Benefits, Assessment, and Preferences of Physical Activity in Psychosis

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Benefits, Assessment, and Preferences of Physical Activity in Psychosis 273

Shuichi Suetani*,†,‡, Joseph Firth§,¶,k *Metro South Mental Health and Addiction Services, Brisbane, QLD, Australia, † Queensland Centre for Mental Health Research, The Park Centre for Mental Health, Wacol, QLD, Australia, ‡Queensland Brain Institute, The University of Queensland, St Lucia, QLD, Australia, §NICM Health Research Institute, University of Western Sydney, Sydney, NSW, Australia, ¶Division of Psychology and Mental Health, University of Manchester, Manchester, United Kingdom, k Centre for Youth Mental Health, University of Melbourne, Melbourne, VIC, Australia

Key Learning Objectives n n n

To understand how physical inactivity may contribute towards the physical health inequalities in people with psychosis To appreciate both the benefits and barriers towards increasing physical activity in people with psychosis To gain insight into the development and evaluation of physical activity interventions for people with psychosis

INTRODUCTION It has been estimated that people with psychosis lose approximately 15 years of potential life to the illness (Hjorthoj, Sturup, McGrath, & Nordentoft, 2017). The majority of this reduced life expectancy is due to preventable cardio-metabolic diseases such as ischaemic heart disease and diabetes mellitus (Olfson, Gerhard, Huang, Crystal, & Stroup, 2015). Cardio-metabolic risk status for people with psychosis has been well described in the Survey of High Impact Psychosis, or the SHIP, study from Australia. With data from over 1800 people living with psychosis, the Survey of High Impact Psychosis study found that: (i) three-quarters of participants were either overweight or obese with more than 80% having central abdominal obesity, (ii) two-thirds of participants were A Clinical Introduction to Psychosis. https://doi.org/10.1016/B978-0-12-815012-2.00012-2 © 2020 Elsevier Inc. All rights reserved.

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Box 12.1 Metabolic Syndrome The metabolic syndrome is a cluster of risk factors comprising: n n n

n n

Elevated waist circumference: Cut-offs vary by gender and ethnicity Elevated triglyceride concentration (or drug treatment for elevated triglycerides): 1.7 mmol/L Reduced high-density lipid concentration (or drug treatment for reduced HDL-C): <1.0 mmol/L in men, <1.3 mmol/L in women Elevated blood pressure (or drug treatment for hypertension): 130 systolic or 85 diastolic Elevated fasting glucose concentration (or drug treatment for elevated glucose): >5.5 mmol/L

Prior to 2009, there was considerable controversy about the many definitions of metabolic syndrome. Following a meeting of several major national and international organisations, a joint statement was released in an attempt to provide unifying criteria. Based on this attempt to harmonise existing definitions, the presence of three or more of the risk factors is now considered diagnostic of the metabolic syndrome (Alberti et al., 2009). The metabolic syndrome is considered indicative of increased risk of cardiovascular diseases, and associated elevation in mortality rate, but remains an active area of debate.

current cigarette smokers, and (iii) more than half the people in the study met the criteria for metabolic syndrome (see Box 12.1; Galletly et al., 2012). There is now a general acknowledgment among professionals involved in the care of people with psychosis regarding the importance of physical health and associated lifestyle modifications (Suetani, Scott, & McGrath, 2017). In particular, physical activity is increasingly recognised as a safe, cost-effective, and efficacious intervention to reduce cardio-metabolic risk factors in this vulnerable patient cohort (Suetani, Rosenbaum, Scott, Curtis, & Ward, 2016; Vancampfort et al., 2010). The main challenge we now face in the field is translating the efficacy of physical activity interventions seen in research into effectiveness among our patients in everyday clinical practice (Bartels, 2015; Lederman et al., 2017). To understand physical activity better, we need to know how good it is, how we can measure it, and how we can implement it among our patients. Accordingly, we have divided this chapter into three main sections. In the first section, we briefly describe the magnitude of the benefit of physical activity in people living with psychosis. In the second section, we outline what we know about motivation factors and preferences for physical activity in people with psychosis. Finally, in the third section, we describe physical activity can be measured and assessed, and strengths and limitations of various physical activity measurement tools.

BENEFITS OF PHYSICAL ACTIVITY FOR PEOPLE LIVING WITH PSYCHOSIS Physical activity is most commonly defined as ‘any bodily movement produced by skeletal muscles that results in energy expenditure’. (Caspersen, Powell, &

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Christenson, 1985). Physical activity can be either structured (e.g. exercise) or Exercise is a subtype of physical activity that is incidental (e.g. occupational and transport related). In the general population, there is a large body of evidence to indicate beneficial effects of physical activity in reducing mortality (Leitzmann et al., 2007), particularly by its effect on reducing the magnitude of cardio-metabolic morbidities (Lee et al., 2012). Even though the World Health Organisation recommends at least 150 min of moderate-intensity aerobic physical activity per week for adults aged 18–64 to improve cardiorespiratory fitness and reduce risks of chronic physical conditions and depression, the evidence is accumulating that any physical activity is better than no physical activity (see Box 12.2). For example, a very large study (n ¼ 661,137) that examined combined data from six population-based cohorts from the United States and Europe demonstrated a comparable benefit of physical activity in those who met, or exceeded the recommended physical activity level. Of note, even those who did not meet the recommended physical activity level showed a lesser yet statistically significant reduction in mortality with a hazard ratio of 0.80 with 95% confidence interval of 0.78 and 0.82 compared to those who engaged in no physical activity at all (Arem et al., 2015) (see Box 12.3, for a reminder on how hazard ratios are calculated). In addition, a large (n ¼ 204,542) Australian prospective study (Gebel et al., 2015) with a mean follow up of 6.5 years also showed the beneficial effect of physical activity, even at the level below the recommended amount (hazard ratio ¼ 0.66: 95% confidence interval: 0.61–0.71) compared to those who engaged in no physical activity at all. The magnitudes of benefits were, however, larger for those who met or exceeded the recommendation, especially those who engaged in vigorous physical activity.

planned, repetitive, and structured, and has a specific intention of improving or maintaining fitness.

Box 12.2 Intensity of Physical Activity The intensity of physical activity can be expressed in terms of Metabolic Equivalent of Task, or, MET. One MET is defined as the energy cost of sitting at rest, and equivalent to a caloric consumption of 1 kcal/kg/h. It is

estimated that compared with sitting quietly, a person’s caloric consumption is three to six times higher when engaged in moderate physical activity (3–5.9 METs) and six times or higher when engaged in vigorous physical activity (>6 METs) (WHO, 2010).

Box 12.3 Hazard Ratios A hazard ratio is an estimate of the ratio of the hazard rates (e.g. mortality rates) between one group (e.g. those who met the physical activity recommendation) and comparison group/s (e.g. those who did not) over the entire study duration.

The hazard rate is the rate of participants experiencing the event of interest (e.g. death) over a shorter time interval within each of the groups examined in the study.

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SECTION 2 Assessment Furthermore, a recent study consisting of 63,591 older adults (mean age of 58.6) demonstrated that compared with the inactive participants, the hazard ratio for all-cause mortality was 0.70 (95% confidence interval, 0.60–0.82) in what they called the ‘weekend warrior’ participants—that is, those reporting more than 150 min in moderate-intensity or 75 min in vigorous-intensity activities from one or two sessions per week. This benefit was comparable to those who were engaged in regular physical activity over the week (hazard ratio ¼ 0.65: 95% confidence interval, 0.58–0.73). Once again, even those who did not meet the recommended amount demonstrated comparable benefit (hazard ratio ¼ 0.66: 95% confidence interval, 0.62–0.72) from physical activity (O’Donovan, Lee, Hamer, & Stamatakis, 2017). Even though these studies were limited by the use of subjective measures (i.e. self-report questionnaires) to assess physical activity levels, the consistency of the findings indicates the robustness of the evidence.

Many people with psychotic disorders are missing out on the wellknown benefits gained from physical activity.

Among people living with psychosis, the Survey of High Impact Psychosis study in Australia estimated that nearly 50% of people with psychosis were engaged in insufficient level of physical activity (Suetani, Waterreus, et al., 2016). Likewise, in a cohort of 450 community patients with psychosis in the United Kingdom, 44% were engaged in insufficient levels of physical activity (Gardner-Sood et al., 2015). Further, a meta-analysis consisting of 35 studies with 3453 people estimated that people with psychosis engaged in 80.4 min of light-intensity physical activity, 16.2 min of moderate-intensity physical activity, and only 1.1 min of vigorous-intensity physical activity per day, with over 40% of them not meeting the recommended 150 min of moderate physical activity per week (Stubbs et al., 2016). The same review found that in comparison to the general population, people with psychosis engaged in significantly less moderate-intensity physical activity (14.2 min less per day) and vigorous-intensity physical activity (3.4 min less per day). It is important to note, however, these studies were limited by relying on selfreported physical activity engagement using different questionnaires. As discussed later in the chapter, the way physical activity engagements are measured in population studies remains a major weakness of the current evidence base in this field. There is a growing research evidence base for the benefits of physical activity for cardiovascular functioning in people with schizophrenia. Using data from 20 studies with 695 participants, a systematic review by Firth, Cotter, Elliott, French, and Yung (2015) found that even though physical activity interventions had no significant effect on body mass index, or, BMI (see Box 12.4), they led to improvement in measures of physical fitness, as well as reducing both positive and negative symptoms of schizophrenia. The study also found that the benefits of physical activity were prominent in those who were engaged in around 90 min or more per week of moderate/vigorous physical activity. Furthermore, several systematic reviews have demonstrated a wide range of benefits of physical activity interventions for people with psychosis beyond cardiovascular functioning. Dauwan, Begemann, Heringa, and Sommer (2016) examined 29 studies consisting of 1109 individuals to find that physical activity interventions can improve quality of life in addition to clinical symptoms of

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Box 12.4 Body Mass Index Body mass index (BMI) is a commonly used indicator of anthropometric height to weight characteristics in adults. It allows individuals to be categorised into different groups according to their nutritional status. The body mass index is calculated as an individual’s weight in kilograms divided by the square of the individual’s height in metres (kg/m2). The body mass index is categorised as follows:

n n n n

Less than 18.5 kg/m2: underweight Between 18.5 and 24.9 kg/m2: normal weight Between 25.0 and 29.9 kg/m2: overweight More than 30.0 kg/m2: obese

schizophrenia. This review utilised Hedges’ g to estimate effect sizes of included studies. Physical activity interventions had significant benefit on quality of life (Hedges’ g ¼ 0.55: 95% confidence interval, 0.35–0.76), the effect size comparable to the benefits seen in clinical symptoms total psychiatric symptoms (Hedges’ g ¼ 0.39: 95% confidence interval, 0.19–0.58), positive symptoms (Hedges’ g ¼ 0.49: 95% confidence interval, 0.14–0.50), negative symptoms (Hedges’ g ¼ 0.49: 95% confidence interval, 0.31–0.67), and depression (Hedges’ g ¼ 0.71: 95% confidence interval, 0.33–1.09). This review also examined cognition in four subdomains (working memory, long-term memory, processing speed, and attention and executive functioning) to find no significant benefit of physical activity interventions on cognitive function. In contrast, another systematic review by Firth, Stubbs, Rosenbaum, et al. (2017) specifically examined effects of physical activity interventions on cognitive functioning. Using ten studies consisting of 385 participants with schizophrenia, the review found that physical activity interventions significantly improved global cognition (Hedges’ g ¼ 0.33: 95% confidence interval, 0.13–0.53), as well the subdomains of working memory, social cognition, and attention/vigilance but no benefit was found in processing speed, verbal memory, visual memory, and reasoning and problem solving. Another systematic review explored the impact of physical activity on brain volume (Firth, Cotter, Carney, & Yung, 2017). The authors identified five studies that examined the relationship between physical activity engagement and brain volume in people with schizophrenia. All five studies examined hippocampus volume; two studies reporting increase in hippocampus volume while three found no change. Two of the three studies that found no change in hippocampus volume demonstrated increases in volumes of other regions of the brain (left anterior lobe in one and total cerebral volume in another). In addition, the only one study that found no association between physical activity and brain volumes was limited by its very small sample number (only five participants in the study). Combined with the existing evidence indicating positive association between physical activity and increased brain volumes in other populations, the review proposed that simulation of neurogenesis may be one of the pro-cognitive mechanisms of physical activity in people with schizophrenia (Firth, Cotter, et al., 2017).

Hedges’ g estimates the effect size for the difference between means of two distinct samples. As a rough rule, Hedges’ g of 0.2, 0.5, and 0.8 represent small, medium, and large effect, respectively.

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Cardiorespiratory fitness is the ability of the circulatory, respiratory, and muscular systems to supply oxygen during sustained physical activity.

Related to physical activity, a similar yet distinct concept of cardiorespiratory fitness is gaining much interest currently. Cardiorespiratory function is defined as the ability of the circulatory, respiratory, and muscular systems to supply oxygen during sustained physical activity (Caspersen et al., 1985). People with psychosis have significantly reduced cardiorespiratory function compared to the general population, and physical activity interventions with higher intensity or frequency are associated with greater improvement in cardiorespiratory function (Vancampfort, Rosenbaum, et al., 2017). These findings suggest that cardiorespiratory function in people with psychosis may be independently associated with the increased cardiovascular mortality rate, thus making it another potential treatment target. Another important measure of fitness that is related to cardiorespiratory fitness is muscular strength. Reduced muscular strength is associated with increased mortality rate in the general population (Leong et al., 2015; Ortega, Silventoinen, Tynelius, & Rasmussen, 2012). Maximal isometric handgrip is an easy-to-measure proxy assessment of muscular strength in clinical settings (Firth et al., 2018). While there have been few studies that explored the clinical implication of handgrip strength in people with psychosis, a recent large cross-sectional study found that maximal isometric handgrip strength was associated with visual memory and reaction time, but not prospective memory, number memory, or reasoning, in people with schizophrenia (Firth et al., 2018). Thus, there is a growing interest in how this brief assessment can be incorporated into future research and clinical practice for people with psychosis. However, the research to date has only established these relationships in older adults, and the generalisability to other populations is unknown. In particular, there is an absence of research examining the relationships between muscular strength and health outcomes in psychiatric populations. Over the last several years, a few notable intervention studies have explored the efficacy of physical activity treatment in people with severe mental disorders. The Achieving Healthy Lifestyles in Psychiatric Rehabilitation (ACHIEVE) trial was a randomised control study of 18 months’ duration. The study consisted of 291 overweight/obese participants with severe mental disorders with more than half (58%) of participants having a diagnosis of schizophrenia (Daumit et al., 2013). The intervention group received both individual and group physical activity and nutritional counselling, as well as on-site physical activity sessions. The control group received standard nutrition and physical activity information at baseline with general health classes offered quarterly. At the completion of the study, the mean weight loss for the intervention group was 3.4 kg compared to 0.3 kg in the control group. Similarly, 37.8% of people in the intervention group lost 5% or more of their initial weight, compared to 22.7% in the control group (P ¼ 0.009). Another randomised controlled trial from the United States, the STRIDE trial, included 200 participants with severe mental disorders with an initial body mass index of over 27 (i.e. in the overweight range) (Green et al., 2015). Almost all, 98%, of the participants had a diagnosis of either schizophrenia or affective

Benefits, Assessment, and Preferences CHAPTER 12 psychosis/bipolar disorder. The intervention in the STRIDE trial consisted of two 6-month phases. The first 6 months—or the active phase—consisted of two 1-h group meetings covering topics, including nutrition, physical activity, and lifestyle changes as well as a 20-min physical activity session. The participants then moved on to the maintenance phase for another 6 months. During this second phase, or the maintenance phase, participants engaged in monthly group meetings and individual monthly contacts from intervention group facilitators. At the completion of the active phase, participants in the intervention group lost an average of 4.4 kg more than those in the control group. At the completion of the maintenance phase, those in the intervention group lost an average of 2.6 kg more than those in the control group. Additionally, the intervention group also had a significant decline in their fasting glucose level, while those in the control group did not. It is important to acknowledge, however, that most of the weight loss in the intervention group occurred in the first six months. There was no statistically significant difference in the weight loss between the groups in the maintenance phase. Finally, the In SHAPE study compared the In SHAPE fitness program with a free fitness club membership and education (which acted as control) (Bartels et al., 2013). The study included 133 participants with severe mental disorders with a body mass index greater than 25, with just over 40% of the participants having a diagnosis of schizophrenia. People in the intervention group received weekly supervised training session at a gym with a qualified fitness trainer. After 12 months, 40% of the participants in the intervention group achieved a clinically meaningful improvement in fitness as defined by an improvement of more than 50 m in the 6-min walk test—twice that of the control group (20%). There was, however, no significant difference between the groups in terms of clinically meaningful weight loss (weight loss of more than 5% of the initial weight). When the study was replicated at a larger scale (n ¼ 200) a couple of years later, 51% of the participants in the intervention group achieved clinically meaningful improvement in either fitness or weight loss, compared to only 38% in the control group (Bartels et al., 2015). Furthermore, the benefit appeared to be sustained 6 months after the completion of the study, with 48% of people in intervention group still maintaining the improvement. More recently, the same group was able to further implement the In SHAPE intervention in multiple community mental health centres within a naturalistic setting (Bartels et al., 2018). Outside of the United States, the Keeping the Body in Mind (KBIM) Program in Sydney, Australia, provides a pragmatic example of how lifestyle interventions with an emphasis on physical activity can be integrated within a public mental health service setting. KBIM began with the implementation of routine metabolic screening in a first-episode psychosis service, gradually evolving over a number of years to incorporate a range of interventions to reduce the cardio-metabolic risk profile of people with psychosis. Located within a public community mental health centre, an in-house gym was built with an exercise physiologist working one-on-one with patients to prescribe and supervise individualised exercise

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SECTION 2 Assessment programs. This led to a multidisciplinary KBIM mental health team consisting of a senior nurse, a dietician, an exercise physiologist, and a peer-support worker, with medical input from both psychiatrists and an endocrinologist. An evaluation of the KBIM program showed that those who engaged in the KBIM intervention (a 12-week program of individual sessions with members of the KBIM team and the opportunity to participate in weekly sports groups) experienced significantly less weight gain (1.8 kg) compared to those in the standard care group (who gained an average of 7.8 kg) (Curtis et al., 2016). In sum, the current body of research evidence indicates that physical activity interventions are feasible in clinical practice, and can greatly improve both psychiatric symptoms and physical parameters in people living with psychosis.

INFLUENCING FACTORS AND PREFERENCES OF PHYSICAL ACTIVITY IN PEOPLE LIVING WITH PSYCHOSIS To enable translation of the efficacy demonstrated in experimental studies into effectiveness in clinical practice, recognising and addressing factors influencing physical activity, and patient preferences of physical activity engagement, are critical (see Box 12.5, for a lived experience perspective). A comprehensive systematic review (Vancampfort et al., 2012) found factors such as the presence of negative symptoms, and cardio-metabolic comorbidities such as metabolic syndrome and obesity to be strongly associated with low physical activity status in people with psychosis. To a lesser degree, factors such as medication side effects, lack of knowledge regarding cardio-metabolic risk profile, low self-efficacy and physical self-perception, unhealthy eating habits, and social isolation were also found to be associated with low physical activity status. Further, using the data from the Survey of High Impact Psychosis study, Suetani, Waterreus, et al. (2016) found that factors such as older age, employment/

Box 12.5 A Lived Experience Perspective ‘Miguel’s’ experience (described in Noordsy, Burgess, Hardy, Yudofsky, & Ballon, 2018) Miguel had been actively involved in team sports whilst at school. He experienced signs of early psychosis, at age 16, and initial treatment led to weight gain and lethargy. Following further evaluation at an early psychosis program, Miguel was given a diagnosis of schizophreniform disorder.

Miguel’s initial treatment plan included regular physical exercise (alongside cognitive-behavioural therapy for psychosis and medication) which he enjoyed, and led to improvements in mood, relaxation, and symptoms. Importantly, Noordsy and colleagues note that ‘Both the patient and his family agreed that he felt his best during exercise, and his family committed to support him in regular participation’ (Noordsy et al., 2018, p. 209).

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educational nonparticipation, and loneliness were associated with low physical activity status in people with psychosis. Having a better understanding of these correlates will assist us in understanding the underlying mechanisms behind physical activity as a behaviour and help us optimise the physical activity treatment implementation. For example, the findings from these studies suggest that people with psychosis who are older, heavier, and have less social support may be particularly vulnerable to having lower physical activity status, and thus need to be specifically targeted for physical activity interventions. Another systematic review demonstrated that, much like the general population, many people with psychosis considered things like weight loss, improved mood, and reduced stress as major motivating factors to engage in physical activity (Firth et al., 2016). At the same time, related factors such as low mood and high level of stress, as well as lack of social support, were seen as major barriers to physical activity engagement by people with psychosis. Further, a systematic review and meta-analysis that included data from 19 randomised controlled trials consisting of 594 individuals with psychosis found that those that were supervised by qualified physical activity professionals had statistically significantly reduced dropout rates from the studies (Vancampfort et al., 2016). In an Australian study examining physical activity preferences among 142 community dwelling participants with mental illness (with 45% reporting psychotic disorders), Chapman et al. found that walking was the most preferred type of physical activity (83%). Most participants reported that they preferred activities that are done close to home (84%) and are part of a healthy lifestyle program (76%), with the most preferred source of support being exercise instructor guiding them through each exercise session (71%) (Chapman, Fraser, Brown, & Burton, 2016). Likewise, another cross-sectional study from England examined 120 participants with mental illness (43.3% diagnosed with psychotic disorders) to find that the majority of participants (90%) preferred exercising at home, with walking being the most preferred type of exercise (70%). Despite their preference for exercising at home, less than half (48%) of participants reported that they would exercise more at home compared to at the gym, and more than half (58%) reported that having an instructor would help increase their exercise level (Ussher, Stanbury, Cheeseman, & Faulkner, 2007). More recently, a study conducted in Canada (Subramaniapillai et al., 2016) explored physical activity preference of 173 people with diagnoses of schizophrenia (65.3%) or bipolar disorder (34.7%). They found that participants preferred outdoors (52.0%) or gym (48.6%) over home (37.0%), and moderate intensity physical activity (61.3%) over high (27.7%) or low (22.5%) intensity. The most preferred type of activity was walking (59.5%). Of note, a majority (67.6%) wanted to incorporate strength or resistance training to their physical activity routines. Combined together, the current limited evidence suggest that walking is the most preferred type of physical activity among people with mental illness, and having an exercise instructor was also commonly considered to be beneficial. This is, however, an area that needs further exploration, particularly among those with psychotic disorders specifically.

Factors motivating engagement in physical activity vary between individuals, and may include stress reduction, mood regulation, and weight loss.

Considering motivations and preferences for physical activity will assist when developing a case formulation with your clients.

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SECTION 2 Assessment In their overview, Lederman et al. (2017) examined potentially useful strategies in achieving sustainable physical activity intervention implementation based on some successful examples in Australia. They identified that most successful physical activity interventions for people with psychosis included components such as an early intervention approach, including prevention when possible, routine metabolic monitoring, multidisciplinary team approach including patient and carer involvement, the use of behavioural change strategies, as well as programs being both individualised and supervised. They also argued that for sustainable implementation of physical activity interventions to occur within mental health services, factors such as creating cultural changes within the mental health services (i.e. acknowledgement that physical wellbeing of our patients is as important as their mental health), building capacity among staff members to allow for facilitation of physical activity interventions, and developing formalised collaboration with community organisations, are essential. Combined together, current research evidence suggest that future physical activity interventions for people with psychosis should address weight loss/attenuation, or prevention of weight gain when possible, in a socially supportive manner, with consideration given for individual patient preferences for types and settings of exercise, and should be supervised by physical activity professionals to maximise engagement and minimise dropouts. Moreover, existing studies have also identified particular vulnerable subpopulation within people with psychosis—those who are obese, with prominent negative symptoms, and little social support—the same cohort of people who are traditionally difficult to recruit into physical activity intervention studies. Thus, there remains an urgent need to design and conduct pragmatic studies that can help us understand how to understand those who are hardest to engage with, yet likely to benefit most from, physical activity interventions.

ASSESSMENT OF PHYSICAL ACTIVITY IN PEOPLE LIVING WITH PSYCHOSIS How best to measure physical activity in people with psychotic disorders is still being actively investigated, with new tools currently in development.

Despite the established benefit of physical activity in people with psychosis, how best to measure physical activity status remains unestablished, both in research and clinical settings. Physical activity is defined as ‘any bodily movement produced by skeletal muscles that requires energy expenditure’ (Caspersen et al., 1985). As such bodily movement is embedded in everyday life, often unstructured, and varies from minute to minute in both intensity and duration, measuring and assessing physical activity is inherently complex and difficult (Knowles, 2017). This is an important consideration especially in research, as imprecise measurements may lead to misleading conclusions. Currently, the measurement tools for physical activity can essentially be divided into two broad types: either objective or subjective measures. Objective physical activity measurement tools include doubly labelled water, accelerometers, and pedometers.

Benefits, Assessment, and Preferences CHAPTER 12 Subjective physical activity measurement tools include log books, structured interviews, and self-report questionnaires. In determining usefulness of each measurement tool, there are many factors that need to be considered (Dowd et al., 2018). One needs to be certain of the accuracy of the measurement tools—this may include methodological concepts such as validity (are we measuring what we are intending to measure?), reliability (does the measurement tool produce consistent results regardless of who is administering it or when it is being administered?), and sensitivity (does the measurement tool capture changes over time adequately?). Further, the practicality of measurement tools is also important. The measurement tool needs to be feasible in implementation, acceptable to the participants, and tolerated in terms of discomfort and potential side effects. Thus, most appropriate physical activity measurement tool is likely to be different depending on the setting and participants, as well as the intention behind measurement. The gold standard measurement tools for physical activity energy expenditure during free-living conditions remains doubly labelled water assessment (Klein et al., 1984). Briefly, in this assessment, participants have to consume a dose of doubly labelled water containing H18 2 O and H2O isotopes on day one. Subsequently, daily urine samples are collected for 10–14 days. The difference in the elimination rates of the two isotopes from the body is equivalent to the rate of carbon dioxide production, which can be converted to the average daily energy expenditure. One study from Brisbane, Queensland in Australia (Sharpe, Stedman, Byrne, Wishart, & Hills, 2006), examined the physical activity level of eight men with schizophrenia who were on long-term clozapine treatment in a residential mental health facility using the doubly labelled water assessment. While their findings confirmed that the participants were much less physically active compared to the population average, the study also highlighted practical difficulties of using this method widely in clinical research. For example, only eight out of 43 people approached for the study agreed to participate, and the cost and availability of doubly labelled water also limited the recruitment. Other objective measurement tools have been used more widely in people with psychotic disorders. Pedometers are much more cost effective and seem more feasible compared to doubly labelled water, but there may be difficulties associated with recording of daily step logs (Kane, Lee, Sereika, & Brar, 2012). Further, compared to other objective measures, the range of information that pedometers gather is limited (i.e. step counts) and they do not allow for exploration of other aspects of physical activity such as domain, intensity, and diurnal variation. With the rapid advancement in technology, decreasing costs and increasing availability, accelerometers and similar devices are being used more commonly in research studies both in the general population (Dohrn, Sjostrom, Kwak, Oja, & Hagstromer, 2017; Huberty, Ehlers, Kurka, Ainsworth, & Buman, 2015) and in people with psychosis (Bueno-Antequera, Oviedo-Caro, & Munguia-Izquierdo, 2017; Petzold et al., 2017). For example, Bueno-Antequera and colleagues examined physical activity using a SenseWear Pro3 Armband (BodyMedia Inc., Pittsburgh, PA, United States). In this study, participants were

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Measurement of physical activity must be practical: tools need to be feasible, acceptable, well tolerated by patients, and appropriate to the clinical setting.

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SECTION 2 Assessment required to wear the SenseWear on their left arm triceps muscle for 9 consecutive days, 24 h per day, except when showering or swimming. Forty-three participants with psychosis from outpatient settings in Spain were able to complete the 9 days monitoring to be included in the study (Bueno-Antequera et al., 2017). Likewise, 84 participants were recruited from outpatient settings in Germany to measure physical activity using ActiGraph GT1M accelerometers (ActiGraph, Pensacola, FL, United States). The participants in this study wore the accelerometers on average for around 13 h per day, with the average number of valid days (defined as meeting the minimal wear requirement of 10 h per day) of 5.9 out of seven requested (Petzold et al., 2017). Murakami et al. (2016) recently compared estimation of energy expenditure between a wide range of wearable objective devices and doubly labelled water. While the study consisted of only 19 healthy adults, it found that all wearable devices examined (including those used in research like Garmin Vivofit and ActiGraph GT3X) underestimated the daily total energy expenditure by 69–590 kcal per day compared to doubly labelled water. The authors postulated that the underestimation may be due to periods of not wearing the devices during the measurement period. Future studies examining the relationship with a larger number of participants, and those with psychosis, would be useful in further determining the validity of wearable objective physical activity measurement devices. Even though objective measurements may have more favourable features in terms of validity, reliability, and sensitivity compared to subjective measurements, this needs to be weighed against practical issues such as feasibility, acceptability, and tolerability, especially if the study requires the participants to wear these devices for a considerable amount of time. People with psychosis may also have additional challenges such as positive symptoms of the illness influencing the adherence with wearing the watches, especially in acute psychotic phases as many persecutory delusions consist of fear of being monitored. Negative and cognitive symptoms of the illness may also lead to lower motivation or forgetting to put the devices back on. Self-report questionnaires, on the other hand, are much less resource intensive both from the participants’ and researchers’ points of view. While there are many self-report questionnaires designed to assess physical activity status, the International Physical Activity Questionnaire or, IPAQ, remains one of the most widely validated and used research tools in population studies (Craig et al., 2003; Lee, Macfarlane, Lam, & Stewart, 2011). The International Physical Activity Questionnaire asks for self-report on the frequency, intensity (sitting, walking, moderate, vigorous) and duration of activity over the past seven days in four different domains (job-related physical activity, transport-related physical activity, domestic and gardening activities, and leisure-time physical activity). The International Physical Activity Questionnaire short form consists of seven items covering all domains of physical activity within generic intensity-specific items (e.g. vigorous activities are defined as any activity that ‘take hard physical effort and make you breathe much harder than normal’, moderate physical activity is any activity that make you breathe

Benefits, Assessment, and Preferences CHAPTER 12 ‘somewhat harder than normal’). The International Physical Activity Questionnaire long form, on the other hand, consists of 27 items that examines domainspecific activity for each intensity-specific category (Bauman et al., 2009). Faulkner, Cohn, and Remington (2006) assessed the test-retest reliability and validity compared to accelerometer of the International Physical Activity Questionnaire short-form among 35 patients with psychosis. The study reported reliability of ρ ¼ 0.68 based on Spearman’s correlation, and validity of ρ ¼ 0.37, suggesting that the International Physical Activity Questionnaire has acceptable reliability but limited validity. These findings were comparable to the reliability and validity found in the general population (ρ ¼ 0.76 and ρ ¼ 0.30 respectively (Craig et al., 2003)). A more recent study (Duncan, Arbour-Nicitopoulos, Subramanieapillai, Remington, & Faulkner, 2017) expanded on this by examining the reliability of the International Physical Activity Questionnaire over a longer time period, and assessing validity with a larger sample number. Among 130 people with psychosis enrolled, 113 participants completed the study. The testretest reliability in this study was found to be ρ ¼ 0.47, suggesting that the International Physical Activity Questionnaire may not be as reliable in this particular cohort. The validity, however, was once again found to be comparable at ρ ¼ 0.30. These studies illustrate the limitations of psychometric properties of self-report physical activity measurement tools, but these limitations appear largely comparable to those seen in the general population. A recent study (Vancampfort, De Hert, et al., 2017) consisting of only 19 patients with first-episode psychosis examined the validity of International Physical Activity Questionnaire with the Sensewear Armband. The study found that there was no significant correlation between the self-reported mean time (minutes per day) spent in activity based on the International Physical Activity Questionnaire and that recorded with the Sensewear Armband, for either moderate physical activity (correlation: 0.29, P ¼ 0.23) or vigorous physical activity (correlation: 0.11, P ¼ 0.66). They also found that the International Physical Activity Questionnaire overestimated moderate physical activity by 35% and vigorous physical activity by 54%. Based on their findings, the authors recommended using the International Physical Activity Questionnaire with caution in this population. Given the small number of participants, however, the study may have been underpowered, thus contributing to the null results. At a much larger scale, Firth, Stubbs, Vancampfort, et al. (2017) utilised the dataset from the United Kingdom Biobank to compare physical activity status as measured by the International Physical Activity Questionnaire with that measured by accelerometer (Axivity AX3 wrist-worn triaxial accelerator) among people with psychosis (n ¼ 1078) and those without (n ¼ 450,549). Of note, the study demonstrated that even though there was no difference in physical activity status reported by the International Physical Activity Questionnaire in people with psychosis and the general population, accelerometer data showed that people with psychosis engaged in significantly less physical activity. These recent findings demonstrating the impreciseness of self-report measures compared to objective measures have some important implications in

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Spearman’s correlation coefficient, rho (ρ) measures strength of association between the rankings of two variables. Spearman’s ρ of 1 and 1 indicate a perfect positive and a perfect negative correlation respectively.

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SECTION 2 Assessment interpreting results from research studies. For instance, in a study that examined the effects of different physical activity measurement tools on the relationship between physical activity status and cardio-metabolic factors in the general population (Celis-Morales et al., 2012), the authors found that the International Physical Activity Questionnaire underestimated the strength of many risk factors examined, suggesting that the International Physical Activity Questionnaire was not accurate enough to find significant associations between physical activity and cardio-metabolic risk factors that accelerometers were able to identify. Similarly, even though Suetani, Saha, et al. (2017) found no significant crosssectional association between physical activity and depression among 8841 people using a self-report physical activity questionnaire in Australia, a smaller (n ¼ 2862) cohort study from the Netherlands observed strong cross-sectional association between higher levels of physical activity and reduced odds of depression (Vallance et al., 2011). These conflicting findings raise the possibility that self-reported physical activity may not be precise enough to find potentially significant associations between physical activity and mental disorders. There remains an urgent need for researchers in this field to explore an appropriate and consistent tool to measure physical activity status in both research and clinical settings. Further, given how quickly the technology is advancing, it is likely that most measurement devices that are used at the baseline data collection today will be out of date by the follow-up point in longitudinal studies with long durations. Thus, subjective physical activity measurement tools will be likely to retain an important role in the future. Currently, Rosenbaum, Ward, and International Working Group (2016) and an international working group are in the process of validating the Simple Physical Activity Questionnaire, or SIMPAQ. The Simple Physical Activity Questionnaire is a five-item self-report questionnaire specifically designed to capture physical activity status in people with mental disorders in clinical settings. The questionnaire is available in many different languages (see www.simpaq.org). Such questionnaires may be able to better strike the balance between the methodological robustness and practicality needed for people with mental disorders, and improve the preciseness of selfreported physical activity status. Another variable that is being increasingly used in people with psychosis in combination with physical activity status measurements is measurement of cardiorespiratory fitness. There have been a few studies to suggest that people with psychosis have significantly reduced cardiorespiratory fitness compared to the general population, which may be independently associated with the increased cardiovascular mortality rate (Vancampfort, Rosenbaum, et al., 2017). In terms of symptoms, lower cardiorespiratory fitness has been associated with a higher level of negative symptoms in some cross-sectional studies (Vancampfort, Rosenbaum, Probst, et al., 2015). The ‘gold standard’ measure for cardiorespiratory fitness is VO2 max (Ross et al., 2016). Testing VO2 max, however, requires the participant to undergo a graded exercise test using either a treadmill or a cycle ergometer while wearing a VO2 mask to measure ventilation as well as oxygen and carbon dioxide concentration of the inhaled and exhaled air. VO2 max is

Benefits, Assessment, and Preferences CHAPTER 12 defined as the point where oxygen consumption plateaus in spite of an increase in workload. The utility of the VO2 max testing is somewhat limited in clinical settings due to the availability of, and the discomfort associated with, the equipment required. On the other hand, proxy measures of cardiorespiratory fitness such as the 6-min walk test can be conducted among people with psychosis without much difficulty. In essence, the test measures the distance covered over a time of 6 min to estimate the submaximal level of functional exercise capacity. Participants are asked to walk as far as possible, at a self-determined pace, within the 6-min period. The test only requires a long flat, straight, hard surfaced, enclosed corridor of at least 30 m, a pulse oximeter, and a stop watch (Laboratories, 2002). Using such proxy measures of cardiorespiratory fitness, the understanding of the importance of cardiorespiratory fitness in people with mental disorders is growing (Vancampfort, Rosenbaum, Probst, et al., 2015; Vancampfort, Rosenbaum, Ward, & Stubbs, 2015). Therefore, measures of cardiorespiratory fitness may represent a suitable modifiable risk factor worth monitoring in both research and clinical practice in the near future.

CONCLUSION People living with psychosis suffer from disproportionally higher rates of mortality and morbidity compared to those without. Current research evidence indicates short-term benefits of physical activity interventions for both physical and psychological well-being of people with psychosis. The next critical step in this field is to translate the existing research evidence into sustainable implementation in our day-to-day practice to improve physical activity status for people with psychosis. To achieve this, we need to continue asking difficult research and clinical questions, like how do we engage people who are hardest to engage and how do we accurately assess, monitor and evaluate physical activity status in different settings?

QUIZ QUESTIONS 1. Which of the following is a subjective method of measuring physical activity? (a) Double-labelled water method (b) Accelerometry (c) The SIMPAQ (d) Pedometers 2. Self-reported physical activity measures in people with psychosis generally seem to: (a) Overestimate actual physical activity (b) Underestimate actual physical activity (c) Accurately measure actual physical activity (d) Have no relationship with actual physical activity 3. Which of the following factors in people with psychosis reduces their likelihood of engaging in PA? (a) Obesity

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SECTION 2 Assessment (b) Young age (c) Social support (d) All of the above 4. Along with the benefits for physical health, top-tier evidence from metaanalyses of randomised controlled trials have demonstrated that exercise interventions for schizophrenia also improve: (a) Quality of life (b) Psychiatric symptoms (c) Cognitive functioning (d) All of the above

ANSWERS TO QUIZ QUESTIONS: 1. 2. 3. 4.

(c) (a) (a) (d)

SELF-DIRECTED LEARNING Firth, J., Carney, R., Elliott, R., French, P., McPhee, J. S., McIntyre, R., & Yung, A. R. (2016). Exercise as an intervention for first-episode psychosis: A feasibility study. Early Intervention in Psychiatry, 12 (3), 307–315. Firth, J., Stubbs, B., Vancampfort, D., Ward, P. B., Schuch, F. B., Rosenbaum, S., Sarris, J., & Yung, A. R. (2017). The validity and value of self-reported physical activity and accelerometry in people with schizophrenia: A population-scale study of the UK Biobank. Schizophrenia Bulletin. doi: https:// doi.org/10.1093/schbul/sbx149. Korman, N. H., Shah, S. H., Suetani, S. U., et al. Evaluating the feasibility of a pilot exercise intervention implemented within a residential rehabilitation unit for people with severe mental illness: GO HEART. Frontiers in Psychiatry, 9, 343. Yung, A. R., & Firth, J. (2016). How should physical exercise be used in schizophrenia treatment? Expert Review of Neurotherapeutics, 17 (3), 213–214.

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SECTION 2 Assessment Rosenbaum, S., Ward, P. B., & International Working Group. (2016). The simple physical activity questionnaire. Lancet Psychiatry, 3(1), e1. https://doi.org/10.1016/S2215-0366(15)00496-4. Ross, R., Blair, S. N., Arena, R., Church, T. S., Despres, J. P., Franklin, B. A., et al. (2016). Importance of assessing cardiorespiratory fitness in clinical practice: A case for fitness as a clinical vital sign: A scientific statement from the American Heart Association. Circulation, 134(24), e653–e699. https://doi.org/10.1161/CIR.0000000000000461. Sharpe, J. K., Stedman, T. J., Byrne, N. M., Wishart, C., & Hills, A. P. (2006). Energy expenditure and physical activity in clozapine use: Implications for weight management. Australian and New Zealand Journal of Psychiatry, 40(9), 810–814. https://doi.org/10.1080/j.1440-1614.2006.01888.x. Stubbs, B., Firth, J., Berry, A., Schuch, F. B., Rosenbaum, S., Gaughran, F., et al. (2016). How much physical activity do people with schizophrenia engage in? A systematic review, comparative metaanalysis and meta-regression. Schizophrenia Research, 176(2), 431–440. Subramaniapillai, M., Arbour-Nicitopoulos, K., Duncan, M., McIntyre, R. S., Mansur, R. B., Remington, G., et al. (2016). Physical activity preferences of individuals diagnosed with schizophrenia or bipolar disorder. BMC Research Notes, 9, 340. https://doi.org/10.1186/s13104-0162151-y. Suetani, S., Rosenbaum, S., Scott, J. G., Curtis, J., & Ward, P. B. (2016). Bridging the gap: What have we done and what more can we do to reduce the burden of avoidable death in people with psychotic illness? Epidemiology and Psychiatric Sciences, 25(3), 205–210. https://doi.org/10.1017/ S2045796015001043. Suetani, S., Saha, S., Milad, A., Eakin, E., Scott, J. G., & McGrath, J. J. (2017). Common mental disorders and recent physical activity status: Findings from a National Community Survey. Social Psychiatry and Psychiatric Epidemiology, 52(7), 795–802. https://doi.org/10.1007/s00127-0161307-3. Suetani, S., Scott, J. G., & McGrath, J. J. (2017). The importance of the physical health needs of people with psychotic disorders. Australian and New Zealand Journal of Psychiatry, 51(1), 94–95. https:// doi.org/10.1177/0004867416662151. Suetani, S., Waterreus, A., Morgan, V., Foley, D. L., Galletly, C., Badcock, J. C., et al. (2016). Correlates of physical activity in people living with psychotic illness. Acta Psychiatrica Scandinavica, 134(2), 129–137. https://doi.org/10.1111/acps.12594. Ussher, M., Stanbury, L., Cheeseman, V., & Faulkner, G. (2007). Physical activity preferences and perceived barriers to activity among persons with severe mental illness in the United Kingdom. Psychiatric Services, 58(3), 405–408. https://doi.org/10.1176/ps.2007.58.3.405. Vallance, J. K., Winkler, E. A., Gardiner, P. A., Healy, G. N., Lynch, B. M., & Owen, N. (2011). Associations of objectively-assessed physical activity and sedentary time with depression: NHANES (2005–2006). Preventive Medicine, 53(4–5), 284–288. https://doi.org/10.1016/j. ypmed.2011.07.013. Vancampfort, D., De Hert, M., Myin-Germeys, I., Rosenbaum, S., Stubbs, B., Van Damme, T., et al. (2017). Validity and correlates of the International Physical Activity Questionnaire in first-episode psychosis. Early Intervention in Psychiatry. https://doi.org/10.1111/eip.12521. Vancampfort, D., Knapen, J., Probst, M., Scheewe, T., Remans, S., & De Hert, M. (2012). A systematic review of correlates of physical activity in patients with schizophrenia. Acta Psychiatrica Scandinavica, 125(5), 352–362. https://doi.org/10.1111/j.1600-0447.2011.01814.x. Vancampfort, D., Knapen, J., Probst, M., van Winkel, R., Deckx, S., Maurissen, K., et al. (2010). Considering a frame of reference for physical activity research related to the cardiometabolic risk profile in schizophrenia. Psychiatry Research, 177(3), 271–279. https://doi.org/10.1016/j. psychres.2010.03.011. Vancampfort, D., Rosenbaum, S., Probst, M., Soundy, A., Mitchell, A. J., De Hert, M., et al. (2015). Promotion of cardiorespiratory fitness in schizophrenia: A clinical overview and meta-analysis. Acta Psychiatrica Scandinavica, 132(2), 131–143. https://doi.org/10.1111/acps.12407.

Benefits, Assessment, and Preferences CHAPTER 12 Vancampfort, D., Rosenbaum, S., Schuch, F. B., Ward, P. B., Probst, M., & Stubbs, B. (2016). Prevalence and predictors of treatment dropout from physical activity interventions in schizophrenia: A meta-analysis. General Hospital Psychiatry, 39, 15–23. https://doi.org/10.1016/j. genhosppsych.2015.11.008. Vancampfort, D., Rosenbaum, S., Schuch, F., Ward, P. B., Richards, J., Mugisha, J., et al. (2017). Cardiorespiratory fitness in severe mental illness: A systematic review and meta-analysis. Sports Medicine, 47(2), 343–352. https://doi.org/10.1007/s40279-016-0574-1. Vancampfort, D., Rosenbaum, S., Ward, P. B., & Stubbs, B. (2015). Exercise improves cardiorespiratory fitness in people with schizophrenia: A systematic review and meta-analysis. Schizophrenia Research, 169(1–3), 453–457. https://doi.org/10.1016/j.schres.2015.09.029. WHO. (2010). Global recommendations on physical activity for health. Geneva, Switzerland: WHO.

Definition of Key Terms Body mass index A commonly used indicator of anthropometric height to weight characteristics in adults. The body mass index is calculated as an individual’s weight in kilograms divided by the square of the individual’s height in metres (kg/m2). Cardiorespiratory fitness The ability of the circulatory, respiratory, and muscular systems to supply oxygen during sustained physical activity. Exercise A subtype of physical activity that is planned, repetitive, and structured, and it has a specific intention of improving or maintaining fitness. Metabolic syndrome A cluster of risk factors comprising of elevated waist circumference, elevated triglyceride concentration, reduced high-density lipid concentration, elevated blood pressure, and elevated fasting glucose concentration. The presence of three or more of the risk factors is diagnostic of the metabolic syndrome. Physical activity Any bodily movement produced by skeletal muscles that results in energy expenditure.

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