Mental Health Through Physical Activity Counseling

The physical health benefits of regular physical activity (PA) are well documented. Numerous articles in Canadian Family Physician have argued for the need for more PA counseling to manage and prevent physical illness. Scientific data indicates that PA is also effective in promoting mental health and managing problems of this nature. 

Given that family physicians are the preferred source of health information and the most frequent providers of care for mental health issues,9,10 greater integration of PA counseling could serve to promote well -be both physical and mental. Counseling about PA is necessary for most patients, since more than half of the Canadian population is not active enough to derive physical or mental benefits from it.

Physical activity and mental health 

Studies of PA as a treatment for anxiety and depression have found it to be as effective as antidepressants or psychotherapy for mild to moderate cases. For example, a review by Cochrane argued that PA had moderate to large clinical effects in the treatment of depression12 and a randomized controlled trial13 demonstrated that PA provided benefits comparable to those of antidepressants. For cases of severe mental health problems (eg, schizophrenia), PA has been shown to be an important complementary therapy. Regular PA has also been shown to improve behavioral functioning in those with ADHD symptoms15 and to promote mental health in various ways (e.g., increased self-esteem, contact social, stress reduction). For patients who do not currently suffer from mental health problems, PA can be a means of improving well-being, which, after all, is an overriding goal of primary care in Canada. Moreover, there is an inverse relationship between PA participation and mental health problems, suggesting, without conclusively, that PA promotion may also prevent the development such problems7,8. Mental Health Promotion Guidelines recommend an accumulation each week of a minimum of 150 minutes of moderate-intensity activity or a minimum of 75 minutes of vigorous exercise, in increments of at least 25 minutes 3 to 5 days a week16.

Physical Activity Counselling

The Evidence Brief (approximately 3 minutes) PA counseling interventions, similar to those for smoking cessation, have been shown to result in modest benefit. A written prescription given to the patient is more effective than only verbal advice, and brief counseling interventions with follow-up are more effective than those without follow-up4. Family physicians are well positioned to rally people with multiple health conditions and to use a multidisciplinary approach to increase the effectiveness of counselling. Although the benefits of PA counseling are modest, even modest effects can translate into substantial community health benefits in terms of improved individual health and reduced economic and social costs of PA. physical inactivity.

Counseling Method  

The 5A Technique The effectiveness of the 5As model (Analyze, Warn, Agree, Assist, Arrange) for counseling and changing patient health behaviors is now proven. This approach emphasizes patient choice and autonomy. Below 5 steps to follow in counseling about PA using this model. These steps may involve one or more healthcare professionals depending on the setting (eg, collaborative care), the patient's needs and the time available to you.

Step 1: Analyze degree of PA, health risks, capacities and willingness to change. 

Assess the patient's current level of PA, including the number of minutes of moderate and vigorous activity per week and the number of minutes at a time. Assess the patient's health risks, including whether they are stable enough to engage in moderate or vigorous exercise; if not, plan for ongoing medical care. The PAR-Q19 questionnaire is a health risk screening tool that can be administered in a short time in the waiting room. Review with the patient any contraindications or physical barriers to increased PA. Assess how the patient perceives their ability to do PA and discuss issues that might make PA more difficult (eg, arthritis). Also begin to assess the patient's willingness to change; this process lasts throughout counseling on PA. His willingness to change is measured by the importance he places on the change in improving his health and the confidence he has in being able to make this change. You might ask, “On a scale of 0 to 10, with 0 being unimportant and 10 being very important, how important is increasing your physical activity to you right now?” You can ask the same kind of question for the degree of confidence. The lower the scores obtained, the less chance the person has. To determine focus areas, you might ask what it would take to raise importance and improve trust.

Step 2:  Educate the person about the health risks and benefits and about the benefits and FITT principles (frequency, intensity, type and time)

Keeping the guidelines in mind, tailor the specific message and advice to the patient's readiness for change. For example, to a patient who is not ready to become more active (low importance and low confidence), you might say, "As your doctor, I think it's important to tell you that if you become more active, your mood and stress level would be improved. I understand that you have many other priorities in your life, but I would strongly recommend that you do more activities. What is stopping you from becoming more active? [Validate the patient's reasons.] What do you think would be some possible benefits of being more active? [Say that you agree with the patient’s reasons.] We will talk more about physical activity when we meet next.” To a patient who is considering or is ready to become active (medium to high importance and confidence), you might advise: “As your doctor, I believe it is important that you consider [or have decided] to become more active. This is an important step to improving your health, but it is sometimes difficult. What do you think would be the possible benefits of being more active? [Say that you agree with the patient's reasons and add other benefits.] What might prevent you from doing more activities? [Validate reasons.] Next, write your advice as a patient-tailored PA prescription, specifying recommended FITT goals (e.g., “Go Green” prescription, Lifescripts)20,21. Give a copy of the prescription to the patient and keep one in their file.

Step 3: Agree on goals and develop an action plan 

The patient needs to be actively involved in setting goals and discussing obstacles and solutions to be motivated to change. Discuss goals based on orders and guidelines. The best goals are specific, concrete and defined in behavioral terms (e.g. I will take a 10-minute walk twice a week in my neighborhood, in the morning before going to work). Avoid defining them in terms of outcomes (eg, I won't feel depressed anymore). Realistic goals are more likely to promote continued participation in activities, especially in depressed and anxious patients who may be prone to setting unreasonable goals. By giving them a weekly planning calendar and encouraging them to write down their goals, the likelihood of success is greater. Tools can help patients decide what will work best for them (e.g. Physical Activity Guidelines).

Step 4: Help patients overcome barriers and connect them to resources in the community 

Help patients overcome identified challenges and find opportunities in the community. It may be helpful to provide patients with a list of local PA resources (eg, community gyms, walking groups, parks) and help them find solutions when they encounter problems.

Step 5: Schedule follow-up appointments for assessment, feedback and support 

Follow-up is associated with more consistency in behavior change. This could be another appointment, a quick phone call, a postcard or letter, or a request to see another professional (eg. exercise specialist, nurse practitioner consultant, psychologist). Goals should be reviewed to move towards recommended levels of activity for mental health benefits, and continuity of activity should also be emphasized.

Family physicians play an important role in empowering patients to take charge of their own physical and mental health; counseling about PA to promote mental health is an important strategy.