Clinical Practice & Epidemiology in Mental Health




ISSN: 1745-0179 ― Volume 14, 2018
ARTICLE COMMENTARY

Physical Activity, Exercise and Sport Programs as Effective Therapeutic Tools in Psychosocial Rehabilitation



Federica Sancassiani1, *, Sergio Machado3, 4, Antonio Preti1, 2
1 Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
2 Center for Consultation-Liaison Psychiatry and Psychosomatics, University Hospital, University of Cagliari, Cagliari, Italy
3 Laboratory of Panic and Respiration, Institute of Psychiatry of Federal University of Rio de Janeiro (IPUB/UFRJ), Rio de Janeiro, RJ, Brazil
4 Physical Activity Neuroscience, Physical Activity Sciences Postgraduate Program - Salgado de Oliveira University, Niterói, Brazil

Abstract

People with severe psychosocial disabilities have a 20-years shorter lifespan due to chronic somatic comorbidities and the long-term consequences of the side-effects of antipsychotic drugs.

They often are sedentary and show lower levels of physical activity, factors which can contribute to their shorter lifespan, because of the greater cardiovascular risk.

An increasing amount of evidence, including clinical trials, pointed out that sport, physical activity and structured exercise programs improve physical and psychological wellbeing of people with psychosocial disabilities, playing also an important role against their social isolation and self-stigma.

The NICE and APA guidelines include exercise and physical activity for the management of depressive symptoms.

Safe and effective programs require multidisciplinary teams that should always include mental health professionals, able to recognize the psychosocial needs, the impact of symptomatology, the role of secondary effects of psychotropic medication, the effect of previous exercise history, the lack of motivation, the inexperience with effort intensity and the frustration of people with psychosocial disabilities.

Keywords: Sport, Exercise, Physical activity, Psychosocial disability, Psychosocial rehabilitation, Multidisciplinary.


Article Information


Identifiers and Pagination:

Year: 2018
Volume: 14
First Page: 6
Last Page: 10
Publisher Id: CPEMH-14-6
DOI: 10.2174/1745017901814010006

Article History:

Received Date: 15/11/2017
Revision Received Date: 16/12/2017
Acceptance Date: 15/1/2018
Electronic publication date: 21/02/2018
Collection year: 2018

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© 2018 Sancassiani et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.


* Address correspondence to this author at the Department of Medical Sciences and Public Health, University of Cagliari, SS554, 09042 Monserrato Cagliari, Italy, Tel: 30039 3493119215; E-mail: federicasancassiani@yahoo.it




According to the World Health Organization [1World Health Organization,. Mental Health Action Plan 2013-2020. 2013 http://apps.who.int/iris/ bitstream/10665/ 89966/1/9789241506021_eng.pdf?ua=1 ] mental, neurological and substance use disorders account for 13% of the total global burden of disease in the year 2004. Depression alone accounts for 4.3% of the global burden of disease and it is among the largest single causes of disability worldwide (11% of all years lived with disability globally), particularly for women”.

People with severe psychosocial disabilities (i.e. schizophrenia, major depressive and bipolar disorders) have a 20-years shorter lifespan due to chronic somatic comorbidities, such as diabetes, overweight, obesity, cardiovascular and dysmetabolic diseases, also including to the long-term consequences of the side-effects of antipsychotic drugs [2Henderson DC, Vincenzi B, Andrea NV, Ulloa M, Copeland PM. Pathophysiological mechanisms of increased cardiometabolic risk in people with schizophrenia and other severe mental illnesses. Lancet Psychiatry 2015; 2(5): 452-64.[http://dx.doi.org/10.1016/S2215-0366(15)00115-7] [PMID: 26360288] -4Hall I, Shah A, Thomson H. Improving physical health for people taking antipsychotic medication in the Community Learning Disabilities Service 2016; 5(1): u209539.w3933.[http://dx.doi.org/10.1136/bmjquality.u209539.w3933] ]. Persons with severe psychosocial disabilities are also significantly more sedentary and show lower levels of physical activity than healthy persons [4Hall I, Shah A, Thomson H. Improving physical health for people taking antipsychotic medication in the Community Learning Disabilities Service 2016; 5(1): u209539.w3933.[http://dx.doi.org/10.1136/bmjquality.u209539.w3933] , 5Vancampfort D, Firth J, Schuch F, et al. Physical activity and sedentary behavior in people with bipolar disorder: A systematic review and meta-analysis. J Affect Disord 2016; 201: 145-52. [a].[http://dx.doi.org/10.1016/j.jad.2016.05.020] [PMID: 27235817] ], factors which can contribute to their shorter lifespan, because of the greater cardiovascular risk that these unhealthy habits entail. It must be emphasized that sedentary behavior and low physical activity levels are independent yet modifiable risk. It must be emphasized that sedentary behavior and low physical physical activity levels are independent yet modifiable risk factors for premature mortality of these people [4Hall I, Shah A, Thomson H. Improving physical health for people taking antipsychotic medication in the Community Learning Disabilities Service 2016; 5(1): u209539.w3933.[http://dx.doi.org/10.1136/bmjquality.u209539.w3933] -6Vancampfort D, Firth J, Schuch FB, et al. Sedentary behavior and physical activity levels in people with schizophrenia, bipolar disorder and major depressive disorder: A global systematic review and meta-analysis. World Psychiatry 2017; 16(3): 308-15.[http://dx.doi.org/10.1002/wps.20458] [PMID: 28941119] ]. For this reason, the interest in the integration of sport, physical activity and exercise programs as a component of treatment and rehabilitation for this population has been growing over the last decades.

Over time, much evidence pointed out the benefits of sport, physical activity and structured exercise programs in the mental health promotion field [7Rosenbaum S, Tiedemann A, Sherrington C, Curtis J, Ward PB. Physical activity interventions for people with mental illness: A systematic review and meta-analysis. J Clin Psychiatry 2014; 75(9): 964-74.[http://dx.doi.org/10.4088/JCP.13r08765] [PMID: 24813261] -9Wegner M, Helmich I, Machado S, Nardi AE, Arias-Carrion O, Budde H. Effects of exercise on anxiety and depression disorders: Review of meta- analyses and neurobiological mechanisms. CNS Neurol Disord Drug Targets 2014; 13(6): 1002-14.[http://dx.doi.org/10.2174/1871527313666140612102841] [PMID: 24923346] ], in particular for depressive and anxiety disorders [9Wegner M, Helmich I, Machado S, Nardi AE, Arias-Carrion O, Budde H. Effects of exercise on anxiety and depression disorders: Review of meta- analyses and neurobiological mechanisms. CNS Neurol Disord Drug Targets 2014; 13(6): 1002-14.[http://dx.doi.org/10.2174/1871527313666140612102841] [PMID: 24923346] -20Jayakody K, Gunadasa S, Hosker C. Exercise for anxiety disorders: Systematic review. Br J Sports Med 2014; 48(3): 187-96.[http://dx.doi.org/10.1136/bjsports-2012-091287] [PMID: 23299048] ].

Sport, exercise and physical activity are not synonymous [21Budde H, Schwarz R, Velasques B, et al. The need for differentiating between exercise, physical activity, and training. Autoimmun Rev 2016; 15(1): 110-1.[http://dx.doi.org/10.1016/j.autrev.2015.09.004] [PMID: 26384527] , 22Duché P, Rochette E, Merlin E. Reply to the Letter to the Editor: The need for differentiating between exercise, physical activity, and training. Budde et al Autoimmun Rev Autoimmun Rev 2015; 15(3): 289-90. 2016 Mar[http://dx.doi.org/10.1016/j.autrev.2015.09.004] ]. Traditionally, physical activity is referred to “any bodily movement produced by skeletal muscles that results in energy expenditure” [23Caspersen 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.[PMID: 3920711] ] and its components are occupational, transport, domestic, and leisure time, which consists of exercise, sport, and unstructured recreation. From this perspective, most sports contribute to overall physical activity [24Khan KM, Thompson AM, Blair SN, et al. Sport and exercise as contributors to the health of nations. Lancet 2012; 380(9836): 59-64.[http://dx.doi.org/10.1016/S0140-6736(12)60865-4] [PMID: 22770457] ]. Exercise is a “planned, structured and repetitive bodily movement, the objective of which is to improve or maintain physical fitness” [23Caspersen 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.[PMID: 3920711] ]. Sport is defined as “a subset of exercise that can be undertaken individually or as a part of a team. Participants adhere to a common set of rules or expectations, and a defined goal exists” [24Khan KM, Thompson AM, Blair SN, et al. Sport and exercise as contributors to the health of nations. Lancet 2012; 380(9836): 59-64.[http://dx.doi.org/10.1016/S0140-6736(12)60865-4] [PMID: 22770457] ].

Studies have shown that even a small increase in physical activity has a positive impact on symptoms, functioning, severity of the condition, physical health (i.e.: cardiovascular risk profile) and sleep quality in people with psychosocial disabilities [17Schuch FB, Vancampfort D, Rosenbaum S, Richards J, Ward PB, Stubbs B. Exercise improves physical and psychological quality of life in people with depression: A meta-analysis including the evaluation of control group response. Psychiatry Res 2016; 241: 47-54.[http://dx.doi.org/10.1016/j.psychres.2016.04.054] [PMID: 27155287] , 25Vancampfort D, Stubbs B, Ward PB, Teasdale S, Rosenbaum S. Integrating physical activity as medicine in the care of people with severe mental illness. Aust N Z J Psychiatry 2015; 49(8): 681-2. [a].[http://dx.doi.org/10.1177/0004867415590831] [PMID: 26041791] -31Chalfoun C, Karelis AD, Stip E, Abdel-Baki A. Running for your life: A review of physical activity and cardiovascular disease risk reduction in individuals with schizophrenia. J Sports Sci 2016; 34(16): 1500-15.[http://dx.doi.org/10.1080/02640414.2015.1119875] [PMID: 26630458] ]. Recent evidence from clinical trials pointed out that these benefits include improvements about weigh, motor difficulties, psychiatric symptoms, cognitive and social functioning, self-esteem, self-efficacy and quality of life [32Hardoy MC, Seruis ML, Floris F, et al. Benefits of exercise with mini tennis in intellectual disabilities: effects on body image and psychopathology. Clin Pract Epidemol Ment Health 2011; 7: 157-60.[http://dx.doi.org/10.2174/1745017901107010157] [PMID: 22016751] -42Kerling A, Tegtbur U, Gützlaff E, et al. Effects of adjunctive exercise on physiological and psychological parameters in depression: A randomized pilot trial. J Affect Disord 2015; 177: 1-6.[http://dx.doi.org/10.1016/j.jad.2015.01.006] [PMID: 25743367] ].

Furthermore, sport, exercise and physical activity programs seem to play an important role against social isolation [32Hardoy MC, Seruis ML, Floris F, et al. Benefits of exercise with mini tennis in intellectual disabilities: effects on body image and psychopathology. Clin Pract Epidemol Ment Health 2011; 7: 157-60.[http://dx.doi.org/10.2174/1745017901107010157] [PMID: 22016751] -36Sancassiani F, Lorrai S, Cossu G, et al. The Effects of “VelaMente?!” project on social functioning of people with severe psychosocial disabilities. Clin Pract Epidemiol Mental Health 2017; 13(3) [b].], a typical phenomenon closely linked with the experience of suffering from a psychosocial disability [43Linz SJ, Sturm BA. The phenomenon of social isolation in the severely mentally ill. Perspect Psychiatr Care 2013; 49(4): 243-54.[http://dx.doi.org/10.1111/ppc.12010] [PMID: 25187445] ].

Psychosocial disabilities cause an elevated burden in terms of lost opportunities and this leads to higher self-perceived stigma [44Angermeyer MC, van der Auwera S, Carta MG, Schomerus G. Public attitudes towards psychiatry and psychiatric treatment at the beginning of the 21st century: A systematic review and meta-analysis of population surveys. World Psychiatry 2017; 16(1): 50-61.[http://dx.doi.org/10.1002/wps.20383] [PMID: 28127931] ], as well as to lower self-efficacy and quality of life [45Abraham KM, Miller CJ, Birgenheir DG, Lai Z, Kilbourne AM. Self-efficacy and quality of life among people with bipolar disorder. J Nerv Ment Dis 2014; 202(8): 583-8.[http://dx.doi.org/10.1097/NMD.0000000000000165] [PMID: 25010107] ]. Conversely, when people with psychosocial disabilities are offered a chance of employing their time in engaging social activities, such as sport and exercise programs, from which they are often kept apart, they benefit from the opportunity [32Hardoy MC, Seruis ML, Floris F, et al. Benefits of exercise with mini tennis in intellectual disabilities: effects on body image and psychopathology. Clin Pract Epidemol Ment Health 2011; 7: 157-60.[http://dx.doi.org/10.2174/1745017901107010157] [PMID: 22016751] -36Sancassiani F, Lorrai S, Cossu G, et al. The Effects of “VelaMente?!” project on social functioning of people with severe psychosocial disabilities. Clin Pract Epidemiol Mental Health 2017; 13(3) [b].].

The evidence available regarding the management of depressive symptoms has led to the inclusion of exercise and physical activity into the guidelines from the National Institute for Health & Clinical Excellence (NICE) [46National Institute for Health and Clinical Excellence Depression The treatment and management of depression in adults (updated edition).. Available from: https://www.nice.org.uk/guidance/cg90 2016.] and the American Psychiatric Association (APA) [47American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major Depressive Disorder 3rd ed.. 2010.3rd ed..]. The NICE guidelines [46National Institute for Health and Clinical Excellence Depression The treatment and management of depression in adults (updated edition).. Available from: https://www.nice.org.uk/guidance/cg90 2016.] recommend regular physical activity programs, 3 times/week, 45-60 minutes over 12 weeks for people with persistent subthreshold depressive symptoms or mild-moderate depression. The APA guidelines [47American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major Depressive Disorder 3rd ed.. 2010.3rd ed..] suggest that people with depression of any severity and without any comorbid medical contraindications in relation to physical activity and exercise should include them as an add-on treatment.

However, these guidelines do not include any specific recommendations about the intensity and the suitable dose for exercise and physical activity [48Carneiro L, Rosenbaum S, Mota MP, Schuch F, Ward PB, Vasconcelos-Raposo J. Exercise as an essential therapeutic tool in mental health: Closing the gap from research to practice, A portuguese perspective. Acta Med Port 2017; 30(5): 354-5.[http://dx.doi.org/10.20344/amp.8436] [PMID: 28865497] ], as well as any considerations about administration (i.e.: which kind of health professionals should conduct these interventions). In so far there is consistent evidence that supervised aerobic exercise is effective in reducing depressive symptoms when carried out 3 times/week, at moderate intensity for at least 9 weeks [49Stanton R, Reaburn P. Exercise and the treatment of depression: A review of the exercise program variables. J Sci Med Sport 2014; 17(2): 177-82.[http://dx.doi.org/10.1016/j.jsams.2013.03.010] [PMID: 23602562] ]. It is unclear how the effects that were observed for mild to moderate depression are generalizable to more severe psychosocial disabilities. Overall, safe and effective programs are expected to require the involvement of multidisciplinary teams that should always include mental health professionals, able to recognize the psychosocial needs, the impact of symptomatology, the role of the secondary effects of psychotropic medication, the effects of previous exercise history, and the lack of motivation, inexperience with effort intensity, and the frustration of people with psychosocial disabilities [48Carneiro L, Rosenbaum S, Mota MP, Schuch F, Ward PB, Vasconcelos-Raposo J. Exercise as an essential therapeutic tool in mental health: Closing the gap from research to practice, A portuguese perspective. Acta Med Port 2017; 30(5): 354-5.[http://dx.doi.org/10.20344/amp.8436] [PMID: 28865497] ].

The evidence on the potentially beneficial effects of physical activity, exercise and sports on the course of severe psychosocial disabilities, particularly as far their quality of life is concerned, make hopeful that in the future the care for people with psychosocial disabilities should always include a focus on improving their fitness. Adequate programs should be carried out in stimulating environments, by qualified healthcare professionals, able to motivate and support participants in maintaining an active lifestyle [50Farholm A, Sørensen M. Motivation for physical activity and exercise in severe mental illness: A systematic review of intervention studies. Int J Ment Health Nurs 2016; 25(3): 194-205.[http://dx.doi.org/10.1111/inm.12214] [PMID: 26916699] -52Thompson Coon J, Boddy K, Stein K, Whear R, Barton J, Depledge MH. Does participating in physical activity in outdoor natural environments have a greater effect on physical and mental wellbeing than physical activity indoors? A systematic review. Environ Sci Technol 2011; 45(5): 1761-72.[http://dx.doi.org/10.1021/es102947t] [PMID: 21291246] ]. To achieve these goals, changes in the mental health care system [53Carta MG, Angermeyer MC, Sancassiani F, et al. A follow-up on patients with severe mental disorders in Sardinia after two changes in regional policies: poor resources still correlate with poor outcomes. BMC Psychiatry 2013; 13: 333.[http://dx.doi.org/10.1186/1471-244X-13-333] [PMID: 24313930] , 54Rosenbaum S, Watkins A, Ward PB, Pearce D, Fitzpatrick K, Curtis J. Psychiatry HeAL thyself! Aust N Z J Psychiatry 2016; 50(6): 600.[http://dx.doi.org/10.1177/0004867415620023] [PMID: 26619896] ] and the recognition of the same priority to physical, social and mental health needs of people with psychosocial disabilities are required.

CONSENT FOR PUBLICATION

Not applicable.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

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Endorsements



"Open access will revolutionize 21st century knowledge work and accelerate the diffusion of ideas and evidence that support just in time learning and the evolution of thinking in a number of disciplines."


Daniel Pesut
(Indiana University School of Nursing, USA)

"It is important that students and researchers from all over the world can have easy access to relevant, high-standard and timely scientific information. This is exactly what Open Access Journals provide and this is the reason why I support this endeavor."


Jacques Descotes
(Centre Antipoison-Centre de Pharmacovigilance, France)

"Publishing research articles is the key for future scientific progress. Open Access publishing is therefore of utmost importance for wider dissemination of information, and will help serving the best interest of the scientific community."


Patrice Talaga
(UCB S.A., Belgium)

"Open access journals are a novel concept in the medical literature. They offer accessible information to a wide variety of individuals, including physicians, medical students, clinical investigators, and the general public. They are an outstanding source of medical and scientific information."


Jeffrey M. Weinberg
(St. Luke's-Roosevelt Hospital Center, USA)

"Open access journals are extremely useful for graduate students, investigators and all other interested persons to read important scientific articles and subscribe scientific journals. Indeed, the research articles span a wide range of area and of high quality. This is specially a must for researchers belonging to institutions with limited library facility and funding to subscribe scientific journals."


Debomoy K. Lahiri
(Indiana University School of Medicine, USA)

"Open access journals represent a major break-through in publishing. They provide easy access to the latest research on a wide variety of issues. Relevant and timely articles are made available in a fraction of the time taken by more conventional publishers. Articles are of uniformly high quality and written by the world's leading authorities."


Robert Looney
(Naval Postgraduate School, USA)

"Open access journals have transformed the way scientific data is published and disseminated: particularly, whilst ensuring a high quality standard and transparency in the editorial process, they have increased the access to the scientific literature by those researchers that have limited library support or that are working on small budgets."


Richard Reithinger
(Westat, USA)

"Not only do open access journals greatly improve the access to high quality information for scientists in the developing world, it also provides extra exposure for our papers."


J. Ferwerda
(University of Oxford, UK)

"Open Access 'Chemistry' Journals allow the dissemination of knowledge at your finger tips without paying for the scientific content."


Sean L. Kitson
(Almac Sciences, Northern Ireland)

"In principle, all scientific journals should have open access, as should be science itself. Open access journals are very helpful for students, researchers and the general public including people from institutions which do not have library or cannot afford to subscribe scientific journals. The articles are high standard and cover a wide area."


Hubert Wolterbeek
(Delft University of Technology, The Netherlands)

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(Sapienza - University of Rome, Italy)

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Philippe Hernigou
(Paris University, France)

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Peter Chiba
(University of Vienna, Austria)

"Open access journals are probably one of the most important contributions to promote and diffuse science worldwide."


Jaime Sampaio
(University of Trás-os-Montes e Alto Douro, Portugal)

"Open access journals make up a new and rather revolutionary way to scientific publication. This option opens several quite interesting possibilities to disseminate openly and freely new knowledge and even to facilitate interpersonal communication among scientists."


Eduardo A. Castro
(INIFTA, Argentina)

"Open access journals are freely available online throughout the world, for you to read, download, copy, distribute, and use. The articles published in the open access journals are high quality and cover a wide range of fields."


Kenji Hashimoto
(Chiba University, Japan)

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(Chinese University of Hong Kong, Hong Kong)

"It is a modern trend for publishers to establish open access journals. Researchers, faculty members, and students will be greatly benefited by the new journals of Bentham Science Publishers Ltd. in this category."


Jih Ru Hwu
(National Central University, Taiwan)


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