La condición física como signo clínico vital en personas con trastorno mental grave para identificar riesgos para la salud que requieren intervenciones urgentes, y la adherencia al ejercicio físico como herramienta para promover el bienestar y la recuperación en contextos clínicos de salud mental. The PsychiActive Project

Abstract

People with severe mental illness (SMI), such as schizophrenia, bipolar disorder, major depression, or personality disorders, have a reduced life expectancy of up to 20 years, mainly due to physical conditions such as cardiovascular diseases, respiratory disorders, sarcopenic obesity, which lead to functional deterioration. These conditions contribute to higher rates of mortality, disability, and frailty, surpassing the impact of other diseases such as cancer, respiratory diseases, and diabetes. These disparities underline the urgent need to integrate physical healthcare into mental health strategies to address this critical situation in people with SMDs.

The general objective of this Doctoral Thesis was to explore the utility of physical condition as a vital clinical sign in individuals with severe mental illness, in order to assess and detect situations of vulnerability that require urgent interventions, as well as to identify the barriers, facilitators, and techniques that support adherence to physical exercise interventions in mental health clinical settings, to promote well-being and recovery. This thesis is framed within the PsychiActive Project and includes five main studies with adult participants diagnosed with SMI according to ICD-10 criteria (n= 82 to 305) and stabilized with antipsychotic treatment. The participants were recruited from seven outpatient mental health settings in southern Spain. Physical fitness was assessed using the "Senior Fitness Test" battery, complemented by handgrip strength measured with a dynamometer and isometric strength of legs and arms with a portable manual dynamometer. Self- reported physical fitness was measured with the "International Fitness Scale" (IFIS), and functional limitations (physical fitness values below the 25th percentile) were also assessed. Adherence to the program was calculated as the total percentage of session attendance, and perceived barriers were collected through the ABPEF questionnaire. The multi-component community-based program led by the PowerONyou group was designed and implemented with a multidisciplinary approach to improve participation, adherence, sustainability, and physical health in ambulatory patients with SMI.

The main results of this doctoral thesis suggest: (1) Physical fitness, particularly muscle strength and cardiorespiratory fitness, reflects a higher vulnerability in people with severe mental illness compared to the general population, emphasizing the need to intervene in these modifiable risk factors through evidence-based physical exercise programs. (2) Reference values for physical fitness in adults with severe mental illness were presented, segmented by sex and age (20-39, 40-59, >60 years). Men performed better in cardiorespiratory fitness, while women excelled in lower-limb flexibility. In general, performance decreased with age. (3) The 30-s Chair Stand Test (30s-CST) seems to be a valid tool for assessing muscle strength in people with severe mental illness, especially in women, where a greater concordance between methods was observed. (4) The 5-sit-to-stand test (5-STS) presents itself as a valid and accurate alternative for assessing muscle strength in people with severe mental illness, compared to more complex or demanding tests. (5) The 30s-Arm Curl Test (30s-ACT) also appears to be a valid tool for assessing upper body muscle strength in this population, although factors such as body mass index and sex may influence its reliability. (6) The International Fitness Scale (IFIS) has proven effective in assessing physical fitness and functional deficits in people with severe mental illness, allowing the detection of vulnerabilities and classification of fitness levels, thus facilitating screening and prioritization of interventions. (7) The incorporation of physical exercise programs into mental health environments is fundamental to reducing disparities in healthcare for this population. The integration of physical educators as part of the mental health team significantly contributes to improving the physical and mental well-being of patients with SMI, promoting more comprehensive care and reducing inequities in access to appropriate treatments. (8) The lack of training and resources among mental health professionals regarding physical exercise constitutes a significant barrier to promoting an active lifestyle, hindering the implementation of physical exercise programs in clinical settings and negatively affecting patient adherence. (9) Encouraging autonomous motivation should be a priority in physical exercise interventions, as it is closely linked to higher levels of physical activity and better adherence to programs. Professionals should support the basic psychological needs for autonomy, competence, and social relationships, which facilitates progress through different stages of behaviour change. The application of behaviour change techniques (BCTs) such as goal setting, self-assessment, objective review, and social support can be particularly effective. (10) The intervention program led by the PowerONyou group has shown that the implementation of structured and adapted physical exercise as a therapeutic tool in outpatient mental health settings is viable, safe, and effective for people with severe mental illness, reporting improvements in physical, mental, and social well-being. (11) The multidisciplinary program «De la Pastilla a la Zapatilla» by PowerONyou has demonstrated that physical exercise is an effective, valid, and feasible tool for improving the health and well-being of patients with severe mental illness. The inclusion of physical exercise programs in treatment facilitates rehabilitation and recovery and prevents physical comorbidities, underlining the need for a paradigm shift in mental health treatment, particularly in the hospital setting.

This doctoral thesis provides evidence on the validity of various tests to assess physical fitness in people with severe mental illness in clinical settings, facilitating the identification of vulnerability situations. It also presents the first reference values segmented by age and sex, allowing the prioritization of interventions and detection of functional deficits. The effectiveness of structured, evidence-based physical exercise to improve the physical and mental health of these patients is highlighted. However, the lack of training and resources among mental health professionals remains an important barrier. The program led by PowerONyou demonstrates that the implementation of adapted physical exercise in outpatient mental health settings is viable, safe, and effective, supporting its inclusion as a therapeutic tool in clinical settings.