People with mental illness who enrolled in the In SHAPE health promotion program accrued health benefits in a variety of domains. They increased participation in regular exercise, reduced waist circumference, improved satisfaction with their fitness, and reported improvements in mental health functioning and negative symptoms. They also demonstrated trends toward increased readiness to limit caloric intake and improved self-efficacy for participation in activities. These findings confirm that a community-integrated, individualized health promotion program can substantially benefit consumers of public mental health services.
The In SHAPE program was successful in encouraging people to engage in physical activity, particularly in low-intensity walking and swimming, as well as other cardiovascular and resistance exercises. We suspect that this willingness to substantially increase exercise behavior may be due to the fact that exercise activities were offered in integrated, community settings, although without a comparison group in a segregated setting we could not test this hypothesis. In spite of the positive outcomes on increased exercise, significant weight loss was not observed overall. We suspect that this was due to a lack of change in dietary behaviors, which may reflect the challenges of modifying these behaviors in community-residing participants, including financial limitations and reliance on food pantries. We also found that health mentors focused on exercise goals over dietary behaviors, consistent with their training in fitness and lack of expertise in nutrition.
Our study is consistent with other literature which shows that mental health consumers participating in a health promotion program can significantly improve mental health functioning (Callaghan 2004
; Craft and Landers 1998
) and reduce severity of negative symptoms (Faulkner and Biddle 1999
). Changes in mental health functioning (as measured by the SF-12 MCS) reflect an increased ability to perform social roles, similar to that seen by Chen et al. (2009)
in their 10-week group-based health promotion program. These changes may be fostered by encouragement from health mentors and reinforcement for participation in community activities. Improved mental health functioning may be associated with positive health behaviors, such as our trend findings of greater self-efficacy to engage in social situations, or findings by others which show improved consumer empowerment associated with a exercise-focused health promotion program (Skrinar et al. 2005
). Reductions in negative symptoms, which are strongly related to social competence and psychosocial functioning (Mueser et al. 1991
; Pogue-Geile and Harrow 1985
), suggest that support provided by health mentors (Shiner et al. 2008
) may reduce apathy and improve motivation and social skills. Improved mental health functioning and reduced negative symptoms were not primary goals of the In SHAPE program, yet clinically important changes were observed in some participants. For example, one woman described rarely leaving her house for a period of 9 years before enrolling in the In SHAPE program. While participating in In SHAPE and engaging with her health mentor, she gained the confidence to use YMCA resources and return to competitive employment. Gains were unique and clinically important to each individual, yet are not easily captured with available measures of functioning and symptoms. Improved psychosocial functioning in the context of physical health promotion is noteworthy and warrants further study.
There are a number of limitations to this study. First, this pilot study did not include a control group, thus we are unable to comment on the usual course of exercise and dietary behaviors, health indicators, and psychological functioning. However, the literature on obesity, poor diet, lack of exercise, and cardiac risk associated with early mortality suggests that fitness among people with SMI is generally poor in the absence of targeted interventions. Second, despite including a dietary component, engagement in dietary changes remained low. Third, despite the importance of the health mentor relationship (Shiner et al. 2008
), we did not control for the effect of specific health mentors. Fourth, we do not report on exercise capacity, which we believe was enhanced based on anecdotal reports from health mentors. Anecdotal reports align with previous research which has found that exercise capacity of people with schizophrenia and depression can significantly increase following participation in an exercise program (Blumenthal et al. 1999
; Pelletier et al. 2005
). Our assessment battery included the 6-min walk test (Peeters and Mets 1996
), however, low completion of this test at baseline and inconsistent data collection methodology prevented us from reporting on this outcome. Fifth, while our finding of lower negative symptoms following participation in the In SHAPE program align with previous findings for people with schizophrenia (Faulkner and Biddle 1999
), this finding is based on the Scale for the Assessment of Negative Symptoms (SANS) which has not been validated among persons with non-psychotic disorders. However, symptoms assessed using this instrument (i.e., apathy, anhedonia, asociality, and amotivation) are common to people with mood disorders and are likely to affect an individual’s engagement and success in a health promotion intervention. Post-hoc analyses did not indicate differential SANS response patterns in persons with psychotic and non-psychotic disorders. Sixth, although several psychiatric medications commonly prescribed to people with mental illness are associated with weight gain (Allison and Casey 2001
; Allison et al. 1999
), the modest sample size and observational nature of this study did not allow for examining the differential effects of these medications on weight outcomes. Finally, post-hoc analyses should be interpreted with caution due to the potential for Type I error.
Several strengths of the study also should be noted. First, the 9-month duration of this evaluation allowed for an assessment of the sustainability of change over time and showed that participants can maintain health benefits with substantial personal supports and reinforcement. To our knowledge, only four health promotion studies that focus on both exercise and diet behaviors have evaluated outcomes beyond a 6-month period (Centorrino et al. 2006
; Chen et al. 2009
; Melamed et al. 2008
; Menza et al. 2004
). Of note, we found the strongest outcomes in the first 3-month evaluation period, with a leveling of improvement for most indicators thereafter. This may represent heightened motivation and enthusiasm to engage in a new health promotion program. The sustainability of these changes has important implications for creating lasting health behavior change and health benefits in people with SMI. Second, findings extend prior research by demonstrating health improvements across a broad array of outcome indicators. Third, our study demonstrates the feasibility and value of providing a health promotion program in an integrated, community setting. Finally, the heterogeneous diagnostic composition of our sample is representative of populations commonly served by public sector mental health service providers. As such, results are likely to generalize to populations that receive services from these types of settings.
In summary, people with mental illness can experience significant improvements in physical exercise, waist circumference, satisfaction with fitness, mental health functioning, and negative symptoms by participating in the In SHAPE individualized health promotion program. Based on these promising findings, the effectiveness of In SHAPE is being tested by our research group in randomized controlled trials funded by the Centers for Disease Control and Prevention and the National Institute of Mental Health.