Psychology Today (original article)

When you think about your mental health, how often do you consider that your physical health may be a part of the picture? As people manage their mental health, how often do they take into account the possibility that their levels of fitness may play a role?

Perhaps you have a relative with bipolar disorder who is constantly seeking the right combination of medication and psychotherapy in reducing her symptoms. However, have you noticed her lifestyle habits? Does she smoke, avoid all forms of physical activity, and eat nothing but junk food? You’re trying to help her deal with everything from being able to hold a steady job to finding relationship partners, but have you ever suggested the possibility that these unhealthy habits are contributing to the strains of her daily life?

In general, people in the United States have high levels of physical inactivity, even though there is technically enough time in their day to exercise. As a result, Americans place themselves at risk of developing metabolic syndrome, leading to chronic health conditions that can shorten their lives, if not their healthy lifespans (disability-free years).

A new study by Wen-Chii Tzeng and colleagues (2019) of the School of Nursing, National Defence Medical Centre in Taipei, Taiwan suggests that the problem of lack of physical activity has additional consequences for people with serious mental illness. The psychological disorders that fall into this category of serious mental illness include not only bipolar disorder and major depressive disorder, but also schizophrenia.

As the term implies, metabolic syndrome comprises a set of factors that involve the inner workings of the body’s systems in regulating dietary intake. The five components of this physiological condition include elevated “bad” cholesterol, higher than desirable triglycerides (fatty cells in the blood), high blood pressure just short of hypertension, high glucose levels just short of diabetes, and a waist circumference that borders on obesity.

If you have 3 of the 5 criteria that make up this syndrome, you are considered at risk for serious chronic health conditions such as hypertension, heart disease, and diabetes. You might imagine that some of these indexes reflect hereditary factors, but as noted by the study authors, it’s lifestyle that represents the primary contributor to their development.

For people with serious mental illness, defined as having a diagnosis of major depression, bipolar disorder, or schizophrenia, there can be additional contributors to metabolic syndrome that result from the medications that individuals with these disorders require in order to regulate their psychological symptoms. As Tzeng and collaborators note, antipsychotic medications, mood stabilizers, and antidepressants can all cause weight gain. The irony in the equation is the fact that the very measures that people take to improve their mental health can also contribute to poorer physical health, which in turn exacerbates the symptoms of a serious psychological disorder.  Additionally, some of the sociodemographic risk factors for serious mental illnesses, such as lower levels of education and social class, are also associated with a higher risk of developing metabolic syndrome through behaviors such as smoking and lack of physical activity.

Previous research has provided insight into mental-physical health linkages but has left some questions open about the role of age and gender in these relationships. Such information would be of use in developing targeted intervention programs, the authors note, for high-risk individuals.

To address these questions, the authors recruited patients with a diagnosed serious mental illness from two hospitals in Taipei City, Taiwan. All were hospitalized at the time of the study and, to meet the inclusion criteria, could not be in an actively psychotic state. The sample consisted of a total of 260 participants (approximately evenly divided by sex) with an average age of 50 years old. Most were single and unemployed. In addition to their psychiatric diagnoses, they also had a range of chronic illnesses, including gastrointestinal disorders, hypertension, high cholesterol, diabetes, arthritis, kidney disease, gout, cancer, and stroke. About half had a history of smoking and about 40% were moderate to heavy drinkers; over half were overweight or obese. The levels of physical activity in this sample were far lower than that of the national average for Taiwan of 65%, with only 9.6% engaging in regular physical activity.

Given the nature of the medical conditions represented in the sample, as well as their unhealthy lifestyle habits, it is not surprising that there were high levels of metabolic syndrome among the participants, with an overall rate of 41%. Women, as the authors predicted, had higher rates of metabolic syndrome (47%) compared to men (35%). However, these averages disguise the fact the rates drastically increased across adult age groups, amounting to 64% of women 60 and older and 40% of men.

The conundrum in these startling figures is to identify where the cycle of lack of physical activity, poor physical health, and poor mental health originates. Does the process begin with poor physical health which, in turn, leads to lower rates of physical activity? As the authors note, “low levels of physical activity could be associated with fatigue and lack of motivation among patients with serious mental illness“ (p. 7). In this scenario, it’s the disorder (and perhaps the associated medications) that lead to the unhealthy lifestyle habits that increase the risk of physical illness.

It’s also possible, as the authors suggest, that individuals with these psychiatric conditions cannot afford to join gyms or hire personal trainers, limiting their ability to reverse a lifetime of poor health behaviors. Adding to a lack of activity in increasing the risk of metabolic syndrome are unhealthy diets. These individuals adopt fixed eating habits in which they continue to purchase and consume the same convenience foods and when presented with the kind of delicacies associated with Taiwanese family gatherings, are unable to resist temptation. The same might be said for any culture, when you consider the typical celebratory fares of most countries which heavily feature sweets, high-fat foods, and alcoholic beverages.

Another vicious cycle develops in the lives of women with serious mental illness who experience changes in metabolism associated with menopause. As their weight climbs, they avoid the gym because they dread “displaying any symptoms of the disease and anticipated rejection or labeled by others, resulting in social isolation or stressful relationships” (p. 9). You may be able to relate to this experience if you’ve felt you weren’t in good enough shape to go out and get in shape where you might be judged by your more physically fit fellow gym members.

As the authors conclude, mental health workers can benefit from knowing the potential risks of a physically unhealthy lifestyle and, as a result, incorporate physical fitness into the treatment plans for their patients. That vicious cycle may be hard to break, especially in older women who feel embarrassed about their lack of fitness. If you’re trying to help your own relatives who are struggling with psychological disorders, the Tzeng et al. study suggests that the earlier you intervene, the better.

Returning to the case of your relative, you might consider offering to be a “gym buddy” and partner up long enough to allow her to get over her initial reluctance to set foot on a treadmill. Similarly, with regard to food habits, you could offer help and advice in cooking proper meals and even consider a joint trip to a supermarket that offers healthy (and affordable) grocery options.

To sum up, people with serious psychological disorders face challenges to their ability to adapt to daily life, but by attending to their lifestyle, they can lower their risk of added physical stress.

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