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Exercise and People with Serious, PersistentMental Illness

A group walking program may be an effective way to lower the risk of comorbidities.

Psychiatric illnesses such asschizophrenia, bipolar dis-order, major depression,

obsessive–compulsive disorder, orpanic disorder, when coupled witha functional disability such as aninability to maintain employmentor live independently, are catego-rized as “serious and persistent”mental illnesses.1

Although estimates vary, seri-ous and persistent mental illness(hereafter called simply “seriousmental illness”) is known toaffect millions of U.S. adults andis a leading cause of disability.2

According to the NationalInstitute of Mental Health, in agiven year major depressive dis-order affects 14.8 million adults,panic disorder affects 6 million,bipolar disorder 5.7 million,schizophrenia 2.4 million, andobsessive–compulsive disorder2.2 million, with many peoplehaving more than one mentaldisorder.2

which are prominently impairedin schizophrenia.12 There are noknown serious complications tothe combination of exercise andpsychotropic medication.13

In 2003 we conducted a pilotstudy with colleagues that wasdesigned with two goals: todetermine whether a regularwalking program would specifi-cally benefit people with seriousmental illness and to test whetherit could help them to exerciseregularly.14 The study involved 15 outpatients with serious men-tal illness; diagnoses includedschizophrenia or schizoaffectivedisorder (10 patients), bipolar illness (four patients), and majordepression (one patient). The 12-week group walking programincluded educational workshopsto increase motivation and pro-vide support, and all walks wereled by the principal investigator(one of the authors of this article,McDevitt) and a psychosocialcase manager. Participantsdemonstrated high adherenceboth to walking (76% averageattendance at the walking ses-sions) and to the 12-week pro-gram (87% completed the study).After the study ended, severalparticipants formed a group inorder to continue walkingtogether. The following is a casestudy of one of the participants.

CASE STUDYSharon Galena (a pseudonym), a47-year-old woman, had been liv-ing with a schizoaffective disorder

Judith McDevitt is a clinical assistant professorand JoEllen Wilbur is a professor at theUniversity of Illinois at Chicago (UIC) College of Nursing. In addition, McDevitt is a familynurse practitioner at the College of Nursing’sCenter for Integrated Health Care, and Wilbur isthe associate dean of the College of Nursing’sCenter for Research Facilitation. The pilot studydescribed in this article was funded by the UICCampus Research Board and by the Center forResearch on Cardiovascular and RespiratoryHealth (CRCRH) at the UIC College of Nursing.Manuscript preparation was supported in part bythe CRCRH, which is funded by a grant (P20NR07812) from the National Institutes ofHealth. The authors would like to thank theUIC’s Center for Integrated Health Care andThresholds Psychiatric Rehabilitation Centers forgranting permission to recruit participants andproviding space to conduct the study. Contactauthor: Judith McDevitt, jmcdev1@uic.edu. Beatsand Breaths is coordinated by Julie JohnsonZerwic, PhD, RN: juljohns@uic.edu.

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People with serious mental ill-ness are at increased risk formedical conditions such ashypertension, diabetes, heartproblems, and obesity.3, 4 Reasonsfor this increase are related tolifestyle—for example, patientswith serious mental illness aremore likely to smoke and lesslikely to engage in light or vigor-ous physical activity5—and theadverse effects of some psy-chotropic medications. Manynewer, commonly prescribedpsychotropic agents, includingclozapine (Clozaril, FazaClo),olanzapine (Zyprexa), quetia-pine (Seroquel), and risperidone(Risperdal), can cause significantweight gain, lipid abnormalities,and glucose dysregulation.Exercise may help such patientsto modify their risk of these andother conditions.

The research on the out-comes of exercise in people withserious mental illness has beenlimited, mainly consisting ofcase reports and small groupstudies. Reviews of these studiessuggest that although exercisehas little effect on the underly-ing mental illness, it may help toimprove mood, decrease com-mon symptoms such as lack ofenergy and psychosocial with-drawal, and relieve comorbiddepression and anxiety.6-9 It alsoappears to improve brain andcognitive function in sedentaryolder adults, particularly whenthey’re engaged in tasks involv-ing executive functions,10, 11

A periodic column from the Center for Research on Cardiovascular andRespiratory Health, University of Illinois at Chicago.

By Judith McDevitt, PhD, APN, CNP, andJoEllen Wilbur, PhD, APN, FAAN

for more than 25 years. Hersymptoms were controlled witholanzapine and lithium (Eskalithand others), and she was doingwell in her rehabilitation pro-gram. Although not a smoker, shehad been gaining weight in recentyears, and her family historyincluded an early heart attack (herfather, at age 50) and type 2 dia-betes (an older sister). Her onlyregular form of physical activitywas walking short distances toand from bus stops.

On physical examination,blood pressure was 116/70 mmHg;pulse, 88 beats per minute; andbody mass index (BMI) 37.8,which the National Heart, Lung, and Blood Institute catego-rizes as class II obesity. Her fasting triglycerides level was

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140 mg/dL, within the normalrange. Her high-density lipopro-tein (HDL) cholesterol level, 51 mg/dL, was within the recommended range; her low-density lipoprotein (LDL) choles-terol level, 132 mg/dL, wasslightly above the recommendedrange. No other abnormalitieswere noted.

On exercise testing using thestandardized treadmill test (alsoknown as the Bruce protocol)modified for sedentary subjects,Ms. Galena attained a heart rateof 165 beats per minute withouthaving any significant ST seg-ment shifts on electrocardiogra-phy. This result was satisfactoryfor ruling out occult heart dis-ease, since her heart rate was98.8% of the maximum age-

predicted heart rate for her ageand sex. However, her heart ratereached 165 beats per minute injust 9.5 minutes, indicating poorcardiovascular fitness. Becausenot all of the program partici-pants were at the same level offitness, exercise prescriptionswere tailored somewhat to theindividual, especially as theyentered the program. Accordingly,Ms. Galena’s exercise prescriptionincluded an initial four-week con-ditioning period, during whichtime she walked twice a week,gradually increasing walk dura-tion from 10 minutes to 20 min-utes and effort intensity from“very light” to “fairly light.”During weeks 5 through 12, shewalked three times a week, withduration gradually increasing

Artist Charles Kaiman, MSN, NP, RN, CS, a clinical nurse specialist in psychiatric–mental health nursing, provided two paint-ings for this article that depict exercise programs at the New Mexico Veterans Affairs Health Center in Albuquerque, NewMexico. The watercolor above shows a weekly walk with patients with serious mental illness, mainly bipolar disorder or schizophrenia. “It’s a social outlet and helps in weight control and diabetes management,” Kaiman says of the supervisedwalks. “Some of the newer antipsychotics can cause weight gain, and the walks help minimize or eliminate these problems.”

and/or symptoms of various car-diovascular, pulmonary, andmetabolic diseases, as well asconditions . . . that may beaggravated by exercise,”25 aswell as men age 45 or older andwomen age 55 or older, get med-ical clearance and possibly astress test before participating inan exercise program.25

For cardiorespiratory benefit,the ACSM guidelines suggest aminimum of three to five 20-to-60-minute moderate-to-vigor-ous walking sessions eachweek.25 Alternatively, the goalmight be to accumulate at least 30 minutes of moderate-intensity exercise per day byincorporating “short bouts ofactivity” such as walking shortdistances instead of driving andusing stairs instead of eleva-tors—an approach that favorslifestyle changes rather than aformal exercise regimen.23

Although adherence amonghealthy adults has been shownto be higher with home-basedexercise programs,26 people withserious mental illness may bene-fit more from a group-basedprogram. Group programs canprovide consistent support andhelp build initial motivation byhelping participants understandhow exercise will benefit them.27

As participants become morephysically active, such programscan help them address barriersthat may arise. Structure, feed-back, and encouragement areessential in walking programsfor people with serious mentalillness, who may experienceavolition (defined in TheDiagnostic and StatisticalManual of Mental Disorders,fourth edition, text revision, as“an inability to initiate and per-sist in goal-directed activities”)or amotivation (the belief thatactions have no control overoutcomes) or have difficulty

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from 20 minutes to 30 minutesand effort intensity increasingfrom “fairly light” to “somewhathard to hard” (brisk walking).Each session also includedstretching and five-minute warm-up and cool-down periods.

Ms. Galena’s family historyof heart disease and type 2 dia-betes and her class II obesityplaced her at very high risk fortype 2 diabetes, hypertension,and cardiovascular disease.15

However, she found that sheenjoyed walking and walkedboth with the group three timesa week and additionally on herown. After 12 weeks in the pro-gram, she was walking brisklyfor 30 minutes each time, hadlost 6 lbs., and had lowered herBMI from 37.8 to 36.7. Withcontinued walking and gradualweight loss, it’s likely she willfurther lower her disease risk.

THE BENEFITS OF EXERCISE The U.S. Department of Healthand Human Services’ HealthyPeople 2010: Objectives forImproving Health endorsesphysical activity as an evidence-based way to prevent or reducethe impact of cardiovasculardisease and promote health;either vigorous or moderate lev-els of physical activity “can havesignificant health benefits.”16 Ametaanalysis of randomized,controlled intervention trials con-cluded that moderate exercisecan lower systolic and diastolicblood pressure.17 A literaturereview considered the effects ofmoderate-to-vigorous exercise onblood lipids; although resultswere inconsistent, “the mostcommonly observed change wasan increase in HDL cholesterol[the type that can lower risk ofcardiovascular disease], withreductions in total cholesterol,LDL cholesterol, and triglyc-erides less frequently

observed.”18

Exercise can also help in theprevention and treatment of type2 diabetes. Two large studiestesting the impact of modifica-tions to both diet and exerciseeach demonstrated a 58% reduc-tion in the incidence of diabetesover three-year periods19, 20;another study found that anintervention involving exercisealone led to a 46% reduction indiabetes risk over six years.21 Aliterature review concluded thatmoderate exercise improves glu-cose metabolism, insulin sensitiv-ity, and glycemic control inpeople with type 2 diabetes,although more research was nec-essary to identify the mechanismsand dose-response threshold.22

The growing body of evi-dence supporting the benefits ofexercise is considered so com-pelling that the Centers forDisease Control and Prevention,the American College of SportsMedicine (ACSM), and theAmerican Heart Associationconcur in recommending that alladults “should accumulate 30minutes or more of moderate-intensity physical activity onmost, preferably all, days of theweek.”23 Interestingly, walking isthe most frequently reportedactivity among adults meetingthese recommendations.24

PLANNING A WALKING PROGRAMSome conditions can be exacer-bated by even moderate activitysuch as walking, especially inpeople with serious mental ill-ness, who are at heightened riskfor comorbidities such as hyper-tension and heart disease.3, 4 ThePhysical Activity ReadinessQuestionnaire (www.csep.ca/pdfs/par-q.pdf) is a simple, vali-dated tool that can be used toscreen for a risk of such condi-tions. The ACSM recommendsthat people with “risk factors

learning new skills.The support of a group can

be particularly helpful in thispopulation, by providing model-ing, assistance with problemsolving, and socialization oppor-tunities. Modeling by peers canencourage those who have diffi-culty working toward new goals.Bandura has theorized that mod-eling is one of four modesthrough which self-efficacydevelops.28 Problem solving bythe group can help individualsovercome barriers and counterbeliefs that one’s actions have noinfluence. Socialization around acommon purpose such as exer-cising facilitates social persua-sion (affirmation by others thatone has the capability to suc-ceed), another mode throughwhich self-efficacy develops28;this can be especially importantfor people with serious mentalillness, who tend to have smallsocial networks.29

Knowing how to exercisesafely is also important, and agroup exercise program can assistpeople with serious mental illnessin this regard as well. It’s impor-tant for participants to under-stand the difference betweennormal changes induced by mod-erate exercise (for example, feelingwarm and slightly out of breath,noticing a faster heart rate) andsymptoms of potentially seriousconditions (such as chest pain).Participants should also knowhow to respond to minor achesand pains that may arise as theybecome more active. Graduallyincreasing walking pace and dura-tion, knowing how to warm upand cool down, and wearingproper footwear can help preventproblems.25 Although the evidenceregarding whether stretching pre-vents injuries is inconclusive,according to a literature review,30

stretching gently after walking is arelaxing way to complete a ses-

sion and may help increaseawareness of the favorable effectsof regular exercise.

Because of obesity, amotiva-tion, or avolition, some partici-pants may not be able to walkbriskly.14 However, although arelationship between greaterexercise intensity and improvedcholesterol profiles has beenobserved in many studies,31 thereis also evidence that it may bethe amount of exercise that hasthe clearest effects. Kraus andcolleagues found that jogging ata moderate pace to obtain thecaloric equivalent of 17 to 18miles per week had a greaterbeneficial effect on lipoproteinlevels than did either walking orjogging 11 miles per week; how-ever, all three regimens studiedwere more beneficial than wasbeing sedentary.32 Nurses canreassure patients that engaging inany level of activity from “verylight” to “somewhat hard” isbetter than remaining sedentary.

In our experience, the mostcommon reason sedentary peo-ple have for beginning to exer-cise—whether they have seriousmental illness or not—is thedesire to lose weight. But theymay have unrealistically highexpectations of a program thatinvolves moderate activity (suchas walking), resulting in disap-pointment and their droppingout of the program. At the startof a walking regimen, nursesshould explain that weight lossthrough exercise alone will bemodest, but that it will confermany other benefits such asimproved cardiovascular fitness,increased energy, and better cho-lesterol profiles.

Feedback that includes evi-dence of any improvements canbe a powerful motivator in helping participants to changebehavior successfully.33 In ourstudy, participants used a simple

weekly log to record theirwalks.14 One metaanalysis con-cluded that using objective mea-surement in addition toself-reporting—for example,using a pedometer to measureand record distance walked (insteps counted)—correlated withgreater increases in physicalactivity than the use of self-reporting alone, although fewstudies employed both meth-ods.34 Pedometers are inexpen-sive, reliable, easy to use, andcan be worn throughout the day,and the feedback they providemay help motivate the user. Inone 18-week walking programinvolving people with seriousmental illness, most participantswere able to use pedometers to

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Group programs can provide consistent

support and help build initial motivation.

track their daily step counts,although their step counts didn’tincrease as a result.35

In part because weight gain isa frequent adverse effect seenwith antipsychotic medications,many psychosocial rehabilita-tion programs are beginning tooffer exercise programs for theirpatients, whose participation indeveloping them is often encour-aged. Nurses can talk individu-ally with their patients aboutincreasing physical activity aswell. Although much is knownabout factors that influenceexercise adherence in the generalpopulation, more research isneeded among people with seri-ous mental illness, in order toestablish how best to assist themin beginning and maintaining aprogram of regular physicalactivity. t

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