Promotion of cardiorespiratory fitness in schizophrenia: a clinical overview and meta-analysis

Effect of psychological nursing interventions on effectiveness and quality of life in schizophrenia patients receiving modified electroconvulsive therapy

BACKGROUND

Schizophrenia is a common and severe mental disorder characterized by severe thought disturbances, hallucinations, delusions, and emotional instability. For some patients, conventional treatment methods may not effectively alleviate symptoms, necessitating the use of alternative therapeutic approaches. Modified electroconvulsive therapy (MECT) is an effective treatment modality for schizophrenia, inducing anti-depressive and antipsychotic effects through the stimulation of brain electrical activity.

AIM

To explore the impact of psychological nursing intervention (PNI) before and after MECT on the efficacy and quality of life of patients with schizophrenia.

METHODS

Eighty patients with schizophrenia who received MECT treatment from 2021 to 2023 were randomly divided into two groups: The intervention group (n = 40) and the control group (n = 40). The intervention group received PNI before and after MECT, while the control group received routine nursing care. The efficacy of MECT was evaluated by the Positive and Negative Syndrome Scale (PANSS) and the Clinical Global Impression Scale (CGI) before and after the treatment. The quality of life was assessed by the Short Form 36 Health Survey (SF-36) after the treatment.

RESUITS

The intervention group had significantly lower scores of PANSS and CGI than the control group after the treatment (P < 0.05). The intervention group also had significantly higher scores of SF-36 than the control group in all domains except physical functioning (P < 0.05).

CONCLUSION

PNI before and after MECT can improve the efficacy and quality of life of patients with schizophrenia. It is suggested that nurses should provide individualized and comprehensive psychological care for patients undergoing MECT to enhance their recovery and well-being.

Systematic Review and Meta-analysis of Exercise Interventions for Psychotic Disorders: The Impact of Exercise Intensity, Mindfulness Components, and Other Moderators on Symptoms, Functioning, and Cardiometabolic Health

BACKGROUND AND HYPOTHESIS

Exercise therapy has been shown to be an effective complementary treatment for patients with psychotic disorders. However, the specific impacts of different training modalities remain poorly understood. This article aims to quantitatively review the moderating influence of different exercise modalities, hypothesizing that higher exercise intensity as well as utilization of mindfulness-based exercise (MBE) components, will improve intervention outcomes.

STUDY DESIGN

PubMed, Web of Science, and PsycINFO were searched from 2010 to March 2022 for randomized controlled trials investigating exercise interventions in patients with psychotic disorders (preregistration: https://doi.org/10.17605/OSF.IO/J8QNS). Outcomes considered were positive/negative symptoms, Positive and Negative Syndrome Scale (PANSS) General Psychopathology/Total scores, depressive symptoms, psychosocial functioning, quality of life, cardiorespiratory fitness, and body mass index. Separate meta-analyses, including moderator analyses, were performed to evaluate the moderating influence of different training modalities.

STUDY RESULTS

Of 6653 studies, 40 (n = 2111 patients) were included in the meta-analysis. The effects of moderate-intensity exercise exceed low-intensity approaches for PANSS Total scores (P = .02) and depressive symptoms (P = .04). The presence of MBE components was associated with improvements in positive symptoms (P = .04) and PANSS General Psychopathology subscores (P = .04) but also with higher error and between-study heterogeneity. Our analysis also shows improved intervention effects on depression in younger patients (P = .012) and improved psychosocial functioning scores following more frequent sessions (P < .01).

CONCLUSIONS

A minimum of moderate intensity should be considered. More frequent training sessions per week also seem to be beneficial. While adding mindfulness elements is promising, it increases heterogeneity and requires caution in terms of generalization.

As We Were and as We Should Be, Combined Exercise Training in Adults with Schizophrenia: CORTEX-SP Study Part I

INTRODUCTION

Given the health benefits and the role of exercise as an anti-inflammatory adjuvant program, this study aimed to determine the effectiveness of a combined exercise program on cardiorespiratory fitness (CRF), body composition, and biochemical levels in adults with schizophrenia (SZ) characterized at baseline as metabolically unhealthy overweight with low CRF.

METHODS

Participants diagnosed with SZ ( n = 112, 41.3 ± 10.4 yr, 28.7% women) were randomly assigned into a treatment-as-usual control group ( n = 53) or a supervised exercise group ( n = 59, 3 d·wk -1 ). Each combined exercise session consisted of both a low-volume high-intensity interval training (<10 min of high-intensity time per session) and a resistance circuit-training program. All variables were assessed before and after the intervention (20 wk). For the assessment of CRF, a peak cardiopulmonary exercise test on a cycle ergometer was used.

RESULTS

After the intervention, participants from the exercise group ( n = 51) showed increases in CRF ( P < 0.001) through peak oxygen uptake (L·min -1 ; Δ = 17.6%; mL·kg -1 ·min -1 , Δ = 19.6%) and the metabolic equivalent of task (Δ = 19%), with no significant changes ( P > 0.05) in body composition and biochemical variables. However, the treatment-as-usual group ( n = 38) did not show any significant change in the study variables ( P > 0.05). Between-group significant differences ( P ≤ 0.05) were observed in CRF, first ventilatory threshold, and heart rate peak after the intervention period, favoring the exercise group.

CONCLUSIONS

This study demonstrated that a supervised combined exercise program in people with SZ helps to maintain body composition values and improve CRF levels. This could lead to an important clinical change in the characterization from metabolically unhealthy overweight to a metabolically healthy overweight population. Hence, exercise should be considered a co-adjuvant program in the treatment of the SZ population.

Experiences with physical activity, health and well-being among young adults with serious mental illness

PURPOSE

To explore how young adults with serious mental illness (SMI) experience physical activity and how these experiences influence their perceived health and well-being.

METHODS

Nine young adults with SMI who had participated in an aerobic high-intensity interval training program were interviewed in depth. The interviews were transcribed and subjected to reflexive thematic analysis.

RESULTS

The results indicated that people with SMI mainly experience physical activity as a meaningful activity that contributes to an increased sense of well-being and better health. However, to overcome various barriers, it is crucial to experience social support and encouragement. The following three main themes were identified through reflexive thematic analysis: (1) positive changes in focus and an increase in well-being occur through physical activity; (2) increased mental strength results from physical activity; and (3) a lack of support and feelings of safety prevent physical activity.

CONCLUSIONS

This study shows that adapted physical activity is an important resistance resource that can promote stronger self-identity, increased mental well-being and social engagement and thus contribute to an improved ability to manage stressors. Furthermore, the findings reveal that to engage in physical activity and promote sustainable life changes, it is important for individuals to choose a physical activity based on personal interest and meaning.

Physical Function Assessment of Older Veterans With Serious Mental Illness

OBJECTIVE

To characterize the physical function of older veterans with serious mental illness (SMI) across endurance, strength, and mobility domains.

DESIGN

Retrospective analysis of clinical performance data.

SETTING

Gerofit program, a national outpatient supervised exercise program for older veterans, delivered in Veterans Health Administration sites.

PARTICIPANTS

Older veterans aged 60 and older (n = 166 with SMI, n = 1,441 without SMI) enrolled across eight national Gerofit sites between 2010 and 2019.

MEASUREMENTS

Performance measures of physical function covering endurance (6-minute walk test), strength (chair stands, arm curls), and mobility (10-m walk, 8-foot-up-and-go), were administered at Gerofit enrollment. Baseline data from these measures were analyzed to characterize the functional profiles of older veterans with SMI. One sample t tests were examined to compare functional performance of older veterans with SMI to age- and sex-based reference scores. Propensity score matching (1:3) and linear mixed effects models were used to evaluate differences in function between veterans with and without SMI.

RESULTS

Older veterans with SMI performed worse on all measures of function (chair stands, arm curls, 10-m walk, 6-minute walk test, 8-foot-up-and-go) compared to age- and sex-based reference scores with statistically significant differences present in the male sample. Functional performance of those with SMI was also worse compared to propensity-score matched older veterans without SMI with statistically significant differences on chair stands, 6-minute walk test, and 10-m walk.

CONCLUSION

Older veterans with SMI have compromised strength, mobility, and endurance. Physical function should be a core component of screening and treatment for this population.

Alterations in inflammatory markers after a 12-week exercise program in individuals with schizophrenia-a randomized controlled trial

Background

In individuals with schizophrenia, inflammation is associated with depression, somatic comorbidity and reduced quality of life. Physical exercise is known to reduce inflammation in other populations, but we have only limited knowledge in the field of schizophrenia. We assessed inflammatory markers in plasma samples from individuals with schizophrenia participating in an exercise intervention randomized controlled trial. We hypothesized that (i) physical exercise would reduce levels of inflammatory markers and (ii) elevated inflammatory status at baseline would be associated with improvement in cardiorespiratory fitness (CRF) following intervention.

Method

Eighty-two individuals with schizophrenia were randomized to a 12-week intervention of either high-intensity interval training (HIIT, n = 43) or active video gaming (AVG, n = 39). Participants were assessed at baseline, post intervention and four months later. The associations between exercise and the inflammatory markers soluble urokinase plasminogen activator receptor, c-reactive protein, tumor necrosis factor (TNF), soluble TNF receptor 1 and interleukin 6 (IL-6) were estimated using linear mixed effect models for repeated measures. For estimating associations between baseline inflammation and change in CRF, we used linear regression models.

Results

Our main findings were (i) TNF and IL-6 increased during the intervention period for both groups. Other inflammatory markers did not change during the exercise intervention period; (ii) baseline inflammatory status did not influence change in CRF during intervention, except for a positive association between baseline IL-6 levels and improvements of CRF to post intervention for both groups.

Conclusion

In our study, HIIT and AVG for 12-weeks had no reducing effect on inflammatory markers. Patients with high baseline IL-6 levels had a positive change in CRF during intervention. In order to increase our knowledge regarding association between inflammatory markers and exercise in individuals with schizophrenia, larger studies with more frequent and longer exercise bout duration are warranted.

The efficacy of exercise interventions for all types of inpatients across mental health settings: A systematic review and meta-analysis of 47 studies

This systematic review and meta-analysis investigated the benefits, safety and adherence of exercise interventions delivered in inpatient mental health settings, quantified the number of exercise trials that provided support to maintain engagement in exercise post-discharge, and reported patient feedback towards exercise interventions. Major databases were searched from inception to 22.06.2022 for intervention studies investigating exercise in mental health inpatient settings. Study quality was assessed using Cochrane and ROBINS-1 checklists. Fifty-six papers were included from 47 trials (including 34 RCTs), bias was high. Exercise improved depression (Standardised mean difference = -0.416; 95% Confidence interval -0.787 to -0.045, N = 15) compared to non-exercise comparators amongst people with a range of mental illnesses, with further (albeit limited) evidence suggesting a role of exercise in cardiorespiratory fitness and various other physical health parameters and ameliorating psychiatric symptoms. No serious exercise-related adverse events were noted, attendance was ≥80% in most trials, and exercise was perceived as enjoyable and useful. Five trials offered patients post-discharge support to continue exercise, with varying success. In conclusion, exercise interventions may have therapeutic benefits in inpatient mental health settings. More high-quality trials are needed to determine optimal parameters, and future research should investigate systems to support patients to maintain exercise engagement once discharged.

Associations between aerobic fitness, negative symptoms, cognitive deficits and brain structure in schizophrenia—a cross-sectional study

Negative symptoms and cognitive deficits are common in individuals with schizophrenia, greatly affect their outcome, and have been associated with alterations in cerebral gray and white matter volume (GMV, WMV). In the last decade, aerobic endurance training has emerged as a promising intervention to alleviate these symptoms and improved aerobic fitness has been suggested as a key moderator variable. In the present study, we investigated, whether aerobic fitness is associated with fewer cognitive deficits and negative symptoms and with GMVs and WMVs in individuals with schizophrenia in a cross-sectional design. In the largest study to date on the implications of fitness in individuals with schizophrenia, 111 participants at two centers underwent assessments of negative symptoms, cognitive functioning, and aerobic fitness and 69 underwent additional structural magnetic resonance imaging. Multilevel Bayesian partial correlations were computed to quantify relationships between the variables of interest. The main finding was a positive association of aerobic fitness with right hippocampal GMV and WMVs in parahippocampal and several cerebellar regions. We found limited evidence for an association of aerobic fitness with cognitive functioning and negative symptoms. In summary, our results strengthen the notion that aerobic fitness and hippocampal plasticity are interrelated which holds implications for the design of exercise interventions in individuals with schizophrenia.

Impact of Moderating Demographic Variables on a Health Intervention for People with Serious Mental Illness

Purpose

Healthy lifestyle interventions can improve the health of people with serious mental illness (SMI). Little is known whether demographic variables moderate the effectiveness of these interventions on health outcomes.

Method

Data from an effectiveness trial of a peer-led healthy lifestyle intervention (PGLB) for people with SMI examine whether age, racial/ethnic minoritized status, and gender moderated the effectiveness of PGLB compared to usual care (UC) in achieving clinically significant improvements in weight, cardiorespiratory fitness, and cardiovascular disease (CVD) risk reduction.

Results

Compared to UC, PGLB was most beneficial for participants age 49 and younger for achieving clinically significant weight loss and from racial/ethnic minoritized communities for achieving clinically significant weight loss and reductions in CVD risk.

Conclusions

These findings suggest the impact of healthy lifestyle interventions for people with SMI may not be uniform and adaptations may be needed to make these interventions responsive to the needs of diverse populations.

Physical activity can reduce hopelessness among women admitted to psychiatric short stay unit following a suicide crisis

BACKGROUND

In a growing number of countries, brief hospitalizations in psychiatric short stay units (SSUs) are proposed to patients in acute mental health crisis (typically suicide crisis).

AIMS

This pilot study's purpose was to assess the feasibility, acceptability, and plausible efficacy of two days of 30 min of brisk-walking/jogging compared to 30 min of sedentary activities in suicidal inpatients from a French psychiatric SSU.

METHODS

Twelve female adults completed the study. Participants in the brisk-walking/jogging group (n = 6) received two exercise sessions of 30 min separated by a time interval of 24 h. Participants in the control group (n = 6) did not receive the exercise intervention, but were asked to engage in sedentary activities of similar duration at the same time of the day. Measures of hopelessness and optimism/pessimism were administered at the intake and final assessments. In addition, other performance indicators were explored and provide the readers with information about the feasibility and acceptability of intervention.

RESULTS

Findings showed strong feasibility and acceptability (no serious adverse event, adherence and retention rates around 75%-80%, and high patients satisfaction ratings). Significant differences between groups favoring women who exercised were oberved in the score change of hopelessness (Hedges's g = -1.29, 95% CI [-2.65, -0.08]).

CONCLUSION

The present study provides preliminary evidence for the plausible adjunctive efficacy of physical activity to alleviate the psychological distress suffered by suicidal patients in a psychiatric SSU.

Learning, doing and sticking with it: A qualitative study on achieving clinically significant reduction in cardiovascular disease risk in a healthy lifestyle intervention for people with serious mental illness

People with serious mental illness (SMI; e.g. schizophrenia) have mortality rates two to three times higher than the general population, largely due to a higher prevalence of cardiovascular disease (CVD). Healthy lifestyle interventions can improve the health of people with SMI, but information about why these interventions work for some and not others is scarce. Our study aims to qualitatively explore differences in these two groups' overall experiences and application of the intervention. Data were drawn from a randomised effectiveness trial of a peer-led healthy lifestyle intervention. Qualitative data from interviews and focus groups with 21 participants were linked to their 12-month outcome data. Grounded theory was used to compare the experiences of participants who achieved clinically significant CVD risk reduction (i.e. clinically significant weight loss or clinically significant improvements in cardiorespiratory fitness) versus those who did not. Three qualitative themes: learning, change, sticking with it - differentiated participants who achieved CVD risk reduction and those that did not. Participants achieving CVD risk reduction described learning and applying specific knowledge and skills related to a healthy lifestyle when making health decisions, made healthy concrete changes to diet and physical activity, and stuck with those changes. Participants not achieving clinically significant CVD risk reduction reported surface-level learning about healthy lifestyle practices, difficulty sticking with healthy changes, and were more likely to report ambiguous or no changes. Our findings suggest that healthy lifestyle interventions for people with SMI should provide experiential in-vivo learning experiences while periodically assessing participants' understanding and then tailoring the intervention to their needs. It is important to build self-efficacy for health behaviour changes by creating early perceptions of success, which was found to enhance motivation and sustain behaviour change. Helping people with SMI develop and strengthen their support systems will also be an important factor for building and sustaining health behaviour changes.

Effects of Aerobic, Resistance, and Combined Exercise Training on Psychiatric Symptom Severity and Related Health Measures in Adults Living With Schizophrenia: A Systematic Review and Meta-Analysis

Previous research has demonstrated the efficacy, effectiveness, and safety of exercise training in persons living with schizophrenia. However, the optimal exercise training program remains unclear. The aim of this paper was to conduct a systematic review and meta-analysis of the effects of aerobic, resistance, and combined aerobic and resistance training on health-related physical fitness and positive and negative symptoms in persons living with schizophrenia. Six electronic databases were searched systematically from their inception to December 2020 [MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, SPORTDiscus, and Cumulative Index to Nursing and Allied Health Literature (CINAHL)] to identify literature examining the effects of exercise training on psychiatric symptoms and health-related physical fitness indicators in persons living with schizophrenia. A total of 22 studies (n = 913) were included in this review, and 12 studies (n = 554) included within the meta-analysis reported the effects of exercise training (aerobic, resistance, and combined aerobic and resistance) in persons living with schizophrenia. Aerobic training had a significant decrease on Positive and Negative Syndrome Scale (PANSS) negative scores (ES −2.28, 95% CI −3.57 to −1.00; p = 0.0005) and PANSS general scores (ES −2.51, 95% CI −3.47 to −1.55; p &lt; 0.00001). Resistance training did not lead to significant effects on PANSS total scores. Combined aerobic and resistance training did not lead to significant changes in body mass index, PANSS positive scores, or PANSS total scores. However, grouping together the results from all exercise training modalities (including aerobic training, resistance training, and combined aerobic and resistance training) revealed significant effects on body mass index (ES 1.86, 95% CI 0.84 to 2.88; p = 0.0003), maximal/peak oxygen consumption (ES 2.54, 95% CI 1.47 to 3.62; p = &lt; 0.00001), body weight (ES 6.58, 95% CI 2.94 to 10.22; p = 0.0004), PANSS negative scores (ES −1.90, 95% CI −2.70 to −1.10; p &lt; 0.00001), and Scale for the Assessment of Negative Symptoms (SANS) total (ES −14.90, 95% CI −22.07 to −7.74; p &lt; 0.0001). Collectively, these findings support the importance of exercise participation (aerobic and resistance training) in persons living with schizophrenia.

The efficacy and safety of exercise and physical activity on psychosis: A systematic review and meta-analysis

BACKGROUND

Treatment of psychosis typically focuses on medication, but some of these medications can have unintended side effects, exercise has global health benefits, with minimal side effects. The purpose of this systematic review and meta-analysis is to investigate the effectiveness and safety of exercise and physical activity on psychotic symptoms, in people with psychosis when compared to usual care, in a hospital setting.

METHODS

A systematic electronic search of the literature was performed in June 2022, in PubMed, Scopus, and PsychINFO with no date restrictions. We included randomized trials (RCTs) with patients with psychosis that received an exercise intervention within a hospital setting. The primary outcome of interest was Positive and Negative Symptom Severity Scale (PANSS) overall score. Secondary outcomes were adverse or serious adverse events.

RESULTS

A total of 24 trials were included in this systematic review, with 9 included in the meta-analysis, including 1,426 participants. Aerobic had more pronounced effects when compared to usual care in PANSS positive (-0.23, 95% CI -0.53 to 0.07), negative (-0.38, 95% CI -0.65 to -0.10), general (-0.42, 95% CI -0.71 to -0.13) and overall scores (-0.25, 95% CI -0.52 to 0.03). Yoga when compared to usual care had no difference in PANSS subscale and overall scores. We found no difference on relapsing of psychiatric symptoms or somatic hospitalization when we compared aerobic or yoga to usual care (Risk Ratio, 1.12 95% CI 0.44-2.81).

CONCLUSION

Aerobic activity as an exercise modality in a hospital setting can be effective in decreasing negative and general psychosis symptom severity scores compared to usual care, however, it was uncertain if the effects were clinically important. More trials are needed to confirm the clinically benefit of aerobic exercise.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42021224997].

Biopsychology of Physical Activity in People with Schizophrenia: An Integrative Perspective on Barriers and Intervention Strategies

People with severe mental illness such as schizophrenia experience high physical comorbidity, leading to a 15-20-year mortality gap compared with the general population. Lifestyle behaviours such as physical activity (PA) play important roles in the quest to bridge this gap. Interventions to increase PA engagement in this population have potential to be efficacious; however, their effectiveness can be hindered by low participant engagement, including low adherence and high drop-out, and by implementation of interventions that are not designed to compensate for the cognitive and motivational impairments characteristic for this group. Moreover, and importantly, the negative symptoms of schizophrenia are associated with neurobiological changes in the brain, which-based on principles of biopsychology-can contribute to poor motivation and impaired decision-making processes and behavioural maintenance. To increase PA levels in people with schizophrenia, better understanding of these neurological changes that impact PA engagement is needed. This has the potential to inform the design of interventions that, through enhancement of motivation, could effectively increase PA levels in this specific population. Incorporating strategies that address the dopamine dysregulation associated with schizophrenia, such as boosting the role of reward and self-determined motivation, may improve long-term PA maintenance, leading to habitual PA. Consideration of motivation and behavioural maintenance is also needed to impart health benefits such as prevention of chronic disease, which is associated with currently low PA levels in this high metabolic risk population. Taking a biopsychological perspective, we outline the neural pathways involved in motivation that are impacted by schizophrenia and propose strategies for promoting motivation for and PA engagement from adoption to habit formation.

Association between aerobic fitness and the functional connectome in patients with schizophrenia

BACKGROUND

Schizophrenia is accompanied by widespread alterations in static functional connectivity associated with symptom severity and cognitive deficits. Improvements in aerobic fitness have been demonstrated to ameliorate symptomatology and cognition in people with schizophrenia, but the intermediary role of macroscale connectivity patterns remains unknown.

OBJECTIVE

Therefore, we aim to explore the relation between aerobic fitness and the functional connectome in individuals with schizophrenia. Further, we investigate clinical and cognitive relevance of the identified fitness-connectivity links.

METHODS

Patients diagnosed with schizophrenia were included in this cross-sectional resting-state fMRI analysis. Multilevel Bayesian partial correlations between aerobic fitness and functional connections across the whole brain as well as between static functional connectivity patterns and clinical and cognitive outcome were performed. Preliminary causal inferences were enabled based on mediation analyses.

RESULTS

Static functional connectivity between the subcortical nuclei and the cerebellum as well as between temporal seeds mediated the attenuating relation between aerobic fitness and total symptom severity. Functional connections between cerebellar seeds affected the positive link between aerobic fitness and global cognition, while the functional interplay between central and limbic seeds drove the beneficial association between aerobic fitness and emotion recognition.

CONCLUSION

The current study provides first insights into the interactions between aerobic fitness, the functional connectome and clinical and cognitive outcome in people with schizophrenia, but causal interpretations are preliminary. Further interventional aerobic exercise studies are needed to replicate the current findings and to enable conclusive causal inferences.

TRIAL REGISTRATION

The study which the manuscript is based on is registered in the International Clinical Trials Database (ClinicalTrials.gov identifier [NCT number]: NCT03466112) and in the German Clinical Trials Register (DRKS-ID: DRKS00009804).

The short and long-term effects of aerobic, strength, or mixed exercise programs on schizophrenia symptomatology

The purpose of this study was to compare the effects of three different physical exercise programs on the symptomatology, body composition, physical activity, physical fitness, and quality of life of individuals with schizophrenia. A total of 432 patients were assessed for eligibility and 86 were randomized into the aerobic (n = 28), strength (n = 29) or mixed (n = 29) groups. Positive, negative, and general symptoms of psychosis, body mass index (BMI), physical activity (IPAQ-SF), physical fitness (6-min walk test [6MWT] and hand-grip strength [HGS]), and quality of life (WHOQUOL-BREF) were assessed at baseline, post-intervention (16 weeks), and at 10-months. Our results at 16 weeks showed significant improvements in all three groups in the negative, general, and total symptoms with moderate to large effect sizes (P < 0.01, η_p² > 0.11), no change in the BMI, 6MWT or IPAQ-SF, and a significant improvement in the HGS test in the strength and mixed groups (P ≤ 0.05, η_p² > 0.08). Nonetheless, all the improvements had disappeared at 10 months. We concluded that 3 weekly sessions of a moderate to vigorous progressive exercise program for 16 weeks improved the symptomatology of individuals with schizophrenia in all three groups, with no differences between them. However, the effects had declined to baseline levels by the 10-month follow-up, suggesting that exercise interventions should be maintained over time.

Interoception abnormalities in schizophrenia: A review of preliminary evidence and an integration with Bayesian accounts of psychosis

Schizophrenia research has traditionally focused almost exclusively on how the brain interprets the outside world. However, our internal bodily milieu is also central to how we interpret the world and construct our reality: signals from within the body are critical for not only basic survival, but also a wide range of brain functions from basic perception, emotion, and motivation, to sense of self. In this article, we propose that interoception-the processing of bodily signals-may have implications for a wide range of clinical symptoms in schizophrenia and may thus provide key insights into illness mechanisms. We start with an overview of interoception pathways. Then we provide a review of direct and indirect findings in various interoceptive systems in schizophrenia and interpret these findings in the context of computational frameworks that model interoception as hierarchical Bayesian inference. Finally, we propose a conceptual model of how altered interoceptive inference may contribute to specific schizophrenia symptoms-negative symptoms in particular-and suggest directions for future research, including potential new avenues of treatment.

Ideal Cardiovascular Health in Racially and Ethnically Diverse People with Serious Mental Illness

Cardiovascular disease is a primary contributor to premature death among people with serious mental illness (SMI). This study used baseline data (N=314) from an effectiveness trial testing a healthy lifestyle intervention for racial/ethnically diverse participants with overweight/obesity and SMI living in supportive housing. We examined the prevalence and correlates of a modified version of the American Heart Association (AHA) metric of ideal cardiovascular health (ICVH). Five AHA ICVH metrics (smoking, body mass index, diet, physical activity, and blood pressure) were used to create a composite ICVH score. The mean ICVH score was 3.15 (range 0-8). Multivariate analysis indicated that higher ICVH scores were associated with lifetime cancer diagnosis and better cardiorespiratory fitness. Lower scores were associated with female gender, racial/ethnic minority status, and antipsychotic use, suggesting that these subgroups of people with SMI may benefit from targeted screening and interventions to improve their cardiovascular health.

Effects of the aerobic and Pilates exercises on mental health in inactive older women

This study aimed to compare the effect of the Aerobic and Pilates exercises on mental health in inactive older women. Seventy-five inactive aged women were randomly divided into three groups (n = 25); aerobic (62.48 ± 2.87 years), Pilates (62.66 ± 1.68 years), and control group (63.80 ± 3.35 years). The Goldberg General Health Questionnaire assessed mental health. The exercise program was performed for 12 weeks. The results indicate that Pilates exercises are more valuable than aerobic training in depression (p ≤ .05). However, in other mental health components, the difference between the two exercise groups was not statistically significant. According to our results, physical activity, particularly Pilates and aerobic exercises, improves physical health and has a close correlation with the mental health of inactive older women. These results highlight the role of these physical exercise training in older women.

Improved self-esteem and activity levels following a 12-week community activity and healthy lifestyle programme in those with serious mental illness: A feasibility study

BACKGROUND

Those with serious mental illness (SMI) including both psychotic and affective disorders are recognized to have a premature mortality compared to the general population, at least in part due to elevated cardiovascular risk profile.

AIM

To examine the effect of a 12-week, pragmatic, sustainable, low-cost intervention involving community activity, nutritional advice and exercise that could be accessible to patients attending a community clinic.

METHODS

Participants (N = 35) with SMI attending a community mental health service who were considered at risk of metabolic syndrome were referred by their clinical teams to a specialized healthy activity and nutritional programme. The intervention involved participation in exercise, dietary education and targeted lifestyle advice focused on community activities. Data on physical health and clinical parameters were collected pre- and post-intervention.

RESULTS

Physical activity increased following the intervention along with a statistically significant increase in self-esteem scores. There was no significant reduction in body mass index or lowering of anxiety and depression scores.

CONCLUSIONS

It is feasible to develop a relatively low-cost, community-based physical activity programme, integrating both nutritional advice and healthy activities. This may lead to improved outcomes in cardiovascular risk profile and improved life expectancy.

Targeting Physical Health in Schizophrenia: Results from the Physical Activity Can Enhance Life (PACE-Life) 24-Week Open Trial

Poor health and low cardiorespiratory fitness (CRF) contribute substantially to the shortened lifespan of individuals with schizophrenia spectrum disorders (SSDs). Increasing physical activity has demonstrated value; however, there are limited interventions that are accessible and adequately address motivational challenges. This paper reports on an open trial of Physical Activity Can Enhance Life (PACE-Life), a motivational theory-based manualized multicomponent walking intervention. The primary aim was to examine the feasibility of implementing PACE-Life through meeting the recruitment target (n=14), attendance and adherence rates, and participant feedback. The secondary aim was to assess the impact of PACE-Life on intermediate targets (autonomous motivation and satisfaction of autonomy, relatedness, and competence needs), proximal outcomes (Fitbit steps/day and minutes spent walking), the primary outcome (CRF), and secondary outcomes (loneliness, symptoms, resting heart rate, blood pressure, weight, body mass index, and hip and waist circumference). Seventeen participants with SSDs enrolled in a 24-week open trial. Assessments occurred at baseline, midpoint, post-test, and one-month follow-up. The recruitment target was exceeded, the group attendance rate was 34%, Fitbit adherence rate was 54%, and participant feedback indicated satisfaction with the intervention as well as a positive group environment. There was a large improvement in the primary outcome of CRF with 77% of participants achieving clinically significant improvement at post-test. Small and medium effect size increases were observed in autonomous motivation and satisfaction of autonomy, relatedness, and competence needs. Fitbit data and secondary outcomes generally remained unchanged or worsened during the intervention. Results from this open trial indicate that PACE-Life leads to meaningful changes in CRF among people with SSDs.

Circulating IGFBP-2 levels reveal atherogenic metabolic risk in schizophrenic patients using atypical antipsychotics

OBJECTIVES

Second generation antipsychotics (SGAs) induce weight gain and dyslipidemia, albeit with important intervariability. Insulin-like growth factor binding protein (IGFBP)-2 is proposed as a circulating biomarker negatively associated with waist circumference and hypertriglyceridemia. Thus, we tested whether metabolic alterations developed upon the use of SGAs are associated with plasma IGFBP-2 levels.

METHODS

A cross-sectional study was performed in 87 men newly diagnosed with schizophrenia and administered for approximately 20 months with olanzapine or risperidone as their first antipsychotic treatment. Plasma IGFBP-2 concentration, anthropometric data, as well as glucose and lipid profiles were determined at the end of the treatments.

RESULTS

IGFBP-2 levels were similar between patients using olanzapine or risperidone and were negatively correlated with waist circumference, insulin sensitivity, and plasma triglycerides (TG). A higher proportion of men with a hypertriglyceridemic (hyperTG) waist phenotype was found in patients with IGFBP-2 levels lower than 220 ng/mL (43% for olanzapine and 13% for risperidone) compared to those with IGFBP-2 above this threshold (10% and 0%, respectively).

CONCLUSIONS

IGFBP-2 may have a role in altering metabolic risk in schizophrenic patients using SGAs. Longitudinal studies are required to evaluate whether IGFBP-2 can predict the development of a hyperTG waist phenotype in this population.

The Impact of Pharmacological and Non-Pharmacological Interventions to Improve Physical Health Outcomes in People With Schizophrenia: A Meta-Review of Meta-Analyses of Randomized Controlled Trials

(Reprinted with permission from World Psychiatry 2019;18:53-66).

In- and outpatient lifestyle interventions on diet and exercise and their effect on physical and psychological health: a systematic review and meta-analysis of randomised controlled trials in patients with schizophrenia spectrum disorders and first episode of psychosis

Patients with non-affective psychosis often lead unhealthy lifestyles. We performed a systematic review and meta-analysis on non-pharmacological RCTs for improvement of diet and physical activity in non-affective psychosis patients, including first-episode psychosis. A variety of outcomes was analysed, including metabolic, psychopathology, cognitive, functional and quality of life outcomes. Fifty-nine studies were included. An improvement in anthropometric measurements (BMI, weight, waist circumference) was observed post-intervention, persisting after follow-up. Post-intervention benefit was found also for psychotic symptoms severity (also persisting after follow-up), many cognitive domains and physical and global functioning and quality of life. Conversely, no effect was observed in relation to most blood metabolites, blood pressure and non-psychotic psychopathology and spontaneous physical activity. Improvement was generally larger for interventions including exercise, especially moderate/vigorous aerobic exercise, but follow-up maintenance was greater for psychotherapy interventions. Sensitivity analyses limited to chronic stages of psychosis and low risk of bias studies produced comparable results. Further studies are needed to design optimized interventions in this vulnerable population.

Effect of high-intensity interval training on cardiorespiratory fitness, physical activity and body composition in people with schizophrenia: a randomized controlled trial

BACKGROUND

Exercise may improve cardiorespiratory fitness in people with schizophrenia, however, possible condition-specific cardiorespiratory disadvantages, a scarcity of methodologically sound studies, and conflicting results raise questions about the effect of exercise on maximal oxygen uptake (VO_2max) in this group. The primary aim of this study, therefore, was to investigate the effect of high-intensity interval training on VO_2max in people with schizophrenia. Second, we sought to determine whether the intervention would have an effect on general physical activity (PA) level and body composition.

METHODS

Eighty-two patients with schizophrenia were randomly assigned to supervised high-intensity interval training or computer gaming skills training, performed twice a week for 12 weeks. Oxygen uptake was measured directly, during a maximum exercise session on a treadmill. PA level were assessed using ActiGraph accelerometer, and body composition was assessed by bioelectrical impedance. Differences between groups were assessed by analysis of variance using a univariate general linear model.

RESULTS

There were no significant differences between the groups on any of the cardiorespiratory variables neither at baseline nor after the program. There were also no significant within-group differences in any of the cardiorespiratory fitness variables between the baseline and post-program time points, despite that 61% of the participants performing high-intensity interval training showed a significant increase in workload on the treadmill. However, 47% of the participants in the high-intensity interval training group had a ≥ 5% increase in VO_2max. Participants supervised by mental health care providers with PA competence (e.g. rehabilitation center staff, sport scientist, physical trainer) had a much larger increase in VO_2max compared to participants supervised by mental health workers without such competence, and when adding PA competence to the model, the intervention group increased VO_2max significantly compared to the comparison group. The intervention had no significant effect on PA level or body composition.

CONCLUSIONS

The intervention did not improve VO_2max, PA level or body composition but succeeded in increasing workload on the treadmill. With regard to VO_2max, approximately half of the patients may be considered responders.

TRIAL REGISTRATION

ClinicalTrials.gov ; NCT02205684 , registered July 2014.

Correlates of Physical Activity and Cardiorespiratory Fitness in Racially and Ethnically Diverse People with Serious Mental Illness in Supportive Housing

We examined demographic, health, and mental health correlates of physical activity and cardiorespiratory fitness (CRF) in racially and ethnically diverse people with serious mental illness (SMI) living in supportive housing. We used baseline data from 314 people with SMI enrolled in a randomized effectiveness trial of a peer-led healthy lifestyle intervention. Sedentary behavior and physical activity were measured with the International Physical Activity Questionnaire. CRF was measured with the 6-min walking test (6MWT). Correlates were identified via ordinary least squares and logistic regressions. Participants were mostly male and racial/ethnic minorities. Thirty-four percent engaged in at least 150-min-per-week of at least moderate-intensity physical activity. On average, participants walked 316.8 m in the 6MWT. Our models show that physical activity and CRF were not evenly distributed in racially and ethnically diverse people with SMI and are associated with multiple demographic, mental health, and health factors. Our findings suggest subgroups and factors that can be targeted to develop health interventions to improve the physical health of people with SMI.

A comparison study of three physical activity measurement tools examining acceptability in people with psychosis

OBJECTIVE

To compare the acceptability of three distinct physical activity measurement tools in people with psychosis: an objective measurement tool, a self-report measure, and an exercise capacity test.

METHODS

We measured the completion rate for each measurement tool. Participants rated the ease/difficulty of each measure using a 7-point Likert scale. Participants were also asked to rank the three tools in order of the ease of use.

RESULTS

Sixty-six per cent (46/69) of participants completed all three assessment tools, and 60.9% (42/69) completed the acceptability questionnaire. The majority of the participants found it easy to complete all three measurement tools. The majority (52.8%) of the participants ranked the objective measurement tool as the easiest to use.

CONCLUSION

All three measures were acceptable to people with psychosis, but objective measurement tools may be easier to use.

Does physical activity reduce the risk of psychosis? A systematic review and meta-analysis of prospective studies

Longitudinal prospective cohorts have suggested that physical activity (PA) may be a protective factor against psychosis and schizophrenia. However, no meta-analysis has been conducted. The study aims to examine the prospective relationship between PA and incident psychosis/schizophrenia. Major databases were searched from inception to July 2019 for prospective studies that calculated the odds ratio (OR) or the adjusted odds ratio (AOR) of incident psychosis/schizophrenia in people with higher PA against people with lower PA. Methodological quality was assessed using the Newcastle-Ottawa Scale (NOS). A random-effects meta-analysis was conducted, for OR and AOR, separately. Across 4 cohorts (N = 30,025 median males = 50%, median follow-up = 32 years), people with high self-reported PA (versus low PA) were at reduced odds of developing psychosis/schizophrenia (OR = 0.73, 95%CI 0.532 to 0.995, p = 0.047). Analysis including 2 cohorts presenting AOR were not statistically significant (AOR = 0.59, 95%CI 0.253 to 1.383, p = 0.226). Overall study quality was high (mean NOS = 7.0). The literature on the topic is scarce, whilst crude analysis suggests that PA may be a protective factor against the emergence of psychosis/schizophrenia, but when adjusting for covariates, the association is no longer significant. Further studies with objective physical activity and adjustment for confounders are needed.

High Intensity Interval training (HIIT) for people with severe mental illness: A systematic review & meta-analysis of intervention studies- considering diverse approaches for mental and physical recovery

There is a mortality gap of 15 to 20 years for people with severe mental illness (SMI - psychotic spectrum, bipolar, major depressive disorders). Modifiable risk factors include inactivity and low cardiorespiratory fitness (CRF). Exercise can improve mental and physical outcomes; optimal type and intensity of exercise for people with SMI has yet to be determined. High Intensity Interval training (HIIT) is an exercise with distinct cardio-metabolic advantages in other disease populations compared to traditional moderate intensity continuous training (MCT). We investigated the feasibility and efficacy of HIIT for people with SMI. Major electronic databases were searched, identifying HIIT studies for adults experiencing SMI.Data on feasibility, safety, study design, sample characteristics, and physical and psychological outcomes were extracted and systematically reviewed. Meta-analyses were conducted within group, pre and post HIIT interventions, and between group, to compare HIIT with control conditions. Nine articles were identified including three pre/post studies, one non randomised and five randomised trials, (366 participants, 45.1% female). HIIT appears as feasible as MCT, with few safety concerns. Following HIIT, there was a moderate improvement in CRF and depression. There was no difference between HIIT and MCT for adherence or CRF.HIIT improved depression more than MCT.

Exercise and Schizophrenia

Schizophrenia is a psychiatric disorder characterized by distortions of thinking and perception, with no strictly pathognomonic symptoms that can be divided into positive, negative, and cognitive symptom domains. People with schizophrenia have, between others, a reduced life expectancy and cardiorespiratory and muscular fitness and increased risk of cardiovascular disease, metabolic syndrome, obesity, hypertension, and hyperlipidemia compared to the general population. Furthermore, the economic burden of mental disorders including schizophrenia is evident and it is expected to increase to more than double by 2030. Therefore, reducing the growing burden of mental disorders such as schizophrenia should be a health priority. Improved prevention and treatment are two key factors that may reduce the burden of schizophrenia. Pharmacological- and psychotherapy-based interventions have been traditionally considered for treating schizophrenia disorders; however, there is an increasing amount of scientific evidence confirming that physical activity and physical exercise should be highly considered in prevention and treatment of schizophrenia disorders. In this chapter, we aim to summarize and discuss the research progress of physical activity and exercise in prevention and treatment of schizophrenia disorder. Specifically, we summarized and discussed the research progress of the prognostic use of physical activity for incident schizophrenia; the importance of other outcomes typically improved by physical activity/exercise such as obesity and fitness (cardiorespiratory and muscular fitness) for future schizophrenia; the research progress of the evidence of the benefits of exercise in people with schizophrenia disorders differentiating between effects of exercise on varied health outcomes, cognitive functioning, and cardiorespiratory fitness; and finally the clinical practice recommendations.

Feasibility and Acceptability of a Student-Led Lifestyle (Diet and Exercise) Intervention Within a Residential Rehabilitation Setting for People With Severe Mental Illness, GO HEART (Group Occupation, Health, Exercise And Rehabilitation Treatment)

PURPOSE

People with severe mental illness (SMI) experience poor physical health and premature mortality, contributed significantly by modifiable lifestyle risk factors such as poor nutrition, low cardiorespiratory fitness, and physical inactivity. Lifestyle interventions can reduce cardiometabolic risk and confer a range of other positive mental and physical health benefits. We assessed the feasibility, acceptability, safety, and preliminary effectiveness of a lifestyle (combined dietary and exercise) intervention lead by senior exercise and dietetics students in a residential mental health rehabilitation setting.

DESIGN

Single arm, prospective study evaluating outcomes pre and post a 10-week dietary and exercise intervention.

METHOD

People with SMI from three residential rehabilitation units participated in a mixed aerobic and resistance training exercise intervention three times per week that was combined with a dietary intervention (six individual and group sessions). Primary outcome considerations were feasibility (recruitment, retention, and participation rates), acceptability, and adverse events. Secondary outcomes were preliminary effectiveness; (functional exercise capacity, volume of exercise, and metabolic markers), psychiatric symptoms, quality of life, and attitudes to exercise.

RESULTS

Forty-two participants were recruited (92% primary diagnosis of schizophrenia). Intervention feasibility was supported by high levels of recruitment (68%), retention (77%), and participation (70% exercise, 65% diet sessions); and the absence of serious adverse events. Significant improvements in functional exercise capacity, volume of exercise, general psychiatric symptoms, and negative psychotic symptoms occurred. Anthropometric and metabolic blood markers did not change. While the intervention was acceptable to participants, motivation for and perceived value of exercise reduced over 10 weeks.

CONCLUSIONS

A brief pragmatic student-led lifestyle intervention integrated into usual mental health care was feasible, acceptable, safe, and scalable across two additional mental health residential rehabilitation sites, and resulted in physical and mental health improvements. Increased frequency of dietary sessions and length of dietary intervention may improve metabolic outcomes in the future. People with SMI living in residential rehabilitation units should have access to lifestyle programs to address modifiable lifestyle risk factors. While this brief intervention was feasible and acceptable, this study highlights some of the challenges associated with maintaining motivation for healthy lifestyles for people with SMI. Longer term investigation of real-world lifestyle interventions is warranted, together with additional interventions that may support people with SMI to sustain motivation to address lifestyle factors.

CLINICAL TRIAL REGISTRATION

The trial was registered with the Australian New Zealand Clinical Trials Registry (ANZCTR), Unique Identifier: ACTRN 12618000478213, http://www.anzctr.org.au Universal trial number (UTN)-U1111-1211-4009.

Association of Depression With Functional Mobility in Schizophrenia

BACKGROUND

Functional immobility can cause functional disability in patients with schizophrenia and has been linked to prognosis and mortality. Although depression might be a barrier for physical activity engagement, scarce data are present on the relationship between depression and functional mobility (FM) in schizophrenia. Thus, we aimed to investigate the associations among FM, depression, and other clinical correlates in individuals with schizophrenia.

METHODS

FM was evaluated by the pedometer-assessed daily steps and Timed Up-and-Go (TUG) test in the daily-living and clinical settings, respectively. Psychiatric symptoms were assessed using the Beck Depression Inventory, Brief Psychiatric Rating Scale (BPRS), and State-Trait Anxiety Inventory. Cognitive function was evaluated using the Sternberg Working Memory (SWM) Task. Multiple regression analyses were performed to identify predictive factors associated with FM, with adjustment for relevant covariates.

RESULTS

Sixty patients were enrolled in this study. Depression was the most consistent explanatory variable for both pedometer (β = -0.34, p = 0.011) and TUG time (β = 0.32, p = 0.018). Additionally, SWM accuracy (β = -0.29, p = 0.018), BPRS-Withdrawal (β = 0.19, p = 0.139), and fasting blood sugar (β = 0.34, p = 0.008) were associated with TUG time. However, psychotic symptoms and anxiety were not associated with pedometer and TUG.

CONCLUSIONS

We identified an association between depression and FM after adjusting for other disorder-related correlates in schizophrenia. Since the intervention goal is functional recovery, improving FM by treating depression may have considerable therapeutic value.

Improving Cognition via Exercise (ICE): Study Protocol for a Multi-Site, Parallel-Group, Single-Blind, Randomized Clinical Trial Examining the Efficacy of Aerobic Exercise to Improve Neurocognition, Daily Functioning, and Biomarkers of Cognitive Change in Individuals with Schizophrenia

Individuals with schizophrenia (SZ) display cognitive deficits that have been identified as major determinants of poor functioning and disability, representing a serious public health concern and an important target for interventions. At present, available treatments offer only minimal to moderate benefits to ameliorate cognitive deficits. Thus, there remains an urgent need to identify novel interventions to improve cognition in people with SZ. Emerging evidence from animal and basic human research suggests aerobic exercise training (AE) has beneficial effects on cognition. Preliminary findings suggest that AE is efficacious in improving cognitive functioning in SZ, however the extant studies have been limited by small samples, a dearth of information on biologically-relevant covariates, and limited information on impact on daily functioning. Additionally, while AE-related cognitive benefits have been linked to Brain-Derived Neurotrophic Factor (BDNF) upregulation, this putative mechanism needs confirmation. The present report describes a study protocol designed to address these limitations-we review and summarize the current literature on treatment of cognitive deficits in SZ, state the rationale for employing AE to target these deficits, and describe the current protocol-a multi-site, single-blind, randomized clinical trial aiming to recruit 200 community-dwelling individuals with SZ. Participants are randomized to one of two 12-week interventions: AE using active-play video games (i.e., Xbox Kinect) and traditional cardiovascular exercise equipment or a stretching-and-toning (ST) control intervention. Participants undergo assessments of aerobic fitness, cognition, and daily functioning, as well as BDNF and other biomarkers of cognitive change, at baseline and after 6-and 12-weeks.

Test-retest reliability, concurrent validity and correlates of the two-minute walk test in outpatients with psychosis

The aim of this study was to investigate the test-retest reliability of the 2-minute walk test (2MWT) and the concurrent validity with the 6-minute walk test (6MWT) in outpatients with psychosis. We also explored whether there was a practice effect, determined minimal detectable changes (MDC) and assessed which factors are associated with the 2MWT performance. Fifty outpatients [22 women; 33.5 (14.3) years] performed the 2MWT twice and the 6MWT once and completed the Simple Physical Activity Questionnaire (SIMPAQ) and Brief Symptoms Inventory -18. The median (interquartile) 2MWT score on the first and second test were 128.0 (44.0) meters and 128.0 (31.5) meters, without significant difference between the two trials. The intraclass coefficient was 0.94 (95% confidence interval=0.91-0.97). The significant Spearman Rho correlation between the second 2MWT and the 6MWT was 0.69. The MDC was 22 m for men and 21 m for women. There was no evidence for a practice effect. Variability in SIMPAQ sedentary, exercise, incidental physical activity and leg pain following the test explained 54.6% of the variance in 2MWT score. The current study demonstrates that the 2MWT is a reliable, valid and clinically feasible tool for assessing and evaluating the functional exercise capacity in outpatients with psychosis.

Aerobic interval training in standard treatment of out-patients with schizophrenia: a randomized controlled trial

OBJECTIVE

To evaluate the feasibility and effects of integrating aerobic interval training (AIT) in standard care of out-patients with schizophrenia on aerobic capacity and conventional cardiovascular disease (CVD) risk factors.

METHODS

Out-patients with schizophrenia spectrum disorder were randomized to the following: 1) a training group (TG), performing AIT 2 day/week at the clinic with adherence support from municipal services; or 2) a control group (CG), given two AIT sessions and encouraged to exercise on their own. Feasibility was assessed through retention/adherence. V˙O2peak was measured directly along with conventional CVD risk factors before and after 12 weeks.

RESULTS

Of 48 out-patients, 16/25 and 18/23 completed the TG and CG respectively. After 12 weeks, V˙O2peak was higher (2.7 ± 4.8 ml/kg/min, P < 0.01) in the TG compared with the CG. The TG improved V˙O2peak by 3.1 ± 3.7 ml/kg/min (P < 0.01), while no change in the CG was observed. No intergroup difference in weight, body mass index (BMI), waist circumference, blood pressure, lipids, or glucose at posttest was observed. Weight (1.9 ± 4.0 kg, P < 0.05) and BMI (0.5 ± 1.1 kg/m² , P < 0.05) increased in the CG, with no change in the TG.

CONCLUSION

AIT, combined with adherence support, of out-patients with schizophrenia was feasible, improved V˙O2peak , and may be integrated in standard care. (ClinicalTrials.gov identifier: NCT02743143).

Physical performance is more strongly associated with cognition in schizophrenia than psychiatric symptoms

BACKGROUND

Although neurocognitive dysfunction and physical performance are known to be impaired in patients with schizophrenia, evidence regarding the relationship between these two domains remains insufficient. Thus, we aimed to investigate the relationship between various physical performance domains and cognitive domains in individuals with schizophrenia, while considering other disorder-related clinical symptoms.

METHODS

Sixty patients with schizophrenia participated in the study. Cardiorespiratory fitness and functional mobility were evaluated using the step test and supine-to-standing (STS) test, respectively. Executive function and working memory were assessed using the Stroop task and Sternberg working memory (SWM) task, respectively. Clinical symptoms were evaluated using the Brief Psychiatric Rating Scale, Beck Depression Inventory, and State-Trait Anxiety Inventory. Multivariate analyses were performed to adjust for relevant covariates and identify predictive factors associated with neurocognition.

RESULTS

Multiple regression analysis revealed that the step test index was most strongly associated with reaction time in the Stroop task (β = 0.434, p = 0.001) and SWM task (β = 0.331, p = 0.026), while STS test time was most strongly associated with accuracy on the Stoop task (β=-0.418, p = 0.001) and SWM task (β=-0.383, p = 0.007). Total cholesterol levels were positively associated with Stroop task accuracy (β=-0.307, p = 0.018) after controlling for other clinical correlates. However, clinical symptoms were not associated with any variables in Stroop or SWM task.

CONCLUSIONS

The present findings demonstrate the relationship between physical performance and neurocognition in patients with schizophrenia. Considering that these factors are modifiable, exercise intervention may help to improve cognitive symptoms in patients with schizophrenia, thereby leading to improvements in function and prognosis.

EPA guidance on physical activity as a treatment for severe mental illness: a meta-review of the evidence and Position Statement from the European Psychiatric Association (EPA), supported by the International Organization of Physical Therapists in Mental Health (IOPTMH)

Physical activity (PA) may be therapeutic for people with severe mental illness (SMI) who generally have low PA and experience numerous life style-related medical complications. We conducted a meta-review of PA interventions and their impact on health outcomes for people with SMI, including schizophrenia-spectrum disorders, major depressive disorder (MDD) and bipolar disorder. We searched major electronic databases until January 2018 for systematic reviews with/without meta-analysis that investigated PA for any SMI. We rated the quality of studies with the AMSTAR tool, grading the quality of evidence, and identifying gaps, future research needs and clinical practice recommendations. For MDD, consistent evidence indicated that PA can improve depressive symptoms versus control conditions, with effects comparable to those of antidepressants and psychotherapy. PA can also improve cardiorespiratory fitness and quality of life in people with MDD, although the impact on physical health outcomes was limited. There were no differences in adverse events versus control conditions. For MDD, larger effect sizes were seen when PA was delivered at moderate-vigorous intensity and supervised by an exercise specialist. For schizophrenia-spectrum disorders, evidence indicates that aerobic PA can reduce psychiatric symptoms, improves cognition and various subdomains, cardiorespiratory fitness, whilst evidence for the impact on anthropometric measures was inconsistent. There was a paucity of studies investigating PA in bipolar disorder, precluding any definitive recommendations. No cost effectiveness analyses in any SMI condition were identified. We make multiple recommendations to fill existing research gaps and increase the use of PA in routine clinical care aimed at improving psychiatric and medical outcomes.

The impact of pharmacological and non-pharmacological interventions to improve physical health outcomes in people with schizophrenia: a meta-review of meta-analyses of randomized controlled trials

We summarized and compared meta-analyses of pharmacological and non-pharmacological interventions targeting physical health outcomes among people with schizophrenia spectrum disorders. Major databases were searched until June 1, 2018. Of 3,709 search engine hits, 27 meta-analyses were included, representing 128 meta-analyzed trials and 47,231 study participants. While meta-analyses were generally of adequate or high quality, meta-analyzed studies were less so. The most effective weight reduction interventions were individual lifestyle counseling (standardized mean difference, SMD=-0.98) and exercise interventions (SMD=-0.96), followed by psychoeducation (SMD=-0.77), aripiprazole augmentation (SMD=-0.73), topiramate (SMD=-0.72), d-fenfluramine (SMD=-0.54) and metformin (SMD=-0.53). Regarding waist circumference reduction, aripiprazole augmentation (SMD=-1.10) and topiramate (SMD=-0.69) demonstrated the best evidence, followed by dietary interventions (SMD=-0.39). Dietary interventions were the only to significantly improve (diastolic) blood pressure (SMD=-0.39). Switching from olanzapine to quetiapine or aripiprazole (SMD=-0.71) and metformin (SMD=-0.65) demonstrated best efficacy for reducing glucose levels, followed by glucagon-like peptide-1 receptor agonists (SMD=-0.39), dietary interventions (SMD=-0.37) and aripiprazole augmentation (SMD=-0.34), whereas insulin resistance improved the most with metformin (SMD=-0.75) and rosiglitazone (SMD=-0.44). Topiramate had the greatest efficacy for triglycerides (SMD=-0.68) and low-density lipoprotein (LDL)-cholesterol (SMD=-0.80), whereas metformin had the greatest beneficial effects on total cholesterol (SMD=-0.51) and high-density lipoprotein (HDL)-cholesterol (SMD=0.45). Lifestyle interventions yielded small effects for triglycerides, total cholesterol and LDL-cholesterol (SMD=-0.35 to -0.37). Only exercise interventions increased exercise capacity (SMD=1.81). Despite frequent physical comorbidities and premature mortality mainly due to these increased physical health risks, the current evidence for pharmacological and non-pharmacological interventions in people with schizophrenia to prevent and treat these conditions is still limited and more larger trials are urgently needed.

Community participation factors and poor neurocognitive functioning among persons with schizophrenia

Poor neurocognitive functioning among individuals with schizophrenia is typically conceptualized as resulting from a disease process. The objective of this article is to further expand understanding of poor neurocognition beyond pathogenesis toward a perspective that also incorporates community participation factors. This article focuses on three such factors-sedentary behavior, loneliness, and poverty-that have been demonstrated to be related to neurocognition and are highly prevalent among individuals with schizophrenia. This article provides an overview of the research on each factor and discusses its possible connection to neurocognitive challenges for individuals with schizophrenia. Implications for research, policy, and practice efforts are then proposed to broaden approaches to understanding and addressing neurocognitive challenges in this population. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Test-retest reliability and clinical correlates of the Eurofit test battery in people with alcohol use disorders

People with alcohol use disorder (AUD) are at an increased risk for cardiovascular diseases (CVD). Physical fitness is a predictor of CVD and premature mortality. Currently, no existing measures of physical fitness used in the general population have been tested for validity and reliability in this vulnerable population. Therefore, we examined the reproducibility, feasibility and correlates of the Eurofit test battery in this population. From 32 men (age = 40.8 ± 13.8years; illness duration = 10.2 ± 10.3years; body mass index, BMI = 24.8 ± 3.8) and 13 women (age = 41.9 ± 12.1years; illness duration = 13.7 ± 13.1years; BMI = 26.3 ± 4.9) with AUD two trials of the Eurofit test, administered within one week, were analyzed. All patients also completed the International Physical Activity Questionnaire, the Positive Affect and Negative Affect Scale and Alcohol Use Disorders Identification Test. All Eurofit items showed good reproducibility with intraclass correlation coefficients ranging from 0.82 for the flamingo balance test to 0.97 for the standing broad jump and handgrip strength tests. Better performance on Eurofit test items was associated with younger age, a shorter illness duration, a lower BMI and higher physical activity levels. The current study demonstrates that the Eurofit test can be recommended as a reliable test for evaluating the physical fitness of inpatients with alcohol use disorder.

Prospective associations of physical fitness and cognitive performance among inpatients with Schizophrenia

There is a paucity of longitudinal research investigating fitness and cognitive performance in people with schizophrenia. This study examined the prospective associations of physical fitness and cognitive performance among inpatients with schizophrenia. A prospective cohort study over two years was undertaken in 190 inpatients with schizophrenia. Four domains of physical fitness (body composition, muscle endurance, flexibility, and cardiovascular fitness) were measured at baseline in addition to the cognitive domains of attention, hand dexterity and working memory. At baseline, compared to general population normative data, more than one third of the sample had poor cardiovascular fitness, and over half were overweight/obese, had poor muscular fitness and poor flexibility. In the schizophrenia sample, better cardiovascular fitness at baseline was significantly associated with better attention, dexterity, and memory. However, the relationships dissipated after adjusting for baseline cognitive scores. In the final models, aside from baseline cognitive scores, only illness duration was significantly associated with dexterity, and smoking status and duration of hospitilization were associated with working memory. Our data suggest that in a cohort of people with established schizophrenia who already had evidence of cognitive dysfunction, better physical fitness was not associated with improved cognitive performance over two years.

Physical activity pattern and cardiorespiratory fitness in individuals with schizophrenia compared with a population-based sample

OBJECTIVE

Thorough description of objectively assessed physical activity (PA) and sedentary time in people with schizophrenia is lacking, and previous studies comparing PA and cardiorespiratory fitness levels with healthy controls are limited by their small sample size and/or poor methodology.

METHOD

PA, sedentary behavior, and cardiorespiratory fitness level were assessed in 67 adults diagnosed with schizophrenia (EPHAPS study) and compared with a population-based sample of 2809 adults (NPASS study).

RESULTS

Fifty-five percent of the participants with schizophrenia had the unhealthy combination of not meeting the PA recommendations and sitting >7.5 h per day compared to 32% in the population-based sample. The PA level was especially low on weekday afternoons and evenings and throughout most of the day on weekends. The peak oxygen uptake for EPHAPS women was on average 23% lower than that for NPASS women, while EPHAPS men achieved on average 34% lower oxygen uptake on the exercise test compared with NPASS men.

CONCLUSION

People with schizophrenia are significantly less physically active, more sedentary, and have a poorer cardiorespiratory fitness level compared with the general population. Tailor-made PA interventions for people with schizophrenia should target their PA and sedentary behavior on afternoons and weekends especially.

The Validity and Value of Self-reported Physical Activity and Accelerometry in People With Schizophrenia: A Population-Scale Study of the UK Biobank

BACKGROUND

Previous physical activity (PA) research in schizophrenia has relied largely upon self-report measures. However, the accuracy of this method is questionable. Obtaining accurate measurements, and determining what may influence PA levels in schizophrenia, is essential to understand physical inactivity in this population. This study examined differences in self-reported and objectively measured PA in people with schizophrenia and the general population using a large, population-based dataset from the UK Biobank.

METHODS

Baseline data from the UK Biobank (2007-2010) were analyzed; including 1078 people with schizophrenia (54.19 ± 8.39 years; 55% male) and 450549 without (56.44 ± 8.11; 46% male). We compared self-reported PA with objectively measured accelerometry data in schizophrenia and comparison samples. We also examined correlations between self-report and objective measures.

RESULTS

People with schizophrenia reported the same PA levels as those without, with no differences in low, moderate, or vigorous intensity activity. However, accelerometry data showed a large and statistically significant reduction of PA in schizophrenia; as people with schizophrenia, on average, engaged in less PA than 80% of the general population. Nonetheless, within the schizophrenia sample, total self-reported PA still held significant correlations with objective measures.

CONCLUSIONS

People with schizophrenia are significantly less active than the general population. However, self-report measures in epidemiological studies fail to capture the reduced activity levels in schizophrenia. This also has implications for self-report measures of other lifestyle factors which may contribute toward the poor health outcomes observed in schizophrenia. Nonetheless, self-report measures may still be useful for identifying how active individuals with schizophrenia relative to other patients.

Evaluating the Feasibility of a Pilot Exercise Intervention Implemented Within a Residential Rehabilitation Unit for People With Severe Mental Illness: GO HEART: (Group Occupational Health Exercise and Rehabilitation Treatment)

Purpose: People with severe mental illness are sedentary, have high cardio-metabolic risks and significantly reduced life expectancy. Despite considerable data regarding positive physical and mental health outcomes following exercise interventions, implementation and evaluation of real-world programs is lacking. The primary aim of this study was to assess the feasibility of an exercise intervention implemented by exercise physiology (EP) students within a residential rehabilitation unit for residents with severe mental illness, together with assessment of a range of secondary physical and mental health outcomes pre- and post- the intervention. Design: Single arm, prospective pilot study evaluating outcomes pre- and post- a 10 week intervention. Method: Inactive people with severe mental illness participated in a mixed aerobic and resistance exercise intervention, three times per week for 10 weeks. Data was obtained from a sample of 16 residents with severe mental illness; primary diagnosis schizophrenia (n = 12). Primary outcomes were feasibility as assessed using recruitment, retention and participation rates, as well as reasons for withdrawal and amount of exercise achieved. Secondary outcomes included: functional exercise capacity was measured by the 6-min walk test; metabolic data obtained from anthropometric measurements; blood pressure; fasting cholesterol and blood sugar levels; and physical activity levels and mental health as assessed by self- administered questionnaires measured before and after the intervention. Results: Broad level acceptance of the program: high recruitment (81%), retention (77%), and participation (78%) rates were observed. Promising improvements in functional exercise capacity, volume of exercise, and negative symptoms was demonstrated in those who completed. Conclusions: Exercise interventions delivered by EP students in a residential rehabilitation setting for people with SMI are feasible; group setting, supervision and choice for engagement are important considerations. Evaluation of longitudinal, multi site studies, with the addition of dietary interventions within residential rehabilitation units are warranted. Addressing cost feasibility and cost effectiveness of such programs is recommended. The trial was registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) number, Unique Identifier: ACTRN 12618000478213, http://www.anzctr.org.au Universal trial number (UTN) - U1111-1211-4009.

Chronotropic incompetence of the heart is associated with exercise intolerance in patients with schizophrenia

The elevated cardiovascular risk of patients with schizophrenia contributes to a reduced life expectancy of 15-20years. This study investigated whether cardiac autonomic dysfunction (CADF) in schizophrenia is related to chronotropic incompetence, an established cardiovascular risk marker. We investigated thirty-two patients suffering from paranoid schizophrenia and thirty-two control subjects matched for age, sex, body mass index and fat free mass. A cardiopulmonary exercise test (CPET) was performed to study heart rate responses to exercise as well as submaximal (ventilatory threshold 1, VT₁) and maximal endurance capacities (peak oxygen consumption, VO_2peak; peak power output, P_peak). In addition, epinephrine and norepinephrine levels were assessed in a subset of patients. Fitness parameters were significantly reduced in all patients. Most investigated physiological parameters were significantly different at rest as well as during peak exercise being in line with previously described CADF in schizophrenia. In particular, 14 out of 32 patients were classified as chronotropically incompetent whereas no control subject was below the cut-off value. In addition, a positive correlation of a slope reflecting chronotropic incompetence with peak oxygen uptake (p<0.001) was observed in patients only indicating a close correlation to the lack of physical fitness. The catecholamine increase was reduced in patients after exercise. This study identified a novel cardiac risk factor in patients with schizophrenia. Moreover, it seems to be associated with reduced physical fitness and indicates targets for exercise intervention studies. Future studies are warranted to elucidate pathophysiological mechanisms of this cardiac condition.

Relationship between objectively measured sedentary behavior and health outcomes in schizophrenia patients: The PsychiActive project

This study aimed to investigate possible relationships between sedentary behavior and body mass index (BMI), cardiorespiratory fitness (CRF), and health-related quality of life (HRQoL) in schizophrenia patients. Variables contributing to the variability in sedentary behavior were identified. Eighty-two schizophrenia outpatients (mean age±SD: 41.0±8.7years, 87% men, mean illness duration±SD: 17.1±8.9years) wore a multisensor armband for 7 consecutive full days to objectively measure sedentary behavior. BMI, walking capacity (6-minute walking test) as a proxy for CRF estimation and HRQoL (Short Form 36-Item Health Survey questionnaire version 2) were also assessed. Correlation (Pearson or Spearman coefficients) and multiple regression analysis were used. Sedentary behavior was significantly associated with BMI, CRF, and the physical component summary score of HRQoL (r values, -0.34-0.41; all P<0.001) and remained significant after adjustments for age, illness duration, symptom severity, adherence to Mediterranean diet, smoking, and antipsychotic medication (all P<0.05). BMI, CRF and vitality were identified as determinants of sedentary behavior. Consistent relationships between sedentary behavior and BMI, CRF, and the physical component summary score of HRQoL were found in schizophrenia patients. All the identified determinants of sedentary behavior are modifiable and may be important areas for future interventions in this population.

Cardiorespiratory Fitness in Severe Mental Illness: A Systematic Review and Meta-analysis

BACKGROUND

Cardiorespiratory fitness (CRF) among people with severe mental illness (SMI) (i.e., schizophrenia, bipolar disorder, and major depressive disorder) is a critical clinical risk factor given its relationship to cardiovascular disease and premature mortality.

OBJECTIVES

This study aimed to: (1) investigate the mean CRF in people with SMI versus healthy controls; (2) explore moderators of CRF; and (3) investigate whether CRF improved with exercise interventions and establish if fitness improves more than body mass index following exercise interventions.

METHODS

Major electronic databases were searched systematically. A meta-analysis calculating Hedges' g statistic was undertaken.

RESULTS

Across 23 eligible studies, pooled mean CRF was 28.7 mL/kg/min [95 % confidence interval (CI) 27.3 to 30.0 mL/kg/min, p < 0.001, n = 980]. People with SMI had significantly lower CRF compared with controls (n = 310) (Hedges' g = -1.01, 95 % CI -1.18 to -0.85, p < 0.001). There were no differences between diagnostic subgroups. In a multivariate regression, first-episode (β = 6.6, 95 % CI 0.6-12.6) and inpatient (β = 5.3, 95 % CI 1.6-9.0) status were significant predictors of higher CRF. Exercise improved CRF (Hedges' g = 0.33, 95 % CI = 0.21-0.45, p = 0.001), but did not reduce body mass index. Higher CRF improvements were observed following interventions at high intensity, with higher frequency (at least three times per week) and supervised by qualified personnel (i.e., physiotherapists and exercise physiologists).

CONCLUSION

The multidisciplinary treatment of people with SMI should include a focus on improving fitness to reduce all-cause mortality. Qualified healthcare professionals supporting people with SMI in maintaining an active lifestyle should be included as part of multidisciplinary teams in mental health treatment.

Effect of Breastfeeding in Early Life on Cardiorespiratory and Physical Fitness: A Systematic Review and Meta-Analysis

BACKGROUND

Numerous studies have reported the associations between the type of feeding during infancy and subsequent chronic diseases.

OBJECTIVE

The objective of this systematic review is to synthesize the available literature concerning the effect of breastfeeding in infancy on physical and cardiorespiratory fitness in children and adolescents.

MATERIALS AND METHODS

We performed a comprehensive search of medical bibliographic databases to identify observational studies reporting the association between breastfeeding and cardiorespiratory or physical fitness. Random effects model was used for calculating the pooled estimates.

RESULTS

Three studies with 2,792 children were included in the meta-analysis. The mean value of VO₂max was similar between formula-fed and 1-3 months breastfed participants (standardized mean difference [SMD]: 0.1, 95% confidence intervals [CI]: -0.09 to 0.29, p = 0.31). There was no difference between 3 and 6 months breastfed (SMD: 0.17, 95% CI: -0.01 to 0.35, p = 0.06), >6 months breastfed (SMD: 0.37, 95% CI: -0.03 to 0.78, p = 0.07), and formula-fed children. The pooled SMD in handgrip strength was 0.09 (95% CI: -0.04 to 0.23; p = 0.17) between 1 and 3 months breastfed and formula-fed children .Nevertheless, 3-6 months (SMD: 0.13; 95% CI: 0.03-0.24) and >6 months (SMD: 0.19; 95% CI: 0.01-0.37) breastfeeding was associated with higher handgrip strength compared with formula-fed children. Breastfeeding for 1-3 (SMD: 0.20; 95% CI: 0.12-0.28), 3-6 (SMD: 0.27; 95% CI: 0.18-0.37), and >6 months (SMD: 0.34; 95% CI: 0.11-0.58) led to a significantly higher standing long-jump performance compared with formula feeding.

CONCLUSIONS

Breastfeeding shows beneficial effects on physical fitness, but further well-designed studies need to clarify effects of breastfeeding on cardiorespiratory fitness.

Reduced cardiovascular fitness associated with exposure to clozapine in individuals with chronic schizophrenia

Studies show that individuals with schizophrenia have impaired cardiovascular fitness (i.e., low peak aerobic power (VO₂peak)). It is speculated that antipsychotics with adverse cardiovascular and metabolic profiles, in particular clozapine, have a significant impact on VO₂peak. In this cross-sectional study, we examined whether exposure to clozapine was associated with further reduced VO₂peak compared with non-clozapine antipsychotics. Thirty participants with chronic schizophrenia or schizoaffective disorder were divided into clozapine and non-clozapine groups. Mean daily doses of antipsychotics were standardized to chlorpromazine equivalents and haloperidol equivalents for antagonism of alpha₁- and alpha₂-adrenergic receptors. Participants completed an incremental-to-maximal symptom-limited exercise test on a cycle ergometer for the assessment of VO₂peak. The clozapine group demonstrated significantly lower VO₂peak than the non-clozapine group. Haloperidol equivalents for alpha-adrenergic receptor antagonism, but not chlorpromazine equivalents, demonstrated significant inverse associations with VO₂peak. The clozapine group had a significantly higher amount of antagonistic activity at alpha-adrenergic receptors than the non-clozapine group. In conclusion, exposure to clozapine was associated with further reduced cardiovascular fitness, which may be explained by the drug's greater antagonistic activity at alpha-adrenergic receptors. Cardiovascular fitness needs to be promoted in individuals treated with antipsychotics, particularly clozapine, to prevent the risk of cardiovascular disease and mortality.