Consensus statement on the role of Accredited Exercise Physiologists in the treatment of mental disorders: A guide for mental health professionals

This document provides a consensus statement on the role of Accredited Exercise Physiologists (AEPs) within mental health.

Exercise Physiologists (EPs) are university-qualified health professionals, trained in providing evidence-based exercise interventions to individuals at high-risk of developing, or with existing, chronic and complex medical conditions and injuries. Exercise & Sports Science Australia (ESSA) is the peak body providing national accreditation of Accredited Exercise Physiologists (AEPs).  AEPs are allied health clinicians who work in a range of private and public settings. They deliver clinical services to clients across the full range of inpatient (acute) and community (subacute) care settings. AEPs qualify for provider status through Medicare Australia, the Department of Veterans’ Affairs and most Private Health Insurers and compensation schemes[1]. 

AEPs have experience and expertise in the assessment, design, and delivery of exercise and behaviour change interventions. This includes working with those living with, or at risk of chronic conditions, including mental illness. AEPs represent a growing workforce within the mental health sector. With increasing opportunities for AEPs in mental health, it is essential that the broader mental health sector is aware of the types of interventions, modes of delivery, and likely benefits to service users associated with the utilisation of AEP interventions.

Specifically this document will:

• Define the scope and capacity of AEPs practising in the mental health sector
• Raise awareness of AEPs services and identify referral pathways available to mental health professionals
• Describe the benefits of AEP interventions for individuals utilising mental health services.         

This statement has been developed in consultation with AEPs with expertise in mental health, mental health clinicians and academics.

Defining the need for AEP services within mental health:

• Mental illness represents the third highest disease burden behind cancer and cardiovascular disease, with nearly one-half of Australians experiencing mental illness at some stage in their life [2, 3].
• Mental illness is associated with poor physical health outcomes. People living with severe mental illness (e.g. schizophrenia, bipolar affective disorder) experience twice the risk of cardiometabolic diseases, including obesity, type 2 diabetes mellitus (T2DM), metabolic syndrome and cardiovascular diseases (CVD) [4].
• Australians living with severe mental illness face a 15-20 year reduction in life expectancy, primarily due to preventable lifestyle-related conditions [5]. This gap is comparable to that seen in indigenous Australians, and continues to widen as life expectancy increases in the general population.
• High levels of sedentary behaviour, low levels of physical activity, poor dietary habits, high rates of tobacco use and substance misuse are key modifiable risk factors contributing to the increased burden of cardiometabolic diseases seen in this population [6-10].
• Psychotropic medication-induced weight gain further contributes to the high rates of cardiometabolic diseases [6].
• People experiencing mental illness often experience considerable barriers to initiating and maintaining behaviour change including; mental health symptoms such as amotivation, avolition, sedative effects of medication, and a lack of access to resources and services [11].
• Mental illness has a significant impact on overall psychosocial functioning and requires a holistic approach to treatment that addresses a variety of factors including symptomatology, social and occupational functioning, sleep behaviour, physical health and quality of life.
• Access to physical health care services may be less than optimal within mental health facilities. Service users often feel their physical health is neglected once they are diagnosed with a mental illness, referred to as diagnostic overshadowing [12].
• Mental health service users are entitled to quality, evidence-based care and treatment for all aspects of their health, including their physical health [13]. AEP interventions remain an underutilised resource, despite service users believing that exercise can make a valuable contribution to their recovery [14].

AEP Scope of Practice and Mental Health

AEPs place emphasis on implementing individualised lifestyle modification strategies that are both achievable and sustainable. These strategies can be achieved through empowering individuals towards greater independence and self-management of personal health and wellbeing. Examples of chronic conditions that may benefit from AEP interventions include diabetes, cardiovascular disease, cancer, musculoskeletal disorders and chronic pain. Mental health is an area of growing prominence for AEP practice. There is an increasing body of evidence regarding the efficacy of exercise interventions for both physical and mental health outcomes of people experiencing mental illness [15-19]. Despite the growing evidence supporting exercise interventions within targeted mental health settings, AEPs remain an underutilised resource [20, 21]. The inclusion of AEPs as part of the multidisciplinary mental health team will lead to improved physical and mental health outcomes for people with mental illness.

Integration of AEPs within the multidisciplinary mental health team

AEPs working in mental health:

• Have an understanding of symptoms of mental illness, and can identify and appropriately respond to symptom driven behaviour or changes in symptom presentation, and initiate a referral to mental health professionals.
• Recognise and appreciate that symptomatology, side effects of medication and possible reluctance to engage present as common barriers in this population.
• Incorporate various evidence-based strategies to overcome barriers including: rapport building, barrier identification, motivational interviewing, education and goal setting.
• Understand the relative and absolute contraindications to exercise for individuals with mental illness.
• Understand the roles of other members of the multidisciplinary mental health team, and work in liaison to provide a holistic approach to client-centred care.

What are the roles of AEP led interventions within mental health services?

• Design and implement evidence-based physical activity interventions to improve the physical health profile and prevent/manage the development of metabolic and cardiovascular disease [1].
• Work as part of a multidisciplinary team to conduct and promote regular physical health screening and metabolic monitoring (body weight, body mass index (BMI), waist circumference, blood glucose levels and blood pressure) [22] as part of standard care and in line with treatment guidelines.
• Consider clinical outcomes, risk factors and comorbidities such as cardiometabolic health, aerobic fitness, strength, movement capacity, and other health parameters (e.g. medication side-effects, sleep, fatigue and/or pain) that will inform the appropriateness and specificity of exercise interventions.
• Play a key role in the prevention/management of psychotropic-induced weight gain by increasing physical activity levels, reducing sedentary behaviour [23] and providing basic healthy eating advice.
• Encourage positive lifestyle choices before discharge (for inpatients) and facilitate referral to relevant AEP services in the community including; Community Managed Organisations (CMOs) e.g. Schizophrenia Fellowships of NSW Inc. New Moves program.
• Contribute to the mental health team through a client-centred approach incorporating recovery and strength-based models to achieve client-specific health related goals.
• Incorporate health coaching techniques such as motivational interviewing, physical activity education sessions (individual or group-based) regarding the benefits of physical activity, and goal-setting strategies to encourage effective and sustainable behaviour change for people with mental illness [24]. Using such strategies will aid in empowering independent physical activity/ exercise participation.
• Promote ‘Healthy Active Lives’ for people experiencing mental illness, to achieve the physical activity targets outlined in the HeAL declaration [25] , developed by an international working group comprising clinicians, researchers and consumers, which was endorsed in 2014 by Exercise & Sports Science Australia (more information at http://www.iphys.org.au/).
• Work collaboratively with mental health clinicians and other health professionals involved in the multidisciplinary team to provide a holistic and integrated approach to care. This would meet the International Organization of Physical Therapy in Mental Health (IOPTMH) call for ‘shared responsibility’ of health care providers, general practitioners, psychiatrists, policy makers and society as a whole to promote healthy and active lifestyles [26].
•  Facilitate linkages with general practitioners (GPs), other allied health professionals (e.g. dietitians, occupational therapists and social workers), community gyms and sports teams that can assist with a multidisciplinary approach to better health management.
• Assist in reducing the stigma and minimizing barriers for community-based clients utilising mental health services. Exercise is a normalised activity, particularly for young people, and therefore can act as a facilitator ensuring greater engagement with mental health services [23, 27, 28].

Examples of AEP-led interventions:

• Incorporate health coaching techniques such as motivational interviewing, physical activity education sessions (individual or group-based) regarding the benefits of physical activity, and goal-setting strategies to encourage effective and sustainable behaviour change.
• Design and implement accessible group exercise programs to encourage and enable higher levels of participation.
• Conduct exercise and functional capacity assessments.
• Conduct and promote regular physical health screening and metabolic monitoring (body weight, body mass index (BMI), waist circumference, blood glucose levels and blood pressure).
• Provide access to interventions using assertive outreach strategies to engage with individuals in the community, as a means of improving service utilisation.
• Provide basic healthy eating advice in the absence of a dietitian.
• Provide in-service training for the mental health workforce on the implementation of exercise and physical activity in mental health settings.
• Consult with mental health clinicians and GP’s on the most effective strategies to improve the health of clients including basic physical activity recommendations and referral pathways.
• Conduct information and training seminars on the role of physical activity in mental health for people with mental illness, their carers, friends and family, and interested community members.

By incorporating these strategies, AEPs can apply clinical skills and knowledge to increase physical activity and exercise participation in order to assist service users to achieve a range of positive outcomes including;

Physical Health Outcomes

• Weight management (weight loss, maintenance and prevention of weight gain)[23, 29-32]
• Reduce the risk of chronic disease (i.e. cardiovascular disease, metabolic syndrome & T2DM)[4, 28, 31, 33, 34]
• Improved psychosocial function i.e. activities of daily living, social and occupational functioning[35-39]
• Contribute to longer life expectancy through improvement in cardiovascular fitness and reduction in cardiometabolic risk[28, 40]

Mental Health Outcomes

• Decrease symptoms of depression, anxiety, stress and schizophrenia [16, 17, 41-43]
• Decrease social isolation[44]
• Improve sleep quality [45, 46]
• Increase engagement with treatment and service utilisation [23, 28]
• Reduce cravings and withdrawal in substance use disorders (SUD) and alcohol addiction [47-49]
• Increase self-esteem [50]
• Improve quality of life [16, 51, 52]

Evidence to date has focused on interventions for adult populations, however it is acknowledged that there is likely to be scope for AEP intervention for children experiencing mental illness. Likewise the evidence regarding the benefits of exercise for healthy aging and neurological disorders is growing, highlighting the potential role for AEP interventions for this population.

Referral pathways to community-based AEP services 

• Medicare Chronic Disease Management Plan (formerly Enhanced Primary Care or EPC) – For patients with chronic and complex health, defined as two or more medical conditions lasting 6 months or longer, a GP can set up a Team Care Arrangement and coordinate treatment plans. Medical conditions may include cardiovascular diseases, obesity, diabetes or chronic musculoskeletal conditions, all of which are common comorbidities in patients with serious mental illness. A treatment plan can include referral to various care providers including AEPs for a specified number of sessions, determined by the GP (up to 5 sessions per year).  
• Discharge planning for transition from inpatient settings into community-based AEP services. For example private exercise physiologists, community based mental health services that incorporate a physical health program or Community Managed Organisations (CMO’s) e.g. The Personal Helpers and Mentors program (PHaMs), NEAMI and Young People’s Outreach Program (Y-POP).
• Direct referrals via private psychologist/psychiatrists represent further opportunities for AEPs to contribute to the multidisciplinary health care team. For individuals who may have private health insurance, they may be eligible for rebate, as most private health insurers recognise AEPs services.

Authors involved in this report:

Oscar Lederman - Keeping the Body in Mind Team, South Eastern Sydney Local Health District, Sydney, NSW, and; School of

Psychiatry, University of New South Wales, Sydney, NSW, and; Department of Exercise Physiology, School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia

Kristine Grainger - Wellbeing Unit, Macquarie Hospital, Northern Sydney Local Health District, Sydney, NSW, Australia

Robert Stanton - School of Medical and Applied Sciences, Central Queensland University, Rockhampton, QLD, Australia

Angela Douglas - School of Medicine, University of Wollongong, Wollongong, NSW, Australia

Kirrily Gould - School of Psychiatry, University of New South Wales, Sydney, NSW, and; St John of God Hospital, North Richmond, NSW, Australia

Amy Perram - Keeping the Body in Mind Team, South Eastern Sydney Local Health District, Sydney, NSW, Australia

Rishi Baldeo - Keeping the Body in Mind Team, South Eastern Sydney Local Health District, Sydney, NSW, Australia

Theodora Fokas - Keeping the Body in Mind Team, South Eastern Sydney Local Health District, Sydney, NSW, Australia

Fiona Nauman - Queensland University of Technology, School of Exercise & Nutrition Science, Brisbane, QLD, Australia

Amanda Semaan - University of Sydney, Faculty of Health Sciences, Sydney, NSW, and; Integrated Care Unit, South Eastern Sydney Local Health District, Sydney, NSW, Australia

Jude Hewavasam - Secure Extended Care Unit, Monash Health, Melbourne, VIC, Australia

Louise Pontin - Headspace, Alfred Health, Melbourne, VIC, Australia

Simon Rosenbaum - Keeping the Body in Mind Team, South Eastern Sydney Local Health District, Sydney, NSW, and;

Department of Exercise Physiology, School of Medical Sciences, University of New South Wales, Sydney, NSW, Australia

__________

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