Early death in people with severe mental illness (SMI) is well recognised, well evidenced and endemic across the world (>40 ‘mortality gap‘ blogs over the last decade tells its own story). These deaths are most often attributable to physical health conditions that in the general population would usually be prevented, delayed, or treated. People with SMI die on average 15 to 20 years earlier than the general population and have 3 times the rate of death under 75 (Liu, N.H., et al. 2017).
The Lancet Psychiatry Physical Health Commission has published its third report. The first report outlined a blueprint for protecting the physical health of people with a mental illness, through summarising advances in the field so far, and outlining future directions for research, clinical care, and health promotion (Firth, J., et al. 2019). The second report focused on the prevention and management of physical health side effects of psychotropic medication (Halstead, S., et al. 2025).
The third report focuses on the implementation of lifestyle interventions in mental health care. The report focuses on four common areas in lifestyle medicine: physical activity, nutrition, smoking cessation, and sleep. The report is split into five parts:
- The effects of the original 2019 Lancet Psychiatry Commission
- Investigating what current lifestyle interventions look like
- Examining which components of lifestyle interventions are effective
- Analysing the enablers and barriers to implementation
- Recommendations for implementation.
People with severe mental illness die up to 20 years sooner. This report explores how we can best implement lifestyle interventions to prevent this.
Methods
To assess how the 2019 Commission has contributed to the evidence base, the authors performed a citation search for policy documents, guidelines, consensus and position statements, and journal articles.
Next, the authors systematically scoped articles published since the 2019 Commission to investigate what current lifestyle interventions look like, and to generate case studies.
The authors conducted a scoping review to identify meta-analyses of standalone and multicomponent lifestyle interventions, to identify the most effective components of interventions.
To discuss enablers and barriers to implementation, the authors created a qualitative synthesis of the evidence base identified through a scoping review.
Finally, the authors created a list of recommendations on implementation, with support and consultation from their Global South Advisory Group and their Lived Experience Advisory Group.
Results
The 2019 Commission has been cited in 17 policy documents and guidelines. These include international and national statements. The documents typically used the Commission report to acknowledge disparities in life expectancy and physical health, with few citations related to lifestyle interventions. 319 journal articles cited the 2019 Commission.
The scoping review identified 89 studies on lifestyle intervention. 99% of these studies were in high-income countries. Most interventions were focused on physical activity (64%), with other common components including dietary/nutritional interventions (42%), smoking cessation (38%) and sleep interventions (17%). There was a wide range in intervention delivery from individual-only, mixed individual-group, and group-only. Reporting on adherence, attrition and intervention fidelity was inconsistent and commonly absent. Most studies showed an improvement in psychiatric and quality of life outcomes (85%). Most studies that looked at cardiometabolic outcomes also showed improvement (58%). Only 6 studies looked at cost-effectiveness, but 5 of them showed favourable outcomes.
The authors identified 6 real-world case studies, and have provided mapping diagrams covering inputs, processes, highlights of the key success factors, and lessons learned. Examples included a physical health activity programme in South Yorkshire, a psychiatric intensive care unit inpatient physical activity programme in north London, and a smoking cessation service in Sydney.
The scoping review on effective components found that exercise interventions grounded in motivational theory (such as self-determination theory and social cognitive theory) were effective. Interventions grounded in one theoretical model of motivation had larger effect sizes than interventions based on multiple motivational theories. One study found that fewer people dropped out of interventions when autonomous motivation strategies were used. These strategies are self-determined and are consistent with participants’ intrinsic goals. More people dropped out of interventions that are done for external reasons, for example, perceived approval by others.
There was mixed and often conflicting evidence on the efficacy of group interventions compared to individual interventions. The authors recommend that services offer a variety of intervention delivery models to suit individual needs and a wide range of presentations.
Involving specialist practitioners improved outcomes across a range of interventions. Specialist dieticians and exercise practitioners were highlighted as particularly beneficial in improving outcomes and reducing dropout rates. The review also found evidence that “task-shifting” to non-specialist providers in resource-poor settings can still be effective.
The review showed that lifestyle interventions are effective for both physical parameters and symptoms of mental illness (such as negative symptoms of psychosis) at early stages of illness, but also for established persistent illness.
Common barriers to implementation included inadequate reimbursement and funding at the macro level; lack of time, training and infrastructure at the meso level; and lack of practitioner engagement, and staff scepticism of patients’ abilities at the micro level.
The review found that lifestyle interventions are effective for both physical parameters and symptoms of mental illness at early stages of illness, but also for established persistent illness.
Conclusions
The Commission found a wide range of studies on the effectiveness of lifestyle interventions, but further work is needed to refine implementation and create greater definition to an often-conflicting evidence base.
From these results, the Commission created a list of recommendations for implementation. These include aligning lifestyle interventions within an organisation’s wider strategy, addressing the culture of staff scepticism, creating capacity and training within teams on lifestyle intervention, offering a range of flexible delivery methods, and grounding interventions in a single motivational theory which fosters autonomous intrinsic motivation.
The Commission found a wide range of studies on the effectiveness of lifestyle interventions, but further work is needed to refine implementation and create greater definition to an often-conflicting evidence base
Strengths and limitations
This report benefited from a multimodal methodology to address a range of research questions. The report’s recommendations provide clear statements where evidence is strong on particular factors for implementation, but also recommends a flexible and personalised approach to implementing lifestyle interventions in areas where the evidence is more complicated. The report also provides a strong direction of travel to highlight where further research is needed.
However, the authors do not shy away from highlighting the limitations of the underlying evidence base. Many of the included studies suffered from inadequate reporting, particularly on questions like intervention fidelity. Only 4% of studies reported on this.
The authors also highlight that “lifestyle interventions” in the research are often narrowly focused on very specific interventions in smoking cessation, physical activity, nutrition, and sleep. The authors suggest broader targets for lifestyle interventions including sedentary behaviour and stress management. Lifestyle interventions in the literature focus on individual behaviour change and often do not consider upstream factors such lack of access to healthcare, food deserts and food insecurity, and unsafe neighbourhoods.
Despite the best efforts of the authors to enhance the applicability of their findings through involving a Global South Advisory Group and a Lived Experience Advisory Group, they identified several hard barriers to making their recommendations work across a global context. For instance, of the 89 recent intervention studies reviewed, 99% were conducted in high-income countries, and 88% of policy citations came from the Global North. This severely restricts the applicability of the findings to low- and middle-income countries, where much of the global burden of disease lies. However, the authors point this out as an opportunity for further research.
Most evidence for lifestyle interventions comes from high-income settings – 99% of studies and 88% of policy citations – limiting relevance for low- and middle-income countries, where the burden is greatest.
Implications for practice
This report effectively builds on the more conceptual and principled contributions of the previous Commission reports, and focuses on real-world implementation and delivery of lifestyle interventions. As a result, clinicians and organisations delivering clinical services may find this report more useful for patient care than the previous Commission reports.
If I am pitching to my commissioner about incorporating lifestyle interventions in the services I work in, I can use this paper to provide clear evidence of clinical and cost-effectiveness.
When developing a proposal with my service manager, we can use this paper to make a clear specification of the motivational theory that we want staff to work within.
When delineating the scope of what we offer to patients we can use this paper to steer us on which strictly delivered interventions have the best evidence base. But we can also use this paper to know where the evidence is less certain, so we know when to offer a more flexible and individualised approach. This will help us think about how much time we need to incorporate into people’s job plans, and what training and support they will require to deliver a service.
I can use the case studies detailed in the paper to notice similarities and differences to my own service, to avoid having to think about my service development from square one.
Finally, I can use the clear lessons from this paper to address my own feelings of helplessness and futility. Improving the physical healthcare of people with mental illness requires consistent, careful and patient work. This paper reminds me how crucial it is for me to focus on the whole of a person’s health, and the strengths I can bring as a medical doctor to addressing a wide range of lifestyle factors.
This paper is a wake-up call that the evidence is there for these interventions, but evidence means nothing if we don’t implement it. The paper is clear that our own scepticism and underestimation of patients’ abilities to change can do them a huge disservice. Addressing our own biases and negativity about the effectiveness of this work is a vital component for getting this delivered to patients. With the mortality gap as large as it is, we cannot afford to be our own worst enemies.
The evidence for lifestyle interventions improving physical and mental health is there, but evidence means nothing if we don’t implement it.
Statement of interests
Gavin Tucker is a Presidential Scholar for Physical Health at the Royal College of Psychiatrists.
Editor
Edited by Laura Hemming.
Links
Primary paper
Scott Teasdale, Katarzyna Machaczek, Wolfgang Marx, Melissa Eaton, Justin Chapman, Alyssa Milton, Adawele Oyeyemi, Dicky Pelupessy, Felipe Schuch, Grace Gatera, Helal Uddin Ahmed, Hervita Diatri, Ibrahim Jidda, Miguel Gutiérrez-Peláez, Mohamed Elshazly, Muhammad Abba Fugu, Natalia Grinko, Pillaveetil Sathyadas Indu, San San Oo, Suhavana Balasubramanian, Jeroen Deenik, Davy Vancampfort, Brendon Stubbs, Evan Matthews, Philip Ward, Jackie Curtis, Lamiece Hassan, Samuele Cortese, Simon Gilbody, Joseph Firth and Simon Rosenbaum (2025). Implementing lifestyle interventions in mental health care: third report of the Lancet Psychiatry Physical Health Commission. The Lancet Psychiatry, 12(9), 700-722.
Other references
Firth, J., Siddiqi, N., Koyanagi, A et al (2019). The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness. The Lancet. Psychiatry, 6(8), 675–712. https://doi.org/10.1016/S2215-0366(19)30132-4
Halstead S, Yap C, Warren N et al. (2025) Holistic prevention and management of physical health side-effects of psychotropic medication: second report of the Lancet Psychiatry Physical Health Commission. The Lancet Psychiatry, 12, 673-699 https://doi.org/10.1016/S2215-0366(25)00162-2
Liu, N. H., Daumit, G. L., Dua, T et al. (2017). Excess mortality in persons with severe mental disorders: a multilevel intervention framework and priorities for clinical practice, policy and research agendas. World Psychiatry: official journal of the World Psychiatric Association (WPA), 16(1), 30–40. https://doi.org/10.1002/wps.20384
