Physical activity as a therapeutic strategy in mental health : an integrative review with implication for nursing care

This study is an integrative review with the aim to identify and describe the scientific evidence of the practical effect of physical activity in people with mental disorders. For the selection of articles, the databases CINAHL, MEDLINE, LILACS, SciELO, Cochrane and Scopus were used. The sample of this review consisted of eight articles. Their analysis resulted in the categories: obesity and metabolic syndrome, specialized nursing, sedentary and healthy lifestyles, support and social network, incentive to the practice of physical activity, and anxiety and physical activity. The benefits to physical health were partially elucidated by the sample. The implications for nursing care arise from the therapeutic efficacy of physical activity by people with mental disorders, adding individual and collective benefits that provide socialization and promotion of well-being.


INTRODUCTION
Physical activity (PA) is a complex and multidimensional behavior that can be described as "any body movement produced by activation of skeletal muscles, resulting in a substantial increase in energy expenditure above resting metabolism". 1 Assuming this definition, PA can be split into different domains: 1) sports activity, focused on the individual's performance; 2) leisure activity, developed especially in spare time; 3) labor activity, carried out at work and at home; 4) activity during active transport, involving walking or bike riding and 5) rehabilitation activity, directed to people who are recovering from a physical condition. 2,3Physical exercise is a subset of PA, specialized and planned, executed and repeated with specific goals.
Over the past decades, there was an inversion in the global morbimortality profile, with a decrease in the prevalence of infectious diseases and an increase in the prevalence of chronic illnesses, which raised interest in their associated factors.The little importance given to PA by the general public is a current public health challenge, taking into account that it is a modifiable factor related to a higher frequency of chronic and degenerative diseases. 4he practice of PA as a therapeutic modality inserted in the context of life of a person with a mental disorder can be seen as an outstanding way to create health benefits.The search for social reinsertion through the practice of PA in situations associated with mental health can therefore be seen as a possibility for reclaiming the therapeutic efficacy of social relationships.In this line of reasoning, PA is especially important when applied to institutionalized people, easing the feeling of isolation and making the person more engaged and cooperative in activities they take part, which improves their physical willingness, increases their self-esteem and reduces their idleness. 5 research issue arises before the evidence gathered in reviews about the practice of PA by people with mental disorders in several countries.New proposals for its use in Brazilian mental health services can be implemented, taking into consideration the benefits, treatment and recovery of the patients.
The Brazilian Psychiatric Reform proposal seeks inclusion and integration of people with mental disorders in different spaces of society.The practice of PA as a therapeutic activity is a strategy to favor social reinsertion of patients with mental disorder and corroborates the assumptions of this reform. 6Thus, the object of this study is the therapeutic efficacy of the practice of PA by people with mental disease.Its objective was to identify and describe the scientific evidence related to regular practice of PA by people with mental disorders.
This review can be justified by numerous innovations in the mental health area, which demand from nurses a care practice grounded in scientific principles to select the most appropriate intervention for the specific care situation of each patient with mental disorder.Thus, it is considered that the develoment of this integrative review (IR) having the evidence-based practice (EBP) as a guide will contribute to integrate knowledge that will allow nurses to safely include PA in mental health care.

METHODS
Integrative review (IR) 7 of scientific literature is a research method that enables the search, critical evaluation and synthesis of the available evidence about a certain subject, in the case of this study the therapeutic efficiency of PA in people with mental disorders.The six steps of this type of review were followed: nursing", with no selected studies; 3 rd round -"Physical activity", "Social support", "Mental disorders" and "Nursing", with four selected publications; 4 th round -"Physical activity", "Social support", "Therapeutics" and "Nursing", with one selected study; and 5 th round -"Physical activity", "Mental disorders", "Therapeutics" and "Nursing", with four selected publications.The study screening resulted in 14 selected publications after the five rounds of scientific literature search.The repetition of a few studies was identified in some rounds and databases and, after their exclusion, the sample of this review had eight publications.3) Categorization of the studies, with data extraction through the application of the reading protocol in the study sample.The data were organized and summarized with the application of thematic content analysis consisting of the following categories: Obesity and metabolic syndrome, Specialized nursing, Sedentary and healthy lifestyles, Support and social network, Incentive to the practice of physical activity, and Anxiety and physical activity.Table 2 exhibits a synopsis to guide quantitative and qualitative analysis of the publications.4) Evaluation of the studies included in the review, with their critical analysis.5) Interpretation of results, with discussion and recommendation proposals classified in the categories: I. Obesity and metabolic syndrome; II.Specialized nursing; III.Sedentary and healthy lifestyles; IV.Support and social network; V. Incentive to the practice of physical activity; and VI.Anxiety and physical activity.6) Synhesis of information or presentation of the review, with a summary of available evidence and the details of the review in a descriptive document (the present paper).

RESULTS AND DISCUSSION
Table 2 presents the distribution of publications by analysis variable.The elements for practice of PA, its benefits and the elements for social reinsertion of patients were addressed and discussed separately.
Among the countries where the selected papers originated, Australia stood out with three publications, followed by Sweden, with two papers, and United States of America, United Kingdom and Taiwan, with one publication each.It is important to emphasize the absence of papers produced by Brazilian researchers, which corroborates the need to investigate this area and stresses the relevance of the present integrative review.
Regarding the year of publication, it was observed that there is a higher concentration of papers in the last five years, with the years 2008 and 2013 presenting the highest number of publications about the subject in question, with three papers, followed by 2011 and 2012, with one paper each.There was also a gap in years 2014 and 2015, with no published studies on the topic under discussion.
The most cited journals in the review were Issues in Mental Health Nursing and International Journal of Mental Health Nursing, with three papers each.The other two articles were published in the Research in Nursing & Health and in the Journal of Advanced Nursing.
The hierarchical classification system for evidence quality was applied to evaluate the scientific evidence levels, with analysis of methodological data of each study presented in Table 2.The following stratification in levels of evidence was identified: five level 6 and three level 2 publications.
After the reading and data extraction from the papers included in this IR, assisted by a data collection instrument, six thematic categories emerged: obesity and metabolic syndrome, specialized nursing, sedentary and healthy lifestyles, support Table 1.Selected publications after five rounds of bibliographic survey.Rio de Janeiro, January 2016.

Selected publications according to inclusion and exclusion criteria
Total number in each database 1 st round 2 nd round 3 rd round 4 th round 5 th round Total number per round 5 0 4 1 4 14

Records found 14
Records after exclusion of repeated publications in the five rounds 8

Physical activity in mental health
Lourenço BS, Peres MAA, Porto IS, Oliveira RMP, Dutra VFD  and social network; incentive to the practice of physical activity, and anxiety and physical activity.This classification is shown in Table 3.

Obesity and metabolic syndrome
A study with 24 people with schizophrenia investigated the effects of the practice of physical activity and revealed that all the women and half the men in the sample were obese. 10nspired by these results, Australian researchers 12 created the "Passport 4 Life" program based on the best scientific evidence available, to help antipsychotic users to adopt a healthy lifestyle and consequently maintain or lose weight (from 1 to 4 kg or 10% of their body mass).The program included a healthy diet and an increase in the practice of PA.
Another randomized study 11 with people with psychotic disorder who took second-generation antipsychotic medications and were enrolled in the "Passport 4 Life" program was also carried out.However, contrary to expectations, the research did not show statistically significant results regarding weight loss.The stipulated time interval for the experiment, 12 weeks, was insufficient to reach the research goals.
Other studies 8,13,16,17 stressed the importance of preventing metabolic syndrome in patients with mental disorders and active psychotic symptoms who take antipsychotic medications, because they have an increased risk of cardiometabolic comorbidities, including metabolic conditions such as obesity, insulin resistance, hypertension and diabetes. 16These comorbid conditions can shorten life expectancy of people with a severe mental disorder 20% more than in people with no mental disease. 10Care to a person with mental disorder with a risk for the development of a metabolic syndrome demands a comprehensive view by the healthcare professional, which favors measures to create interventions related to physical health.
Studies point to a way that has not been clearly demonstrated, once its methodological pathways did not allow a full estratification of evidence.This path needs to be elucidated, because the practice of PA can help in this process.More and longer studies with a higher number of participants have to be carried out, aligned with what literature describes to be enough to lose weight effectively and improve metabolic rates in people with mental disorders who take second-generation antipsychotic medication.
It is important to emphasize that these papers linked the development of metabolic syndrome and the contribution of PA to prevent it or decrease its deleterious effects in patients using this type of drug.They did not address the resocialization process of these patients through PA; among other reasons, this benefit was not sought in the countries where this research was performed.

Sedentary and healthy lifestyles
Sedentary lifestyles afflict the modern world at increasing rates.The consequence is the emergence of health problems in the population, especially cardiovascular issues. 16The implementation of changes in the lifestyle of people with mental disorders is a difficult, but achievable, experiment.Even with most people with mental disorders knowing the importance of a healthy lifestyle, there were difficulties to change habits, because these patients had to implement these modifications and deal with and accept the psychotic symptoms. 8Thus, the study identified that negative symptoms and cognitive alterations were the main obstacles to implement lifestyle changes in this population.
Studies 8,9,18 with people with schizophrenia, an important psychotic disorder in the mental health field, confirm their low level of PA. 18 Healthy adults took, on average, between 7,000 and 13,000 steps in the first day of study, whereas the participants with that mental disorder took, on average, between 2,384 to 4,399 steps in the same time interval.This result shows that a sedentary lifestyle prevails in people with this disease. 18vidence suggests that the adoption of a healthy lifestyle can help reduce physical inactivity.Mental health professionals, mainly nurses, aligned with the initiative of an evidence-based practice, should surely invest in PA and the promotion of healthier habits.

Support and social network
Even with scientific evidence pointing to the importance of changing the mental health scenario with healthier practices, a study revealed that its participants had received psychiatric care for many years and only recently realized a change toward giving more importance to PA than just to mental health in the healthcare professionals' behavior. 9ocial support is probably a prerequesite for successul introduction and maintenance of PA for most people.However,

Physical activity in mental health
Lourenço BS, Peres MAA, Porto IS, Oliveira RMP, Dutra VFD there are currently few investigations about how social support can be more effectively offered to people with mental disorders who wish to develop a regular exercise routine. 14nclusion of a nurse in the leadership of activities and exercises is an important component for the participants. 12,14A member of the healthcare staff taking part in exercise sessions with their clients motivates participation and increases social interaction. 8,11,12,14nother possibility to achieve adherence to the practice of PA is the development of awareness actions on the activity's potential benefits.Information support helped raise interest and motivation in the participants of one of the studies to start practicing a certain exercise or sport activity. 14Health education, an element of information support, must play a coordinating 1 and enhancing role in any assistance action.
Tangible help, regarding the financial aspect of social support, had a simple but significant effect on the commitment to PA and sports practice.Its importance was clearer in the form of a financial aid and the satisfaction of basic needs, such as transportation, which minimized the barrier in the access to the facilities where the PA took place. 14However, not possessing financial resources cannot be the reason for not practicing PA, because walking is free and accessible to all.
Prescription of PA must take into account patients' financial situation. 12,15,16The study with the "Passport 4 Life" program developed an exercise series that included a variety of low-cost or free activities, such as walking, swimming and group sports.The paper suggests that tangible help in the form of financial support is probably an essential social support element, given the socioeconomic obstacles faced by many people with severe and permanent mental disorders.
Being inserted in a care network and receiving social support in different areas of life are important factors for people who receive community social support. 14In practice, it means that these community workers help the individual to exert, for instance, the option of walking instead of taking a bus or that these workers are involved in grocery shopping so that the individual purchases suitable products. 9,13ocial support in the context of mental health is not a oneway path; people with mental disorders benefit from social help, but sometimes they can also benefit from giving social assistance to others through sharing and association of PA or in a team sport.This sharing process can be an important way to restore a sense of community among people who are experiencing and recovering from severe mental diseases. 14he pathway to social reinsertion of a person with mental disorder is tortuous and full of obstacles.It is up to people involved in social insertion projects to find social care possibilities that meet individual needs of health promotion.The evidence shown in this study can help nurses to establish these care approaches in mental health.

Incentive to the practice of physical activity
A study with healthcare professionals, most of them mental health nurses, who deal with people with psychotic disorders, described that people with mental disorders should be encouraged to practice regular exercises or prescribed ones, for instance daily walking. 8ven if professionals consider it important to invest in a healthier lifestyle for people with mental disorders, they stuck to the planning phase of PA practice and did not implement it. 9The fact that mental disorders affect the patient's volition seems to be one of the reasons that lead them to this type of behavior.Without motivation for the practice of PA, people with mental disorders find it more and more difficult to change their habits.
People who exercise regularly often report an effect of wellbeing. 11Corroborating this, PA is not just an efficient option to lose weight but also to alleviate symptoms observed in depression and hallucinations, and should therefore be encouraged. 9hysical activity increases people's self-esteem, for instance, by helping in weight loss and physical force strengthening, leading patients to like their body image.
Considering that most successful interventions related to weight loss include a combination of approaches rather than just one measure, the described intervention was developed through the association of educational practices, exercises, lifestyle changes and dieting. 8,11ontrary to the expected, the motivational approach, which values the practice of PA and adoption of healthy habits, seemed not to work, considering that the application of the "Passport 4 Life" program did not show statistically important results. 11ossibly this technique did not have a significant impact on the global result or the motivational techniques have to be used more than once a week (more often than in the study) so that behavioral changes occur.
Incentive to the practice of PA must be incorporated to the care routine of mental health professionals.Motivational approaches can be a strategy so that people with mental disorders understand the importance of the regular practice of PA.It is worth reminding that it cannot be an isolated strategy neither can be applied once or a few times throughout an activity program.It is necessary to offer the practice regularly, so that patients keep motivated to practice PA and adopt a healthy lifestyle.

Anxiety and physical activity
Even though the trace of anxiety does not have a direct influence on PA, it caused an indirect effect on other variables, resulting in lower levels of PA.The outcomes suggest that for people with anxiety, the trace of anxiety is a crucial factor that influences emotional states and cognitive processes. 15herefore, anxiety itself can hinder the practice of PA.

Physical activity in mental health
Lourenço BS, Peres MAA, Porto IS, Oliveira RMP, Dutra VFD The results of the studies indicate that stress had a strong influence on the anxiety state for these individuals.This suggests that healthcare educators must emphasize PA as a beneficial strategy to manage stress in intervention programs for people with anxiety. 15enefits of practicing PA were observed throughout the study carried out in Taiwan.The authors suggest that therapies for patients with anxiety must include regular programs of PA and incorporation of short programs about health education, focused on group discussion about exchange of experiences, which will benefit patients. 15egular PA is beneficial for individuals with depression and anxiety symptoms, with emphasis on the effects of aerobic exercises on depression symptoms.][21][22] Anxiety is present in society in a general context.Daily stress and obstacles may trigger anxiety states, hampering a person's performance.Again, the evidence revealed in these papers indicate the benefits of the practice of PA. 19,20 Although this category has a publication with strong evidence, new studies are necessary in different regions of the world for PA to have its importance recognized for application in distinct contexts of mental health care.Nevertheless, the present study can be used as a basis for the development of PA programs specific for people with anxiety.

CONCLUSION
This IR revealed the therapeutic efficacy of the practice of PA by people with mental disorders, mainly by social reinsertion, holding important individual and colective benefits related to health promotion.The change in lifestyle promoted by PA reduced anxiety and incited the integration of people with mental disorders in society.It is important to emphasize the need to broaden studies on scientific evidence of the effects of PA on health regarding weight gain and prevention of metabolic syndrome.
The sample of this IR did not include studies originating in Brazil, which inspires new studies in the field of mental health related to PA as a therapeutic strategy and, particularly, as regards the role of nursing care.
This study provides an analysis on the effects of PA practiced by people with mental disorders and its importance in the context of social rehabilitation.Nursing care actions in mental health must be broadened, including new therapeutic strategies to improve patients' lifestyle considering not just PA but also other educational practices that can impact the quality of life of people and groups.

Table 2 .
Composition of the IR sample after five rounds of bibliographic survey.Rio de Janeiro, 2016.

Table 3 .
Distribution of the papers in the identified categories.Rio de Janeiro, January 2016.