The impact of exercise training complementary to early intervention in patients with first-episode psychosis: a qualitative sub-study from a randomized controlled feasibility trial

The schizophrenia spectrum encompasses psychotic disorders, which are serious mental disorders with typical onset in adolescence and in the early 20s, with few being diagnosed after the age of 40 [1]. Although some patients recover, a substantial proportion will experience persistent functional and cognitive impairments [2]. For these reasons, psychotic disorders are ranked among the most burdensome and costly illnesses worldwide [3‐5].

Specialised early intervention in psychosis is described as the most successful recent addition to the treatment of schizophrenia [6]. Early intervention in psychosis in Denmark comprises specialised outpatient multidisciplinary teams called OPUS. OPUS is a well-documented, intensive treatment modality for patients with first-episode psychosis (FEP) including schizophrenia [7]. OPUS is not an acronym; the name comes from the world of music and symbolizes the necessity for different instruments to play together [8]. OPUS include treatment with antipsychotic medication, cognitive-based case management, psychoeducational family involvement, and social skills training [9]. All team members, except the psychiatrist, function as primary team member for a given patient, and the caseload is 10:1 [10].

Despite considerable progress in treatment, people with schizophrenia are 2–2.5 times more likely to die earlier than the general population, with an average life expectancy that is 15–20 years shorter [11, 12]. Cardiovascular diseases constitute a significant contributing factor to this mortality gap, which may be partly attributable to weight gain induced by antipsychotic medication [13]. However, also modifiable lifestyle factors such as smoking, substance abuse and physical inactivity play a central role [13].

It is widely acknowledged that physical activity including exercise training is effective in preventing and managing cardiovascular diseases in non-psychiatric populations [14, 15]. Moreover, a recent, large cross-sectional study documents that exercise is significantly and meaningfully associated with fewer days of poor self-reported mental health in the general population [16]. Furthermore, a recent meta-analysis [17] documented that exercise can improve cognitive functioning among people with schizophrenia, particularly in interventions with higher doses of exercise. Currently, however, OPUS does not exercise training as a standard treatment, and, to our knowledge, only one previous study [18] examined the perceived effects of exercise participation as experienced by people in the early stages of psychosis. Firth and colleagues [18] interviewed nineteen people with FEP who had recently participated in a 10-week moderate-to-vigorous exercise intervention. The authors reported that the participants experienced that their mental health improved [18]. Moreover, few non-randomized studies [19‐21] that have demonstrated promising results in relation to supervised exercise in young people with FEP, including prevention of antipsychotic-induced weight gain [19], improved cardiorespiratory fitness [20], and symptomatic, neurocognitive and metabolic outcomes [21].

Functional training programmes characterised by functional movements (i.e. movements which replicate activities of daily living) performed at moderate to high intensity and with constantly varying movements, e.g. CrossFit®, constitute a growing fitness regimen [22]. Functional training programmes are well marketed and have become increasingly popular due to their motivational and challenging nature [22]. This may be related to a great sense of community and enjoyment compatible with that presented in sports practice [23]. However, little is known about the acceptability of functional exercise training as an adjunct to early intervention in FEP.

Against this background, we designed COPUS (i.e. Corpus plus OPUS), a randomised feasibility trial intended to examine the recruitment, retention, acceptability and potential efficacy of a supervised, group-based, functional exercise training programme in patients with FEP. While quantitative data related to feasibility including evaluation of possible changes in cardiorespiratory fitness, body composition and muscle strength are reported in a separate paper, the overall aim of the current qualitative sub-study was to provide an understanding of the complexity of the programme. This includes description of contextual factors of importance in the planning and execution of a subsequent Phase III trial and potential programme implementation.

The specific aims of the current study were four-fold:

Sixteen participants (12 women, 4 men, mean age 25.0 ± 4.5 years) were interviewed at baseline of whom 13 were randomised to the intervention group. Of these, nine participants (6 women, 3 men, mean age 24.3) were interviewed individually after completing the programme, including one participant who had dropped out after the first training session. Table 2 provides an overview of the medical and sociodemographic characteristics of the participants.

The analysis resulted in three main themes and ten subthemes, which are described below and illustrated in Fig. 2. In the following, quotes by participants are written in italics and Table 3 provides additional examples of especially illustrative quotes and fieldnotes.

The overall aim of this study was to provide an understanding of the complexity and contextual factors related to an eight-week moderate to high intensity exercise training programme in patients with FEP by exploring social interaction and perspectives of participants and exercise instructors responsible for delivery of the programme. Overall, the findings suggest that the programme was appealing to, and appreciated by, the participants because of its potential to create an equally challenging and caring environment.

The fact that the programme was delivered in a non-clinical setting (i.e. a commercial fitness centre), supported the participants in feeling like normal young adults in a real-world setting (i.e. a conventional exercise setting) under the supervision of non-health professionals. The participants’ need to feel safe and to receive care was supported by the fact that the programme was designed, promoted and delivered in collaboration with OPUS staff and that it was exclusively for patients with FEP. Figure 3 provides an illustration of an interpretation of the current study’s main finding, i.e. the programme’s ability to embrace a youth and a mental illness perspective simultaneously.

It is widely acknowledged that young adulthood constitutes a core period for identity development and is often a challenging time [28]. Thus, providing the individuals with FEP the opportunity to better navigate between being a patient with a mental illness and being a young adult could have therapeutic potential, including supporting recovery and preventing social isolation [8].

Specialised early intervention treatment for patients with FEP provides a necessary and imperative focus on schizophrenia, which assist in helping young adults to understand and navigate what it means to be mentally ill [8]. Focusing too greatly on, and being constantly reminded of, being mentally ill may be an unfavourable approach for recovery as doing so may decrease the individual’s feeling of connectedness to peers, potentially disturbing the (re) building of identity, risking that schizophrenia becomes the main identity of the young adult, thereby worsening its severity and chronicity [29].

The findings indicate that exercise training delivered in a non-clinical setting may represent an opportunity for patients with FEP to explore and experience the aspect of being a young adult, with minimal focus on mental illness. The programme offered participants a flexible space that made it possible to integrate being mentally ill and in need of treatment and care as a patient, with being a young adult in need of social inclusion and challenging activities. Because current, specialised early intervention treatments for patients with FEP primarily take place in a patient setting, this programme may provide a novel addition to existing treatment regimens.

To our knowledge, the current study is the first to explore moderate to high-intensity exercise targeting patients with FEP, delivered in a commercial fitness centre outside the patient setting. A systematic review and meta-ethnographic synthesis exploring the experiences of people with schizophrenia and exercise, concluded that exercise interventions should be patient-centred to help protect and reassure individuals and to aid adherence [30]. While this is important, our findings suggest that emphasis on experiences of being a normal young adult may be especially important in relation to FEP.

A notable finding of the current study was the contribution of the instructors in creating a caring yet challenging environment. We believe that several factors are important to consider in this regard. First, the instructors supervising the current programme were within the same age-range as the participants. Moreover, they represented an exercise community (i.e. students at the University of Copenhagen Department of Exercise and Nutrition), rather than that of health professionals. This implied that the instructors were unfamiliar with the treatment of mental illness, possibly enabling them to challenge the participants like they would have challenged any other person without mental illness. It is widely acknowledged in the mental health literature that exercise and lifestyle interventions supervised by professionals with relevant training, including physical educators, physiotherapists and exercise physiologists is associated with greater improvements in comparison to unsupervised interventions and/or intervention supervised by other health professionals [31, 32]. Furthermore, previous studies have found that exercise instructors can play an important role in creating a feeling among participants of partaking in a normalised activity, helping to reverse the negative stigma of mental illness [33]. A qualitative review of mental health and physical activity including exercise (in participants with severe and enduring mental health difficulties) also found that exercise instructors played an important role, and were described by participants as key to providing a sense of safety and support [34]. This indicates that non-health professional instructors of exercise programmes in patients with FEP, can play an important role in providing a potentially anti-stigmatising and challenging, yet caring, environment. However, more research is needed to understand the potential benefits related to the involvement of young adults without mental illness as exercise instructors in treatment of FEP.

Another interesting finding was that the participants appreciated that they did not feel like they were being forced to be social because the purpose of the programme was exercise training. Participants explained that the programme provided and promoted easy social interaction, which is consistent with previous studies, which found that exercising provided a safe and meaningful opportunity for interaction, where mental illness did not matter [34]. Participants also explained that participation in the programme provided a conversation topic in other social settings, i.e. at OPUS or with family and friends, making it easier to be social in other contexts as well. Additionally, the participants appreciated the circuit training component, as it allowed them to do the exercises either alone or together. While other types of group-based exercise programmes may be especially motivating, our findings indicate that providing the individual with the flexibility to oscillate between socialising or not may be especially relevant in patients with FEP. This is confirmed by other studies, which indicate that social interaction is particularly difficult for people with schizophrenia and often results in withdrawal from social interactions leading to self-isolation [8], which means it may constitute a barrier for exercise participation. On the other hand, offering people with mental illness the opportunity to socialise with peers on their own premises is a central part of recovery [29, 35]. A study examining the experience of exercising among men with serious mental illness, found that one of the main motivations for participating in a popular sport was to create and talk about an achievement that was shared by, and could potentially be shared with, many others in society [36]. In the current study, this specific experience appeared to be shared by both women and men, thus not necessarily gender specific. This indicates that satisfaction of basic psychological needs (including autonomy, competence and relatedness), as suggested by health promotion models of self-determination theory, may explain motivational processes behind exercise behaviour in FEP in the same way as in the general population [32, 37]. However, more research is warranted in relation to how participation in peer-based exercise among people with serious mental illness can be applied to increase confidence in socialising in other life contexts. Furthermore, long-term studies are warranted to explore potential post-intervention adherence, including the potential implications of exercise for participants’ experience of recovery, i.e. how exercising may be used as a means to improve recovery in association with mental health services [33].

Although the current study does not provide any evidence in relation to the potential efficacy of exercise as complementary to treatment of FEP, it is interesting that the participants described the programme as providing a distraction from symptoms both during and after exercising. Specifically, the structure of the individual sessions, including clear plans and instructions in relation to the day’s workout, appeared to have supported the participants’ feeling of being able to structure their thoughts in way that made prevent anxiety from building up. This is in accordance with a comparable qualitative study targeting people with FEP which found that participating in a 10-week individualised exercise training programme improved participants’ mental health and confidence and gave them a sense of achievement [18]. A qualitative review of mental health and physical activity found that many mental health service users experienced that exercising helped subdue voices/delusions and redirect attention away from their symptoms [34].

Supervised, group-based, moderate to high intensity exercise training delivered by non-health professionals in a non-clinical setting has the potential to provide a normal, non-stigmatising youth environment, potentially supporting physical activity adherence and recovery in patients with first-episode psychosis.