Download Effectiveness of Exercise as an Adjunct Therapy

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The Effectiveness of Exercise as an Adjunct Treatment for Schizophrenia
Jennifer Pawson
University of New Hampshire
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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
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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
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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
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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
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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
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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).
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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
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(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
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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.
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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
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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 addon treatment in the management of patients with schizophrenia – a randomized controlled
trial. Acta Psychiatrica Scandinavica, 116(3), 226-232 Retrieved from Academic Search
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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.
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Gorczynski, P. & Faulkner, G. (2010). Exercise therapy for schizophrenia. Cochrane Database
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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.
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A literature review. Journal of Psychiatric & Mental Health Nursing, 15(10), 857-863.
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Taylor, C., Lillis, C., LeMone, P. & Lynn, P. (2008). Fundamentals of Nursing: The Art and
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