EPA guidance on physical activity as a treatment for severe mental illness: a meta-review of the evidence and Position Statement from the European Psychiatric Association (EPA), supported by the International Organization of Physical Therapists in Mental Health (IOPTMH)
Open accessAbstract
Physical activity (PA) may be therapeutic for people with severe mental illness (SMI) who generally have low PA and experience numerous life style-related medical complications. We conducted a meta-review of PA interventions and their impact on health outcomes for people with SMI, including schizophrenia-spectrum disorders, major depressive disorder (MDD) and bipolar disorder. We searched major electronic databases until January 2018 for systematic reviews with/without meta-analysis that investigated PA for any SMI. We rated the quality of studies with the AMSTAR tool, grading the quality of evidence, and identifying gaps, future research needs and clinical practice recommendations. For MDD, consistent evidence indicated that PA can improve depressive symptoms versus control conditions, with effects comparable to those of antidepressants and psychotherapy. PA can also improve cardiorespiratory fitness and quality of life in people with MDD, although the impact on physical health outcomes was limited. There were no differences in adverse events versus control conditions. For MDD, larger effect sizes were seen when PA was delivered at moderate-vigorous intensity and supervised by an exercise specialist. For schizophrenia-spectrum disorders, evidence indicates that aerobic PA can reduce psychiatric symptoms, improves cognition and various subdomains, cardiorespiratory fitness, whilst evidence for the impact on anthropometric measures was inconsistent. There was a paucity of studies investigating PA in bipolar disorder, precluding any definitive recommendations. No cost effectiveness analyses in any SMI condition were identified. We make multiple recommendations to fill existing research gaps and increase the use of PA in routine clinical care aimed at improving psychiatric and medical outcomes.
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Moderate-to-vigorous intensity aerobic exercise alone or in combination with resistance training over at least 12 weeks and achieving 90 min per week appears the optimal mode of delivery of structured exercise.
“Thus, moderate-to-vigorous intensity aerobic exercise alone or in combination with resistance training [44] over at least 12 weeks and achieving 90 min per week appears the optimal mode of delivery of structured exercise.”
From Exercise as Medicine for Mental and Substance Use Disorders: A Meta-review of the Benefits for Neuropsychiatric and Cognitive Outcomes (2020) · cites this paper as [44]
Section 4.4 (page unavailable) reports benefits from aerobic exercise alone and combined aerobic and strength training in people with schizophrenia-spectrum disorders. It also reports optimal effects with over 90 minutes of moderate-to-vigorous activity per week. Although it describes a 12-week aerobic-exercise intervention, it does not establish at least 12 weeks as the optimal minimum duration. (LLM, conf=0.85)
Experimental — accuracy not yet measuredExercise is safe in serious mental illness.
“However, several recent studies have suggested that exercise is safe in serious mental illness [44,119].”
From Exercise as Medicine for Mental and Substance Use Disorders: A Meta-review of the Benefits for Neuropsychiatric and Cognitive Outcomes (2020) · cites this paper as [44]
Section 4.7 reports no difference in serious or non-serious adverse events between exercise and control groups in major depression. Section 4.5 reports no adverse events for walking in one schizophrenia-spectrum study, but says information on harms is scarce; sections 4.3 and 4.9 report no adverse-event information for pooled severe mental illness and bipolar disorder. These findings offer limited support for safety, not a general conclusion that exercise is safe across serious mental illness. (LLM, conf=0.86)
Experimental — accuracy not yet measuredThe European Psychiatric Association's guidelines on physical activity in mental illness put forth that there is sufficient evidence to recommend structured exercise training as an effective first-line treatment option for moderate depression, and as an adjunctive intervention for improving symptomatic recovery in severe mental illness.
“Notably, the European Psychiatric Association's guidelines 17 on physical activity in mental illness put forth that there is sufficient evidence to recommend structured exercise training as an effective first-line treatment option for moderate depression, and as an adjunctive intervention for improving symptomatic recovery in severe mental illness.”
From A meta-review of "lifestyle psychiatry": the role of exercise, smoking, diet and sleep in the prevention and treatment of mental disorders (2020) · cites this paper as [17]
Section 6.1 recommends supervised exercise for mild-to-moderate depression, but describes it as an adjunctive treatment for major depressive disorder, not a first-line replacement for standard treatment. Section 6.2 supports adjunctive physical activity to improve symptoms in schizophrenia-spectrum disorders; the claim’s reference to severe mental illness more broadly is less specific than that recommendation. Page numbers were not available in the indexed passages. (LLM, conf=0.90)
Experimental — accuracy not yet measuredExercise interventions can play an important role in reducing the physical health inequalities observed in people with mental illness.
“Whilst not the focus of this review, along with the neuropsychiatric benefits, exercise interventions can also play an important role in reducing the physical health inequalities observed in people with mental illness [44].”
From Exercise as Medicine for Mental and Substance Use Disorders: A Meta-review of the Benefits for Neuropsychiatric and Cognitive Outcomes (2020) · cites this paper as [44]
Exercise has clear potential to improve the poor physical health among people with schizophrenia.
“Given the mental health benefits, along with the clear potential for exercise to improve the poor physical health among people with schizophrenia [44], further research should now be dedicated towards establishing feasible and sustainable methods for engaging this population with moderate-to-vigorous intensity exercise training in real-world settings.”
From Exercise as Medicine for Mental and Substance Use Disorders: A Meta-review of the Benefits for Neuropsychiatric and Cognitive Outcomes (2020) · cites this paper as [44]
International public health consortia agree that exercise has antidepressant effects as a low-risk adjunct for optimal mental health.
“International public health consortia are in concert with the antidepressant effects of exercise as a low-risk adjunct for optimal mental health 9– 11 .”
The contrasting statements conveyed by international treatment guidelines preclude drawing definitive conclusions regarding the role of exercise as a treatment for non-severe depression.
“The contrasting statements conveyed by international treatment guidelines preclude drawing definitive conclusions regarding the role of exercise as a treatment for non-severe depression.”
The European Psychiatric Association report states that there is sufficient data supporting exercise for the management of mild-to-moderate depression.
“This contradicts the report by the European Psychiatric Association that states that there is sufficient data supporting exercise for the management of mild-to-moderate depression.19”
The use of exercise as an alternative treatment for non-severe depression is endorsed by several treatment guidelines (EPA in Europe, CANMAT in Canada, NICE in the UK and RANZCP in Australia).
“Specifically, the use of exercise as an alternative treatment for non-severe depression is endorsed by several treatment guidelines (EPA in Europe, CANMAT in Canada, NICE in the UK and RANZCP in Australia).19–22”
Our findings align with recommendations from European, Canadian, Australian and UK treatment guidelines supporting exercise as an alternative treatment for non-severe depression.
“Our findings align with the recommendations provided by European, Canadian, Australian and UK treatment guidelines supporting the use of exercise as an alternative treatment for non-severe depression.19–22”
An effective treatment against AD still does not exist.
“Although many remedial methods, including consuming chemical and herbal medicine and different ways of physical activity to inhibit AD progress, are available, an effective treatment against AD still does not exist (30,31).”
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Self-citationEkkekakis, P. (2015) · Mental Health and Physical Activity · doi:10.1016/j.mhpa.2014.12.001 · Cited by 114 · see citing works
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Self-citationThe Simple Physical Activity Questionnaire
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Self-citationCognitive Impairment in Euthymic Pediatric Bipolar Disorder: A Systematic Review and Meta-Analysis
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Self-citationA systematic review of cognitive effects of exercise in depression
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Self-citationA meta-analysis of prevalence estimates and moderators of low bone mass in people with schizophrenia
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Self-citationLung function and respiratory diseases in people with psychosis: Population-based study
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A brief review of exercise, bipolar disorder, and mechanistic pathways
Thomson, D., Turner, A., Lauder, S., Gigler, M. E., Berk, L., Singh, A., Pasco, J. A., Berk, M., & Sylvia, L. G. (2015) · Frontiers in Psychology · doi:10.3389/fpsyg.2015.00147 · Cited by 79 · see citing works
The pro‐cognitive mechanisms of physical exercise in people with schizophrenia
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Self-citationIntegrating physical activity as medicine in the care of people with severe mental illness
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Self-citationEmerging drugs for schizophrenia: an update
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The benefits of walking for individuals with schizophrenia spectrum disorders: A systematic review
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A systematic review of trials investigating strength training in schizophrenia spectrum disorders
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Potential Therapeutic Effects of Physical Exercise for Bipolar Disorder
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The relevance of EPA guidance papers in the framework of the European Psychiatric Association
Heun, R., & Gäebel, W. (2015) · European Psychiatry · doi:10.1016/j.eurpsy.2015.02.001 · Cited by 13 · see citing works
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Self-citationThe Exercise and Sports Science Australia position statement: Exercise medicine in cancer management
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Self-citationCardiovascular disease in patients with severe mental illness
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Self-citationSporting Mind: The Interplay of Physical Activity and Psychological Health
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Physical activity, exercise, and mental disorders: it is time to move on
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Passive Versus Mentally Active Sedentary Behaviors and Depression
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Self-citationPhysical Activity Interventions to Alleviate Depressive Symptoms in Children and Adolescents
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EPA guidance on treatment of negative symptoms in schizophrenia
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Self-citationMarx, W., Manger, S., Blencowe, M., Murray, G., Ho, F. Y., Lawn, S., Blumenthal, J. A., Schuch, F. B., Stubbs, B., Ruusunen, A. A., et al. (2022) · The World Journal of Biological Psychiatry · doi:10.1080/15622975.2022.2112074 · Cited by 189 · see citing works
Self-citationThe role of exercise in the treatment of depression: biological underpinnings and clinical outcomes
Ross, R. E., VanDerwerker, C. J., Saladin, M. E., & Gregory, C. M. (2023) · Molecular Psychiatry · doi:10.1038/s41380-022-01819-w · Cited by 176 · see citing works
Guddal, M. H., Stensland, S. Ø., Småstuen, M. C., Johnsen, M. B., Zwart, J., & Storheim, K. (2019) · BMJ Open · doi:10.1136/bmjopen-2018-028555 · Cited by 182 · see citing works
Hagi, K., Nosaka, T., Dickinson, D., Lindenmayer, J. P., Lee, J., Friedman, J. I., Boyer, L., Han, M., Rashid, N. A. A., & Correll, C. U. (2021) · JAMA Psychiatry · doi:10.1001/jamapsychiatry.2021.0015 · Cited by 171 · see citing works
Self-citationRosenbaum, S., Morell, R., Abdel‐Baki, A., Ahmadpanah, M., Anilkumar, T. V., Baie, L., Bauman, A. E., Bender, S., Han, J. B., Brand, S., et al. (2020) · BMC Psychiatry · doi:10.1186/s12888-020-2473-0 · Cited by 164 · see citing works
Self-citationVella, S. A., Aidman, E., Teychenne, M. J., Smith, J. J., Swann, C., Rosenbaum, S., White, R. L., & Lubans, D. R. (2023) · Journal of science and medicine in sport · doi:10.1016/j.jsams.2023.01.001 · Cited by 147 · see citing works
An integrative collaborative care model for people with mental illness and physical comorbidities
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Self-citationEuropean Psychiatric Association guidance on treatment of cognitive impairment in schizophrenia
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Self-citationCurcumin in Depression: Potential Mechanisms of Action and Current Evidence—A Narrative Review
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Management of depressive symptoms in peri- and postmenopausal women: EMAS position statement
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Severe mental illness: cardiovascular risk assessment and management
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Self-citationFernández-Abascal, B., Suárez‐Pinilla, P., Cobo-Corrales, C., Crespo‐Facorro, B., & Suárez‐Pinilla, M. (2021) · Neuroscience & Biobehavioral Reviews · doi:10.1016/j.neubiorev.2021.01.005 · Cited by 93 · see citing works
Exercise as a therapeutic modality for the prevention and treatment of depression
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Stress and coping in women with breast cancer:unravelling the mechanisms to improve resilience
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Predictors of depression, anxiety and stress among remote workers during the COVID-19 pandemic
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Self-citationCardiovascular effects of psychotic illnesses and antipsychotic therapy
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Umbrella reviews (systematic review of reviews)
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Self-citationLifestyle interventions for mental health
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Self-citationThe evidence for physical activity in the management of major mental illnesses
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Self-citationStrategies to counter antipsychotic-associated weight gain in patients with schizophrenia
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Self-citationDeenik, J., Tenback, D. E., Tak, E. C. P. M., Henkemans, O. B., Rosenbaum, S., Hendriksen, I. J. M., & van Harten, P. N. (2019) · BMC Health Services Research · doi:10.1186/s12913-019-4608-x · Cited by 60 · see citing works
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Antipsychotic-Induced Metabolic Syndrome: A Review
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Effectiveness of yoga for major depressive disorder: A systematic review and meta-analysis
Wu, Y., Yan, D., & Yang, J. (2023) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2023.1138205 · Cited by 54 · see citing works
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Self-citationEditorial: Lifestyle Psychiatry
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Self-citation
- Authors
- Stubbs, B., Vancampfort, D., Hallgren, M., Firth, J., Veronese, N., Solmi, M., Brand, S., Cordes, J., Malchow, B., Gerber, M., Schmitt, A., Correll, C. U., De Hert, M., Gaughran, F., Schneider, F., Kinnafick, F., Falkai, P., Möller, H.-J., & Kahl, K. G.
- Affiliations
- King's College London (GB)
- KU Leuven (BE)
- Karolinska Institutet (SE)
- The University of Melbourne (AU)
- National Research Council (IT)
- University of Padua (IT)
- University of Basel (CH)
- Heinrich Heine University Düsseldorf (DE)
- Ludwig-Maximilians-Universität München (DE)
- Universidade de São Paulo (BR)
- Hofstra University (US)
- RWTH Aachen University (DE)
- Loughborough University (GB)
- Medizinische Hochschule Hannover (DE)
- Corresponding author
- Stubbs, Brendon
- ORCID
- Venue
- European Psychiatry
- Publisher
- Cambridge University Press (CUP)
- Published
- 2018-07-18
- Volume
- 54
- Pages
- 124-144
- ISSN
- 0924-9338 (ISSN-L)
- 1778-3585
- OpenAlex
- W2887909476
- Semantic Scholar
- 567a3e019a6376dd5c8a6931e3048be7aba1b933
- Cited by
- 697
- References
- 100
- Citations by year
- 2026: 90 · 2025: 83 · 2024: 124 · 2023: 97 · 2022: 87 · 2021: 77 · 2020: 78 · 2019: 58 · 2018: 3
- FWCI
- 7.07
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- European Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Loughborough University Institutional Repository (Loughborough University) (submittedVersion, cc-by-nc-nd)
- edoc (University of Basel) (submittedVersion)
- Figshare (submittedVersion)
- Loughborough University Research Repository (Loughborough University) (submittedVersion, cc-by-nc-nd)
- Nova Science Publishers (Nova Science Publishers, Inc.) (submittedVersion)
- Research Portal (King's College London) (submittedVersion)
- Lirias (submittedVersion)
- RWTH Publications (RWTH Aachen) (submittedVersion)
- Research Explorer (The University of Manchester) (submittedVersion)
- MPG.PuRe (Max Planck Society) (submittedVersion)
- Padua Research Archive (University of Padova) (submittedVersion)
- Funders
- King's College Hospital NHS Foundation Trust
- Maudsley Charity
- National Institute for Health and Care Research (CL-2017-03-001, ICA-CL-2017-03-001, CL-2017, NIHR-INF-0685)
- Department of Health and Social Care
- King's College London
- Topics
- Health Sciences › Medicine › Physiology › Physical Activity and Health
- Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
- Health Sciences › Medicine › Pharmacology › Treatment of Major Depression
- Keywords
- physical activity, severe mental illness, schizophrenia spectrum disorders, major depressive disorder, bipolar disorder, exercise intervention, aerobic exercise, cardiorespiratory fitness, quality of life, cognitive function, adverse events, cost-effectiveness, clinical guidelines
- MeSH terms
- Cardiorespiratory Fitness, Bipolar Disorder, Major Depressive Disorder, Humans, Mental Health, Psychiatry, Psychotic Disorders, Quality of Life, Schizophrenia, Schizophrenic Psychology, Societies, Medical, Societies, Scientific, Exercise, Physical Therapists
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