Walk the Talk: VA Mental Health Care Professionals’ Role in Promoting Physical Activity

Physical activity is a key determinant of health. Low levels of activity are associated with onset of and poorer outcomes of many chronic health conditions (eg, obesity, coronary artery disease, type 2 diabetes mellitus, chronic pain, hypertension^1-4) and with higher rates of mental health conditions (eg, depression, anxiety^5-8).

Behavioral interventions (Table 1) can increase activity and improve physical health and mental health (Table 2).^9-21 However, only 20% of adults in the U.S. meet federal recommendations for physical activity.²² The situation is particularly grim in the veteran population. Littman and colleagues found that veterans were less likely than nonveterans were to meet physical activity standards, and VA patients were even less likely than were non-VA veterans to meet the recommendations.²³

Given that exercise can positively affect physical and mental health and that VA mental health care professionals (MHCPs) have training in motivational enhancement and behavior modification, these clinicians are well positioned to intervene. The question arises, though: How can VA MHCPs do more to effectively promote physical activity in veterans?

Addressing Physical Activity

There are numerous ways in which VA MHCPs can address physical activity with their patients. Several studies have demonstrated that physical activity interventions provided within primary care–mental health integration programs resulted in increased physical activity.^28,29 The number of VA health care providers (HCPs) offering such programs is increasing, which could mean that behavioral health support for physical activity promotion could become easier for veterans to access.³⁰

In addition, National Center for Health Promotion and Disease Prevention initiatives have led to an expansion of programs, such as the VA MOVE! Weight Management Program.³¹ Often cofacilitated by dieticians and MHCPs, MOVE! includes nutrition education, behavior modification, and physical activity promotion.³² Preliminary research suggests that MOVE! helps veterans lose weight and improve their health-related quality of life.^33-36

Further, psychological and behavioral interventions can specifically target exercise and have been shown to increase physical activity, improve mood symptoms, and reduce health risk factors.^9-21,37 However, little is known about the extent of exercise promotion in VA outpatient mental health services. For instance, some HCPs may educate patients about the benefits of physical activity, while others may facilitate physical activity scheduling, address barriers, and monitor, reinforce, and problem-solve physical activity goals.

Research also has supported the efficacy of technology-based interventions in physical activity promotion by MHCPs. These interventions include phone counseling, text messaging or smartphone application monitoring systems (including the MOVE! Coach mobile app), DVD-based approaches, and web-based interventions.^38-42 However, these interventions may be most effective when complemented with face-to-face support (eg, psychotherapy, nutrition/exercise classes).⁴³ Although MHCPs can promote physical activity in various ways, intensive focus on this target is not standard practice in many mental health care settings.

Barriers to Physical Activity

Despite physical activity promotion efforts, patients struggle to implement and maintain physical activity recommendations.^22,44,45 For many patients, exercise is a new or long abandoned activity, and instruction on how to exercise properly is needed.⁴⁶ Lack of financial resources may limit access to a gym, trainer, or physical therapist.⁴⁷ Some patients avoid exercise because of body image concerns, and many think they lack the self-discipline and time for exercise.^46,48,49

Additional barriers to physical activity are pain, fatigue, and other physical symptoms.^50-52 Obese patients may find physical activity less enjoyable and more uncomfortable.⁵³ Some patients fear exercise will exacerbate medical problems or have negative physical consequences.^51,52

Psychiatric symptoms and medication adverse effects are commonly reported barriers.⁵⁴ Some patients with anxiety avoid physical activity because the resulting physiologic sensations (eg, rapid heart rate, sweating) are similar to anxiety symptoms.⁵⁵ Patients with posttraumatic stress disorder (PTSD) are less likely to exercise, secondary to PTSD-related avoidance, even though they were physically active before their trauma.^56-58 Some patients with depression avoid exercise and other activities because their symptoms (eg, fatigue, anhedonia) make it difficult for them to take action. Many patients put off exercise while waiting for relief of mental health symptoms, even though evidence suggests that physical activity may help improve those symptoms.^5,6

These barriers often render ineffective the approach of simply recommending exercise or encouraging patients to exercise. Counseling alone may not be sufficient to effect meaningful change in exercise habits. Many effective physical activity interventions have both a counseling and exercise components,^59-61 and research suggests that such interventions may be most effective when they include a form of experiential exercise.¹⁰

Clinician-Assisted Experiential Exercise

Exercise interventions may involve information dissemination, counseling, an experiential exercise program, or a combination of these activities. Research has yet to determine precisely which components are most effective. Given the barriers to adhering to exercise recommendations, however, exercise interventions that include an experiential component may be more likely to affect behavior change.