Physical health,community participation and schizophrenia

Introduction

Limited literature exists that engages the relationship between community participation and co-occurring physical health conditions among individuals with schizophrenia (Auslander and Jeste, 2002; Medeiros-Ferreira et al., 2013; Minsky et al., 2011; Waghorn et al., 2008). This relationship is important to consider as physical health issues are elevated among those with a psychiatric diagnosis as indicated by a mortality rate that is almost triple that of the general population (Von Hausswolff-Juhlin et al., 2009). Contributing factors include limited exercise, obesity, cardiovascular disease, poverty, high levels of smoking, malnutrition, as well as anti-psychotic medications due to their metabolic and sedating side effects (Auquier et al., 2006; Brown et al., 2000, 2010; Correll et al., 2015; Von Hausswolff-Juhlin et al., 2009). Moreover, within psychiatric practice, community participation has been shown to help individuals with mental illness in their recovery and is a focus of many psychosocial interventions (Brown et al., 2008; Kidd et al., 2010; Ministry of Health Services BC, 2008; Nelson et al., 2001). Community participation is also noted as a key priority in national mental strategies in Canada and the United States (Mental Health Commission of Canada, 2012; State of Illinois, 2013). However, despite the interest in community integration within clinical practice and policy discussion, the term and its lived reality for individuals with psychosis are poorly understood (Kidd et al., 2015). Understanding the links between physical health, community, and mental health is therefore important. In order to supplement the limited existing literature, it is the objective of this article to identify the links between physical health and community participation among individuals with schizophrenia or psychosis and suggest areas for future investigation.

Methods

Participants were from a large Canadian city and had schizophrenia or a psychosis spectrum mental illness. Individuals were recruited through care providers with stratified purposeful sampling to include participants of different racial backgrounds, place of residence, age, gender, and hospitalization history. Prior to enrollment, informed consent was attained from each participant. Semi-structured qualitative and quantitative interviews were carried out three times over the span of 10 months to collect demographic data (gender, identity, sexual orientation, relationship status, racial and ethnic background, country of origin, time since immigration, religious affiliation, age, housing type, sources of income, education levels, and hospitalization history) and to understand community participation as it related to a range of mental and physical health determinant domains. Tours of each participant’s community were also conducted with the interviewer. Interviews and tours were documented using audio recordings and field notes, which were transcribed verbatim and analyzed using a grounded theory coding strategy (Charmaz, 1995; Charmaz and Mitchell, 2001). For a detailed description of the methods, see Kidd et al. (2015). This study was approved by the Centre for Addiction and Mental Health (CAMH) Ethics Review Board.

Results

Thirty individuals with schizophrenia or psychosis spectrum mental illness participated in this study. Participants had an average age of 45 years (standard deviation (SD) = 10.9 years), and 50 percent were female. All participants were heterosexual and five were married or in a dating relationship. The majority were first generation immigrants (18) and not in the labor force or looking for work (16), while a minority had a University or College degree (4). A large proportion lived in supported or subsidized housing alone (15) or with others (9). The average number of hospitalizations and years since last hospitalization were 4 (SD = 6.3 years) and 7 years (SD = 9.8 years), respectively.

The interviews described a bidirectional process whereby physical health impacted community participation and community participation impacted physical health. In terms of the link between physical health and community participation, key processes emerged around mobility, the detrimental impacts of poverty, and the empowering impact of physical activity.

Physical health problems prevented individuals from being able to move around in ways that they wished, which shaped the places they could go and the degree to which they could access services. Sore feet, sore legs, chest pains, obesity, and fatigue were all cited as common reasons for this limited mobility. As one respondent remarked,

My physical health is just so-so. I have a number of problems so … even the doctor said I was having a number of medical conditions. Schizophrenia, diabetes and blood pressure, stomach problems and anaemia, a number of problems. I’m having medication so it’s hard for me to get around.

Poverty played a role in the relationship between physical health problems and community involvement. Poor nutrition was linked to the inability to afford higher quality, nutritious foods and negatively impacted one’s levels of energy and sped up the onset of fatigue, posing as a significant barrier to community involvement.

Physical health was described as a means to feel empowered. Physical activity was described by individuals as making them feel good physically, but it was also a source of community involvement and feeling a part of society. For example, one participant gained a significant amount of personal satisfaction and pleasure from long daily strolls throughout the city. Factors that facilitated or motivated achieving physical health goals included relationships with others, group home environments, case management, and good relationships with family doctors. However, not being able to achieve such physical health ideals can also negatively shape one’s vision of themselves or their identity, which in turn leads to self-consciousness and feelings of embarrassment to engage in the community or make relationships. This was evident in cases where medications led to undesirable physical health consequences, such as weight gain:

… I changed a lot because I don’t look the way I used to … So you know, I’m embarrassed when I go around [my family] because they look really good, and you know, I look—I just get really ugly and fat and I don’t fit the family anymore. So I feel bad when I go around them. So I let them visit me. I don’t go visit them because I don’t want anybody to go, “That’s your sister. That’s your daughter. What happened?” you know.

In terms of the relationship between community participation and physical health, the findings emphasized the physical health impacts of coping with isolation, the health promotion effects of personal relationships, and health services as a source of community.

The interviews found that many of the participants engaged in negative health behaviors as a strategy for coping with social isolation and problems with community. For instance, eating high-calorie meals at fast-food or sit-down restaurants was used by some as a means to feel good and to feel as a “normal” part of society. In addition to unhealthy eating, smoking tobacco, consuming alcohol, and smoking marijuana were all described as strategies for coping with isolation and stress: “… Like right now, that’s where I’d be. I’d be outside and hopefully somebody would have a cigarette for me to start my day. I start my day with a cigarette.”

We also found that relationships can be an important source of healthy living through the support of loved ones. However, physical health issues around mobility can limit one’s access to relationships, including those with family and friends. The resulting isolation and loneliness can in turn exacerbate health issues through the processes mentioned above, like sedentary behavior and coping through negative health behaviors in a repeating cycle:

She [recreational therapist] gave me seven exercises to do to improve my core and my legs. But unless I’m doing it with somebody else, like doing the same thing that gives me encouragement. But to do it by myself, there’s something wrong in my head, I can’t wrap my head around it.

People did seem to visit health-related services, such as diabetes clinics, family physicians, recreation programs, and walking groups—places that could be an important avenue of physical health care, but also promote feelings of community involvement through small talk and by creating a feeling of caring. Health care workers were a key source of community and were often listed as key people in many of the respondents’ social networks. Conversely, there was also evidence of access issues, including transportation costs and the stigma pertaining to individuals not always wanting to access services with psychiatric populations.

Discussion

In terms of potential policy and clinical implications, the findings point to the value of ensuring good access to physical health care for people with mental health conditions as a means of promoting both positive physical health and facilitating community participation. One option would involve training or collaborating with family physicians on how to support and work with people with a psychiatric diagnosis (Iglesias and Avellar, 2016), while taking into account the role of psychiatric medication in producing weight gain either directly or indirectly through lowered motivation. Additionally, policy and clinical practice needs to be designed to ensure that the health promotion opportunities appeal to the mental health community. Many of our respondents did not want to access programming throughout their city with those who were more disabled than they were, especially younger individuals. Furthermore, most of the respondents relied on provincial disability support payments, which placed them well below Statistics Canada low income cut-offs (Statistics Canada, 2012). As such, our research provides important evidence that policy needs to address poverty issues among this population and promote policies that harness what is effective as evidenced by our research, such as supporting case managers to promote physical fitness opportunities, especially in group living environments. There is also a need for supporting friends and family members to engage in physical fitness opportunities with their loved ones, as well as fostering access to gyms and community recreation spaces where people with mental health conditions can find community and physical fitness at the same time.

Overall, our research provides some preliminary evidence that links between physical health and community participation among individuals with schizophrenia exist. This relationship needs to be explored in the future by developing a more thorough understanding of the challenges and resources needed to promote community participation and physical health. Expanding this research to multiple rural and urban settings over a greater period of time would allow for a deeper understanding of this relationship and would be more generalizable to this population.