Counseling on physical activity to promote mental health

The physical health benefits of regular physical activity (PA) are well documented.¹ Numerous articles in Canadian Family Physician have articulated the need to increase PA counseling for the management and prevention of physical illnesses.^2–6 Evidence also indicates that PA is effective in the treatment and promotion of mental health.^7,8 Given that family physicians are a preferred source of health information and the most common treatment provider for mental health complaints,^9,10 increased integration of PA counseling into primary care could serve to promote both physical and mental well-being. Counseling on PA is relevant for most patients, as more than half of Canadians are not sufficiently active to achieve physical or mental health benefits.¹¹

Physical activity and mental health

Trials of PA as a treatment for anxiety and depression have found PA to be as effective as antidepressant medication or psychotherapy for mild to moderate anxiety and depression. For instance, a Cochrane review found a moderate to large clinical effect of PA for the treatment of depression,¹² and a randomized controlled trial found that the benefits of PA were comparable to those of antidepressant medication.¹³ For more severe mental health problems (eg, schizophrenia), PA has been found to be an important complementary therapy.¹⁴ Regular PA has also been found to improve behavioural functioning among those with symptoms of attention deficit hyperactivity disorder,¹⁵ as well as to promote mental health in various ways (eg, enhanced self-esteem, social contact, decreased stress). For those patients not currently experiencing mental health problems, PA can be a way of enhancing well-being, which after all, is an overarching objective of primary care in Canada. Moreover, there is an inverse relationship between participation in PA and having mental health problems, suggesting, albeit not conclusively, that promoting PA might also prevent the development of such problems.^7,8 The guideline for promoting mental health recommends an accumulation each week of a minimum of 150 minutes of exercise at moderate intensity or a minimum of 75 minutes at vigorous intensity, in bouts of at least 25 minutes over 3 to 5 days per week.¹⁶

Physical activity counseling: the evidence

Brief PA counseling interventions (approximately 3 minutes), similar to smoking cessation counseling, have been shown to have modest benefits. Providing a written PA prescription is more effective than verbal advice alone, and brief counseling interventions with follow-up are more effective than those without follow-up.⁴ Family physicians are in a position to engage individuals with multiple health problems and to use a multidisciplinary approach to enhancing counseling effectiveness. Although the benefit of PA counseling is modest, even modest effects can translate into considerable benefits for the health of a community in terms of both improved individual health and reduction in the economic and social costs of physical inactivity.¹⁷

How to counsel: using the 5 As

The 5-A model (assess, advise, agree, assist, arrange) of behaviour change and counseling has been demonstrated to be effective in helping patients to modify their health behaviour.¹⁸ This approach emphasizes patient choice and autonomy. Below, we describe 5 steps to PA counseling using this model. These steps could involve one or more providers and they are modifiable depending on the setting (eg, collaborative care setting), patient needs, and available time.

Step 1: Assess PA levels, health risks, abilities, and readiness to change.

Assess patients’ current level of PA, including how many minutes of moderate and vigorous activity they engage in per week, and how many minutes at a time. Assess patients’ health risks, including whether medical conditions are stable enough for moderate or vigorous exercise; if not, arrange for ongoing condition management. The Physical Activity Readiness Questionnaire¹⁹ is a short health risk screening tool that can be administered in waiting rooms. Review any health contraindications or physical barriers to increasing PA with patients. Assess patients’ perceived ability to participate in PA and discuss conditions that could make PA more difficult (eg, arthritis). Also begin to assess patients’ readiness for change; this process continues throughout counseling on PA. A patient’s readiness consists of how important he or she perceives the change to be in improving health and his or her confidence in being able to carry out the change. You could ask, “On a scale of 0 to 10, with 0 meaning not at all important and 10 being very important, how important is increasing your physical activity to you right now?” The same type of question could be asked for level of confidence. The lower the scores are, the further an individual is from action. To assess areas for intervention, you could ask what it would take to improve importance and confidence.

Step 2: Advise on personal health risks and benefits and the FITT principles (frequency, intensity, type, and time)

With the guidelines in mind, provide a tailored message and specific advice appropriate for the patient’s stage of change. For instance, for a patient not ready to become more active (low importance and confidence), you might advise, “As your provider, I feel it is important to tell you that becoming more active would likely improve your mood and help with stress. I understand that you have lots of other priorities in your life, but I would strongly recommend that you consider doing more activity. What things are keeping you from being more active? [Validate the patient’s reasons.] What are some possible benefits of doing more activity? [Agree with the patient’s reasons.] Let’s talk more about physical activity next time we meet.”

For a patient contemplating or ready to become more active (medium to high importance and confidence), you might advise, “As your provider, I think it is important that you are considering becoming [or have decided to become] more active. This is an important step to better health, but it can be difficult. What are some possible benefits of doing more activity? [Agree with and add to the reasons.] What things can you see keeping you from being more active? [Validate the reasons.]” Then, record advice as a tailored PA prescription outlining the recommended FITT targets (eg, “Go for Green” Prescription; Lifescripts).^20,21 Provide the patient with a copy of the prescription and keep a copy in the chart.

For patients already achieving the recommended level of PA, congratulate them, review their goals, anticipate future barriers, and provide advice on modifications (eg, increasing variety, injury prevention). Pekmezi and colleagues outline strategies to promote PA for patients at different stages of change.²²

Previously sedentary patients who begin PA programs should start with short sessions (5 to 10 minutes) of PA and gradually build up to the desired level. Leisure-time PA seems to have benefits over occupational PA²³ and therefore should be recommended even for patients who are active during work. Otherwise, there is no conclusive evidence on what type of activity (eg, endurance, strength training) is best. Therefore, the focus should be on helping your patient adopt and maintain an active lifestyle by engaging in preferred and accessible activities and enhancing social supports for an active lifestyle.^7,12 It is important to keep in mind, however, that guidelines for minimizing injury and promoting optimal overall health suggest a mix of activities (eg, endurance, strength training, flexibility), and increasing activity variety might be a goal for those patients who are already active.

Step 3: Agree on goals and develop an action plan.

The patient needs to be actively involved in the process of goal setting and discussing barriers and solutions in order to motivate change. Discuss goals in terms of prescriptions and guidelines. Goals are best when they are specific, concrete, and defined in behavioural terms (eg, I will take a 10-minute walk twice a week in my neighbourhood in the morning before work) and not outcomes (eg, I will no longer feel depressed). Realistic goals are most likely to promote continued participation in activity, particularly for depressed and anxious patients who might tend to set unreasonably high goals for themselves. Providing a weekly goal-planning sheet and encouraging patients to schedule and write down their goals will increase the likelihood of success. Self-help tools can help patients decide what will work best for them (eg, the Canadian Physical Activity Guidelines²⁴).

Step 4: Assist in overcoming barriers and linking with community resources.

Help patients overcome identified barriers and locate community opportunities. It can be helpful to provide patients with a list of local active resources (eg, community gyms, walking groups, parks) and help patients problem solve when they face challenges.

Step 5: Arrange for follow-up assessment, feedback, and support.

Follow-up is associated with better maintenance of behaviour change. It can take the form of another appointment, a brief telephone call, a postcard or letter, or a referral to another provider (eg, exercise specialist, counselor, nurse practitioner, psychologist). Goals should be reviewed to build to recommended activity levels for mental health benefits, and it is important that continued activity be reinforced.

Conclusion

Family physicians have an important role to play in promoting self-management of physical and mental health among patients; counseling on PA to promote mental health is one important strategy.