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Early Intervention in Psychiatry 2015; ••: ••–••

doi:10.1111/eip.12238

Brief Report How can we increase physical activity and exercise among youth experiencing first-episode psychosis? A systematic review of intervention variables Simon Rosenbaum,1,2,3 Oscar Lederman,2 Brendon Stubbs,4 Davy Vancampfort,5,6 Robert Stanton7 and Philip B. Ward1 Abstract 1

School of Psychiatry, University of New South Wales, 2Early Psychosis Programme, The Bondi Centre, South Eastern Sydney Local Health, 3Musculoskeletal Division, The George Institute for Global Health and School of Public Health, The University of Sydney, Sydney, New South Wales, 7School of Medical and Applied Sciences, Central Queensland University, Rockhampton, Queensland, Australia; 4 Faculty of Education and Health, University of Greenwich, London, UK; 5 Department of Neurosciences, University Psychiatric Centre KU Leuven, Kortenberg and 6Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium Corresponding author: Dr Simon Rosenbaum, The Bondi Centre, 26 Llandaff Street, Bondi Junction, NSW 2022, Australia. Email: [email protected] Received 14 November 2014; accepted 16 February 2015

Aims: To review intervention variables and outcomes of studies designed to increase physical activity or exercise participation among people experiencing first-episode psychosis. Methods: A systematic review of electronic databases was conducted from inception to November 2014. Results: Eleven eligible studies describing 12 interventions were included (n = 351; 14–35 years) incorporating health coaching (n = 5), exercise prescriptions based on physiological parameters (e.g. heart rate) (n = 3), supervised, individually

Conclusions: Considerable heterogeneity in the design, implementation and assessment of interventions was found. There is an urgent need to better understand how physical activity can be increased in line with the internationally endorsed HeaL (Healthy Active Lives) Declaration 5-year physical activity target.

Key words: early psychosis, exercise, physical activity.

INTRODUCTION The 2013 Healthy Active Lives (HeAL) Declaration was developed by an international working group (iphYs) to reduce cardiovascular risk in young people experiencing first-episode psychosis (FEP) (www.iphys.org.au).1 The HeAL Declaration, endorsed by leading national and international bodies, provides ambitious 5-year targets regarding the physical health of young people experiencing FEP, including: • 75% of people gain no more than 7% of their preillness weight 2 years after initiating treatment. • 75% of people maintain blood glucose, lipid profile and blood pressure within the normal © 2015 Wiley Publishing Asia Pty Ltd

tailored programmes (n = 2), an Internet-delivered intervention and a yoga intervention. The majority of the interventions were delivered over 12 weeks (n = 6) and in community settings (n = 11). Five studies assessed aerobic capacity (VO2 max or VO2 peak) and three studies assessed selfreported physical activity levels.

range 2 years after initiating antipsychotic treatment. • Physical health inequalities diminish so that 2 years after the onset of psychosis more than 50% engage in age-appropriate physical activity, for example, at least 150 min of moderate-intensity activity per week (HeAL). The importance of physical activity and hence the final HeAL target is increasingly gaining attention given the increased cardiometabolic risk among youth with FEP2,3 and the established impact of physical activity on both physical and mental health outcomes.4,5 Increased physical activity is also related to increased functional aerobic capacity, a known correlate of psychosocial functioning in both 1

Physical activity and FEP FEP and established schizophrenia.6–8 Despite the call for physical activity programmes to be central in the multidisciplinary management of young people with FEP (HeAL), evidence regarding the optimal delivery (e.g. frequency, intensity, time/ duration and type/modality of exercise) of such interventions is unclear. Given the importance of this, the current review aimed to summarize the existing literature regarding interventions designed to increase physical activity or exercise participation among people with FEP, with the goal of helping clinicians and services to meet the HeAL physical activity target.9

RESULTS A total of 1190 articles (excluding duplicates) were identified. After screening, 11 eligible studies were included (n = 351; 14–35 years) (see Fig. 1). Trials were primarily excluded if they were not specifically targeting FEP, rather schizophrenia spectrum disorders or psychotic disorders more broadly. Of the 11 identified studies, 4 were study protocols,12–15 2 were pilot studies,16,17 3 were randomized controlled trials18–20 and 2 were prospective interventional studies.21,22 Physical activity interventions and outcomes

METHODS The current systematic review was conducted in line with the PRISMA statement10 and was prospectively registered on the PROSPERO database (#CRD42014014630). Two independent reviewers (S.R. and O.L.) conducted an electronic database search from inception to November 2014 using MEDLINE, Embase, Cochrane Central Register of Clinical Trials, PsycINFO, SPORTDiscus, CINAHL, Psychbite, PsychARTICLES, Google Scholar and PEDro using key words for ‘physical activity’, ‘exercise’, ‘psychosis’, ‘early psychosis’ and ‘first episode psychosis’. The reference lists of relevant systematic reviews were also manual-searched.4,5,11 In the case of study protocols or published conference abstracts, authors were contacted to provide additional and updated information where necessary regarding the details of the interventions employed. Studies were included if they described an intervention aiming to increase overall physical activity or structured exercise among people experiencing a Diagnostic and Statistical Manual Mental Disorders (DSM), International Classification of Disease (ICD) or clinician-confirmed diagnosis of FEP who were aged less than 35 years. Lifestyle interventions that identified increasing physical activity as a focus were also included. Given that the aim of this review is to summarize the intervention variables and outcome measures of existing studies, no restriction was placed on study design, reported outcomes or language. Two independent reviewers (S.R. and O.L.) assessed study eligibility and disagreements were resolved by a third reviewer (P.W.). The same reviewers extracted the data and trial information. The intervention variables were assessed against the ‘FITT’ criteria (frequency, intensity, time/duration and type/modality of the intervention). Data on intervention supervision were also extracted. 2

Table 1 summarizes the included trials. A range of physical activity and exercise modalities were utilized in the identified studies. Five studies used a health coaching and behavioural intervention approach,12,13,17,18,20 three studies utilized specific exercise prescriptions (based on physiological parameters, e.g. maximum heart rate, peak volume of oxygen consumption (VO2)),4,16,19 two studies used supervised, individually tailored programmes,14,22 one study used an Internet-delivered intervention15 and one used a yoga intervention.19 In total, 12 interventions were included as one study utilized two separate intervention groups.19 The majority of the interventions were delivered over 12 weeks,14,17–19,21,22 with the longest intervention spanning 18 months.13 The range of weekly sessions was 0–3.19 Four of the identified studies stated that university-trained kinesiologists or exercise physiologists supervised the interventions.14,16,21,22 Five studies (45%) assessed aerobic capacity (VO2 max or VO2 peak)16,17,19,21,22 as an outcome measure whereas four studies assessed self-reported physical activity, predominantly using the International Physical Activity Questionnaire-Short Form.14,20–22

DISCUSSION To our knowledge, this systematic review is the first to investigate the exercise programme parameters and characteristics of physical activity and exercise interventions for young people with FEP. We identified 11 studies aimed at increasing physical activity or exercise participation among young people experiencing FEP. There was considerable heterogeneity in the interventions and program variables utilized, implying the absence of a ‘gold-standard’ approach to increasing physical activity for this vulnerable population. The lack of standardized outcome measures relating to the physical activity © 2015 Wiley Publishing Asia Pty Ltd

S. Rosenbaum et al.

Idenficaon

FIGURE 1. PRISMA flow diagram (Reproduced from Moher et al.,10 with permission).

Records idenfied through database searching (n = 1,333)

Addional records idenfied through other sources (n = 7)

Included

Eligibility

Screening

Records aer duplicates removed (n = 1,190)

Records screened (n = 1,190)

Full-text arcles assessed for eligibility (n = 105)

Full-text arcles excluded, with reasons (n = 94) Not first episode n = 66 No intervenon n = 18 Not physical acvity n = 5 Overlap of data n = 5

Studies included in qualitave synthesis (n = 11)

interventions is a key finding of this review. Comprehensive evaluation of intervention outcomes should include measures of aerobic capacity (e.g. Astrand cycle ergometer test23) and measures of physical activity participation using accelerometry or via self-report. Although not without limitation, these measures should be encouraged until the development of more targeted, population-specific tools.24 In this manner, mental health services and clinicians may evaluate intervention outcomes against HeAL targets, ensuring optimal treatment for youth with FEP. In this review, only 4 of the 12 interventions were supervised by exercise professionals such as physiotherapists, exercise physiologists or kinesiologists. This is despite clear evidence from trials in other clinical populations such as type 2 diabetes,25 and reviews in populations with mental illness4 demonstrating superior outcomes from structured, supervised and progressive exercise compared with nonstructured, unsupervised interventions. Although likely a product of limited funding for dedicated exercise clinicians (and corresponding evaluation) within mental health services, the growing evidence base and expertise of allied health clinicians in this © 2015 Wiley Publishing Asia Pty Ltd

Records excluded (n = 1,085)

area26–29 can have a considerable impact on the effectiveness of such interventions. A recent international study of 151 physical therapists from the International Organization of Physical Therapists in Mental Health (IOPTMH) found that a lack of motivation among patients and the low priority of physical activity among the multidisciplinary team were the most frequently cited barriers, while maximizing esteem support was the most cited facilitator to increasing physical activity levels.30 Building on this rapidly growing body of research and incorporating allied health clinicians as part of the multidisciplinary treatment team is consistent with the recent call to ‘activate and integrate’ physical and mental health care31 while representing best practice, evidence-based care.32,33 The relatively small number of studies identified was another important finding given the overwhelming evidence regarding the metabolic changes that occur in young people with FEP following initial exposure to antipsychotic medications.2,3,9,34 Further studies are needed to establish optimal program variables incorporating principles of theoretical behaviour change, to increase physical activity participation among young people 3

4 Pilot

16 29.8 (8.6) Canada



14–35

15–25

34



5

Healthy living intervention

Stationary cycling

Protocol Lifestyle prospective intervention Protocol Lifestyle intervention

Australia Prospective

England

Canada

RCT

105 25.6 (5.5) England

Yoga or aerobic exercise

Integrative health coaching Running

Lifestyle programme

Behavioural intervention Lifestyle programme

Interval training

PA modality

12

12

78

52

12

9

26

12

12

12

14

Duration (weeks)

Components of PA intervention and supervision (where specified)

Community Couch to 5 km mobile application FEP service Community Yoga: 3× 60 min group (Hatha) sessions FEP service per week supervised by a Yoga instructor Aerobic exercise: 3× 40–50 min sessions per week at 45–49% VO2 max on a treadmill and stationary bike Community Motivational and behavioural; seven FEP service face-to-face sessions over 6 months delivered by support time and recovery workers following 3-day training. Optional group activities also provided. – Solution-focused psychotherapy, walking groups Community 45-min group cardiovascular exercise or FEP service individual programme at university gym supervised by an exercise physiologist Community 2× 45 min sessions/week stationary cycling FEP service at 65% VO2 peak

Community 1 h twice monthly integrative health FEP service coaching including goal setting

Community 2× 30 min/week on a treadmill (10–30 s FEP service intervals at 80–95% MHR) supervised by kinesiologist Community One to four sessions, collaboratively FEP service developed individual programme Outpatient Patients asked to exercise twice per week; psychiatric parameters not specified clinic Community Individualized, supervised programme FEP service developed by exercise physiologists in an in-service gym as part of routine care

Setting

FEP, first-episode psychosis; MHR, maximal heart rate; PA, physical activity; RCT, randomized controlled trial.

Rosenbaum et al. (under review)21

Robertson et al. (2010)13 Smith et al. (2014)14

Lovell et al. (2014)20

Australia Protocol

Protocol RCT

RCT

15–24



Killackey et al. (2011)15 Lin et al. (2011)19

Canada

120 25.2 (7.6) China

How can we increase physical activity and exercise among youth experiencing first-episode psychosis? A systematic review of intervention variables.

To review intervention variables and outcomes of studies designed to increase physical activity or exercise participation among people experiencing fi...
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