The Effectiveness of Exercise as an Adjunct Treatment for ...



The Effectiveness of Exercise as an Adjunct Treatment for Schizophrenia

Jennifer Pawson

University of New Hampshire

Introduction

Affecting as many as 1 out of 100 people in the general population, schizophrenia is a severe mental illness in need of effective and thoroughly researched treatment options (Varcarolis & Halter, 2010). Current research shows that while 90% of patients with schizophrenia will respond to pharmacological treatments, one of the common side effects for current antipsychotic medications is weight gain (Varcarolis & Halter, 2010, pp. 326-327). Exercise and physical activity have been shown to help reduce obesity in the general population, and as patients with schizophrenia are at an increased risk for obesity, exercise may need to become one of the front-runners for adjunct therapy for schizophrenia (Taylor, Lillis, LeMone & Lynn, 2008, p. 1277; Varcarolis & Halter, 2010, pp. 326 - 327).

While at New Hampshire Hospital, a mental health inpatient center, I witnessed the use of exercise in a therapeutic regimen and I found that patients who attended physical activity groups appeared to have reduced anxiety, improved social skills, and calmer dispositions. These groups were open to most patients, and though the results I observed were not definitive, many of the providers advocated for the use of exercise as an adjunct therapy in all forms of mental illness. As schizophrenia is a lifelong, chronic illness, providers must be made aware of the available treatment options, so that patients can be provided with the most effective therapies. Furthermore, as exercise programs can be run through community mental health centers, physical activity could reduce strain on inpatient services, especially if patients experience fewer relapses of the disease. Exercise may also be a cost-effective adjunct therapy, which could reduce the number of patients who discontinue their therapeutic regimen due to financial constraints. The effectiveness of exercise as an adjunct therapy for schizophrenia should be adequately researched so that patients, providers, and the mental health system can provide the highest quality of care to this vulnerable population.

Background Information on Schizophrenia

Schizophrenia is a severe mental illness characterized by hallucinations, disorganized or catatonic behavior and patients may also have an inappropriate or depressed affect and associative looseness (Varcarolis & Halter, 2010, p. 307). Schizophrenia has two main classes of symptoms: positive and negative. Positive symptoms include hallucinations, delusions, and bizarre behavior, while negative symptoms are similar to symptoms of depression and include a flat affect, alogia, and anhedonia (Varcarolis & Halter, 2010, p. 313). Schizophrenia affects more than 3 million in the United States, and symptoms typically present during the late adolescence and young adulthood (Varcarolis & Halter, 2010, p. 307). Males are affected by this illness at a slightly higher rate, and males typically are affected at a younger age, which tends to have a poorer prognosis (Varcarolis & Halter, 2010, p. 307-308). Common co-morbidities of schizophrenia include substance abuse, anxiety, and premature death (Varcarolis & Halter, 2010, p. 308). The life expectancy of a patient with schizophrenia tends to be twenty-eight years shorter than that of general population, due to physical health issues “such as hypertension (22%), obesity (24%), cardiovascular disease (21%), [and] diabetes (12%)” (Varcarolis & Halter, 2010, pp. 308-309).

Current treatment options for schizophrenia include two classes of antipsychotics, which may be prescribed concurrently with an antidepressant, an anxiolytic, or a mood stabilizer, in order to control recurrent symptoms or to increase the effectiveness of the antipsychotic (Varcarolis & Halter, 2010, p. 331). However, as Varcarolis & Halter (2010) points out “in most cases, schizophrenia does not respond fully to available treatments, leaving residual symptoms and causing varying degrees of disability” (p. 311). It is this gap between current pharmacological treatments and mental well-being that exercise may be able to help close.

Research Methodology

I searched on CINHANL Plus, Health Source: Nursing/Academic Edition; Medline, PsycArticles, PsycCritique, Cochrane Database of Systematic Reviews, and PsycInfo and used the terms exercise and schizophrenia. I then narrowed down the search to include only article published between 2000 and 2010, and from there, I only used articles that I could guarantee access to by June 25th, 2010. This limited my search to mainly full-text articles, but there was a large wealth of data available, so I went forth with my research. I also used the search term “schizophrenia” on the National Guideline Clearinghouse, and determined the most current guidelines of treatment for patients with schizophrenia. Furthermore, I saw an article abstract in Varcarolis & Halter’s Foundations in Psychiatric Mental Health Nursing, and I sought out the original article to verify the results. In total, I found 147 articles, of which I chose 11 based on their specific focus on exercise’s effectiveness as an adjunct therapy for schizophrenia.

Discussion of Results

Of the articles that were obtained during this literature review, none proved conclusively that exercise was the grade A recommendation as an adjunct therapy for schizophrenia. Current literature did show that exercise may help in reducing co-morbidities, reducing side effects of antipsychotic medications, and reducing the negative symptoms of schizophrenia. According to a Cochrane review conducted by Gorczynski & Faulkner in 2010, the effectiveness of exercise as an adjunct therapy for schizophrenia needs to be researched further, since previous studies were flawed and therefore could only provide a low level of evidence, despite promising findings (p. 12).

In terms of reducing common co-morbidities of schizophrenia, Beebe et al. (2005) studied the effect of exercise program on body mass index, body fat, and “six minute walking distance” in patients with schizophrenia (p. 662). The participants were randomly assigned to either a control group or a treatment group, who attended a structured sixteen week treadmill walking program (Beebe et al., 2005, pp.664-665). While the sample size was small (4 participants in the treatment group and 6 in the control group), results from this study were promising, as participants in the exercise program had statistically significant decreases in their body fat when compared to those in the control group (Beebe et al., 2005, pp. 670-671). Since this was not a small double blind study, the decrease in body fat in exercise group participants may not be a definitive result of all exercise programs in this population. However, as Beebe et al. (2005) recommends, further research should be conducted to “identify the most effective exercise interventions and the most feasible delivery modalities for persons with schizophrenia in community settings” (p.674). As obesity commonly occurs alongside schizophrenia and reduces life expectancy, this research should prompt mental health providers to seek out exercise programs for this patient population (Varcarolis & Halter, 2010, pp. 308-309).

In a similar study, Poulin et al. (2007) researched the effectiveness of exercise on reducing weight gain caused by the use of atypical antipsychotics (p. 980). The participants were all taking second generation antipsychotics, and they had a diagnosis of schizophrenia, schizoaffective disorder or bipolar disorder (Poulin et al., 2007, p. 982). The size of the study was much greater than Beebe (2005) with 59 participants in the exercise program and 51 in the control group (Poulin et al., 2007, p. 982). With this larger sample size, the results were more definitive and showed that exercise can decrease the body mass index, body weight and waist circumference in participants (Poulin et al., 2007, p. 984). As current research shows that a high waist circumference (more than 40 inches in males and 35 in females) may indicate a higher risk for cardiovascular disease and obesity related illness, this research helps prove the importance of exercise in this population (“Aim for a Healthy Weight,” n.d.). Furthermore, Lowe & Lubos (2008) conducted literature review, which showed that exercise, alongside long-term dietary and psychoeducation, helps reduce weight gain secondary to antipsychotic treatment in patients with schizophrenia (p. 861).

Though Gorczynski & Faulkner (2010) found little data to support this, exercise is believed by many researchers to reduce the positive symptoms of schizophrenia (p. 11). This is illustrated by Faulker & Sparkes (1999) who stated “[e]xercise is shown to reduce auditory hallucinations, raise self-esteem, and improve sleep patterns and general behaviour in people living with schizophrenia” (as cited in Callaghan, 2004, p. 478). However, the study conducted by Beebe et al. (2005) showed that positive and negative syndrome scale (PANSS) scores (objective measurements of schizophrenia symptoms) only improved marginally for patients who exercised (pp. 668, 672).

On the other hand, all sources corroborate the effectiveness of exercise on the negative symptoms of schizophrenia. According to a qualitative study conducted by Fogarty & Happell (2005), participants in a voluntary exercise program stated that the exercise gave them more energy. For instance, one patient remarked:

"[W]hen I’ve become unwell I’ve become very lethargic . . . I’ve been able to perform better over the last three months, continually better . . . I’ve reached the stage now where I can basically get on a treadmill by myself or go for a walk. (Fogarty & Happell, 2005, p. 346)."

Gorczynski & Faulkner (2010) also found evidence of fewer negative symptoms in exercise participants in their review, and concluded “[i]ndividuals with schizophrenia can improve components of mental health by participating in regular exercise” (p. 13). Callaghan’s review (2004) also showed that exercise can reduce anxiety, which is known to impact the functioning of patients with schizophrenia (pp. 479-480). Duraiswarmy, Thirthalli, Nagendra & Gangadhar (2007) had similar conclusions when studying the effectiveness of yoga on PANSS scores. The authors found that patients that underwent yoga therapy had improved PANSS scores compared to a control group, but determined that the effect was like a result of reducing stress (Duraiswarmy et al., 2007, pp. 229-230). Overall, exercise appears to have significant mental and physical health benefits for patients with schizophrenia, and providers should be aware of these benefits and help recommend appropriate physical activity programs to this population.

Nursing Considerations

Nurses can use exercise as a way of observing and recording typical side effects of antipsychotic medications, maintaining activities of daily living (ADLs), and promoting a high level of baseline health. In mental health facilities, nurses can effectively and efficiently monitoring side effects of antipsychotic medication. According to Soundy, Faulker & Taylor’s qualitative study (2007), changes in exercise behavior can indicate that the presence of a side effect or that patient is inadequately medicated (p. 497). For example, one case study indicated that Ben (one patient with schizophrenia) experienced paranoia which was exhibited by decreasing his participation at a nearby sports center (Soundy, Faulkner & Taylor, 2007, p. 497). Nurses can use attendance and participation in exercise programs as part of a mental health assessment, and this data can allow for a continual evaluation of effectiveness in first line treatments for all forms of mental illness, including schizophrenia.

Research has also shown that exercise may reduce negative symptoms, thereby possibly eliminating the need for polypharmacy. Noordsy & Cote (2010) hypothesize that antipsychotic polypharmacy is associated with an increased incidence of potentially fatal side effects, such as neuroleptic malignant syndrome. The team reviewed charts from mental health facilities and concluded that there were more reported cases of neuroleptic malignant syndrome which occurred alongside with the use of two or more antipsychotic medications (Noordsy & Cote, 2010). As exercise has been proven to decrease negative symptoms of schizophrenia, nurses may be able to advocate for reduced polypharmacy as a way to both reduce incidence of dangerous side effects and to reduce costs. Noordsy & Cote (2010) estimated that 1.2 million dollars is spent annually to obtain a second antipsychotic medication for psychiatric patients. Further research should be done to determine whether exercise could reduce financial strain on patients or providers.

In addition to exercise’s effectiveness in monitoring or reducing side effects, nurses may be able to help patients maintain ADLs through physical activity. According to Putzhammer, Perfahl, Pfeiff & Hajak (2005), “disturbed motor performance is consistently associated with schizophrenia, and the degree of impairment correlates with the degree of psychosis and antipsychotic treatment” (p. 303). Schizophrenia effect on gait may interfere with a patient’s ability to complete ADLs or to integrate themselves seamlessly into the community. Fortunately, Putzhammer et al. (2005) stated that exercise (specifically on a treadmill) can reduce this effect (p. 309). Nurses may want to encourage treadmill walking with patients who have schizophrenia in order to reduce the impact of gait disturbance related to the pathophysiology of schizophrenia.

Nurses can also promoting a good baseline health by encouraging exercise. Soundy, Faulkner & Taylor (2007) found that “[a] low level of support [to engage in exercise] was a consistent and compelling theme throughout the interviews” (p. 496). Nurses need to be aware of these programs, their effectiveness, and current recommendations. Present recommendations from the National Guidelines Clearinghouse do not include exercise or physical activity; however, exercise or team sports may increase hope, which is top recommendation for providers working with patients who have schizophrenia (Jacobs, 2010, p. 42; National Collaborating Centre for Mental Health, 2009).

Conclusion

As an adjunct therapy, patients will find that exercise can decrease body fat, waist circumference, and body mass index, which all help to reduce co-morbidities associated with schizophrenia. Furthermore, exercise has had a significant effect on decreasing negative symptoms, which may lessen the need for additional pharmacological interventions and thereby reduce the incidence of adverse effects common to antipsychotic polypharmacy. Mental health providers, such as psychiatric nurses will also see the benefit, since exercise may allow providers help monitor relapses of schizophrenia and may decrease financial burden of patients or the system. By reducing co-morbidities and relieving anxiety, providers may also see a decreased use of hospitals and in-patient mental health services.

However, as Beebe (2005) mentions “[r]esponses to exercise and preferred modalities are highly individualized, making it difficult to design programs formulized for maximum appeal to the majority of persons” (p. 673). Providers also need to be aware that long-term studies have not been done about the sustainability of the weight loss. Further research must also be done to determine the re-hospitalization rates for patients with schizophrenia who engage in exercise on a regular basis. It appears that although exercise has definite benefits for this population, researchers need to investigate the long term implications of exercise to determine whether it should become part of mental health guidelines.

References

Beebe, L., Tian, L., Morris, N., Goodwin, A., Allen, S., & Kuldau, J. (2005). Effects of exercise on mental and physical health parameters of persons with schizophrenia. Issues in Mental Health Nursing, 26(6), 661-676. Retrieved from CINAHL Plus with Full Text database.

Callaghan, P. (2004). Exercise: a neglected intervention in mental health care?. Journal of Psychiatric & Mental Health Nursing, 11(4), 476-483. Retrieved from CINAHL Plus with Full Text database.

Duraiswamy, G., Thirthalli, J., Nagendra, H., & Gangadhar, B. (2007). Yoga therapy as an add-on treatment in the management of patients with schizophrenia – a randomized controlled trial. Acta Psychiatrica Scandinavica, 116(3), 226-232 Retrieved from Academic Search Premier database. doi:10.1111/j.1600-0447.2007.01032.x.

Fogarty, M., & Happell, B. (2005). Exploring the benefits of an exercise program for people with schizophrenia: a qualitative study. Issues in Mental Health Nursing, 26(3), 341-351. Retrieved from CINAHL Plus with Full Text database.

Gorczynski, P. & Faulkner, G. (2010). Exercise therapy for schizophrenia. Cochrane Database of Systematic Reviews, (6), Retrieved from Cochrane Database of Systematic Reviews database.

Jacobs, B. J. (2010). Game On!: Bringing the Locker Room into the Consulting Room. Psychotherapy Networker, 34(3), 39-44.

Lowe, T., & Lubos, E. (2008). Effectiveness of weight management interventions for people with serious mental illness who receive treatment with atypical antipsychotic medications. A literature review. Journal of Psychiatric & Mental Health Nursing, 15(10), 857-863. Retrieved from CINAHL Plus with Full Text database.

National Collaborating Centre for Mental Health (2009). Schizophrenia: core interventions in the treatment and management of schizophrenia in adults in primary and secondary care. London (UK): National Institute for Health and Clinical Excellence (NICE) clinical guideline; no. 82.

Noordsy, D.L., & Cote, R.O. (2010, June 17). The Risks and Benefits of Antipsychotic Polypharmacy: Potential for Neuroleptic Malignant Syndrome. Lecture presented for New Hampshire Hospital Professional Grand Rounds, New Hampshire Hospital, Concord, NH.

Poulin, M., Chaput, J., Simard, V., Vincent, P., Bernier, J., Gauthier, Y., et al. (2007). Management of antipsychotic-induced weight gain: prospective naturalistic study of the effectiveness of a supervised exercise programme. Australian & New Zealand Journal of Psychiatry, 41(12), 980-989. Retrieved from CINAHL Plus with Full Text database.

Putzhammer, A., Perfahl, M., Pfeiff, L., & Hajak, G. (2005). Gait disturbances in patients with schizophrenia and adaptation to treadmill walking. Psychiatry And Clinical Neurosciences, 59(3), 303-310. Retrieved from MEDLINE database.

Soundy, A., Faulkner, G., & Taylor, A. (2007). Exploring variability and perceptions of lifestyle physical activity among individuals with severe and enduring mental health problems: a qualitative study. Journal of Mental Health, 16(4), 493-503. Retrieved from CINAHL Plus with Full Text database.

Taylor, C., Lillis, C., LeMone, P. & Lynn, P. (2008). Fundamentals of Nursing: The Art and Science of Nursing Care, 6th Edition. Philadelphia, PA: Wolters Kluwer Health and Lippincott Williams & Wilkins.

Varcarolis, E. & Halter, M. (2010). Foundations of Psychiatric Mental Health Nursing: a Clinical Approach. St. Louis, Missouri: Saunders/Elsevier.

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