A Framework for Health Promotion Services for

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A Framework for Health Promotion Services for People with Psychiatric Disabilities ▼

Dori S. Hutchinson, Cheryl Gagne, Alexandra Bowers, Zlatka Russinova, Gary S. Skrinar & William A. Anthony

The concepts of wellness and its complement, health promotion, have popularized the notion that health itself is more than simply the absence of disease. Furthermore, the wellness concept has advanced the idea of the importance of en-

Dori S. Hutchinson, ScD, is the Director of Services at the Center for Psychiatric Rehabilitation at Boston University. Cheryl Gagne, ScD, is a Senior Training Associate at the Center for Psychiatric Rehabilitation at Boston University.

gaging in certain health promoting behaviors within healthy environments, not simply for the purpose of preventing or better managing a disease, but also to enhance one’s well-being and quality of life (Green & Kreuter, 1991; Mullen, 1986). Encouraging this emphasis on wellness is Healthy People 2010 (U.S. Department of Health and Human Services, 2000), a national ten-year plan intended to in-

Alexandra Bowers, MSW, MPH, is a Senior Program Evaluation Specialist at the Center for Psychiatric Rehabilitation at Boston University.

crease quality and years of life and eliminate disparities which for the now features

Zlatka Russinova, PhD, is a Senior Research Specialist at the Center for Psychiatric Rehabilitation at Boston University.

wellness—including for people with disabilities—is being recognized (Rimmer &

Gary S. Skrinar, PhD, is a Professor and Director, Programs in Human Physiology, Exercise Science and Applied Human Anatomy and Physiology at Sargent College of Health and Rehabilitation Sciences at Boston University. William A. Anthony, PhD, is the Executive Director of the Center for Psychiatric Rehabilitation at Boston University.

Contact the main author at: Boston University Center for Psychiatric Rehabilitation 940 Commonwealth Avenue West Boston, MA 02215 Email: [email protected]

Acknowledgements We would like to thank Dr. Malcolm B. Bowers, Jr. of Yale University School of Medicine, Department of Psychiatry and Yale New Haven Hospital and Richard Surles, PhD of Comprehensive Neuroscience, Inc. for their edits and comments on the drafts of this paper.

a new area that recognizes the importance of health promotion and disease prevention in the lives of people with disabilities. Increasingly, the value of promoting Braddock, 2002).

Presently, the voluminous attention to wellness in the popular and professional literature (Kickbusch & Payne, 2003) has pressured the mental health system to examine its health promoting practices and policies concerning people with psychiatric disabilities. Furthermore, health promotion services are consistent with the mental health system’s redefinition of itself as a system that promotes recovery from severe mental illnesses rather than simply alleviating illnesses (New Freedom Commission on Mental Health, 2003). In the letter to the President accompanying the report of the Commission, the Chair of the

Commission recommends a transformation of the nation’s approach to mental health care, so as to ensure “that the mental health services and supports actively facilitate recovery…Too often, today’s system simply manages symptoms and accepts long-term disability” (New Freedom Commission on Mental Health, 2003, p. i). Within the mental health field, conceptual distinctions have been made between primary prevention and wellness enhancement. The former emphasizes forestalling dysfunction, particularly in those situations of high risk, while the latter emphasizes promoting psychological

P s y c h i at r i c R e h a b i l i tat i o n J o u r n a l

health and physical well-being in all people, not just those at high risk (Cowen, 1973; 2002). Specifically, we assert that people with serious mental illnesses have a right to optimal health. We propose that people with severe mental illnesses can be well even if their psychiatric diagnoses suggest that they are ill, and that various health promotion practices can in fact increase their health and wellbeing. A recent Call To Action from the U.S. Surgeon General supported this assertion, advocating for greater attention to, support for, and services promoting wellness for people with disabilities (U.S. Department of Health and Human Services, 2005). Experiencing psychiatric symptoms or disability does not preclude experiencing wellness (Mullen, 1986; Swarbrick, 1997). The mental health system’s primary focus on ameliorating the negative consequences of severe mental illnesses, i.e., people’s impairment, dysfunction and disability (Anthony, Cohen, Farkas & Gagne, 2002), must be complemented by an emphasis on promoting the health of the people served. Mental health interventions that target illness and its consequences differ in philosophy from interventions that promote health. While sickness alleviation and health promotion may at times be offered by the same agency and/or practitioner, they must be separated conceptually so that health promotion services are not overlooked. As reviewed in later sections of this paper, this dual focus is particularly important because of the poor health of people with severe mental illnesses and the lack of attention given to issues of wellness in the last century by the mental health system. Health Status of People with Severe Mental Illnesses Health issues and medical comorbidity are extremely prevalent among per-

A Framework for Health Promotion Services for People with Psychiatric Disabilities

sons with psychiatric disabilities (Brown, Birtwistle, Roe & Thompson, 1999; Davidson et al., 2001; Sokal et al., 2004). Research reviews have documented that people with psychiatric disabilities have elevated rates of comorbid diseases and related mortality, with their risk of premature death estimated at 2.4 to 2.85 times higher than that of the general population (Berren, Hill, Merikile, Gonzalez, & Santiago, 1994; Brown, Inskip & Barraclough, 2000; Segal & Kotler, 1991). Physical disease in all mental illnesses including ischemic heart disease, pulmonary, metabolic disorders and certain cancers account for 60% of premature deaths not related to suicide (Joukamaa, Heliovaara & Knekt, 2001; Lambert, Velakoulis & Pantelis, 2003; Lawrence, Holman, Jablensky & Hobbs, 2003). People with serious mental illnesses also experience a disturbing array of serious adverse health consequences including obesity, diabetes, the metabolic syndrome, osteoporosis, peridontic disease and sexual dysfunction induced or accelerated by atypical antipsychotic medications (Academic Highlights, 2005; Allison, Mackell & McDonnell, 2003; Meltzer, 2005; Meyer & Nasrallah, 2003). People with severe mental illnesses receive less primary and preventive health care than the general population and are high users of expensive emergency room services (Folsom et al., 2002; Goldberg, Seybolt & Lehman, 2002). Individuals with serious mental illness also often fail to seek necessary medical care due to fear of coercive treatment or commitment to a psychiatric facility and lack of adequate insurance (Hahm & Segal, 2005). It is also welldocumented that people with psychiatric disabilities are at much higher risk than the general public for developing substance abuse disorders, and are at higher risk for HIV infection and AIDS (Davidson et al., 2001;

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Klinkenberg et al., 2003; McKinnon, Cournos & Herman, 2002; Razzano, 2003). The mediating factors that contribute to these heightened risks are complex, but most likely include a psychosocial and environmental etiology. People with serious mental illness often live well below poverty guidelines, lead extremely sedentary lives, consume poor diets, are heavy tobacco users, and have much lower rates of recommended health behaviors (Aquila, 2002; George, Vessicchio & Termine, 2003). Self-esteem, quality of life, socialization and role recovery are also negatively impacted by poor health status (Allison & Casey, 2001; Spaniol, Gagne & Koehler, 2003). Clearly, the lack of wellness contributes powerfully to the disability experienced by a person diagnosed with a mental illness (Allison, Mackell & McDonnell, 2003; Strassnig, Brar & Ganguli, 2003). History of Health Promotion and Wellness in the Mental Health Field A research base supports the interconnectedness of mental and physical health in persons with psychiatric disabilities (Faulkner & Sparkes, 1999; Skrinar, Huxley, Hutchinson, Menninger & Glew, 2005; Hutchinson, Skrinar & Cross, 1999; Moller & Murphy, 1997). This interest in health promotion within the mental health field stems from three divergent sources. The first is the recognition of significant and severe co-morbid conditions experienced by people with severe mental illnesses that lead to secondary disability and premature death. A more positive influence is the urge to align the mental health field with the philosophical change in healthcare, as society moves from an illness approach to a wellness approach. Finally, people with psychiatric disabilities have long sought, used, and advocated for wellness services

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and resources in their recovery. These three streams of influence have deep roots both in society and within the mental health system. Historically, many cultures over time have recognized that physical health and mental health are closely interrelated. Yet the relationship between mental and physical health has intermittently been recognized and ignored as an important variable in the treatment and rehabilitation of persons with serious mental illnesses. The first public psychiatric hospitals in the United States in the eighteenth century included the use of physical exercise as a key therapeutic activity. However as these institutions became grossly overcrowded, wellness activities as treatment were de-emphasized for over a century (Viney & Zorich, 1982). With the development of the first generation of psychiatric medications and biological treatments in the mid 20th century, the use of health promotion approaches for treatment and rehabilitation of mental illnesses essentially disappeared. While the intense focus on pharmacological advances to treat the neurobiological aspects of mental illnesses has contributed greatly to our treatment and understanding of these diseases, the medical model of mental illnesses that has emerged does not focus on the whole person who is living with a mental illness; treatment and rehabilitation services are driven by outcomes that are defined through the disease model. Symptom reduction, level of dysfunction, disability status, community tenure and recidivism have become equated with success. The treatment and rehabilitation environments that embrace this paradigm may unwittingly promote unhealthy lifestyles, engender a lack of self-determination and contribute to the comorbidity and lack of wellness experienced by people with psychiatric disabilities (Hutchinson, 2000; Swarbrick, 1997).

Ridgeway et al. (2002) concluded that while traditional mental health services focused on pathology, diagnosis and illness, individuals’ physical health and lack of wellness was ignored or, worse, viewed as attentionseeking behavior. An abundance of scientific research demonstrates that people experience substantial health benefits and increased well-being as a result of a commitment to a healthier lifestyle and improved self-care (U.S. Department of Health and Human Services, 1996). Survey research has documented that people with mental illness strongly agree and use a variety of integrative and complementary health practices and treatments as they pursue improved well-being and increased community integration (Ridgeway et al., 2002; Russinova, Wewiorksi & Cash, 2002). The importance of health and wellness has also stimulated the development of wellness education materials and tools (Copeland, 1997; 1998; 2002). These educational tools offer empowering opportunities to achieve health and wellness despite the general lack of attention to health promotion services within the mental health system. Program evaluation studies conducted in a myriad of mental health settings, using evidence-based wellness practices developed for the general population, have attempted to address the serious health issues prevalent in people with serious mental illnesses (Camann, 2001; Ekpe, 2001; Faulkner, Soundy & Lloyd, 2003; Faulkner & Sparkes, 1999; Skrinar et al., 2005; Moller & Murphy, 1997, Razzano, 2003). These qualitative and quantitative evaluations have focused on health promotion, health education, lifestyle change (exercise and nutrition), health support services, and health management interventions. While limited by methodological issues, these studies are promising as articles

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they suggest that health education and promotion and structured health interventions may lead to not only improved health outcomes, but to greater participation in community environments. One evidence-based practice that is receiving attention is the Illness Management and Recovery program (Gingerich & Mueser, 2004). This program provides a standardized intervention that emphasizes skill development to help people more effectively cope with their psychiatric illnesses so they can pursue personal goals. This educational curriculum bundles several evidence-based interventions including some health promotion strategies that promote overall well-being. Barriers to Health Promotion There are numerous micro and macro level barriers to the health promotion of individuals with psychiatric disabilities. The unhealthy lifestyle behaviors including poor diet, inactivity, chronic smoking, unsafe sexual practices and substance abuse most certainly contribute to the documented excessive morbidity (Davidson et al., 2001; Meyer & Nasrallah, 2003; Razzano, 2003). Mental illnesses and their varying symptomatology, cognitive and communication deficits, self-care issues and the side effect profiles of medications are also important barriers to health (Allison et al., 1999; Dixon, Postrado, Delahanty, Fischer & Lehman, 1999; Meyer & Nasrallah, 2003). Personal poverty, inadequate health insurance and poor quality of care stand out as potent determinants of poor health outcomes for a disproportionate number of people with serious mental illness (Druss, Bradford, Rosenheck, Radford & Krumholz, 2001; Meyer & Nasrallah, 2003). The mind-body duality as the prevalent perspective in mental health centers where many people receive services has inhibited the attainment of optimal health (Duckworth, 2004). Examples of


these types of barriers include: the failure of most mental health treatment plans to prescribe primary care and disease prevention interventions, the smoking policies of psychiatric hospitals which allow people access to outdoors only if they smoke and the continued persistence in the provision of only traditional groups on psychiatric illness management versus the infusion of services that address lifestyle and health considerations. Providing health promotion services involves a myriad of challenges to community mental health centers because of differing staff training and philosophy, funding and reimbursement barriers, scarce resources, and time constraints (Bell & Shern, 2002). The fragmentation of health care in our society is magnified in the mental health system. The lack of financial resources and reimbursement strategies for health promotion services are formidable barriers that are compounded by the prejudice and discrimination surrounding mental illnesses (Hennessy, Green-Hennessy & Buck, 2003; Meyer & Nasrallah, 2003). Furthermore, health promotion services for people with serious mental illnesses are not universally valued as worthwhile or cost saving to the system. Health Promotion Models Relevant to People with Psychiatric Disabilities By examining how health promotion and wellness are understood in other fields, and particularly in the field of public health, we are able to identify possibilities for health and wellness services for people with psychiatric disabilities. In general, public health definitions of wellness are extremely comprehensive and broad, indicating an underlying philosophy that suggests wellness implies living a balanced, fulfilling and optimal life. The field of public health has captured the public’s increasing interest not only in


living without disease but also in living closer to our health potential. In contrast to the field of mental health, the field of public health has long embraced a holistic, multidimensional, future-oriented view of health as vital not only to individuals but also to groups and communities. Even definitions of the word “health” in research articles or position papers in public health are oriented towards a wellness perspective. For example, the American Journal of Health Promotion posits a definition not of health but of “optimal health” which is considered to be “…a balance of physical, emotional, social, spiritual, and intellectual health.” (O’Donnell, 1989, p. 5) The public health orientation is distinguished from a mental health approach by its holistic language and its ecological, multi-leveled approach to intervention planning. The public health approach seeks to examine not just individual level determinants of healthy behavior, but also those at the group, institution, community, and policy levels which contribute to or inhibit people’s ability to attain a state of “optimal health” (O’Donnell, 1989). An effective approach to health promotion for people with psychiatric disabilities must involve a dynamic exchange of ideas, values, and expertise. Health promotion models and approaches have not been used widely to address issues related to recovery from serious mental illnesses. However, many public health models have been used for decades with great success for health promotion and health education programming with diverse groups of people and in challenging geographic and cultural environments, indicating the potential for these strategies to be adapted for use in mental health (Green & Kreuter, 1991). The added dimensions that a public health approach might bring to the mental

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health field include: knowledge of health issues (health literacy), the availability of health information, access to health education/promotion services and policies that create opportunities for people to obtain health resources (i.e. groups/classes for consumers on nutrition, metabolic issues, sexual health, etc.), consideration of the social support and communication received from health providers, and practice guidelines, policies and laws that support health behavior change (i.e. psychiatrists routinely prescribing exercise as part of a treatment plan). Another public health model, the chronic care model (Wagner, 1998), that also holds promise for health promotion in mental health, emphasizes productive communication between informed service recipients who take an active role in their health with their providers with the outcomes of healthier people, cost savings and satisfied providers. A Conceptual Framework for Integrating Health Promotion Services into the Mental Health System The proposed framework that integrates health promotion services into the mental health system is based on a specific, albeit working definition of wellness for people with severe mental illnesses. Furthermore, this conceptual framework reflects the fact that during their lifetimes people with severe mental illnesses typically access a variety of services that focus on many different aspects of their life. Therefore, within the context of severe mental illnesses and the environment of the mental health system, the concept of wellness must be integrated into the system of other mental health services that are desired by people with severe mental illnesses. Health promotion services for people with severe mental illnesses must be compatible with the fact that other services exist (e.g., crisis intervention, treatment, rehabilitation), yet


Table 1—Essential Services in a Service System Focused on Recovery Service Category

Description

Consumer Outcome

Treatment

Alleviating symptoms and distress

Symptom relief

Crisis intervention

Controlling and resolving critical or dangerous problems

Personal safety assured

Case management

Obtaining the services client needs and wants

Services accessed

Rehabilitation

Developing clients’ skills and supports related to clients’ goals

Role functioning

Enrichment

Engaging clients in fulfilling and satisfying activities

Self-development

Rights protection

Advocating to uphold one’s rights

Equal opportunity

Basic support

Providing the people, places, and things client needs to survive (e.g., shelter, meals, health care)

Personal survival assured

Self-help

Exercising a voice and a choice in one’s life

Empowerment

Health promotion

Promoting healthy lifestyles and environments quality of life

Functional health and

Adapted from: Cohen, M., Nemec, P. B., Farkas, M. & Forbess, R., 1988; Anthony, 1997.

expansive enough to insure that wellness thinking is brought into the field as a full partner in the pursuit of recovery from severe mental illnesses. In addition, a framework for integrating health promotion services into the mental health system must include a definition of wellness consistent with a public health approach. For example, within public health the concept of wellness was initially defined by Dunn (1961) as “an integrated method of functioning which is oriented toward maximizing the potential of which the individual is capable” (p. 4). In addition, the active ongoing nature of the wellness process emphasizes a commitment to lifestyle choices that empower the individual for productive community participation (Cadell, Karabanow & Sanchez, 2001; Hatfield & Hatfield, 1992). The Ottawa Charter for health promotion, one of the seminal documents that serves as a foundation of the field, frames health as a resource which enables people to function in their environments and to lead individually, socially, and economically productive lives (WHO, 1986), or in the

language of mental health, enables people to recover. Accordingly, we define wellness as people’s growth toward healthy physical, mental and spiritual lifestyles expressed in healthy environments, and the reduction of co-morbid health conditions and disorders. Health exists within the experience of the psychiatric disability, yet is distinct from the disability. Similar to other mental health services (e.g., case management, crisis intervention), the health promotion service process leading toward unique wellness outcomes must be explicated. Anthony (2000) has described a recovery oriented service system as being comprised of an array of mental health services guided by an overall recovery vision. These services include treatment services, crisis intervention services, case management services, rehabilitation services, enrichment services, rights protection services, basic support services, self-help services and health promotion services (Table 1). A service is defined by the specific characteristics of its process leading to a specific outcome (Anthony

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et al., 2002). Thus, we view health promotion services as a person’s awareness, choice and action (the process) with respect to the practice of healthy mind, body and spirit lifestyles within healthy environments (the characteristics) leading to enhancements in functional health and quality of life (the outcomes). Russinova (2002), based on her extensive survey work with people with severe mental illnesses who are recovering, has categorized possible health promotion outcomes across 7 different dimensions. This outcome categorization scheme provides suggestions for functional health outcome dimensions to measure when providing health promotion services (Table 2). In essence, the incorporation of health promotion practices and philosophy into the mental health system complements the recovery vision of the mental health system in several ways. First, health promotion services emphasize the need of a holistic understanding of human functioning as representing the inseparable unity of body, mind and spirit, as well as the need of delivering all types and modalities of mental



Table 2—Potential health promotion outcomes for persons with serious mental illness Physical Dimension

Self Dimension

Improved health

Increased self-awareness

Increased energy

Increased self-acceptance

Improved stamina

Increased self-esteem

Improved fitness

Increased inner strength/empowerment

Improved sleep

Improved self-control

Increased physical relaxation

Increased sense of responsibility

Decreased physical pain

Increased capacity to tolerate uncertainty

Reduced somatization

Increased openness Increased capacity for self-expression

Emotional Dimension Increased emotional stability

Social Dimension

Increased capacity for mood containment

Feeling accepted/supported by others

Increased capacity for emotional self-regulation

Improved social skills

Increased calmness

Decreased social isolation

Decreased fears

Increased sense of trust

Decreased social anxiety

Increased capacity for empathy

Increased sense of safety/security

Increased tolerance of others

Increased capacity for emotional expression

Spiritual Dimension

Increased capacity for release of negative feelings Increased hopefulness

Decreased impulsivity

Increased connectedness Cognitive Dimension

Increased sense of meaning/purpose in life

Decreased negative thinking

Sense of spiritual fulfillment

Decreased delusional thinking

Sense of inner peace

Decreased racing thoughts

Increased capacity for forgiveness

Improved concentration

Overall Functioning

Improved memory Decreased self-destructive behavior

Increased coping behaviors

Improved adaptive behavior Improved vocational capacity Improved capacity for self-care Improved coping capacity Increased sense of well-being

health and rehabilitation services in a way that addresses this unity. Second, the integration of health promotion services into the mental health system raises the important questions of whether the mental health system should take a primary responsibility not only for the delivery of mental

health services but also for the coordination of services relevant to the physical health of individuals with psychiatric disabilities. Third, it sheds light on the importance of the vastly ignored area of spirituality as pertinent to the needs, beliefs and everyday activities of individuals with serious menarticles

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tal illnesses. Fourth, since wellness is not viewed as the opposite of illness, the experience of clinical symptoms does not preclude the experience of wellness (Mullen, 1986). Fifth, the integration of health promotion services into the range of recovery oriented services suggests that a degree of well-


ness can be experienced at any point of the process of recovery from serious mental illnesses, including during its early stages when individuals often feel overwhelmed by the disability (Spaniol, Wewiorski, Gagne & Anthony, 2002). Thus, we argue that the recovery paradigm of needed services has to include the concept of health promotion in treatment planning and service delivery to persons with serious mental illnesses. Principles of Health Promotion The principles of health promotion on which services to people with psychiatric disabilities should be based are listed in Table 3. These principles are grounded in the fact that people with severe mental illnesses can and do recover (Anthony et al., 2002; Harding, Brooks, Ashikaga, Strauss & Breier, 1987), and are consistent with (or not opposed to) the principles inherent in the field of public health (O’Donnell, 1989). The principles of health promotion rest on the recognition that there is a deep connection between health and human rights and the assertion that people with psychiatric disabilities have a right to optimal health. These principles acknowledge the personhood of people with psychiatric disabilities in their individuality, their unique needs and goals, their desire for active involvement in their own health promotion activities, and in the complexity of their whole lives. These principles operate independently of the setting in which health promotion activities happen and the professional disciplines of the practitioner. Implications for Policy, Program Design and Research The introduction of health promotion services into the mental health system is extremely complex and represents a major change in comparison to the practices of the previous century. Awareness of a problem must be followed with proposed solutions that ad-

Table 3—Principles of Health Promotion for People with Serious Psychiatric Disabilities 1. Health and access to health care are universal rights of all people. 2. Health promotion recognizes the potential for health and wellness for people with psychiatric disabilities. 3. Active participation of people with serious psychiatric disabilities in health promotion activities is ideal. 4. Health education is the cornerstone of health promotion for people with psychiatric disabilities. 5. Health promotion for people with psychiatric disabilities addresses the health characteristics of environments where people live, learn, and work. 6. Health promotion is holistic and eclectic in its use of many strategies and pathways. 7. Health promotion addresses each individual’s resource needs. 8. Health promotion interventions must address differences in people’s readiness for change.

dress the issues of systemwide funding of effective interventions that promote healthy lifestyle choices. The literature has effectively documented the health problems of people with severe mental illnesses and the promise of health promotion interventions. However, unlike traditional health promotion interventions, which are more often designed to prevent or reduce risk for major health problems (Smith, Orleans & Jenkins, 2004), health promotion interventions for people with serious mental illnesses are multifaceted in terms of outcomes. Health promotion activities in this arena are designed to reduce the risk and prevalence of comorbid conditions, as well as improve the functional health and quality of life of individuals already experiencing a serious health condition. Whenever a new and pressing need is identified, the tendency in the mental health system often is to institute a new setting, program or team to address the issue. In this time of fiscal restraint we do not believe in the viability of a solution that proposes major types of innovations. Fortunately, there are existing resources that can be responsive to the unique health needs of peoarticles

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ple with severe mental illnesses. Health services for many people with severe mental illnesses are funded through Medicaid insurance. Expanding the range of health services that are reimbursed is paramount to improving the functional health of people with serious mental illness. Knowledgeable, supportive healthcare professionals with the responsibility to advocate for these health services are needed to help people access practical health promotion services. A promising response, already implemented in some settings, involves stationing a nurse practitioner in a community mental health center to engage people to insure that each receives optimal primary health care and screenings. This practical intervention utilizes a staff role often already in place in mental health settings and offers people access to a professional who can provide health education, individualized encouragement and health advocacy within the larger health system (Boardman, 2003). Providing more opportunities for people to self-direct their health care with the educational support of a person they choose is another important op-


tion to consider. Other alternative strategies might involve teaching people positive self-care behaviors and health promotion strategies in day treatment programs, clubhouses and outpatient services rather than as many “services as usual.” It is postulated that these environments are protective in terms of mortality because they provide social support, education and active care (Leff et al., 2004). We believe that as ever increasing attention is brought to this issue, other intervention alternatives will be used to address the human and economic costs inherent in the status quo. Additional health promotion procedures might involve macro level procedures, such as medical identification cards that people carry indicating their health issues, their providers and choice of care to help reduce the tendency to treat medical conditions as psychiatric symptoms, care guidelines for monitoring the health status of people, providing healthy options in settings that serve meals and beverages and providing health promotion educational materials to both service recipients and care providers. Guidelines are now available on the implementation of physical activity interventions in mental health settings (Richardson et al., 2005). Other essential strategies will need to involve enhancing communication between mental health and medical providers. This might be accomplished by linking medical records to psychiatric records to help inform, coordinate and provide better treatment and reduce costly poly pharmacy. Inclusion of private sector consumers and providers in these initiatives through reimbursement strategies for health promotion services is equally important.


promotion services is recognized. The challenge is that data with respect to the impact of these activities are still not routinely collected which ultimately limits the potential for equitable financial reimbursement. While there are promising evaluation studies of health promotion interventions for people with serious mental illness, many are lacking in methodological rigor that is required for a service to be labeled “evidence-based.” There are important questions and considerations that must be addressed about the role of health promotion in recovery from serious mental illness. Experimental intervention studies are needed to assess a variety of outcomes including cost, using mixed methods approaches. It is critical to study services as usual with the addition of health promotion services on recovery outcomes. The proposed solutions should focus both on the ecology of the health care system itself (Terry, 2003), as well as primarily intervening to empower individuals to change their lifestyle practices. As new health promotion interventions are implemented in mental health settings, the effect on both human and financial benefits must be assessed. Only in this way can health promotion services be funded to take their rightful place in the repertoire of essential services for people with severe mental illnesses.

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