Introduction
Physical activity, physical fitness, and medical health outcome in patients with MDD, BD, and SZ
Effects of aerobic exercise on symptoms of MDD
Year | Publication | Study design and diagnosis | Sample size, n | Intervention | Control | Measurement of CRF and PA | Intervention duration /follow-up | Outcome | |
---|---|---|---|---|---|---|---|---|---|
IG | CG | ||||||||
2019 | Asthon et al. 2020 [52] | Exploratory subanalysis of an RCT (145 of 181 who reported data on PA) Bipolar depression | (A) 50 (B) 46 | 49 | (A) N-acetylcysteine alone (B) N-acetylcysteine with a combination of nutraceuticals | Placebo | MADRS at week 16 IPAQ-SF at week 4 MADRS at week 16 And others | 16 weeks | PA was unrelated to change in depression symptoms across study duration In patients receiving combination treatment, total PA significantly predicted changes in bipolar depression symptoms |
2019 | Gujral et al. 2019 [97] | RCT, double blind Pilot study Major depressive episode | 7 | 8 | Venlafaxine XR AND supervised exercise Sessions: individualized, 3x/week, 1 h Moderate intensity (60–75% of age-based HR for ~ 45 min on a treadmill and/or cycle ergometer) Supervised: yes | Venlafaxine XR | CRF: submaximal VO2 test PA: Body Media Sensewear armband, triaxial accelerometer | 12 weeks | No significant changes in fitness in the exercise group Significant reduction of depressive symptoms in both groups Association between improvement in fitness and increased cortical thickness in the anterior cingulate cortex |
2018 | Gerber et al. 2019 [98] | Secondary analysis of RCT MDD | 53 Randomization: n.a | (A) Sprint interval training: 25 repetitions of 30 s high-intensity burst at 80% of max. power output, followed by 30 s of total rest (B) Continuous aerobic exercise training: 20 min continuous aerobic exercise on a bicycle ergometer with an intensity level of 60% of the maximal power output Both sessions: 3x/week, 35 min Intensity: prescribed individually to each participant Supervised by an experienced exercise coach | n.a | CRF: VO2max, bicycle ergometer Fitness Questionnaire, not specified | 4 weeks | Improvements in VO2max were associated with fewer depressive symptoms, better mental wellbeing, and better sleep post-intervention Improvements in perceived fitness were associated with less depression symptoms and better sleep higher mental wellbeing post-intervention Improvements in VO2max and perceived fitness were associated with favorable changes in depressive symptoms, mental wellbeing, and sleep | |
2018 | Minghetti et al. 2018 [48] | RCT MDD | (A) 30 (B) 29 | (A) Continuous aerobic exercise training [108]: 20 min continuous exercise at a power output corresponding to 60% of the maximal power output (B) Sprint interval training (SIT): 25 repetitions of 30 s high-intensity bursts at 80% of maximal power output followed by 30 s of total rest (remaining seated on the bicycle) Sessions: 3x/week, 35 min Supervised by an experienced exercise coach Medication was counterbalanced in both intervention arms | n.a | CRF: exhausting incremental exercise test, bicycle ergometer Beck Depression Inventory-II | 4 weeks | BDI-II scores substantially decreased in both groups, while submaximal and maximal variables improved in both groups Short-term SIT leads to similar results as CAT in patients with MDD | |
2018 | Patten et al. 2019 [44] | Pilot Study Depressive symptoms | 18 | 18 | Free membership in fitness center for 12 weeks AND Six 30-min individually tailored sessions with an exercise counselor; included aerobic exercise, strength training, stretching, and recommendations to exercise regularly Exercise at the fitness center and at home were both encouraged, but no supervised exercise was provided | Free membership in fitness center for 12 weeks but no additional intervention | CRF: 6–12-min submaximal cardiorespiratory test, cycle ergometer PA: evaluation of trunk flexibility, resting heart rate, blood pressure and body composition measured by bioelectrical impedance Questionnaires: Stage of change for exercise, IPAQ, Beck Depression Inventory-II | 12 weeks | No group differences were found in IPAQ or BDI-II scores at week 12. Increases from baseline in IPAQ moderate/vigorous activity minutes were associated with decreases in BDI-II scores at week 12 |
2017 | Rethorst et al. 2017 [40] | Randomized, secondary analysis MDD | Two exercise doses: (A) 4 kcal/kg/week (B) 16 kcal/kg/week Exercise intensity was self-selected and monitored with an HR monitor Supervised: yes (complete dose in week 1, two in week 2, and 1 in week 3–12; rest unsupervised) | 12 weeks | Predictors of remission were higher levels of brain-derived neurotrophic factor (BDNF) and Interleukin-1B, greater depressive symptom severity, and higher post-exercise positive affect. Predictors of treatment non-response were low cardiorespiratory fitness, lower levels of IL-6 and BDNF, and lower post-exercise positive affect. Models including these predictors resulted in predictive values greater than 70% (true predicted remitters/all predicted remitters) with specificities greater than 25% (true predicted remitters/all remitters) | ||||
2015 | Carneiro et al. 2015 [41] | RCT; only women Clinical depression | 13 | 13 | Aerobic exercise group: indoor/outdoor natural circuit workouts AND Pharmacotherapy Sessions: 45–50 min/week; 3x/week Intensity: based on baseline fitness. First month: at least 65% of %HRmax; second month: to 70%; third month: 80%. Diverse Supervised: yes Motivational strategies (e.g., multidisciplinary teams; Facebook page; outings in the sunlight and in pleasant settings; etc.) | Pharmacotherapy only | Physical functioning: Distance walked in 6 min Number of times they could sit and stand from a chair in 30 s A seated medicine ball throw | 4 months | Decrease in BDI-II and DASS-21 total score scales in exercise group. Relative to DASS-21, a significant decrease in anxiety and stress is found Improvement in relation to physical functioning parameters in exercise group Anthropometric parameters only significant different between groups in fat mass percentage No differences between groups in weight, body mass index, waist circumference, and self-esteem |
2015 | Doose et al. 2015 [42] | RCT Unipolar depression | 30 | 16 | Walking/running aerobic exercise program at a local sports club Sessions 3x/week, 60 min, outside Intensity: self-selected exercise intensity according to perceived exertion Supervised by teams of coaches and medical students | Wait list | CRF: Fitness Index, VO2max as estimated or UKK 2 km Walk Test | 8 weeks | Large reduction of depressive symptoms in HRSD-17 scores. BDI-II, FI scores, and VO2 max did not change significantly |
2015 | Kerling et al. 2015 [92] | Randomized Pilot trial Inpatient Moderate to severe depression | 22 | 20 | Exercise training 3x/week, 45 min: 25 min bicycle and 20 min cross trainer, stepper, arm ergometer, treadmill, etc. as preferred Moderate intensity: 50% of maximum workload from incremental test; above the VAT and below anaerobic lactate threshold Supervised by physicians, group format | Treatment as usual | CRF: VO2peak, VAT, Watts, lactate on bicycle ergometer MetS | 6 weeks | Cardiorespiratory fitness (VO2peak, VAT, Watts), waist circumference and HDL cholesterol significantly improved in exercise group. Treatment response (expressed as ≥ 50% MADRS reduction) was more frequent in the exercise group |
2014 | Danielsson et al. 2014 [47] | RCT MDD | (A) Aerobic exercise: Training in the rehab center (e.g., cross trainer, jumping ropes, stationary bikes, etc.) Intensity: intervals with higher perceived intensity (B) Basic body awareness therapy: body scanning and stretch-release movements, postural stability, movement flow, and free breathing Both programs: 2 sessions/week, 1 h during which 5–8 participants trained at the same time Supervised by experienced physical therapists | Single consultation with advice on PA | CRF: VO2max, submaximal bicycle test | 10 weeks | Improvements in MADRS score and cardiovascular fitness in the exercise group. Per-protocol analysis confirmed the effects of exercise and indicated that BBAT has an effect on self-rated depression | ||
2014 | Krogh et al. 2014 [84] | RCT MDD | 41 | 38 | Aerobic exercise intervention on stationary bikes Sessions: 3x/week, 45 min Intensity: 80% of their maximal heart rate Supervised: yes | Attention CG | CRF: VO2max, bicycle cardiopulmonary exercise test | 12 weeks | Post-intervention the mean VO2max increased with 3.90 ml/kg/min in the aerobic exercise group and 0.95 ml/kg/min in the control group The hippocampal volume, BDNF, VEGF, or IGF-1 did not differ between the two groups Positive association found post hoc between change in hippocampal volume and verbal memory and change in hippocampal volume and depressive symptoms |
2014 | Oertel-Knöchel et al., 2014 [37] | ?? MDD and SZ | (A) 16 (B) 17 | 18 | (A) CT combined with aerobic physical exercise: boxing, circuit training Intensity: 60–70% of individual HRmax (calculated from HRmax from ECG) Supervised by a trained physical exercise instructor (B) CT combined with relaxation training (no yoga or PMR, just breathing, “enjoy exercises”) Both 3x/week, 75 min: 30 min CT and 45 min training CT and relaxation conducted by an exercise instructor | Waiting list CG | Complete physical examination, ECG, blood investigation Validated questionnaires | 4 weeks | Increase in cognitive performance in visual learning, working memory and speed of processing Increase in subjective quality of life between pre- and post-testing Significant reduction in depressive symptoms and state anxiety The effects in SZ patients compared with MDD patients were stronger for cognitive performance, whereas there were stronger effects in MDD patients than in SZ patients in individual psychopathology values |
2012 | Krogh et al. 2012 [93] | Outpatient RCT MDD | 56 | 59 | Aerobic exercise 3x/week: cycle ergometer Intensity: first 4 weeks: at least 65% of maximal capacity (VO2max), progressing to 70% and 80% during the second and third month, respectively Supervised by a physiotherapist | Stretching, low intensity | CRF: estimated VO2max, bicycle cardiopulmonary exercise test | 12 weeks | After the intervention, the mean difference between groups was 20.78 points on the HAM-D17 At follow-up, higher VO2max and visuospatial memory on Rey’s Complex Figure Test and lower blood glucose levels and waist circumference in aerobic exercise group compared with stretching exercise group |
2010 | Oeland et al. 2010 [94] | Controlled clinical study Panic disorder, generalized anxiety disorder, mild and moderate depression, mild and moderate recurrent depressive disorder | 27 | 21 | Group exercise: aerobic training (30 min) as circuit training Intensity: high intensity, at least 65–75% of maximum aerobic capacity AND Non-aerobic weightlifting with five basic exercises for muscles in legs, chest, abdomen, and lower and upper back: 8–10 repetitions with an intensity of 10 RM AND The instructor encouraged the participants to exercise once a week on their own initiative, at least 30 min; they were free to choose intensity and type of exercise 2x/week, 90 min Supervised: yes | Yes, but n.a | Aerobic capacity: submaximal bicycle ergometer test Muscle strength: Senior Fitness Test Questionnaires | 20 weeks 12 weeks’ follow-up | Increase of physical activity and VO2max in intervention group VO2max increase was maintained after a 12-week follow-up period |
2009 | Krogh et al. 2009 [49] | RCT, outpatient Unipolar depression | (A) 55 (B) 55 | 55 | (A) Strength group: circuit training with 6 machine exercises for large muscle groups Intensity: Initially 12 repetitions of 50% of RM 2 or 3 times per exercise. As the patients progressed, the numbers of repetitions were reduced to 10 and 8, and RM was increased to 75% (B) Aerobic group program: 10 different aerobic exercises for large muscle groups: cycling, running, stepping, etc Intensity: During the first 8 sessions, each exercise was done twice for 2 min at an intensity level of 70% of maximal heart rate and followed by a 2-min rest. This gradually increased to a level during the last 8 sessions at which each exercise was done for 3 min at an intensity level of 89%, with a 1-min rest Sessions: 2x/week, 1.5 h Supervised by a physiotherapist | Relaxation group | CRF: VO2max, bicycle ergometry; RM | 4 months 6 months’ follow-up | Increase of strength measured by 1 RM in strength training group compared to relaxation group at month 4 Increase of VO2max in aerobic group compared to relaxation group at month 4 No statistically significant effect on cognitive abilities |
2009 | Hoffman et al. 2008 [95] | RCT MDD | (A) 51 (B) 53 (C) 49 | 49 | (A) Supervised aerobic exercise: 3x/week; individual training ranges equivalent to 70–85% HR reserve, calculated from the HRmax achieved during initial treadmill test (B) Home-based aerobic exercise: one initial training and 2 follow-up sessions with an exercise physiologist A and B: individual training ranges equivalent to 70–85% HR reserve, calculated from the HRmax achieved during initial treadmill test (C) Sertraline | Placebo pill | Aerobic capacity: VO2peak, graded treadmill exercise testing | 16 weeks | Higher levels of VO2peak and longer treadmill times in supervised exercise patients than in those who exercised at home No differences in neuropsychological tests between groups Better performance on tests of executive function but not on tests of verbal memory or verbal fluency/working memory in exercise group |
2007 | Legrand and Heuze 2007 [43] | Pilot study, randomized Depression | (A) 8 (B) 8 | 7 | (A) High-frequency exercise: 3–5 sessions/week, within their THR on a motorized treadmill, a stationary bicycle, or a rowing ergometer (B) High-frequency exercise AND group-based intervention: 3–5 sessions/week AND group support: e.g., collective training sessions, asking participants to wear group T-shirts, encouraging participants to chat and to cheer each other on Supervision by first author of the study | Low-frequency exercise: 30 min/week of one aerobic exercise | Reaction to group intervention: participants’ scores of perceived cohesions Questionnaire sur l’Ambiance du Groupe | 8 weeks | Lower depression scores in high-frequency aerobic exercise group than in CG at week 4 and 8 Alleviation in depressive symptoms was not found to be greater in those participants who received a group-based intervention |
2002 | Penninx et al. 2002 [112] | RCT, single blind Knee arthritis plus depression | (A) 112 low dep: 34 high (B) 115 low; 28 high | 113 (36 high-dep) | (A) Resistance exercise: facility-based program, 3x/week, 1 h AND a 15-month home-based program. Repetitions of various upper and lower body exercises with dumbbells and cuff weights Supervised: yes (B) Aerobic exercise: indoor track; walking at an intensity equivalent to 50–70% of the HRR (determined from a screening exercise treadmill test). In months 4–6, the exercise leader visited participants four times and called them six times to offer assistance and support in the development of a walking exercise program in their home environment | Health education | Self-reported disability, 6-min walking speed, knee pain | 3 months 15 months’ home-based follow-up | Significant decrease of depressive symptoms in aerobic exercise group compared to control group No such effect was observed for resistance exercise Reduction of depressive symptoms in both participants: with initially high and low depressive symptomatology Significant decrease of disability and pain and increase of walking speed in aerobic and resistance exercise group |
1999 | Blumenthal et al. 1999 [96] | RCT MDD | (A) 53 (B) 48 (C) 55 | (A) Aerobic exercise session: 10 min warm up, 30 min continuous walking or jogging, 5 min cool down (B) Medication: antidepressants: Sertraline hydrochloride (C) Exercise + medications combined Sessions 3x/week Intensity: 70–85% of HRR calculated from HRmax Supervised: yes | n.a | Symptom-limited graded exercise treadmill test under continuous electrocardiographic recording | 16 weeks | No statistical difference in groups on HAM-D or BDI scores Patients in the exercise and combination groups showed significant improvements in aerobic capacity, whereas patients in the medication group did not | |
1989 | Martinsen et al. 1989 [45] | RCT Inpatient Depression | 51 | 47 | Aerobic exercise: Brisk walks and jogging Intensity: corresponding to approximately 70% of maximum aerobic capacity 3x/week, 1 h, 5–10 persons/group Supervision by an experienced instructor | Non-aerobic, low intensity, muscular strength training | CRF: VO2max, submaximal bicycle ergometer test | 8 weeks | Significant increase of VO2max in the aerobic group No change in the non-aerobic group Significant reduction of depression scores in both scores during the study Correlation between increase in physical fitness and reduction in depression scores was low |
Effects of physical activity on symptoms of BD
Aerobic exercise training improves cognition and symptoms in patients with SZ
Year | Publication | Study design and diagnosis | Sample size, n | Intervention | Control | Measurement of CRF and PA | Intervention duration /follow-up | Outcome | |
---|---|---|---|---|---|---|---|---|---|
IG | CG | ||||||||
2021 | Kimhy et al. 2021 [105] | Single-blind RCT SZ | 16 | 17 | Aerobic exercise program with 2 active-play video games (Xbox 360 Kinect) and traditional aerobic exercise equipment (treadmill, bike) Sessions: 3x/week, 1 h Moderate intensity: activities that expend 3.0–5.9 times the energy expended at rest; 60% of HRmax in week 1, 65% in week 2, 70% in week 3, and 75% in weeks 4–12 Supervision by a BSc in Science of Therapeutic Recreation | UC | CRF: VO2peak, cycle ergometer | 12 weeks | ↑ In VO2max by 18.0% vs. 0.5% 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 Significant improvement in SF (23.0% vs. − 4.2%) |
2020 | Andersen et al. 2020 [99] | RCT SZ | 21 | 26 | HIIT Walking/running on a treadmill, Sessions: 2x/week, 45 min Intensity: 4 × 4 min 85–95% of HRmax, active breaks consisting of 3 min of ~ 70% of HRmax Supervision by mental health care providers with or without PA competence (half of the participants, respectively) | PC gaming skills (Nintendo Wii sports console), supervised | CRF: VO2max (treadmill, maximum exercise session, mod. Balke protocol) PA: Actigraph GT3X + accelerometer | 12 weeks | No significant within-group differences in CRF ↑ Workload in 61% of HIIT ↑ In VO2max when adding PA competence of the mental health care providers No significant effect on PA level or body composition |
2020 | Dubreucq et al. 2020 [113] | Quasi experimental trial SZ | 57 | 30 | Exercise-enriched integrated social cognitive remediation intervention Sessions: 1x/week, 2 h Intensity: not defined Supervised by two facilitators | Active CG practicing Touch Rugby 12 × 2-h sessions Supervised by specialized sport scientists | 12 weeks 6 months’ follow-up | Moderate to large improvements in social function, symptom severity, verbal abstraction, aggression bias, and self-stigma that were specific to the IG and were not observed in participants playing only Touch Rugby. Effects were persistent over time and even larger between post-treatment and follow-up | |
2020 | Korman et al. 2020 [102] | Single arm, prospective feasibility study SMI; 92% SZ | 42 | No CG | Mixed aerobic and resistance training: circuit training, combined with a dietary intervention (six individual and group sessions) Sessions: 3x/week, 1 h Intensity: Moderate from week 3. (RPE at 2–3 for the first 2 weeks, then increased to a minimum RPE of 4/10 by week 3 and further increased as per individual participant's capacity) Supervised by exercise physiology students | No CG | Functional exercise capacity: 6 MWT PA: questionnaire SIMPAQ Motivation towards exercise: BREQ | 10 weeks | Significant improvements in functional exercise capacity, volume of exercise, general psychiatric symptoms, and negative psychotic symptoms No change in anthropometric and metabolic blood markers |
2020 | Massa et al. 2020 [101] | RCT Outpatient SZ | 21 | 17 | Aerobic exercise on a stationary bicycle, groups of about 5 participants Sessions: 3x/week, initially 20 min to 45 min (increasing 5 min each week) Intensity began at low levels (50% of maximal HRR) to 80% of HRmax (increased by 5% every week) Supervised by at least one qualified instructor | Stretching and balance training for same amount of time, groups of about 5 participants | 400 m walk test → Estimate VO2max | 12 weeks 8 weeks’ follow-up | Subjects in both groups were slower at the 400 m walk in week 12 compared with baseline, but the IG had significantly less slowing than the CG Between week 12 and week 20, the aerobic exercise group had a significantly greater change score on the Composite and Visual Learning Domain of the MATRICS Consensus Cognitive Battery |
2019 | Brobakken et al. 2019 [100] | RCT Feasibility study SZ | 25 | 23 | Aerobic interval training in groups, walking/running on a treadmill Sessions: 2x/week, 35 min Intensity: 4 × 4 min 85–95% of HRpeak, active pauses consisting of 3 min of ~ 70% of HRpeak Supervised by experienced healthcare professionals | Two aerobic interval training sessions and encouragement to exercise on their own | CRF: VO2peak | 12 weeks | ↑VO2peak by 10%, no change in the CG No intergroup difference in weight, body mass index (BMI), waist circumference, blood pressure, lipids, or glucose at posttest ↑Weight and BMI in the CG, no change in the IG |
2019 | Hallgren et al. 2019 [60] | Single-arm feasibility study First-episode psychosis; majority SZ | 91 | No CG | Circuit training: high-volume resistance exercises, aerobic training, and stretching Sessions: at least 3x/week, 1 h Supervised by exercise science graduates and exercise physiologist | No CG | 12 weeks | Significant post-intervention improvements for processing speed, visual learning, and visual attention; all with moderate effect sizes | |
2019 | Larsen et al. 2019 [114] | RCT, Feasibility study First-episode psychosis, SZ, Schizotypal and delusional disorder, and other non-organic psychotic disorders | 13 | 12 | Cross-fit-oriented training Session: 3x/week, 1 h Moderate to high intensity Supervised by two instructors (undergraduate students) | Waiting list CG | 8 weeks | Three main themes and ten subthemes emerged during the analysis: (1) motivation and expectations for enrollment (subthemes: routines and structure, social obligation, goal setting and self-worth); (2) new demands and opportunities (subthemes: practicalities of the training, an understanding exercise setting, and alone and together); and (3) looking ahead—reflections on impact (subthemes: restored sleep and circadian rhythm, energy and sense of achievement, changed everyday life, and hope of finding a new path) | |
2019 | Shimada et al. 2019 [62] | Pilot RCT SZ | (A) 16 | 15 | (A) Aerobic exercise: individual and group programs Sessions: 2x/week, 1 h Intensity: individually calibrated at 60–80% of aerobic capacity. Patients were required to participate in a minimum of 75% of each session Supervised by occupational therapists | UC | n.a | 12 weeks | IG and CG patients showed significant improvements in cognition, intrinsic motivation, psychiatric symptoms, and interpersonal relations |
2017 | Bhatia et al. 2017 [115] | Single-blind RCT SZ | A) 104 (B) 90 | 92 | (A) Yoga training (postures and breathing) (B) Physical exercise training: brisk walks, jogging, and directed aerobic exercises Sessions: 5x/week, 1 h Supervised by qualified instructors | UC | n.a | 21 days 6 months’ follow-up (provided with a yoga training booklet, compliance charts) | Speed index of attention domain in group (A) showed greater improvement than group (B) at 6 month follow-up In group (B), accuracy index of attention domain showed greater improvement than UC alone at 6-month follow-up For several other cognitive domains, significant improvements were observed with (A) or (B) compared with UC alone |
2017 | Cheng et al. 2017 [107] | RCT SZ | 26 | 28 | Aerobic dance program Sessions: 2x/week, 60 min Intensity: 60–79% of predicted HRmax Supervised by professional instructor | UC | Muscular endurance (1-min flexed leg sit-up), flexibility (sit-and-reach test), cardiorespiratory endurance (3-min step test; HR) | 8 weeks 4 weeks’ follow-up | Significant between-group differences at posttest and in the follow-up for all of the health-related fitness outcomes with the exception of muscular endurance |
2017 | Curcic et al. 2017 [63] | RCT SZ | 40 | 40 | Individual training: Walking/running 2–4 km outside Sessions: 4x/week, 45 min Intensity: 65–75% HRmax Supervised by a fitness trainer | UC | CRF: VO2max | 12 weeks | After 12 weeks, patients in IG showed a significant increase of VO2max and significantly higher level of VO2max compared to the CG Significant differences on PANSS general psychopathology subscale and on PANSS total score. The pharmacotherapy and exercise had influence on PANSS general psychopathology and PANSS total score |
2016 | Duncan et al. 2016 [116] | Randomized cross-over study SZ | 28 | Bout of exercise: walking on the treadmill Intensity: moderate (64–76% of the calculated HRmax) 1 × 10 min | Passive sitting for 14 min | Mean HR, percent maximum HR, Borg RPE | 10-min post-tests after 14 and 24 min | Significant differences between pleasure at baseline, both immediately after task and 10 min after task. No other main effects or interactions | |
2016 | Ho et al. 2016 [68] | RCT Chronic SZ | (A) 51 (B) 51 | 49 | (A) Tai Chi: 22 simple movements (B) Moderate aerobic exercise routine to achieve 50–60% of maximal oxygen consumption Both groups: 1x/week, 60 min AND 2x/week, 45 min Supervised by mental health professionals | Wait list control UC; they were offered the Tai chi or exercise class on a voluntary basis after the 3-month post-intervention follow-up assessment | Heart rate | 12 weeks 3 months’ follow-up | Compared with CG, the Tai-chi group showed significant decreases in motor deficits and increases in backward digit span and mean cortisol, while the exercise group displayed significant decreases in motor deficits, negative and depression symptoms and increases in forward digit span, daily living function, and mean cortisol No significantly different therapeutic effects of the two interventions, except for fewer symptom manifestations in the exercise group |
2016 | Kang et al. 2016 [67] | RCT Chronic SZ | 118 | 126 | Community-based integrated intervention = Tai Chi Intervention AND Social Skills Training Sessions 2x/month, 120 min: 45 min social skill training, 45 min Tai Chi, 30 min break Supervised by three full-time psychiatrists and one assistant Both groups received medication maintenance treatment to prevent relapse | Medical treatment alone | 12 months | Compared with the medical treatment alone group, the community-based integrated intervention group had lower scores on PANSS and negative symptoms, a lower risk for aggressive behavior, and a greater improvement in adherence to medication after 1 year of intervention | |
2016 | Keller-Varady et al. 2016 [29] | Controlled interventional study SZ | (A) 22 (B) 21 | 22 healthy controls | (A) Endurance group: dynamic aerobic endurance training on bicycle ergometers Sessions: 3x/week, 30 min Intensity: set according to the individual results of a baseline assessment of endurance capacity, equivalent to blood lactate concentrations of 2 mmol/l Supervised by sport scientist (B) Table soccer group: table soccer Sessions: 3x/week, 30 min Supervision: n.a All participants continued with their usual medication | Healthy control in endurance group | Endurance capacity by ergometer stress test Standardized questionnaire, specially developed for measuring PA | 12 weeks 3 and 6 months’ follow-up | Improvements of endurance capacity in (A), but not in (B) Patients and healthy controls showed comparable adaptations to endurance training, as assessed by physical working capacity and maximal achieved power Differences in changes of performance at a lactate concentration of 3 mmol/l |
2016 | Malchow et al. 2016 [88] | RCT SZ | 2021 healthy controls | 19 | Endurance training on bicycle ergometers Sessions: 3x/week, 30 min Intensity: individually defined intensity, gradually increased according to blood lactate concentrations of approximately 2 mmol/l, HR, Borg Scale Supervised by sports scientists From week 6, the computer-assisted training program COGPACK was added as an intervention in each group to train cognitive performance | Table soccer in groups (2–4 players) | Endurance capacity (PWC130) by maximal exercise stress test PA was monitored throughout the study, not defined | 6 weeks 3 months | No significant increases in the volumes of the hippocampus or hippocampal substructures in SZ patients or healthy controls Increased volume of the left superior, middle, and inferior anterior temporal gyri compared with baseline in SZ patients after the endurance training, whereas patients playing table soccer showed increased volumes in the motor and anterior cingulate cortices. After the additional training-free period, the differences were no longer present Improvements of endurance capacity in exercising patients and healthy controls No change in psychopathological symptoms |
2016 | Su et al. 2016 [61] | 3-month follow-up study, single blind, randomized SZ | 30 | 27 | Aerobic exercise: individually tailored for each participant because exercise prescriptions were based on each individual's age-adjusted HRmax Sessions: at least 3x/week, 40 min One-on-one supervision throughout the sessions | Stretching and toning control group, individually conducted, own pace Same social interactions as those in aerobic exercise group | Estimated VO2max | 12 weeks 3 months’ follow-up | No significant difference between the two groups in any cognitive outcome measured at follow-up; improvement over time was noted in certain cognitive domains in the IG No significant between-group differences in aerobic fitness at posttest and follow-up Fitness level was not related to changes in cognitive performance |
2016 | Yoon et al. 2016 [108] | Single-arm pilot study SZor schizoaffective disorder | 24 | No CG | Exercise intervention: group-based outdoor cycling 1x/week, at least 40 min Individual performance (average speed, distance, and duration) and heart rate, were monitored by individual supervising staff during every session.) Supervised by two professional cyclists and other staff: medical doctors, nurses, and social workers | No CG | Cardiorespiratory function test (step test): 3-min YMCA step test | 3 months 6 months’ follow-up | Significant increase in participant’s self-esteem, positive relationship, global function, and quality of life CRF significantly improved after 3 months At the 9-month follow-up, 6 months after program completion, only in interpersonal relationship change the improved effects were maintained |
2015 | Kaltsatou et al. 2015 [69] | RCT, outpatient SZ | 16 | 15 | Greek traditional dancing program Sessions: 3x/week, 60 min Intensity: 60–70% of individual HRmax (220-age) Supervised by a PA instructor | Sedentary CG, Patients were asked to refrain from any other form of organized PA during study period | 6 MWT Sit-to-stand test, 10 times Lower limb strength testing Hand-grip strength | 8 months | ↑ Walking distance in the 6 MWT, sit-to-stand test, Berg Balance Scale score, lower limbs maximal isometric force, Positive and Negative Syndrome Scale total score, Global Assessment of Functioning scale total score, and Quality of Life total score |
2015 | Kimhy et al. 2015 [117] | Single-blind RCT, inpatient SZ | 16 | 17 | Aerobic exercise program utilizing 2 active-play video games (Xbox 360 Kinect) and traditional aerobic exercise equipment (treadmill, bike) Sessions: 3x/week, 1 h Intensity: moderate intensity, minimal aerobic exercise intensity was set to 60% of HRmax in week 1, 65% in week 2, 70% in week 3, and 75% in weeks 4–12 Supervised by a BSc in Science of Therapeutic Recreation | UC | CRF: VO2peak | 12 weeks | ↑ VO2peak by 18.0% in the IG vs a − 0.5% decline in the CG Improvement of neurocognition by 15.1% vs − 2.0% CRF and increases in BDNF predicted 25.4% and 14.6% of the neurocognitive improvement variance, respectively |
2015 | Loh et al. 2015 [118] | RCT, inpatient SZ | 52 | 52 | Structured, organized walking intervention, 3x/week, supervised 3x/week, the first month: 20-min walking exercise, second month: 30-min walking exercise, third month: 40-min walking HR was monitored before and after the exercise to prevent overexertion Supervised by ward staff nurses and assistant medical officers | Treatment as usual | IPAQ-M | 12 weeks 3 months’ follow-up | At 3-month follow-up, significant within-group differences in QOL (SF-36), psychiatric symptoms (PANSS), and personal and social performance (PSP) Increase in the median SF-36 scores, with increases shown in physical functioning, physical role limitations, social functioning Reduction of median PANSS in positive and negative symptom, and general psychopathology scales Increase in the median PSP score Between-group differences at post-intervention (favoring intervention) were significant for PANSS positive and SF-36 |
2015 | Malchow et al. 2015 [58] | RCT SZ | 2223 healthy controls | 21 | Endurance training on bicycle ergometers Sessions: 3x/week, 30 min Intensity: individually defined intensity, gradually increased according to blood lactate concentrations of approximately 2 mmol/l, HR, Borg Scale Supervised by sports scientists From week 6, the computer-assisted training program COGPACK was added as an intervention in each group to train cognitive performance | Table soccer in groups (2–4 players) | Endurance capacity (PWC130) by a maximal exercise test on a bicycle ergometer | 6 weeks 3 months 6 months’ follow-up | After 3 months, improvement in GAF and SAS-II social/leisure activities and household functioning adaptation in the endurance training augmented with cognitive remediation, but not in the table soccer augmented with cognitive remediation group Significant improvements in the severity of negative symptoms and performance in the VLMT and WCST in the endurance training augmented with cognitive remediation group from week 6 to the end of the 3-month training period |
2015 | Masa-Font et al. 2015 [111] | RCT Severe mental illness; 67% SZ | 169 | 163 | Educational program AND PA program based on different stages → 24 sessions 2x/week over 3 months: The first 8 sessions (40 min) consisted of making first contact with PA. The other 16 sessions (60 min) aimed to increase the number of daily steps taken to reach 10,000 steps per day on routes adapted to the physical condition of the participants AND Dietary intervention → 16 sessions 2x/week, 20 min to provide basic knowledge on healthy dietary habits Supervised by professionals | No intervention, usual program of regular check-ups with their reference psychiatrist All the participants in both the IG and CG kept up their usual visits with their reference mental health professional and continued the usual treatment for their disease | PA: IPAQ, METs expended per week | 3 months 12 months’ follow-up | ↑ Average weekly walking METs in the IG BMI decreased significantly more in the CG No significant differences in the waist circumference |
2015 | Silva et al. 2015 [70] | RCT “blind” SZ | (A) 12 (B) 9 | 13 | (A) Resistance: progressive resistance training Intensity: from 40% 1RM in week 1 up to 85% 1RM in week 20 (B) Concurrent exercise: endurance training and strength resistance training Intensity: from 40% VO2max in week 1 up to 75% VO2max in week 20 Sessions: 2x/week, 60 min Supervised by professional physical educators | Control: equipment load was kept at a minimum, treadmill speed remained at 4 km/h | CRF: VO2max | 20 weeks | A significant time-by-group interaction was found for (A) and (B) on the Positive and Negative Syndrome Scale total score for disease symptoms, positive symptoms, and on the arm extension one-repetition maximum test Improvements in (A) on negative symptoms, on the role-physical domain of the Short Form-36 Health Survey, and on the chest press 1RM test |
2015 | Svatkova et al. 2015 [90] | RCT SZ | (A) 16 (B) 17 | (A) 24 (B) 24 healthy controls | (A) Aerobic and anerobic exercise. Aerobic exercise: bicycle ergometer, rowing machine, cross trainer, treadmill and muscle strength exercises (6 exercises per week, 3 times). Anaerobic exercise: working with weights 2x/week, 1 h: 40 min aerobic training, 20 min anaerobic training Intensity: n.a Supervision: n.a (B) No exercise = life-as-usual | (A) exercise (B) no exercise = life- as-usual Healthy controls | CRF: VO2peak Structured questionnaire to assess the level of daily life physical activities at baseline Brain scans | 6 months | Irrespective of diagnosis, regular physical exercise of an overlearned skill, such as bicycling, significantly increases the integrity, especially of motor functioning-related white matter fiber tracts, whereas life-as-usual leads to a decrease in fiber integrity Significant differences in the exercise and non-exercise group from the first to the second measurement in Wpeak and VO2peak |
2014 | Oertel-Knöchel et al. 2014 [37] | MDD (n = 22) and SZ (n = 29) | (A) 16 (B) 17 | 18 | (A) Cognitive training combined with aerobic physical exercise: boxing, circuit training Intensity: 60–70% of individual HRmax (calculated from HRmax from ECG) Supervised by a trained physical exercise instructor (B) CT combined with relaxation training (no yoga or PMR, just breathing, “enjoy exercises”) CT and relaxation conducted by instructors Both sessions: 3x/week, 75 min (30 min CT and 45 min training) | Waiting list CG | 4 weeks | Increase in cognitive performance in the domains visual learning, working memory and speed of processing; decrease in state anxiety; and increase in subjective quality of life in the total group of patients The effects in SZ patients compared with MDD patients were stronger for cognitive performance, whereas there were stronger effects in MDD patients compared with SZ patients in individual psychopathology values. MDD Reductions in depressive symptoms and state anxiety values in patients Reduction of negative symptoms severity in SZ patients | |
2014 | Vancampfort et al. 2014 [119] | Pilot Study cross-sectional SZ | 88 | No intervention | Spirometry: 2 spirometry attempts while seated, conducted by trained technicians CRF: 6-min walk test PA: IPAQ | Screening: 6 months | Patients with MetS had a reduced predicted forced expiratory volume for 1 s and predicted forced vital capacity Significantly more patients with MetS were diagnosed with restrictive lung dysfunction SZ patients with restrictive lung dysfunction had a significantly larger waist circumference, were less physically active and walked less on the 6 MWT than patients without | ||
2013 | Scheewe et al. 2013 [64] | RCT SZ | 31 | 32 | Exercise therapy: Muscle strength exercises (six exercises/week, 3 × 10 to 15 RM for biceps, triceps, abdominal, quadriceps, pectoral, and deltoid muscles). 2x/week, 1 h Intensity: increased stepwise: week 1–3, 45%; week 4–12, 65%; week 13–26, 75% of HR reserve based on baseline CPET data Supervised by a psychomotor therapist | Occupational therapy creative and recreational activities | CRF: VO2peak and Wpeak | 6 months | ↑ Wpeak in IG compared with CG Exercise therapy reduced symptoms of SZ, depression, need of care, and increased VO2peak in the IG compared with CG No effect for MetS factors |
2013 | Scheewe et al. 2013 [85] | RCT SZ | (A) 18 (B) 14 | (A) 25 (B) 27 | (A) Exercise therapy intervention: upright and recumbent bicycle ergometer, rowing machine, cross trainer, and treadmill AND muscle strength exercises (for biceps, triceps, abdominal, quadriceps, pectoral, deltoid muscles) 1 h of exercise consisting of both cardiovascular exercises (40 min) and muscle strength exercises (20 min) twice weekly Supervised by a psychomotor therapist specialized in psychiatry (B) Occupational therapy by an occupational therapist 1 h/twice weekly: Occupational therapy comprised creative and recreational activities, no physical activity | (A) Exercise therapy (B) Life as usual More details n.a | CRF: VO2peak | 6 months | Significantly smaller baseline cerebral (gray) matter, and larger third ventricle volumes, and thinner cortex in most areas of the brain in patients versus controls No changes in global brain and hippocampal volume or cortical thickness CRF improvement was related to increased cerebral matter volume and lateral and third ventricle volume decrease in patients and to thickening in the left hemisphere in large areas of the frontal, temporal and cingulate cortex irrespective of diagnosis 1–2 h of exercise therapy did not elicit significant brain volume changes in patients or controls CRF improvement attenuated brain volume changes |
2012 | Scheewe et al. 2012 [106] | RCT SZ | (A) Exercise therapy 31// Healthy controls 27 (B) Occupational therapy 32 | 28 | Exercise therapy: (A) Muscle strength exercises (six exercises weekly; three times 10–15 RM for biceps, triceps, abdominal, quadriceps, pectoral, and deltoid muscles) Sessions: 2x/week, 1 h Intensity was increased stepwise (week 1–3, 45%; week 4–12, 65%; week 13–26, 75% of HRR based on baseline CPET data Supervised by a psychomotor therapist (B) Patients not randomized to exercise therapy were offered occupational therapy 2x/week, 1 h: creative and recreational activities | Life as usual, not allowed to incorporate moderate physical activity more than 1 h weekly | CRF: VO2peak and Wpeak | 6 months | Patients had higher resting HR and lower peak HR, peak systolic blood pressure, relative VO2peak, Wpeak, RER, minute ventilation and HR recovery than controls In patients, exercise therapy increased relative VO2peak compared with decreased relative VO2peak after occupational therapy In controls, relative VO2peak increased after exercise therapy and to a lesser extent after life-as-usual Exercise therapy increased Wpeak in patients and controls compared with decreased Wpeak in nonexercising patients and controls |
2012 | Takahashi et al. 2012 [87] | ?? SZ | 13 | 10 | Program including exercise, nutrition education and medication counseling Exercise module: aerobic exercise (walking and jogging), muscle-stretching exercise and sports exercise (basketball). The exercise module was 30–60 min long, and was delivered twice a day (a total of 60–120 min per day) from Monday to Saturday For each participant, the exercise intensity level was set at 11–13 (fairly light to somewhat hard) on the Borg scale Supervised by a group of professionals from diverse disciplines (physical therapists, psychiatric nurses, psychiatrists, nutritionists, and pharmacists) All patients received antipsychotics, and their medications remained unchanged during this study | Attended the day-hospital unit but not the program | 3 months | Body mass index and general psychopathology scale of PANSS were significantly reduced in the program group but not in the control group after a 3-month interval Compared with baseline, activation of the body-selective extrastriate body area [23] in the posterior temporal-occipital cortex during observation of sports-related actions was increased in the program group. In this group, increase in EBA activation was associated with improvement in the general psychopathology scale of PANSS Sports participation had a positive effect not only on weight gain but also on psychiatric symptoms in schizophrenia | |
2011 | Heggelund et al. 2011 [104] | RCT SZ | 12 | 7 | HIIT Sessions: 3 days/week, 36 min: 4 × 4 min Intensity: 4 min 85–95%, 3 min 70% HRpeak Supervised by an exercise physiologist | Played PC (Tetris) games; 3 days/week, 36 min Supervised by the same exercise physiologist | CRF: VO2peak | 8 weeks | The HIIT group improved VO2peak by 12% compared with the CG group Net mechanical efficiency of walking improved 12% in the HIIT group compared with the CG group No significant changes in PANSS, CDSS or SF-36 in either group |
2011 | Methapatara and Srisurapanont 2011 [120] | RCT SZ | 32 | 32 | Pedometer walking AND motivational interviewing program → 5 × 1-h sessions: First session: individual motivational interviewing with a focus on obesity/overweight and motivation for adequate daily walking Second session: group education on nutrition, exercise, warming up, cooling down, and implementation of pedometer Third session: specific, measurable, acceptable, realistic, and timed criteria were used to set an individual goal, the first goal of daily walking was set at a minimum of 3000 steps per day Forth session: group practicing of pedometer walking under supervision Fifth session: therapist gave feedback on the patients’ practice, informed about self-regulation principles to cope with lapses and relapse | Control patients received the usual care only and no pedometer | 12 weeks | Bodyweight of intervention group decreased more than that of the control group at week 4, 8, and 12 BMI at week 12 was significantly different between groups The decreases of waist circumference were significantly more in the intervention group for all three time-points of assessment | |
2011 | Vancampfort et al. 2011 [65] | Pilot study SZ | (A) 40 (B) 40 | 40 | (A) One single 30-min yoga session, trained by a physiotherapist (B) One single 20-min aerobic exercise session, performed on an electronically braked ergometer; consisted of cycling for 20 min at self-selected intensity with heart rate feedback. A physiotherapist was present during exercise | No exercise, participants sat quietly in a room for 20 min and were allowed to read. A physiotherapist was also present | n.a | One single event | After single sessions of yoga and aerobic exercise, individuals with SZ or schizoaffective disorder showed significantly decreased state anxiety, decreased psychological stress, and increased subjective wellbeing compared to a no-exercise control condition. The magnitude of the changes did not differ significantly between yoga and aerobic exercise |
2010 | Pajonk et al. 2010 [57] | RCT, day-hospital/outpatient SZ | 88 healthy control | 8 | Aerobic exercise training (cycling) Sessions: 3x/week, 30 min Intensity: heart rate (± 10 beats/min) corresponding to a blood lactate concentration of about 1.5–2 mmol/l (14–18 mg/dl) derived from the results of the pretest Supervised by one of the investigators | Played table football The comparison group of patients played tabletop football for 30 min, 3 times per week, in a setting with comparable levels of stimulation to those provided for aerobic exercise. Tabletop football enhances coordination and concentration but does not improve aerobic fitness | CRF: VO2max | 3 months | After exercise training, relative hippocampal volume increased significantly in patients (12%) and healthy individuals (16%), with no change in the non-exercise group of patients Changes in hippocampal volume in the exercise group were correlated with improvements in aerobic fitness measured by change in maximum oxygen consumption In the SZ exercise group, change in hippocampal volume was associated with a 35% increase in the N-acetylaspartate to creatine ratio in the hippocampus Improvement in test scores for short-term memory in the combined exercise and non-exercise SZ group was correlated with change in hippocampal volume |
Neuroplasticity effects of aerobic exercise
Improvements of CRF in patients with severe mental illness
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The American College of Sports Medicine recommends that adults engage in moderate-intensity cardiorespiratory exercise training for ≥ 30 min/day on ≥ 5 days/week for a total of ≥ 150 min/week, or vigorous-intensity cardiorespiratory exercise training for ≥ 20 min/day on ≥ 3 days/week for a total of ≥ 75 min/week [110].
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Further studies are needed to identify the most effective exercise interventions (type, duration, frequency).
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Because most studies were conducted over a relatively short intervention period of 3 to 4 months, were supervised and did not include a follow-up, future studies should focus on long-term adherence to exercise (e.g., by implementing motivational strategies supported by telemedicine and apps and by identifying and targeting typical barriers to exercise in this patient population).
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This patient group has a high prevalence of cardiovascular disease, so researchers should consider measuring the associated risk factors when performing exercise intervention studies.
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CRF should be comprehensively assessed in both clinical studies and clinical practice by direct measurements of maximal oxygen uptake.
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Exercise interventional studies in patients with BD need to be conducted because this patient group is underrepresented.