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Schizophrenia, poor physical health and physical activity: evidence-based interventions are required to reduce major health inequalities

  • Lily McNamee (a1), Gillian Mead (a1), Steve MacGillivray (a1) and Stephen M. Lawrie (a1)
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Abstract

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Corresponding author

Stephen M. Lawrie, Division of Psychiatry, Royal Edinburgh Hospital, Morningside, Edinburgh EH10 5HF, UK. Email: s.lawrie@ed.ac.uk

References

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1 Saha, S., Chant, D., McGrath, J. A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? Arch Gen Psychiatry 2007; 64: 1123–31.
2 The Schizophrenia Commission. The Abandoned Illness: A Report from the Schizophrenia Commission. Rethink Mental Illness, 2012.
3 McCreadie, RG. Diet, smoking and cardiovascular risk in people with schizophrenia: Descriptive study. Br J Psychiatry 2003; 183: 534–9.
4 Gorczynski, P., Faulkner, G. Exercise therapy for schizophrenia. Cochrane Database Syst Rev 2010; 5: CD004412.
5 Vancampfort, D., Probst, M., Helvik Skjaerven, L., Catalán-Matamoros, D., Lundvik-Gyllensten, A., Gómez-Conesa, A., et al Systematic review of the benefits of physical therapy within a multidisciplinary care approach for people with schizophrenia. Phys Ther 2012; 92: 1123.
6 Álvarez-Jiménez, M., Hetrick, SE, González-Blanch, C., Gleeson, JF, McGorry, PD. Non-pharmacological management of antipsychotic-induced weight gain: systematic review and meta-analysis of randomised controlled trials. Br J Psychiatry 2008; 193: 101–7.
7 Vancampfort, D., Knapen, J., De Hert, M., van Winkel, R., Deckx, S., Maurissen, K., et al Cardiometabolic effects of physical activity interventions for people with schizophrenia. Phys Ther Rev 2009; 14: 388–98.
8 Department of Health. Start Active, Stay Active: A Report on Physical Activity for Health from the Four Home Countries' Chief Medical Officers. Department of Health, 2011.
9 Faulkner, G., Cohn, T., Remington, G. Validation of a physical activity assessment tool for individuals with schizophrenia. Schizophrenia Res 2006; 82: 225–31.
10 Townsend, N., Bhatnagar, P., Wickramasinghe, K., Scarborough, P., Foster, C., Rayner, M. Physical Activity Statistics 2012. British Heart Foundation, 2012.
11 Richardson, CR, Faulkner, G., McDevitt, J., Skrinar, GS, Hutchinson, DS, Piette, JD. Integrating physical activity into mental health services for persons with serious mental illness. Psychiatr Serv 2005; 56: 324–31.
12 Johnstone, R., Nicol, K., Donaghy, M., Lawrie, S. Barriers to uptake of physical activity in community-based patients with schizophrenia. J Ment Health 2009; 18: 523–32.
13 Campbell, M., Fitzpatrick, R., Haines, A., Kinmonth, AL, Sandercock, P., Spiegelhalter, D., et al Framework for design and evaluation of complex interventions to improve health. BMJ 2000; 321: 694–6.
14 Glasgow, RE, Klesges, LM, Dzewaltowski, DA, Estabrooks, PA, Vogt, TM. Evaluating the impact of health promotion programs: using the RE-AIM framework to form summary measures for decision making involving complex issues. Health Educ Res 2006; 21: 688–94.

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Schizophrenia, poor physical health and physical activity: evidence-based interventions are required to reduce major health inequalities

  • Lily McNamee (a1), Gillian Mead (a1), Steve MacGillivray (a1) and Stephen M. Lawrie (a1)
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eLetters

Impaired Reward Circuitry in Schizophrenia

Feargus F O'Croinin, Staff Psychiatrist
02 December 2013

The editorial by McNamee et al (1) emphasizing physical activity in schizophrenia is important and timely. What is health promoting for the general population is even more so for individuals with schizophrenia.

Why is physical activity not a regular occurrence given the obvious health benefits? Is it a consequence of the amotivation seen in schizophrenia, a medication related effect or a consequence of physical illness?

Together with obesity and the increased smoking found with schizophrenia, a case can be made for an impaired reward circuitry in schizophrenia. Smoking involves dopaminergic reward circuitry as does obesity (2,3). Does the medication related dopamine blockade blunt any perceived reward usually associated with exercise?

Of interest is a recent animal study (4) where restoration of a gut lipid messenger restored reward sensitivity related to dopamine deficiency.

Further research focusing on reward circuitry in schizophrenia may offer new treatment strategies that are health promoting for individuals with schizophrenia.

1.McNamee L, Mead G, MacGillivray S, Lawrie S. Schizophrenia, poor physical health and physical activity: evidence-based interventions are required to reduce major health inequalities. Br J Psychiatry 2013; 203, 239-241

2.Doyon W, Dong Y, Ostroumov A, Thomas A, Zhang T, Dani J. NicotineDecreases Ethanol-Induced Dopamine Signaling and Increases Self-Administration via Stress Hormones. Neuron 2013; 79, 530-540

3.DiLeone R, Taylor J, Picciotto M. The drive to eat: comparisons and distinctions between mechanisms of food reward and drug addiction. Nature Neuroscience 2012; 15, 1330-1335

4.Tellez L, Medina S, Han W, Ferreira J, Licona-Limon P, Ren X et al. A GUT Lipid Messenger Links Excess Dietary Fat to Dopamine Deficiency. Science 2013; 341: 800-802

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Conflict of interest: None declared

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Taking physical activity in schizophrenia seriously means re-appraising all aspects of care.

Emma K Davis, Research Worker
02 December 2013

We read with interest the Editorial by McNamee et al., who rightfullybring attention to an ignored intervention for people with schizophrenia: improving physical activity through targeted behavioural approaches. They point out a need for systematically building evidence on improving this. We fully agree, though would make the following points, with regard to current care:

1.The limits of current evidence should not preclude guideline groupsand policy-makers, and all aspects of care should take into account physical activity and CVD. For example, the authors mention "flexible tailored physical activity programmes aligned to psychiatric services": wewould suggest services go even further, and consider the use of psychotropic medication and effects on physical activity. Every practisingclinician is aware that some antipsychotics will undoubtedly have detrimental effects on physical activity, with no clinically significant differences in efficacy between some compounds (Leucht et al., 2013).We are unaware of whether this is borne in mind when offering antipsychotics to people with schizophrenia. If patient choice is to be implemented, there will be a need to integrate information on the effects of antipsychotic medication as a barrier to physical activity, as well as looking at other interventions to improve physical activity. How many prescribers bear these issues in mind when offering pharmacotherapy?

2.Furthermore, service re-design means significant numbers of people with schizophrenia will be discharged from secondary to primary care. The rationale for re-referral to secondary care has ordinarily been related torelapse, and if care of physical health is to be taken seriously, will there be a need for pharmacotherapy to be tailored to enable this, and will secondary services be happy to advise on this, and encourage re-referral, if necessary, for this purpose?

We would agree that research be undertaken promptly, though hope thatall aspects of patient care prioritise physical activity, and physical health, and that this be considered by policy-makers.

References Leucht, S., Cipriani, A., Spineli, L., Mavridis, D., Orey, D., Richter, F., ... & Davis, J. M. (2013). Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. The Lancet,382(9896), 951-962.

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Conflict of interest: None declared

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Physiotherapists can help implement physical activity programmes in clinical practice

Davy Vancampfort, Post doc researcher
05 November 2013

Dear Sir,

We read with great interest the editorial by McNamee et al1. The authors made an important call for evidence based physical activity research and interventions to reduce the physical health disparity seen in people with schizophrenia. Since this an area which is constantly evolving, we wanted to highlight some new evidence that is available that may assist clinicians and researchers to develop evidence based physical activity interventions.

McNamee et al1 report some important barriers to physical activity uptake and maintenance. However, our understanding of the barriers to physical activity participation go beyond negative symptoms, side effects of medication and social isolation1. Recent review evidence2 incorporating25,013 unique people with schizophrenia provides further indications of specific barriers which should be considered in this population. This comprehensive review2 suggests that cardio-metabolic co-morbidity, lack of knowledge on cardiovascular disease risk factors, lower self-efficacy, and other unhealthy lifestyle habits including smoking must be carefully considered as barriers when developing physical activity interventions for patients with schizophrenia.

We agree with McNamee et al 1 that there is a high need for theoretically based research on the motivational processes linked to the commencement and continuation with physical activity in patients with schizophrenia. Research has recently started to meet this call. New evidence relying on the self-determination theory3 suggests that people with schizophrenia's level of autonomous motivation towards an active lifestyle (which involves the experience of volition and choice), feelings of competence and social relatedness may play an important role in the adoption and maintenance of physical activity.

We also agree with McNamee et al1 that it is essential that all members of the mental health multidisciplinary team (MDT) should promote and empower people with schizophrenia to engage in physical activity. The International Organization of Physical Therapists in mental health(IOPTMH)4 recently emphasized that mental health MDT's approach to the care of patients with schizophrenia should take this into account, both at policy-making and clinical levels. Without this crucial step the physical health of patients with schizophrenia is unlikely to be improved. The IOPTMH therefore endorses the editorial of McNamee et al1 that active physical health promotion must be routinely included in the care plans of people with schizophrenia and accepted as the responsibility of all healthcare staff. The IOPTMH is committed to supporting future research in this field and believes that physiotherapists are well placed to lead the translation of physical activity in clinical practice5 which McNamee etal1 called for. Future research is required and this should for example define which strategies mental health physiotherapists should adopt in order to assist persons with schizophrenia in the transition from hospital to community care.4,5 Together with McNamee et al1 , we are convinced that this is essential in order to ensure physical activity is successfully used to significantly improve the physical health and health related quality of life of people with schizophrenia.

References

1.McNamee L, Mead G, Macgillivray S, Lawrie SM. Schizophrenia, poor physical health and physical activity: evidence-based interventions are required to reduce major health inequalities. Br J Psychiatry. 2013;203:239-241

2.Vancampfort D, Knapen J, Probst M, Scheewe T, Remans S, De Hert M.A systematic review of correlates of physical activity in patients with schizophrenia. Acta Psychiatr Scand. 2012;125(5):352-62

3. Vancampfort, D., De Hert, M., Vansteenkiste, M., De Herdt,A., Scheewe, T.W., Soundy, A., Stubbs, B., Probst, M. (2013). The importance of self-determined motivation towards physical activity in patients with schizophrenia. Psychiatr Res. Accepted for publication.

4.Vancampfort, D., De Hert, M., Skjaerven, L., Gyllensten, A., Parker, A., Mulders, N., Nyboe, L., Spenser, F., Probst, M. (2012). International Organization of Physical Therapy in Mental Health consensus on physical activity within multidisciplinary rehabilitation programmes for minimising cardio-metabolic risk in patients with schizophrenia. Disability and Rehabilitation, 34(1), 1-12.

5.Stubbs, B., Soundy, A., Probst, M., De Hert, M., De Herdt, A., Vancampfort, D. (2013). Understanding the role of physiotherapists inschizophrenia: An International perspective from members of the International Organisation of Physical Therapists in Mental Health (IOPTMH). In press in Journal of Mental Health.

Authors

Mr Brendon Stubbs, MSc, PhD student, School of Health and Social Care, University of Greenwich, Eltham, London, SE9 2UG, UK

Prof Michel Probst, PhD, KU Leuven Department of Rehabilitation Sciences, Tervuursevest 101, 3000 Leuven, Belgium; University Psychiatric Centre KU Leuven, Campus Kortenberg. Leuvensesteenweg 517, B-3070 Kortenberg, Belgium

Dr Andy Soundy, PhD, Department of Physiotherapy, School of Health and Population Science, University of Birmingham, Birmingham B15 2TT, UK

Ms Anne Parker, Royal Edinburgh Hospital, Morningside, Edinburgh EH10 5HF, UK

Miss Amber De Hert, KU Leuven Department of Rehabilitation Sciences, Tervuursevest 101, 3000 Leuven, Belgium

Prof Marc De Hert, PhD, MD, University Psychiatric Centre KU Leuven, Campus Kortenberg. Leuvensesteenweg 517, B-3070 Kortenberg, Belgium Dr Alex J. Mitchell, MD, Leicestershire Partnership Trust, Leicester, UK; 2Department of Cancer Studies and Molecular Medicine, University of Leicester, Leicester, UK

Dr Davy Vancampfort, PhD, KU Leuven Department of Rehabilitation Sciences, Tervuursevest 101, 3000 Leuven, Belgium; University Psychiatric Centre KU Leuven, Campus Kortenberg. Leuvensesteenweg 517, B-3070 Kortenberg, Belgium. Tel.: +32 2 758 05 11; Fax: +32 2 759 9879

On behalf of the International Organization of Physical Therapists in Mental Health
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Conflict of interest: None declared

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