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1、Preventive Medicine 81 (2015) 216220 Adopting and maintaining physical activity behaviours in people with severe mental illness: The importance of autonomous motivation Davy Vancampfort a,b, Brendon Stubbs c,d, Sumanth Kumar Venigalla e, Michel Probst a,b a UPC KU Leuven, Campus Kortenberg, Universi

2、ty of Leuven, Department of Neurosciences, Kortenberg, Belgium b University of Leuven, Department of Rehabilitation Sciences, Leuven, Belgium c Physiotherapy Department, South London and Maudsley NHS Foundation Trust, Denmark Hill, London SE5 8AZ, United Kingdom d Health Service and Population Resea

3、rch Department, Institute of Psychiatry, Kings College London, De Crespigny Park, London Box SE5 8AF, United Kingdom e Institute of Mental Health, Singapore, Singapore a r t i c l e i n f o Available online 16 September 2015 Keywords: Physical activity Exercise Motivation Schizophrenia Depression Bi

4、polar disorder a b s t r a c t Objective. Physical activity can improve the health of people with serious mental illness (SMI) but many are inactive. Adopting theoretically-based research considering the motivational processes linked to the adoption and maintenance of an active lifestyle between dif

5、ferent diagnostic groups of people with SMI can assist in understanding physical activity in this group. Within the Self-Determination Theory (SDT) and the Trans- Theoretical Model (TTM) (stages of change) frameworks, we investigated differences in motives for physical activity between different dia

6、gnostic groups. Methods. All participants completed the Behavioral Regulation in Exercise Questionnaire 2 (BREQ-2), the International Physical Activity Questionnaire (IPAQ) and the Patient-centered Assessment and Counseling for Exercise (PACE) questionnaire. Results. Overall 294 persons with SMI (19

7、0) (43.6 13.6 years) agreed to participate. People with affective disorders had higher levels of introjected regulations than people with schizophrenia. No signicant differences were found for other motivational regulations. Moreover, no signicant differences were found according to gender, setting

8、and educational level. Multivariate analyses showed signicantly higher levels of amotivation and external regulations and lower levels of identied and intrinsic regulations in the earlier stages of change. Strongest correlations with the IPAQ were found for motivational regulations towards walking.

9、Conclusions. Our results suggest that in all people with SMI the level of identied and intrinsic motivation may play an important role in the adoption and maintenance of health promoting behaviours. The study provides a platform for future research to investigate the relationships between autonomy s

10、upport, motivational regulations and physical and mental health variables within lifestyle interventions for this population. 2015 Elsevier Inc. All rights reserved. Introduction People with severe mental illness (SMI) experience a marked pre- mature mortality which is largely attributed to natural

11、causes and in particular cardiovascular disease (Walker et al., 2015). Physical activity is broadly as effective as pharmacological interventions to treat cardio- vascular disease in the general population (Naci and Ioannidis, 2013). A recent systematic review established that physical activity impr

12、oves the physical and mental health and health related quality of life of people with severe mental illness (SMI) (Rosenbaum et al., 2014). Despite this promising evidence, only a minority of individuals with SMI engage * Corresponding author at: UPC KU Leuven, Campus Kortenberg, KU Leuven, Universi

13、ty of Leuven, Department of Neurosciences, Leuvensesteenweg 517, 3070 Kortenberg, Belgium. Fax: +32 2 759 9879. E-mail address: davy.vancampfortuc-kortenberg.be (D. Vancampfort). in physical activity and exercise at a level compatible with public health recommendations (Soundy et al., 2014a). One ex

14、planation for this is that many people with SMI lack sufcient motivation to adopt and maintain an active lifestyle (Soundy et al., 2014a). This lack of motiva- tion can be explained by several factors. First, the presence of psychiatric symptoms may result in people with SMI being disinterested or n

15、ot val- uing the benecial health outcomes enough to make physical activity a priority (Vancampfort et al., 2015a). Second, people with SMI may not feel sufciently competent to transform their intention into action and maintained engagement (Kramer et al., 2014), or are suffering from so- matic co-mo

16、rbidities that present a real or perceived barrier (Stubbs et al., 2014, 2015; Vancampfort et al., 2013a). Nevertheless, a better un- derstanding of the motivational decits in people with SMI, may hold the key to increasing physical activity in this group. Thus, there is a need for theoretically bas

17、ed research investigating the motivational processes linked to the adoption and maintenance of physical activity in people with SMI (Vancampfort and Faulkner, 2014). http:/dx.doi.org/10.1016/j.ypmed.2015.09.006 0091-7435/ 2015 Elsevier Inc. All rights reserved. Contents lists available at ScienceDir

18、ect Preventive Medicine journa l h omepage: D. Vancampfort et al. / Preventive Medicine 81 (2015) 216220 217 One approach to address this is by utilising the Self-Determination Theory (SDT) (Deci and Ryan, 2000). The SDT examines the differential effects of qualitatively different types of motivati

19、on that can underlie physical activity behaviour (Deci and Ryan, 2000). SDT describes moti- vation as being multidimensional and residing along a continuum of in- creasing self-determination (also called autonomous motivation). At the lowest end of the continuum is amotivation, in which case individ

20、- uals lack the motivation to adopt an active lifestyle. External regulation refers to commencing and continuing physical activity to avoid punish- ment or other-disappointment or to obtain promised rewards or other- appreciation. Next, introjected regulation refers to the imposition of pressures by

21、 feelings of guilt or self-criticism while identied regula- tions indicate that for the person the physical activity outcomes are per- sonally important (for example mental health improvements or prevent somatic co-morbidities). Finally, intrinsic motivation represents the most autonomous type of mo

22、tivation and involves being physically active for its own sake, because one nds it challenging or enjoyable. Recent research has considered the SDT in people with schizophre- nia (Vancampfort et al., 2013b, 2014) and among people with affective disorders (Vancampfort et al., 2015b) establishing that

23、 higher autono- mous motivation is signicantly related to greater participation in phys- ical activities. However, data comparing these different diagnostic groups with each other is currently lacking. If any difference in motiva- tion towards adopting and maintaining an active lifestyle in a subgro

24、up is observed, this could potentially help guide health care professionals in their treatment decisions. In addition, comparing data across and be- tween major diagnostic categories allows for investigation of the effect of demographic variables (age, gender, body mass index, diagnosis, set- tings,

25、 educational level) on a larger scale. Moreover, since many mental health services include people with each diagnostic group in one set- ting, the results will have wider implications and reect typical mental health services. In light of the complex and dynamic nature of physical activity be- haviou

26、r in people with SMI, it also is essential to assess a persons phys- ical activity patterns over a longer term. Although a longitudinal design would be ideal to answer this question, an individuals intentions to maintain engagement in physical activity can be indirectly captured through the assessme

27、nt of the stages of change of the transtheoretical model (TTM) (Prochaska and Di Clemente, 1983; Prochaska and Marcus, 1994). The TTM provides a framework for categorising a persons readiness to change their behaviour and includes ve stages. In the pre-contemplation phase, individuals are physically

28、 inactive and are not thinking about becoming more active within the next six months while in the contemplation stage they think about becoming more active within the next six months. In the preparation stage indi- viduals are engaging in some physical activity, while in the penultimate action stage

29、 individuals have been regularly active for less than six months. Lastly, the maintenance stage is characterised by an individual having sustained regular physical activity for more than six months. Given the aforementioned, the current study has four major aims: (1) to establish if motivation towar

30、ds physical activity differs between diagnostic subgroups (schizophrenia versus major depressive disorder versus bipolar disorder); (2) to explore whether differences in motiva- tion towards physical activity exist according to gender (male versus fe- male), educational status (low versus high educa

31、tion), and setting (inpatients versus outpatients) in a large sample of persons with SMI; (3) to evaluate differences in motivation towards physical activity across the stages of change; (4) investigate if current physical activity levels of people with SMI are related to different motivation types.

32、 Methods Participants and procedure The procedure of this multi-centre cross-sectional study has been described elsewhere more in detail (Vancampfort et al., 2014, 2015b). Fifteen (see Acknowledgments section) of 16 invited psychiatric centres agreed to partici- pate. One centre did not participate

33、due to organizational reasons (lack of time). Data were collected in 2 waves. Over a 4-month period in- and outpa- tients with a DSM-IV diagnosis of schizophrenia were invited to participate (rst wave). In the second wave, a 6-month period, in- and outpatients with a DSM-IV diagnosis of either major

34、 depressive disorder or bipolar disorder (American Psychiatric Association, 2000) were invited to participate. The diag- nosis for all included participants was established by experienced psychiatrists responsible for the patients treatment and who were not involved in the study. Only patients with

35、a clinical global impression severity scale (Guy, 1976) score of 3 or less assessed by a trained psychiatrist during a semi-structured inter- view, and who were able to concentrate for 20 to 25 min were included. No in- centive was provided for participation. The study procedure was approved by the

36、15 local ethical committees and all participants provided written informed consent. Demographic variables Demographic variables assessed included gender, age and body mass index (BMI). Next to this, dichotomous variables were constructed for education (lower: non, vocational or technical training, g

37、eneral education; higher: college or university) and treatment setting (in- versus out-patients). Behavioral Regulation in Exercise Questionnaire 2 (BREQ-2) The Dutch version of the BREQ-2 (Markland and Tobin, 2004) was used. The BREQ-2 considers an individuals motivation towards exercise. We adapte

38、d the BREQ-2 by replacing the term “exercise” with the term “physical activity”. The BREQ-2 comprises 19 items relating to ve motivation types from the SDT. Each item is measured on a ve-point Likert-scale, from 0 (Not true for me) to 4 (Very true to me). The mean of the 5 retrieved subscales is cal

39、culated on a ve-point scale to score the extent of each motivation type separately. The International Physical Activity Questionnaire (IPAQ)-short version The IPAQ-short version (Craig et al., 2003) was used. The IPAQ utilises a 7- day recall period. Data from the IPAQ is summarized according to tot

40、al minutes of walking, moderate and vigorous physical activity per week. Stage of readiness to change: Patient-centered Assessment and Counseling for Exercise (PACE) questionnaire Stages of change were assessed using a modied version of the stage of change questionnaire from the PACE questionnaire (

41、Long et al., 1996). For this study, physical activity was dened as moderate intensity activity for 30 min on most days of the week (e.g., activities that take moderate physical effort and make you breathe somewhat harder than normal). Participants chose one of ve options: “Im not physically active a

42、nd I dont intend to start” (pre- contemplation); “Im not physically active but Im thinking about starting” (con- templation); “Im active occasionally” (preparation); “Im active regularly and started in the last 6 months” (action); and “Im active regularly and have been for longer than 6 months” (mai

43、ntenance). Statistical analyses Multiple one-way analyses of variance (MANOVA) with post hoc Scheffe were applied to explore differences between different diagnostic groups. Un- paired t-tests were executed to investigate the differences in motivation to- wards physical activity between: (1) men and

44、 women, (2) persons with a high versus a low educational level, (3) in- and out-patients. Differences across stages of change were tested with MANOVA with post hoc tests (Scheffe). Lastly, associations between variables were explored with Pearson correlations. Due to the exploratory nature of this s

45、tudy, we did not control for multiple testing but present the precise P-values so that the degree of chance for each analysis is ev- ident allowing readers to consider this when interpreting the current ndings. Signicance level was set at P b 0.05. SPSS 22.0 was used for data analysis (SPSS Inc, Chi

46、cago, IL). 218 D. Vancampfort et al. / Preventive Medicine 81 (2015) 216220 Results Participants A total of 294 (190) Belgian patients with SMI were recruited, in- cluding 129 persons with schizophrenia (43.9%), 96 individuals with major depressive disorder (32.6%), and 69 with bipolar disorder (23.

47、5%). The exact number who declined participation is unclear due to insufcient data in several participating centres but based on extrap- olation it is estimated that almost 25% of the eligible participants re- fused. No signicant differences in demographical variables were found between participants

48、 and decliners for whom data were avail- able. The mean ( SD) age was 43.6 13.6 years and the mean ( SD) body mass index (BMI) 26.2 4.9. Eighty-seven patients (29.6%) were outpatients. Overall, 186 (63.3%) participants were classi- ed as having lower educational status. The mean ( SD) minutes of vig

49、orous physical activity, moderate physical activity and walking per week was respectively 37.2 71.0, 81.4 113.0, and 173.0 145.4. There were no signicant differences in physical activity behaviour be- tween the different diagnostic groups. Investigating differences in motivation according to diagnosis, gender, educational level, treatment setting and current level of physical activity People with bipolar disorder and major depressive disorder have higher