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

A Supervised Exercise Intervention for Youth at Risk for Psychosis: An Open-Label Pilot Study

OBJECTIVE

A rapidly accumulating body of research suggests that exercise can improve symptoms and well-being in patients suffering from psychosis. Exercise may also promote neurogenesis in the hippocampus, a structure that plays an important role in the pathophysiology of psychosis. To date, there has not been an intervention focused on exercise prior to the onset of psychosis, a critical time for prevention of more serious illness.

METHODS

In this pilot study, 12 young adults at ultrahigh risk (UHR) for psychosis were enrolled in a 12-week open-label exercise intervention. Participants were randomly assigned to exercise 2 or 3 times each week and exercised between 65% and 85% of maximum oxygen capacity (Vo2max) for 30 minutes each session under the supervision of an exercise physiologist. Positive and negative symptoms, social and role functioning, performance on neurocognitive tests, cardiovascular fitness, and hippocampal structure and functional connectivity were evaluated before and after the trial.

RESULTS

A total of 9 participants completed the exercise intervention. Participants showed improved positive and negative symptoms and social and role functioning; improvement in multiple areas of cognition; and increased functional connectivity between the left hippocampus and occipital cortex after 12 weeks of exercise.

CONCLUSIONS

The results of this study suggest that exercise interventions are feasible in a UHR sample and may promote improvement in clinical, social, and cognitive domains as well as changes to brain function in regions impacted by the development of psychosis. These findings set the stage for an ongoing phase 2 randomized controlled trial.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02155699.

Does Integrated Neurocognitive Therapy (INT) reduce severe negative symptoms in schizophrenia outpatients?

Negative symptoms often inhibit the social integration of people suffering from schizophrenia. Reducing severe negative symptoms (SNS) in a clinically relevant way is a major unmet need. The aim of this study was to investigate whether Integrated Neurocognitive Therapy (INT), a group cognitive remediation therapy (CRT), reduces SNS in schizophrenia outpatients. INT was compared with Treatment As Usual (TAU) in a randomized-controlled trial (RCT). A total of 61 SNS outpatients participated in the study, 28 were allocated to the INT group and 33 to the TAU group. A test-battery was used at baseline, post-treatment at 15weeks, and 1-year-follow-up. Remission rates of SNS after therapy were significantly higher for INT compared to TAU. A trend favoring INT was obtained at follow-up. Furthermore, INT showed significantly higher functional outcome during follow-up compared to TAU. Regarding cognition, the strongest significant effect was found in attention post-treatment. No effects between groups on more complex neurocognition and social cognition were evident. SNS outpatients seem to accept INT group intervention as suggested by the high attendance rate.

Yoga as part of a package of care versus standard care for schizophrenia

BACKGROUND

Yoga is an ancient spiritual practice that originated in India and is currently accepted in the Western world as a form of relaxation and exercise. It has been of interest for people with schizophrenia to determine the efficacy of yoga delivered as a package of care versus standard care.

OBJECTIVES

To examine the effects of yoga as a package of care versus standard care.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register (latest 30 March 2017) which is based on regular searches of MEDLINE, PubMed, Embase, CINAHL, BIOSS, AMED, PsychINFO, and registries of clinical trials. We searched the references of all included studies. There are no language, date, document type, or publication status limitations for inclusion of records in the register.

SELECTION CRITERIA

All randomised controlled trials (RCTs) including people with schizophrenia comparing yoga as a package of care with standard-care control.

DATA COLLECTION AND ANALYSIS

The review authors independently selected studies, quality rated these, and extracted data. For binary outcomes, we calculated risk difference (RD) and its 95% confidence interval (CI), on an intention-to-treat (ITT) basis. For continuous data, we estimated the mean difference (MD) between groups and its CI. We employed mixed-effect and fixed-effect models for analysis. We examined heterogeneity (I² technique), assessed risk of bias for included studies, and created a 'Summary of findings' table using GRADE (Grading of Recommendations Assessment, Development and Evaluation).

MAIN RESULTS

Three studies are included in this review. All outcomes were short term (less than eight weeks). Useable data were reported for two outcomes only; leaving the study early and quality of life. None of the participants left the studies early and there was some evidence in favour of the yoga package for quality of life endpoint scores (1 RCT, n=80, MD 22.93 CI 19.74 to 26.12, low-quality evidence). Leaving the study early data were equivocal between the treatment groups (3 RCTs, n=193, RD 0.06 CI -0.01 to 0.13, medium-quality evidence, high heterogeneity). Overall, this review has an inordinate number of missing key outcomes, which included mental and global state, social functioning, physical health, adverse effects and costs of care.

AUTHORS' CONCLUSIONS

A small number of small studies were included in this review and these lacked many key outcomes. The sparse data means we cannot state with any degree of certainty if yoga delivered as a package of care is beneficial in comparison to standard care.

Yoga versus non-standard care for schizophrenia

BACKGROUND

Yoga is an ancient spiritual practice that originated in India and is currently accepted in the Western world as a form of relaxation and exercise. It has been of interest for people with schizophrenia as an alternative or adjunctive treatment.

OBJECTIVES

To systematically assess the effects of yoga versus non-standard care for people with schizophrenia.

SEARCH METHODS

The Information Specialist of the Cochrane Schizophrenia Group searched their specialised Trials Register (latest 30 March 2017), which is based on regular searches of MEDLINE, PubMed, Embase, CINAHL, BIOSIS, AMED, PsycINFO, and registries of clinical trials. We searched the references of all included studies. There are no language, date, document type, or publication status limitations for inclusion of records in the register.

SELECTION CRITERIA

All randomised controlled trials (RCTs) including people with schizophrenia and comparing yoga with non-standard care. We included trials that met our selection criteria and reported useable data.

DATA COLLECTION AND ANALYSIS

The review team independently selected studies, assessed quality, and extracted data. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated the mean difference (MD) between groups and its 95% CI. We employed a fixed-effect models for analyses. We examined data for heterogeneity (I2 technique), assessed risk of bias for included studies, and created a 'Summary of findings' table for seven main outcomes of interest using GRADE (Grading of Recommendations Assessment, Development and Evaluation).

MAIN RESULTS

We were able to include six studies (586 participants). Non-standard care consisted solely of another type of exercise programme. All outcomes were short term (less than six months). There was a clear difference in the outcome leaving the study early (6 RCTs, n=586, RR 0.64 CI 0.49 to 0.83, medium quality evidence) in favour of the yoga group. There were no clear differences between groups for the remaining outcomes. These included mental state (improvement in Positive and Negative Syndrome Scale, 1 RCT, n=84, RR 0.81 CI 0.62 to 1.07, low quality evidence), social functioning (improvement in Social Occupational Functioning Scale, 1 RCT, n=84, RR 0.90 CI 0.78 to 1.04, low quality evidence), quality of life (mental health) (average change 36-Item Short Form Survey (SF-36) quality-of-life sub-scale, 1 RCT, n=69, MD -5.30 CI -17.78 to 7.18, low quality evidence), physical health, (average change WHOQOL-BREF physical-health sub-scale, 1 RCT, n=69, MD 9.22 CI -0.42 to 18.86, low quality evidence). Only one study reported adverse effects, finding no incidence of adverse events in either treatment group. There were a considerable number of missing outcomes, which included relapse, change in cognition, costs of care, effect on standard care, service intervention, disability, and activities of daily living.

AUTHORS' CONCLUSIONS

We found minimal differences between yoga and non-standard care, the latter consisting of another exercise comparator, which could be broadly considered aerobic exercise. Outcomes were largely based on single studies with limited sample sizes and short-term follow-up. Overall, many outcomes were not reported and evidence presented in this review is of low to moderate quality - too weak to indicate that yoga is superior or inferior to non-standard care control for management of people with schizophrenia.

Physical Activity Diminishes Symptomatic Decline in Chronic Schizophrenia: A Systematic Review

Physical activity has been shown to positively influence a number of parameters in chronic schizophrenia, including cognition, social well being, and quality of life. Here, we present a systematic review of randomized controlled trials reporting on reduction of positive and negative symptoms using PANSS grading after the implementation of a physical activity protocol. Review of 64 articles yielded 6 relevant to our discussion. We found that physical activity significantly improved aggregate total PANSS score as well as positive symptoms PANSS score. While negative PANSS score showe a trend toward improvement, this was nonsignificant. Overall, we find the various forms of physical activity discussed within to be an appropriate adjunct to standard pharmacotherapy for the reduction of symptoms in chronic schizophrenia.

Physical activity and quality of life in long-term hospitalized patients with severe mental illness: a cross-sectional study

BACKGROUND

Increasing physical activity in patients with severe mental illness is believed to have positive effects on physical health, psychiatric symptoms and as well quality of life. Till now, little is known about the relationship between physical activity and quality of life in long-term hospitalized patients with severe mental illness and knowledge of the determinants of behavioural change is lacking. The purpose of this study was to elucidate the relationship between objectively measured physical activity and quality of life, and explore modifiable psychological determinants of change in physical activity in long-term hospitalized patients with severe mental illness.

METHODS

In 184 inpatients, physical activity was measured using an accelerometer (ActiGraph GTX+). Quality of life was assessed by EuroQol-5D and WHOQol-Bref. Attitude and perceived self-efficacy towards physical activity were collected using the Physical Activity Enjoyment Scale and the Multidimensional Self Efficacy Questionnaire, respectively. Patient and disease characteristics were derived retrospectively from electronic patient records. Associations and potential predictors were analysed using hierarchical regression.

RESULTS

Physical activity was positively related with and a predictor of all quality of life outcomes except on the environmental domain, independent of patient and disease characteristics. However, non-linear relationships showed that most improvement in quality of life lies in the change from sedentary to light activity. Attitude and self-efficacy were not related to physical activity.

CONCLUSIONS

Physical activity is positively associated with quality of life, especially for patients in the lower spectrum of physical activity. An association between attitude and self-efficacy and physical activity was absent. Therefore, results suggest the need of alternative, more integrated and (peer-)supported interventions to structurally improve physical activity in this inpatient population. Slight changes from sedentary behaviour to physical activity may be enough to improve quality of life.

Association between altered physical activity and neurocognitive function among people with schizophrenia: A minimum 6-months' follow-up study

BACKGROUND

The long-term benefits of physical activity on neurocognitive function among patients with schizophrenia, specifically among inpatients, remain unclear. This preliminary study, with a minimum of 6-months' follow-up, examined alterations in physical activity and neurocognitive function in both inpatients and outpatients with schizophrenia.

METHODS

Symptoms and neurocognitive function were assessed at 2 intervals using the Positive and Negative Symptom Scale and Cognitrax, respectively. After each testing period, participants wore an accelerometer for 1week to measure their levels and duration of physical activity. After the 6-months' follow-up (average duration, 235.9±36.2days), participants were divided into 2 groups based on either increased or decreased activity, as compared with baseline: increased-activity and decreased-activity groups.

RESULTS

Of the 29 initially enrolled participants, 25 (mean age, 56.8±11.8years) completed the follow-up. Reaction times in the increased-activity group in daily activity (n=10) improved as compared with the decreased-activity group (n=15). Moreover, cognitive flexibility and executive function improved in the increased-activity group in steps (n=7) compared with the decreased-activity group (n=18). Finally, there was no association between the duration of moderate or vigorous exercise and neurocognitive function.

CONCLUSIONS

Together, our results suggest that increased daily activity and walking, but not high intensity activity, are associated with improved neurocognitive function in patients with schizophrenia.

Polygenic risk has an impact on the structural plasticity of hippocampal subfields during aerobic exercise combined with cognitive remediation in multi-episode schizophrenia

Preliminary studies suggest that, besides improving cognition, aerobic exercise might increase hippocampal volume in schizophrenia patients; however, results are not consistent. Individual mechanisms of volume changes are unknown but might be connected to the load of risk genes. Genome-wide association studies have uncovered the polygenic architecture of schizophrenia. The secondary analysis presented here aimed to determine the modulatory role of schizophrenia polygenic risk scores (PRSs) on volume changes in the total hippocampus and cornu ammonis (CA) 1, CA2/3, CA4/dentate gyrus (DG) and subiculum over time. We studied 20 multi-episode schizophrenia patients and 23 healthy controls who performed aerobic exercise (endurance training) combined with cognitive remediation for 3 months and 21 multi-episode schizophrenia patients allocated to a control intervention (table soccer) combined with cognitive remediation. Magnetic resonance imaging-based assessments were performed at baseline and after 3 months with FreeSurfer. No effects of PRSs were found on total hippocampal volume change. Subfield analyses showed that the volume changes between baseline and 3 months in the left CA4/DG were significantly influenced by PRSs in schizophrenia patients performing aerobic exercise. A larger genetic risk burden was associated with a less pronounced volume increase or a decrease in volume over the course of the exercise intervention. Results of exploratory enrichment analyses reinforced the notion of genetic risk factors modulating biological processes tightly related to synaptic ion channel activity, calcium signaling, glutamate signaling and regulation of cell morphogenesis. We hypothesize that a high polygenic risk may negatively influence neuroplasticity in CA4/DG during aerobic exercise in schizophrenia.

Behavioural Regulation in Exercise Questionnaire in people with schizophrenia: construct validity of the Portuguese versions

PURPOSE

People with schizophrenia have low physical activity levels that can be explained by the restriction in motivation. The Behavioural Regulation in Exercise Questionnaire-2 is a 19-item scale commonly used to assess five different motivational subtypes for physical activity. However, there are limited psychometric analyses of this version in the schizophrenia context. Moreover, there is a lack of information related to the psychometric properties of version 3 of this questionnaire, with 24 items and six different motivational subtypes. The aim of this study was to examine the construct validity of both Portuguese versions in people with schizophrenia.

METHODS

A total of 118 persons with schizophrenia were included (30 women). Cronbach's alpha was used for internal consistency, Pearson's correlation for the retained motivation-types, confirmatory factor analysis for the structural validity of version 2 and exploratory factor analysis for the factor structure of version 3.

RESULTS AND CONCLUSIONS

Analyses of version 2 provided an adequate fit index for the structure of the five factors. Exploratory analyses suggested retaining 2 factors of version 3. The results of this study suggest that version 3 was an appropriate measure to assess controlled and autonomous motivation for physical activity in people with schizophrenia and support its use in clinical practice and research. Implications for Rehabilitation This study supports the need to identify the reasons why people with schizophrenia practice physical activity. For that purpose, it is important to use valid and cost-effective instruments. The Portuguese version of BREQ-2 confirmed a 5-factor model and showed adequate fit for the application in people with schizophrenia. However, the incremental indices values were lower than expected. The Portuguese version of BREQ-3 showed acceptable psychometric properties to assess controlled and autonomous motivation for physical activity in people with schizophrenia.

The effect of acute exercise on blood concentrations of brain-derived neurotrophic factor in healthy adults: a meta-analysis

It has been hypothesized that one mechanism through which physical activity provides benefits to cognition and mood is via increasing brain-derived neurotrophic factor (BDNF) concentrations. Some studies have reported immediate benefits to mood and various cognitive domains after a single session of exercise. This meta-analysis sought to determine the effect of a single exercise session on concentrations of BDNF in peripheral blood, in order to evaluate the potential role of BDNF in mediating the beneficial effects of exercise on brain health. MEDLINE, Embase, PsycINFO, SPORTDiscus, Rehabilitation & Sports Medicine Source, and CINAHL databases were searched for original, peer-reviewed reports of peripheral blood BDNF concentrations before and after acute exercise interventions. Risk of bias within studies was assessed using standardized criteria. Standardized mean differences (SMDs) were generated from random effects models. Risk of publication bias was assessed using a funnel plot and Egger's test. Potential sources of heterogeneity were explored in subgroup analyses. In 55 studies that met inclusion criteria, concentrations of peripheral blood BDNF were higher after exercise (SMD = 0.59, 95% CI: 0.46-0.72, P < 0.001). In meta-regression analysis, greater duration of exercise was associated with greater increases in BDNF. Subgroup analyses revealed an effect in males but not in females, and a greater BDNF increase in plasma than serum. Acute exercise increased BDNF concentrations in the peripheral blood of healthy adults. This effect was influenced by exercise duration and may be different across genders.

Aerobic exercise and its effects on cognition in schizophrenia

PURPOSE OF REVIEW

Schizophrenia is a severe neuropsychiatric disorder with incomplete remission because of negative and cognitive symptoms in a large proportion of patients. Antipsychotic medication is successful in modulating positive symptoms, but only to a lower extent negative symptoms including cognitive dysfunction. Therefore, development of innovative add-on treatment is highly needed. In this review, recent evidence from clinical studies reveals effects of aerobic exercise on cognitive deficits in schizophrenia patients.

RECENT FINDINGS

First studies and meta-analyses on aerobic exercise in schizophrenia patients have shown effects on positive, negative, and global symptoms and cognitive domains such as global cognition, working memory, and attention. Underlying neurobiological mechanisms such as neuroplasticity-related synaptogenesis and neurogenesis have been identified in animal studies and possibly mediate effects of aerobic exercise on brain structure and function.

SUMMARY

Different aspects of methods (e.g., endurance training versus yoga and Tai Chi), length and dose of the intervention, supervision of patients by sports therapists as well as maintenance of cognitive improvement after cessation of training have been raised by previous studies. However, minimal and most effective dosage of the intervention and mechanisms underlying changes in neuroplasticity need to be answered in future basic and large-scale randomized clinical trials.

Aerobic Exercise Improves Cognitive Functioning in People With Schizophrenia: A Systematic Review and Meta-Analysis

Cognitive deficits are pervasive among people with schizophrenia and treatment options are limited. There has been an increased interest in the neurocognitive benefits of exercise, but a comprehensive evaluation of studies to date is lacking. We therefore conducted a meta-analysis of all controlled trials investigating the cognitive outcomes of exercise interventions in schizophrenia. Studies were identified from a systematic search across major electronic databases from inception to April 2016. Meta-analyses were used to calculate pooled effect sizes (Hedges g) and 95% CIs. We identified 10 eligible trials with cognitive outcome data for 385 patients with schizophrenia. Exercise significantly improved global cognition (g = 0.33, 95% CI = 0.13-0.53, P = .001) with no statistical heterogeneity (I2 = 0%). The effect size in the 7 studies which were randomized controlled trials was g = 0.43 (P < .001). Meta-regression analyses indicated that greater amounts of exercise are associated with larger improvements in global cognition (β = .005, P = .065). Interventions which were supervised by physical activity professionals were also more effective (g = 0.47, P < .001). Exercise significantly improved the cognitive domains of working memory (g = 0.39, P = .024, N = 7, n = 282), social cognition (g = 0.71, P = .002, N = 3, n = 81), and attention/vigilance (g = 0.66, P = .005, N = 3, n = 104). Effects on processing speed, verbal memory, visual memory and reasoning and problem solving were not significant. This meta-analysis provides evidence that exercise can improve cognitive functioning among people with schizophrenia, particularly from interventions using higher dosages of exercise. Given the challenges in improving cognition, and the wider health benefits of exercise, a greater focus on providing supervised exercise to people with schizophrenia is needed.

Managing Negative Symptoms of Schizophrenia: How Far Have We Come?

The specific efficacy of antipsychotics on negative symptoms is questionable, suggesting an urgent need for specific treatments for negative symptoms. This review includes studies published since 2014 with a primary or secondary focus on treating negative symptoms in schizophrenia. Special emphasis is given to recently published meta-analyses. Topics include novel pharmacological approaches, including glutamatergic-based and nicotinic-acetylcholinergic treatments, treatments approved for other indications by the US FDA (or other regulatory bodies) (antipsychotics, antidepressants, and mood stabilizers), brain stimulation, and behavioral- and activity-based approaches, including physical exercise. Potential complications regarding the design of current negative symptom trials are discussed and include inconsistent placebo effects, lack of reliable biomarkers, negative symptom scale and inclusion criteria variability, attempts to distinguish between primary and secondary negative symptoms, lack of focus on early psychosis, and the potential iatrogenic bias of clinical trials.

Exercise Treatments for Psychosis: A Review

Schizophrenia is a devastating mental illness that has profound effects on a person's health and quality of life. Exercise represents a promising new treatment option that may supplement current psychosocial and pharmacological interventions for psychosis. A large body of work suggests that exercise can improve cardio-metabolic and health behavior and facilitate neurogenesis in areas of the brain that are notably impacted by psychosis. Recent efforts to incorporate exercise as either stand-alone or adjunctive treatment for individuals with schizophrenia range from yoga and light stretching to moderately intense walking, bike riding, or team sports. These interventions suggest that moderately intense exercise may be beneficial for improving both positive and negative symptomatology, cognition and functioning. Indeed, exercise may be beneficial for decreasing risk factors for a wide range of health problems often observed in patients with schizophrenia, including weight gain and metabolic syndrome as well as tobacco and substance use. Given the positive results from interventions in schizophrenia patients, there is an impetus for incorporating exercise in the early stages of the disorder. Notably, individuals at ultrahigh risk (UHR) for psychosis report more sedentary behavior and perceive less benefit from exercise; interventions prior to the onset of the disorder may be helpful for increasing health behaviors, perhaps delaying or preventing the onset of psychosis. Taken together, for individuals with psychosis, exercise may provide holistic benefits for the neural to the social impairments.

Effects of childhood and adolescence physical activity patterns on psychosis risk-a general population cohort study

Schizophrenia spectrum disorders are associated with high morbidity and mortality in somatic diseases. The risk factors of this excess mortality include, e.g., obesity, dietary factors, and physical inactivity, especially after the onset of psychosis, but there are limited early developmental data on these factors in individuals who later develop psychosis. A population-based cohort study "Cardiovascular Risk of Young Finns" started in 1980 with 3596 children and adolescents from six different age groups (3, 6, 9, 12, 15, and 18 years). Cardiovascular health parameters, including questionnaire of physical activity before first hospitalization (≤18 years), were studied in 1980, 1983, and 1986. All psychiatric diagnoses of the participants were derived from the Finnish Hospital Discharge Register up to the year 2012. We identified diagnostic groups of non-affective psychosis (n = 68, including a schizophrenia subgroup, n = 41), personality disorders (n = 43), affective disorders (n = 111), and substance-related disorders (n = 49), based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Groups were compared with controls with no psychiatric diagnoses (n = 3325). Sex, age, body mass index, birth weight, non-preterm birth, and mother's mental disorders were included in the statistical model. Low physical activity in childhood and adolescence (9-18 years) independently predicted later development of non-affective psychosis. Lower physical activity index (relative risk 1.26 [1.1-1.5]), lower level of common activity during leisure time (relative risk 1.71 [1.2-2.5]), and non-participation in sports competitions (relative risk 2.58 [1.3-5.3]) were associated with a higher risk for later non-affective psychosis (expressed as increase in relative risk per physical activity unit). The findings were even stronger for schizophrenia, but no such link was observed for other diagnoses. The cause of low physical activity in premorbid/prodromal phase is likely to be multifactorial, including deviant motor and cognitive development. The results provide a rationale for including exercise and physical activity interventions as a part of psychosis prevention programs.

Correlations between physical activity and neurocognitive domain functions in patients with schizophrenia: a cross-sectional study

BACKGROUND

Neurocognitive dysfunction is a critical target symptom of schizophrenia treatment. A positive correlation between physical activity level and neurocognitive function has been reported in healthy individuals, but it is unclear whether such a correlation exists in patients with schizophrenia and whether the relationship is different according to inpatients or outpatients. This study aimed to examine the differences in the correlations between physical activity and multiple neurocognitive domains in inpatients and outpatients with schizophrenia and obtain suggestions for further study to facilitate this field.

METHODS

Twenty-nine patients with schizophrenia were examined (16 inpatients and 13 outpatients, 56.0 ± 11.4 years of age). Current symptoms were assessed using the Positive and Negative Symptom Scale and neurocognitive functions using Cognitrax, which yields a composite neurocognitive index (NCI) and 11 domain scores. After testing, participants wore an HJA-750C accelerometer for one week to measure physical activity levels and durations. Partial correlation analyses were performed between exercise and cognitive parameters.

RESULTS

In the outpatient group, higher physical activity was associated with faster Motor and Psychomotor Speeds in outpatients. However, higher physical activity was associated with lower overall NCI, Attention score, and Memory scores in inpatients.

CONCLUSION

Although higher physical activity was associated with better neurocognitive functions of outpatients, in inpatients with non-remitted schizophrenia, higher physical activity was associated with worsening of several cognitive domains. In a future study examining the relationship between physical activity and neurocognitive function for facilitating this research field, separation between inpatients and outpatients are needed because the relationship is different between inpatients and outpatients.

Enhancing Neuroplasticity to Augment Cognitive Remediation in Schizophrenia

There is a burgeoning need for innovative treatment strategies to improve the cognitive deficits in schizophrenia. Cognitive remediation (CR) is effective at the group level, but the variability in treatment response is large. Given that CR may depend on intact neuroplasticity to produce cognitive gains, it is reasonable to combine it with strategies that harness patients' neuroplastic potential. In this review, we discuss two non-pharmacological approaches that can enhance neuroplasticity and possibly augment the effects of CR in schizophrenia: physical exercise and transcranial direct current stimulation (tDCS). Substantial body of evidence supports the beneficial effect of physical exercise on cognition, and a handful of studies in schizophrenia have shown that physical exercise in conjunction with CR has a larger impact on cognition than CR alone. Physical exercise is thought to stimulate neuroplasticity through the regulation of central growth factors, and current evidence points to brain-derived neurotrophic factor as the potential underlying mechanism through which physical exercise might enhance the effectiveness of CR. tDCS has emerged as a potential tool for cognitive enhancement and seems to affect the cellular mechanisms involved in long-term potentiation (LTP). A few reports have demonstrated the feasibility of integrating tDCS with CR in schizophrenia, but there are insufficient data to determine if this multimodal approach leads to incremental performance gain in patients. Larger randomized controlled trials are necessary to understand the mechanisms of the combined tDCS-CR intervention. Future research should take advantage of new developments in neuroplasticity paradigms to examine the effects of these interventions on LTP.

The Roles of Exercise and Yoga in Ameliorating Depression as a Risk Factor for Cognitive Decline

Currently, there are no effective pharmaceutical treatments to reduce cognitive decline or prevent dementia. At the same time, the global population is aging, and rates of dementia and mild cognitive impairment (MCI) are on the rise. As such, there is an increasing interest in complementary and alternative interventions to treat or reduce the risk of cognitive decline. Depression is one potentially modifiable risk factor for cognitive decline and dementia. Notably, exercise and yoga are two interventions known to both reduce symptoms of depression and improve cognitive function. The current review discusses the efficacy of exercise and yoga to ameliorate depression and thereby reduce the risk of cognitive decline and potentially prevent dementia. Potential mechanisms of change, treatment implications, and future directions are discussed.

Wearable devices and mobile technologies for supporting behavioral weight loss among people with serious mental illness

Promoting physical activity is essential for addressing elevated cardiovascular risk and high obesity rates affecting people with serious mental illness. Numerous challenges interfere with exercise participation in this high-risk group including mental health symptoms, low motivation, and limited access to safe and affordable options for physical activity. Wearable devices and mobile health technologies may afford new opportunities for promoting physical activity and supporting behavioral weight loss efforts. This exploratory study examined whether daily step count measured using Fitbit wearable devices was associated with weight loss and improved fitness among individuals with serious mental illness enrolled in a 6-month lifestyle program. Participants (n=34) had a schizophrenia spectrum disorder (23.5%), major depression (50.0%), or bipolar disorder (26.5%), and wore Fitbits most of the days (M=86.2%; SD=18.4%) they were enrolled in the study. At 6-months, higher average daily step count was associated with greater weight loss (F=5.07; df=1,32; p=0.0314), but not improved fitness (F=1.92; df=1,31; p=0.176). These findings demonstrate that encouraging participants with serious mental illness enrolled in lifestyle interventions to collect more steps may contribute to greater weight loss. This suggests that wearable devices may offer a feasible and potentially effective strategy for supporting behavioral weight loss in community mental health settings.

The Effect of Exercise Training on Resting Concentrations of Peripheral Brain-Derived Neurotrophic Factor (BDNF): A Meta-Analysis

Background

The mechanisms through which physical activity supports healthy brain function remain to be elucidated. One hypothesis suggests that increased brain-derived neurotrophic factor (BDNF) mediates some cognitive and mood benefits. This meta-analysis sought to determine the effect of exercise training on resting concentrations of BDNF in peripheral blood.

Methods

MEDLINE, Embase, PsycINFO, SPORTDiscus, Rehabilitation & Sports Medicine Source, and CINAHL databases were searched for original, peer-reviewed reports of peripheral blood BDNF concentrations before and after exercise interventions ≥ 2 weeks. Risk of bias was assessed using standardized criteria. Standardized mean differences (SMDs) were generated from random effects models. Risk of publication bias was assessed using funnel plots and Egger’s test. Potential sources of heterogeneity were explored in subgroup analyses.

Results

In 29 studies that met inclusion criteria, resting concentrations of peripheral blood BDNF were higher after intervention (SMD = 0.39, 95% CI: 0.17–0.60, p < 0.001). Subgroup analyses suggested a significant effect in aerobic (SMD = 0.66, 95% CI: 0.33–0.99, p < 0.001) but not resistance training (SMD = 0.07, 95% CI: -0.15–0.30, p = 0.52) interventions. No significant difference in effect was observed between males and females, nor in serum vs plasma.

Conclusion

Aerobic but not resistance training interventions increased resting BDNF concentrations in peripheral blood.

Engaging cognitive circuits to promote motor recovery in degenerative disorders. exercise as a learning modality

Exercise and physical activity are fundamental components of a lifestyle essential in maintaining a healthy brain. This is primarily due to the fact that the adult brain maintains a high degree of plasticity and activity is essential for homeostasis throughout life. Plasticity is not lost even in the context of a neurodegenerative disorder, but could be maladaptive thus promoting disease onset and progression. A major breakthrough in treating brain disorders such as Parkinson's disease is to drive neuroplasticity in a direction to improve motor and cognitive dysfunction. The purpose of this short review is to present the evidence from our laboratories that supports neuroplasticity as a potential therapeutic target in treating brain disorders. We consider that the enhancement of motor recovery in both animal models of dopamine depletion and in patients with Parkinson's disease is optimized when cognitive circuits are engaged; in other words, the brain is engaged in a learning modality. Therefore, we propose that to be effective in treating Parkinson's disease, physical therapy must employ both skill-based exercise (to drive specific circuits) and aerobic exercise (to drive the expression of molecules required to strengthen synaptic connections) components to select those neuronal circuits, such as the corticostriatal pathway, necessary to restore proper motor and cognitive behaviors. In the wide spectrum of different forms of exercise, learning as the fundamental modality likely links interventions used to treat patients with Parkinson's disease and may be necessary to drive beneficial neuroplasticity resulting in symptomatic improvement and possible disease modification.

Work out by Walking: A Pilot Exercise Program for Individuals With Schizophrenia Spectrum Disorders

The health benefits of exercise are well documented, yet annual health care costs related to physical inactivity are well within the billions. Furthermore, individuals with schizophrenia spectrum disorders (SSDs) are more likely to lead sedentary lives, exercise less than the general population, and die prematurely from preventable causes. Previous research examining the effects of exercise on individuals with SSDs has been encouraging yet limited in creating accessible and sustainable interventions. The current pilot study developed and evaluated the impact of Work out by Walking (WOW), a multicomponent group walking intervention on the health of 16 individuals with SSDs. Results indicated improvements in indicators of physical health, activity level, social support, and mental health and a high level of program satisfaction. Future research should examine multicomponent group walking programs for individuals with SSDs in larger samples and with the inclusion of a comparison condition.

Aerobic Exercise as a Tool to Improve Hippocampal Plasticity and Function in Humans: Practical Implications for Mental Health Treatment

Aerobic exercise (AE) has been widely praised for its potential benefits to cognition and overall brain and mental health. In particular, AE has a potent impact on promoting the function of the hippocampus and stimulating neuroplasticity. As the evidence-base rapidly builds, and given most of the supporting work can be readily translated from animal models to humans, the potential for AE to be applied as a therapeutic or adjunctive intervention for a range of human conditions appears ever more promising. Notably, many psychiatric and neurological disorders have been associated with hippocampal dysfunction, which may underlie the expression of certain symptoms common to these disorders, including (aspects of) cognitive dysfunction. Augmenting existing treatment approaches using AE based interventions may promote hippocampal function and alleviate cognitive deficits in various psychiatric disorders that currently remain untreated. Incorporating non-pharmacological interventions into clinical treatment may also have a number of other benefits to patient well being, such as limiting the risk of adverse side effects. This review incorporates both animal and human literature to comprehensively detail how AE is associated with cognitive enhancements and stimulates a cascade of neuroplastic mechanisms that support improvements in hippocampal functioning. Using the examples of schizophrenia and major depressive disorder, the utility and implementation of an AE intervention to the clinical domain will be proposed, aimed to reduce cognitive deficits in these, and related disorders.

Feasibility of PRIME: A Cognitive Neuroscience-Informed Mobile App Intervention to Enhance Motivated Behavior and Improve Quality of Life in Recent Onset Schizophrenia

Background

Despite improvements in treating psychosis, schizophrenia remains a chronic and debilitating disorder that affects approximately 1% of the US population and costs society more than depression, dementia, and other medical illnesses across most of the lifespan. Improving functioning early in the course of illness could have significant implications for long-term outcome of individuals with schizophrenia. Yet, current gold-standard treatments do not lead to clinically meaningful improvements in outcome, partly due to the inherent challenges of treating a population with significant cognitive and motivational impairments. The rise of technology presents an opportunity to develop novel treatments that may circumvent the motivational and cognitive challenges observed in schizophrenia.

Objective

The purpose of this study was two-fold: (1) to evaluate the feasibility and acceptability of implementing a Personalized Real-Time Intervention for Motivation Enhancement (PRIME), a mobile app intervention designed to target reward-processing impairments, enhance motivation, and thereby improve quality of life in recent onset schizophrenia, and (2) evaluate the empirical benefits of using an iterative, user-centered design (UCD) process.

Methods

We conducted two design workshops with 15 key stakeholders, followed by a series of in-depth interviews in collaboration with IDEO, a design and innovation firm. The UCD approach ultimately resulted in the first iteration of PRIME, which was evaluated by 10 RO participants. Results from the Stage 1 participants were then used to guide the next iteration that is currently being evaluated in an ongoing RCT. Participants in both phases were encouraged to use the app daily with a minimum frequency of 1/week over a 12-week period.

Results

The UCD process resulted in the following feature set: (1) delivery of text message (short message service, SMS)-based motivational coaching from trained therapists, (2) individualized goal setting in prognostically important psychosocial domains, (3) social networking via direct peer-to-peer messaging, and (4) community “moments feed” to capture and reinforce rewarding experiences and goal achievements. Users preferred an experience that highlighted several of the principles of self-determination theory, including the desire for more control of their future (autonomy and competence) and an approach that helps them improve existing relationships (relatedness). IDEO, also recommended an approach that was casual, friendly, and nonstigmatizing, which is in line with the recovery model of psychosis. After 12-weeks of using PRIME, participants used the app, on average, every other day, were actively engaged with its various features each time they logged in and retention and satisfaction was high (20/20, 100% retention, high satisfaction ratings). The iterative design process lead to a 2- to 3-fold increase in engagement from Stage 1 to Stage 2 in almost each aspect of the platform.

Conclusions

These results indicate that the neuroscience-informed mobile app, PRIME, is a feasible and acceptable intervention for young people with schizophrenia.

Depression and the Link with Cardiovascular Disease

This review provides an outline of the association between major depressive disorder (MDD) and coronary heart disease (CHD). Much is known about the two individual clinical conditions; however, it is not until recently, biological mechanisms have been uncovered that link both MDD and CHD. The activation of stress pathways have been implicated as a neurochemical mechanism that links MDD and CHD. Depression is known to be associated with poorer outcomes of CHD. Psychological factors, such as major depression and stress, are now known as risk factors for developing CHD, which is as important and is independent of classic risk factors, such as hypertension, diabetes mellitus, and cigarette smoking. Both conditions have great socioeconomic importance given that depression and CHD are likely to be two of the three leading causes of global burden of disease. Better understanding of the common causal pathways will help us delineate more appropriate treatments.