Physical Activity as a Treatment for Schizophrenia Spectrum Disorders

Individuals living with schizophrenia spectrum disorders (SSDs) experience significant disability, underpinned by functional impairment in almost every domain of life.¹ Treatment resistance to first-line antipsychotic medications can be as high as 30%. Negative and cognitive symptoms typically respond poorly to medications and, together with positive symptoms, contribute to limited personal and functional recovery. These challenges are further compounded by physical health multimorbidity (co-occurrence of multiple, serious, largely preventable physical health conditions in parallel) that develops from a much younger age and leads to cumulative health risks and a premature mortality gap of approximately 15 to 20 years compared with the general population.^2,3

Modifiable lifestyle risk factors—such as low levels of moderate to vigorous physical activity (MVPA), low cardiorespiratory fitness, and high levels of sedentary behavior—compound the cardiometabolic adverse effects of antipsychotic medications, contributing to high cardiometabolic risk.⁴ Emerging evidence also suggests that low muscular strength may be an independent risk factor for premature mortality. The cardiorespiratory fitness and muscular strength of individuals living with SSDs are comparable to those of individuals decades older in the general population and can be seen as signs of premature aging.⁵ Practically, this can result in difficulties with mobility and activities of daily living, further exacerbating global functional impairment.

Physical activity (PA) is defined as “any bodily movement produced by skeletal muscles that results in energy expenditure.”⁶ PA may offer dual benefits for physical and mental health; in line with this, there is growing recognition of its potential to improve health outcomes among individuals with SSDs.

Physical Health

Although weight loss is the most commonly reported motivation for individuals with SSDs to engage in PA, PA alone has not consistently produced significant weight loss. A small number of studies have found that MVPA may contribute modestly to weight reduction; however, the most robust evidence for this outcome comes from multimodal lifestyle interventions (combinations of nutritional counseling, weight management programs, physical activity, health education, and motivational interviewing).⁸ Thus, we believe that lifestyle interventions should be offered from the onset of illness and antipsychotic treatment, tailored to both the individual and the illness, and integrated into routine psychiatric care.

Cardiorespiratory fitness is a strong predictor of mortality, independent of adiposity or other risk factors.⁹ Thus, for individuals with SSDs, improving cardiorespiratory fitness may be a more achievable target than weight loss from PA alone. A large meta-review of patients with SSDs found PA can improve cardiorespiratory fitness, with the greatest improvements observed following interventions of at least moderately vigorous intensity, and when delivered by qualified exercise professionals, such as exercise physiologists and physiotherapists.¹⁰ Emerging research from a small number of studies suggests resistance training can improve muscular strength.¹¹

Case Study 1

“Alan” is a 47-year-old single, unemployed man living with SSD who had an undergraduate degree in business and a pre-illness history of amateur competitive cycling. He was admitted to a residential psychiatric rehabilitation facility with remitted positive symptoms but a profound negative syndrome, lying in bed for 23 hours per day. His elderly mother provided all daily care for him. At the rehabilitation facility, Alan began to engage in a moderate-intensity whole-body resistance training program, 3 times per week under the supervision of an exercise physiologist, delivered onsite and integrated into usual care. Over 8 weeks, his lower and upper body strength gradually improved until he was able to start exercising independently, and he began biking to the store for his own groceries. In addition to the restoration of physical and daily functioning, he described a significant improvement in self-confidence:

“It was very helpful to my physical health and my core strength that I use just for getting around every day, and I think it did help in some small way to my emotional state; I feel like I’ve done something, or that I’m capable of doing something…[with] confidence in myself.”

Mental Health and Functioning

There has been consistent evidence of the benefits of PA for individuals with SSDs on mental health outcomes, including negative and cognitive symptoms, global functioning, and quality of life.¹⁰ The findings relating to negative and cognitive symptoms are particularly relevant, as they show a promising impact on outcomes that do not respond well to medications, thus highlighting the role of PA as an important augmentation strategy for mental health. Most of the current evidence is derived from aerobic studies, with greater benefits when intensity is at least moderate. However, yoga has been found to have some promising benefits for positive and negative symptoms, although a greater number of high-quality trials in a broader range of settings are required to make definitive recommendations.¹²

Case Study 2

“Brandon” is a 24-year-old single man with treatment-resistant schizophrenia with a partial response to clozapine. Despite assertive augmentation of the clozapine with other medications, electroconvulsive therapy, and cognitive behavior therapy for psychosis, Brandon continued to present with persistent distressing auditory hallucinations. After Brandon started engaging in aerobic MVPA 3 times per week, supervised by an exercise physiologist, he reported acute improvements in mood, a significant reduction in the auditory hallucinations for several hours after a session, and an increase in overall quality of life. Over time, sessions were increased to 5 days per week, but he struggled to continue with PA without supervision. Support workers were sought, and he was able to continue the PA therapy in the community in the longer term.

“On the days that I do training, I’m in a good mood all day; even the voices, they don’t really bother me, I can ignore them,” he said.

Physical Activity Type

In terms of type, aerobic exercise has been the most widely studied; however, preference for exercise engagement is vital. Evidence from systematic reviews demonstrates benefits from a range of PA types, including sports, resistance training, yoga, walking, and high-intensity interval training in individuals with SSDs.^13,14 Encouraging individuals with SSDs to engage in the type of PA they enjoy and are most likely to sustain engagement is important.

How Much Physical Activity?

The World Health Organization (WHO) recommends at least 150 minutes of MVPA per week for general health benefits.¹⁵ For patients with SSDs, even small amounts of PA (ie, less than 150 minutes of MVPA) may confer benefits and are better than none.¹⁶ Achieving WHO guideline levels may be challenging—and potentially discouraging—for individuals who have been recently inactive. Recent work has highlighted the value of promoting open goals (eg, nonspecific, exploratory, graded outcomes) for those who find behavior change difficult. Hence, in the initial phase of PA adoption, encouraging people—for example, to “see how many steps you can do today”—may be preferable to setting specific targets that may feel unattainable.¹⁷

Implementation in the Real World

While the feasibility of PA interventions evaluated in structured research trials is comparable with psychological therapies and medications, sustaining engagement for PA in the real world can be challenging for individuals with SSDs. Numerous individual factors (eg, obesity, pain, negative symptoms, low support) and environmental factors (eg, cost, stigma, access, opportunity) can be barriers to participation. Neurobiologically mediated impairments in reward processing also underpin motivational deficits for PA—one of the most commonly cited barriers to PA in this population.¹⁸ Autonomous motivation for PA has been associated with greater engagement in patients with SSDs and should be actively fostered.¹⁹ For example, this may mean supporting intrinsic reasons, such as “I do physical activity for fun” or because “I personally value the benefits,” rather than more external types of motivation, such as “I need to do physical activity to please others” or “because I feel guilty.”

According to self-determination theory, the necessary conditions for autonomous motivation are relatedness, autonomy, and competence. In addition to choice of PA type or intensity where resources permit, providing options for the format (ie, individual or group) is also optimal. Mobilizing emotional and practical support is vital and may include input from mental health clinicians, family, carers, and nonclinical or peer supports.²⁰

At a systems level, structural changes in mental health service delivery—such as enhancing access to and integration of exercise programs and gyms into mental health services, as well as incorporating exercise professionals into multidisciplinary teams—have recently gained traction. Such models are likely to help translate the promising efficacy seen in clinical trials into real-life effectiveness.⁴

Adverse events from PA interventions appear to be low; however, routine screening can detect those who require medical assessments for suitability: Most patients with SSDs without specific risks can readily engage in light to moderate-intensity PA.²¹

In line with international guidelines, psychiatrists and mental health clinicians are encouraged to incorporate routine screening of PA into usual care, which can be done using simple self-report tools, such as the physical activity as a vital sign questionnaire, or an internationally validated self-report screening tool, the simple physical activity questionnaire.²² Psychiatrists can play an important role in the promotion of PA to individuals with SSDs by considering an “exercise is medicine” approach, and are well positioned to provide advice about health and behavior change. At a policy level, there is also a role for psychiatrists in advocacy for equitable access to services and qualified professionals to support the integration of PA interventions into psychiatric services.

Acknowledgements

We would like to thank the individuals living with SSDs who provided consent for the deidentified use of their clinical information and comments.

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