissemination Ethics approval has been obtained from the Royal Brisbane and Women’s Hospital (HREC/17/QRBW/302). We plan to submit a manuscript on protocol development from pilot work, and a manuscript of the results to a peer-reviewed journal. Results will be presented at conferences, community and consumer forums and hospital grand rounds. Trial registration number ACTRN12617001017314; Pre-results.
Full-text available
Objectives: Evaluation of physical activity (PA) programs among populations with severe mental illness (SMI) has predominately focused on efficacy and therapeutic benefits. There is now strong evidence to support the benefits of PA in people with SMI. What remains is a gap in the implementation of pragmatic and sustainable PA interventions in mental-health settings. The current paper provides examples of interventions that have been successfully implemented in Australian settings, identifies key components of successful PA interventions and outlines practical strategies that can assist with widespread implementation of PA interventions in mental-health settings. Conclusions: There is an emergence of PA interventions being imbedded within a variety of mental-health settings. These interventions vary in terms of mode and intensity of service delivery. Yet, all aim to increase PA and reduce sedentary behaviour. Adopting the identified strategies may help facilitate successful implementation and increase access to PA interventions for mental-health service users.
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Background: The SMILES trial was the first randomized controlled trial (RCT) explicitly designed to evaluate a dietary intervention, conducted by qualified dietitians, for reducing depressive symptomatology in adults with clinical depression. Objectives: Here we detail the development of the prescribed diet (modified Mediterranean diet (ModiMedDiet)) for individuals with major depressive disorders (MDDs) that was designed specifically for the SMILES trial. We also present data demonstrating the extent to which this intervention achieved improvements in diet quality. Methods: The ModiMedDiet was designed using a combination of existing dietary guidelines and scientific evidence from the emerging field of nutritional psychiatric epidemiology. Sixty-seven community dwelling individuals (Melbourne, Australia) aged 18 years or over, with current poor quality diets, and MDDs were enrolled into the SMILES trial. A retention rate of 93.9 and 73.5% was observed for the dietary intervention and social support control group, respectively. The dietary intervention (ModiMedDiet) consisted of seven individual nutrition counselling sessions delivered by a qualified dietitian. The control condition comprised a social support protocol matched to the same visit schedule and length. Results: This manuscript details the first prescriptive individualized dietary intervention delivered by dietitians for adults with major depression. Significant improvements in dietary quality were observed among individuals randomized to the ModiMedDiet group. These dietary improvements were also found to be associated with changes in depressive symptoms. Discussion/Conclusion: The ModiMedDiet, a novel and individually tailored intervention designed specifically for adults with major depression, can be effectively implemented in clinical practice to manage this highly prevalent and debilitating condition. Trial registration: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12612000251820. Registered 29 February 2012
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Background In people with psychosis, physical comorbidities, including cardiovascular and metabolic diseases, are highly prevalent and leading contributors to the premature mortality encountered. However, little is known about physical health multimorbidity in this population or in people with subclinical psychosis and in low- and middle-income countries (LMICs). This study explores physical health multimorbidity patterns among people with psychosis or subclinical psychosis. Methods Overall, data from 242,952 individuals from 48 LMICs, recruited via the World Health Survey, were included in this cross-sectional study. Participants were subdivided into those (1) with a lifetime diagnosis of psychosis (“psychosis”); (2) with more than one psychotic symptom in the past 12 months, but no lifetime diagnosis of psychosis (“subclinical psychosis”); and (3) without psychotic symptoms in the past 12 months or a lifetime diagnosis of psychosis (“controls”). Nine operationalized somatic disorders were examined: arthritis, angina pectoris, asthma, diabetes, chronic back pain, visual impairment, hearing problems, edentulism, and tuberculosis. The association between psychosis and multimorbidity was assessed by multivariable logistic regression analysis. Results The prevalence of multimorbidity (i.e., two or more physical health conditions) was: controls = 11.4% (95% CI, 11.0–11.8%); subclinical psychosis = 21.8% (95% CI, 20.6–23.0%), and psychosis = 36.0% (95% CI, 32.1–40.2%) (P < 0.0001). After adjustment for age, sex, education, country-wise wealth, and country, subclinical psychosis and psychosis were associated with 2.20 (95% CI, 2.02–2.39) and 4.05 (95% CI, 3.25–5.04) times higher odds for multimorbidity. Moreover, multimorbidity was increased in subclinical and established psychosis in all age ranges (18–44, 45–64, ≥ 65 years). However, multimorbidity was most evident in younger age groups, with people aged 18–44 years with psychosis at greatest odds of physical health multimorbidity (OR = 4.68; 95% CI, 3.46–6.32). Conclusions This large multinational study demonstrates that physical health multimorbidity is increased across the psychosis-spectrum. Most notably, the association between multimorbidity and psychosis was stronger among younger adults, thus adding further impetus to the calls for the early intervention efforts to prevent the burden of physical health comorbidity at later stages. Urgent public health interventions are necessary not only for those with a psychosis diagnosis, but also for subclinical psychosis to address this considerable public health problem.
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Exercise can improve clinical outcomes in people with severe mental illness (SMI). However, this population typically engages in low levels of physical activity with poor adherence to exercise interventions. Understanding the motivating factors and barriers towards exercise for people with SMI would help to maximize exercise participation. A search of major electronic databases was conducted from inception until May 2016. Quantitative studies providing proportional data on the motivating factors and/or barriers towards exercise among patients with SMI were eligible. Random-effects meta-analyses were undertaken to calculate proportional data and 95% confidence intervals (CI) for motivating factors and barriers toward exercise. From 1468 studies, 12 independent studies of 6431 psychiatric patients were eligible for inclusion. Meta-analyses showed that 91% of people with SMI endorsed ‘improving health’ as a reason for exercise ( N = 6, n = 790, 95% CI 80–94). Among specific aspects of health and well-being, the most common motivations were ‘losing weight’ (83% of patients), ‘improving mood’ (81%) and ‘reducing stress’ (78%). However, low mood and stress were also identified as the most prevalent barriers towards exercise (61% of patients), followed by ‘lack of support’ (50%). Many of the desirable outcomes of exercise for people with SMI, such as mood improvement, stress reduction and increased energy, are inversely related to the barriers of depression, stress and fatigue which frequently restrict their participation in exercise. Providing patients with professional support to identify and achieve their exercise goals may enable them to overcome psychological barriers, and maintain motivation towards regular physical activity.
Objective: This article aims to draw mental health clinicians' attention to the connections between nutrition and mental health, and the roles that Accredited Practising Dietitians play in improving mental and physical health through dietary change. Methods: Selective narrative review. Results: Unhealthy dietary practices are common in high prevalence and severe mental illness. Epidemiological evidence demonstrates that nutrients and dietary patterns impact on mental health. In addition, poor physical health is well documented in people with mental illness and the greatest contributor to the mortality gap. Dietary intervention studies demonstrate improved mental and physical health outcomes. Accredited Practising Dietitians translate nutrition science into practical advice to improve the nutritional status of patients with mental illness, and prevent and manage comorbidities in a variety of care settings. Conclusions: Medical Nutrition Therapy offers opportunities to improve the physical and mental health of people living with mental illness.
To inform improvement in the process and outcomes of care by describing the views and practices of psychologists working in public mental health services (PMHS) regarding provision of physical healthcare for consumers. Cross-sectional qualitative study employing a theoretical model of behaviour (capability, opportunity, motivation, and behaviour; COM-B model). Data collected in semi-structured interviews with maximum diversity sample of 29 psychologists were analysed using the framework approach. Participants were cognisant of the need to improve physical health among people with severe mental illness (SMI); they endorsed, to varying extents, the obligation of PMHS and potential of psychologists, collectively to contribute to this goal through provision of interventions targeting health behaviours. Within a context in which psychology was generally underutilised, practice varied widely, ranging from avoidance to integration of physical health care in clinical practice. In combination, mixed-messages about service priorities, role ambiguity, competing demands, and concern about adequacy of knowledge and skills inhibited attention to physical health for most participants, particularly those working in generic case management roles. Some highly motivated psychologists, most of whom worked in specialised teams within which attention to physical health was normative, made and capitalised on opportunities to develop and apply skills to enable consumers to change behaviour and improve physical health. While further education and training will enhance capability and motivation of psychologists, realisation of the potential contribution to improvement in physical health of people with SMI will fundamentally, require assertion of the identity and value of the profession within mental health services. Ensuring optimal use of scarce resources necessitates careful consideration of deployment of discipline specific expertise, and clarity about responsibilities of psychologists within teams.