Exercise Improves Clinical Symptoms, Quality of Life, Global Functioning, and Depression in Schizophrenia: A Systematic Review and Meta-analysis

Effects of Pilates-Based Exercises on Functional Capacity and Mental Health in Individuals with Schizophrenia: A Pilot Study

BACKGROUND

Although there is considerable evidence that exercise improves the physical and mental health of individuals with schizophrenia, the most useful exercise technique for this population is still the subject of research.

PURPOSE

The aim of this study was to investigate the effects of Pilates exercises on functional capacity and mental health in individuals with schizophrenia.

METHODS

Twenty-three participants were not randomly assigned to either Pilates exercise group (PEG) or nonspecific exercise group (NSEG). Ten participants from each group completed the study (87% response rate). The PEG participated in a 6-week Pilates exercise training twice per week, while the NSEG participated in a nonspecific activity program. 6-Minute Walk Distance (6-MWD) was assessed for functional capacity. Mental health was evaluated using Calgary Depression Scale for Schizophrenia (CDSS), and Brief Psychiatric Rating Scale (BPRS).

RESULTS

6-MWD significantly increased (p = .025), CDSS (p = .023) and BPRS (p = .012) scores significantly decreased in the PEG compared to baseline. Inter-group comparison showed that PEG had significantly better scores than NSEG in terms of the final 6-MWD (p = .005), CDSS (p = .008) and BPRS (p = .008).

CONCLUSION

Results showed that Pilates may help improve the functional capacity and mental health of individuals with schizophrenia, but the small sample size and methodological limitations limit the interpretability of this study.

COMT-Val158Met polymorphism modulates antipsychotic effects on auditory verbal hallucinations and temporal lobe gray matter volumes in healthy individuals-symptom relief accompanied by worrisome volume reductions

Investigation of auditory verbal hallucinations (AVHs) in schizophrenics is complicated by psychiatric symptoms. Investigating healthy individuals with AVHs (H-AVHs) can obviate such confounding factors. The objective of this study was to explore the effects of antipsychotic treatment on AVHs and gray matter volumes (GMVs) in H-AVH subjects and whether such are effects are influenced by COMT-Val158Met genotype. Magnetic resonance imaging (MRI) and genotyping studies were completed for 42 H-AVH subjects and 42 well-matched healthy controls (HCs). COMT-Met/Met homozygotes (158th codon) were identified as COMT-Met genotype; COMT-Met/Val heterozygotes and COMT-Val/Val homozygotes were identified as COMT-Val genotype. Data were compared across groups (H-AVH vs. HC, and between genotypes) with two-sample t-tests. The H-AVH COMT-Met group showed a stronger response to antipsychotic treatment than the H-AVH COMT-Val group (p < 0.001). Both H-AVH genotype groups exhibited temporal lobe GMV reductions after treatment, and relative to their respective genotype-matched HC groups. Antipsychotic treatment effects in H-AVH subjects were influenced by COMT-Val158Met genotype and associated with widespread GMV reductions. These findings provide clues for further exploration of treatment targets for AVHs. Treatment associated GMV reductions, however, raise concerns about use of antipsychotics in H-AVH subjects.

Management of constipation in patients with schizophrenia—a case study and review of literature

Background

Schizophrenia is a disorder that affects about 1% of the US population, with an extensive impact on patients’ health and their risk of later developing comorbidities from treatment. While literature on the side effect profile of antipsychotics is abundant, there are few studies on identification of anticholinergic effects on gut motility and prophylaxis development. The aim of this review is to consider antipsychotic-associated constipation in patients with schizophrenia and to discuss management of antipsychotic-induced constipation as documented in the literature.

Main body

We present a case of antipsychotic-induced constipation and conducted a literature review assessing the prevalence of this issue in this population. The search was done on Embase, MEDLINE, Cochrane Library, and PubMed databases. Key word searches included constipation with concurrent antipsychotic use, antipsychotics and anticholinergic effects, factors causing constipation in schizophrenia, social disparities involved with constipation, and colorectal cancer screenings.

Main findings included high complication rates that may be explained by clozapine-specific side effects, negative health habits, disease, and treatment-related metabolic disorders. Co-existing negative symptoms could also be associated with health outcomes and was found to have adverse consequences on schizophrenia progression. Comorbidities of diabetes and cardiovascular complications contributed to gut hypomotility. Caregiver burden was a factor in delayed recognition of constipation as a side effect. Routine surveillance for symptoms and optimization of medications facilitates early recognition of constipation.

Conclusion

Overall, there is insufficient trial-based evidence to compare the effectiveness and safety of common pharmacological interventions for constipation, such as lactulose, polyethylene glycol, stool softeners, and lubricant laxatives.

EPA guidance on treatment of negative symptoms in schizophrenia

Negative symptoms of schizophrenia remain a major therapeutic challenge. The progress in the conceptualization and assessment is not yet fully reflected by treatment research. Nevertheless, there is a growing evidence base regarding the effects of biological and psychosocial interventions on negative symptoms. The importance of the distinction between primary and secondary negative symptoms for treatment selection might seem evident, but the currently available evidence remains limited. Good clinical practice is recommended for the treatment of secondary negative symptoms. Antipsychotic treatment should be optimized to avoid secondary negative symptoms due to side effects and due to positive symptoms. For most available interventions, further evidence is needed to formulate sound recommendations for primary, persistent, or predominant negative symptoms.

However, based on currently available evidence recommendations for the treatment of undifferentiated negative symptoms (including both primary and secondary negative symptoms) are provided. Although it has proven difficult to formulate an evidence-based recommendation for the choice of an antipsychotic, a switch to a second-generation antipsychotic should be considered for patients who are treated with a first-generation antipsychotic. Antidepressant add-on to antipsychotic treatment is an option. Social skills training is recommended as well as cognitive remediation for patients who also show cognitive impairment. Exercise interventions also have shown promise. Finally, access to treatment and to psychosocial rehabilitation should be ensured for patients with negative symptoms. Overall, there is definitive progress in the field, but further research is clearly needed to develop specific treatments for negative symptoms.

Cognitive benefits of exercise interventions: an fMRI activation likelihood estimation meta-analysis

Despite a growing number of functional MRI studies reporting exercise-induced changes during cognitive processing, a systematic determination of the underlying neurobiological pathways is currently lacking. To this end, our neuroimaging meta-analysis included 20 studies and investigated the influence of physical exercise on cognition-related functional brain activation. The overall meta-analysis encompassing all experiments revealed physical exercise-induced changes in the left parietal lobe during cognitive processing. Subgroup analysis further revealed that in the younger-age group (< 35 years old) physical exercise induced more widespread changes in the right hemisphere, whereas in the older-age group (≥ 35 years old) exercise-induced changes were restricted to the left parietal lobe. Subgroup analysis for intervention duration showed that shorter exercise interventions induced changes in regions connected with frontoparietal and default mode networks, whereas regions exhibiting effects of longer interventions connected with frontoparietal and dorsal attention networks. Our findings suggest that physical exercise interventions lead to changes in functional activation patterns primarily located in precuneus and associated with frontoparietal, dorsal attention and default mode networks.

Enhancement of aerobic fitness improves social functioning in individuals with schizophrenia

Individuals with schizophrenia display substantial deficits in social functioning (SF), characterized by chronic, lifelong presentations. Yet, at present there are few effective interventions to enhance SF in this population. Emerging evidence from studies of clinical populations that display similar SF deficits suggests that aerobic exercise (AE) may improve social skills. However, this putative impact has not been investigated in schizophrenia. Employing a single-blind, randomized clinical trial design, 33 individuals with schizophrenia were randomized to receive 12 weeks of Treatment-As-Usual (TAU; n = 17) or TAU + AE (n = 16) utilizing active-play video games (Xbox 360 Kinect) and traditional AE equipment. Participants completed an evaluation of aerobic fitness (VO2max) as well as self-, informant-, and clinician-reported SF measures at baseline and after 12 weeks. Twenty-six participants completed the study (79%; TAU = 13; AE = 13). At follow-up, the AE participants improved their VO2max by 18.0% versus - 0.5% in the controls (group x time interaction, F1,24 = 12.88; p = .002). Hierarchical stepwise regression analyses indicated improvements in VO2max significantly predicted enhancement in SF as indexed by self-, informant-, and clinician-reported measures, predicting 47%, 33%, and 25% of the variance, respectively (controlling for baseline demographics, medications, mood symptoms, and social networks). Compared to the TAU group, AE participants reported significant improvement in SF (23.0% vs. - 4.2%; group × time interaction, F1,24 = 7.48, p = .012). The results indicate that VO2max enhancement leads to improvements in SF in people with schizophrenia. Furthermore, low VO2max represents a modifiable risk factor of SF in people with schizophrenia, for which AE training offers a safe, non-stigmatizing, and nearly side-effect-free intervention.

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.

A web-based adapted physical activity program (e-APA) versus health education program (e-HE) in patients with schizophrenia and healthy volunteers: study protocol for a randomized controlled trial (PEPSY V@Si)

Patients with schizophrenia (SZ) have a high level of cardiovascular morbidity and some clinical symptoms of illness remain resistant to pharmacological approaches. A large number of studies support the effectiveness of physical activity (PA) in SZ. The aims of this trial is to assess the effects of a remote, web-based adapted PA program (e-APA) compared to a health education program (e-HE) on brain plasticity in SZ and healthy volunteers (HV) and on psychiatric, neurocognitive, circadian and physical variables. The study is an interventional, multicenter, randomized open-label trial. Forty-two SZ will be randomized to either the active group (e-APA, N = 21) or nonactive group (e-HE, N = 21), and 21 HV will be matched to SZ according to age, gender, and level of PA in both e-APA and e-HE groups. Interventions will consist of 32 sessions (2 × 60 min/week, for 16 weeks) via supervised home-based videoconferencing. Cerebral magnetic resonance imaging, psychiatric symptoms, neurocognitive and circadian rhythms assessments as well as physical tests and biological analyses will be assessed at baseline and 16 weeks after the intervention. To our knowledge, this is the first study aiming to evaluate the efficacy of APA delivered by supervised home-based videoconferencing in SZ. Moreover, using multimodal MRI, this study could clarify the pathophysiological mechanisms underlying the efficacy of APA. Finally, this innovative approach might also increase participation in long-term PA since PA-based programs are known to have low adherence and early dropout. Trial registration: ClinicalTrials.gov identifier: NCT03261817. Registered on 16 August 2017.

High-intensity interval training and active video gaming improve neurocognition in schizophrenia: a randomized controlled trial

There is a need for treatments targeting neurocognitive dysfunctions in schizophrenia. The aim of this study was to investigate the neurocognitive effect of aerobic high-intensity interval training (HIIT). A comparison group performed sport simulating active video gaming (AVG). We anticipated that HIIT would improve neurocognition beyond any effect of AVG, due to engagement in higher intensity cardiorespiratory demands. Recent research on the beneficial neurocognitive effect of AVG challenges this expectation but added new relevance to comparing the two interventions. This is an observer-blinded randomized controlled trial. Eighty-two outpatients diagnosed with schizophrenia were allocated to HIIT (n = 43) or AVG (n = 39). Both groups received two supervised sessions per week for 12 weeks. The attrition rate was 31%, and 65% of the participants were defined as protocol compliant study completers. Intention-to-treat analyses showed significant improvements in the neurocognitive composite score from baseline to post-intervention and from baseline to 4 months follow-up in the total sample. The same pattern of results was found in several subdomains. Contrary to our hypothesis, we found no interaction effects of time and group, indicating equal effects in both groups. Separate within-group analysis unexpectedly showed trends of differential effects in the learning domain, as HIIT showed post-intervention improvement in verbal but not visual learning, while AVG showed improvement in visual but not verbal learning. HIIT and AVG improve neurocognition equally, suggesting that both interventions may be applied to target neurocognition in schizophrenia. Future research should investigate trends towards possible differential effects of exercise modes on neurocognitive subdomains. NCT02205684, 31.07.14.

Aerobic endurance training to improve cognition and enhance recovery in schizophrenia: design and methodology of a multicenter randomized controlled trial

Even today, patients with schizophrenia often have an unfavorable outcome. Negative symptoms and cognitive deficits are common features in many patients and prevent recovery. In recent years, aerobic endurance training has emerged as a therapeutic approach with positive effects on several domains of patients' health. However, appropriately sized, multicenter randomized controlled trials that would allow better generalization of results are lacking. The exercise study presented here is a multicenter, rater-blind, two-armed, parallel-group randomized clinical trial in patients with clinically stable schizophrenia being conducted at five German tertiary hospitals. The intervention group performs aerobic endurance training on bicycle ergometers three times per week for 40-50 min/session (depending on the intervention week) for a total of 26 weeks, and the control group performs balance and tone training for the same amount of time. Participants are subsequently followed up for 26 weeks. The primary endpoint is all-cause discontinuation; secondary endpoints include psychopathology, cognition, daily functioning, cardiovascular risk factors, and explorative biological measures regarding the underlying mechanisms of exercise. A total of 180 patients will be randomized. With currently 162 randomized participants, our study is the largest trial to date to investigate endurance training in patients with schizophrenia. We hypothesize that aerobic endurance training has beneficial effects on patients' mental and physical health, leading to lower treatment discontinuation rates and improving disease outcomes. The study results will provide a basis for recommending exercise interventions as an add-on therapy in patients with schizophrenia.The study is registered in the International Clinical Trials Database (ClinicalTrials.gov identifier [NCT number]: NCT03466112) and in the German Clinical Trials Register (DRKS-ID: DRKS00009804).

Physical Activity Can Enhance Life (PACE-Life): results from a 10-week walking intervention for individuals with schizophrenia spectrum disorders

BACKGROUND

Premature mortality in individuals with schizophrenia spectrum disorders (SSDs) is largely due to high rates of chronic health conditions. Although exercise has been shown to improve health in this population, scalable and accessible interventions are limited.

AIM

To examine the impact of Physical Activity Can Enhance Life (PACE-Life), a novel walking intervention, on physical activity, and on secondary outcomes of cardiorespiratory fitness (CRF), physical health, autonomous motivation, social support, and quality of life.

METHOD

Sixteen individuals with SSDs were enrolled in a 10-week open trial. The intervention included walking groups, home-based walks, Fitbit use, and goal-setting and if-then plans. Within-group effect sizes were calculated to represent changes from baseline to post-test and 1-month follow-up.

RESULTS

Participants increased self-reported weekly walking minutes and decreased daily hours spent sitting; however, Fitbit-recorded exercise behavior changed only minimally. There were also improvements in secondary outcomes including autonomous motivation and hip circumference. CRF improved only minimally, and findings were relatively unchanged with outliers removed from the full sample.

CONCLUSIONS

This open trial demonstrates modest improvements in key parameters of exercise behavior and physical health from participating in PACE-Life. Future research should assess the efficacy of this intervention in a randomized controlled trial.

Effects of aerobic walking on cognitive function in patients with schizophrenia: A randomized controlled trial

Cognitive deficits, which are core manifestations in schizophrenia and exhibit a limited response to antipsychotic treatment, contribute to poor treatment outcomes and functional disability. Evidence on the effect of aerobic walking (AW) and exercise intensity on cognitive function in patients with schizophrenia is lacking. In total, 79 patients with schizophrenia were recruited for a 12-week randomized control trial and allocated to the treatment-as-usual (TAU, n = 38) and treatment-as-usual plus AW (TAW, n = 39) groups. The TAW participants joined a supervised 12-week AW program consisting of 30-min sessions five times per week while wearing a Fitbit Charge 2 device. Cognitive function was evaluated using the Brief Assessment of Cognition in Schizophrenia. After randomization, 67 (34 TAU and 33 TAW) participants joined the 12-week trial and were included in the intention-to-treat analysis. Multivariate general linear model repeated measures analysis revealed no significant time × group interaction effect on cognitive function changes between the TAU and TAW groups and a marginally significant group effect on verbal fluency (p = 0.09). The interaction effect of time and treatment group on verbal fluency (p = 0.05) was marginally significant between the high and low AW intensity groups, whereas a significant group effect on attention and processing speed (p = 0.04) was observed. Supervised 12-week AW of moderate intensity may have potential cognitive benefits for patients with schizophrenia.

Changes in inflammation are related to depression and amount of aerobic exercise in first episode schizophrenia

INTRODUCTION

Elevated levels of pro-inflammatory cytokines have been reported in meta-analyses of multi-episode schizophrenia patients when compared to controls. However, little is known about whether these same relationships are present in the early course of schizophrenia.

OBJECTIVE

To assess first episode schizophrenia patients for depression and to assay blood samples collected at baseline and at 6 months for interleukin-6 (IL-6).

MATERIALS AND METHODS

Trained raters used the Brief Psychiatric Rating Scale to assess depressive symptoms and a standard lab assay kit to assess for IL-6 levels in plasma.

CONCLUSIONS

Decreases in pro-inflammatory IL-6 levels were significantly related to decreases in depressive symptoms. Within a subset of patients in a 6-month aerobic exercise protocol, the number of exercise sessions completed was significantly correlated with the amount of decrease in IL-6. The reductions observed in IL-6 with aerobic exercise suggest exercise is a promising intervention to reduce brain inflammation effects in schizophrenia patients.

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.

Identification of Risk Factors to Predict the Occurrences of Relapses in Individuals with Schizophrenia Spectrum Disorder in Iran

Schizophrenia Spectrum Disorder (SSD) is a chronic psychiatric disorder with a modest treatment outcome. In addition, relapses are commonplace. Here, we sought to identify factors that predict relapse latency and frequency. To this end, we retrospectively analyzed data for individuals with SSD. Medical records of 401 individuals with SSD were analyzed (mean age: 25.51 years; 63.6% males) covering a five-year period. Univariate and multivariate Penalized Likelihood Models with Shared Log-Normal Frailty were used to determine the correlation between discharge time and relapse and to identify risk factors. A total of 683 relapses were observed in males, and 422 relapses in females. The Relapse Hazard Ratio (RHR) decreased with age (RHR = 0.99, CI: (0.98–0.998)) and with participants’ adherence to pharmacological treatment (HR = 0.71, CI: 0.58–0.86). In contrast, RHR increased with a history of suicide attempts (HR = 1.32, CI: 1.09–1.60), and a gradual compared to a sudden onset of disease (HR = 1.45, CI: 1.02–2.05). Gender was not predictive. Data indicate that preventive and therapeutic interventions may be particularly important for individuals who are younger at disease onset, have a history of suicide attempts, have experienced a gradual onset of disease, and have difficulties adhering to medication.

Impact of aerobic exercise on cognitive function in patients with schizophrenia during daily nursing: A protocol for systematic review and meta-analysis

OBJECTIVES

To assess the effect of aerobic exercise (AE) on cognition function in people with schizophrenia (SZ) during daily nursing.

METHODS

The literature search will be conducted via PubMed, Embase, Cochrane Library, and Web of Science. Weighted mean difference (WMD) or standardized mean difference (SMD) and 95% confidence intervals (CIs) will be adopted to calculate the association between AE and cognitive function in patients with SZ. Publication bias will be performed by Begg test. When there is publication bias, "cut-and-fill method" will be adopted to adjust publication bias. Sensitivity analysis will be used to test the stability of the result. When the heterogeneity is large (I2 ≥ 50%), meta regression will be used to explore the source of inter-study heterogeneity. When the heterogeneity is large (I2 ≥ 50%) and the results are statistically significant (P < .05), age, sex, duration of disease, duration of intervention, amount of exercise per week, improvement of cardiopulmonary health, and other factors will be sub-analyzed.

CONCLUSION

This meta-analysis will evaluate the impact of aerobic exercise on cognitive function in patients with SZ during daily nursing on the basis of existing evidence.

OSF REGISTRATION NUMBER

10.17605/OSF.IO/C8ABX.

Locomotor activities as a way of inducing neuroplasticity: insights from conventional approaches and perspectives on eccentric exercises

Corticospinal excitability, and particularly the balance between cortical inhibitory and excitatory processes (assessed in a muscle using single and paired-pulse transcranial magnetic stimulation), are affected by neurodegenerative pathologies or following a stroke. This review describes how locomotor exercises may counterbalance these neuroplastic alterations, either when performed under its conventional form (e.g., walking or cycling) or when comprising eccentric (i.e., active lengthening) muscle contractions. Non-fatiguing conventional locomotor exercise decreases intracortical inhibition and/or increases intracortical facilitation. These modifications notably seem to be a consequence of neurotrophic factors (e.g., brain-derived neurotrophic factor) resulting from the hemodynamic solicitation. Furthermore, it can be inferred from non-invasive brain and peripheral stimulation studies that repeated activation of neural networks can endogenously shape neuroplasticity. Such mechanisms could also occur following eccentric exercises (lengthening of the muscle), during which motor-related cortical potential (electroencephalography) is of greater magnitude and lasts longer than during concentric exercises (i.e., muscle shortening). As single-joint eccentric exercise decreased short- and long-interval intracortical inhibition and increased intracortical facilitation, locomotor eccentric exercise (e.g., downhill walking or eccentric cycling) may be even more potent by adding hemodynamic-related neuroplastic processes to endogenous processes. Besides, eccentric exercise is especially useful to develop relatively high force levels at low cardiorespiratory and perceived intensities, which can be a training goal alongside the induction of neuroplastic changes. Even though indirect evidence let us think that locomotor eccentric exercise could shape neuroplasticity in ways relevant to neurorehabilitation, its efficacy remains speculative. We provide future research directions on the neuroplastic effects and underlying mechanisms of locomotor exercise.

The Effects and Mechanisms of Exercise on the Treatment of Depression

Background: It is necessary to seek alternative therapies for depression, because side effects of medications lead to poor adherence and some patients do not achieve a clinical treatment effect. Recently the role of exercise as a low-cost and easy-to-use treatment for depression has gained attention with a number of studies showing that exercise is effective at reducing depressive symptoms and improving body functions such as cardiorespiratory system and cognitive function. Because of the heterogeneity of exercise therapy programs, there is no standardized and unified program. Few studies have summarized the specific properties of exercise programs (type, intensity, duration, and frequency) and clinical prescriptions for exercise are not mentioned in most articles. Aims: This study aimed to investigate the feasibility and efficacy of exercise therapy for patients with depression, in order to appraise the evidence and outline accepted guidelines to direct individualized treatment plans for patients with depression based on their individual situations. Methods: A systematic review of English language literature including papers published from 2010 to present in PubMed was performed. Given the feasibility of prescribing exercise therapy for patients with depression, nearly 3 years of clinical studies on the treatments of depressive symptoms with exercise were first reviewed, comparing the exercise programs utilized. Conclusions: Exercise has therapeutic effects on depression in all age groups (mostly 18-65 years old), as a single therapy, an adjuvant therapy, or a combination therapy, and the benefits of exercise therapy are comparable to traditional treatments for depression. Moderate intensity exercise is enough to reduce depressive symptoms, but higher-dose exercise is better for overall functioning. Exercise therapy has become more widely used because of its benefits to the cardiovascular system, emotional state, and systemic functions. Recommendations: Aerobic exercise/mind-body exercise (3-5 sessions per week with moderate intensity lasting for 4-16 weeks) is recommended. Individualized protocols in the form of group exercise with supervision are effective at increasing adherence to treatment.

Differential Physical and Mental Benefits of Physiotherapy Program Among Patients With Schizophrenia and Healthy Controls Suggesting Different Physical Characteristics and Needs

In contrast to several other severe illnesses marked by inflammation and autoimmunity that now have potent and efficient treatments and even cures, schizophrenia (SCZ) is a disease still associated with poor outcome, incapacity, and social burden. Even after decades of research on the brain and behavior, this illness is still associated with profound effects on both mental health and physical health, with recent studies showing that treatment is more efficient when associating drugs with psychological and physical treatments. Most of the studies measured the effects of physical intervention compared with usual care and demonstrated a positive effect as an add-on treatment. What remains unclear is the different effects of the same intervention in normal subjects in a sample of patients with the illness. The study aimed to evaluate the effects of physical intervention over motor functional capacity and mental health in patients with SCZ compared with healthy controls (HC). The outcomes were (a) functional capacity [by 6-min walk test (6MWT)], (b) body flexibility index (Wells' bench), (c) disease severity [by Brief Psychiatric Rating Scale (BPRS)], (d) quality of life [by 36-Item Short Form (SF-36) questionnaire], and (e) physical activity [Simple Physical Activity Questionnaire (SIMPAQ)]. The intervention was associated with significant decrease of body mass index (BMI), blood pressure, disease severity, and improvement in daily life activities. Unexpectedly, it was observed that schizophrenics, compared with matched HC, were at a lower level of performance in the beginning, remained below HC over the studied time despite similar physical intervention, and had different changes. The intervention had lower effects over physical capacity and better effects over quality of life and disease severity. The results confirm previous studies comparing patients receiving physical intervention but suggest that they may receive different types of intervention, suited for their different baseline fitness, motivation, and capacity to engage in physical effort over sustained time. Additionally, they point to extended time of intervention of multidisciplinary treatment (physical and psychological-cognitive techniques) to improve outcomes in SCZ.

Diagnosis and treatment depression in schizophrenia

Depression is the third most common illness among patients with schizophrenia which negatively affects the course of the disease and significantly contributes to the mortality rate, due to increased suicide. Depression, along with negative symptoms and cognitive deficits, is one of the main factors that significantly decreases the quality of life and the disease prognosis in patients with schizophrenia. In addition, depression increases the frequency of exacerbations and readmissions, decreases the quality and duration of remissions and is associated with more frequent substance abuse and an increased economic burden. Data on the prevalence of depression among patients with schizophrenia are contradictory and are associated with a low detection rate of depression in such patients, a lack of clear diagnostic criteria and difficulties in differentiation between extrapyramidal and negative symptoms. The average prevalence of depression that meets the diagnostic criteria of major depressive episodes in patients with schizophrenia is 25% at a specific point, and 60% over the course of a lifetime; the frequency of subsyndromal depression is much higher. It is essential to distinguish between primary (axial syndrome) and secondary depressive symptoms (extrapyramidal symptoms, psychogenic or nosogenic reactions, social factors, etc.) to determine treatment strategies. The published data relating to randomized clinical trials for the development of evidence-based guidelines are limited. Current recommendations are based mainly on the results of small-scale trials and reviews. Certain atypical antipsychotics (quetiapine, lurasidone, amisulpride, aripiprazole, olanzapine, clozapine) are superior to typical antipsychotics in the reduction of depressive symptoms. Clozapine is effective in the management of patients at risk from suicide. The additional prescription of antidepressants, transcranial magnetic stimulation and electroconvulsive therapy are not always effective and are only possible following the management of acute psychosis in cases when antipsychotic monotherapy proved to be ineffective.

Diet and Psychosis: A Scoping Review

INTRODUCTION

Schizophrenia spectrum disorders (SSD) represent a cluster of severe mental illnesses. Diet has been identified as a modifiable risk factor and opportunity for intervention in many physical illnesses and more recently in mental illnesses such as unipolar depression; however, no dietary guidelines exist for patients with SSD.

OBJECTIVE

This review sought to systematically scope the existing literature in order to identify nutritional interventions for the prevention or treatment of mental health symptoms in SSD as well as gaps and opportunities for further research.

METHODS

This review followed established methodological approaches for scoping reviews including an extensive a priori search strategy and duplicate screening. Because of the large volume of results, an online program (Abstrackr) was used for screening and tagging. Data were extracted based on the dietary constituents and analyzed.

RESULTS

Of 55,330 results identified by the search, 822 studies met the criteria for inclusion. Observational evidence shows a connection between the presence of psychotic disorders and poorer quality dietary patterns, higher intake of refined carbohydrates and total fat, and lower intake or levels of fibre, ω-3 and ω-6 fatty acids, vegetables, fruit, and certain vitamins and minerals (vitamin B12 and B6, folate, vitamin C, zinc, and selenium). Evidence illustrates a role of food allergy and sensitivity as well as microbiome composition and specific phytonutrients (such as L-theanine, sulforaphane, and resveratrol). Experimental studies have demonstrated benefit using healthy diet patterns and specific vitamins and minerals (vitamin B12 and B6, folate, and zinc) and amino acids (serine, lysine, glycine, and tryptophan).

DISCUSSION

Overall, these findings were consistent with many other bodies of knowledge about healthy dietary patterns. Many limitations exist related to the design of the individual studies and the ability to extrapolate the results of studies using dietary supplements to dietary interventions (food). Dietary recommendations are presented as well as recommendations for further research including more prospective observational studies and intervention studies that modify diet constituents or entire dietary patterns with statistical power to detect mental health outcomes.

The Physical Health Care Fidelity Scale: Psychometric Properties

Mental health programs need an instrument to monitor adherence to evidence-based physical health care for people with serious mental illness. The paper describes the Physical Health Care Fidelity Scale and study interrater reliability, frequency distribution, sensitivity to change and feasibility. Four fidelity assessments were conducted over 18 months at 13 sites randomized to implementation support for evidence-based physical health care. We found good to excellent interrater reliability, adequate sensitivity for change, good feasibility and wide variability in fidelity across sites after 18 months of implementation. Programs were more successful in establishing Policies stating physical health care standards than in implementing these Policies. The Physical Health Care Fidelity Scale measures and guides implementation of evidence-based physical health care reliably.Trial registration: ClinicalTrials.gov Identifier: NCT03271242.

Effects of physical exercise on executive function in cognitively healthy older adults: A systematic review and meta-analysis of randomized controlled trials: Physical exercise for executive function

OBJECTIVE

To assess the effect of physical exercise interventions on executive function in cognitively healthy adults aged 60 years and older.

METHODS

Four electronic databases, the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Web of Science and Embase, were comprehensively searched from their inception to November 25, 2019. Randomized controlled trials (RCTs) examining the effect of physical exercise on executive function in cognitively healthy older adults were included.

RESULTS

Twenty-five eligible trials with fair methodological quality were identified. Compared to a no-exercise intervention, physical exercise had positive effect on working memory (Hedge's g=0.127, p<0.01, I²= 0%), cognitive flexibility (Hedge's g=0.511; p=0.007, I²=89.08%), and inhibitory control (Hedge's g=0.136; p=0.001, I²=0%) in cognitively healthy older adults. The moderator analysis indicated that more than 13 weeks of aerobic exercise significantly improved working memory and cognitive flexibility, and intervention lasting more than 26 weeks significantly improved inhibition; mind-body exercise significantly improved working memory. No significant effect on planning or semantic verbal fluency (SVF) was found.

CONCLUSION

Regular physical exercise training, especially aerobic exercise and mind-body exercise, had positive benefit for improving working memory, cognitive flexibility and inhibitory control of executive function in cognively healthy older adults. Further well-designed RCTs should focus on the impact of specific exercise forms with a standardized exercise scheme on executive function in cognitively healthy older adults.

The Relationship of Functional Status of Cortisol, Testosterone, and Parameters of Metabolic Syndrome in Male Schizophrenics

Background

The cross-sectional study is aimed at investigating the relationship between cortisol, testosterone, and metabolic characteristics among male schizophrenics.

Methods

174 patients were grouped based on their risk of metabolic syndrome (MetS) into the non-MetS, high-risk-MetS (HR-MetS), or MetS groups. Metabolic indices (body mass index (BMI), mean arterial pressure (MAP), cholesterol, triglyceride, and fasting blood glucose (FBG)) were associated with cortisol and testosterone levels using correlation analysis. Multiple linear regression analysis was used to associate the correlations between the WHO Quality of Life–BREF (WHOQOL–BREF) score and the five metabolic indices.

Results

The WHOQOL–BREF score for the non-MetS group significantly differed from the scores of the HR-MetS and MetS groups. The triglyceride level was positively correlated with the cortisol level, while all five metabolic indices were negatively correlated with testosterone level. Stepwise regression analysis produced a model predicting WHOQOL–BREF scores with four variables including MAP, intelligence quotient (IQ), FBG, and age. The correlation analysis then showed that there was a weak linear correlation between the testosterone level and all five metabolic indices.

Conclusions

Among the five metabolic indices, the risks of hypertension and hyperglycemia are correlated with the quality of life in male schizophrenics rather than those of obesity or hyperlipidemia.

Suicide Reduction in Schizophrenia via Exercise (SUnRISE): study protocol for a multi-site, single-blind, randomized clinical trial of aerobic exercise for suicide risk reduction in individuals with schizophrenia

BACKGROUND

Suicide risk among individuals with schizophrenia (SZ) is intractably high, with over 40% of individuals attempting to take their own lives during their lifetime and an estimated 5-10% completing suicide. At present, available pharmacological and psychotherapeutic treatments offer limited risk reduction benefits, and thus, there remains an urgent need to explore novel interventions that will ameliorate this risk. Aerobic exercise (AE) has been shown to improve a number of predictors of suicide risk (e.g., depressed mood, sleeping difficulties). As individuals with SZ display a highly sedentary lifestyle, AE may reduce suicide risk.

METHODS

Employing a multi-site, single-blind, randomized clinical trial design, we will examine the impact of AE on risk for suicide and related variables in individuals with SZ. Participants will be randomized to one of two 12-week exercise interventions: AE or a stretching and toning (ST) control intervention. Primary outcome measures will include suicide risk (Columbia Suicide Severity Rating Scale, C-SSRS) and aerobic fitness (VO2max), along with additional measures of suicide risk, mood, emotion regulation, sleep, cognition, and physical activity, with assessments completed at baseline and after 6 and 12 weeks of interventions.

DISCUSSION

It is hypothesized that AE will reduce suicide risk among individuals with SZ. This study may offer support for a more efficacious treatment method for this population in addition to the pre-existing pharmacological and psychotherapeutic treatment regimens.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03270098 . Registered on September 1, 2017.

[Sports Activity and Mental Diseases]

Current meta-analyses demonstrate convincing evidence regarding the efficacy of exercise on depression, insomnia, anxiety disorders, schizophrenia and ADHD. However, exercise and sports therapy approaches for patients with psychological disorders are mostly integrated in psychiatric inpatient or rehabilitation settings, but not applied in the outpatient sector. Thus, the German Health sector does not take the advantage of the compelling therapeutic effects of exercise. This review covers the theoretical and empirical fundamentals of the effects of exercise and illustrates practical implications by means of the presentation of the group-therapeutic exercise program ImPuls, that was specifically designed for patients with psychological disorders in outpatient settings. ImPuls integrates current evidence of the effects of exercise (type of sport, duration, frequency, intensity) and the facilitation of motivational and volitional strategies to support patients to integrate exercise in their daily life routines.

An 18-month longitudinal study of suicidality in patients diagnosed with schizophrenia

BACKGROUND

Suicide kills over 30,000 people annually in the US. Schizophrenia increases the risk, even in psychiatric populations. Identifying high-risk groups within this patient population is central to suicide prevention. We tested the effects of known and putative risk factors for suicide in a clinically recognizable population with symptoms of schizophrenia and unstable illness.

METHODS

We studied 1439 subjects with schizophrenia participating in the NIMH-funded Clinical Antipsychotic Treatment for Intervention Effectiveness (CATIE) trial and followed for 18 months. The dependent variable was moderate to severe self-reported suicidal thinking and self-reported suicide attempts. The independent variables comprised potential risk factors for suicidality including measures of clinical change during follow-up. Proportional hazards models of time to first suicidality generated bivariate and multivariate hazard ratios (HRs).

RESULTS

Altogether 96 patients (7.6%) experienced moderate to severe suicidality in the course of 18 months. Multivariate analyses showed that baseline moderate or severe suicidality was the strongest correlate of subsequent moderate or severe suicidality (HR 5.1). An increase in a subject's depression score during follow-up was also independently and strongly associated with suicidality (HR 3.5). A change in psychotic symptoms was not.

CONCLUSIONS

Depression and despair may be more important risk factors for suicidality among people with schizophrenia than psychotic decompensation. Strategies for prevention that seek to identify groups at high risk of suicide should focus on these variables, as well as the effect of prior suicidality.

The Effect of Aerobic Exercise on Physical and Cognitive Outcomes in a Small Cohort of Outpatients with Schizophrenia

Background:

Schizophrenia (SCZ) is a severe, chronic illness characterized by psychotic symptoms and impairments in many cognitive domains. Dysregulation of brain derived neurotrophic factor (BDNF) is associated with the cognitive impairments seen in patients with SCZ. Given the growing literature supporting a positive effect of aerobic exercise on cognition in other populations, we hypothesized that a structured aerobic exercise program would improve cognitive and functional outcomes in subjects with SCZ, potentially mediated by increases in BDNF.

Methods:

The study was a small randomized parallel group clinical trial of subjects with SCZ comparing 12 weeks of aerobic exercise (AE) against control (CON) stretching and balance training. At Baseline, Week 12, and Week 20 we collected serum samples for analysis of brain derived neurotrophic factor (BDNF), and assessed functional, physical, and cognitive outcomes. Linear regression models were used to compare change scores between timepoints.

Results:

We randomized 21 subjects to AE and 17 to CON; however, only 9 AE and 6 CON completed their programs. Subjects in both groups were slower at the 400 m walk in Week 12 compared to Baseline, but the AE group had significantly less slowing than the CON group (B = –28.32, p = 0.011). Between Week 12 and Week 20, the AE group had a significantly greater change score on the Composite and Visual Learning Domain of the MATRICS Consensus Cognitive Battery (B = 5.11, p = 0.03; B = 13.96, p = 0.006).

Conclusion:

These results indicate that participation in a structured aerobic exercise paradigm may modestly blunt physical function decline and enhance cognitive function in individuals with SCZ.

Effects of aerobic exercise on cardiorespiratory fitness and social functioning in veterans 40 to 65 years old with schizophrenia

The usual physical activity level of people with chronic histories of schizophrenia is very low. In this pilot study, we examined the effects of an easy to implement aerobic exercise (AE) program on cardiorespiratory fitness and social functioning in 54 Veterans aged 40-65 years old with schizophrenia. Participants were randomized 2:1 to AE (36 forty-minute sessions conducted 3 times per week over 12 weeks) versus a non-aerobic stretching exercise condition conducted under the same regimen and timeframe. Cardiorespiratory fitness improved significantly within the AE group (p<.0001), and differed significantly from the comparison group (p<.02; Cohen's d=.41). Trend-level improvements were seen in social functioning within the AE group (p<.09) and showed a similar trend level difference in the between-group comparison (p<.06; Cohen's d=.35). Improvements in social functioning were significantly related to gains in cardiorespiratory fitness (r=.42; p<.01). AE effects on other physical and mental health indices were also examined. Overall, the AE intervention was well-tolerated, safe, and showed low rates of attrition after the commencement of training. Our findings indicate it is feasible to improve cardiorespiratory fitness in this clinical population, and there is suggestive evidence that the interventions aimed to do so may also benefit social functioning.

Exercise as Medicine for Mental and Substance Use Disorders: A Meta-review of the Benefits for Neuropsychiatric and Cognitive Outcomes

BACKGROUND

Exercise may improve neuropsychiatric and cognitive symptoms in people with mental disorders, but the totality of the evidence is unclear. We conducted a meta-review of exercise in (1) serious mental illness (schizophrenia spectrum, bipolar disorder and major depression (MDD)); (2) anxiety and stress disorders; (3) alcohol and substance use disorders; (4) eating disorders (anorexia nervosa bulimia nervosa, binge eating disorders, and (5) other mental disorders (including ADHD, pre/post-natal depression).

METHODS

Systematic searches of major databases from inception until 1/10/2018 were undertaken to identify meta-analyses of randomised controlled trials (RCTs) of exercise in people with clinically diagnosed mental disorders. In the absence of available meta-analyses for a mental disorder, we identified systematic reviews of exercise interventions in people with elevated mental health symptoms that included non-RCTs. Meta-analysis quality was assessed with the AMSTAR/+.

RESULTS

Overall, we identified 27 systematic reviews (including 16 meta-analyses representing 152 RCTs). Among those with MDD, we found consistent evidence (meta-analyses = 8) that exercise reduced depression in children, adults and older adults. Evidence also indicates that exercise was more effective than control conditions in reducing anxiety symptoms (meta-analyses = 3), and as an adjunctive treatment for reducing positive and negative symptoms of schizophrenia (meta-analyses = 2). Regarding neurocognitive effects, exercise improved global cognition in schizophrenia (meta-analyses = 1), children with ADHD (meta-analyses = 1), but not in MDD (meta-analyses = 1). Among those with elevated symptoms, positive mental health benefits were observed for exercise in people with pre/post-natal depression, anorexia nervosa/bulimia nervosa, binge eating disorder, post-traumatic stress disorder and alcohol use disorders/substance use disorders. Adverse events were sparsely reported.

CONCLUSION

Our panoramic meta-overview suggests that exercise can be an effective adjunctive treatment for improving symptoms across a broad range of mental disorders.

Exercise as a protective mechanism against the negative effects of oxidative stress in first-episode psychosis: a biomarker-led study

First-episode psychosis (FEP) is a psychiatric disorder, characterised by positive and negative symptoms, usually emerging during adolescence and early adulthood. FEP represents an early intervention opportunity for intervention in psychosis. Redox disturbance and subsequent oxidative stress have been linked to the pathophysiology of FEP. Exercise training can perturb oxidative stress and rebalance the antioxidant system and thus represents an intervention with the potential to interact with a mechanism of disease. The aim of this study was to assess the effect of exercise on markers of redox status in FEP. Twenty-two young men were recruited from Birmingham Early Intervention services and randomised to either a 12-week exercise programme or treatment as usual (control). Measures of blood and brain glutathione (GSH), markers of oxidative damage, inflammation, neuronal health, symptomology and habitual physical activity were assessed. Exercise training was protective against changes related to continued psychosis. Symptomatically, those in the exercise group showed reductions in positive and general psychopathology, and stable negative symptoms (compared to increased negative symptoms in the control group). Peripheral GSH was increased by 5.6% in the exercise group, compared to a significant decrease (24.4%) (p = 0.04) in the control group. Exercise attenuated negative changes in markers of neuronal function (brain-derived neurotrophic factor), lipid damage (thiobarbituric acid-reactive substances) and total antioxidant capacity. C-reactive protein and tumour necrosis factor-α also decreased in the exercise group, although protein and DNA oxidation were unchanged. Moderate-intensity exercise training has the ability to elicit changes in markers of oxidative stress and antioxidant concentration, with subsequent improvements in symptoms of psychosis.

DAily time use, Physical Activity, quality of care and interpersonal relationships in patients with Schizophrenia spectrum disorders (DiAPASon): an Italian multicentre study

BACKGROUND

Schizophrenia spectrum disorders (SSD) are ranked among the leading causes of disabilities worldwide. Many people with SSD spend most of their daily time being inactive, and this is related to the severity of negative symptoms. Here, we present the 3-year DiAPAson project aimed at (1) evaluating the daily time use among patients with SSD living in Residential Facilities (RFs) compared to outpatients with SSD and to the general population (Study 1); (2) evaluating the quality of staff-patient relationships, its association with specific patient outcomes and the quality of care provided in RFs (Study 2); and (3) assessing daily activity patterns in residential patients, outpatients with SSD and healthy controls using real-time methodologies (Study 3).

METHODS

Study 1 will include 300 patients with SSD living in RFs and 300 outpatients; data obtained in these clinical populations will be compared with normative data obtained by the National Institute of Statistics (ISTAT) in the national survey on daily time use. Time use assessments will consist of daily diaries asking participants to retrospectively report time spent in different activities. In Study 2, a series of questionnaires will be administered to 300 residential patients (recruited for Study 1) to evaluate the quality of care and staff-patient relationships, level of well-being and burnout of RFs' staff, and quality of RFs using a European standardized questionnaire (QuIRC-SA). In Study 3, the daily time use will be evaluated in a subgroup of 50 residential patients, 50 outpatients and 50 healthy controls using the Experience Sampling Method approach (participants will complete a brief questionnaire -about time use, mood and perceived energy- on a smartphone 8 times a day for 1 week) to compare retrospective and real-time reports. Moreover, their level of physical activity, sleep patterns, and energy expenditure will be monitored through a multi-sensor device.

DISCUSSION

This project is highly innovative because it combines different types of assessments (i.e., retrospective and real-time reports; multi-sensor monitoring) to trace an accurate picture of daily time use and levels of physical activity that will help identify the best therapeutic options promoting daily activities and physical exercise in patients with SSD.

TRIAL REGISTRATION

ISRCTN registry ID ISRCTN21141466.

Telepsychotherapy with Youth at Clinical High Risk for Psychosis: Clinical Issues and Best Practices during the COVID-19 Pandemic

Early detection and prevention of psychosis has become an international priority. Much of this work has focused on youth presenting with attenuated symptoms of psychosis-those at Clinical High Risk for psychosis (CHR)-given their elevated probability of developing the full disorder in subsequent years. Individuals at CHR may be prone to exacerbated psychological distress during the COVID-19 pandemic and its subsequent physical isolation measures, due to heightened stress sensitivity and comorbid mental health problems. Telepsychotherapy holds promise for reaching this population, especially during the current COVID-19 outbreak. However, there are limited evidence-based guidelines or interventions for use of telepsychotherapy with this population. In this paper, we review common clinical issues for individuals at CHR and how they might be exacerbated by the COVID-19 pandemic; best practices for treatment and adaptations for telepsychotherapy for individuals at CHR; and highlight real clinical issues that we are currently experiencing in a United States-based specialized CHR clinic as we conduct telepsychotherapy via videoconferencing. We conclude with questions for those in the field to contemplate, as well as potential challenges and benefits in using telepsychotherapy with individuals at CHR and their families.

Nonpharmacological treatment of dyscognition in schizophrenia: effects of aerobic exercise

Cognitive symptoms are a core feature of schizophrenia and are related to an unfavorable disease outcome. So far, there are no satisfactory pharmacological approaches to address cognitive symptoms. For some time now, aerobic exercise has been demonstrated in various trials to be a promising candidate for this indication. The aim of this brief qualitative review was to present the most recent meta-analyses regarding the capacity of exercise to improve cognition in schizophrenia patients. Additionally, we give a short overview of the effects in other conditions, like healthy subjects and patients with major depression. We conducted a focused literature search using the PubMed database, concentrating on meta-analyses which are based on a systematic search. The most recent meta-analysis investigating the efficacy of aerobic exercise on cognitive impairments in schizophrenia patients provides evidence that exercise has positive effects on cognitive functioning in this population. However, the effect seems not to be specific; there were positive findings regarding healthy subjects and patients with depressive disorders as well, even if they were less consistent. As most available trials have a small to modest sample size and have no consensus with regard to the intervention regime, nor to the assessment of cognition, the findings are difficult to generalize. In the future, standardized clinical trials focusing on the long-term effects of exercise are needed to evaluate whether the improvements in cognition are sustainable.


Functioning in schizophrenia: a Delphi study covering the perspective of physiotherapists

PURPOSE

This qualitative study explores the barriers, personal characteristics/resources, and environmental factors that experienced physiotherapists identify as relevant in the assessment and treatment of persons living with schizophrenia, and whether the identified aspects are represented in the International Classification of Functioning, Disability and Health Core Sets for schizophrenia.

METHODS

A three-round Delphi study with physiotherapists was conducted between April and July 2018. In the first round, participants had to list all the aspects they considered to be relevant when assessing and/or treating individuals with schizophrenia, and they were asked six open-ended questions. Their responses were linked to categories. In the second and third rounds, physiotherapists had to judge whether each category/personal factor was relevant for describing functioning in schizophrenia.

RESULTS

Thirteen of 22 eligible physiotherapists from eight countries responded to the first round, and 10 completed all three rounds. Eighty-two (84.5%) of the 97 categories in the Comprehensive Core Set for schizophrenia and all 25 categories in the Brief Core Set were considered relevant. A total of five categories were additionally identified.

CONCLUSIONS

The barriers, personal characteristics/resources, and environmental factors from the physiotherapists' perspective have been identified. The results largely confirm the content validity of the Core Sets for schizophrenia.Implications for rehabilitationThis study shows which barriers, personal characteristics/resources, and environmental factors in persons with schizophrenia are relevant from physiotherapists' perspective and should be integrated in the rehabilitation process.The content validity of the Comprehensive and Brief Core Sets for schizophrenia is largely supported from the physiotherapists' perspective and therefore could be used in the assessment of functioning in persons with schizophrenia.The Comprehensive and Brief ICF Core Sets for schizophrenia could be used to plan and assess multidisciplinary rehabilitation interventions.

Yoga for People With Chronic Pain in a Community-Based Setting: A Feasibility and Pilot RCT

The purpose of this feasibility pilot study was to assess benefits of 8 weeks of yoga in people with chronic pain. Participants completed baseline assessments and were randomized to yoga or usual care. Yoga was offered twice a week for 8 weeks. We assessed feasibility and the Brief Pain Inventory (BPI) was the primary outcome, assessing pain-severity and pain interference on daily activities. Eighty-three people were recruited; 67 people completed the study and were included in the analyses. Average age of participants was 50.78 ± 10.43 years and most participants had pain >10 years. The intervention appeared feasible and there were significant improvements (P < .05) in multiple measures for the yoga group, including a decrease in BPI interference scores from 7.15 ± 1.70 to 6.14 ± 2.21 (P = .007). There was a significant difference in body responsiveness and pain management scores between groups at 8 weeks. It appears that yoga was feasible and positively influenced multiple outcome measures for people with chronic pain.

Rethinking Schizophrenia and Depression Comorbidity as One Psychiatric Disorder Entity: Evidence From Mouse Model

Schizophrenia is frequently accompanied by depressive symptoms, but the pathological mechanisms remain to be elucidated. In this study, we used chronic unpredicted mild stress plus MK801 injection to generate a mouse model of schizophrenia with depression, in which in vivo 2-photon calcium imaging and electrophysiological recordings were performed in conjunction with behavioral phenotyping. Compared to mice models with classical depression or to schizophrenia models, the animal models with schizophrenia and depression comorbidity presented worse psychotic and depressive symptoms. These behavioral deficits are associated with impaired neuronal calcium activities in the frontal cortex and thalamic nuclei. Moreover, in sharp contrast to classical models that have a satisfactory response to antipsychotic or antidepressant drugs, this novel schizophrenia with depression model is resilient to combined drug treatment in terms of behavioral and functional recovery. Taken together, these data indicate that schizophrenia with depression likely involves a unique pathophysiology that is different from schizophrenia or depression alone.

Aerobic exercise and cognitive functioning in schizophrenia: Results of a 1-year follow-up from a randomized controlled trial

We previously reported that adding combined, individual, and group aerobic exercise (AE) interventions to the treatment as usual (TAU) for schizophrenia showed significant improvements in cognition and other outcomes compared to those with TAU alone in a randomized controlled trial. Following the promising results of our previous study, this 1-year follow-up study evaluated the improvements in cognition and other outcomes with TAU + AE compared to those with TAU alone. Of 41 randomized patients, 40 were included in the intent-to-treat population-20 in the TAU + AE and 20 in the TAU alone; all patients completed the 1-year follow-up. Mixed models were applied to assess changes in outcome measures over time from baseline to 1-year follow-up. At 1-year follow-up, the TAU + AE demonstrated significant group by time interaction effects in several cognitive domains, intrinsic motivation, negative symptom, interpersonal relations, and functional outcome compared with the TAU alone. Our results demonstrate that the improvements in cognition and other outcomes with TAU + AE were maintained and that functional outcome improved over 1-year follow-up. These findings show that the improvements sustained for each outcome over 1 year have the potential to offer opportunities for greater transitions to improvement of functional outcome.

Designing a feasible exercise intervention in first-episode psychosis: Exercise quality, engagement and effect

First-episode psychosis (FEP) is the first presentation of a psychotic disorder that usually propagates during early adulthood. FEP represents an important early intervention point to attenuate the metabolic risks associated with psychosis and its treatment. Exercise has potential to improve metabolic and functional outcome, but engaging this population in regular exercise is typically difficult. Promoting enjoyment and attendance may improve participation. 22 men with FEP were randomised to a 12-week intervention of exercise training, or treatment as usual. Exercise was pre-standardised based on measures of heart rate to assess intensity. Symptoms of psychosis were assessed, alongside measures of quality of life, disability and habitual activity. The study observed 83% attendance at exercise sessions, with target intensity attained. There were clinically meaningful decreases in PANSS positive (17.31%) and general psychopathology (10.98%) scores and exercise was protective of negative score increase observed in the control group (13.89%). Assessment of disability declined after training (12.65%) compared with a 20.78% increase in controls. This study demonstrated that engagement of FEP patients in an intervention of high quality exercise was possible. Positive changes in psychopathology scores and disability show that the benefits of regular exercise are achievable with a potential positive impact on clinical presentation.

Parvalbumin Interneuron Activation-Dependent Adult Hippocampal Neurogenesis Is Required for Treadmill Running to Reverse Schizophrenia-Like Phenotypes

Physical exercise can alleviate some of the schizophrenia symptoms in patients, the mechanisms, however, are still unclear. To investigate whether the GABAergic interneuron involved in the therapeutic effect of treadmill running on schizophrenia, the parvalbumin (PV)-positive GABAergic interneurons in the dentate gyrus (DG) was specifically activated or abolished and the effects were evaluated. In the MK801-induced schizophrenia-like animal model, we found:(1) Treadmill running rescued the schizophrenia-related behavioral phenotypes, promoted the adult hippocampal neurogenesis, and increased the dendrite number and complexity of newborn neurons. (2) Treadmill running increased the number of PV-positive interneurons in the DG; genetic ablation of these interneurons reduced adult neurogenesis and abolished the effect of treadmill running on the schizophrenia-related behaviors. Consistently, chemogenetic activation of these interneurons improved neurogenesis and alleviated the schizophrenia-related behaviors. These results suggest a pivotal role of PV-positive interneuron-mediated adult neurogenesis in exercise. (3) However, schizophrenia-related behavioral phenotypes and adult neurogenesis in the DG could still be reversed by exercise after specifically knocking out the schizophrenia-related gene ErbB4 in PV interneurons, as a means to reduce their GABA release. These results suggest that activation of PV interneurons in the DG is sufficient for treadmill running to reverse schizophrenia-like phenotypes.

Effects of therapeutic lifestyle change mentoring on cardio-metabolic factors for schizophrenia

Considering that the prevalence of cardio-metabolic syndrome in patients with chronic schizophrenia is two or three times higher than the general population, this study aimed to provide patients with schizophrenia using community psychiatric rehabilitation services with therapeutic lifestyle change (TLC) mentoring using a smartphone application and provide inpatients in a psychiatric ward with structured TLC mentoring, to compare improvement in cardio-metabolic factors between the two groups. The home-based community service users using a TLC application were more likely to experience an improvement in their cardio-metabolic factors than the inpatients provided with the structured TLC program.

Effect of aerobic exercise combined with cognitive remediation on cortical thickness and prediction of social adaptation in patients with schizophrenia

Aerobic exercise is a promising intervention for patients with schizophrenia, but structural neuroplastic effects on brain regions relevant to the pathophysiology of the disease remain unclear. This study aimed to elucidate longitudinal changes in cortical thickness after aerobic exercise intervention in schizophrenia patients and the relationship of these changes to clinical correlates. We investigated 21 schizophrenia patients and 23 healthy controls who performed aerobic exercise and 21 schizophrenia patients who played table soccer. The 12-week exercise intervention was combined with computer-assisted cognitive remediation training from week 6 to week 12. Magnetic resonance imaging (MRI) scans were acquired at baseline and weeks 6, 12, and 24. The thickness of the entorhinal, parahippocampal, and lateral and medial prefrontal cortices was assessed with FreeSurfer 6.0. The schizophrenia aerobic exercise group showed a significant increase of cortical thickness in the right entorhinal cortex at week 6, and we found a significant correlation between the cortical thickness of the right lateral prefrontal cortex at baseline and improvement of social adaptation at week 12. In the schizophrenia table soccer and healthy control groups, we found no significant longitudinal change in cortical thickness through the intervention and follow-up period and no correlation of cortical thickness at baseline with clinical measures. Our results suggest that aerobic exercise in schizophrenia modulates the thickness of the entorhinal cortex, a structure adjacent to the hippocampus. Greater cortical thickness of the right lateral prefrontal cortex appears to predict better clinical response to an aerobic exercise intervention in patients with schizophrenia.

Lessons Learned From a Physical Activity Intervention in Psychiatric Treatment: Patient, Staff, and Leader Perspectives

OBJECTIVE

To explore how the implementation of a motivational physical activity (PA) intervention for inpatients with severe mental illness was experienced by patients, staff, and leaders at a psychiatric institution.

METHOD

After the intervention individual semi-structured interviews were conducted with patients (n = 6) and staff (n = 6), and a focus group interview was conducted with the leaders (n = 4).

RESULTS

All had a positive view on PA as part of psychiatric treatment, thinking it would benefit the patients' health. There were some differences among the groups as to the importance of PA relative to traditional treatments. Positive outcomes were reported from all three groups, but with different foci. The patients and the staff underscored the importance of PA professionals in order to achieve high quality activities, whereas the leaders, due to restraints in resources, could not prioritize to hire PA professionals.

CONCLUSION

PA was considered a positive part of treatment. Ideas about what it takes to obtain the potential physical, mental, and social benefits of PA differed between patients, the staff involved, and the leaders. Having staff with PA as a primary responsibility and with sufficient competence as PA instructors seems to be important.

Outdoor cycling improves clinical symptoms, cognition and objectively measured physical activity in patients with schizophrenia: A randomized controlled trial

PURPOSE

The therapeutic effects of outdoor cycling (OC) and its benefits on physical activity (PA) were investigated in people with schizophrenia.

METHODS

Sixty patients with schizophrenia were randomly assigned to 16-weeks of Outdoor Cycling (OC) (n = 30, 50% male; mean age, 38.7 ± 10.1) or Occupational Therapy (OT) (n = 30, 50% male; mean age, 39.0 ± 8.6). OC and OT involved one 90-min group session per week. OC consisted of structured exercise programs and OT addressed daily living skills. Primary outcome measurements were mental health variables, such as Brief Psychiatric Rating Scale, Beck's Depression Inventory, State and Trait Anxiety Inventory, Rosenberg Self-Esteem Scale, Global Assessment of Functioning and executive function (Wisconsin Card Sorting Test, WCST). Secondary measures were the adherence and PA. PA was measured by responding to the Physical Activity Scale (K-PASE) and wearing a pedometer for 2 days.

RESULTS

Repeated measures ANOVA revealed improved psychotic symptoms (p = .014), depression (p = .007), state (p = .031) and trait anxiety (p = .002) and global functions (p = .024) in the OC group compared with OT group. The OC group showed increased correct rates (p = .022) and categories completed (p = .033) in the WCST. There was no difference in total K-PASE score between groups; however, there was a significant improvement in the number of daily steps in the OC group compared with the OT group (p = .030).

CONCLUSION

OC significantly improved mental health and executive function in individuals with schizophrenia. Further, OC significantly increased PA measured by the pedometers. These findings suggest that OC offers a safe and attrition-lowering intervention promoting mental health and PA.

TRIAL REGISTRATION

cris.nih.go.kr identifier: KCT-0000873.

Physical exercise for negative symptoms of schizophrenia: Systematic review of randomized controlled trials and meta-analysis

INTRODUCTION

The negative symptoms of schizophrenia contribute strongly to functional impairment but are inadequately treated by antipsychotic medication. Several studies have suggested that physical exercise could reduce the negative symptoms.

METHODS

We conducted a systematic review and a meta-analysis of randomized controlled trials (RCTs) examining the effectiveness of physical exercise interventions in improving the negative symptoms of schizophrenia using different databases and trial registries.

RESULTS

Seventeen RCTs were included in the meta-analysis (n = 954 patients). Overall, the results revealed a significant beneficial effect of physical exercise on negative symptoms. We conducted a subgroup analysis differentiating between aerobic interventions (12 RCTs) and non-aerobic interventions (5 RCTs). Aerobic exercise reduced negative and positive symptoms, while this was not the case for non-aerobic interventions. A sensitivity analysis including only studies with a low risk of bias confirmed the effect on negative but not on positive symptoms.

CONCLUSION

Aerobic exercise had a beneficial effect on negative symptoms, albeit with a small effect size. The conclusions are limited by the fact that the included studies did not assess patients for predominant or primary negative symptoms. Given the important role of exercise for physical health, the additional effects on negative symptoms are promising and justify further research to disentangle the effects on primary and secondary negative symptoms.

Resistance training in patients with schizophrenia: Concept and proof of principle trial

Resistance training has been shown to contribute to the prevention and management of cardiovascular diseases, which is why it can help reducing morbidity and mortality in schizophrenia patients. Moreover, positive effects on different schizophrenia symptom domains have been proposed. However, a specific resistance training tailored to the needs of schizophrenia patients and its evaluation is still lacking. The objective in this proof of principle trial was to evaluate the feasibility and efficacy of a newly developed 12-week resistance program according to current recommendations of the WHO and the American College of Sports Medicine. We employed a single blind, parallel assignment clinical trial design with participants randomized to attend either a resistance training including three 50min units per week or a balance and tone program as control condition. The primary outcome was the impact on health-related difficulties assessed with the World Health Organization Disability Assessment Schedule (WHO-DAS). Secondary outcome parameters included the level of functioning, schizophrenia symptoms, selected cognitive parameters as well as risk factors for cardiovascular diseases. In our proof of principle trial, we could not find significant time or group effects of resistance training on the WHO-DAS. However, we could observe significant positive effects on the level of functioning assessed with the Global Assessment of Functioning Scale (GAF) over the course of time, which were more pronounced in the intervention group. Our findings indicated that patients with schizophrenia could safely participate in resistance training with relevant improvements in their level of functioning. Well-powered replication trials are needed to provide more efficacy data.