Impacts of Physical Activity Interventions on Psychiatric Symptom Severity in Adults with Severe Mental illness: A Systematic Review

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Rhodes This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3411748/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background There is a well-established relationship between physical activity (PA) and improved mental and physical health. However, the focus has been on mild to moderate anxiety and depression, while there has been a paucity in the literature regarding the impacts of PA on psychiatric symptoms in individuals with severe mental illness (SMI), and the potential utility of PA as an adjunctive treatment for these conditions. The purpose of this narrative analysis was to examine the effects of PA interventions on psychiatric symptoms among individuals with SMI, which we defined as schizophrenia spectrum disorders, bipolar disorders, and major depressive disorders. Methods A search was conducted in MEDLINE PsycInfo, and SPORTDiscus databases concluding in January 2023 that included studies published in an English peer-reviewed journal, with a PA intervention, conducted with adults ( ≥ 18yrs) diagnosed with a schizophrenia spectrum disorder, bipolar disorder, or major depressive disorder. The search returned 119 articles, and 10 met eligibility criteria. Results Results clearly showed that PA caused no harm and that a small improvement in psychiatric symptom severity was achieved, with effect sizes ranging from 0.013 to 0.712. Conclusions Physical activity interventions can decrease psychiatric symptom severity in persons with severe mental illness and may be an efficacious adjuvant treatment to pharmacological management of schizophrenia, bipolar and major depressive disorders. Physical activity interventions did not have any adverse effects on individuals with severe mental illness. However, the current literature is heterogeneous in terms of PA types, frequency, duration, and intensity, and further research is needed before specific PA recommendations can be made as an adjunctive treatment for individuals with SMI. schizophrenia bipolar disorder major depressive disorder physical activity exercise Figures Figure 1 Background Regular physical activity (PA) has well known physical and mental health benefits for the general population ( 1 , 2 ). Achieving the recommended 150 min per week of moderate intensity physical activity has been linked to decreased obesity, decreased risk of cardiovascular disease, improved mood, and a plethora of other positive health outcomes. Despite the robust evidence showing the health benefits of regular PA, most people do not engage in PA to the extent that would be necessary to realize these benefits. Based on data from 1.9 million participants, it is estimated that more than a quarter of all adults globally are not engaging in PA at levels adequate to achieve the health benefits ( 3 ). While the physical health benefits of regular PA have been thoroughly researched, the additional benefits of regular PA for individuals with a severe mental illness (SMI) has only more recently become a focus of research. In 2008, the National Institute of Mental Health defined SMI as schizophrenia, severe bipolar disorder, and severe major depressive disorder, which affects approximately 4.4% of the population ( 4 ). The same definition of SMI was used in this review. Individuals with SMI may reap all the same physical health benefits as the general population. This is particularly relevant because individuals with SMI have a greater prevalence of physical ailments, such as cardiovascular disease and diabetes, resulting in lower quality of life and higher mortality compared to the general population ( 5 – 7 ). For example, a diagnosis of schizophrenia is associated with over 15 years of potential life lost ( 8 ). However, despite the overwhelming evidence in support of regular PA as an effective way to improve physical health, studies show that individuals with SMI are even less likely to engage in regular PA than the general population. One reason for this difference in PA levels may be the considerable barriers that individuals with SMI face to participating in regular PA. A recent systematic review compiled 16 qualitative studies examining the experiences of individuals with SMI in PA initiation and the unique barriers faced and supports needed, which offers some insight into the lower level of PA in this population. This study identified support from a trusted source as a key piece to helping this population overcome some of the unique challenges they face when attempting to engage in regular PA ( 9 ). Unfortunately, without support, individuals with SMI continue to be far less able to achieve healthy levels of PA as demonstrated in studies comparing PA data from the general population to individuals with SMI. One study using self-report on PA found only 30% of individuals diagnosed with schizophrenia engage in PA compared to 63% of the general population ( 10 ). Another study found that among individuals prescribed clozapine, a common antipsychotic medication, only 25% achieved the recommended weekly 150min of moderate to intense PA ( 11 ). Furthermore, we know that psychopharmacology, the current standard treatment, is only partially efficacious in managing symptoms of severe mental illness, and that these medications often have significant side effects that negatively impact individuals’ physical health ( 12 ). For example, antipsychotic medications can reduce positive symptoms but have minimal efficacy in treatment of negative symptoms or neurocognitive deficits ( 13 , 14 ). Additionally, antipsychotic medication is notorious for a plurality of side effects that significantly impact individuals’ overall health and quality of life ( 15 ). Pharmacological treatment limitations have fueled an interest in adjunctive and alternative interventions and PA interventions may show promise in reducing psychiatric symptoms while improving physical health outcomes. There continues to be a paucity in our understanding of the current literature. There has been many reviews of PA and mental health. There has also been work by Firth and colleagues focusing only on schizophrenia disorder ( 16 ). Even the barriers and challenges individuals with SMI face to engaging in PA has been compiled in a recent review ( 9 ). However, there have been no systematic reviews of the efficacy of PA in reducing symptom severity in the SMI population. Given the uniqueness of this population and the complex challenges these individuals face when engaging in PA, it is necessary to also review the efficacy of PA in this context. We did not seek to address the relationship between PA and mental illness prevention, issues of access and barriers, or impacts on physical health. This systematic review builds on a recent broader narrative reviews on the matter ( 17 ). The purpose of this review is therefore to examine the efficacy of regular PA as a potential adjunctive treatment for psychiatric symptoms specifically in individuals with SMI, defined as schizophrenia disorders, severe bipolar disorders, and severe major depressive disorder, who had access to a PA program. Sub-analyses of potential moderators included study design, intervention type, sample characteristics (age, gender, diagnosis), country of study and type of control. Additionally, we focused our review specifically on persons living with an established serious mental illness. Methods This systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines ( 18 ). Inclusion and Exclusion Criteria The following eligibility criteria were used to determine which studies would be included in the analysis: 1) primary study examining effects of intervention/program, 2) study participants aged 18+, 3) diagnosis of a severe mental illness, defined as a diagnosis of schizophrenia spectrum disorder, bipolar disorders and major depressive disorder, 4) physical activity was the independent variable, defined as any bodily movement produced by skeletal muscle that results in energy expenditure ( 19 ), 5) peer-reviewed journal articles published between June 2013 and present. June 2013 was chosen as the start date to coincide with the publication of the DSM-V. Unfortunately, most studies continued to use diagnoses based on the DSM-IV or other diagnostic manuals. We chose to keep this as the start date regardless to limit results to the past 10 years, which encompasses the 2016 opiate crisis, housing crisis, and COVID-19 pandemic. This was done to keep results relevant to the current context. Studies were excluded if 1) the participants did not have a primary diagnosis of a schizophrenia spectrum disorder, major depressive disorder, or bipolar disorder, 2) they included children or adolescents below 18 years, 3) measured physical health outcomes instead of psychiatric outcomes. Search Strategy A systematic search of EBSCO Medline, EBSCO PsycINFO and EBSCO SPORTDiscus electronic databases was completed by the first author in October 2019. Additional studies were collected through ancestry and supplementary search. An updated search using the same criteria and search phrase was completed by the first author in January 2023. The Boolean language search phrase “(exercise OR "physical activity") AND (program OR programme OR intervention) AND (“severe mental illness” OR schizophren* OR “bipolar disorder” OR “major depressive disorder”) AND adult” was used to search all databases. Results were limited to publications between 2013-present, peer-reviewed journal articles, English and age 18–64. Title and Abstract Screening The titles and abstracts of all initial search results remaining after relevant filters were applied were screened using key words and exclusion criteria. Articles were excluded if titles did not match inclusion criteria, or they met any exclusion criteria. If titles provided vague or insufficient information, the abstract was screened for same. Articles were excluded based on title alone, a further 14 articles were excluded after abstract review. The abstract review of the articles remaining after title review are summarized in Appendix 1. The searches were repeated in January 2023 and title and abstract screening was completed on the remaining 1, 445 records by two researchers, (CG, AT) and yielded 3 additional records for full review. Full Text Review The remaining articles were reviewed in full using the inclusion and exclusion criteria. Articles meeting all inclusion and exclusion criteria and were included in the final review. Data Collection Process and Data Items Data were extracted for intervention, psychiatric symptom measurements, participant characteristics, and effect size. Intervention characteristics included: type of intervention, duration, type of comparison group (waitlist control, active control, usual care), whether psychiatric symptom severity was the primary outcome measure, and country where study was conducted. Measurement characteristics included any recognized scale or test for psychiatric symptom severity. Participant characteristics included: sample size, age range of participants and diagnosis. This is summarized in Appendix 3. Risk of Bias Risk of bias assessment was done using the Public Health Research, Education and Development (PHRED) tool developed by McMaster University School of Nursing ( 20 ). This tool assesses 8 components of a study: selection bias, study design, confounders, blinding, data collection methods, withdrawals and drop-outs, intervention integrity and analyses. The component scores are combined into a global rating of weak, moderate, or strong of overall study quality. First and second authors assessed study quality, and any ambiguities were resolved via discussion between both authors. Following risk of bias assessment, studies were classified into weak, moderate, or strong quality using the scoring system outlined in the PHRED tool. A detailed quality assessment for each item by study is included in Appendix 2. Analysis Following initial read-throughs of the final, included studies, synthesis of results was narrative ( 21 , 22 ), with findings grouped by outcome. Due to the clinical and methodological heterogeneity of the studies, a meta-analysis was not performed. While there were similarities in sample population, there was no consistency in intervention type, intervention duration, control group, and there was only limited similarity in outcome measures. Additionally, there was great variance in the statistical analysis performed, making direct comparison or amalgamation by effect size unfeasible ( 23 ). Therefore, this review did not attempt to assimilate the studies, but rather compiled the evidence to date. The narrative analysis is summarized in Table 1 . Structured tabulation of sample size, participant diagnoses, intervention and conclusions across studies was also completed and is summarized in Table 2 . Table 1 Characteristics of the Studies in the Review Characteristics Sample: N = 10 independent data sets Percentages Gender Male Female Mixed - - 10 - - 100% PA Levels at Baseline Meeting guidelines Not meeting guidelines Mixed Not reported - 1 - 9 - 10% - 90% Population Inpatient Community 2 8 20% 80% Diagnosis Schizophrenia Schizophrenia spectrum Major Depressive Disorder Bipolar Disorder Mixed sample 2 3 3 - 2 20% 30% 30% - 20% Type of Intervention Aerobic activity Strength/Resistance Yoga Tai-Chi Mixed 5 1 1 1 2 50% 10% 10% 10% 20% Geographical Location USA Denmark China Germany Brazil Taiwan Canada 3 1 1 2 1 1 1 30% 10% 10% 20% 10% 10% 10% Type of Control Waitlist Control Active Control Treatment as usual Multiple No control group 2 3 1 3 1 20% 30% 10% 30% 10% Quality Rating Weak Moderate Strong 4 5 1 40% 50% 10% Table 2 Study results and direction of effects Authors Sample size Diagnosis Intervention Conclusion Strassnig et al. 24 n = 12 Schizophrenia, schizoaffective bipolar disorder 2/week high velocity resistance circuit training Significant improvement in BACS, PANSS total score Jakobsen et al. 25 n = 428 Schizophrenia Schizoaffective Psychotic disorder NOS CHANGE intervention = CHANGE coach to encourage daily PA, healthy dietary changes, and smoking cessation Care coordination = nurse to facilitate access to primary care for optimal treatment of physical ailments Treatment as usual = access to general practitioner and annual metabolic screening No statistically significant difference in psychotic symptom between groups Woodward et al. 26 n = 17 Schizophrenia Schizoaffective 3/week 30min individualized exercise session with trainer + standardized 10min warm up and cool down Aerobic: 40–59% max heart rate using different exercise modalities (cycle ergometer, treadmill, elliptical) Weight-bearing: weight training based on individual muscular capacity Participants enrolled in either exercise intervention had more rapid improvement in symptoms and social functioning scores Trend for reduced depression severity in exercise intervention (p = 0.06) Mean total PANSS score decreased from 95.3 to 79.7 Su et al. 27 n = 44 Schizophrenia, schizoaffective Aerobic exercise intervention: individual session with trainer 3–5 times/week; 5min warm up, 30min individualized aerobic exercise at 55–69% max heart rate, 5min cool down Stretching/toning control: 30min program of 14 flexibility, toning and balance exercises performed with trainer 3–5 times per week Significantly improved processing speed and attention scores in aerobic exercise group: Greer et al. 28 n = 126 MDD High dose (16kcal/kg body weight) vs low dose (4kcal/kg) aerobic exercise 60-70min/week moderate-intensity physical activity significantly reduces depressive symptomology; dose-dependent Malchow et al. 29 n = 66 Schizophrenia Endurance training 3 x30min sessions 3x/week Active control engaged in table soccer instead of endurance training All participants engaged in computer assisted cognitive remediation training using program called COGPACK starting at week 6; 30min sessions 2x/week from week 6–12 Time effects were found for PANSS total score and PANSS negative sub score PANSS positive sub score decreased in table soccer group and in PANSS total score Oertel-Knöchel et al. 30 n = 51 Schizophrenia MDD Cognitive training: group tasks followed by individual tasks to train multiple cognitive domains such as motor skills, executive function and attention. Combined training from 2 manuals established for cognitive training in psychiatry ('COG-PACK' and 'cognitive training after Stengel') Physical exercise: 10min warm-up, 25min exercise at 60–70% VO2max (boxing and circuit training − 60sec work, 20sec rest - in alternate order; circuit included trampoline, endurance exercise with and without weight, physiotherapy balls), 10min cool down/stretch Relaxation: 45min breathing exercises, 'imagery journey', 'enjoy exercises' for all sensory modalities, relaxation or acceptance and awareness training Physical exercise intervention improved clinical symptoms in schizophrenia and major depressive disorder inpatients Kang et al. 31 n = 244 Schizophrenia 45 min Social skills training - self-management of medication, self-monitoring of symptoms, community re-entry, recreation for leisure, other social independence living skills 45 min Thai-Chi intervention Significant overall improvements in intervention group from baseline to 12 months Siqueria et al. 32 n = 40 MDD Individualized and supervised sessions of continuous and intermittent aerobic activity for 20-60min Both groups treated with SSRI antidepressant sertraline either 0mg, 50mg or 100mg dose Aerobic exercise decreased the need for higher doses of antidepressant to achieve antidepressant efficacy but no significant differences between groups in symptom severity Decrease in HAM-D and BDI scores in both groups; significant main effect of time but not intervention Streeter et al. 33 n = 30 MDD Participants randomized to: 1) High dose group (3 x 90min yoga/week + 4x30min homework sessions/week) 2) Low dose group (2x90min yoga/week + 3x30min homework sessions/week) No significant difference in response or remission rates between the groups from screening to week 12. Results indicate that both groups completed sufficient intervention minutes to improve rates of remission and response significantly Results The original electronic database search returned a total of 263,061 articles. Results were limited to English language, peer-reviewed, and publication date reduced to June 2013-present. Three duplicate articles were removed and 116 articles (66 from EBSCO Medline, 50 from EBSCO PsycINFO and none from EBSCO SPORTDiscus) were screened for title and abstract eligibility. 98 articles were excluded based on eligibility criteria and 18 full articles were reviewed based on eligibility criteria. A further 8 were excluded. The final 10 articles were assessed and rated for quality using the PHRED tool, summarized in Appendix 2. All 10 articles were included in the narrative synthesis, and 6 of these articles were included in the tabulation of results. An updated search was conducted in January 2023 and yielded 38, 687 additional records that were screened using the same criteria. 37, 242 of the results were excluded with automated filters. 2 duplicate records were removed. Title and abstract screening were completed on the remaining 1, 445 records by two researchers, (CG, AT) and yielded 3 additional records for full review. 2 of these records were study protocols only and therefore did not meet the inclusion criteria for this review. The final record did report participants’ age or diagnosis and did not use a validated measure to psychiatric symptoms. The final record was therefore also excluded. The literature search is summarized in Fig. 1 . General Study and Participant Characteristics Table 1 provides a summary of characteristics of the 10 studies and 1, 058 participants included in the review. Sample sizes ranged from n = 12 (Strassnig et al., 2015) to n = 428 (Jakobsen et al., 2017). Samples also varied in age. Although studies with participants below age 18 were excluded, one study only included participants aged 19 and older (Woodward et al., 2018), and another only included participants aged 20 and older (Su et al., 2016). The upper age limit of participants also varied from 50 (Woodward et al., 2018) to 75 years old (Strassnig et al., 2015). All samples were mixed gender. One study reported PA at baseline (Greer et al., 2016), but this information was not reported in the other nine studies. Although participants in all studies had a diagnosis of a severe mental illness, defined in this review as a schizophrenia spectrum disorder, bipolar disorder or major depressive disorder, the studies were quite heterogeneous in diagnostic profile of participants. Only two studies focused on psychiatric inpatients (Malchow et al., 2015; Oertel-Knöchel et al., 2014), the remaining eight studies excluded inpatients and focused on individuals with severe mental illness living in the community. None of the included studies focused exclusively on bipolar disorder. Two studies only included individuals with a diagnosis of schizophrenia (Kang et al., 2016; Malchow et al., 2015), three studies included all schizophrenia spectrum disorders (Jakobsen et al., 2017; Su et al., 2016; Woodward et al., 2018), three studies included only participants with major depressive disorder (Greer et al., 2016; Siqueira et al., 2016; Streeter et al., 2017), and two studies had mixed samples (Oertel-Knöchel et al., 2014; Strassnig et al., 2015). Of interest, the studies were geographically diverse. The 10 studies were conducted in the United States (Greer et al., 2016; Strassnig et al., 2015; Streeter et al., 2017), Denmark (Jakobsen et al., 2017), China (Kang et al., 2016), Germany (Malchow et al., 2015; Oertel-Knöchel et al., 2014), Brazil (Siqueira et al., 2016), Taiwan (Su et al., 2016) and Canada (Woodward et al., 2018). The type of physical activity intervention was also diverse. Five studies focused on aerobic activity (Greer et al., 2016; Malchow et al., 2015; Oertel-Knöchel et al., 2014; Siqueira et al., 2016; Su et al., 2016), although the details of the exercise varied. The other five studies included strength training (Strassnig et al., 2015), yoga (Streeter et al., 2017), Tai-chi (Kang et al., 2016) and mixed interventions (Jakobsen et al., 2017; Woodward et al., 2018). All studies varied greatly in duration, intensity, and other intervention details. Risk of Bias assessments were completed on the final ten studies using the PHRED tool ( 24 ). 40% of studies were classified as weak (Malchow et al., 2015; Oertel-Knöchel et al., 2014; Strassnig et al., 2015; Woodward et al., 2018), 50% as moderate (Greer et al., 2016; Jakobsen et al., 2017; Siqueira et al., 2016; Streeter et al., 2017; Su et al., 2016), and only one study (10%) as strong (Kang et al., 2016). Experimental Effects on Psychiatric Symptom Severity The ten studies included in the tabulation of direction of effects are summarized in Table 2 ; effect sizes for the six studies included in the quantitative synthesis are summarized in Table 3 . Four studies (Malchow et al., 2015; Oertel-Knöchel et al., 2014; Strassnig et al., 2015; Woodward et al., 2018) were excluded from the synthesis because insufficient data was provided to calculate effect size on the measures of interest. Table 3 Means, standard deviations and Cohen’s d effect sizes for all studies included in quantitative synthesis. Study Timepoint Outcome measure Control Group Experimental Group Effect size (d) Jakobsen et al. 25 Baseline 2 years SAPS SANS BACS SAPS SANS BACS 2.12 (1.61) 2.50 (1.14) 228.31 (48.68) 1.4 (1.2) 1.5 (1.1) 251.6 (46.5) 2.12 (1.61) 2.50 (1.14) 228.31 (48.68) 1.6 (1.1) 1.7 (1.0) 254.3 (44.9) --- --- --- 0.124 0.175 0.055 Su et al. 27 Baseline 6 months PANSS positive PANSS negative Processing speed Working memory PANSS positive PANSS negative Processing speed Working memory 18.18 (7.11) 21.82 (8.72) 32.11 (6.74) 42.45 (6.21) 15.14 (7.01) 21.68 (10.45) 33.60 (6.96) 43.76 (6.73) 16.05 (6.48) 22.36 (9.65) 33.71 (5.96) 46.27 (5.62) 13.55 (3.71) 15.68 (6.43) 36.74 (4.92) 48.77 (6.70) --- --- --- --- 0.136 -0.712 0.243 0.201 Greer et al. 28 Baseline 12 weeks SF-36 Mental Health SF-36 Mental Health 49.1 (15.9) 62.4 (21.0) 50.7 (13.9) 67.2 (18.5) --- 0.215 Kang et al. 31 Baseline 12 months PANSS Positive symptoms Negative symptoms General Psychopathology PANSS Positive symptoms Negative symptoms General Psychopathology 45.2 (3.0) 10.2 (1.6) 13.6 (1.5) 21.7 (2.0) 44.7 (2.6) 10.0 (1.4) 13.4 (1.4) 21.5 (1.8) 44.5 (3.0) 10.1 (1.4) 13.4 (1.5) 22.0 (2.0) 43.3 (2.7) 10.0 (1.4) 12.6 (1.2) 21.7 (1.9) --- --- --- --- -0.233 -0.2 -0.4 -0.05 Siqueria et al. 32 Baseline 4 weeks HAM-D BDI-II HAM-D BDI-II 20.42 (2.99) 33.92 (9.64) 12.64 (5.74) 20.05 (10.21) 19.20 (3.14) 29.51 (9.46) 11.38 (3.94) 18.39 (9.00) --- --- -0.013 0.288 Streeter et al. 33 Baseline 12 weeks BDI-II total score BDI-II total score 27.7 (8.0) 10.1 (7.9) 24.6 (6.7) 6.0 (3.8) --- -0.136 It should be noted that with the BDI-II, HAM-D, PANSS, SAPS and SANS scales a higher score indicates more severe psychiatric symptoms so a decrease in score indicates improvement in psychiatric symptoms. A negative effect size would therefore indicate reduction in symptom severity. With the SF-36 and BACS scales, an increase in score and positive effect size indicates improvement in functioning and decrease in psychiatric symptom severity. Overall, none of the studies found a negative effect of PA on individuals with SMI. Nine of the studies found some benefit from PA on psychiatric symptom severity, even if effect sizes were small (effect size d ranged from 0.05 to 0.71). Only the Jakobsen et al. (2017) study found no significant difference on any experimental measure between the intervention group and two active control groups over two years. Among the six studies included in the synthesis, effect sizes ranged from 0.01 to 0.71 (Table 3 ). Two of the studies’ effect sizes were negligible ( 25 , 26 ). Streeter et al. (2017) found an effect size of d=-0.14 but reported significant improvement in depressive symptomology in both intervention and active control groups. They concluded that both groups had received sufficient exercise to improve psychiatric symptom severity. Two of the studies (Greer et al., 2016; Siqueira et al., 2016) reported only small effect sizes. Kang et al., (2016) found medium effect size d=-0.40 on negative symptoms. Su et al. (2016) found large effect size (d=-0.712) on PANSS negative symptom subscale. Greer et al. (2016) found a dose-dependent effect of moderate to intense aerobic exercise in weekly 60-70min sessions on depressive symptomology over 12 weeks. The study compared an active control group exercising at a lower intensity to an experimental group exercising at higher intensity. Both groups improved, but the experimental group had a greater reduction in symptom severity as measured using the SF-36 Mental Health. The effect size was small (d = 0.215). Similarly, Streeter et al. (2017) found a dose-dependent effect of yoga intervention on depressive symptomology comparing a high dose group (three 90min sessions per week) with a low dose group (two 90min sessions per week). Effect size was d = -0.14 using the BDI-II total score, where a lower score indicates a reduction in symptom severity. Woodward et al. (2018) compared an aerobic exercise with a weight-bearing exercise intervention and found improvements in depressive symptomology in both groups. It was not possible to calculate effect size on measures of interest from the data provided. Siqueria et al. (2016) compared anti-depressant dosage required to manage depressive symptomology in an aerobic exercise intervention group compared to a control group and found that individuals in the aerobic exercise group required lower doses of antidepressant medication to manage their symptoms. The effect sizes were small at d=-0.01 on the HAM-D and d = 0.29 on the BDI-II. Oertel-Knöchel et al. (2014) used a circuit training intervention and found improvements in PANSS negative symptom subscale and depressive symptoms (BDI-II score) in both the exercise intervention group and active control relaxation intervention group, but not the waitlist control group. Effect sizes could not be calculated from the data provided. Strassnig et al. (2015) study also used a circuit training intervention administered twice per week over eight weeks and reported significant improvements in PANSS total score, depressive symptomology (CDSS score), and cognition (BACS score). It should be noted that Strassnig et al. (2015) did not have a control group and that insufficient data was reported to allow for calculation of effect size. Su et al. (2016) also found improvements in PANSS negative symptom subscale (medium effect size of d= -0.71), and cognition, namely processing speed (small effect size of d = 0.24) and working memory (small effect size of d = 0.20), in an aerobic exercise intervention group compared to the active control stretching/toning group. Kang et al. (2016) and Malchow et al. (2015) found improvements in PANSS scores from a Tai-Chi and aerobic exercise interventions respectively. Both studies used active controls and both interventions incorporated additional non-PA interventions. The Kang et al. (2016) intervention included social skills and self-management training for all participants, the Malchow et al. (2015) intervention included cognitive remediation training. Kang et al. (2016) found a small effect size of d=-0.23 for PANSS total score, d=-0.20 for positive symptoms and d=-0.40 for negative symptoms. Discussion The purpose of the review was to examine the efficacy of regular PA as a potential adjunctive treatment to reduce psychiatric symptom severity in individuals with SMI, defined as schizophrenia spectrum disorders, bipolar disorders, and major depressive disorder diagnosed based on DSM or ICD criteria. While there is an abundance of evidence on the benefits of PA on mood and wellness in the general population, and the physical health benefits of all people, there is a paucity of research on the efficacy of PA in reducing psychiatric symptom severity in individuals with severe mental illness. This is unique population that faces significant barriers to participation in regular PA yet could benefit immensely ( 9 , 27 ). The physical health benefits of regular PA among this population are well established and were therefore not a focus of this review. The sample included in the review was quite heterogenous, differing in gender, diagnosis, geographical location, psychiatric symptom measures, PA intervention, and including both inpatient and community-based populations. Direct comparison of groups and any sub-groups conclusions could not be made, but there is sufficient evidence to support that PA interventions generally result in small improvements on multiple indicators of psychiatric symptom severity. While effect sizes were small, many of the studies found participants had some improvement in psychiatric symptom severity and none of the studies reported any negative outcomes or harm resulting from the PA intervention. This lack of harm and potential for physical and psychiatric health benefit was consistent across an immensely diverse sample, providing some robust support and evidence for promotion of PA as an adjunctive treatment for individuals with SMI. Even though effect sizes are small, there is a clear beneficial effect of PA in this population and no harm. Further research should explore the specific PA interventions, frequency, and duration for maximal reduction of psychiatric symptom severity so that recommendations can be made on how to use PA as an adjuvant intervention for people with SMI. Of the ten studies included in the final review, 40% of studies scored as weak and 50% scored as moderate on the quality rating assessment. The lower quality scores were typically due to selection bias and lack of blinding. Because the studies focus on individuals with severe mental illness, a vulnerable population, it is likely that ethics created some logistical barriers to study design. Some of the studies explicitly refer to informing participants of the research question at the request of the ethics board. Active recruitment may also have been denied by ethics committees, particularly in in-patient settings, which would limit researchers to more passive recruitment such as displaying recruitment posters. While this protects potential participants from real or perceived abuse of power, it does introduce selection bias and would make recruitment of larger numbers challenging, particularly among individuals with psychotic disorders or severe depression, where the motivation and organization needed to independently contact researchers may be impacted. In future, it is critical that research include vulnerable populations, such as persons living with mental illness, so that we can better understand and treat these conditions. The American Psychiatric Association has summarized the aforementioned challenges and provided a list of recommendations for future study designs to ethically include this population ( 28 ). Several studies also had small sample sizes, which was also likely due to the pragmatic challenges of recruiting participants, conducting research with individuals with SMI, and the ability of those individuals to consent to and participate in a study for the duration of the study. As mentioned previously, low motivation, anhedonia and other common symptoms of the disorders being examined are likely to have created barriers in recruitment, participation, and retention. Future research could potentially circumvent some of these barriers by doing retrospective studies on physical activity initiatives in settings such as tertiary care where residents are required to partake in daily activity programs and selection bias is therefore less likely to influence results. Another limitation of many of the studies was a lack of control groups. Only three of the ten studies included in the final analysis had control groups that received no intervention. Two of the studies, Strassnig et al. (2015) and Woodward et al. (2018), had no control group. Five of the studies had active control groups. For example, both Greer et al. (2016) and Streeter et al. (2017) administered the same intervention to the experimental and active control groups, but at different levels of intensity and frequency. They then assessed dose-dependent effects of the intervention. The efficacy of the intervention itself cannot be quantified in this type of study design because both groups will have gained some benefit, and the effect size will be diluted. Oertel-Knöchel et al. (2014) compared an exercise intervention group with an active control group enrolled in a relaxation program. This design makes it difficult to discern if improvements are due to PA or enrollment in a program that provides structure, support, social connection, or other benefits to participants. This study design was likely due to ethics requirements when working with vulnerable populations. Future research should consider how to better control confounding variables in the study design, perhaps by using waitlist control groups instead of active control groups, or by comparing group PA interventions to individual PA interventions. Similarly, several studies compared the intervention group with an active control group who were engaged in a different activity. Malchow et al. (2015) compared an aerobic intervention to an active control group who partook in table soccer instead of the aerobic exercise. Su et al. (2016) compared an aerobic exercise intervention with a stretching/toning active control group. The Woodward (2018) study design was even more convoluted as it compared an aerobic intervention group with a weight-bearing exercise intervention group. Depressive symptomology improved in both groups, and there was no non-PA intervention control group. With these types of study designs, particularly because there is a paucity in knowledge about the effects of any type of PA on psychiatric symptom severity and the mechanisms underlying these effects, it becomes difficult to parse apart causation. It is possible that participants are benefiting simply by being enrolled in a program. The improvements in psychiatric symptom severity could be due to the structure, social connection, and mental stimulation of program involvement and not the PA intervention. We first need to understand the effects of PA on psychiatric symptoms in general, and then begin to parse apart the potentially unique effects of different types of PA interventions. Several of the studies included interventions in addition to the PA intervention. Malchow et. Al (2015) and Oertel-Knöchel et al. (2014) both used PA interventions in conjunction with computer assisted cognitive remediation training using ‘COG-PACK’. It is possible then that improvement in symptoms is due, fully, or partially, to benefits of the cognitive training. The effects of the PA intervention cannot be clearly quantified or assessed. Kang et al. (2016) included a social skills and self-management training components to their Thai-Chi intervention that makes it unclear if improvements were due to PA or non-PA interventions. Perhaps the most complex study was the Jakobsen et al. (2017) study, which compared the CHANGE intervention with “care coordination” and “treatment as usual” control groups. The CHANGE intervention was a 1-year affiliation with a coach who would take a multifaceted, holistic, and individualized approach to wellness that included encouraging daily PA, but also addressed dietary issues, smoking, and other lifestyle factors. The care coordination group provided participants with a specially trained psychiatric nurse to coordinate access to primary health care, and the “treatment as usual group” were given access to a general practitioner and annual metabolic screening. With the complexity of these interventions and no measurable, controlled, or consistent PA intervention, it is not possible to draw causative connections between PA in the CHANGE group and psychiatric symptom severity. Additionally, there is the pragmatic challenge of being able to test PA efficacy in psychiatric symptom management without withholding treatment for these conditions, which would of course be unethical. For example, Siqueria et al. (2016) assessed the efficacy of an aerobic exercise intervention in decreasing depressive symptomology in individuals with major depressive disorder but did so by looking at the dosage of antidepressant medication required to manage symptoms. They found that the exercise group required lower doses of medication. This is clearly not a direct measure of the efficacy of the intervention in reducing symptomology, but it would be unethical to allow one group to experience more severe symptoms by withholding medication or keeping medication doses controlled and at subtherapeutic levels so that the PA intervention can be assessed. If medication were controlled at a therapeutic level, symptoms would be controlled, and it would not be possible to detect improvements from PA. Despite this review compiling broad, global evidence unanimously supporting PA as an adjuvant treatment for SMI, there were some limitations. We searched the three main databases for this domain for all English-language articles, but articles not listed in one of these databases or published in another language would be not have been retrieved. Conclusion To the best of our knowledge, this is the first review since publication of the DSM-V examining the efficacy of physical activity specifically on psychiatric symptom severity exclusively in individuals with severe mental illness. The results from ten studies showed a small improvement in psychiatric symptom severity that was achieved through physical activity intervention. None of the studies found any harm resulting from physical activity. However, the current literature is very heterogeneous in terms of PA types, frequency, duration, and intensity, and further research is needed before specific PA recommendations can be made as an adjunctive treatment for individuals with SMI. Based on the current literature, individuals with SMI should be encouraged and supported to engage in regular PA as there is no known harm, they can reap the same physical health benefits as the general population, and they may reduce the severity of psychiatric symptoms beyond what would be achieved with psychopharmacology alone. Abbreviations SMI – Severe Mental Illness PA – Physical Activity Declarations Ethics approval and consent to participate : Not applicable. This was a systematic review and therefore did not have any participants. Consent for publication : Both authors consent to publication with BMC Psychiatry. Availability of data and materials : All data and materials have been submitted with this review. Competing interests : None. Funding : There was no funding for this review. Authors' contributions : AT conceived of the paper, developed the search strategy, provided the main searches, wrote the Methods, and developed the Tables. Both authors performed the analyses. AT wrote the paper. All authors edited the paper and had final approval of the manuscript. Authors' information : Ryan E. Rhodes, Ph.D., Behavioural Medicine Laboratory, Faculty of Education, PO Box 3010 STN CSC, University of Victoria, Victoria, B.C., V8W 3N4 CANADA, Tel: (250) 721‑8384, Fax: (250) 721‑7767, EM: [email protected] Anika Todd, MSc, Behavioural Medicine Laboratory, School of Exercise Science, Physical and Health Education, University of Victoria, Victoria, BC, Canada This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. References Hupin D, Roche F, Gremeaux V, Chatard JC, Oriol M, Gaspoz JM, et al. Even a low-dose of moderate-to-vigorous physical activity reduces mortality by 22% in adults aged ≥60 years: a systematic review and meta-analysis. Br J Sports Med. 2015 Oct 1;49(19):1262–7. Warburton DE, Charlesworth S, Ivey A, Nettlefold L, Bredin SS. A systematic review of the evidence for Canada’s Physical Activity Guidelines for Adults. Int J Behav Nutr Phys Act. 2010 Dec;7(1):1–220. Guthold R, Stevens GA, Riley LM, Bull FC. Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1·9 million participants. Lancet Glob Health. 2018 Oct 1;6(10):e1077–86. Substance Abuse and Mental Health Services Administration. Results from the 2008 National Survey on Drug Use and Health: National Findings. Office of Applied Studies; 2009. (NSDUH Series H-36). Report No.: HHS Publication No. SMA 09-4434. Harris EC, Barraclough B. Excess mortality of mental disorder. Br J Psyciatry. 1998;173(1):11–53. Joukamaa M, HeliöVaara M, Knekt P, Aromaa A, Raitasalo R, Lehtinen V. Mental disorders and cause-specific mortality. Br J Psychiatry. 2001;179(6):498–502. Laursen TM, Musliner KL, Benros ME, Vestergaard M, Munk-Olsen T. Mortality and life expectancy in persons with severe unipolar depression. J Affect Disord. 2016 Mar 15;193:203–7. Hjorthøj C, Stürup AE, McGrath J, Nordentoft M. SA57. Life Expectancy and Years of Potential Life Lost in Schizophrenia: A Systematic Review and Meta-Analysis. Schizophr Bull. 2017 Mar;43(suppl_1):S133–4. Quirk H, Hock E, Harrop D, Crank H, Peckham E, Traviss-Turner G, et al. Understanding the experience of initiating community-based group physical activity by people with serious mental illness: A systematic review using a meta-ethnographic approach. Eur Psychiatry. 2020 ed;63(1):e95. Lindamer LA, McKibbin C, Norman GJ, Jordan L, Harrison K, Abeyesinhe S, et al. Assessment of physical activity in middle-aged and older adults with schizophrenia. Schizophr Res. 2008 Sep 1;104(1):294–301. Faulkner G, Cohn T, Remington G. Validation of a physical activity assessment tool for individuals with schizophrenia. Schizophr Res. 2006 Feb 28;82(2):225–31. Lake J, Turner MS. Urgent Need for Improved Mental Health Care and a More Collaborative Model of Care. Perm J. 2017 Aug 11;21:17–024. Gold JM. Cognitive deficits as treatment targets in schizophrenia. Schizophr Res. 2004 Dec 15;72(1):21–8. Reynolds GP. Schizophrenia, antipsychotics and metabolic disease. J Psychopharmacol (Oxf). 2007 Jun 1;21(4):355–6. Lambert M, Conus P, Naber D. Impact of present and past antipsychotic side-effects on attitude toward typical antipsychotic treatment and compliance. Schizophr Res. 2003 Mar 15;60(1, Supplement):360. Firth J, Cotter J, Elliott R, French P, Yung AR. A systematic review and meta-Analysis of exercise interventions in schizophrenia patients. Psychol Med. 2015;45(7). Schuch FB, Vancampfort D. Physical activity, exercise, and mental disorders: it is time to move on. Trends Psychiatry Psychother. 2021 Oct 22;43(3):177–84. Moher D, Liberati A, Tetzlaff J, Altman DG. Academia and Clinic Annals of Internal Medicine Preferred Reporting Items for Systematic Reviews and Meta-Analyses : Ann Intern Med. 2009;151(4):264–9. Caspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep. 1985;100(2):126–31. Thomas BH, Ciliska D, Dobbins M, Micucci S. A Process for Systematically Reviewing the Literature: Providing the Research Evidence for Public Health Nursing Interventions. Worldviews Evidence‐Based Nurs. 2004 Sep 1;1(3):176–84. McKenzie J, Brennan S. Chapter 12: Synthesizing and presenting findings using other methods. In: Cochrane Handbook for Systematic Reviews of Interventions [Internet]. version 6.3. 2022 [cited 2022 Dec 23]. Available from: https://training.cochrane.org/handbook/current/chapter-12 Verbeek J, Ruotsalainen J, Hoving JL. Synthesizing study results in a systematic review. Scand J Work Environ Health. 2012;38(3):282–90. Field AP. Dread returns to Mega-Silly One. Health Psychol Rev. 2015 Jan;9(1):15–20. Armijo-Olivo S, Stiles CR, Hagen NA, Biondo PD, Cummings GG. Assessment of study quality for systematic reviews: a comparison of the Cochrane Collaboration Risk of Bias Tool and the Effective Public Health Practice Project Quality Assessment Tool: methodological research. J Eval Clin Pract. 2012 Feb;18(1):12–8. Jakobsen AS, Speyer H, Nørgaard HCB, Karlsen M, Birk M, Hjorthøj C, et al. Effect of lifestyle coaching versus care coordination versus treatment as usual in people with severe mental illness and overweight: Two-years follow-up of the randomized CHANGE trial. Plos One. 2017 Oct 6;12(10):e0185881–e0185881. Streeter CC, Gerbarg PL, Whitfield TH, Owen L, Johnston J, Silveri MM, et al. Treatment of Major Depressive Disorder with Iyengar Yoga and Coherent Breathing: A Randomized Controlled Dosing Study. J Altern Complement Med N Y N. 2017 Mar;23(3):201–7. Rastad C, Martin C, Asenlöf P. Barriers, benefits, and strategies for physical activity in patients with schizophrenia. Phys Ther. 2014 Oct;94(10):1467–79. Ethical Principles and Practices for Research Involving Human Participants With Mental Illness. Psychiatr Serv. 2006 Apr;57(4):552–7. Oertel-Knöchel V, Mehler P, Thiel C, Steinbrecher K, Malchow B, Tesky V, et al. Effects of aerobic exercise on cognitive performance and individual psychopathology in depressive and schizophrenia patients. Eur Arch Psychiatry Clin Neurosci. 2014 Oct;264(7):589–604. Additional Declarations No competing interests reported. Supplementary Files Appendix1SummaryofInclusionandexclusiondecisions.docx Appendix2RiskofBiasAssessment.docx Appendix3Dataextractiontableallstudies.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Rhodes","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAnklEQVRIiWNgGAWjYDACCTCyYWBgJlFLGulaDpPgLvPZzQdvfPhzPnHDceYHDD9qiNAic+dYsuXMttuJGw6zGTD2HCPGXRI5ZtK8DbcTZzbzAL3DRqyWP3/OQbX8I1YLA9uBxH5moBbGNqK0pCVb9rYlG/czsxkc7O0jSkvywRs//tjJtvEffvjgxzcitKCAA6RqGAWjYBSMglGAAwAAKJQwpowqWqoAAAAASUVORK5CYII=","orcid":"","institution":"University of Victoria","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Ryan","middleName":"E.","lastName":"Rhodes","suffix":""}],"badges":[],"createdAt":"2023-10-05 00:44:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3411748/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3411748/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":44602274,"identity":"5ba4803a-25a9-4383-9cc1-f4e18666de7e","added_by":"auto","created_at":"2023-10-13 21:06:16","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":249524,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flow diagram of obtained articles from the literature search to studies\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3411748/v1/1f40007bd130d637adf656ed.jpg"},{"id":49272291,"identity":"3c7621bc-348a-4f77-8c24-ddd6cc513a5d","added_by":"auto","created_at":"2024-01-07 08:22:21","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":553016,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3411748/v1/c9bae3ea-5b57-479f-a5b6-1259cd279e37.pdf"},{"id":44600741,"identity":"8eb0aad9-9866-44bc-a95a-f8c82fe6dae8","added_by":"auto","created_at":"2023-10-13 20:50:16","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":48060,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1SummaryofInclusionandexclusiondecisions.docx","url":"https://assets-eu.researchsquare.com/files/rs-3411748/v1/307f4d4d44585b22addadc08.docx"},{"id":44602029,"identity":"dcd66025-2952-4d64-b0a2-755983409d9f","added_by":"auto","created_at":"2023-10-13 20:58:16","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":29002,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix2RiskofBiasAssessment.docx","url":"https://assets-eu.researchsquare.com/files/rs-3411748/v1/f60fac7a118ce97aa4ef5e07.docx"},{"id":44600744,"identity":"34ca0331-ccf2-43c7-bb0e-3548b8495354","added_by":"auto","created_at":"2023-10-13 20:50:16","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":23398,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix3Dataextractiontableallstudies.docx","url":"https://assets-eu.researchsquare.com/files/rs-3411748/v1/d4ee688b40ba149f30403cc0.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impacts of Physical Activity Interventions on Psychiatric Symptom Severity in Adults with Severe Mental illness: A Systematic Review","fulltext":[{"header":"Background","content":"\u003cp\u003eRegular physical activity (PA) has well known physical and mental health benefits for the general population (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Achieving the recommended 150 min per week of moderate intensity physical activity has been linked to decreased obesity, decreased risk of cardiovascular disease, improved mood, and a plethora of other positive health outcomes. Despite the robust evidence showing the health benefits of regular PA, most people do not engage in PA to the extent that would be necessary to realize these benefits. Based on data from 1.9\u0026nbsp;million participants, it is estimated that more than a quarter of all adults globally are not engaging in PA at levels adequate to achieve the health benefits (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile the physical health benefits of regular PA have been thoroughly researched, the additional benefits of regular PA for individuals with a severe mental illness (SMI) has only more recently become a focus of research. In 2008, the National Institute of Mental Health defined SMI as schizophrenia, severe bipolar disorder, and severe major depressive disorder, which affects approximately 4.4% of the population (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The same definition of SMI was used in this review. Individuals with SMI may reap all the same physical health benefits as the general population. This is particularly relevant because individuals with SMI have a greater prevalence of physical ailments, such as cardiovascular disease and diabetes, resulting in lower quality of life and higher mortality compared to the general population (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). For example, a diagnosis of schizophrenia is associated with over 15 years of potential life lost (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, despite the overwhelming evidence in support of regular PA as an effective way to improve physical health, studies show that individuals with SMI are even less likely to engage in regular PA than the general population. One reason for this difference in PA levels may be the considerable barriers that individuals with SMI face to participating in regular PA. A recent systematic review compiled 16 qualitative studies examining the experiences of individuals with SMI in PA initiation and the unique barriers faced and supports needed, which offers some insight into the lower level of PA in this population. This study identified support from a trusted source as a key piece to helping this population overcome some of the unique challenges they face when attempting to engage in regular PA (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Unfortunately, without support, individuals with SMI continue to be far less able to achieve healthy levels of PA as demonstrated in studies comparing PA data from the general population to individuals with SMI. One study using self-report on PA found only 30% of individuals diagnosed with schizophrenia engage in PA compared to 63% of the general population (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Another study found that among individuals prescribed clozapine, a common antipsychotic medication, only 25% achieved the recommended weekly 150min of moderate to intense PA (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurthermore, we know that psychopharmacology, the current standard treatment, is only partially efficacious in managing symptoms of severe mental illness, and that these medications often have significant side effects that negatively impact individuals\u0026rsquo; physical health (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). For example, antipsychotic medications can reduce positive symptoms but have minimal efficacy in treatment of negative symptoms or neurocognitive deficits (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Additionally, antipsychotic medication is notorious for a plurality of side effects that significantly impact individuals\u0026rsquo; overall health and quality of life (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePharmacological treatment limitations have fueled an interest in adjunctive and alternative interventions and PA interventions may show promise in reducing psychiatric symptoms while improving physical health outcomes.\u003c/p\u003e \u003cp\u003eThere continues to be a paucity in our understanding of the current literature. There has been many reviews of PA and mental health. There has also been work by Firth and colleagues focusing only on schizophrenia disorder (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Even the barriers and challenges individuals with SMI face to engaging in PA has been compiled in a recent review (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). However, there have been no systematic reviews of the efficacy of PA in reducing symptom severity in the SMI population. Given the uniqueness of this population and the complex challenges these individuals face when engaging in PA, it is necessary to also review the efficacy of PA in this context. We did not seek to address the relationship between PA and mental illness prevention, issues of access and barriers, or impacts on physical health. This systematic review builds on a recent broader narrative reviews on the matter (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe purpose of this review is therefore to examine the efficacy of regular PA as a potential adjunctive treatment for psychiatric symptoms specifically in individuals with SMI, defined as schizophrenia disorders, severe bipolar disorders, and severe major depressive disorder, who had access to a PA program. Sub-analyses of potential moderators included study design, intervention type, sample characteristics (age, gender, diagnosis), country of study and type of control. Additionally, we focused our review specifically on persons living with an established serious mental illness.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eInclusion and Exclusion Criteria\u003c/h2\u003e \u003cp\u003eThe following eligibility criteria were used to determine which studies would be included in the analysis: 1) primary study examining effects of intervention/program, 2) study participants aged 18+, 3) diagnosis of a severe mental illness, defined as a diagnosis of schizophrenia spectrum disorder, bipolar disorders and major depressive disorder, 4) physical activity was the independent variable, defined as any bodily movement produced by skeletal muscle that results in energy expenditure (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), 5) peer-reviewed journal articles published between June 2013 and present. June 2013 was chosen as the start date to coincide with the publication of the DSM-V. Unfortunately, most studies continued to use diagnoses based on the DSM-IV or other diagnostic manuals. We chose to keep this as the start date regardless to limit results to the past 10 years, which encompasses the 2016 opiate crisis, housing crisis, and COVID-19 pandemic. This was done to keep results relevant to the current context.\u003c/p\u003e \u003cp\u003eStudies were excluded if 1) the participants did not have a primary diagnosis of a schizophrenia spectrum disorder, major depressive disorder, or bipolar disorder, 2) they included children or adolescents below 18 years, 3) measured physical health outcomes instead of psychiatric outcomes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSearch Strategy\u003c/h2\u003e \u003cp\u003eA systematic search of EBSCO Medline, EBSCO PsycINFO and EBSCO SPORTDiscus electronic databases was completed by the first author in October 2019. Additional studies were collected through ancestry and supplementary search. An updated search using the same criteria and search phrase was completed by the first author in January 2023. The Boolean language search phrase \u0026ldquo;(exercise OR \"physical activity\") AND (program OR programme OR intervention) AND (\u0026ldquo;severe mental illness\u0026rdquo; OR schizophren* OR \u0026ldquo;bipolar disorder\u0026rdquo; OR \u0026ldquo;major depressive disorder\u0026rdquo;) AND adult\u0026rdquo; was used to search all databases. Results were limited to publications between 2013-present, peer-reviewed journal articles, English and age 18\u0026ndash;64.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eTitle and Abstract Screening\u003c/h2\u003e \u003cp\u003eThe titles and abstracts of all initial search results remaining after relevant filters were applied were screened using key words and exclusion criteria. Articles were excluded if titles did not match inclusion criteria, or they met any exclusion criteria. If titles provided vague or insufficient information, the abstract was screened for same. Articles were excluded based on title alone, a further 14 articles were excluded after abstract review. The abstract review of the articles remaining after title review are summarized in Appendix 1. The searches were repeated in January 2023 and title and abstract screening was completed on the remaining 1, 445 records by two researchers, (CG, AT) and yielded 3 additional records for full review.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eFull Text Review\u003c/h2\u003e \u003cp\u003eThe remaining articles were reviewed in full using the inclusion and exclusion criteria. Articles meeting all inclusion and exclusion criteria and were included in the final review.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Collection Process and Data Items\u003c/h2\u003e \u003cp\u003eData were extracted for intervention, psychiatric symptom measurements, participant characteristics, and effect size. Intervention characteristics included: type of intervention, duration, type of comparison group (waitlist control, active control, usual care), whether psychiatric symptom severity was the primary outcome measure, and country where study was conducted. Measurement characteristics included any recognized scale or test for psychiatric symptom severity. Participant characteristics included: sample size, age range of participants and diagnosis. This is summarized in Appendix 3.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eRisk of Bias\u003c/h2\u003e \u003cp\u003eRisk of bias assessment was done using the Public Health Research, Education and Development (PHRED) tool developed by McMaster University School of Nursing (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). This tool assesses 8 components of a study: selection bias, study design, confounders, blinding, data collection methods, withdrawals and drop-outs, intervention integrity and analyses. The component scores are combined into a global rating of weak, moderate, or strong of overall study quality.\u003c/p\u003e \u003cp\u003eFirst and second authors assessed study quality, and any ambiguities were resolved via discussion between both authors. Following risk of bias assessment, studies were classified into weak, moderate, or strong quality using the scoring system outlined in the PHRED tool. A detailed quality assessment for each item by study is included in Appendix 2.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eAnalysis\u003c/h2\u003e \u003cp\u003eFollowing initial read-throughs of the final, included studies, synthesis of results was narrative (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), with findings grouped by outcome. Due to the clinical and methodological heterogeneity of the studies, a meta-analysis was not performed. While there were similarities in sample population, there was no consistency in intervention type, intervention duration, control group, and there was only limited similarity in outcome measures. Additionally, there was great variance in the statistical analysis performed, making direct comparison or amalgamation by effect size unfeasible (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Therefore, this review did not attempt to assimilate the studies, but rather compiled the evidence to date. The narrative analysis is summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Structured tabulation of sample size, participant diagnoses, intervention and conclusions across studies was also completed and is summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of the Studies in the Review\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSample:\u003c/p\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;10 independent data sets\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercentages\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003cp\u003eMixed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e100%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePA Levels at Baseline\u003c/p\u003e \u003cp\u003eMeeting guidelines\u003c/p\u003e \u003cp\u003eNot meeting guidelines\u003c/p\u003e \u003cp\u003eMixed\u003c/p\u003e \u003cp\u003eNot reported\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e10%\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e90%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePopulation\u003c/p\u003e \u003cp\u003eInpatient\u003c/p\u003e \u003cp\u003eCommunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20%\u003c/p\u003e \u003cp\u003e80%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiagnosis\u003c/p\u003e \u003cp\u003eSchizophrenia\u003c/p\u003e \u003cp\u003eSchizophrenia spectrum\u003c/p\u003e \u003cp\u003eMajor Depressive Disorder\u003c/p\u003e \u003cp\u003eBipolar Disorder\u003c/p\u003e \u003cp\u003eMixed sample\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20%\u003c/p\u003e \u003cp\u003e30%\u003c/p\u003e \u003cp\u003e30%\u003c/p\u003e \u003cp\u003e-\u003c/p\u003e \u003cp\u003e20%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of Intervention\u003c/p\u003e \u003cp\u003eAerobic activity\u003c/p\u003e \u003cp\u003eStrength/Resistance\u003c/p\u003e \u003cp\u003eYoga\u003c/p\u003e \u003cp\u003eTai-Chi\u003c/p\u003e \u003cp\u003eMixed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50%\u003c/p\u003e \u003cp\u003e10%\u003c/p\u003e \u003cp\u003e10%\u003c/p\u003e \u003cp\u003e10%\u003c/p\u003e \u003cp\u003e20%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeographical Location\u003c/p\u003e \u003cp\u003eUSA\u003c/p\u003e \u003cp\u003eDenmark\u003c/p\u003e \u003cp\u003eChina\u003c/p\u003e \u003cp\u003eGermany\u003c/p\u003e \u003cp\u003eBrazil\u003c/p\u003e \u003cp\u003eTaiwan\u003c/p\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30%\u003c/p\u003e \u003cp\u003e10%\u003c/p\u003e \u003cp\u003e10%\u003c/p\u003e \u003cp\u003e20%\u003c/p\u003e \u003cp\u003e10%\u003c/p\u003e \u003cp\u003e10%\u003c/p\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of Control\u003c/p\u003e \u003cp\u003eWaitlist Control\u003c/p\u003e \u003cp\u003eActive Control\u003c/p\u003e \u003cp\u003eTreatment as usual\u003c/p\u003e \u003cp\u003eMultiple\u003c/p\u003e \u003cp\u003eNo control group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20%\u003c/p\u003e \u003cp\u003e30%\u003c/p\u003e \u003cp\u003e10%\u003c/p\u003e \u003cp\u003e30%\u003c/p\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuality Rating\u003c/p\u003e \u003cp\u003eWeak\u003c/p\u003e \u003cp\u003eModerate\u003c/p\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40%\u003c/p\u003e \u003cp\u003e50%\u003c/p\u003e \u003cp\u003e10%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStudy results and direction of effects\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSample size\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDiagnosis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eConclusion\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStrassnig et al.\u003csup\u003e24\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSchizophrenia, schizoaffective\u003c/p\u003e \u003cp\u003ebipolar disorder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2/week high velocity resistance circuit training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSignificant improvement in BACS, PANSS total score\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJakobsen et al.\u003csup\u003e25\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;428\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSchizophrenia \u003c/p\u003e \u003cp\u003eSchizoaffective \u003c/p\u003e \u003cp\u003ePsychotic disorder NOS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCHANGE intervention\u0026thinsp;=\u0026thinsp;CHANGE coach to encourage daily PA, healthy dietary changes, and smoking cessation\u003c/p\u003e \u003cp\u003eCare coordination\u0026thinsp;=\u0026thinsp;nurse to facilitate access to primary care for optimal treatment of physical ailments\u003c/p\u003e \u003cp\u003eTreatment as usual\u0026thinsp;=\u0026thinsp;access to general practitioner and annual metabolic screening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo statistically significant\u003c/p\u003e \u003cp\u003edifference in psychotic symptom between groups\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWoodward et al.\u003csup\u003e26\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSchizophrenia\u003c/p\u003e \u003cp\u003eSchizoaffective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3/week 30min individualized exercise session with trainer\u0026thinsp;+\u0026thinsp;standardized 10min warm up and cool down\u003c/p\u003e \u003cp\u003eAerobic: 40\u0026ndash;59% max heart rate using different exercise modalities (cycle ergometer, treadmill, elliptical)\u003c/p\u003e \u003cp\u003eWeight-bearing: weight training based on individual muscular capacity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eParticipants enrolled in either exercise intervention had more rapid improvement in symptoms and social functioning scores\u003c/p\u003e \u003cp\u003eTrend for reduced depression severity in exercise intervention (p\u0026thinsp;=\u0026thinsp;0.06)\u003c/p\u003e \u003cp\u003eMean total PANSS score decreased from 95.3 to 79.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSu et al.\u003csup\u003e27\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSchizophrenia, \u003c/p\u003e \u003cp\u003eschizoaffective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAerobic exercise intervention: individual session with trainer 3\u0026ndash;5 times/week; 5min warm up, 30min individualized aerobic exercise at 55\u0026ndash;69% max heart rate, 5min cool down\u003c/p\u003e \u003cp\u003eStretching/toning control: 30min program of 14 flexibility, toning and balance exercises performed with trainer 3\u0026ndash;5 times per week\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSignificantly improved processing speed and attention scores in aerobic exercise group:\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGreer et al.\u003csup\u003e28\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMDD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eHigh dose (16kcal/kg body weight) vs low dose (4kcal/kg) aerobic exercise\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e60-70min/week moderate-intensity physical activity significantly reduces depressive symptomology; dose-dependent\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMalchow et al.\u003csup\u003e29\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSchizophrenia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEndurance training 3 x30min sessions 3x/week\u003c/p\u003e \u003cp\u003eActive control engaged in table soccer instead of endurance training\u003c/p\u003e \u003cp\u003eAll participants engaged in computer assisted cognitive remediation training using program called COGPACK starting at week 6; 30min sessions 2x/week from week 6\u0026ndash;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTime effects were found for PANSS total score and PANSS negative sub score\u003c/p\u003e \u003cp\u003ePANSS positive sub score decreased in table soccer group and in PANSS total score\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOertel-Kn\u0026ouml;chel et al.\u003csup\u003e30\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSchizophrenia\u003c/p\u003e \u003cp\u003eMDD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCognitive training: group tasks followed by individual tasks to train multiple cognitive domains such as motor skills, executive function and attention. Combined training from 2 manuals established for cognitive training in psychiatry ('COG-PACK' and 'cognitive training after Stengel')\u003c/p\u003e \u003cp\u003ePhysical exercise: 10min warm-up, 25min exercise at 60\u0026ndash;70% VO2max (boxing and circuit training \u0026minus;\u0026thinsp;60sec work, 20sec rest - in alternate order; circuit included trampoline, endurance exercise with and without weight, physiotherapy balls), 10min cool down/stretch\u003c/p\u003e \u003cp\u003eRelaxation: 45min breathing exercises, 'imagery journey', 'enjoy exercises' for all sensory modalities, relaxation or acceptance and awareness training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePhysical exercise intervention improved clinical symptoms in schizophrenia and major depressive disorder inpatients\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKang et al.\u003csup\u003e31\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;244\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSchizophrenia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45 min Social skills training - self-management of medication, self-monitoring of symptoms, community re-entry, recreation for leisure, other social independence living skills\u003c/p\u003e \u003cp\u003e45 min Thai-Chi intervention \u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSignificant overall improvements in intervention group from baseline to 12 months\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSiqueria et al.\u003csup\u003e32\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMDD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eIndividualized and supervised sessions of continuous and intermittent aerobic activity for 20-60min\u003c/p\u003e \u003cp\u003eBoth groups treated with SSRI antidepressant sertraline either 0mg, 50mg or 100mg dose\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAerobic exercise decreased the need for higher doses of antidepressant to achieve antidepressant efficacy but no significant differences between groups in symptom severity\u003c/p\u003e \u003cp\u003eDecrease in HAM-D and BDI scores in both groups; significant main effect of time but not intervention\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStreeter et al.\u003csup\u003e33\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMDD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eParticipants randomized to: \u003c/p\u003e \u003cp\u003e1) High dose group (3 x 90min yoga/week\u0026thinsp;+\u0026thinsp;4x30min homework sessions/week)\u003c/p\u003e \u003cp\u003e2) Low dose group (2x90min yoga/week\u0026thinsp;+\u0026thinsp;3x30min homework sessions/week)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNo significant difference in response or remission rates between the groups from screening to week 12.\u003c/p\u003e \u003cp\u003eResults indicate that both groups completed sufficient intervention minutes to improve rates of remission and response significantly\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe original electronic database search returned a total of 263,061 articles. Results were limited to English language, peer-reviewed, and publication date reduced to June 2013-present. Three duplicate articles were removed and 116 articles (66 from EBSCO Medline, 50 from EBSCO PsycINFO and none from EBSCO SPORTDiscus) were screened for title and abstract eligibility. 98 articles were excluded based on eligibility criteria and 18 full articles were reviewed based on eligibility criteria. A further 8 were excluded. The final 10 articles were assessed and rated for quality using the PHRED tool, summarized in Appendix 2. All 10 articles were included in the narrative synthesis, and 6 of these articles were included in the tabulation of results. An updated search was conducted in January 2023 and yielded 38, 687 additional records that were screened using the same criteria. 37, 242 of the results were excluded with automated filters. 2 duplicate records were removed. Title and abstract screening were completed on the remaining 1, 445 records by two researchers, (CG, AT) and yielded 3 additional records for full review. 2 of these records were study protocols only and therefore did not meet the inclusion criteria for this review. The final record did report participants\u0026rsquo; age or diagnosis and did not use a validated measure to psychiatric symptoms. The final record was therefore also excluded. The literature search is summarized in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eGeneral Study and Participant Characteristics\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e provides a summary of characteristics of the 10 studies and 1, 058 participants included in the review. Sample sizes ranged from n\u0026thinsp;=\u0026thinsp;12 (Strassnig et al., 2015) to n\u0026thinsp;=\u0026thinsp;428 (Jakobsen et al., 2017). Samples also varied in age. Although studies with participants below age 18 were excluded, one study only included participants aged 19 and older (Woodward et al., 2018), and another only included participants aged 20 and older (Su et al., 2016). The upper age limit of participants also varied from 50 (Woodward et al., 2018) to 75 years old (Strassnig et al., 2015). All samples were mixed gender. One study reported PA at baseline (Greer et al., 2016), but this information was not reported in the other nine studies.\u003c/p\u003e \u003cp\u003eAlthough participants in all studies had a diagnosis of a severe mental illness, defined in this review as a schizophrenia spectrum disorder, bipolar disorder or major depressive disorder, the studies were quite heterogeneous in diagnostic profile of participants. Only two studies focused on psychiatric inpatients (Malchow et al., 2015; Oertel-Kn\u0026ouml;chel et al., 2014), the remaining eight studies excluded inpatients and focused on individuals with severe mental illness living in the community. None of the included studies focused exclusively on bipolar disorder. Two studies only included individuals with a diagnosis of schizophrenia (Kang et al., 2016; Malchow et al., 2015), three studies included all schizophrenia spectrum disorders (Jakobsen et al., 2017; Su et al., 2016; Woodward et al., 2018), three studies included only participants with major depressive disorder (Greer et al., 2016; Siqueira et al., 2016; Streeter et al., 2017), and two studies had mixed samples (Oertel-Kn\u0026ouml;chel et al., 2014; Strassnig et al., 2015).\u003c/p\u003e \u003cp\u003eOf interest, the studies were geographically diverse. The 10 studies were conducted in the United States (Greer et al., 2016; Strassnig et al., 2015; Streeter et al., 2017), Denmark (Jakobsen et al., 2017), China (Kang et al., 2016), Germany (Malchow et al., 2015; Oertel-Kn\u0026ouml;chel et al., 2014), Brazil (Siqueira et al., 2016), Taiwan (Su et al., 2016) and Canada (Woodward et al., 2018). The type of physical activity intervention was also diverse. Five studies focused on aerobic activity (Greer et al., 2016; Malchow et al., 2015; Oertel-Kn\u0026ouml;chel et al., 2014; Siqueira et al., 2016; Su et al., 2016), although the details of the exercise varied. The other five studies included strength training (Strassnig et al., 2015), yoga (Streeter et al., 2017), Tai-chi (Kang et al., 2016) and mixed interventions (Jakobsen et al., 2017; Woodward et al., 2018). All studies varied greatly in duration, intensity, and other intervention details.\u003c/p\u003e \u003cp\u003eRisk of Bias assessments were completed on the final ten studies using the PHRED tool (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). 40% of studies were classified as weak (Malchow et al., 2015; Oertel-Kn\u0026ouml;chel et al., 2014; Strassnig et al., 2015; Woodward et al., 2018), 50% as moderate (Greer et al., 2016; Jakobsen et al., 2017; Siqueira et al., 2016; Streeter et al., 2017; Su et al., 2016), and only one study (10%) as strong (Kang et al., 2016).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eExperimental Effects on Psychiatric Symptom Severity\u003c/h2\u003e \u003cp\u003eThe ten studies included in the tabulation of direction of effects are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e; effect sizes for the six studies included in the quantitative synthesis are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Four studies (Malchow et al., 2015; Oertel-Kn\u0026ouml;chel et al., 2014; Strassnig et al., 2015; Woodward et al., 2018) were excluded from the synthesis because insufficient data was provided to calculate effect size on the measures of interest.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMeans, standard deviations and Cohen\u0026rsquo;s d effect sizes for all studies included in quantitative synthesis.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTimepoint\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOutcome measure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eControl Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eExperimental Group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEffect size (d)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJakobsen et al.\u003csup\u003e25\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003cp\u003e2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSAPS\u003c/p\u003e \u003cp\u003eSANS\u003c/p\u003e \u003cp\u003eBACS\u003c/p\u003e \u003cp\u003eSAPS\u003c/p\u003e \u003cp\u003eSANS\u003c/p\u003e \u003cp\u003eBACS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.12 (1.61)\u003c/p\u003e \u003cp\u003e2.50 (1.14)\u003c/p\u003e \u003cp\u003e228.31 (48.68)\u003c/p\u003e \u003cp\u003e1.4 (1.2)\u003c/p\u003e \u003cp\u003e1.5 (1.1)\u003c/p\u003e \u003cp\u003e251.6 (46.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.12 (1.61)\u003c/p\u003e \u003cp\u003e2.50 (1.14)\u003c/p\u003e \u003cp\u003e228.31 (48.68)\u003c/p\u003e \u003cp\u003e1.6 (1.1)\u003c/p\u003e \u003cp\u003e1.7 (1.0)\u003c/p\u003e \u003cp\u003e254.3 (44.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003cp\u003e---\u003c/p\u003e \u003cp\u003e---\u003c/p\u003e \u003cp\u003e0.124\u003c/p\u003e \u003cp\u003e0.175\u003c/p\u003e \u003cp\u003e0.055\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSu et al.\u003csup\u003e27\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003cp\u003e6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePANSS positive\u003c/p\u003e \u003cp\u003ePANSS negative\u003c/p\u003e \u003cp\u003eProcessing speed\u003c/p\u003e \u003cp\u003eWorking memory\u003c/p\u003e \u003cp\u003ePANSS positive\u003c/p\u003e \u003cp\u003ePANSS negative\u003c/p\u003e \u003cp\u003eProcessing speed\u003c/p\u003e \u003cp\u003eWorking memory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18.18 (7.11)\u003c/p\u003e \u003cp\u003e21.82 (8.72)\u003c/p\u003e \u003cp\u003e32.11 (6.74)\u003c/p\u003e \u003cp\u003e42.45 (6.21)\u003c/p\u003e \u003cp\u003e15.14 (7.01)\u003c/p\u003e \u003cp\u003e21.68 (10.45)\u003c/p\u003e \u003cp\u003e33.60 (6.96)\u003c/p\u003e \u003cp\u003e43.76 (6.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.05 (6.48)\u003c/p\u003e \u003cp\u003e22.36 (9.65)\u003c/p\u003e \u003cp\u003e33.71 (5.96)\u003c/p\u003e \u003cp\u003e46.27 (5.62)\u003c/p\u003e \u003cp\u003e13.55 (3.71)\u003c/p\u003e \u003cp\u003e15.68 (6.43)\u003c/p\u003e \u003cp\u003e36.74 (4.92)\u003c/p\u003e \u003cp\u003e48.77 (6.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003cp\u003e---\u003c/p\u003e \u003cp\u003e---\u003c/p\u003e \u003cp\u003e---\u003c/p\u003e \u003cp\u003e0.136\u003c/p\u003e \u003cp\u003e-0.712\u003c/p\u003e \u003cp\u003e0.243\u003c/p\u003e \u003cp\u003e0.201\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGreer et al.\u003csup\u003e28\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003cp\u003e12 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSF-36 Mental Health\u003c/p\u003e \u003cp\u003eSF-36 Mental Health\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49.1 (15.9)\u003c/p\u003e \u003cp\u003e62.4 (21.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50.7 (13.9)\u003c/p\u003e \u003cp\u003e67.2 (18.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003cp\u003e0.215\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKang et al.\u003csup\u003e31\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003cp\u003e12 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePANSS\u003c/p\u003e \u003cp\u003ePositive symptoms\u003c/p\u003e \u003cp\u003eNegative symptoms\u003c/p\u003e \u003cp\u003eGeneral Psychopathology\u003c/p\u003e \u003cp\u003ePANSS\u003c/p\u003e \u003cp\u003ePositive symptoms\u003c/p\u003e \u003cp\u003eNegative symptoms\u003c/p\u003e \u003cp\u003eGeneral Psychopathology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45.2 (3.0)\u003c/p\u003e \u003cp\u003e10.2 (1.6)\u003c/p\u003e \u003cp\u003e13.6 (1.5)\u003c/p\u003e \u003cp\u003e21.7 (2.0)\u003c/p\u003e \u003cp\u003e44.7 (2.6)\u003c/p\u003e \u003cp\u003e10.0 (1.4)\u003c/p\u003e \u003cp\u003e13.4 (1.4)\u003c/p\u003e \u003cp\u003e21.5 (1.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e44.5 (3.0)\u003c/p\u003e \u003cp\u003e10.1 (1.4)\u003c/p\u003e \u003cp\u003e13.4 (1.5)\u003c/p\u003e \u003cp\u003e22.0 (2.0)\u003c/p\u003e \u003cp\u003e43.3 (2.7)\u003c/p\u003e \u003cp\u003e10.0 (1.4)\u003c/p\u003e \u003cp\u003e12.6 (1.2)\u003c/p\u003e \u003cp\u003e21.7 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003cp\u003e---\u003c/p\u003e \u003cp\u003e---\u003c/p\u003e \u003cp\u003e---\u003c/p\u003e \u003cp\u003e-0.233\u003c/p\u003e \u003cp\u003e-0.2\u003c/p\u003e \u003cp\u003e-0.4\u003c/p\u003e \u003cp\u003e-0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSiqueria et al.\u003csup\u003e32\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003cp\u003e4 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHAM-D\u003c/p\u003e \u003cp\u003eBDI-II\u003c/p\u003e \u003cp\u003eHAM-D\u003c/p\u003e \u003cp\u003eBDI-II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.42 (2.99)\u003c/p\u003e \u003cp\u003e33.92 (9.64)\u003c/p\u003e \u003cp\u003e12.64 (5.74)\u003c/p\u003e \u003cp\u003e20.05 (10.21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19.20 (3.14)\u003c/p\u003e \u003cp\u003e29.51 (9.46)\u003c/p\u003e \u003cp\u003e11.38 (3.94)\u003c/p\u003e \u003cp\u003e18.39 (9.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003cp\u003e---\u003c/p\u003e \u003cp\u003e-0.013\u003c/p\u003e \u003cp\u003e0.288\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStreeter et al.\u003csup\u003e33\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBaseline\u003c/p\u003e \u003cp\u003e12 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBDI-II total score\u003c/p\u003e \u003cp\u003eBDI-II total score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e27.7 (8.0)\u003c/p\u003e \u003cp\u003e10.1 (7.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.6 (6.7)\u003c/p\u003e \u003cp\u003e6.0 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e---\u003c/p\u003e \u003cp\u003e-0.136\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIt should be noted that with the BDI-II, HAM-D, PANSS, SAPS and SANS scales a higher score indicates more severe psychiatric symptoms so a decrease in score indicates improvement in psychiatric symptoms. A negative effect size would therefore indicate reduction in symptom severity. With the SF-36 and BACS scales, an increase in score and positive effect size indicates improvement in functioning and decrease in psychiatric symptom severity.\u003c/p\u003e \u003cp\u003eOverall, none of the studies found a negative effect of PA on individuals with SMI. Nine of the studies found some benefit from PA on psychiatric symptom severity, even if effect sizes were small (effect size d ranged from 0.05 to 0.71). Only the Jakobsen et al. (2017) study found no significant difference on any experimental measure between the intervention group and two active control groups over two years.\u003c/p\u003e \u003cp\u003eAmong the six studies included in the synthesis, effect sizes ranged from 0.01 to 0.71 (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Two of the studies\u0026rsquo; effect sizes were negligible (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Streeter et al. (2017) found an effect size of d=-0.14 but reported significant improvement in depressive symptomology in both intervention and active control groups. They concluded that both groups had received sufficient exercise to improve psychiatric symptom severity. Two of the studies (Greer et al., 2016; Siqueira et al., 2016) reported only small effect sizes. Kang et al., (2016) found medium effect size d=-0.40 on negative symptoms. Su et al. (2016) found large effect size (d=-0.712) on PANSS negative symptom subscale.\u003c/p\u003e \u003cp\u003eGreer et al. (2016) found a dose-dependent effect of moderate to intense aerobic exercise in weekly 60-70min sessions on depressive symptomology over 12 weeks. The study compared an active control group exercising at a lower intensity to an experimental group exercising at higher intensity. Both groups improved, but the experimental group had a greater reduction in symptom severity as measured using the SF-36 Mental Health. The effect size was small (d\u0026thinsp;=\u0026thinsp;0.215). Similarly, Streeter et al. (2017) found a dose-dependent effect of yoga intervention on depressive symptomology comparing a high dose group (three 90min sessions per week) with a low dose group (two 90min sessions per week). Effect size was d = -0.14 using the BDI-II total score, where a lower score indicates a reduction in symptom severity. Woodward et al. (2018) compared an aerobic exercise with a weight-bearing exercise intervention and found improvements in depressive symptomology in both groups. It was not possible to calculate effect size on measures of interest from the data provided.\u003c/p\u003e \u003cp\u003eSiqueria et al. (2016) compared anti-depressant dosage required to manage depressive symptomology in an aerobic exercise intervention group compared to a control group and found that individuals in the aerobic exercise group required lower doses of antidepressant medication to manage their symptoms. The effect sizes were small at d=-0.01 on the HAM-D and d\u0026thinsp;=\u0026thinsp;0.29 on the BDI-II.\u003c/p\u003e \u003cp\u003eOertel-Kn\u0026ouml;chel et al. (2014) used a circuit training intervention and found improvements in PANSS negative symptom subscale and depressive symptoms (BDI-II score) in both the exercise intervention group and active control relaxation intervention group, but not the waitlist control group. Effect sizes could not be calculated from the data provided. Strassnig et al. (2015) study also used a circuit training intervention administered twice per week over eight weeks and reported significant improvements in PANSS total score, depressive symptomology (CDSS score), and cognition (BACS score). It should be noted that Strassnig et al. (2015) did not have a control group and that insufficient data was reported to allow for calculation of effect size.\u003c/p\u003e \u003cp\u003eSu et al. (2016) also found improvements in PANSS negative symptom subscale (medium effect size of d= -0.71), and cognition, namely processing speed (small effect size of d\u0026thinsp;=\u0026thinsp;0.24) and working memory (small effect size of d\u0026thinsp;=\u0026thinsp;0.20), in an aerobic exercise intervention group compared to the active control stretching/toning group.\u003c/p\u003e \u003cp\u003eKang et al. (2016) and Malchow et al. (2015) found improvements in PANSS scores from a Tai-Chi and aerobic exercise interventions respectively. Both studies used active controls and both interventions incorporated additional non-PA interventions. The Kang et al. (2016) intervention included social skills and self-management training for all participants, the Malchow et al. (2015) intervention included cognitive remediation training. Kang et al. (2016) found a small effect size of d=-0.23 for PANSS total score, d=-0.20 for positive symptoms and d=-0.40 for negative symptoms.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe purpose of the review was to examine the efficacy of regular PA as a potential adjunctive treatment to reduce psychiatric symptom severity in individuals with SMI, defined as schizophrenia spectrum disorders, bipolar disorders, and major depressive disorder diagnosed based on DSM or ICD criteria. While there is an abundance of evidence on the benefits of PA on mood and wellness in the general population, and the physical health benefits of all people, there is a paucity of research on the efficacy of PA in reducing psychiatric symptom severity in individuals with severe mental illness. This is unique population that faces significant barriers to participation in regular PA yet could benefit immensely (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The physical health benefits of regular PA among this population are well established and were therefore not a focus of this review.\u003c/p\u003e \u003cp\u003eThe sample included in the review was quite heterogenous, differing in gender, diagnosis, geographical location, psychiatric symptom measures, PA intervention, and including both inpatient and community-based populations. Direct comparison of groups and any sub-groups conclusions could not be made, but there is sufficient evidence to support that PA interventions generally result in small improvements on multiple indicators of psychiatric symptom severity. While effect sizes were small, many of the studies found participants had some improvement in psychiatric symptom severity and none of the studies reported any negative outcomes or harm resulting from the PA intervention. This lack of harm and potential for physical and psychiatric health benefit was consistent across an immensely diverse sample, providing some robust support and evidence for promotion of PA as an adjunctive treatment for individuals with SMI. Even though effect sizes are small, there is a clear beneficial effect of PA in this population and no harm. Further research should explore the specific PA interventions, frequency, and duration for maximal reduction of psychiatric symptom severity so that recommendations can be made on how to use PA as an adjuvant intervention for people with SMI.\u003c/p\u003e \u003cp\u003eOf the ten studies included in the final review, 40% of studies scored as weak and 50% scored as moderate on the quality rating assessment. The lower quality scores were typically due to selection bias and lack of blinding. Because the studies focus on individuals with severe mental illness, a vulnerable population, it is likely that ethics created some logistical barriers to study design. Some of the studies explicitly refer to informing participants of the research question at the request of the ethics board. Active recruitment may also have been denied by ethics committees, particularly in in-patient settings, which would limit researchers to more passive recruitment such as displaying recruitment posters. While this protects potential participants from real or perceived abuse of power, it does introduce selection bias and would make recruitment of larger numbers challenging, particularly among individuals with psychotic disorders or severe depression, where the motivation and organization needed to independently contact researchers may be impacted. In future, it is critical that research include vulnerable populations, such as persons living with mental illness, so that we can better understand and treat these conditions. The American Psychiatric Association has summarized the aforementioned challenges and provided a list of recommendations for future study designs to ethically include this population (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSeveral studies also had small sample sizes, which was also likely due to the pragmatic challenges of recruiting participants, conducting research with individuals with SMI, and the ability of those individuals to consent to and participate in a study for the duration of the study. As mentioned previously, low motivation, anhedonia and other common symptoms of the disorders being examined are likely to have created barriers in recruitment, participation, and retention. Future research could potentially circumvent some of these barriers by doing retrospective studies on physical activity initiatives in settings such as tertiary care where residents are required to partake in daily activity programs and selection bias is therefore less likely to influence results.\u003c/p\u003e \u003cp\u003eAnother limitation of many of the studies was a lack of control groups. Only three of the ten studies included in the final analysis had control groups that received no intervention. Two of the studies, Strassnig et al. (2015) and Woodward et al. (2018), had no control group. Five of the studies had active control groups. For example, both Greer et al. (2016) and Streeter et al. (2017) administered the same intervention to the experimental and active control groups, but at different levels of intensity and frequency. They then assessed dose-dependent effects of the intervention. The efficacy of the intervention itself cannot be quantified in this type of study design because both groups will have gained some benefit, and the effect size will be diluted. Oertel-Kn\u0026ouml;chel et al. (2014) compared an exercise intervention group with an active control group enrolled in a relaxation program. This design makes it difficult to discern if improvements are due to PA or enrollment in a program that provides structure, support, social connection, or other benefits to participants. This study design was likely due to ethics requirements when working with vulnerable populations. Future research should consider how to better control confounding variables in the study design, perhaps by using waitlist control groups instead of active control groups, or by comparing group PA interventions to individual PA interventions.\u003c/p\u003e \u003cp\u003eSimilarly, several studies compared the intervention group with an active control group who were engaged in a different activity. Malchow et al. (2015) compared an aerobic intervention to an active control group who partook in table soccer instead of the aerobic exercise. Su et al. (2016) compared an aerobic exercise intervention with a stretching/toning active control group. The Woodward (2018) study design was even more convoluted as it compared an aerobic intervention group with a weight-bearing exercise intervention group. Depressive symptomology improved in both groups, and there was no non-PA intervention control group. With these types of study designs, particularly because there is a paucity in knowledge about the effects of any type of PA on psychiatric symptom severity and the mechanisms underlying these effects, it becomes difficult to parse apart causation. It is possible that participants are benefiting simply by being enrolled in a program. The improvements in psychiatric symptom severity could be due to the structure, social connection, and mental stimulation of program involvement and not the PA intervention. We first need to understand the effects of PA on psychiatric symptoms in general, and then begin to parse apart the potentially unique effects of different types of PA interventions.\u003c/p\u003e \u003cp\u003eSeveral of the studies included interventions in addition to the PA intervention. Malchow et. Al (2015) and Oertel-Kn\u0026ouml;chel et al. (2014) both used PA interventions in conjunction with computer assisted cognitive remediation training using \u0026lsquo;COG-PACK\u0026rsquo;. It is possible then that improvement in symptoms is due, fully, or partially, to benefits of the cognitive training. The effects of the PA intervention cannot be clearly quantified or assessed. Kang et al. (2016) included a social skills and self-management training components to their Thai-Chi intervention that makes it unclear if improvements were due to PA or non-PA interventions.\u003c/p\u003e \u003cp\u003ePerhaps the most complex study was the Jakobsen et al. (2017) study, which compared the CHANGE intervention with \u0026ldquo;care coordination\u0026rdquo; and \u0026ldquo;treatment as usual\u0026rdquo; control groups. The CHANGE intervention was a 1-year affiliation with a coach who would take a multifaceted, holistic, and individualized approach to wellness that included encouraging daily PA, but also addressed dietary issues, smoking, and other lifestyle factors. The care coordination group provided participants with a specially trained psychiatric nurse to coordinate access to primary health care, and the \u0026ldquo;treatment as usual group\u0026rdquo; were given access to a general practitioner and annual metabolic screening. With the complexity of these interventions and no measurable, controlled, or consistent PA intervention, it is not possible to draw causative connections between PA in the CHANGE group and psychiatric symptom severity.\u003c/p\u003e \u003cp\u003eAdditionally, there is the pragmatic challenge of being able to test PA efficacy in psychiatric symptom management without withholding treatment for these conditions, which would of course be unethical. For example, Siqueria et al. (2016) assessed the efficacy of an aerobic exercise intervention in decreasing depressive symptomology in individuals with major depressive disorder but did so by looking at the dosage of antidepressant medication required to manage symptoms. They found that the exercise group required lower doses of medication. This is clearly not a direct measure of the efficacy of the intervention in reducing symptomology, but it would be unethical to allow one group to experience more severe symptoms by withholding medication or keeping medication doses controlled and at subtherapeutic levels so that the PA intervention can be assessed. If medication were controlled at a therapeutic level, symptoms would be controlled, and it would not be possible to detect improvements from PA.\u003c/p\u003e \u003cp\u003eDespite this review compiling broad, global evidence unanimously supporting PA as an adjuvant treatment for SMI, there were some limitations. We searched the three main databases for this domain for all English-language articles, but articles not listed in one of these databases or published in another language would be not have been retrieved.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTo the best of our knowledge, this is the first review since publication of the DSM-V examining the efficacy of physical activity specifically on psychiatric symptom severity exclusively in individuals with severe mental illness. The results from ten studies showed a small improvement in psychiatric symptom severity that was achieved through physical activity intervention. None of the studies found any harm resulting from physical activity. However, the current literature is very heterogeneous in terms of PA types, frequency, duration, and intensity, and further research is needed before specific PA recommendations can be made as an adjunctive treatment for individuals with SMI. Based on the current literature, individuals with SMI should be encouraged and supported to engage in regular PA as there is no known harm, they can reap the same physical health benefits as the general population, and they may reduce the severity of psychiatric symptoms beyond what would be achieved with psychopharmacology alone.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSMI \u0026ndash; Severe Mental Illness\u003c/p\u003e\n\u003cp\u003ePA \u0026ndash; Physical Activity\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e: Not applicable. This was a systematic review and therefore did not have any participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: Both authors consent to publication with BMC Psychiatry.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e: All data and materials have been submitted with this review.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: None.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: There was no funding for this review.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e: AT conceived of the paper, developed the search strategy, provided the main searches, wrote the Methods, and developed the Tables. Both authors performed the analyses. AT wrote the paper. All authors edited the paper and had final approval of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information\u003c/strong\u003e: Ryan E. Rhodes, Ph.D., Behavioural Medicine Laboratory, Faculty of Education, PO Box 3010 STN CSC, University of Victoria, Victoria, B.C., V8W 3N4 CANADA, Tel: (250) 721‑8384, Fax: (250) 721‑7767, EM: [email protected]\u003c/p\u003e\n\u003cp\u003eAnika Todd, MSc, Behavioural Medicine Laboratory, School of Exercise Science, Physical and Health Education, University of Victoria, Victoria, BC, Canada\u003c/p\u003e\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHupin D, Roche F, Gremeaux V, Chatard JC, Oriol M, Gaspoz JM, et al. Even a low-dose of moderate-to-vigorous physical activity reduces mortality by 22% in adults aged \u0026ge;60 years: a systematic review and meta-analysis. Br J Sports Med. 2015 Oct 1;49(19):1262\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eWarburton DE, Charlesworth S, Ivey A, Nettlefold L, Bredin SS. A systematic review of the evidence for Canada\u0026rsquo;s Physical Activity Guidelines for Adults. Int J Behav Nutr Phys Act. 2010 Dec;7(1):1\u0026ndash;220. \u003c/li\u003e\n\u003cli\u003eGuthold R, Stevens GA, Riley LM, Bull FC. Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1\u0026middot;9 million participants. Lancet Glob Health. 2018 Oct 1;6(10):e1077\u0026ndash;86. \u003c/li\u003e\n\u003cli\u003eSubstance Abuse and Mental Health Services Administration. Results from the 2008 National Survey on Drug Use and Health: National Findings. Office of Applied Studies; 2009. (NSDUH Series H-36). Report No.: HHS Publication No. SMA 09-4434. \u003c/li\u003e\n\u003cli\u003eHarris EC, Barraclough B. Excess mortality of mental disorder. Br J Psyciatry. 1998;173(1):11\u0026ndash;53. \u003c/li\u003e\n\u003cli\u003eJoukamaa M, Heli\u0026ouml;Vaara M, Knekt P, Aromaa A, Raitasalo R, Lehtinen V. Mental disorders and cause-specific mortality. Br J Psychiatry. 2001;179(6):498\u0026ndash;502. \u003c/li\u003e\n\u003cli\u003eLaursen TM, Musliner KL, Benros ME, Vestergaard M, Munk-Olsen T. Mortality and life expectancy in persons with severe unipolar depression. J Affect Disord. 2016 Mar 15;193:203\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eHjorth\u0026oslash;j C, St\u0026uuml;rup AE, McGrath J, Nordentoft M. SA57. Life Expectancy and Years of Potential Life Lost in Schizophrenia: A Systematic Review and Meta-Analysis. Schizophr Bull. 2017 Mar;43(suppl_1):S133\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003eQuirk H, Hock E, Harrop D, Crank H, Peckham E, Traviss-Turner G, et al. Understanding the experience of initiating community-based group physical activity by people with serious mental illness: A systematic review using a meta-ethnographic approach. Eur Psychiatry. 2020 ed;63(1):e95. \u003c/li\u003e\n\u003cli\u003eLindamer LA, McKibbin C, Norman GJ, Jordan L, Harrison K, Abeyesinhe S, et al. Assessment of physical activity in middle-aged and older adults with schizophrenia. Schizophr Res. 2008 Sep 1;104(1):294\u0026ndash;301. \u003c/li\u003e\n\u003cli\u003eFaulkner G, Cohn T, Remington G. Validation of a physical activity assessment tool for individuals with schizophrenia. Schizophr Res. 2006 Feb 28;82(2):225\u0026ndash;31. \u003c/li\u003e\n\u003cli\u003eLake J, Turner MS. Urgent Need for Improved Mental Health Care and a More Collaborative Model of Care. Perm J. 2017 Aug 11;21:17\u0026ndash;024. \u003c/li\u003e\n\u003cli\u003eGold JM. Cognitive deficits as treatment targets in schizophrenia. Schizophr Res. 2004 Dec 15;72(1):21\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eReynolds GP. Schizophrenia, antipsychotics and metabolic disease. J Psychopharmacol (Oxf). 2007 Jun 1;21(4):355\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eLambert M, Conus P, Naber D. Impact of present and past antipsychotic side-effects on attitude toward typical antipsychotic treatment and compliance. Schizophr Res. 2003 Mar 15;60(1, Supplement):360. \u003c/li\u003e\n\u003cli\u003eFirth J, Cotter J, Elliott R, French P, Yung AR. A systematic review and meta-Analysis of exercise interventions in schizophrenia patients. Psychol Med. 2015;45(7). \u003c/li\u003e\n\u003cli\u003eSchuch FB, Vancampfort D. Physical activity, exercise, and mental disorders: it is time to move on. Trends Psychiatry Psychother. 2021 Oct 22;43(3):177\u0026ndash;84. \u003c/li\u003e\n\u003cli\u003eMoher D, Liberati A, Tetzlaff J, Altman DG. Academia and Clinic Annals of Internal Medicine Preferred Reporting Items for Systematic Reviews and Meta-Analyses : Ann Intern Med. 2009;151(4):264\u0026ndash;9. \u003c/li\u003e\n\u003cli\u003eCaspersen CJ, Powell KE, Christenson GM. Physical activity, exercise, and physical fitness: definitions and distinctions for health-related research. Public Health Rep. 1985;100(2):126\u0026ndash;31. \u003c/li\u003e\n\u003cli\u003eThomas BH, Ciliska D, Dobbins M, Micucci S. A Process for Systematically Reviewing the Literature: Providing the Research Evidence for Public Health Nursing Interventions. Worldviews Evidence‐Based Nurs. 2004 Sep 1;1(3):176\u0026ndash;84. \u003c/li\u003e\n\u003cli\u003eMcKenzie J, Brennan S. Chapter 12: Synthesizing and presenting findings using other methods. In: Cochrane Handbook for Systematic Reviews of Interventions [Internet]. version 6.3. 2022 [cited 2022 Dec 23]. Available from: https://training.cochrane.org/handbook/current/chapter-12\u003c/li\u003e\n\u003cli\u003eVerbeek J, Ruotsalainen J, Hoving JL. Synthesizing study results in a systematic review. Scand J Work Environ Health. 2012;38(3):282\u0026ndash;90. \u003c/li\u003e\n\u003cli\u003eField AP. Dread returns to Mega-Silly One. Health Psychol Rev. 2015 Jan;9(1):15\u0026ndash;20. \u003c/li\u003e\n\u003cli\u003eArmijo-Olivo S, Stiles CR, Hagen NA, Biondo PD, Cummings GG. Assessment of study quality for systematic reviews: a comparison of the Cochrane Collaboration Risk of Bias Tool and the Effective Public Health Practice Project Quality Assessment Tool: methodological research. J Eval Clin Pract. 2012 Feb;18(1):12\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eJakobsen AS, Speyer H, N\u0026oslash;rgaard HCB, Karlsen M, Birk M, Hjorth\u0026oslash;j C, et al. Effect of lifestyle coaching versus care coordination versus treatment as usual in people with severe mental illness and overweight: Two-years follow-up of the randomized CHANGE trial. Plos One. 2017 Oct 6;12(10):e0185881\u0026ndash;e0185881. \u003c/li\u003e\n\u003cli\u003eStreeter CC, Gerbarg PL, Whitfield TH, Owen L, Johnston J, Silveri MM, et al. Treatment of Major Depressive Disorder with Iyengar Yoga and Coherent Breathing: A Randomized Controlled Dosing Study. J Altern Complement Med N Y N. 2017 Mar;23(3):201\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eRastad C, Martin C, Asenl\u0026ouml;f P. Barriers, benefits, and strategies for physical activity in patients with schizophrenia. Phys Ther. 2014 Oct;94(10):1467\u0026ndash;79. \u003c/li\u003e\n\u003cli\u003eEthical Principles and Practices for Research Involving Human Participants With Mental Illness. Psychiatr Serv. 2006 Apr;57(4):552\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eOertel-Kn\u0026ouml;chel V, Mehler P, Thiel C, Steinbrecher K, Malchow B, Tesky V, et al. Effects of aerobic exercise on cognitive performance and individual psychopathology in depressive and schizophrenia patients. Eur Arch Psychiatry Clin Neurosci. 2014 Oct;264(7):589\u0026ndash;604. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"schizophrenia, bipolar disorder, major depressive disorder, physical activity, exercise","lastPublishedDoi":"10.21203/rs.3.rs-3411748/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3411748/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThere is a well-established relationship between physical activity (PA) and improved mental and physical health. However, the focus has been on mild to moderate anxiety and depression, while there has been a paucity in the literature regarding the impacts of PA on psychiatric symptoms in individuals with severe mental illness (SMI), and the potential utility of PA as an adjunctive treatment for these conditions. The purpose of this narrative analysis was to examine the effects of PA interventions on psychiatric symptoms among individuals with SMI, which we defined as schizophrenia spectrum disorders, bipolar disorders, and major depressive disorders.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA search was conducted in MEDLINE PsycInfo, and SPORTDiscus databases concluding in January 2023 that included studies published in an English peer-reviewed journal, with a PA intervention, conducted with adults (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;18yrs) diagnosed with a schizophrenia spectrum disorder, bipolar disorder, or major depressive disorder. The search returned 119 articles, and 10 met eligibility criteria.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eResults clearly showed that PA caused no harm and that a small improvement in psychiatric symptom severity was achieved, with effect sizes ranging from 0.013 to 0.712.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003ePhysical activity interventions can decrease psychiatric symptom severity in persons with severe mental illness and may be an efficacious adjuvant treatment to pharmacological management of schizophrenia, bipolar and major depressive disorders. Physical activity interventions did not have any adverse effects on individuals with severe mental illness. However, the current literature is heterogeneous in terms of PA types, frequency, duration, and intensity, and further research is needed before specific PA recommendations can be made as an adjunctive treatment for individuals with SMI.\u003c/p\u003e","manuscriptTitle":"Impacts of Physical Activity Interventions on Psychiatric Symptom Severity in Adults with Severe Mental illness: A Systematic Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-10-13 20:50:11","doi":"10.21203/rs.3.rs-3411748/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a1d99b23-43d6-4337-aabb-0df3c0b12148","owner":[],"postedDate":"October 13th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-01-07T08:14:14+00:00","versionOfRecord":[],"versionCreatedAt":"2023-10-13 20:50:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3411748","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3411748","identity":"rs-3411748","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}