People with severe mental illness (schizophrenia, bipolar disorder or major depressive disorder) die up to 15 years prematurely due to chronic somatic comorbidities. Sedentary behavior and low physical activity are independent yet modifiable risk factors for cardiovascular disease and premature mortality in these people. A comprehensive meta-analysis exploring these risk factors is lacking in this vulnerable population. We conducted a metaanalysis investigating sedentary behavior and physical activity levels and their correlates in people with severe mental illness. Major electronic databases were searched from inception up to April 2017 for articles measuring sedentary behavior and/or physical activity with a self-report questionnaire or an objective measure (e.g., accelerometer). Random effects meta-analyses and meta-regression analyses were conducted. Sixty-nine studies were included (N535,682; 39.5% male; mean age 43.0 years). People with severe mental illness spent on average 476.0 min per day (95% CI: 407.3-545.4) being sedentary during waking hours, and were significantly more sedentary than age-and gender-matched healthy controls (p50.003). Their mean amount of moderate or vigorous physical activity was 38.4 min per day (95% CI: 32.0-44.8), being significantly lower than that of healthy controls (p50.002 for moderate activity, p<0.001 for vigorous activity). People with severe mental illness were significantly less likely than matched healthy controls to meet physical activity guidelines (odds ratio 5 1.5; 95% CI: 1.1-2.0, p<0.001, I 2 595.8). Lower physical activity levels and non-compliance with physical activity guidelines were associated with male gender, being single, unemployment, fewer years of education, higher body mass index, longer illness duration, antidepressant and antipsychotic medication use, lower cardiorespiratory fitness and a diagnosis of schizophrenia. People with bipolar disorder were the most physically active, yet spent most time being sedentary. Geographical differences were detected, and inpatients were more active than outpatients and those living in the community. Given the established health benefits of physical activity and its low levels in people with severe mental illness, future interventions specifically targeting the prevention of physical inactivity and sedentary behavior are warranted in this population.Key words: Physical activity, sedentary behavior, severe mental illness, schizophrenia, bipolar disorder, major depressive disorder, physical activity guidelines, cardiovascular disease, premature mortality (World Psychiatry 2017;16:308-315) People with severe mental illness (schizophrenia, bipolar disorder or major depressive disorder) have higher levels of somatic comorbidities and premature mortality than the general population 1-3 . A recent meta-analysis 4 documented that mortality rates are approximately two to three times increased in these people. The higher premature mortality rates are largely attributable to cardiovascular disease 5 .In the general populati...

Poor governance has been identified as a barrier to effective integration of mental health care in low- and middle-income countries. Governance includes providing the necessary policy and legislative framework to promote and protect the mental health of a population, as well as health system design and quality assurance to ensure optimal policy implementation. The aim of this study was to identify key governance challenges, needs and potential strategies that could facilitate adequate integration of mental health into primary health care settings in low- and middle-income countries. Key informant qualitative interviews were held with 141 participants across six countries participating in the Emerging mental health systems in low- and middle-income countries (Emerald) research program: Ethiopia, India, Nepal, Nigeria, South Africa, and Uganda. Data were transcribed (and where necessary, translated into English) and analysed thematically using framework analysis, first at the country level, then synthesized at a cross-country level. While all the countries fared well with respect to strategic vision in the form of the development of national mental health policies, key governance strategies identified to address challenges included: strengthening capacity of managers at sub-national levels to develop and implement integrated plans; strengthening key aspects of the essential health system building blocks to promote responsiveness, efficiency and effectiveness; developing workable mechanisms for inter-sectoral collaboration, as well as community and service user engagement; and developing innovative approaches to improving mental health literacy and stigma reduction. Inadequate financing emerged as the biggest challenge for good governance. In addition to the need for overall good governance of a health care system, this study identifies a number of specific strategies to improve governance for integrated mental health care in low- and middle-income countries.

Low PA levels are associated with increased prevalence of anxiety. There is a need for longitudinal research to establish the directionality of the relationships observed.

BackgroundThe involvement of mental health service users and their caregivers in health system policy and planning, service monitoring and research can contribute to mental health system strengthening, but as yet there have been very few efforts to do so in low- and middle-income countries (LMICs).MethodsThis systematic review examined the evidence and experience of service user and caregiver involvement in mental health system strengthening, as well as models of best practice for evaluation of capacity-building activities that facilitate their greater participation. Both the peer-reviewed and the grey literature were included in the review, which were identified through database searches (MEDLINE, Embase, PsycINFO, Web of Knowledge, Web of Science, Scopus, CINAHL, LILACS, SciELO, Google Scholar and Cochrane), as well as hand-searching of reference lists and the internet, and a snowballing process of contacting experts active in the area. This review included any kind of study design that described or evaluated service user, family or caregiver (though not community) involvement in LMICs (including service users with intellectual disabilities, dementia, or child and adolescent mental health problems) and that were relevant to mental health system strengthening across five categories. Data were extracted and summarised as a narrative review.ResultsTwenty papers matched the inclusion criteria. Overall, the review found that although there were examples of service user and caregiver involvement in mental health system strengthening in numerous countries, there was a lack of high-quality research and a weak evidence base for the work that was being conducted across countries. However, there was some emerging research on the development of policies and strategies, including advocacy work, and to a lesser extent the development of services, service monitoring and evaluation, with most service user involvement having taken place within advocacy and service delivery. Research was scarce within the other health system strengthening areas.ConclusionsFurther research on service user and caregiver involvement in mental health system strengthening in LMICs is recommended, in particular research that includes more rigorous evaluation. A series of specific recommendations are provided based on the review.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1323-8) contains supplementary material, which is available to authorized users.

BackgroundIn people with psychosis, physical comorbidities, including cardiovascular and metabolic diseases, are highly prevalent and leading contributors to the premature mortality encountered. However, little is known about physical health multimorbidity in this population or in people with subclinical psychosis and in low- and middle-income countries (LMICs). This study explores physical health multimorbidity patterns among people with psychosis or subclinical psychosis.MethodsOverall, data from 242,952 individuals from 48 LMICs, recruited via the World Health Survey, were included in this cross-sectional study. Participants were subdivided into those (1) with a lifetime diagnosis of psychosis (“psychosis”); (2) with more than one psychotic symptom in the past 12 months, but no lifetime diagnosis of psychosis (“subclinical psychosis”); and (3) without psychotic symptoms in the past 12 months or a lifetime diagnosis of psychosis (“controls”). Nine operationalized somatic disorders were examined: arthritis, angina pectoris, asthma, diabetes, chronic back pain, visual impairment, hearing problems, edentulism, and tuberculosis. The association between psychosis and multimorbidity was assessed by multivariable logistic regression analysis.ResultsThe prevalence of multimorbidity (i.e., two or more physical health conditions) was: controls = 11.4% (95% CI, 11.0–11.8%); subclinical psychosis = 21.8% (95% CI, 20.6–23.0%), and psychosis = 36.0% (95% CI, 32.1–40.2%) (P < 0.0001). After adjustment for age, sex, education, country-wise wealth, and country, subclinical psychosis and psychosis were associated with 2.20 (95% CI, 2.02–2.39) and 4.05 (95% CI, 3.25–5.04) times higher odds for multimorbidity. Moreover, multimorbidity was increased in subclinical and established psychosis in all age ranges (18–44, 45–64, ≥ 65 years). However, multimorbidity was most evident in younger age groups, with people aged 18–44 years with psychosis at greatest odds of physical health multimorbidity (OR = 4.68; 95% CI, 3.46–6.32).ConclusionsThis large multinational study demonstrates that physical health multimorbidity is increased across the psychosis-spectrum. Most notably, the association between multimorbidity and psychosis was stronger among younger adults, thus adding further impetus to the calls for the early intervention efforts to prevent the burden of physical health comorbidity at later stages. Urgent public health interventions are necessary not only for those with a psychosis diagnosis, but also for subclinical psychosis to address this considerable public health problem.

Background Cardiorespiratory fitness (CRF) among people with severe mental illness (SMI) (i.e., schizophrenia, bipolar disorder, and major depressive disorder) is a critical clinical risk factor given its relationship to cardiovascular disease and premature mortality.Objectives This study aimed to: (1) investigate the mean CRF in people with SMI versus healthy controls; (2) explore moderators of CRF; and (3) investigate whether CRF improved with exercise interventions and establish if fitness improves more than body mass index following exercise interventions. Methods Major electronic databases were searched systematically. A meta-analysis calculating Hedges' g statistic was undertaken.Results Across 23 eligible studies, pooled mean CRF was 28.7 mL/kg/min [95 % confidence interval (CI) 27.3 to 30.0 mL/kg/min, p\0.001, n = 980]. People with SMI had significantly lower CRF compared with controls (n = 310) (Hedges' g = -1.01, 95 % CI -1.18 to -0.85, p \ 0.001). There were no differences between diagnostic subgroups. In a multivariate regression, first-episode (b = 6.6, 95 % CI 0.6-12.6) and inpatient (b = 5.3, 95 % CI 1.6-9.0) status were significant predictors of higher CRF. Exercise improved CRF (Hedges' g = 0.33, 95 % CI = 0.21-0.45, p = 0.001), but did not reduce body mass index. Higher CRF improvements were observed following interventions at high intensity, with higher frequency (at least three times per week) and supervised by qualified personnel (i.e., physiotherapists and exercise physiologists). Conclusion The multidisciplinary treatment of people with SMI should include a focus on improving fitness to reduce all-cause mortality. Qualified healthcare professionals supporting people with SMI in maintaining an active lifestyle should be included as part of multidisciplinary teams in mental health treatment.

BackgroundThere are no nationally representative population-based studies investigating the relationship between physical activity, chronic conditions and multimorbidity (i.e., two or more chronic conditions) in low- and middle-income countries (LMICs), and studies on a multi-national level are lacking. This is an important research gap, given the rapid increase in the prevalence of chronic diseases associated with lifestyle changes in these countries. This cross-sectional study aimed to assess the association between chronic conditions, multimorbidity and low physical activity (PA) among community-dwelling adults in 46 LMICs, and explore the mediators of these relationships.MethodsWorld Health Survey data included 228,024 adults aged ≥18 years from 46 LMICs. PA was assessed by the International Physical Activity Questionnaire (IPAQ). Nine chronic physical conditions (chronic back pain, angina, arthritis, asthma, diabetes, hearing problems, tuberculosis, visual impairment and edentulism) were assessed. Multivariable logistic regression and mediation analyses were used to assess the association between chronic conditions or multimorbidity and low PA.ResultsOverall, in the multivariable analysis, arthritis (OR = 1.12), asthma (1.19), diabetes (OR = 1.33), edentulism (OR = 1.46), hearing problems (OR = 1.90), tuberculosis (OR = 1.24), visual impairment (OR = 2.29), multimorbidity (OR = 1.31; 95% CI = 1.21–1.42) were significantly associated with low PA. More significant associations were observed in individuals aged ≥50 years. In older adults, depression mediated between 5.1% (visual impairment) to 23.5% (angina) of the association between a chronic condition and low PA. Mobility difficulties explained more than 25% of the association for seven of the eight chronic conditions. Pain was a strong mediator for angina (65.9%) and arthritis (64.9%), while sleep problems mediated up to 43.7% (angina) of the association.ConclusionsIn LMICs, those with chronic conditions and multimorbidity are significantly less physically active (especially older adults). Research on the efficacy and effectiveness of PA in the management of chronic diseases in LMICs is urgently needed. Targeted promotion of physical activity to populations in LMICs experiencing chronic conditions may ameliorate associated depression, mobility difficulties and pain that are themselves important barriers for initiating or adopting an active lifestyle.Electronic supplementary materialThe online version of this article (doi:10.1186/s12966-017-0463-5) contains supplementary material, which is available to authorized users.

The current study suggests that higher PA levels are associated with lower SI. However, the associations observed need to be confirmed in prospective observational studies and controlled trials.