A therapeutic resource

People with severe mental illnesses such as schizophrenia, bipolar disorder and major depressive disorders have been experiencing deteriorating life expectancy rates (Nielsen et al. Reference Nielsen, Uggerby, Jensen and McGrath2013); culminating in a 15–20 years reduced life expectancy compared with the general population (Thornicroft, Reference Thornicroft2011). Although much public and political focus is now given to violent or suicide related death (Department of Health, 2015), meta-analytic evidence shows that the early mortality figures for people with severe mental illness is largely attributable to metabolic dysregulation and consequent cardiovascular disease (Correll et al. Reference Correll, Solmi, Veronese, Bortolato, Rosson, Santonastaso, Thapa-chhetri, Fornaro, Gallicchio, Collantoni, Pigato, Favaro, Kohler, Vancampfort, Ward, Gaughran, Carvalho and Stubbs2017); findings which appear to reflect comorbidity of people with severe mental illness documented in Irish research (Nash et al. Reference Nash, Bracken-Scally, Smith, Higgins, Eustace-Cook, Monahan, Callaghan and Romanos2015). This comorbidity is influenced by a number of behavioural practices; such as taking anti-psychotic medications, high rates of tobacco smoking, poor dietary practices, and engaging in low levels of physical activity and frequent prolonged bouts of sedentary behaviour (Vancampfort et al. Reference Vancampfort, Rosenbaum, Ward and Stubbs2015a). Physical activity and sedentary behaviour interventions have proved to be a low risk therapeutic option (Morgan et al. Reference Morgan, Parker, Alvarez-Jimenez and Jorm2013) that can improve metabolic dysregulation, improve cognitive function and improve cardio-respiratory fitness; a proxy indicator of quality of life for people with mental illness (Vancampfort et al. Reference Vancampfort, Stubbs, Mitchell, De Hert, Wampers, Ward, Rosenbaum and Correll2015b; Firth et al. Reference Firth, Stubbs, Rosenbaum, Vancampfort, Malchow, Schuch, Elliott, Nuechterlein and Yung2017; Stubbs et al. Reference Stubbs, Chen, Chung and Ku2017). Perhaps most critically, physical activity interventions may significantly reduce psychiatric symptoms; particularly depression symptoms across multiple mental illness diagnoses (Rosenbaum et al. Reference Rosenbaum, Tiedemann, Sherrington, Curtis and Ward2014; Schuch et al. Reference Schuch, Vancampfort, Richards, Rosenbaum, Ward and Stubbs2016).

Specialised exercise practitioners

Recognising the accumulating evidence, some countries have taken steps to make physical activity and sedentary behaviour interventions part of routine care; bringing physical activity beyond a sub-therapeutic or diversional strategy (Rosenbaum et al. Reference Rosenbaum, Tiedemann, Ward, Curtis and Sherrington2015). In the USA, there have been calls for minimum standards and competencies around mental health care service providers in delivering physical activity (Pratt et al. Reference Pratt, Jerome, Schneider, Craft, Buman, Stoutenberg, Daumit, Bartels and Goodrich2016). In Australia, exercise professionals (accredited exercise physiologist) with particular expertise in exercise prescription for mental health populations have begun delivering and monitoring tailored physical activity and sedentary behaviour interventions as part of routine multidisciplinary care with great effect (Lederman et al. Reference Lederman, Grainger, Stanton, Douglas, Gould, Perram, Baldeo, Fokas, Nauman, Semaan, Hewavasam, Pontin and Rosenbaum2016, Reference Lederman, Suetani, Stanton, Chapman, Korman, Rosenbaum, Ward and Siskind2017). This is exemplified in comprehensive programmes such as the Keeping the Body in Mind Programme in New South Wales, Australia (Curtis et al. Reference Curtis, Watkins, Rosenbaum, Teasdale, Kalucy, Samaras and Ward2016).

Strategic gaps in Ireland

Since 2006, Irish mental health care policy has been guided by a national policy framework document; A Vision for Change (Department of Health and Children, 2006). This document has been subject to recent review and update to meet the demands placed on modern psychiatric services and highlight priority areas for improvement since 2006 (Cullen & McDaid, Reference Cullen and McDaid2017). A Vision for Change makes recommendations for key issues that may impact the delivery of mental health care for people with severe mental illness in Ireland; highlighting a need for resources and change with regard to education, employment and housing. Whilst the mental health care strategy for primary care within A Vision for Change acknowledges that people with severe mental illness face poorer physical health comparative to general population; the role of physical inactivity is omitted. This casual omittance appears symptomatic of a wider strategic level lack of consideration for the physical health of people with mental illness in Ireland.

Unfortunately the role of the accredited exercise physiologist is not included within mental health multidisciplinary teams in Ireland. Similarly, physiotherapists; who are also well placed to contribute to interventions in this regard (Stubbs et al. Reference Stubbs, Soundy, Probst, De Hert, De Herdt and Vancampfort2014), are not consistently represented on rehabilitation focused multi-disciplinary teams in Ireland (Department of Health and Children, 2006). However, international literature shows that mental health nurses may be well placed to play a leadership role in promoting good physical activity behaviours (Happell et al. Reference Happell, Platania-Phung and Scott2011); particularly when this is reflected in the wider multidisciplinary team agenda (Vancampfort & Faulkner, Reference Vancampfort and Faulkner2014). That being said, exploratory research carried out in Ireland shows that mental health service users see lack of training on physical activity among mental health nurses as a barrier to engaging in physical activity interventions (Cullen & McCann, Reference Cullen and McCann2014).

The next step

Interventions that target physical activity and sedentary behaviour are a viable therapeutic resource for multidisciplinary mental healthcare teams in Ireland. We advocate that the next step for Irish mental health strategy should consider physical activity and sedentary behaviours a strategic priority for people with severe mental illnesses as part of an overall focus on physical and mental health. To do this, future Irish mental health strategy should make specific recommendations for funding and engagement with educational institutions to develop the role and expertise of an exercise practitioner who can work across the mental health space. International exercise and sports science governing bodies have highlighted that culture change, infrastructure and training will need to be addressed and resourced to effectively develop and integrate this role effectively (Rosenbaum et al. Reference Rosenbaum, Hobson-powell, Davison, Stanton, Craft, Duncan, Elliot and Ward2018). However, physical inactivity is a multidisciplinary issue that requires immediate attention in the interim. Therefore, it seems that there is justification for mental health clinicians, particularly mental health nurses and occupational therapists, to be upskilled in basic physical activity and sedentary behaviours awareness and training as an immediate priority. Similarly, this will require engagement from key decision makers at a national and educational institution level, which we see as a necessary step for closing the health equality gap for people with severe mental illness in Ireland.