A file audit of gym usage in an Australian private inpatient psychiatric hospital

Abstract

Objective

This study aimed to determine the extent to which people admitted to a private psychiatric inpatient unit access and utilise the gymnasium and individualised coaching with an exercise physiologist (EP).

Methods

An audit of the medical record of 100 consecutive discharges and 60 individuals referred to an EP during the audit period was undertaken. Selected demographic information, physical health status, psychiatric diagnosis and routinely collected outcome data were extracted from files.

Results

Twenty-four percent of people discharged from the hospital had documentary evidence of having attended the gym. These people were noted to have used the gym regularly and had an exercise prescription documented on discharge. Those with substance use disorder were more likely to use the gym than those diagnosed with an affective disorder. There were no significant differences in outcomes between those who were noted to exercise and those who did not.

Conclusion

Those who may most benefit from coaching around exercise in the context of hospital admission are not presently the individuals most likely to be referred to an EP. Standardised procedures for assessment, referral, exercise prescription and ongoing monitoring of activity and outcomes are recommended across the care continuum.

Exercise is a subset of physical activity that is planned, structured and repetitive, undertaken with the aim to improve health and physical fitness. ¹ Exercise is recommended as a first-line treatment or as an adjunctive to treatment for a range of mental health conditions. For example, the American Psychiatric Association's (APA) Practice Guideline for the Treatment of Patients with Major Depressive Disorder recommends exercise as an adjunctive treatment for mild-to-moderate depression. ² The Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical Guidelines for the Management of Major Depressive Disorder also recommend exercise as a first-line treatment for mild-to-moderate depression. ³ The UK National Institute for Health and Care Excellence (NICE) Guidelines for the Management of Depression in Adults similarly recommend exercise as a treatment option for mild-to-moderate depression, either as a sole intervention or as an adjunctive treatment with antidepressant medication or psychotherapy. ⁴ The Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders ⁵ state that regular physical exercise is associated with a reduction in depressive symptoms and can be used as an adjunctive treatment. The guidelines suggest that people with mood disorders should aim for at least 150 min of moderate-intensity exercise per week and that exercise should be tailored to the individual's preferences and capabilities. The potential impact of exercise on well-being is recognised by the public. According to a recent survey of the Australian population in which two in five people reported experiencing a mental disorder at some time and one in five in the past 12 months, 37.5% of respondents stated they increased their level of exercise or physical activity to help manage their mental health. ⁶ This was the single most used strategy to self-manage mental health symptoms.

What is the evidence for exercise?

There is strong evidence that exercise can be helpful in treating various psychiatric disorders. A meta-analysis inclusive of 41 studies found that exercise, including supervised exercise, had a large effect size in reducing symptoms of major depressive disorder (MDD). ⁷ Supervised and group exercise of moderate intensity and incorporating aerobic exercise regimes was recommended for MDD and depressive symptoms. In a systematic review and network analysis (21 RCTS, N = 2551) comparing the effectiveness of exercise to antidepressants, no difference was found between exercise and pharmacological interventions on reductions in depressive symptoms, although exercise interventions had higher drop-out rates than antidepressants. ⁸ A further metanalysis ⁹ (11 trials, N = 455) confirmed that in clinical populations a significant and large antidepressant effect has been observed after aerobic exercise for 45 min, three times a week at moderate intensity.

A meta-analysis of 10 RCTs (N = 3865) found that exercise had a small-to-moderate effect size on global cognition, social cognition and attention/vigilance in schizophrenia. ¹⁰ Other trials have found that high-intensity interval training appears to improve overall cardiorespiratory fitness and depressive symptoms in schizophrenia. ¹¹ Overall, these reviews suggest that exercise can be a useful adjunctive treatment for both high and low-prevalence disorders and that interventions supervised by exercise professionals appeared most beneficial. Despite the potential benefits of exercise, surveys of mental health clinicians continue to find that exercise prescription continues to be influenced by clinician factors such as their own frequency of engagement in exercise. ¹² Introducing exercise programmes supervised by an exercise physiologist (EP) during a hospital stay ought to be an efficient means of exercise prescription to those who ought to be most likely to benefit from such interventions. There are few examples of such programmes being implemented or evaluated in routine care. ¹³

This project was undertaken at a 105-bed private mental health facility on the Gold Coast in Queensland Australia serving adults who ordinarily reside in Southeast Queensland and Northern New South Wales. The Clinic provides inpatients with intensive treatment, group programmes and a well-equipped gym supervised by an EP. The patient profile is typical of private hospitals in Australia, that is, most inpatients have a principal diagnosis of a mood disorder and or a disorder due to the use of substances. The average length of stay at the private hospital was similar to the national average of 17.9 days. ¹⁴ Approximately 10 psychiatrists admit and treat patients at the hospital at any one time.

Methodology

The project received expedited approval as a low-risk research project by the Southern Cross University Human Research Ethics Committee (#2022/018). An audit of the hospital inpatient charts was undertaken prospectively of 100 consecutive discharges. The charts were reviewed after discharge from that episode of inpatient care. A psychiatric registrar in training examined the records for any evidence that individuals had used the gym or had been referred to the EP and collated details on the person’s age, gender, psychiatric diagnosis, comorbid physical health problems and routinely collected outcome measures (the Depression, Anxiety, Stress Scale or DASS). A preliminary file review in preparation for the audit revealed that biometric data such as weight, waist circumference and indeed an assessment of people’s exercise status was not routinely documented in the hospital file. At that time, the DASS ¹⁵ was undertaken on admission and discharge. It was noted that there were few details in the charts about the referral to the EP (a finding in itself) so a more detailed account from the EP was sought of who utilised their service. This included a list of 60 consecutive gym attendees whose files were also audited (there was some overlap), and the characteristics of this cohort noted alongside the analysis of the 100 discharges (See table one). The findings are presented primarily with descriptive statistics. T-tests were undertaken to determine if there were differences between gym attendees and non-attendees on demographic and other variables after testing for normality. ¹⁶

Results

Of 100 consecutive discharges, 24 individuals were noted to have used the gym. Most were male (62.5%, n = 15) although 59% of those discharged were female. As illustrated in table one, gym attendees were somewhat younger (Mean = 40.63 vs 47.97) than non-gym attendees. The total DASS scores of gym attendees on admission were not significantly different from non-attendees. The Mean DASS score of gym attendees was 30.76 on discharge compared with 43.02 in the non-gym attendees but this difference was not significant (t = 1.593, df = 66, p = .116). Those who were noted to have attended the gym did so on average 10.1 times (SD 5.8, range 2 to 27) over the course of their admission. All had a documented prescription or recommendation for further exercise on discharge. None of the non-attendees had an exercise prescription on discharge.

Approximately half of gym attendees listed by the EP did not have an annotation in their record that they used the gym. Gym attendees had a slightly larger mean change in DASS scores over the course of the admission but a smaller percentage reduction in scores. Interpreting these findings is difficult due to the large quantity of missing data with DASS data not available on admission or discharge for 44% (n = 44) of all discharges. Where data was missing these cases were excluded from analysis.

Those who accessed the gym were less likely to have a depressive disorder than those who did not (33.3% vs 5.7%), were more likely to have an anxiety disorder (41.6% vs 30.3%) and had a similar rate of PTSD or Complex PTSD (41.6% vs 43.4%). There were high rates of substance misuse in both groups (70.8% vs 64.5%). Many people in both groups had a medical history or problem which may have impacted on tolerance to exercise, for example, chronic pain, sciatica, osteoporosis, asthma and a history of gastric sleeve surgery (Table 1).

Table 1.

Selected characteristics of 100 consecutive discharges, those who were documented to have used the gym, and characteristics of 60 people noted to have used the gym during a recent hospital stay

	All discharges	Non-gym	Gym	Gym audit
Number	100	76	24	60
Gender	59F 40 M 1 trans	50F 25 M 1 trans	9F 15 M	28F 32 M
Mean age	46.2 (SD = 14.75, range 20–80 years)	47.97 (SD = 15.4, range 21–80)	40.6 (SD = 11.135, range 20–66)	41.1 (SD = 11.9, range 20–66)
Mean DASS on admission	74.85 (range 4–128)	74.86 (range 10–128)	72.74 (SD = 30.76, range 4–118)	78 (SD = 25.2, range 4–130)
Mean DASS on discharge	40 (range 0–120)	43.02 (range 0–120)	30.47 (range 0–112) non sig (t = 1.593, df = 66, p = .116)	38.4 (range 0–122)
Mean DASS change	−32 (53.4% reduction)	−30.7 (57.5% reduction)	−33.9 (41.8% reduction) non sig (t = .405, df = 55, p = 0.687)	−37.4 (52% reduction)
Dass missing on either admission or discharge	44/100	34/76	10/24	21/60
Medical history of physical health problems which may impair exercise tolerance	82	62 (14 with no significant history)	20 (4 with no significant history)	43 (17 with no significant history)
Trauma history noted	43	32	11	26
Mean number of psychiatric diagnosis	2.4 (range 1–4) 17 had one diagnosis only	2.4 (range 1–4) 4 had one diagnosis only.	2.5 (range 1–5). 13 had one diagnosis only	2.3 (range 1–5) 13 had one diagnosis only.
Neurodevelopmental disorder	12	10 (13.2%)	2 (8.3%)	9 (15%)
Schizophrenia	2	2 (2.6%)	0	0
Bipolar affective disorder	5	3 (3.9%)	2 (8.3%)	2 (3.3%)
Depressive disorder	48	40 (52.7%)	8 (33.3%)	21 (35%)
Anxiety disorder	33	23 (30.3%)	10 (41.6%)	22 (36.7%)
Trauma and related	43	33 (43.4%)	10 (41.6%)	26 (43.3%)
Dissociative disorder	1	1 (1.3%)	0	0
Personality disorder	11	9 (11.8%)	2 (8.3%)	7 (11.7%)
Obsessive compulsive disorder	5	4 (5.2%)	1 (4.2%)	3 (5%)
Eating disorder	2	1 (1.3%)	1 (4.2%)	1 (1.7%)
Any substance misuse disorder	66	49 (64.5%)	17 (70.8%)	45 (75%)
Alcohol misuse/addiction only	49	35 (46.0%)	14 (58.3%)	36 (60%)
Addiction – Polysubstance use or other than alcohol	17	14 (18.42%)	3 (12.5%)	9 (15%)

Discussion

The results of this study provide further insight into the possible relationships that exist between mental illness, physical health and health outcomes within a private inpatient setting. This audit has shown that while gym attendance is higher amongst male patients with anxiety disorders and PTSD/CPTSD compared to those with depression, substance misuse and physical comorbidities were common across both attendees and non-attendees. Those who attended the gym had slightly larger mean change in DASS scores over their stay and were recorded to have been discharged with personalised exercise prescription goals, compared to non-attendees who did not receive this. While this study was conducted across a small population with access to private health care, it does build on existing research and observation which highlights the sometimes-lengthy delays in translating clinical guidelines and research findings into mental health practice.

Patients diagnosed with serious mental illness and substance use disorders have been found to have higher prevalence of metabolic risk factors such as hypertension, obesity, sedentary behaviour and poor glucose tolerance. ¹⁷ With higher rates of metabolic syndrome among mood disorders, psychiatric facilities require systemic integration of metabolic and cardiovascular assessment during admission. ¹⁸ Evidence from psychiatric readmission rates has shown that poor assessment and monitoring of metabolic risk factors of inpatients increases the likelihood of readmission^19,20 within a 28-day period. ²¹ While evidence is clear that exercise is beneficial in reducing symptomology in depression, anxiety disorders, bipolar disorder, and schizophrenia, ²² the lack of consistent and well-documented metabolic and cardiovascular assessment may reflect missed opportunities to improve treatment outcomes. ²⁰ The lack of accessible documentation in the hospital file of activity patterns and markers or metabolic health prior to admission, on discharge and post discharge renders it impossible to determine if exercise was beneficial for those that accessed services in hospital.

Physical activity, body-mind programs and regular yoga practice have been found to be effective in mitigating metabolic syndrome, enhancing mood and behavioural regulation to develop a balanced and integrated sense of self.^23–25 Since the audit has taken place, this facility has introduced regular yoga and stretch classes as well as private in-room consultations with an EP. As this study also identified, without a structured assessment and referral pathway, use of the gym was somewhat contingent on patient preferences and the encouragement of the treating doctor towards exercise. It is of concern that only a minority of people with a diagnosed mood disorder were noted to engage in exercise whereas a majority of those with a diagnosed drug or alcohol related disorder utilised the gym during admission. Exercise is considered a potential treatment for drug addiction with different neurobiological mechanisms hypothesised to underpin its efficacy at different phases of the addiction process.^26,27 However, compulsive exercising may also form part of the spectrum of addictive behaviour for at least some people. ²⁸ Whilst a general practitioner screened all people on admission and indicated whether individuals were ‘medically cleared’ to use the gym (of which almost everyone was), there was no standardised process utilised to refer a person to an exercise professional, nor a standardised process to assess or document patterns of activity/exercise or to document outcomes, goals of treatment or change. Exercise prescription was not routinely incorporated into discharge planning. It is feasible to introduce structured evidence-based exercise and physical activity programmes into hospital services in Australia, ²⁹ but attending to these issues would increase the sustainability and reach of such programmes to those who might most benefit.

The primary limitations of this study relate to the methodology which precludes drawing conclusions about cause and effect. The findings from the audit cannot be generalised to other facilities, would likely change over time and is reflective of formalised policies, procedures as well as implicit assumptions about the roles and responsibilities of team members.

Conclusions

Such is the concern about comorbid physical health problems with diagnosed mental illness, and the consequences of unchecked or unmanaged metabolic syndrome and other cardiovascular disease that it is a matter of urgency that modifiable risk factors in vulnerable individuals are systematically addressed. ¹⁸ People with serious mental illness have not benefited from recent medical advances which have seen reductions in associated morbidity and mortality in the general population. ¹⁸ This audit found that approximately 25% of people were noted to avail themselves of the services of an EP and individualised coaching in the context of a private psychiatric inpatient stay. Whilst the audit under-reported the number of people who engaged in exercise, most people with an affective disorder in which exercise is a first-line treatment^2,4,5 did not appear to receive exercise coaching during their hospital stay. Lifestyle related prescriptions are not subject to the same legal scrutiny and standards of practice as prescriptions for medications. If exercise, diet and sleep hygiene are to assume their recommended place as treatments then similar standardised processes need to be developed to account for prescription and adherence similar to other prescribed treatments. In order to substantiate the benefits of exercise in clinical populations and to account for exercise as a prescribed treatment standardised pre-assessment, referral, assessment, planning and documentation of exercise prescription and monitoring of outcomes across the care continuum is required.

Ethical statement

This project received expedited review and approval from the Southern Cross University Human Research Ethics Committee (#2022/018).

Informed consent

This research was reviewed and approved by the Southern Cross University, Human Research Ethics Committee (Approval number 2022/018). No identifying information was gathered or retained. Patient consent was not required.

ORCID iD

Richard lakeman https://orcid.org/0000-0002-4304-5431