Five facts about physiotherapy in mental health
To link in with Stress Down Day, APA Mental Health group members create five discussion points about physiotherapists working across the continuum of mental health.
1. There is a relationship between physical health and mental health
The relationship between mental health and physical health is well supported, with 60 per cent of Australians with a mental illness reporting a physical illness and comorbidity associated with reduced length and quality of life, higher healthcare costs and worse health outcomes (Productivity Commission 2020).
A survey by Musculoskeletal Australia (2021) reports 50 per cent of respondents saying that their physical condition impacts their emotional and mental wellbeing.
Pathways between these forms of health are not fully understood. A mediation analysis of the indirect effects of mental health on physical health, and vice versa, found the two most significant mediating factors to be lifestyle choices and social interactions (Ohrnberger et al 2017). Both factors mediated the indirect effects of past mental health on physical health, while
the most significant indirect mediating factor of past physical health on present mental health was physical activity.
To sum up, past physical activity supported both present physical and mental health, which in turn supported physical activity, social interactions and health behaviours, with potential for future positive health outcomes.
Physiotherapists can play an important role in health promotion and disease prevention and have been encouraged to do so (World Confederation for Physical Therapy 2014).
Many non-communicable diseases share risk factors of tobacco, physical activity, alcohol and diet. Poor health literacy impacts physical health and is associated with greater prevalence of mental health symptoms.
General health literacy is supportive of mental health literacy, which is supportive of reduced stigmatisation, help-seeking and early intervention (Lee et al 2020).
2. Exercise can be as effective as antidepressants for some people with depression
At some point in our lives we have all experienced the mood-enhancing effect of exercise and physical activity. But did you know that regular exercise and physical activity can be a powerful tool for treating severe mental illness such as major depression?
The European Psychiatric Association, supported by the International Organization of Physical Therapists in Mental Health, advocates for the use of exercise and physical activity as a frontline treatment for depression.
This is based on consistent evidence, which supports that physical activity can reduce the symptoms of depression, with comparable effects to antidepressant medications and psychotherapy (Stubbs et al 2018, Schuch et al 2016a, Schuch et al 2016b).
From an evidence-based practice lens, the greatest benefits for treating depression appear to come through aerobic exercise (such as swimming, cycling and jogging), particularly when this is delivered at a moderate- vigorous intensity and under the supervision of a qualified exercise professional like a physiotherapist (Stubbs et al 2018, Sibold & Berg 2010).
Population trends also support the strong influence of physical activity on mood. People who are more physically active appear to have a reduced risk of depression (Schuch & Stubbs 2019, Choi 2018).
Furthermore, physical activity levels and physical health are consistent modifiable risk factors for depression (Köhler et al 2018).
Across clinical settings, physiotherapists are involved in the treatment of people with depression, either directly or indirectly, and should be applying and advocating for the benefits that physical activity and exercise can have for mood and wellbeing as part of whole-person care.
3. Treatment of postnatal depression should include interventions that improve the mother–baby relationship
More than one in seven new mums experience postnatal depression (Austin & Highet 2017). Mothers experiencing depression in the postnatal period often demonstrate difficulties reading baby cues, interacting with their baby and bonding (Stein et al 2014).
Babies who do not form a secure infant attachment may in turn experience poorer social, cognitive and behavioural outcomes (APPG 2015).
Consequently, treating maternal depression without addressing parenting and attachment does not protect infants from the negative impact of depression/anxiety and perpetuates maternal mental illness.
In one review, interventions involving both the mother and her baby improved the mother’s feelings about her baby, whereas treatments involving only the mother were found effective for depression without a significant effect on the mother’s feelings towards her baby (Poobalan 2007).
A 2011 meta-analysis concluded that the most effective parenting interventions for mothers with depression were infant massage and mother–baby interactions (Kersten-Alvarez et al 2011).
Affectionate touch appears to promote an infant’s somatosensory system development, autonomic regulation, parent–infant bonding and social development, reward processing and learning, and immune function (Carozza & Leong 2021).
Physiotherapists treating mothers with postnatal depression are in an excellent position to assist them to improve their maternal sensitivity and interaction with their baby through play, baby handling, massage and exercise.
This may prevent the intergenerational spread of mental illness and trauma.
4. Potentially modifiable risk factors and working in partnership with carers and support networks is beneficial in dementia care
Dementia affects 50 million people globally, with prevalence projected to rise to 152 million by 2050.
It is estimated that over 459,000 Australians are living with dementia (Livingstone et al 2020, Guideline Adaptation Committee 2016), with nine per cent of adults being over 65 years and 30 per cent of adults being over 85 years. Younger onset dementia impacts 27,800 people.
The level of lifetime activity (cognitive, social and physical) and health choices (vascular health, nutrition, and mental health) determines the risk of people developing dementia (Livingstone et al 2020, Guideline Adaptation Committee 2016).
Three new potentially modifiable risk factors have been recently added: excessive alcohol consumption, traumatic brain injury and air pollution (Livingstone et al 2020).
Cognitive reserve theory supports the view that training in brain tasks may be protective. Mentally stimulating activities can engage people living with dementia and can be integrated into functional practice and physical activity.
People living with dementia and their carers invite health professionals to work with the individual and their various support networks (Department of Health and Ageing 2006).
Engaging with people living with dementia will help identify the tasks and activities they enjoy, note the areas that may be more difficult and promote mental health and wellbeing (Poulos 2019).
5. Workplace bullying affects everyone’s wellbeing
Workplace bullying is violence, which is both physically and pyschologically traumatic. Bullying is usually targeted, sustained, unsolicited abusive behaviour that leaves the victim feeling vulnerable, insecure and powerless, with a myriad of physical and mental health concerns (Wolke & Lareya 2015).
Bullying is commonplace in the healthcare sector and healthcare workers are at higher risk of being subjected to bullying behaviours (Brewer 2015). This includes physiotherapy, with practitioners and students being affected (Whiteside et al 2014).
Bullying results in pyschological distress, absenteeism and staff turnover, with impacts on our quality of care.
The carryover effects impact on patients, colleagues, and the greater workplace (Mohanty & Mohanty 2017).
These effects continue into family and personal life, with increased prevalence of musculoskeletal disorders, decreased flexibility and moblity, restrained respiration, inability to relax, widespread pain and psychological distress (Buhaug et al 2021).
Workplace bullying must be addressed in workplace standards. Factors such as limiting job demands, increasing resources and autonomy, encouraging healthy relationships and empathy, and supporting those who are at greater risk may reduce workplace bullying (Buhaug et al 2021).
Ensuring that staff and students can give and receive constructive criticism, practise civility, and use healthy communication and collaboration is essential in modern physiotherapy (Kamens 2018).
Click here for an infographic poster version of this article.
Ellen Lake, APAM, works in inpatient care with Active Rehabilitation Physiotherapy and in clinical and gym- based care with people with chronic conditions and comorbidity. She is national chair of the Mental Health group and is currently completing a Master of Cognitive Behaviour Therapy.
Richard Modderman, APAM, is a physiotherapist currently working at Royal Darwin Hospital. He is a strong advocate for the role of physiotherapy in person-centred care, including physical health promotion and the psychotherapeutic and psychosocial benefits of physiotherapy for mental health and the management of mental illness.
Miranda McLean, APAM, is a physiotherapist working in the Lavender Mother–Baby Inpatient Mental Health Unit at Gold Coast University Hospital. She is with the APA Mental Health group and Queensland Mental Health group, and involved in research within the Mother–Baby Unit. She aims to further research physiotherapy- based interventions within the inpatient setting.
Beth Fuller, APAM, has worked as a physiotherapist (generalist, disability and aged care sectors) and in public health and research. She advocates to build resilience, and promote mental health and wellbeing. She is NSW chair of the Mental Health group, and community advocate on various advisory groups with the local health district.
Dr Olivia Stone, APAM, is the practice manager at the School of Physiotherapy Clinics Christchurch, New Zealand. She has worked internationally in the public, private and tertiary sectors as well as with amateur and professional sports teams. She prefers the holistic approach: healthy body, healthy mind.
Fact 1 References:
Productivity Commission (2020),Mental Health, Report no.95, Canberra.
Musculoskeletal Australia (2021), Making the Invisible Visible, Baseline Survey Report, https://www.msk.org.au
Ohrnberger, J., Fichera, E., Sutton, M. (2017). The Relationship between physical and mental health: A mediation analysis, Soc.Sci.Med., 195, 42-49.
World Confederation for Physical Therapy (2014). WCPT policy statement: non-communicable diseases. Draft. London. UK: WCPT:
Lee,H.Y., Hwang, J., Ball, J., Lee, J., Albright, D. ( 2020). Is health literacy associated with mental health literacy? Findings from Mental Health Literacy Scale, Perspectives in psychiatric care, 56 (2), 393-400.
Fact 2 References:
Stubbs B, Vancampfort D, Hallgren M, Firth J, Veronese N, Solmi M, Brand S, Cordes J, Malchow B, Gerber M, Schmitt A. EPA guidance on physical activity as a treatment for severe mental illness: a meta-review of the evidence and Position Statement from the European Psychiatric Association (EPA), supported by the International Organization of Physical Therapists in Mental Health (IOPTMH). European Psychiatry. 2018 Oct;54:124-44.
Schuch FB, Vancampfort D, Richards J, Rosenbaum S, Ward PB, Stubbs B. Exercise as a treatment for depression: a meta-analysis adjusting for publication bias. Journal of psychiatric research. 2016 Jun 1;77:42-51.
Schuch FB, Vancampfort D, Rosenbaum S, Richards J, Ward PB, Stubbs B. Exercise improves physical and psychological quality of life in people with depression: A meta-analysis including the evaluation of control group response. Psychiatry research. 2016 Jul 30;241:47-54.
Sibold JS, Berg KM. Mood enhancement persists for up to 12 hours following aerobic exercise: a pilot study. Perceptual and motor skills. 2010 Oct;111(2):333-42.
Schuch FB, Stubbs B. The role of exercise in preventing and treating depression. Current sports medicine reports. 2019 Aug 1;18(8):299-304.
Choi KW, Chen CY, Stein MB, Klimentidis YC, Wang MJ, Koenen KC, Smoller JW. Testing causal bidirectional influences between physical activity and depression using Mendelian randomization. bioRxiv. 2018 Jan 1:364232.
Köhler CA, Evangelou E, Stubbs B, Solmi M, Veronese N, Belbasis L, Bortolato B, Melo MC, Coelho CA, Fernandes BS, Olfson M. Mapping risk factors for depression across the lifespan: an umbrella review of evidence from meta-analyses and Mendelian randomization studies. Journal of psychiatric research. 2018 Aug
Fact 3 References:
Austin M-P, Highet N and the Expert Working Group (2017) Mental Health Care in the Perinatal Period: Australian Clinical Practice Guideline. Melbourne: Centre of Perinatal Excellence
Stein, A., Pearson, R. M., Goodman, S. H., Rapa, E., Rahman, A., McCallum, M., Howard, L. M., & Pariante, C. M. (2014). Effects of perinatal mental disorders on the fetus and child. Lancet (London, England), 384(9956), 1800–1819.
1st 1001 Days APPG (2015) Building Great Britons. Conception to Age 2. London: First 1001 Days All Parties Parliamentary Group.
Poobalan, A. S., Aucott, L. S., Ross, L., Smith, W. C., Helms, P. J., & Williams, J. H. (2007). Effects of treating postnatal depression on mother-infant interaction and child development: systematic review. The British journal of psychiatry : the journal of mental science, 191, 378–386.
Kersten‐Alvarez, L.E., Hosman, C.M., Riksen‐Walraven, J.M., Van Doesum, K.T. and Hoefnagels, C. (2011), Which preventive interventions effectively enhance depressed mothers' sensitivity? A meta‐analysis. Infant Ment. Health J., 32: 362-376.
Carozza, S., & Leong, V. (2021). The Role of Affectionate Caregiver Touch in Early Neurodevelopment and Parent-Infant Interactional Synchrony. Frontiers in neuroscience, 14, 613378.
Fact 4 References:
Livingstone G, Huntley J, Sommerlad A, et al (2020) Dementia prevention, intervention, and care:2020 report of the Lancet Commission. 396: 413-446 www.thelancet.com
Guideline Adaptation Committee. Clinical Practice Guidelines and Principles of Care for People with Dementia. Sydney. Guideline Adaptation Committee; 2016.
Dementia – The Caring Experience. A guide for families and carers of people with dementia (2006) Department of Health and Ageing
Poulos CJ et 2019) Supporting independence and function in people living with dementia. A handbook of reablement programs for service providers and others with an interest in improving function. 2nd edition. Sydney. HammondCare
Sarah Ashton’s journey provides insight on early onset dementia, having to adjust life plans and adjustment to changes in her capacity. Watch the video: Sarah Ashton—journey of someone with early onset dementia https://www.youtube.com/watch?v=D7oGpBolKSY
Fact 5 References:
Wolke,D. & Lareya,S.T. (2015). Long-term effects of bullying. Archives of disease in childhood, 100(9), 879-885.
Brewer,G.(2015).Workplace bullying in healthcare professions.International Journal of Occupational Health and Public Health Nursing.
Whiteside, D., Stubbs, B., & Soundy, A. (2014). Physiotherapy students’ experiences of bullying on clinical internships: a qualitative study. Physiotherapy, 100(1), 41-46.
Mohanty, P., & Mohanty, S. (2017). Impact of Workplace Bullying on Performance, Psychological Distress and Absenteeism: An Original Review of Healthcare Sector. International Journal of Economic Perspectives, 11(3).
Buhaug, K., Magerøy, N., Einarsen, S. V., Assmus, J., & Kvåle, A. (2021). A clinical study of musculoskeletal dysfunction in targets of workplace bullying. European Journal of Physiotherapy, 1-10.
Kamens, N. (2018). Re: Exploring the experiences and implementing strategies for physical therapy students who perceive they have been bullied or harassed on clinical placements: participatory action research. Physiotherapy, 104(3), 356.
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