Running for your life: A review of physical activity and cardiovascular disease risk reduction in individuals with schizophrenia

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Motivational coaching augmentation of exercise intervention for early psychotic disorders: A randomised controlled trial

BACKGROUND

Exercise offers improvement to physical and mental health symptoms as well and cognitive function in patients with psychosis. However, patients with psychosis are often less ready to benefit from exercise intervention because of the difficulties in motivation. This study aimed to examine the effectiveness of adjunctive motivational coaching on exercise intervention in women with psychosis in Hong Kong.

METHODS

From a community mental health programme for women, patients with a diagnosis of psychotic disorder (within 5 years of first onset) were randomly allocated to receive 12 30-minute sessions of motivational coaching or psychoeducation in a group format. Both groups additionally received exercise intervention sessions consisting of yoga, stretching and high-intensity interval training. Primary outcome was the total physical activity level measured by the International Physical Activity Questionnaire.

RESULTS

Fifty-seven patients (mean [SD] age, 34.47 [12.44] years) were randomised into motivational coaching (n = 30) or psychoeducation (n = 27) treatment groups. The motivational coaching group had a significantly higher total physical activity level (4601.67 [686.59] vs 2524.82 [723.73] metabolic equivalent task-min/week, r² = 0.473, p = 0.04) after the intervention and at 6 months post-intervention. Moderate and light physical activity levels were significantly higher in the motivational coaching group after intervention and at 6 months, respectively. Additionally, symptoms of bizarre behaviour were improved in the motivational coaching group at 6 months. Younger, unemployed, unmarried and those with longer durations of untreated psychosis generally showed larger improvements in the motivational coaching group.

CONCLUSION

Motivational coaching may augment the effects of exercise interventions, as reflected by higher physical activity participation. Motivational coaching augmentation has the potential to further improve exercise intervention outcomes.

Effects of six weeks outdoor versus treadmill running on physical fitness and body composition in recreationally active young males: a pilot study

Background

Running as exercise may be performed either on an outdoor surface or treadmill surface. However, previous research has indicated that the nature of both the surfaces differ significantly and therefore the training outcomes from running in these surfaces may also vary.

Aim

Therefore, the aim of this pilot study was to compare the effects of 6-weeks of supervised outdoor running (OT) vs treadmill running (TT) on physical fitness and body composition in recreationally active young males.

Methods

Participants (age: 19.82 ± 1.28 years, height: 172.6 ± 4.9 cm, body mass: 64.3 ± 8.7 kg) were randomly assigned to OT (n = 14) or TT (n = 14), and assessed for physical fitness, i.e., 50 m sprint, cardiorespiratory endurance (i.e., 1,600 m run time-trial), standing long jump (SLJ), flexibility (i.e., sit-and-reach test), and upper-body muscle endurance (i.e., push-ups repetitions), alongside body composition, i.e., body mass, body mass index (BMI), fat percentage, fat free mass, and leg skeletal muscle mass (SMM). A two (pre-post intervention) by two (OT, TT) mixed ANOVA analysed exercise-specific effects. For significant group-by-time interactions, Bonferroni adjusted paired (within-group) and independent (between-group comparisons at post) t-tests were used for post-hoc analyses.

Results

Significant time-effect was found in all physical fitness variables (all p < 0.001, η_p ² = 0.67-0.91), body mass (p = 0.23, η_p ² = 0.18), BMI (p = 0.009, η_p ² = 0.24), body fat percentage (p = 0.001, η_p ² = 0.38), and leg SMM (p = 0.002-0.007, η_p ² = 0.25-0.33). Significant group-by-time interaction was found for 50 m sprint (p = < 0.001, η_p ² = 0.74), 1,600 m run (p = 0.001, η_p ² = 0.35), and SLJ (p < 0.001, η_p ² = 0.43), favouring OT. Group-specific post-hoc tests showed improvements in all physical fitness variables after OT (p = < 0.001-0.001, g = 0.69-2.32, %Δ = 3.0-12.4) and TT (p = < 0.001-0.017, g = 0.15-0.65, %Δ = 0.9-11.7), and fat percentage after OT and TT (p = 0.002-0.041, g = 0.14-0.26, %Δ = 4.3-6.0). However, leg SMM decreased in TT (p = 0.001-0.004, g = 0.14-0.15, %Δ = 6.2-6.7).

Conclusions

Both OT and TT improved physical fitness and decreased fat percentage. However, compared to TT, the OT intervention preserved leg SMM and induced greater physical fitness improvements.

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.

Effects of high intensity interval training among overweight individuals with psychotic disorders: A randomized controlled trial

Physical activity has been suggested to reduce the high prevalence of metabolic complications in individuals with psychosis. Although high intensity interval training (HIIT) is efficacious in other populations, it remains poorly studied in psychosis.

METHODS

Randomized controlled study comparing the effects of 6 months HIIT supervised program (30-minute treadmill sessions twice a week) to usual-care waiting-list control group. Anthropometric (primary outcome: waist circumference), body composition, blood profile, blood pressure, psychiatric symptoms and global functioning were measured at baseline and 6 months.

RESULTS

Sixty-six individuals with psychosis (62% men; 30.7 ± 7.2 years old; mean BMI: 32.7 ± 5.7 kg/m²) were randomly assigned to either HIIT (n = 38) or control group (n = 28). Mean attendance rate to HIIT sessions was 64%, although 50% dropped-out the intervention before the end. Few minor adverse events were reported. The intent to treat analysis showed no impact of HIIT on waist circumference (p = 0.25). However, in a post-hoc analysis among the compliant participants (>64% of prescribed sessions), significant improvements in waist circumference (-2.94, SE = 1.41, p = 0.04), negative symptoms (PANSS negative -3.7, SE = 1.39; p = 0.01), social (SOFAS +6.16, SE = 1.76, p = 0.001) and global functioning (GAF +5.38, SE = 2.28, p = 0.02) were observed.

DISCUSSION

HIIT seems to be safe and well accepted in overweight individuals with psychosis. Exercise compliance to HIIT is associated with improvements in waist circumference as well as negative symptoms and functioning. Interventions improving attendance are needed.

Cardiovascular events in hospitalised patients with schizophrenia: a survival analysis

Objective: To evaluate the occurrence of cardiovascular (CV), cerebrovascular events and mortality rates, and compare the predictive ability of two scores, Framingham Risk Score (FRS) and Atherosclerotic Cardiovascular Disease (ASCVD), of detecting a cardiovascular event in a cohort of schizophrenic patients. Methods: A cohort of 329 hospitalised schizophrenic patients is being monitored since 1 January 2013. Patients' file review was performed to detect the CV events of interest. Results: Out of the 329 patients with schizophrenia, with a mean study follow-up of 41.07 ± 12.55 months, 29 cardiovascular events were recorded; of those events, we recorded 4 myocardial infarction, 1 stroke, 6 heart failure and 18 cardiovascular deaths. The major composite outcome of cardiovascular events rate was equal to 9.0 per 100 patient-years. The secondary composite outcome of cardiovascular events rate was equal to 7.2 per 100 patient-years (0.072 events per patient). The association between survival curve of patients with high and low CVR according to FRS score tended to significance (RR = 1.90, p = .078). Patients classified as high cardiovascular risk according to ASCVD presented a reduced cardiovascular survival (RR = 3.35, p = .005). Conclusion: The ASCVD items should be included in the medical assessment in any patient with severe mental illness. Key points The major composite outcome of cardiovascular events rate was equal to 9.0 per 100 patient-years. The secondary composite outcome of cardiovascular events rate was equal to 7.2 per 100 patient-years (0.072 events per patient). The association between survival curve of patients with high and low CVR according to FRS score tended to significance. Patients classified as high cardiovascular risk according to ASCVD presented a reduced cardiovascular survival. The ASCVD items should be included in the medical assessment in any patient with severe mental illness.

Changes in physical and psychiatric health after a multidisciplinary lifestyle enhancing treatment for inpatients with severe mental illness: The MULTI study I

Patients hospitalized with severe mental illness (SMI) often have an unhealthy lifestyle. Changing their sedentary behavior and deficiency in physical activity is challenging and effective interventions are lacking. We evaluated changes in sedentary behavior, physical activity, metabolic health and psychotic symptoms after 18 months of Multidisciplinary Lifestyle enhancing Treatment for Inpatients with SMI (MULTI) compared to treatment as usual (TAU) and explored mediation by change in total activity. We measured sedentary behavior and physical activity using accelerometry (ActiGraph GT3X+), reflected in total activity counts. Data on metabolic health and psychotic symptoms were retrieved from routine screening data within our cohort of inpatients with SMI. Of 65 patients receiving MULTI versus 43 receiving TAU, data were analyzed using linear and logistic multilevel regression, adjusting for baseline values of outcome and differences between groups. Compared to TAU, in which no improvements were observed, we found significantly (p < 0.05) improved total activity (B = 0.5 standardized total activity counts per hour), moderate-to-vigorous physical activity (B = 1.8%), weight (B = -4.2 kg), abdominal girth (B = -3.5 cm), systolic blood pressure (B = -8.0 mmHg) and HDL cholesterol (B = 0.1 mmol/l). No changes in psychotic symptoms were observed. Changes in total activity did not mediate metabolic improvements, suggesting that multiple components of MULTI contribute to these improvements. In contrast to previously unsuccessful attempts to change lifestyle behavior in inpatients with SMI in the longer term, MULTI showed to be a feasible treatment to sustainably improve PA and metabolic health.

Nonpharmacological Interventions for the Treatment of Cardiometabolic Risk Factors in People With Schizophrenia-A Systematic Review

Background: People suffering from schizophrenia are notably vulnerable to cardiometabolic risk factors (CMRF), such as obesity, high blood pressure, hyperglycemia and insulin resistance, high serum triglycerides, and low serum high-density lipoprotein (HDL), which are related to increased mortality and decreased quality of life. The increased risk of "metabolic syndrome" (MS) is related to low physical activity, an unhealthy diet, and side effects of antipsychotic drugs. Nonpharmacological interventions seem to be important in the prevention and therapy of MS. Aim: This paper provides an overview of published studies and a critical analysis of pilot programs involving nonpharmacological measures aimed at prevention and treatment of CMRF in patients with schizophrenia. Material and Method: We searched the PubMed, PsycARTICLES, and Cochrane Library databases to identify clinical trials. We included full-text studies that met the following criteria: age > 18 years, a diagnosis of schizophrenia or schizoaffective disorder, and monitored parameters associated with MS. Results: All 1,555 references were evaluated for inclusion in the review, and 20 met the inclusion criteria. Nonpharmacological interventions led to improvement in physical health and showed a promising potential for implementation in treatment programs dedicated to this particular group of patients. However, a critical analysis revealed limitations, which have implications for the direction of future research. Conclusions: Patients suffering from schizophrenia can benefit from nonpharmacological interventions aimed at counteracting CMRF, improving either metabolic parameters, cardiovascular fitness, or their health perception. Notwithstanding, to achieve long-term effects, future studies should comprise appropriate follow-up procedures.

[Physical activity in patients with schizophrenia: From neurobiology to clinical benefits]

Schizophrenia is a severe chronic mental disorder that mainly manifests by positive symptoms, negative symptoms, disorganized behavior and thought and cognitive impairments. Taken together, these symptoms have substantial impact on quality of life, well-being and functional outcome. Patients with schizophrenia have dramatically higher levels of cardiovascular and metabolic morbidity than the general population due to poor physical fitness and to sedentary lifestyle. They have a reduced life expectancy, and an excess mortality being two or three times more than that in the general population. Moreover, despite major therapeutic advances in the overall management of these patients, some symptomatic dimensions, and more specifically the negative and cognitive ones, remain to be resistant to the usual pharmacological approaches. Moreover, antipsychotics can also reinforce the global cardiovascular risk due to side effects and low neurometabolic tolerance. The benefits of physical activity on health are now well described in the general population and in many medical diseases. More recently, physical activity has also found its place as an adjuvant therapy in severe mental illnesses, particularly in schizophrenia. In the literature physical activity programs, in addition to pharmacological treatments, appear to be feasible in patients and improve both physical and mental health as well as functional outcome. Clinical benefits of physical activity would be underpinned by biological and cerebral mechanisms, which remain unclear. In this review, we propose to present a state of the art and to present an update of the interests of physical activity in the management of patients with schizophrenia. We emphasize the clinical benefits of physical activity regarding the different symptomatic dimensions and its impact specifically on cognitive deficits. Finally, we describe the various underlying pathophysiological mechanisms in particular in the neurobiological, cerebral and physiological fields. We then discuss the barriers, facilitators and motivating factors towards physical activity to enhance health promotion initiatives, to optimize resource allocation when delivering physical activity programs in clinical practice, and to maximize physical activity participation. Physical activity appears to be an original and novel adjunctive therapeutic approach in the management of patients with schizophrenia and would both reduce schizophrenic symptoms and act like pro-cognitive therapy, improve quality of life and long-term functioning in daily life and reduce cardiovascular comorbidities. However, efforts are still needed to increase the motivating factors and adherence towards physical activity participation for people with schizophrenia.

The Impact of General Medical Conditions in Obsessive-Compulsive Disorder

OBJECTIVE

The co-occurrence of general medical conditions (GMCs) and major psychiatric disorders is well documented. The aim of this study was to assess the prevalence of GMCs in patients with a primary diagnosis of obsessive-compulsive disorder (OCD) and, secondly, to investigate which clinical variables are associated with the presence of a GMC.

METHODS

Subjects with a primary diagnosis of OCD were included. Socio-demographic and clinical characteristics were collected. GMCs were classified using the ICD-10 and grouped according to the Cumulative Illness Rating Scale (CIRS) in: cardiac, vascular, hematopoietic, respiratory, ear/nose/throat, upper and lower gastrointestinal, hepatic, renal, genitourinary, musculoskeletal, neurologic, endocrine/metabolic. The association between the presence of GMCs and demographic/clinical variables of OCD was investigated.

RESULTS

A total of 162 patients with OCD were included. 78 (48.1%) patients had at least one comorbid GMC. Most frequent GMCs were endocrine/metabolic diseases (25.9%), followed by upper/lower gastrointestinal (20.5%) and cardio-vascular diseases (13.6%). The presence of a GMC was significantly associated with female gender, older age, duration of untreated illness (DUI), and absence of physical activity.

CONCLUSION

Patients with OCD have high rates of comorbid GMCs. A longer DUI is associated with having at least one GMCs; this might be due to the long-lasting adoption of unhealthy lifestyles, not counterbalanced by appropriate treatment and psychoeducation.

Physical Activity, Exercise and Sport Programs as Effective Therapeutic Tools in Psychosocial Rehabilitation

People with severe psychosocial disabilities have a 20-years shorter lifespan due to chronic somatic comorbidities and the long-term consequences of the side-effects of antipsychotic drugs. They often are sedentary and show lower levels of physical activity, factors which can contribute to their shorter lifespan, because of the greater cardiovascular risk. An increasing amount of evidence, including clinical trials, pointed out that sport, physical activity and structured exercise programs improve physical and psychological wellbeing of people with psychosocial disabilities, playing also an important role against their social isolation and self-stigma. The NICE and APA guidelines include exercise and physical activity for the management of depressive symptoms. Safe and effective programs require multidisciplinary teams that should always include mental health professionals, able to recognize the psychosocial needs, the impact of symptomatology, the role of secondary effects of psychotropic medication, the effect of previous exercise history, the lack of motivation, the inexperience with effort intensity and the frustration of people with psychosocial disabilities.

A systematic review of trials investigating strength training in schizophrenia spectrum disorders

This systematic review analyzed strength training (ST) in patients with schizophrenia. Two independent reviewers searched PubMed and CENTRAL. Only two studies reported on the effects of isolated ST. ST with a single exercise did not improve psychopathology but walking performance. ST for several large muscle groups significantly improved muscle strength and psychopathology. To date, no treatment recommendations can be made for ST. Consistent with recommendations for healthy people combined strength and endurance training can be recommended for schizophrenia. For higher transparency regarding trainings aspects, we recommend for future studies to use the sport science checklist proposed in this paper.