bs_bs_banner

International Journal of Mental Health Nursing (2012) 21, 236–247 doi: 10.1111/j.1447-0349.2012.00816.x

Feature Article _816 236..247

Health behaviour interventions to improve

physical health in individuals diagnosed with
a mental illness: A systematic review
Brenda Happell, Cally Davies and David Scott
School of Nursing and Midwifery, Central Queensland University Australia, Rockhampton, Queensland, Australia

ABSTRACT: Individuals diagnosed with mental illness experience high rates of morbidity and
mortality as a result of poor physical health and unhealthy lifestyle behaviours. The aim of this paper
is to systematically review the literature on health behaviour interventions to improve the physical
health of individuals diagnosed with a mental illness. A systematic search strategy was undertaken
using four of the major electronic databases. Identified articles were screened for inclusion, included
articles were coded, and data were extracted and critically reviewed. A total of 42 articles were
identified for inclusion. The most commonly targeted physical health behaviour was weight manage-
ment. The majority of studies reported improvements in health behaviours following interventions.
The findings provide evidence for the positive effect of health behaviour interventions in improving the
physical health of individuals diagnosed with a serious mental illness. A focus on health behaviour
interventions within the mental health nursing profession might lead to improvements in health
behaviours and general health in consumers of mental health services.
KEY WORDS: health behaviour, intervention, mental illness, physical health.

INTRODUCTION alcohol intake) have a fourfold increased risk of total mor-

Individuals with a mental illness have reduced life expect-
ancy and are highly susceptible to long-term disorders,
including cardiovascular disease, diabetes, and respiratory
and other infectious diseases (Scott & Happell 2011).
Psychotropic medications, and particulary health behav-
iour risk factors, contribute greatly to the poor physical
health of individuals diagnosed with a mental illness
(Lambert et al. 2004). In the general population, individu-
als who demonstrate a combination of poor health behav-
iours (physical inactivity, poor diet, smoking, and excessive
Correspondence: Brenda Happell, Institute for Health and Social
Science Research, School of Nursing and Midwifery, Central
Queensland University Australia, Bruce Highway, Rockhampton, Qld
4702, Australia. Email: b.happell@cqu.edu.au
Brenda Happell, RN, RPN, BA (Hons), Dip Ed, B Ed, M Ed, PhD.
Cally Davies, BHMSc (Hons), PhD.
David Scott, BHM (Hons), PhD.
Accepted January 2012.
tality (Khaw et al. 2008); it is therefore a major concern
that individuals with a mental illness are significantly more
likely to partake in these unhealthy behaviours than those
without a mental illness (Scott & Happell 2011). Health
behaviours can be targeted to reduce comorbidity and
provide significant improvements to the physical health of
individuals within this population (Buka 2008), and these
changes can additionally provide benefits for the manage-
ment of the individual’s psychiatric symptoms (Ellis et al.
2007). As such, health behaviour intervention programmes
might hold great promise as therapeutic strategies within
the mental health nursing profession, but a synthesis of
evidence for the effectiveness of these interventions is
warranted. We conducted a systematic review to examine
the types of health behaviour interventions commonly
implemented in individuals experiencing a mental illness,
and to identify the effect of these interventions on physical
health and health behaviours, such as body weight, physi-
cal activity, nutrition, alcohol use, and smoking.

© 2012 The Authors

International Journal of Mental Health Nursing © 2012 Australian College of Mental Health Nurses Inc.
HEALTH BEHAVIOUR FOR PHYSICAL HEALTH
METHOD
Inclusion criteria
Studies were required to meet the following inclusion
criteria: (i) undertaken within the adult population (over
18 years of age); (ii) involve a health intervention, defined
as targeting health benefits through health behaviours,
such as physical activity, nutrition, alcohol abuse, and
smoking; (iii) include physical health or health behaviours
as one of the main outcome measures; (iv) involve an
experimental design, either including randomization
or a quasi-experimental design that includes baseline
and post-intervention quantitative data in order to assess
changes; (v) published in the English language; (vi)
undertaken in a population diagnosed with The Interna-
tional Statistical Classification of Diseases and Related
Health Problems–10th revision classification for a mental
or behavioural disorder (F20–F69) alone or with a comor-
bid substance abuse disorder; and (vii) include five or
more participants in order to account for some publica-
tion bias. Studies were required to meet all of the above
inclusion criteria to be deemed eligible for inclusion in
the review. In relation to the use of drug therapy, studies
were included only if they: (i) used a drug as an adjunct to
a health behaviour intervention; or (ii) drug therapy was
confined to the comparison group. If, however, studies
delivered a drug therapy- or pharmacological-only pro-
gramme, they were excluded.
Search method
A comprehensive search strategy was undertaken to
identify all possible articles for inclusion. The following
electronic databases were searched: CINHAL (via Ebsco-
Host), Proquest, Informit, and PubMed. The search
process was limited to articles published or those that
had provided ahead of publication access between 1960
to November 2010. Second, reference lists of all relevant
primary studies and review articles were manually
searched for potential studies not yet identified (Higgins
& Green 2008). To identify potential studies, the follow-
ing list of search terms and Boolean operators were
searched in each database: ((programme) OR (service)
OR (intervention) OR (randomi*)) AND ((‘mental
illness’) OR (‘mental health’) OR (schizophrenia) OR
(‘bipolar disorder’) OR (‘mental disorder’)) AND ((‘physi-
cal activity’) OR (‘physical health’) OR (smoking) OR
(alcohol) OR (nutrition) OR (diet) OR (exercise)).
All references, including duplicates, were imported
into EndNote (bibliographic software), including search
terms, database, and date imported. Articles underwent
two phases of screening to identify the final sample. Phase
© 2012 The Authors
International Journal of Mental Health Nursing © 2012 Australian College of Mental Health Nurses Inc.
237
one involved scanning article abstracts for inclusion crite-
ria; this phase was undertaken to rule out literature that
did not meet the inclusion criteria. Subsequently, in
phase two, the full-text versions of remaining articles
were obtained and further screened. The identified
articles were coded and assessed for study quality prior to
determining the final set of articles for inclusion.
Data extraction and study quality assessment
Studies were coded, and data were extracted for all study
characteristics. Forms were developed and pilot tested
for data extraction and methodological quality. The list
was developed based on previous reviews and perusal of
relevant research. Characteristics coded included main
behaviour targeted, country, study setting, recruitment
strategy, participant characteristics (e.g. age, sex, baseline
sample size, and medication), intervention description,
intervention duration, main outcomes, and study quality.
Study quality was assessed based on a previously devel-
oped form (Bradshaw et al. 2005). Study quality was
calculated as a percentage between zero and 100 for each
study. To ensure that only studies of adequate quality
were included in the review, a classification of good (75%
or higher), fair (50–74.9%), and poor (less than 50%) was
given to each article. Studies classified as ‘poor quality’
were excluded from the review in order to avoid the
influence of potentially biased study outcomes on review
findings. Given the variability in study designs, the small
sample sizes, and missing outcome data, effect size calcu-
lations, and subsequently, a meta-analytical review, could
not be conducted. Therefore, a qualitative description of
study characteristics was undertaken.
The search strategy identified 5278 articles; 347 were
duplicate articles and subsequently removed. Following
the scanning of title and abstracts, a further 4802 articles
were removed, leaving a remaining 129 articles. Articles
were excluded if they clearly did not meet the inclusion
criteria identified above, based on their title and abstract.
After this, the reference lists of previous review articles
were screened; this process identified a further four
articles for inclusion. Full-text articles were obtained for
the remaining 133 articles. After the completion of the
full-text screening, 57 articles were found to satisfy all
of the inclusion criteria. Following the coding process, 15
articles were rated as poor quality, and were excluded
from the review. The final set of articles for inclusion
resulted in 42 primary articles (Fig. 1).
Study design and participant characteristics
The identified studies targeted a number of health
behaviour changes, with the majority of studies (n = 17)
238 B. HAPPELL ET AL.

Search of electronic databases using key words:

1380 CINHAL
2351 Proquest
56 Informit
1491 PubMed

Results: 5278

Removal of duplicates

Results: 4931

Screening of title and abstract 4802 excluded, based on information

provided in title and/or abstract
Results: 129

Manual search of review articles’

reference list

Results: 133
76 excluded:
(i) did not meet inclusion criteria;
Screening of full-text abstract (ii) review article;
(iii) connected to already-included
Results: 57 studies;
(iv) unusable outcome measures.

Final set of articles

FIG. 1: Selection process for studies of lif-
15 excluded due to poor study quality estyle interventions for individuals diagnosed
Results: 42
with a serious mental illness.

targeting weight management through improved nutri-
tion and/or physical activity. The remainder focused
on smoking (n = 7), physical activity (n = 7), alcohol
abuse (and other substance abuse; n = 9), and nutrition
(n = 2). Of these studies, 19 targeted multiple behaviours,
whereas 23 targeted a single behaviour. The majority
of studies were conducted in the USA (n = 20), with a
number of studies also from the UK (n = 6), Australia
(n = 5), Canada (n = 3), continental Europe (n = 5), and
Asia (n = 3).
Although not all studies clearly reported the type
of setting used, it was determined that 27 studies used
participants from an outpatient or community setting,
while 11 studies used inpatients or patients in a long-stay
setting, with four studies involving a combination of out-
patients and inpatients. The most common study design
was a pre–post study design (n = 16) and randomized
control trials (n = 16), followed by quasi-experimental
study designs (n = 10). The majority of studies used a one
(n = 16)- or two (n = 22)-group design, and three studies
used a three-group design, with the final study using a
four-group study design. The majority of the included
studies were rated as fair quality (n = 30), and the remain-
der (n = 12) were rated as good quality. The average
methodological quality rating was 67.17 (standard devia-
tion = 12.16), indicating moderate methodological quality
across included studies.
Overall, there were 5246 participants included at
baseline (1 study did not report), with 4085 participants
at follow up (4 studies did not report). Data were able to
be extracted for percentage of participants that were
female for all but three studies, and 38 studies provided
data for the mean age of participants. On average, 57%
of participants were female, and the mean age was
48.8 years. The majority of studies classified included par-
ticipants as being diagnosed with a severe/serious mental
illness (n = 23), or specifically targeted individuals diag-
nosed with schizophrenia spectrum disorders (n = 17) or
major depressive disorder (n = 2).
RESULTS
A summary of intervention characteristics for included
studies is provided in Table 1. Most interventions utilized

© 2012 The Authors

International Journal of Mental Health Nursing © 2012 Australian College of Mental Health Nurses Inc.
 TABLE 1: Intervention design and outcome characteristics
Intervention characteristics Outcomes

Sample
Study size at Duration Study
Study Description of intervention groups baseline (weeks) Main outcomes quality

Addington 1. 7 weekly group sessions, lasting for 75 min. Led by psychiatric nurse. Sessions based on a 1 65 7 42% (immediate post-intervention), 16% (12 weeks post-intervention), and 12% (24 weeks 60

© 2012 The Authors

et al. (1998) 7-session group programme, ‘Freedom From Smoking’, designed by the American Lung post-intervention) of participants changed from smoker to non-smoker status. Individuals
Association, and was modified to meet the needs of individuals with schizophrenia. Included reported being more intrinsically than extrinsically motivated to quit smoking. No changes in
positive reinforcement, learning and practicing alternate behaviours, and anxiety-reduction schizophrenic and extra pyramidal symptoms.
strategies. Also offered nicotine patches.
Archie et al. 1. Used an early intervention service to assess the impact on substance abuse among first-order 1 200 52 Drug abuse (P < 0.001), hazardous alcohol use (P < 0.01), and concurrent drug abuse and 56
(2007) psychosis patients. hazardous alcohol use (P < 0.05) improved over the 12-month period. No reduction in proportion
of participants meeting criteria for heavy drinking.
Ashton et al. 1. Programme provided by a mental health worker and a peer worker, over 10 weeks. Mostly 1 182 10 At 12-month follow up, 13.7% reported abstinence from smoking. Of those who attended 10 or 52
(2010) involving 2 sessions per week for the first 5–6 weeks, then 1 session per week. Each session more sessions, 31.4% reported not smoking after course completion, and 21.3% at the 12-month
ran for 2 hours. Content similar to most standard smoking interventions, with additional follow up.
information about issues relating to mental health.
Ball et al. 1. Weight watchers programme, 10 weekly meetings, taught participants to use point system to 2 32 10 Although the intervention group lost more weight than the control group, there were no 52
(2001) evaluate food choices. Scheduled exercise sessions 3 times per week. differences in BMI between the groups. A significant group by time interaction for BMI was
2. Control group found. Patients remained clinically stable, with no differences between baseline and week-10
HEALTH BEHAVIOUR FOR PHYSICAL HEALTH

scores.
Barrowclough 1. Psychological therapy, which included 26 individual therapy sessions over 12 months at 2 327 52 No difference for percentage days abstinent from substance use. Significant reduction in 92
et al. (2010) participant’s choice of location. Included two phases. Phase 1 focused on motivational intervention group for amount of substance used per substance using day. Intervention group
interviewing and cognitive behavioural strategies. Phase 2 implemented plan for change. increased motivation to reduce substances at 12 months, but not 24 months. No difference
2. Control group. between groups for relapses and admissions or symptoms and functioning.
Beebe et al. 1. 16-week treadmill walking programme. Programme included 10-min warm-up and 2 12 16 Intervention group experienced significant reductions in body fat (3.69%) compared to the 76
(2005) warm-down stretches, with walking at target heart rate. control group (0.02; P = 0.03). Although not significant, the intervention group also reported
2. Control group. improvements in 6-min walking distance (+152.5 feet), BMI (-1.27), and PANNS score (-8.25)
in comparison to the control group (+56.66; -0.14 and +4.66, respectively).
Bloch et al. 1. Sustained-release bupropion, 300 mg day-1 + cognitive behaviour group therapy. 2 61 16 Significant reduction in number of cigarettes smoked from pre–post, but not between groups. 68
(2010) 2. Placebo plus cognitive behaviour group therapy
Blumenthal 1. Exercise group involved 3 supervised exercise sessions per week for 16 weeks. Exercise at 3 156 16 Intervention group significantly improved aerobic capacity, whereas others did not. Significant 84
et al. (1999) 70–85% of individual training range. Sessions included 10-min warm up, followed by 30 min decline in all 3 for depressive symptoms (HAM-D & BDI). No difference across groups. All
of continuous walking or jogging at heart rate range; concluded with 5 min cool down. groups decreased depression diagnosis.
2. Medication group received sertraline.
3. Combined exercise and medication group.
Bradley et al. 1. Open-ended weekly outpatient group intervention, consisting of motivational interviewing 1 39 156 Significant improvements in substance use, symptomatology, treatment non-compliance, overall 52
(2007) and cognitive behavioural therapy. Weekly session lasting 60–90 min. functioning, and unscheduled service use.
Bradshaw 1. 10 ¥ 60-min sessions focusing on advice on healthy living, including diet, physical activity, 1 45 NS Significant increase in physical activity and fruit and vegetable consumption. Small, but 52
et al. (2010) and smoking, using TTM, SMART goals, problem-solving, peer support, self-monitoring and non-significant, reduction in number of cigarettes smoked.

International Journal of Mental Health Nursing © 2012 Australian College of Mental Health Nurses Inc.
tasks. Used workbook for participants and for group sessions.
Brown et al. 1. 12-week weight loss and psychiatric rehabilitation strategies. Included goal setting, 2 59 12 Significant interaction effect, where intervention group improved more than control group for 64
(2006) provisions of instrumental and social support, skills training, and transfer training. Diet was weight, BMI, waist circumference, and PA scores in HPLPII. No difference for BP, total, and
created, weekly intervention sessions and phone calls, dietary education, food label reading, nutrition subscale. In pre–post intervention group, there was a significant improvement in
physical activity. nutrition, PA, and total score. Significant improvements for dietary intake and total energy intake.
2. Control group.
Brown and 1. Provided a Lilly ‘Meaningful Day’ manual, and then attended 6 weekly, 50-min, one-to-one 2 28 6 Small, statistically-significant improvements in weight and exercise in intervention group 64
Chan (2006) health-promotion sessions. Focused mainly on weight reduction, nutrition, activity diaries. compared to the control group in ITT analysis. Non-completers lost small, significant amounts of
2. Control group. weight. Approached significant for well-being. Both groups improved diet by increasing fibre and
decreasing saturated fat.
239
 TABLE 1: Continued 240
Intervention characteristics Outcomes

Sample
Study size at Duration Study
Study Description of intervention groups baseline (weeks) Main outcomes quality

Brown and 1. Provided a Lilly ‘Meaningful Day’ manual, and then attended 6 weekly 50-min, one-to-one 2 26 10 Intervention group lost a small amount of weight (0.8 kg), but it was not significant in compared 76
Smith (2009) health-promotion sessions. Focused mainly on weight reduction, nutrition, activity diaries. to the control group. Both groups improved diet. Intervention group significantly improved
2. Control group. saturated fat, fruit and vegetable intake, and exercise. No difference for well-being.
Centorrino 1. TRIAD: dietary counselling, exercise sessions, and a low-fat, low-calorie food plan. Adapted 1 17 24 Reductions from 0–48 weeks for weight loss (6.0%), BMI (5.5%), BP (10.8–11.3%), pulse (6.5%), 64
et al. (2006) for mental health population to include more dietary education on healthy food choices and serum cholesterol (4.2%), serum triglycerides (15.4%), and serum glucose (2.9). in the
portion sizes. Divided into 2 phases. At 24 weeks, participants met twice weekly in groups 24–48 weeks, participants reported a minimal weight regain of 0.43 kg.
for 90 min. Option to continue for further 24 weeks. Offering weekly group sessions.
Daley et al. 1. Intervention group were offered 2 one-to-one exercise consultations over the 12-week 2 38 12 No difference in exercise between groups. Intervention group reported significantly higher 88
(2008) intervention period, lasting 1 hour. Used psychological counselling, participants were adjusted mean self-efficacy for exercise. No difference in Edinburgh Postnatal Depression Scale
provided a pedometer. Support phone calls lasting 10 min were given during weeks score.
3 and 9.
2. Usual care group.
Evans et al. 1. Six 1-hour nutrition education sessions over a 3-month period. Education was delivered by a 2 51 12 Post-intervention measures: intervention group gained less weight, and had a significantly smaller 76
(2005) trained dietician, and education was taken from booklet, Food for the mind, produced by change in BMI and waist circumference than the control group; 22% of the intervention group
drug company. Primary focus was healthy eating and lifestyle goals. lost weight vs none of the control. There was a significant difference in the intervention group in
2. Control group. describing themselves as more active than the controls, and significantly greater improvements in
QOL, health, and body image were reported. At 6 months’ follow up, only 11 participants were
left in the intervention group, and eight in the control group; no difference reported.
Gallagher 1. CR earned money each visit from abstinence and carbon monoxide levels below 10 ppm, 3 180 16 Salivary cotinine levels as an indicator for quitting smoking at weeks 20 and 36 were not 68
et al. (2007) allowing participants to earn up to $580. significant. Smoking cessation based on carbon monoxide levels was significant at weeks 20 and
2. CR NRT received CR in addition to 21 mg nicotine patches each visit for first 16 weeks. 36. At week 20, there were significantly more readings of light smoking in CR and CR + NRT
3. Self-quit control group. group than self-quit group. No evidence of psychiatric exacerbation.
George et al. 1. Group therapy programme of the American Lung Association (60-min sessions). 2 45 10 Smoking abstinence rates did not differ between the two intervention groups. Atypical 68
(2000) 2. Schizophrenia group therapy included 3 weeks of motivational enhancement therapy, antipsychotic agents, in combination with nicotine patches, significantly enhanced rate of smoking
7 weeks of psychoeducation, social skills training, and relapse prevention. Smoking quit date cessation.
occurred during week 4 of both programmes. All individuals began wearing a nicotine
transdermal patch for 6 weeks, which was later tapered.
Graeber et al. 1. MI: 3 sessions (1 hour per week), focusing on personal choice and responsibility, and 2 30 3 At 8 and 24 weeks, the MI group had a higher proportion of abstinent patients compared to the 72
(2003) de-emphasizing labelling, with therapist using a directive and client-centred style. EI group; 40% of the MI group reported sustained abstinence throughout follow-up period, in
2. EI used didactic, and focused on therapist assuming a directive interpersonal style (1-hour comparison to 0% in the EI group. MI group drank on fewer days in comparison to their EI
session per week). counterparts, indicated a strong MI effect on the frequency of drinking days.
Griffiths et al. 1. Weekly group sessions lasting for 2 hours. Included standardized manuals, with education 1 56 12 Significant decrease in average daily cigarette intake, from 27.97 (16.23) to 4.38 (5.55); 13 (44%) 60
(2010) sessions and goal setting. Included coping strategies. said that they had quit smoking. Significant decline in severity of dependence scale. Self-efficacy
in ability to resist using tobacco increased significantly.
Hall et al. 1. Stepped-care intervention involved two steps: (i) computerized motivational feedback. 2 322 72 Main effect for treatment condition over time on abstinence. Significant treatment by cigarettes 92
(2006) Computerized system that provided individualized feedback. Included smoking behaviour, smoked at baseline interaction. Significant main effect for treatment condition, number of
readiness to quit, and individual characteristics. Based on SOC; (ii) second component was cigarettes at baseline, and previous quitting attempts. Significant effect for propensity score, time,
delivered only to participants who reached at least the contemplation stage of SOC during and treatment. Indicates that a staged-care intervention endorsed a goal of complete and
the first step. Motivational counselling and cessation treatment to willing participants were continued abstinence compared to a control group.
supervised weekly. Counselling provided in 6 sessions of 30 min, each over 8 weeks.
2. Brief contact control received self-help guide.
Herman et al. 1. Mental Health Chemical Dependence programme experimental group based on staged 2 482 4 (or Intervention part significantly reduced days of alcohol use per month (4.71 vs 2.54). 72
(2000) theoretical model. Educational lectures, stabilization of psychiatric and physical symptoms, discharge,) Schizophrenia and alcohol dependency negatively related to days of alcohol use. Stronger intent
family education, support, group therapy. whichever to stay sober at discharge reduced rate.
2. Short-term treatment ward: control group. came first

© 2012 The Authors

B. HAPPELL ET AL.

International Journal of Mental Health Nursing © 2012 Australian College of Mental Health Nurses Inc.
 Kemp et al. 1. ‘Stop using stuff ’: manualized intervention using motivational interviewing and cognitive 2 19 NS Significant main effect was observed in the frequency of alcohol and drug use. Significant 80
(2007) behaviour practices for substance abuse. Comprising of five stages; 4–6 hours of main effect for both groups were observed for DAST, AUDIT, WHOQOL, and SE.
additional treatment than the TUG.
2. TUG.
Peuskens 1. Psychomotor fitness training group: specialized form of psychomotor therapy based on 2 141 16 Intervention group improved in the CRF measure for physical work capacity when 84
et al. (2003) scientific findings regarding training in psychiatric patients and effect on depression and exercising at 60% of MHRR, but not 80% of MHRR. Additionally, the intervention group

© 2012 The Authors

anxiety. Consists of aerobic exercise and resistance training 3 times per week ¥ 45 min. showed greater improvements in all muscular fitness measures.
2. General programme of psychomotor therapy: variety of sports and games, physical
activities, and relaxation techniques, 2 times per week ¥ 45 min.
Lee et al. 1. Diet and exercise management; 12 weekly group sessions lasting 60–90 min. 1 NS 12 Participants showed significant improvements in knowledge of both diet and exercise. 64
(2008) Compliance to diet and exercise median were 7.8 and 8.0, respectively. BMI and body
weight showed a significant reduction, with moderate compliance after 12 weeks. Diet
compliance was the strongest single predictor.
Lindenmayer 1. Combined the SfW and TS programmes. Consisted of detailed instruction and patient 1 275 48 Significant reductions in weight loss, BMI, blood glucose, and triglyceride levels over study 52
et al. (2009) manuals. SfW teaches information and tips about nutrition, fitness and exercise. In TS, duration. No change in cholesterol or HbA1c. Significant increase in a number of knowledge
participants learn about symptoms of mental illness and recovery relapse prevention. measures (e.g. nutrition/healthy lifestyle, fitness, and exercise).
Consisted of 11 modules and 3 levels.
Littrell et al. 1. Weekly 1-hour psychoeducation class on improving diet and lifestyle in a number of 2 70 16 Significant differences were found between the two groups regarding weight change. Weight 60
(2003) areas. in intervention group changed very little over time; in contrast, standard care group weight
2. Standard care group. steadily increased.
HEALTH BEHAVIOUR FOR PHYSICAL HEALTH

McCreadie 1. Fruit and vegetable and instruction: received free fruit and vegetables for 6 months, and 3 102 26 Fruit and vegetable intake increased in both groups 1 and 2, but not in group 3. Fall in 56
et al. (2005) supported by instruction in meal planning and food preparation. consumption after intervention was more gradual in group 1, but not significant.
2. Fruit and vegetables only: received free fruit and vegetables for 6 months.
3. Standard care.
McDevitt 1. Walking programme, meeting 3 times per week for 1 hour, with 4 health information 1 15 12 Significant improvement in mood, the POMS subscale vigor-activity, and psychosocial 64
et al. (2005) workshops at the beginning. Individual exercise prescription by fitness testing and use of functioning (MCAS); in particular, medication compliance and response to stress and
heart rate monitors. anxiety. No changes in health (SF-12).
Melamed 1. Intervention group received weekly small-group counselling by a dietician and 2 59 12 Significant weight reduction and QOL in intervention vs control group from baseline to end 52
et al. (2008) group-based behaviour therapy, focusing on nutrition and exercise; 30-min walks, 5 times of intervention. Intervention group achieved significantly greater weight loss, although
per week. control groups also lost weight. Significant between-group differences regarding weight loss
2. Control group. and weight gain. More participants in the control group vs intervention group gained weight
(39% vs 7.7%). More participants in the intervention group vs control group lost weight
(69% vs 54%). No impact on medication and weight reduction. At 1-year follow up (only 37
participants measured), there were no significant weight changes; control group gained
weight slightly, and intervention group weight was maintained.
Menza et al. 1. Healthy living programme included nutrition counselling, exercise, and behavioural 2 51 52 Intervention group achieved A significant mean weight loss of 3 kg (3% body weight), 72
(2004) interventions. Included self-monitoring, stress management, problem-solving, and social compared to mean gain of 3.2 kg (3.5%) in control group. significant BMI decrease by
support. Lasted for 12 months, but consisted of 4 phases: assessment, intensive, step (5.1%) in intervention group, and 8.1% increase in control group. Significant improvements
down, and weight maintenance. for intervention group in HbA1c, BP, waist and hip measurements, minutes per week of
2. Usual care. exercise, nutrition knowledge and SOC for exercise and weight. No statistically-significant

International Journal of Mental Health Nursing © 2012 Australian College of Mental Health Nurses Inc.
changes for cholesterol, hunger, and pulse when comparing low and high attendees.
Significantly reduced BMI in high attendees.
Milner et al. 1. Brief alcohol intervention 1 242 26 Significantly reduced drinking by approximately 7 days per week-1 over the 6 months of the 52
(2010) study. Reduction from 18.7 (SD = 21.0) to 11.6 (SD = 22.4) drinks per week from baseline
to 6 months. Percentage of people meeting binge drinking criteria was reduced (from 78%
to 51%).
Pelletier et al. 1. 3 ¥ 90-min sessions per week for 16 weeks; 30-min warm-up, customized programme. 1 27 16 Significant difference in submaximal exercise test and walking further. A number of 52
(2005) measures did not attain significance, but were in the hypothesized direction (BMI, body
composition). Change in mental health subscale from SF-36 was significant.
241
 TABLE 1: Continued
Intervention characteristics Outcomes 242
Sample
Study size at Duration Study
Study Description of intervention groups baseline (weeks) Main outcomes quality

Porsdal et al. 1. SfW standardized programme, including manuals and small-group sessions facilitated by 2 373 12 From baseline to 3 months, intervention group decreased weight by an average 0.5 kg, whereas 68
(2010) trained nurse or therapist. The 12 weekly sessions focused on nutrition and physical activity. control group increased weight by average 0.9 kg. Mean weight continued to decrease in the
2. Control group. intervention group by 0.2 kg between 3 and 6 months. Intervention significantly decreased waist
circumference at 3 and 6 months (2.2 & 0.1 cm), whereas control group increased at 3 months
(1.2 cm). QOL, as measured by the SWN, improved in the intervention group compared to the
control group. Intervention decreased CGI by 0.4 at 3 months; this increased by 0.1 at 6 months.
Rowe et al. 1. Group-based classes with topics related to social participation and community integration, 2 114 52 Significantly lower levels of alcohol use at 6 and 12 months in intervention compared to control 84
(2007) followed by projects designed to increase participants’ valued social roles. Peer mentor group. Intervention group decreased, and control increased alcohol use. Both groups showed
assigned. significant main effect for time in decreasing their non-alcohol drug use across basement periods.
2. Standard care. Main effect for time for significant decrease in number of new criminal charges for both groups
at 6 and 12 months.
Skrinar et al. 1. Intervention group: participate in 4 exercise sessions and 1 health seminar each week. 2 30 12 No group differences for physiological variables (cholesterol, lipids). Significant improvements in 72
(2005) Seminars lasted 30–45 min and covered a broad range of topics related to healthy lifestyle general health and empowerment in intervention vs control. Scores also improved in nearly all
(weight, stress management, wellness). SCL-90 variables, and trends were observed for depression, weight loss, OCD, SF-12, and QOL
2. Control group offered intervention upon completion of intervention. subscales.
Smith et al. 1. Enrolees asked to attend minimum of 6 consultations over 2 years. Included weight 1 966 104 Significant reduction in level of risk factors for CVD overall. Fewer people smoked, and more 68
(2007) management and physical activity groups, and comprehensive baseline assessment and had a better diet and increased physical activity. Significant improvements in self-esteem.
discussion of results. Referred to either or weight management groups, general practitioner, Significant reduction in alcohol consumption. No changes in BMI, although 42% lost weight.
specialist, or medication change.
Teesson and 1. Provided education about alcohol and substance abuse, and responsible drinking. 1 67 52 Significant improvements in tobacco and alcohol weekly use and social functioning. 52
Gallagher Motivational interviewing was included.
(1999)
Van Citters Delivered SHAPE programme, which is an individualized health-promotion programme. 1 76 30 Significant increase of 1.1 hours of exercise per week. Significant increase in YPAS overall 64
et al. (2010) Included assigned health mentor who delivered weekly meetings and provided fitness and activity, vigorous activity, and leisurely walking indices. Significant improvements in readiness to
nutritional education instruction. Provided goal setting and individualized information. engage in regular planned exercise. Significant reduction in waist circumference (average 3.2-cm
Included incentives and free access to fitness facilities. loss). Significant improvements in satisfaction with fitness, mental health functioning, and severity
of negative symptoms.
Vreeland 10-week group-based programme, including manual, five sessions per week, to take steps 2 34 10 Intervention group significantly improved BMI (-0.49) in comparison to control group (+0.12). 56
et al. (2010) toward health lifestyle, including motivational techniques using SOC. Significant improvements in knowledge about wellness and attitude towards healthy living in
intervention group compared to control group. Pre–post measures in intervention group showed
improvements in systolic and diastolic BP and waist circumference. No changes in CGI.
Wu et al. 1. Caloric restriction and undertaking physical activity 3 days per week (30 min) for a duration 2 NS 26 At 6 months, triglyceride levels, body weight, BMI, waist circumference, and hip circumference 76
(2007) of 6 months. were significantly lower in intervention group in comparison to control group. Intervention group
2. Control group significantly decreased triglycerides and cortisol levels at 3 and 6 months. Insulin was significantly
lower at 6 months. Triglyceride levels in control group significantly increased.
Wu et al. 1. Metformin-alone group. 4 128 12 Between-group changes show lifestyle + metformin significantly superior to metformin on weight, 84
(2008) 2. Placebo-alone group. BMI, and waist circumference; significantly superior to lifestyle + placebo on weight, BMI, waist
3. Lifestyle intervention + metformin. Lifestyle intervention involved psychoeducational, circumference, insulin, and insulin resistance index; and significantly superior to placebo on
dietary, and exercise programmes, including 30-min exercise sessions based on heart rate. weight, BMI waist, fasting glucose, insulin and insulin resistance index. Metformin significantly
4. Lifestyle intervention + placebo. Lifestyle same as above. superior to lifestyle + placebo and placebo on weight, BMI, waist circumference, fasting glucose,
insulin, and insulin resistance index. Lifestyle + placebo was significantly superior to placebo on
weight, BMI, waist circumference, fasting glucose, insulin, and insulin resistance index.

AUDIT, Alcohol Use Disorders Identification Test; BDI, Beck Depression Inventory; BMI, body mass index; BP, blood pressure; CGI, Clinical Global Impression; CR, contingent reinforcement; CRF, cardiorespiratory fitness; CVD, cardiovascular
disease; DAST, Drug Abuse Screening Test; EI, educational intervention; HAM-D, Hamilton rating scale for Depression; HbA1c, glycated haemoglobin; HPLPII, Health-Promoting Lifestyle Profile II; ITT, intention to treat; MCAS, Multnomah Community
Ability Scale ; MHRR, estimated maximum heart rate reserve; MI, motivational intervention; NRT, nicotine replacement therapy; NS, not stated; OCD, obsessive–compulsive disorder; PA, physical activity; PANSS, Positive and Negative Syndrome Scale;
POMS, Profile of Mood States, QOL, quality of life; SCL-90, Symptom Checklist-90-R; SD, standard deviation; SE, Self Efficacy; SF, Short-Form Health Survey; SfW, Solution for Wellness; SHAPE, Self-Health Action Plan for Empowerment, SMART,
Specific, Measurable, Acceptable, Realistic, Timely; SOC, stages of change; SWN, Subjective Wellbeing under Neuroleptics scale; TTM, Transtheoretical Model; TS, Team Solution; TUG, treatment-as-usual group; WHOQOL, World Health Organization

© 2012 The Authors

B. HAPPELL ET AL.

International Journal of Mental Health Nursing © 2012 Australian College of Mental Health Nurses Inc.
Quality of Life Scale; YPAS, Yale Physical Activity Scale.
HEALTH BEHAVIOUR FOR PHYSICAL HEALTH
a medium-term study length, and 39 studies satisfactorily
reported intervention length. The average interven-
tion length was 27.4 weeks (range: 3–104 weeks). Twenty
three of the studies collected follow-up data immediately
post-intervention, with the remaining studies ranging
from 2 to 72 weeks’ post-intervention. The majority of
studies used a group-based approach for their interven-
tion delivery (n = 25); other studies opted for either an
individualized approach (n = 7), or did not state the deliv-
ery method (n = 10). Additionally, two studies did not
state the type of intervention delivery, and 40 studies
used an in-person approach for the delivery of the
intervention.
In relation to the approach of the intervention to
change behaviour, all studies used a combination of at
least some psychosocial education and behaviour change
instruction (e.g. exercise programme, dietary advice, and
nicotine recommendations). Four studies utilized psycho-
social education only, and 13 used behaviour change
instruction only. The majority of interventions targeting
smoking behaviour also included nicotine replacement
therapy (NRT) (n = 4).
Results of interventions
Weight management
The most commonly reported studies (n = 17) involved
interventions targeting weight management, mostly in
the form of weight loss through changes in nutrition
and/or physical activity. Within six one-group studies, all
reported significant improvements between the pre- and
post-measures for outcomes, including body weight/waist
circumference (Centorrino et al. 2006; Lee et al. 2008;
Lindenmayer et al. 2009; Van Citters et al. 2010), body
mass index (BMI) (Centorrino et al. 2006; Lee et al. 2008;
Lindenmayer et al. 2009), physical activity (Bradshaw
et al. 2010; Smith et al. 2007; Van Citters et al. 2010), and
nutrition (Bradshaw et al. 2010; Smith et al. 2007).
In the 11 studies that used a two or more-group study
design, nine reported significant differences between
groups for body weight (Brown & Chan 2006; Brown
et al. 2006; Littrell et al. 2003; Melamed et al. 2008;
Menza et al. 2004; Vreeland et al. 2010; Wu et al. 2007;
2008), BMI (Brown et al. 2006; Menza et al. 2004;
Vreeland et al. 2010; Wu et al. 2007; 2008), nutrition
(Brown & Smith 2009), and physical activity (Brown &
Chan 2006; Brown & Smith 2009; Brown et al. 2006)
following interventions. Two of these studies also con-
ducted analyses on pre–post change for the intervention
group only, and reported significant improvements for
physical activity (Menza et al. 2004) and nutrition (Brown
et al. 2006). The remaining two studies either did not
© 2012 The Authors
International Journal of Mental Health Nursing © 2012 Australian College of Mental Health Nurses Inc.
243
find significant differences between groups, or failed to
conduct change analyses (Ball et al. 2001; Porsdal et al.
2010).
Smoking cessation
Seven studies focused on smoking cessation, and all but
two involved group-based therapy (Gallagher et al. 2007;
Hall et al. 2006). All seven studies noted some improve-
ments in smoking cessation rates between pre–post mea-
sures within the intervention group (Addington et al.
1998; Ashton et al. 2010; Bloch et al. 2010; Gallagher
et al. 2007; George et al. 2000; Griffiths et al. 2010;
Hall et al. 2006). Of the three studies that utilized a
two or more-group study design, two found significant
differences between groups following the intervention
(Gallagher et al. 2007; Hall et al. 2006). In addition to
self-report measures, one study assessed smoking objec-
tively using measures of carbon levels (Gallagher et al.
2007), and noted improvement in carbon monoxide
levels in addition to self-report measures. The majority
of studies offered NRT as part of the intervention, and
three studies noted the effectiveness of combined NRT
with another type of intervention (Gallagher et al. 2007;
George et al. 2000; Griffiths et al. 2010).
Physical activity
Seven studies aimed to produce changes in physical activ-
ity, physical fitness, or body composition. Five studies
included two or more groups as part of their intervention,
and two studies reported significant post-intervention dif-
ferences between groups for body fat (Beebe et al. 2005),
cardiorespiratory fitness (Peuskens et al. 2003), and
muscular fitness (Peuskens et al. 2003). A further study
reported significant pre–post improvements in the inter-
vention groups for aerobic capacity (Blumenthal et al.
1999), but two studies found no significant differences
between groups, and did not report further pre–post
analyses (Daley et al. 2008; Skrinar et al. 2005). For the
remaining two studies that utilized a one-group study
design, significant improvements in vigorous physical
activity (McDevitt et al. 2005), submaximal exercise
test scores (Pelletier et al. 2005), and distance walked
(Pelletier et al. 2005) were observed.
Nutrition
Two studies focused solely on nutrition. Evans and
colleagues used a two-group study design and found sig-
nificant improvements in weight, BMI, and waist circum-
ference for the intervention group in comparison to
the control group (Evans et al. 2005). The second
study included three groups, and resulted in significant
244
differences between groups for fruit and vegetable
intake immediately post-intervention (3 months), but not
at 12 months (McCreadie et al. 2005). Additionally, no
significant differences for BMI or physical activity were
observed. (McCreadie et al. 2005).
Alcohol misuse
Six of nine studies noted improvements in alcohol misuse
(Archie et al. 2007; Graeber et al. 2003; Herman et al.
2000; Kemp et al. 2007; Milner et al. 2010; Rowe et al.
2007), and a further study noted changes that approached
significance for alcohol misuse (Teesson & Gallagher
1999).
Specifically, significant decreases in hazardous
alcohol use (Archie et al. 2007; Kemp et al. 2007; Rowe
et al. 2007), drinking days (Graeber et al. 2003), drinks
per week (Milner et al. 2010), alcohol use per month
(Herman et al. 2000), concurrent drug and alcohol misuse
(Archie et al. 2007), and binge drinking (Milner et al.
2010) were observed, along with increases in abstinence
from alcohol (Graeber et al. 2003) and intention to stay
sober (Herman et al. 2000). Studies additionally reported
significant decreases in illicit drug use (Archie et al. 2007;
Bradley et al. 2007; Kemp et al. 2007; Rowe et al. 2007),
substance used per substance using day (Barrowclough
et al. 2010), and in post-intervention criminal charges
(Rowe et al. 2007).
DISCUSSION
This paper reviews current literature available on pro-
grammes involving a health behaviour intervention to
improve the physical health of individuals diagnosed with
a mental illness. The 42 included articles covered a wide
scope of behaviours and intervention designs, and the
methodological quality of the studies was average, which
can be problematic for assessing the overall impact of
interventions, and as such, results should be interpreted
with caution. Nevertheless, the findings from this review
provide great promise in relation to changes in health
behaviours of individuals diagnosed with a mental illness.
Articles were relatively evenly distributed between
sexes, which holds great promise for the reach of healthy
living programmes. The USA is leading the field in this
area of research, with other substantial contributions from
Australia and the UK. This might be a cause of restrictions
for the generalizability of the findings to other countries.
The most common behaviours targeted were physical
activity and nutrition, and while further research is
required for these behaviours, smoking and alcohol abuse
interventions require particular attention. The most
International Journal of Mental Health Nursing © 2012 Australian College of Mental Health Nurses Inc.
B. HAPPELL ET AL.
popular form of intervention appears to be group-based
programmes, which also demonstrate a high success rate.
Programmes reported positive changes across all of the
health behaviours targeted. For weight management, a
total of 12 studies reported significant improvements in
body weight and/or BMI, a further six studies observed
improvements in physical activity, and three observed
improvements in nutrition. The interventions targeting
physical activity alone were highly variable in their
measure of physical activity behaviour (including both
physical fitness and activity levels), but four studies
reported significant improvements in this area. Only
two studies specifically targeted changes in nutrition. One
of these found improvements; however, nutrition was
also targeted in a number of weight management pro-
grammes, and studies also reported positive effects for
nutrition. The effectiveness of these programmes to
produce change in dietary habits is still unclear.
Interventions targeting smoking cessation were very
successful, as all seven studies noted some improvement in
rates of smoking cessation. NRT emerged as a consistent
theme throughout these studies, and it should be noted
that all studies found positive results in relation to psychi-
atric symptoms. The studies found no negative effects in
relation to smoking cessation on psychiatric symptoms,
which is extremely promising and provides evidence for
the effectiveness of smoking cessation programmes using
NRT among individual diagnosed with a severe mental
illness. Finally, studies targeting alcohol abuse are also
promising, with six of nine studies reporting improvements
in this behaviour, and several studies reporting additional
improvements in other substance abuse.
The authors attempted to extract information on psy-
chological outcomes, but due to the variety of methodolo-
gies for assessing changes, the information was unable
to be effectively extracted. Briefly, however, 26 studies
reported either baseline or pre–post changes for psycho-
logical variables. Studies targeting physical activity were
the most likely of the behaviour change programmes
to also measure psychological variables. These variables
included general psychosocial health, such as quality of
life and stress, and also specific measures, such as schizo-
phrenia symptoms. The most common improvements
noted throughout the studies were for schizophrenia
symptoms, quality of life, and self-efficacy. Consistently
including these types of measures in future studies is as
important as measuring physical health, due to the recip-
rocal nature of mental and physical health.
The findings of this review are subject to limitations.
The paper presents a qualitative review only, as due infor-
mation provided in included studies and the range of
© 2012 The Authors
HEALTH BEHAVIOUR FOR PHYSICAL HEALTH
health behaviours being examined precluded a quantita-
tive analysis. Finally, the current systemic review was
undertaken only on published English-language articles,
and did not include grey literature.
To further enhance the evidence for healthy health
behaviour programmes specifically for individuals diag-
nosed with a mental illness, future research should aim to
be consistent with previous measures of health behaviours
and to report all relevant findings. Additionally, future
researchers should also aim to include reliable and vali-
dated psychological measures, such as the Short-Form
Health Survey (Ware et al. 1996) or Positive and Negative
Syndrome Scale (Kay et al. 1987), to identify not only
improvements in psychological health, but also links
between physical and mental health changes following
interventions. Overall, the results of this systematic review
are extremely promising, indicating that health behaviour
interventions are effective in producing positive changes
in physical health and in unhealthy behaviours, such as
dietary habits, physical inactivity, smoking, and alcohol
abuse.
Implications for mental health nurses
There is evidence to suggest that the integration of mental
and physical health-care services might significantly
reduce the disparity in physical health observed between
populations with and without mental illness (Scott et al.
2011). We believe that the mental health nursing profes-
sion has an opportunity to adapt the role of the mental
health nurse to include regular consumer physical health
assessments and interventions. The findings of this sys-
tematic review are therefore important, as they suggest
that health behaviour interventions can lead to significant
reductions in the unhealthy behaviours of mental health
consumers.
Moreover, the findings suggest that successful tech-
niques of health behaviour intervention delivery might be
suitable to the mental health nursing role. For instance, all
studies (where information could be extracted) used an
in-person approach for intervention delivery, and mental
health nurses often spend substantial amounts of face-to-
face time with their clients. Study populations included
outpatients and inpatients, those using psychotropics,
and those with a variety of psychiatric diagnoses, and this
reflects the wide range of conditions presented by the
consumers that nurses attend to on a daily basis. A large
number of studies used a group-based approach to deliver
interventions, and this approach might be favoured by
mental health nurses as a means of reducing impact on
time and resources. Finally, it is worth noting that a sub-
stantial proportion (24%) of included studies specifically
© 2012 The Authors
International Journal of Mental Health Nursing © 2012 Australian College of Mental Health Nurses Inc.
245
reported that nurses were involved in intervention delivery
(Addington et al. 1998; Barrowclough et al. 2010; Bradley
et al. 2007; Griffiths et al. 2010; Lee et al. 2008; Linden-
mayer et al. 2009; Littrell et al. 2003; McCreadie et al.
2005; Porsdal et al. 2010; Smith et al. 2007), indicating that
mental health nurses have many of the skills necessary to
provide successful health behaviour interventions.
From a patient perspective, there is evidence that
adherence rates to health behaviour interventions by
mental health consumers are at least comparable to those
of individuals without mental illness (Martinsen 1993), and
therefore, such interventions hold promise. Nevertheless,
it is likely that individuals with a mental illness experience
barriers and motivators for health behaviour change that
differ in type and/or magnitude from the general popula-
tion. There is currently a paucity of data examining differ-
ences in behaviour change and health outcomes for mental
health consumers and individuals without mental illness
following intervention, and this requires further research
in order to best tailor health behaviour interventions to the
needs of mental health consumers.
The findings of this systematic review indicate that
addressing health behaviours in mental health consumers
can result in significant improvements in behaviour and
health outcomes. The mental health nursing fraternity
must consider research projects that examine methods to
more regularly and effectively provide health behaviour
assessment and education to consumers without compro-
mising mental health care. Moreover, in order to increase
their knowledge of health behaviour advice provision,
mental health nurses need ongoing education and train-
ing, and this will require systemic support for their role in
physical health care and in developing and conducting
consumer health behaviour interventions.
ACKNOWLEDGEMENTS
The authors acknowledge the support of CQUniversity
Australia through the Research Advancement Award
Scheme in facilitating the conduct of this work.
REFERENCES
Addington, J., El-Guebaly, N., Campbell, W., Hodgins, D. &
Addington, D. (1998). Smoking cessation treatment for
patients with schizophrenia. The American Journal of
Psychiatry, 155, 974.
Archie, S., Rush, B., Akhtar-Danesh, N. et al. (2007). Substance
use and abuse in first-episode psychosis: Prevalence before
and after early intervention. Schizophrenia Bulletin, 33,
1354.
246
Ashton, M., Miller, C. L., Bowden, J. A. & Bertossa, S. (2010).
People with mental illness can tackle tobacco. Australian &
New Zealand Journal of Psychiatry, 44, 1021–1028.
Ball, M. P., Coons, V. B. & Buchanan, R. W. (2001). A program
for treating olanzapine-related weight gain. Psychiatric
Services, 52, 967–969.
Barrowclough, C., Haddock, G., Wykes, T. et al. (2010). Inte-
grated motivational interviewing and cognitive behavioural
therapy for people with psychosis and comorbid substance
misuse: Randomised controlled trial. BMJ, 341, c6325.
Beebe, L. H., Tian, L., Morris, N., Goodwin, A., Allen, S. S. &
Kuldau, J. (2005). Effects of exercise on mental and physical
health parameters of persons with schizophrenia. Issues in
Mental Health Nursing, 26, 661–676.
Bloch, B., Reshef, A., Cohen, T. et al. (2010). Preliminary
effects of bupropion and the promoter region (HTTLPR)
serotonin transporter (SLC6A4) polymorphism on smoking
behavior in schizophrenia. Psychiatry Research, 175, 38–42.
Blumenthal, J. A., Babyak, M. A., Moore, K. A. et al. (1999).
Effects of exercise training on older patients with major
depression. Archives of Internal Medicine, 159, 2349–2356.
Bradley, A. C., Baker, A. & Lewin, T. J. (2007). Group inter-
vention for coexisting psychosis and substance use disorders
in rural Australia: Outcomes over 3 years. Australian & New
Zealand Journal of Psychiatry, 41, 501–508.
Bradshaw, T., Lovell, K., Bee, P. & Campbell, M. (2010). The
development and evaluation of a complex health education
intervention for adults with a diagnosis of schizophrenia.
Journal of Psychiatric & Mental Health Nursing, 17, 473–
486.
Bradshaw, T., Lovell, K. & Harris, N. (2005). Healthy living
interventions and schizophrenia: A systematic review.
Journal of Advanced Nursing, 49, 634–654.
Brown, C., Goetz, J., Van Sciver, A., Sullivan, D. & Hamera, E.
(2006). A psychiatric rehabilitation approach to weight loss.
Psychiatric Rehabilitation Journal, 29, 267.
Brown, S. & Chan, K. (2006). A randomized controlled trial of a
brief health promotion intervention in a population with
serious mental illness. Journal of Mental Health, 15, 543.
Brown, S. & Smith, E. (2009). Can a brief health promotion
intervention delivered by mental health key workers improve
clients’ physical health: A randomized controlled trial.
Journal of Mental Health, 18, 372–378.
Buka, S. L. (2008). Psychiatric epidemiology: Reducing
the global burden of mental illness. American Journal of
Epidemiology, 168, 977.
Centorrino, F., Wurtman, J. J., Duca, K. A. et al. (2006). Weight
loss in overweight patients maintained on atypical antipsy-
chotic agents. International Journal of Obesity, 30, 1011.
Daley, A., Winter, H., Grimmett, C., McGuinness, M.,
McManus, R. & MacArthur, C. (2008). Feasibility of an
exercise intervention for women with postnatal depression:
A pilot randomised controlled trial. The British Journal of
General Practice, 58, 178–183.
International Journal of Mental Health Nursing © 2012 Australian College of Mental Health Nurses Inc.
B. HAPPELL ET AL.
Ellis, N., Crone, D., Davey, R. & Grogan, S. (2007). Exercise
interventions as an adjunct therapy for psychosis: A critical
review. British Journal of Clinical Psychology, 46, 95–111.
Evans, S., Newton, R. & Higgins, S. (2005). Nutritional inter-
vention to prevent weight gain in patients commenced on
olanzapine: A randomized controlled trial. Australian & New
Zealand Journal of Psychiatry, 39, 479–486.
Gallagher, S. P., Penn, P. P., Schindler, E. P. & Layne, W. M.
(2007). A comparison of smoking cessation treatments
for persons with schizophrenia and other serious mental
illnesses. Journal of Psychoactive Drugs, 39, 487.
George, T., Ziedonis, D., Feingold, A. et al. (2000). Nicotine
transdermal patch and atypical antipsychotic medications for
smoking cessation in schizophrenia. The American Journal of
Psychiatry, 157, 1835.
Graeber, D., Moyers, T., Griffith, G., Guajardo, E. & Tonigan,
S. (2003). A pilot study comparing motivational interviewing
and an educational intervention in patients with schizophre-
nia and alcohol use disorders. Community Mental Health
Journal, 39, 189.
Griffiths, M., Kidd, S. A., Pike, S. & Chan, J. (2010). The
tobacco addiction recovery program: Initial outcome find-
ings. Archives of Psychiatric Nursing, 24, 239–246.
Hall, S. M., Tsoh, J. Y., Prochaska, J. J. et al. (2006). Treatment
for cigarette smoking among depressed mental health outpa-
tients: A randomized clinical trial. American Journal of
Public Health, 96, 1808–1814.
Herman, S. E., Frank, K. A., Mowbray, C. T. et al. (2000).
Longitudinal effects of integrated treatment on alcohol use
for persons with serious mental illness and substance use
disorders. The Journal of Behavioral Health Services and
Research, 27, 286–302.
Higgins, J. & Green, S. (2008). Cochrane Handbook for System-
atic Reviews of Interventions. London: John Wiley and Sons.
Kay, S. R., Flszbein, A. & Opfer, L. A. (1987). The positive
and negative syndrome scale (PANSS) for schizophrenia.
Schizophrenia Bulletin, 13, 261–276.
Kemp, R., Harris, A., Vurel, E. & Sitharthan, T. (2007). Stop
using stuff: Trial of a drug and alcohol intervention for young
people with comorbid mental illness and drug and alcohol
problems. Australasian Psychiatry, 15, 490–493.
Khaw, K.-T., Wareham, N., Bingham, S., Welch, A., Luben, R.
& Day, N. (2008). Combined impact of health behaviours
and mortality in men and women: The EPIC-Norfolk Pro-
spective Population Study. PLoS Medicine, 5, e12.
Peuskens, J., Knapen, K., Pieters, G. (2003). Improvements in
physical fitness of non-psychotic psychiatric patients follow-
ing psychomotor therapy programs. Journal of Sports Medi-
cine and Physical Fitness, 43, 513.
Lambert, T. J. R., Chapman, L. H., Bell, S. et al. (2004).
Diabetes, psychotic disorders and antipsychotic therapy:
A consensus statement. Medical Journal of Australia, 181,
544–548.
Lee, S. J., Choi, E. J. & Kwon, J. S. (2008). A naturalistic
multicenter trial of a 12-week weight management program
© 2012 The Authors
HEALTH BEHAVIOUR FOR PHYSICAL HEALTH
for overweight and obese patients with schizophrenia or
schizoaffective disorder. The Journal of Clinical Psychiatry,
69, 555–562.
Lindenmayer, J. P., Khan, A., Wance, D., Maccabee, N. &
Kaushik, S. (2009). Outcome evaluation of a structured edu-
cational wellness program in patients with severe mental
illness. The Journal of Clinical Psychiatry, 70, 1385–1396.
Littrell, K. H., Hilligoss, N. M., Kirshner, C. D., Petty, R. G. &
Johnson, C. G. (2003). Clinical scholarship. The effects of an
educational intervention on antipsychotic-induced weight
gain. Journal of Nursing Scholarship, 35, 237–241.
Martinsen, E. G. (1993). Therapeutic implications of exercise
for clinically anxious and depressed patients. International
Journal of Sports Psychology, 24, 185–199.
McCreadie, R. G., Kelly, C., Connolly, M. et al. (2005). Dietary
improvement in people with schizophrenia: Randomised
controlled trial. The British Journal of Psychiatry, 187, 346–
351.
McDevitt, J., Wilbur, J., Kogan, J. & Briller, J. (2005). A walking
program for outpatients in psychiatric rehabilitation: Pilot
study. Biological Research for Nursing, 7, 87–97.
Melamed, Y., Stein-Reisner, O., Gelkopf, M. et al. (2008).
Multi-modal weight control intervention for people with per-
sistent mental disorders. Psychiatric Rehabilitation Journal,
31, 194–200.
Menza, M., Vreeland, B., Minsky, S., Gara, M., Radler, D. R. &
Sakowitz, M. (2004). Managing atypical antipsychotic-
associated weight gain: 12-month data on a multimodal
weight control program. The Journal of Clinical Psychiatry,
65, 471–477.
Milner, K. K., Barry, K. L., Blow, F. C. & Welsh, D. (2010).
Brief interventions for patients presenting to the psychiatric
emergency service (PES) with major mental illnesses and
at-risk drinking. Community Mental Health Journal, 46, 149–
155.
Pelletier, J. R., Nguyen, M., Bradley, K., Johnsen, M. &
McKay, C. (2005). A study of a structured exercise program
with members of an ICCD Certified Clubhouse: Program
design, benefits, and implications for feasibility. Psychiatric
Rehabilitation Journal, 29, 89–96.
Porsdal, V., Beal, C., Kleivenes, O. K. et al. (2010). The Scan-
dinavian Solutions for Wellness study – a two-arm observa-
tional study on the effectiveness of lifestyle intervention on
subjective well-being and weight among persons with psychi-
atric disorders. BMC Psychiatry, 10, 42.
© 2012 The Authors
International Journal of Mental Health Nursing © 2012 Australian College of Mental Health Nurses Inc.
247
Rowe, M., Bellamy, C., Baranoski, M. et al. (2007). A peer-
support, group intervention to reduce substance use and
criminality among persons with severe mental illness. Psy-
chiatric Services, 58, 955–961.
Scott, D. & Happell, B. (2011). The high prevalence of poor
physical health and unhealthy lifestyle behaviours in indi-
viduals with severe mental illness. Issues in Mental Health
Nursing, 32, 589–597.
Scott, D., Platania-Phung, C. & Happell, B. (2011). Quality
of care for cardiovascular disease and diabetes amongst
individuals with serious mental illness and those using
anti-psychotic medications. Journal for Healthcare Quality.
In press.
Skrinar, G. S., Huxley, N., Hutchinson, D. S., Menninger, E. &
Glew, P. (2005). The role of a fitness intervention on people
with serious psychiatric disabilities. Psychiatric Rehabilita-
tion Journal, 29, 122.
Smith, S., Yeomans, D., Bushe, C. J. et al. (2007). A well-being
programme in severe mental illness. Reducing risk for
physical ill-health: A post-programme service evaluation at
2 years. European Psychiatry, 22, 413–418.
Teesson, M. & Gallagher, J. (1999). Evaluation of a treatment
programme for serious mental illness and substance use in an
inner city area. Journal of Mental Health, 8, 19–28.
Van Citters, A. D., Pratt, S. I., Jue, K. et al. (2010). A pilot
evaluation of the In SHAPE individualized health promotion
intervention for adults with mental illness. Community
Mental Health Journal, 46, 540–552.
Vreeland, B., Minsky, S., Gara, M. A. et al. (2010). Solutions
for wellness: Results of a manualized psychoeducational
program for adults with psychiatric disorders. American
Journal of Psychiatric Rehabilitation, 13, 55–72.
Ware, J. E., Kosinski, M. & Keller, S. D. (1996). A 12-Item
Short-Form Health Survey: Construction of scales and pre-
liminary tests of reliability and validity. Medical Care, 34,
220–233.
Wu, M., Wang, C., Bai, Y., Huang, C. & Lee, S. (2007). Out-
comes of obese, clozapine-treated inpatients with schizo-
phrenia placed on a six-month diet and physical activity
program. Psychiatric Services, 58, 544.
Wu, R., Zhao, J., Jin, H. et al. (2008). Lifestyle intervention and
metformin for treatment of antipsychotic-induced weight
gain: A randomized controlled trial. JAMA, 299, 185–193.