How should physical exercise be used in schizophrenia treatment?

KEYWORDS:

• Schizophrenia
• psychosis
• early psychosis
• exercise
• physical activity
• cardiovascular disease

1. Introduction

Psychotic disorders such as schizophrenia affect 2–4% of the population and are one of the world’s leading causes of disability [1]. The cost of these illnesses to the UK economy is about £11.8bn per year, resulting from direct health-care costs, lost productivity due to unemployment, and informal costs to family and carers [2]. Tragically, schizophrenia usually begins between the ages of 15 and 24 years, meaning that the many years are lived with the illness.

The main features of schizophrenia are positive symptoms (such as delusions and hallucinations), negative symptoms (such as poor motivation and reduced energy), and cognitive difficulties (e.g. poor memory and attention). Positive symptoms usually improve with antipsychotic medication. However, in about 30% of cases, these symptoms persist, resulting in distress and difficulties in living. Moreover, the features that cause most disability are the negative and cognitive symptoms, and these are not responsive to antipsychotics.

Furthermore, antipsychotics are associated with metabolic side effects such as obesity and glucose and lipid dysregulation [3]. Individuals with schizophrenia also have high rates of smoking [4], poor diet [5], and low levels of physical activity, even in the early stages of illness [6]. It is, therefore, unsurprising that people with schizophrenia have high rates of morbidity and premature mortality of around 20 years, most of which is due to cardiovascular disease [7].

Thus, we are currently facing three areas of suboptimal management of people with schizophrenia

• Lack of effective treatments for negative symptoms and cognitive dysfunction

• Only partially effective treatment for positive symptoms

• High rates of physical health problems, particularly cardiovascular disease.

One treatment is potentially effective for all of these problems: physical exercise. Exercise is effective for improving physical health, symptoms, cognition, and functioning in both established schizophrenia [8,9] and early psychosis [10,11]. Exercise interventions are feasible and acceptable in this group, particularly in the early stages of illness [12].

Exercise may be a particularly suitable intervention for reducing cardiovascular risk and closing the mortality gap observed in this population, since physical activity and fitness are stronger predictors of cardiovascular diseases and premature mortality than other risk factors such as bodyweight or waist circumference [13]. However, to be effective, individuals need to engage in a sufficient volume of activity, of around 90 min of moderate to vigorous exercise per week [8]. The current problem is one of implementation. How can increased physical activity be promoted in patients with psychotic disorders?

2. Barriers to increasing exercise in individual’s psychotic disorders

Evidence suggests that barriers to engaging with exercise include the following:

• Poor motivation, partly due to the negative symptoms of illness and depression [14]

• Anxiety and ‘stress’ about exercising in public, including social anxiety [12,14]

• Tiredness, linked to sedative effects of antipsychotic medication [14]

• Lack of support from others to exercise [14,15]

• Comorbid physical health issues such as obesity which impact upon mobility [16]

3. Facilitating factors to increasing exercise

Factors which may increase exercise participation in people with psychosis include the following:

• An individual’s own motivations for exercise, such as improving physical health and fitness, weight loss, and reducing stress [14,17]

• Type of activity being targeted to a person’s preferences [12,18]

• Presence of a training partner or group [12]

4. Promoting exercise

Taking the barriers and facilitating factors into account, exercise training programs for people with psychotic illnesses should be designed to improve exercise capacities and cardiorespiratory fitness, while also providing the necessary levels of supervision or assistance for each patient to overcome psychological barriers and achieve their goals. Such interventions would be motivating and rewarding for patients, resulting in higher levels of exercise engagement. One model that has proved successful is the integration of a physical therapist into the clinical team complemented by on-site gym facilities [11]. Providing supervised gym sessions to people with psychosis within their community leisure facilities has also been effective for engaging patients [10]. In contrast, unsupervised exercise programs, even when access to facilities and advice are given, have been found to be ineffective for increasing physical activity [19].

5. Cost-effectiveness of exercise as treatment in schizophrenia

Unfortunately, no studies have assessed the cost-effectiveness of exercise supervised programs in schizophrenia. However, financial reports of exercise interventions for diabetes, mild depression, and heart disease indicate that professionally delivered training programs produce large economic benefits from avoided health system costs [20].

6. How should exercise be used in schizophrenia treatment?

In summary, exercise is effective in improving physical and mental health in people with psychotic disorders such as schizophrenia. It should be used as an adjutant to other interventions such as antipsychotic medication and psychological therapies. It needs to be seen as integral to treatment. Merely providing advice to exercise is not enough. Everyone knows that exercise is good for you. Adequate resources are needed to ensure that patients receive supervision and ongoing support in order to achieve an adequate ‘dose’ of exercise. Reforms are currently occurring in England, where it is now mandated that early psychosis patients have access to cognitive therapy and vocational support [21]. While this should be applauded, further support to promote exercise as treatment is also needed. This should include ensuring that a physical therapist is as part of the clinical team.

Declaration of interest

J. Firth has been funded through an MRC PhD Fellowship. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Additional information

Funding

This paper was not funded.