Severe Mental Illnesses (SMIs) are psychological problems causing severe functional and occupational impairment and include diagnoses of psychosis, schizophrenia, and bipolar disorder; the prevalence of SMI in adults is 0.9%: over 400,000 people ( Public Health England, 2018 ). Lack of physical activity, poor diet and poor quality of sleep are contributory factors to rates of chronic physical health diseases that are many times higher for those with SMI than the general population, resulting in reduced life expectancy in SMI of 15 to 20 years ( Hjorthøj et al., 2017 ).

Levels of physical activity are low in people who experience SMI and are linked to more depression symptoms, lower wellbeing, greater hopelessness, lower quality-of-life, and physical health diseases, such as: Cardiovascular Disease (CVD), stroke, cancer, hypertension, osteoarthritis, diabetes, and Chronic Obstructive Pulmonary Disease (COPD) ( Rhodes et al., 2017 ; Schuch et al., 2017 ; Soundy et al., 2013 ; Vancampfort et al., 2015 ).

Within three months of commencing antipsychotic medication, patients experience rapid increases in body weight ( Correll et al., 2009 ). Weight gain is a cause of distress, reduced self-worth, poor sleep, and less physical activity ( Watkins et al., 2020 ; Hargens et al., 2013 ).

Sleep problems are common in people with SMI (rates of 80% reported) and impact negatively on functioning, wellbeing and mental health ( Blanchard et al., 2020 ; Davies et al., 2017 ; Reeve et al., 2019 ; Waite et al., 2016 ). Poor sleep is associated with reduced quality of life, increased suicide risk, cognitive impairment, and worse functioning and mental health symptoms ( Hofstetter et al., 2005 ; Pompili et al., 2009 ; Wulff & Joyce, 2011 ; Bromundt et al., 2011 ; Mulligan et al., 2016 ; Ong et al., 2020 ). Poor sleep has a negative impact on social and occupational functioning ( Faulkner & Bee, 2017 ), emotional distress, fatigue, psychotic symptoms, reduction in daytime activities, and capacity to cope with distressing hallucinations (voices) ( Waite et al., 2016 ).

Psychological barriers to physical activity and healthy lifestyles include psychotic symptoms, anxiety, low motivation, and low self-efficacy ( Brooke et al., 2020 ; Carney et al., 2017 ). Additional barriers include social withdrawal due to poor mental health, stigma, fear of others, and low self-esteem ( Carney et al., 2017 ). There can be practical issues and barriers to adopting a healthy lifestyle, such as: cost, time, and insufficient skills and knowledge ( Carney et al., 2017 ).

For people with SMI, engaging in physical exercise is associated with improved quality of life, cognition, functioning, physical health, and reduced psychotic symptomatology ( Mittal et al., 2017 ). The physical demands of exercise can temporarily subdue positive symptoms and act as a distraction from intrusive voices, delusions, and paranoia; exercise can reduce negative symptoms and depression, as well as improve energy, mood, and motivation levels—partially through stimulating endorphins release ( Mason & Holt, 2012 ; Firth et al., 2018 ). People with SMI report that exercise can alleviate psychiatric symptoms, improve mental health, improve wellbeing, reduce stress, improve hopefulness, enhance self-confidence, boost energy levels, and provide a sense of achievement ( Firth et al., 2018 ; Larsen et al., 2019 ). Achieving exercise goals increases self-efficacy and confidence in other areas of life, such as psychosocial functioning ( Firth et al., 2018 ).

In patients with SMI, a good night’s sleep is associated with wellbeing, happiness, social relationship satisfaction, contentment, feeling energised, improved mental health, and ability to cope; these factors are related to recovery and engaging in and enjoying life ( Waite et al., 2016 ; Griffiths et al., 2022a, 2022b ; Schlarb et al., 2015 ). A virtuous cycle exists whereby sleep and physical activity result in greater self-esteem and confidence, which further enhances motivation and capability to engage socially and in healthy lifestyle activities ( Carney et al., 2017 ). Adoption of a healthy diet can result in improved physical health, self-worth, sleep quality, functioning, and physical activity ( Watkins et al., 2020 ; Hargens et al., 2013 ). Sleep hygiene in SMI can improve quality of sleep ( Klingaman et al., 2015 ; Davies et al., 2017 ).

Feasibility and acceptability of consumer sleep monitoring technology (e.g. Fitbit) in SMI has been found ( Aledavood et al., 2019 ). Using a wearable activity tracker encourages increases in physical activity, self-awareness, motivation, goal-setting, diet, and healthier lifestyles ( Naslund et al., 2016 ; Chum et al., 2017 ). A wearable activity tracker sleep detection is 95% accurate ( Beattie et al., 2017 ). Activity trackers can significantly reduce body weight due to improvements in self-regulated lifestyle ( Kooiman et al., 2018 ). A wearable activity tracker can be a valuable part of lifestyle interventions for people with SMI to reduce CVD risk and weight and improve Cardiorespiratory Fitness (CRF) ( Aschbrenner et al., 2021 ).

A systematic review and meta-analysis of wearable activity tracker-based interventions for healthy lifestyles (no exclusion on participant characteristics) found a significant reduction in weight and increases in physical activity (steps) and moderate-to-vigorous physical activity; the review concluded that goal setting was a condition for better outcomes ( Ringeval et al., 2020 ). Motivational interviewing and goal setting are effective tools for motivating people to engage in healthy lifestyle behaviours ( Hardcastle et al., 2015 ). Interventions to enhance motivation for healthier lifestyles can help elicit long-term healthy lifestyle behaviour change ( McGrane et al., 2015 ). Grounding healthy lifestyle intervention programmes in behaviour change theory can foster self-efficacy and increase the likelihood of intervention efficacy ( Smith et al., 2020 ).

A large RCT of structured lifestyle group education in schizophrenia highlighted the need and patient demand for interventions but had little effect ( Holt et al., 2019 ). However, individualised physical activity programmes in early psychosis have been shown to be effective in improving symptomatology, functioning and physical wellbeing ( Firth et al., 2018 ).

In our three mental health service un-controlled pilots, Well-Track was delivered: the provision of a Fitbit and its software apps, sleep hygiene and physical activity guidance, and three engagement sessions with a clinician. Combining data (n = 43) from pilots one and two, the wellbeing (WEMWBS) improved statistically significantly from Week 1 (49.8) to week 4 (52.9), Z = −2.09, p = .037 ( Griffiths et al., 2021, 2022a ). In the second pilot (n=23), we found that Positive and Negative Affect Schedule (PANAS) negative affect dropped statistically significantly (indicating that the patients had lower levels of negative affect at 4 weeks) and PANAS positive affect was reaching statistical significance ( Griffiths et al., 2022a ). In the third pilot (n = 24) there was a significant improvement in WEMWBS scores (large effect size), sleep quality (Sleep Condition Indicator, SCI), and depression (PHQ-9) (large effect size), and a small non-significant reduction in weight ( Griffiths et al., 2023a ).

Analysis of twenty-seven participant interviews found that most actively used the Fitbit and its software apps to gain information and feedback, and set goals to make changes to their lifestyle and daily routines to improve self-confidence, quality of sleep, levels of physical activity, diet, and exercise ( Griffiths et al., 2021, 2022b, 2023b ). Most participants found Well-Track acceptable and attended all three sessions and reported increased physical activity/exercise and improved sleep and diet. It was found that Fitbit app feedback empowers patients to take control of their own health and increases healthy lifestyle motivation, awareness, and adoption ( Griffiths et al., 2021, 2022b, 2023b ).

All patients with SMI are provided with at least one comprehensive 12-point physical health review annually ( NHS England, 2024 ). Despite calls to “don’t just screen, intervene” ( NHS England, 2017 ) to improve physical health, there is a lack of effective healthy lifestyle interventions at this review point. This present study investigates the impact of Well-Track intervention in SMI, it addresses the question: “What is the effect of Well-Track on mental wellbeing and sleep quality/insomnia for SMI patients?” Our hypothesis was that Well-Track will have a positive impact on mental wellbeing, and sleep quality/insomnia in SMI patients.

Thirty-five participants were males and forty-one were females (five were missing). Mean age was 41.08 years (SD = 11.49), with an age range of 20 - 65 years (see Table 1 ). The baseline WEMWBS mean score of 37.5 was lower than the general population norms for England ( Tennant et al., 2007 ). Based on SCI scores, 24 participants (31.6%) would meet a diagnosis of probable insomnia ( Espie et al., 2014 ).

Prior to statistical analysis, data screening was conducted to confirm that the dataset met the assumptions required of the general linear model. There were no outliers in the data, the Shapiro Wilk’s test assessed all measures were normally distributed, and Mauchly’s test of sphericity indicated that the assumption of sphericity had not been violated for the SCI scale.

WEMWBS data Mauchly’s test of sphericity indicated that the assumption of sphericity had been violated, χ²(2) = .75, p = .016. Due to the estimated epsilon value of .840, Huynh-Feldt correction was used. The increase of the WEMWBS scores was statistically significant at both points during the intervention, F(50.4, 1.7) = 9.946, p < .001, partial η² = .25. The large effect size confers 25% of the improvement in WEMWBS was accounted for by the intervention. Post-hoc analysis with Bonferroni adjustment revealed that there was an increase in the WEMWBS scores from baseline (M = 37.52, SD = 10.18) to week 4 (M = 42.35, SD = 7.14), a statistically significant mean increase of 4.84 95% CI [−8.96, −.72], p = .017. Similarly, an increase in the WEMWBS scores was observed between baseline and week 8 (M = 44.06, SD = 6.03), a statistically significant increase of 6.55 95% CI [−11.03, −2.07], p = .003. Wellbeing improvement was maintained to week 8.

For SCI data, the assumptions for repeated measures ANOVA were met and Mauchly’s test of sphericity indicated that the assumption of sphericity had not been violated, χ²(2) = .91, p = .266. An overall change in sleep index score was statistically significantly improved following the intervention, F(2,60) = 13.49, p < .001, partial η² = .310. A post hoc analysis with a Bonferroni adjustment revealed there was an improvement from baseline (M = 12.03, SD = 7.29) to week 4 (M = 15.45, SD = 8.00), a statistically significant mean improvement of −3.42 95% CI [−5.64, −1.20], p = .001. The average sleep index improved further by week 8 (M = 17.26, SD = 8.12), −5.23 95%CI [−7.85, −2.60], p < .001. At the end of week 8, 14 patients (18.3%) met a diagnosis of probable insomnia ( Espie et al., 2014 ), a remission rate of 41.7%.

This study investigated the impact of Well-Track on mental wellbeing, and sleep quality/insomnia. Well-track was successfully delivered through a SMI physical health check service, and we found most SMI patients will choose to undertake Well-Track and complete all three sessions, providing evidence of feasibility and acceptability. The findings showed that SMI patients could benefit from Well-Track in terms of reducing symptoms of insomnia and improving mental wellbeing and sleep quality. People continued to improve from 4 to 8 weeks, i.e. from the second session to the third indicating a cumulative effect of the intervention.

Healthy lifestyles (diet, physical activity, and sleep quality) are linked to positive psychological wellbeing ( Johnson et al., 2017 ; Harvey et al., 2020 ; Tamminen et al., 2020 ). Participant improvements on the WEMWBS measure indicate a positive impact of Well-Track on individuals’ wellbeing, subjective happiness, life satisfaction, self-realisation, and psychological functioning. These are all factors which are important for quality of life, coping, and thriving.

Whilst there are no directly comparable interventions, the improvement in wellbeing through Well-Track was greater than an intervention providing access to community-based physical activities for participants who were mental health service users ( Malcolm et al., 2013 ), perhaps highlighting the added value of an individualised approach using a motivational interview, goal setting, and feedback. The findings indicate that this study’s approach (providing goal setting, progress monitoring, structure, and support to assist people in physical health and lifestyle management to encourage healthy lifestyles and increase health literacy) supports the evidence of the value of this approach ( Pedley et al., 2018 ).

Reduction in insomnia and improvements in sleep quality seen following Well-Track can have a positive impact on social and occupational functioning, capacity to cope with distressing mental health symptoms, wellbeing, mental health, and quality of life ( Blanchard et al., 2020 ; Davies et al., 2017 ; Reeve et al., 2019 ; Waite et al., 2016 ; Hofstetter et al., 2005 ; Pompili et al., 2009 ; Wulff & Joyce, 2011 ; Bromundt et al., 2011 ; Mulligan et al., 2016 ; Ong et al., 2020 ; Faulkner & Bee, 2017 ; Waite et al., 2016 ). A good night’s sleep allows people to better able engage in daily activities, feel more motivated and energised, and cope with challenges that they face contributing to mental health recovery and enjoying life ( Waite et al., 2016 ; Griffiths et al., 2022a, 2022b ). A virtuous cycle can be created whereby good quality sleep means people feel able to engage in more physical activity increasing physical tiredness that encourages better sleep; this can enhance motivation and capability to engage socially and in healthy lifestyle activities and result in greater self-esteem and confidence ( Carney et al., 2017 ).

Evidence indicates that sleep disturbance plays a role in the pathogenesis of schizophrenia ( Lunsford-Avery et al., 2015 ); and sleep problems are common in people with SMI ( Blanchard et al., 2020 ; Davies et al., 2017 ; Reeve et al., 2019 ; Waite et al., 2016 ). Remission rates of 42% indicate the value of Well-Track in treating insomnia. NICE recommendations for the treatment of short-term insomnia are non-pharmacological interventions, e.g. insomnia Cognitive Behavioural Therapy (iCBT), as the first method and, where this fails, a follow-up with a brief course of a non-benzodiazepine hypnotic prescription ( NICE, 2020 ). Further investigation could consider if Well-Track may be a useful and potentially more acceptable and lower-cost intervention for insomnia than either iCBT or non-benzodiazepine hypnotic prescription.

Study limitations include the lack of control group. A confounding factor is that the participants would have been receiving support and treatment from CMHT services during the Well-Track intervention. People who agreed to participate were self-selected; thus, it is possible more participants with better than average mental health for people with SMI agreed to participate. The participants were from a single UK county reducing generalisability.

Well-Track has a positive impact on insomnia/sleep quality and wellbeing. Benefits are seen at 4 weeks and improved further at 8 weeks. In future research, an appropriately powered multi-site Randomised Controlled Trial (RCT) with longer-term follow-up to investigate efficacy of Well-Track could provide further evidence.

Improved mental and physical health and wellbeing are key aims of SMI services. There is a lack of effective healthy lifestyle interventions available in SMI services ( Larsen et al., 2019 ); Well-Track has been found to be an effective option that could potentially bridge this gap. These results show that CMHT service users can benefit from this relatively simple and low-cost intervention that meets requirements of service delivery goals and Key Performance Indicators (KPIs). A manualised version of Well-Track is now available to access free of charge via: https://www.nhft.nhs.uk/research/ .

We wish to thank the participants and the staff at the NHS Trust for their support in recruitment.

This project is funded by the National Institute for Health Research (NIHR) East Midlands Clinical Research Network (CRN). The views expressed are those of the authors and not necessarily those of the NIHR.