The Mind-Body Well-being Initiative: a better lifestyle for people with severe mental illness

The need for physical health programmes in mental health services

In people with severe mental illness (SMI), particularly for those experiencing psychotic illness, the physical health disparity and mortality gap is well established.^1,2 People with SMI like schizophrenia have a reduced life expectancy of at least 15–20 years. ³ This is largely due to physical health conditions, particularly cardiometabolic and respiratory disease, secondary to the sequelae of illness and treatments.^1,2 Along with the established metabolic side effects of frequently prescribed medications in this cohort, there are modifiable lifestyle-related risk factors, such as smoking, unhealthy diet and physical inactivity, which contribute to poor physical health outcomes in this population.^1–3 While people with SMI have poorer physical health and shortened lifespan, they also experience inequitable access to health care due to mental illness-related factors, side effects of medication, cognitive factors, psychosocial factors and clinician factors.^1–3

Major bodies highlight the physical health needs of this population. The National Mental Health Commission has developed ‘Equally Well’ to advocate a ‘whole-of-person, whole-of-life’ approach to mental health. ³ The Royal Australian and New Zealand College of Psychiatrists (RANZCP) clinical guidelines for both schizophrenia and mood disorders make treatment recommendations for mental health services to provide evidence-based lifestyle therapies.^4–5 The Lancet Psychiatry Commission provides an up-to-date summary of the physical health evidence in mental illness and proposes that future lifestyle interventions in mental health care settings should be adopted. ² The prevention of cardiometabolic risk in SMI is observed in the development of screening algorithms, such as the Australian Positive Cardiometabolic Resource and its Lester UK adaptation. ⁶ However, despite these recommendations, there are critical gaps in the existing research and limited policy to guide models of service delivery within real-world clinical settings. ²

Lifestyle medicine in mental and physical health

Lifestyle medicine involves applying environmental, behavioural, medical and motivational principles to promote self-management of lifestyle-related health problems in clinical and public settings. This approach includes patients as active partners in their own care, placing strong emphasis on motivation and long-term engagement with healthy habits. Interventions within our programme incorporate the six pillars of lifestyle medicine: nutrition, physical activity, sleep, forming and maintaining relationships, managing stress and cessation of tobacco. Evidence indicates that improvements in lifestyle could prevent 93% of diabetes, 81% of heart attacks, 50% of strokes and 36% of all cancers. ⁷ Furthermore, evidence also shows that lifestyle factors contribute directly to mental health pathogenesis and symptomatology.^5,8–10 Randomised controlled trials of dietary and sleep interventions for depression demonstrate substantial efficacy and cost-effectiveness.^8,9 Physical activity has been shown as effective as pharmacotherapy and psychotherapy in those with major depression disorder, and for schizophrenia-spectrum disorders evidence indicates that physical activity can reduce psychiatric symptoms and improves cognition. ¹⁰ Furthermore, evidence-based health coaching and behaviour change methodology, such as motivational interviewing and brief interventions, can improve a patient’s ability to self-manage and adopt healthier lifestyle choices such as reducing smoking, eating more healthily and increasing physical activity. ¹¹

The “AIM Self-Capacity” model of care

We recognised the need to develop a holistic mind and body health programme with multimodal interventions that have biopsychosocial components. Our model of care: AIM Self-Capacity (Figure 1) was informed by the current evidence base supporting assessment and interventions while considering patient, staff and service needs, utilising available resources and connections with external health providers. Our programme is individualised to all patients within our CCU, regardless of diagnosis or stage of illness.

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Figure 1.

Our model of care: AIM Self-Capacity.

In its early development, the CCU staff carried a degree of apprehension, which generally centred around therapeutic nihilism, concerns about additional workload and a perceived lack of knowledge and skills. In response to this, basic training in lifestyle medicine in physical and mental health, motivational interviewing and health coaching was provided. Furthermore, staff with an interest in supporting healthier lifestyles were offered an opportunity to be involved with an area of the initiative that matched their passions. Additional external funding was limited to support the GPSI for 1 day a fortnight. The potential risk of overextending staff was managed by drawing on the internal motivation of staff, patients’ active involvement and assistance in the programmes, regular senior staff support and monitoring, and enhanced locus of control on both programmes and work–rest schedules. Staff feedback is regularly and actively sought by the leadership team and appropriate modifications are made. All the staff have continued to work in their programmes over a 2-year period.

Assessments

Residents are seen in the Mind-Body Well-being Clinic by a clinical nurse and the GPSI, at a triage-guided frequency (e.g. weekly, monthly or at least 3 monthly) based on health needs and motivation. During these visits, a comprehensive assessment of clinical, biochemical and lifestyle parameters is performed, as detailed in Figure 2.

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Figure 2.

Mind-Body Well-being Clinic assessment.

Interventions

Interventions provided at the CCU are summarised in Figure 3. Within our model, we focus on the ‘Big 4’ behavioural determinants of illness, including diet and nutrition, physical activity, smoking and alcohol consumption. In addition, the ‘Little 8’ are also routinely assessed and intervention recommended if required; for example, if assessment indicates obstructive sleep apnoea, patients are referred for sleep studies and treatment. A tailored individualised plan is prescribed for the resident by completing the checklist in Figure 3 based on patient preferences and desired outcomes.

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Figure 3.

BIG 4 Intervention Model.

Interventions at CCU are tailored to meet the needs of the residents and have a rehabilitative focus, that is, to enable the acquisition of new or lost skills and improving health literacy. Examples of such interventions around diet and nutrition include meal planning, shopping, food safety education and meal preparation – for example, ‘Psych-n-Easy’, which an affordable healthy meal programme that is staff facilitated but cooked and prepared almost entirely by patients in an interactive group format. Combined staff and patient lunches are held fortnightly with a GPSI-led health education session to enhance health knowledge, social interaction and relationship building.

Evidence-based physical activities are offered within different settings (both on-site and off-site) and require different types of participation (individual- and group-based activities), to cater for individualised preferences and needs. Most scheduled activities are supervised or supported by a member of the team.

Measures have been put in place at CCU to promote an environment that is more conducive to a healthy lifestyle. Such examples include healthier food options being put on display; cessation of the further ordering of sugar; the routine accessibility of nicotine replacement and the promotion of opportunities for incidental physical activity.

Evidence-based pharmacological interventions are also considered to address risk factors including smoking, drug use, alcohol consumption and cardiometabolic risk factors in suitable residents without contraindications. Furthermore, the psychiatrist considers switching to a psychotropic medication with a lower propensity for weight gain if this is clinically suitable.^2,4,5

Motivational strategies

Behaviour change is difficult and complex, and this is particularly the case in patients with SMI. ² To assist, basic behaviour change methodology is taught to staff and all patients are assigned a staff member trained in basic health coaching to form a collaborative partnership and draw on the patients’ autonomous motivation. This is further enhanced by reviewing patient outcomes in the weekly multidisciplinary team meetings to ensure all team members can support in synergy.

Collaborative working relationships

CCU has deliberately established collaborative working relationships to deliver physical health care and support sustained behaviour change. Referral pathways and partnerships have been established as presented in Figure 4.

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Figure 4.

CCU’s collaborative relationships. CCU = Continuing Care Unit.

Conclusion

The Mind-Body Well-being Initiative in a residential mental health service aims to improve both physical and mental health parameters through the AIM-Self Capacity model of care we have developed. It is a co-designed programme informed by policy and guideline recommendations and incorporates detailed assessment, evidence-based lifestyle interventions, motivation and behaviour change methodology, environmental modification and service collaboration. Further research is required to validate this model of care on physical and mental health outcomes.