Although the physical and psychological benefits of exercise have been well established, it is estimated that over half of Australian adults are inactive, with few achieving the recommended 30 minutes of moderate intensity exercise most days [269]. Insufficient physical activity accounts for approximately 9% of premature mortality worldwide [270]; an estimated 46% of which could be prevented by meeting minimum physical activity requirements [271]. As such, an increasing amount of research has focused on the potential benefits of exercise in AOD and mental health treatment [272]. Physical activity is highlighted as a safe alternative behaviour to AOD use, that is naturally rewarding and engaging, with various health benefits [272, 273]. Physical activity and exercise have been associated with improved health [274], improved depression and mood [275, 276], reduced levels of anxiety [277, 278], reduced effects of AOD withdrawal [279–281], and are considered to be safe when exercises have been individually tailored [282–284]. A study examining the effects of an 8-week structured exercise program (treadmill and weight training) on depression and anxiety symptoms among people in treatment who were newly abstinent from methamphetamine, found those in the exercise group had significantly greater reductions in depression and anxiety symptoms compared to those in the control group (health education sessions) [285]. Further, a dose effect was found, whereby those who had attended more exercise sessions during the eight-week program illustrated greater reductions in depression and anxiety compared to those who had attended fewer sessions [285].
Regular exercise is also associated with other positive behaviours, such as healthy diet and sleep patterns [286, 287], and overall feelings of wellbeing, vitality, high energy, and motivation to maintain healthy lifestyle practices [288–291]. Physical activity is inversely related to smoking status (i.e., people who do not smoke are more physically active than people who smoke [292, 293]), number of cigarettes smoked, and nicotine dependence, and recent evidence suggests that exercise may be an effective complementary intervention to smoking cessation strategies [294–296]. Physical activity improves cardiovascular, pulmonary, and immune functioning, which can in turn assist with the prevention of chronic disease [297]. Smoking cessation is more successful for those who exercise during their attempts to quit smoking [294, 298], and exercise can assist with the prevention of relapse [299]. Physical activity can also alleviate symptoms of smoking withdrawal, such as irritability, depression, restlessness, and stress [279, 300–302].
Research suggests that although people with AOD use disorders may be interested in increasing their levels of physical activity [303], it is unclear how frequently those in AOD treatment regularly engage in moderate to vigorous levels of exercise [272]. Few treatment programs incorporate dedicated time for exercise [272, 304], despite it being a rewarding, accessible, sustainable, and safe behaviour that can be used to manage cravings and urges to use AOD [272]. Three reviews – one systematic and two meta-analyses – examining the effects of exercise-based interventions for AOD use on recovery, physical fitness, and psychological health found that exercise is a potentially promising accompanying treatment for AOD use [305–307]. Physical activity was associated with reductions in AOD use, cravings, withdrawal symptoms, and improved abstinence, alongside improvements in depression, anxiety, stress, and quality of life, as well as significant fitness improvements in the exercise groups [305–307]. Exercising in calmer environments, such as outdoors, has also been associated with greater reductions in stress [308]. Taken in combination, these factors make physical activity an appealing, adjunctive intervention to assist with relapse prevention among those in treatment for AOD use.
There are several physical activity and sedentary behaviour guidelines for adults, outlined in Table 21. Although associated with a range of benefits, the ideal dose (i.e., type of exercise, duration, and intensity) of exercise to maximise the effects of potential health and psychological benefits, is not clear and continues to be the subject of research. Evidence to date suggests that the ideal dose varies considerably between people, and depends on individual preferences, as well as baseline physical fitness levels [309]. However, given that many people with AOD use are fairly inactive, an initial program of light to moderate intensity exercise is likely to be more beneficial than vigorous exercise, may assist with program adherence and retention [310], and align with client preferences [284]. Supervised physical activity may be useful to ensure information about safe exercise (e.g., importance of warm-up, cool-down, and stretching) and exercise intensity are provided (e.g., using heart-rate monitors) [272]. Encouraging the pursuit of home-based exercise is likely to be important for clients to establish and maintain exercise levels after the conclusion of the activity program, and integrating exercise into psychotherapy may enhance treatment outcomes [272].
Evidence examining the exercise attitudes and behaviours of people in AOD treatment identified that, although the majority of those in treatment were interested in participating in physical activities as part of their AOD recovery, many were reluctant due to perceived barriers which included financial costs and lack of motivation [303]. As such, techniques such as self-monitoring, goal setting, contingency management, and relapse prevention planning may be useful [272, 310]. Wearable devices that track physical activity (e.g., pedometers, heart-rate monitors, fitness trackers; sometimes called activity trackers or wearable activity trackers) can increase motivation and reduce AOD use when exercise is used as a coping strategy to manage AOD cravings [311–313]. Data from interviews conducted among people with AOD use disorders suggests that activity trackers can help people stay accountable to an exercise plan, strengthen motivation to remain abstinent from AOD by tracking progress in physical activity goals, and reinforce positive changes that are being made [314]. Cardiovascular (e.g., running), resistance (e.g., weight training), yoga, and isometric exercise have all been successfully piloted as aids to assist smoking cessation, but need further testing in larger RCTs among AOD populations [294]. Education and behaviour change strategies focused on diet and exercise [212] have also been shown to be effective.
| Physical activity and sedentary behaviour guidelines for adults (aged 18–64 years) |
- Any physical activity is better than none. If there is currently none, start with a small amount and gradually build up to the recommended amount.
- Be active most days, and preferably every day.
- Each week, adults should do either:
- 2½–5 hours of moderate intensity physical activity (i.e., out of breath but can still say a few words), such as a brisk walk, bike riding, swimming, mowing the lawn.
- 1¼–2½ hours of vigorous intensity physical activity (i.e., out of breath, difficulty talking), such as soccer, hockey, netball, aerobics, jogging, fast cycling.
- An equivalent combination of both moderate and vigorous activities each week.
- Incorporate muscle strengthening exercises (e.g., squats, lunges, push-ups, pull-ups, lifting weights) at least two days each week.
- Minimise the amount of time spent in prolonged sitting (e.g., consider walking meetings or sessions, using a standing desk, or going for a walk during lunch breaks).
- Break up long periods of sitting as often as possible (e.g., stand up and walk around when using the phone, do squats or lunges between meetings).
- Incorporate physical activity into daily routine (e.g., use the stairs instead of a lift or escalator, get off the bus one stop early and walk the rest of the way, walk to the park for lunch).
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Adapted from the Australian Government Department of Health 2021 [315].
Despite the overwhelming evidence of poor physical health among those with mental health conditions, relatively few workers address the physical health of their clients as part of their practice [316]. This reluctance may be due in part to clinicians questioning whether health and wellness are achievable goals for people with mental health conditions, due to perceived lack of motivation, lifestyle challenges, and the side effects and complications of many medications (e.g., weight gain, glucose and lipid abnormalities, and cardiac side-effects) [316, 317]. Although some research suggests that clients may prefer to make simultaneous behavioural changes [318, 319], clinicians may feel ill-prepared to manage the physical health of clients, particularly with standard screening tools and assessments not addressing the importance of health screening among people with mental health conditions [317, 320, 321]. Similarly, clinicians may feel that addressing the physical health of clients is outside the scope of their role [316]. AOD workers may find the food and physical activity diary located in the Worksheets section of these Guidelines useful for identifying the links between clients’ mood and feelings, their physical activity, and food.