If you were asked to list the most compelling reasons to exercise, you’d likely come up with factors like weight loss, improved cardiovascular fitness, lower blood pressure and cholesterol, and better muscle tone. And rightly so: all of these factors are proven benefits of regular physical activity.

However, with one in four people in the UK experiencing some kind of mental health issue, and a substantive body of evidence showing a link between physical and mental health (see HCM March 11, p36), many experts would like to see more emphasis on the value of exercise for mental wellbeing.

“There’s a clear and strong association between mental health and physical activity, including a positive effect on depression, stress, low self-esteem and even cognitive function,” says professor Stuart Biddle, an exercise psychologist at Loughborough University in the UK. ??

Debbie Lawrence, a qualification development manager for Active IQ and author of The Complete Guide to Physical Activity and Mental Health (Bloomsbury), agrees: “Two things are clear from the research,” she says. “Firstly, that people with mental health issues tend to have poorer physical health. And secondly, that exercise can help to prevent or alleviate many mental health symptoms.”

Physical activity, then, could be an important part of the jigsaw when it comes to prevention and treatment. But statistics suggest it’s still undervalued: 50 million prescriptions for anti-depressants were issued in 2012 – the highest number ever – while a report in 2013 from healthcare charity Nuffield Health found that GPs were 46 times more likely to prescribe medication than explore evidence-based alternatives like exercise. The charity calculated that, if we each did just 12 additional minutes of daily activity, we could save £6.3bn in costs to the NHS, welfare, and loss of earnings related to mental health issues.

Dr Davina Deniszczyc, wellbeing medical director at Nuffield Health, comments: “We encourage all GPs to prescribe exercise, refer patients to support services that can help them exercise and ensure exercise, where applicable, is a central part of the treatment a patient receives.”

Addressing the stigma
But what role could fitness operators play in promoting exercise for mental health? Lawrence believes the industry should shift its message. “The emphasis should be on exercise to feel good, rather than to not feel bad,” she says.

Harriet Heal, a clinical psychologist with an interest in the interaction between physical and mental health, agrees: “Gyms and health clubs tend to focus too much on the physical pay-offs: lose weight, tone up, get fit,” she says. “There needs to be more attention given to the mental benefits. Think of it this way: one in four of the people who walk through the door of your health club or leisure centre has, or has had, a mental health condition.”

It’s hardly a minority group, then. Yet while gyms and health clubs routinely offer classes for pregnant women or for the over-50s, it’s rare to find sessions aimed specifically at those with mental health problems.

“There’s still a long way to go in breaking down the stigma surrounding mental ill health,” says Mark Owen, who led the pioneering Bristol Active Life Project (BALP – see briefing, p58) in his role as physical activity development officer for mental health at Bristol City Council. “Many people aren’t comfortable being ‘labelled’ in public.”

Heal, who co-founded Up and Running – a running group for women in Kent with mental health issues (see briefing, p60) – agrees: “Our poster says ‘Do you suffer from anxiety or depression?’ But I sometimes worry that it puts off as many people as it attracts. I don’t want to avoid terms like ‘depression’ or ‘mental health’, but I also want don’t want to alienate people. We’ve had people enquiring about the group who say: ‘I don’t know if I’m ‘bad enough’ to join...”

When Up and Running launched in 2010, the Sevenoaks Chronicle, in which Heal had placed an ad, published a mocking piece describing the prospect of an exercise and mutual support group for depression and anxiety as “a barrel of laughs”. While the newspaper later issued a written apology, it shows just the sort of negative reaction that might hold people back from seeking support.

A warm welcome
Projects like BALP and Up and Running demonstrate that specifically targeting a mental health market can be successful. But it’s not the only way. “The right approach and attitude can make any exercise environment more welcoming and inclusive,” says Heal.

In 2000, a study conducted by the YMCA in the US set out to identify what kept people coming back to their gyms. After analysing more than 150,000 member satisfaction surveys, they concluded that it wasn’t fancy machines or yoga studios but the human factor: staff knowing members’ names and greeting them with a friendly smile. The research didn’t specifically address a mental health population, but as Heal points out, this positive social interaction would be even more crucial for someone feeling anxious or depressed, or lacking self-esteem.

Owen believes there needs to be more commitment from operators to train staff on mental health: “When we were running BALP, none of the local clubs or leisure centres came to ask us for training – it was always us going to them to offer it,” he says. “Better mental health awareness and education give staff more confidence. And it’s not just the instructors and coaches – it’s all staff. If someone’s been brave enough to take a step through the door, every staff member they encounter could make or break whether they come back.”

Dr Kitrina Douglas, a researcher in exercise, health and sport at the University of Bristol, was involved in evaluating BALP, interviewing participants and staff. “Education is really important,” she agrees. “For many of those we interviewed, medication made morning classes difficult – just getting up and out was a much bigger deal than it is for most of us. Staff didn’t always understand what a big effort it could be even to get to the venue.”

Many of the instructors connected to BALP took the exercise referral course Physical Activity for Persons with Mental Health Conditions, which looks in depth at specific conditions such as bipolar disorder, schizophrenia and post-traumatic stress disorder. “The education we delivered helped practitioners understand what life is like living with long-term mental illnesses,” says Douglas.

So how might a fitness session for a mental health population differ from other sessions? “It’s not so much the format or structure as the atmosphere and approach,” says Owen. Heal agrees: “You might need to take more time over things and focus on the process, rather than the outcome. You don’t want exercise to become another stress for someone.”

Those involved with delivering BALP sessions were taught the importance of creating a safe, supportive environment. “As an instructor or coach, it’s less about knowing all the answers regarding any given mental health condition and more about focusing on the individual’s needs at that time,” says Owen.

Universal benefits
Heal wonders whether gyms would benefit from a resident or attached mental health expert: “You’d expect there to be professionals in physical health – why not in mental health?” she asks. “They could be there to advise the health club users, but also be a point of contact for other staff at the facility.”

Douglas believes the real solution lies in being able to break down the barriers and stigma surrounding mental health issues. “Even the terms we use – ‘people with mental health problems’ – create a rift that makes it seem ‘they’ aren’t normal, and ‘we’ are, when of course all of us, regardless of our mental health status, want to have fun, enjoy social activities and have access to exercise and work opportunities,” she says.

Heal agrees. “We tend to medicalise mental illness, but the truth is that many people slide in and out of depression and anxiety disorders,” she says. “Physical activity has the same benefits for everyone – and while many of these are long-term, perhaps what’s more useful in terms of mental health is to focus on the immediate payoffs. ‘Feel better this afternoon than you did this morning’ is a very powerful message for health clubs to get across.”

See p30 for a discussion on whether the fitness sector is geared up to deal with mental health issues.